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How can carbohydrate restriction be healthy if it means limiting “natural foods” like fruits and vegetables?

How can carbohydrate restriction be healthy if it means limiting “natural foods” like fruits and vegetables?
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This week I’d like to tackle one of the most important questions that I get asked.  However, before getting to the question, I think it’s worth investing a few minutes to frame this discussion around a theme tightly linked to it — sugar.

If you’ve been following the nutrition news lately, you may have noticed that Dr. Rob Lustig has made some headlines.  If you’ll recall, Dr. Lustig is arguably the world’s expert on fructose (i.e., fruit sugar) metabolism, and I included a link to his now-gone-viral YouTube video on fructose toxicity from 2+ years ago in my post, Sugar 101.  In the February 2nd issue of the journal Nature, Dr. Lustig and his two colleagues make the following case:

  1. Sugar consumption is linked to the dramatic rise in obesity, diabetes, cancer, heart disease, and Alzheimer’s disease (i.e., the diseases that cluster around metabolic syndrome).  Effectively, sugar speeds up our aging process.
  2. The metabolic effect of sugar, and fructose in particular (fructose makes up half of sugar – sucrose is 50% glucose, 50% fructose; HFCS is 45% glucose, 55% fructose), is nearly identical to that of ethanol (drinking alcohol).
  3. As such, sugar should be regulated in a manner commensurate with the damage it causes.

If you have access to Nature (or are willing to buy the article for $32), I highly recommend reading it. But if you can’t access it (unfortunately, I can’t share it here), at least look at this.

Let me lay out a few facts.  First, our consumption of sugar is increasing at a staggering rate.  We consume, on average, about four times the amount of sugar today that we did 40 years ago, even though our consumption of sucrose (the white crystals) is going down.  How, you ask?  Because we have more than made up for it with the ubiquitous addition of high fructose corn syrup (HFCS) to darn near everything we eat (e.g., cereal, pasta sauce, salad dressing, virtually every form of “low-fat” food out there, condiments).   Remember the “Peter Principle” – when you see “low fat,” run the other way, as it is almost synonymous with “high sugar.”

The figure, below, from the Nature paper shows the amount of sugar (excluding fruit) that each country produces, in per capita figures.  If you factor in fruit, obviously the numbers are much greater.  A quick glance at this figure shows that (excluding fruit), the U.S. is the reigning undisputed champion of sugar production at over 600 calories per person per day, which means over 175 gm of sugar per person per day, (excluding fruit and fruit juice).   To fully understand why we produce so much sugar requires a discussion beyond the scope of what I want to write about today, but I’m sure most of you already have a pretty good idea: economic incentives.

There’s another interesting observation that can’t help but poke you in the eye when looking at this figure.  How many times do you ask (or get asked), “Why do some cultures eat carbs like rice and not get the same diseases we do?”  A quick glance at China, for example, sheds some light on this.  They may eat rice, but they sure aren’t producing (or eating) much sugar, on average.  Furthermore, the distribution of sugar consumption within the country is wide.  In other words, while the few wealthy people do eat amounts of sugar approaching Western amounts (along with other simple refined grains), the vast majority of non-wealthy inhabitants do not.  So while some have asserted that animal products and fats are the clear culprits explaining the different disease patterns in Asia, they’re missing this important point:  Given the absence of mechanistic and evolutionary reasons why animal products and fats are bad for us, is it more likely that sugar consumption is the single biggest factor differentiating the state of disease across these populations?

Global sugar glut Nature Lustig paper figure

So what’s the upshot of this graph?  Well, for starters we eat a lot of this sugar.  Second, we export it, too.  This wouldn’t be a problem, I guess, if sugar were not so harmful.   How harmful is sugar?  For a long reminder, read Sugar 101.  For a very quick (by proxy) explanation take a look at the following table, also from the Nature paper, and previously presented by Lustig.

Table 1_Lustig Nature paper

This table shows, side-by-side, the health problems that occur with chronic ingestion of ethanol (i.e., drinking alcohol) and fructose.  [Remember: fructose is the sugar found in fruit and fruit juice, but it also makes up 50% of table sugar (i.e., sucrose) and 55% of HFCS.]

I think the figure speaks for itself and suggests that about two-thirds of the pathology that afflicts a heavy consumer of ethanol also afflicts a heavy consumer of fructose.   As Lustig points out, this should not be terribly surprising, given that we ferment ethanol from fructose.

Let’s summarize:

  1. We produce and eat more sugar than any other country on earth, and do so more than at any other time in history.
  2. Consuming sugar is not just “bad” because of the “empty calorie” hypothesis (i.e., the reason one should limit sugar is because the calories from sugar are not as valuable as those from, say, protein); it’s bad because sugar is a chronic toxin.

One last point before we jump in:  Before you angrily email me, or say awful things about me for daring to suggest that Michelle Obama and the USDA might be wrong in recommending we eat 5-6 servings of fruits and vegetables (many vegetables are full of fructose, too) per day, keep one thing in mind.  I am simply making a few points and you need to decide how you want to interpret them and make personal choices around them.  We are all genetically different, and therefore have a very different genetic predisposition in our sensitivities around these foods (and all foods in general).

There are some folks out there who can eat enormous amounts of sugar and experience very little ill effect.  My wife is the poster child for this phenotype – though she doesn’t any longer, she could eat unlimited amounts of sugar and not gain weight*.  Furthermore, as we age, we generally get less adept at processing sugar, and therefore with each passing year a “fixed dose” of sugar appears to cause greater and greater harm to an individual.

*Note that I only commented on the “weight” portion of her phenotype.  When my wife did reduce her sugar intake, she experienced many benefits in her health, perhaps most importantly, her improved cardiac disease risk profile measured by advanced lipid testing.

Here are the points with which I want to challenge you:

  1. Before you assert something is “natural,” be sure to understand what you mean by “natural.”
  2. Don’t be afraid to question the notion that all things “natural” must be healthy (and by extension, that all things “un-natural” are unhealthy).

Let’s address these points in order.

Point I: How do you define “natural?”

Most people assume the fruits and vegetables we eat are “natural,” but in reality fruits and vegetables of today bear little, if any, resemblance to their original form.  Let’s take corn as an example.  [I’m choosing corn because (i) it’s illustrative of the broad science and progression of agriculture, and (ii) I happen to read a lot about it, as I find the evolution of corn cultivation fascinating.]   Bear with me for a moment, as I tell this story.

7,000 years ago — a sliver of time on the evolutionary scale — corn as we know it today was a plant called teosinte.  Teosinte was about the size of your thumb and had a few (maybe 4 or 5) kernels.  Over the next few thousand years we began the shockingly quick (by evolutionary standards) process of “domesticating” this crop from its “natural” state into subsequent states of what we now refer to as maize.   By domestication I mean the process of successive selection of crops that had the most advantageous features for our needs.  Sort of like “domesticating” animals so they would cuddle up with us on the couch instead of trying to eat us.

How did the process of domestication work?  As an example, farmers selected teosinte crops which were larger, had more kernels, were more resistant to drought, and were more resistant to pests and predators.  This process went on, growing season after growing season, until about the period of time leading up to World War II and morphed teosinte into a very different looking crop.  Hence, the progeny crop, maize, looked very different from the parent crop, teosinte.   At that time, around WWII, the average farmer in the U.S. could grow about 18 bushels of corn per acre per year, though progress in yield increase had been stagnant for a few hundred years.

Around 1940, however, the productivity (i.e., the yield improvement) and morphology (i.e., the physical “look”) of corn growth began to change dramatically for two main reasons.  First, this change was driven by the introduction of technologies to make cultivation more efficient (e.g., crop rotation, use of fertilizer and pesticides, improved irrigation).  This was referred to as the “industrialization” of agriculture.  Roughly in parallel to this effort, advanced biologic techniques of active breeding (genetically crossing one plant with another so they could mix genes – the same things animals do when they mate) and mutagenesis (disrupting the genes of the crop, typically using chemicals or other agents, like radiation, to change the genes of crops) significantly increased the functional genetic diversity of the crops, year after year, further increasing yields and other desirable crop properties, such as cost of production.

Furthermore, in the last 20 years or so, the introduction of genetic modification (GM) has made maize even more robust and genetically fit.  Today U.S. farmers can grow nearly 200 bushels of corn per acre per year, up from less than 20 bushels per acres per year in 1940.   Below is a figure showing corn yield data from the National Agricultural Statistics Service, which shows the almost unrelenting productivity gains in corn cultivation over the past 70 years.  The world’s leading technology companies leading this charge (Monsanto, Pioneer, Syngenta) are projecting yields of 300 bushels per acre per year by 2030.  In other words, with each passing year, technology is making corn more and more robust, and therefore more and more distant from what is “natural.”

US corn yields for past 50 years

What about apples? Oranges? Strawberries? Peas? Carrots? It turns out the story I’ve told for corn is virtually identical for every “crop” we grow today, including all of our fruits, vegetables, and grains.  I know what some of you are thinking, “I only eat organic non-GM fruits and vegetables, so I’m ok, right?”  Unfortunately not.  Genetically modified (GM) plants and crops are different from non-GM plants and crops in small genetic ways that generally make them more resistant to pests.  But the hallmark differences between, say, teosinte and modern maize are 95% accounted for without the addition of genetic manipulations.  For the purpose of this discussion, genetically modified crops are a moot point.  In other words, what we grow and eat today, even if we buy “organic” or “non-GM” has absolutely no resemblance to what was “natural,” say, 10,000 years ago.

So the next time you bite into a Fuji apple half the size of your head (these used to be my absolute favorite things to eat, by the way, and I’d easily consume 3 or 4 per day), ask yourself what it has in common with the “apples” your ancestors ate.  The answer, not surprisingly, is very little.

Natural foods

Point 2: Who says everything “natural” is good for you?

The next point I’d like to address is dispelling the myth that all “natural” substances (notwithstanding the argument, above) are healthy.  Let’s examine the role of toxicity in natural things we ingest by first distinguishing between two types of toxicity: acute toxicity and chronic toxicity.  Simply speaking, acute toxins are toxins that can kill you quickly, if you are exposed to a single dose, or a series of repeated doses in a short period of time. Conversely, chronic toxins are toxins that don’t kill you from a single exposure, but over time multiple exposures can kill you.

While there is no shortage of “man-made” toxins in the world, you might be surprised to learn how many “natural” toxins exist, too.  Let’s examine a naturally occurring acute toxin, a naturally occurring chronic toxin, and a naturally occurring toxin that is both acute and chronic.   The figure (below) shows each.

  1. Perhaps the most singularly potent acute toxin on earth is a molecule called tetrodotoxin, or TTX.  Tetrodotoxin is a nerve toxin that blocks sodium channels in our cells.  TTX is so potent that less than 200 pounds of this compound would kill every person living in the United States. In other words, it’s about 10 times more potent that cyanide.  Here’s the catch: TTX is found in nature – it’s 100% natural.  It’s found in puffer fish, newts, toads, and several other sources.  Several people die each year from exposure to TTX when they unknowingly consume animals containing the toxin.  
  2. Tobacco is also a naturally occurring substance.  Whether smoked or chewed, however, it has many forms of chronic toxicity, primarily related to its carcinogenic (i.e., cancer-causing) properties.  In other words, you won’t die from smoking one cigarette or chewing one pack of dip, but if you do it enough, you might.
  3. Finally, ethanol is both an acute and chronic toxic.  While acute toxicity is rare, it is possible to overdose on ethanol (toxicity in this case is usually related to respiratory depression – that is, you stop breathing).  More common, of course, is the chronic toxicity of ethanol, which is well understood and well-documented.  For a quick reminder, take a look at the table I showed earlier in this post from the Nature paper.

Natural toxins

So there you have it.  There are plenty of “natural” compounds on earth that are harmful.  I am not suggesting that eating a Fuji apple is as toxic as smoking a pack of cigarettes, but I am saying that once you begin to understand the metabolic pathways of fructose (there are about 25 grams of fructose in a large apple) you’ll see that an apple, just because it grows on a tree, is not actually “good for you,” even though it is supposedly “natural.”  For some people, eating 10 apples a day causes no harm.  For others, eating 1 apple a day causes harm.  The goal should be to figure out what your “toxic” dose is — and stay well below it.

If you’re reading this and wondering how much sugar you can eat, it’s a bit like asking how much can you drink or smoke.  It depends.   How genetically susceptible are you to the effects of these toxins?  What are you optimizing for — short-term pleasure or long-term health?  This is where we get into the idea of dose-response.  I will address this in a future post, but not right now, as it really deserves a post of its own.

 

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About the Author:

Peter Attia, M.D., is the co-founder and President of the Nutrition Science Initiative (NuSI), a non-profit based in San Diego, CA. He received his B.Sc. from Queen's University in Canada and his M.D. from Stanford Medical School in California. After his surgical residency in general surgery at Johns Hopkins he worked as a consultant at McKinsey & Company. He founded NuSI with scientific journalist Gary Taubes in 2012.

Discussion

  1. mark  February 15, 2012

    Great post! The “it’s natural, so it must be good for you” theory is abundant it seems. I always respond by saying strychnine (sp) and cocaine are natural too. Doesn’t mean they’re good for you!

    mark
    http://www.lowcarblearning.com

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  2. PK  February 15, 2012

    Quick question Dr. Attia:

    A lot of what we “do” depends on accurate measurements.

    For one, we know that many of the “measurements” taken at most of our primary physicians are based in flawed science (to a degree).

    When, in you opinion – will the medical industry truly produce a scale or measurement that will help the common public? I could detail what that would comprise of – but you SURELY know what I’m talking about.

    We have SO MUCH TECHNOLOGY that is SO ADVANCED – you’d think that the so-called “tests” would be lock-step with such advancements. But they ARE NOT.

    Can we peek into this a bit?

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    • Peter Attia  February 15, 2012

      Sure, you can’t treat if you don’t know where you’re starting from, which requires measurement. The biggest single flaw right now is in lipid testing. Too many docs treating LDL-C, rather than LDL-P. I’ll write a great deal about this in the coming months.

  3. Mike Hurley  February 15, 2012

    I find it interesting that most people consider vegetables, and fruits to a lesser extent, to be the ideal food that all humans should eat. Michael Pollan’s “eat food, mostly plants” is a perfect example. It runs counter to what we know about human evolution. The ability to hunt and eat meat is what set humans apart from the other great apes. There are many populations throughout history that have survived on zero plant diets and have been perfectly healthy.

    One of my great interests is anthropology. From all the lectures I’ve been to and books I’ve read on it, everything points to humans as meat eaters. If you think about it, what is a better quality, more nutritionally dense food, a few pieces of fruit or a few strips of meat from wild game? There’s no question that the meat is the better food. It’s more calorically dense, it contains more vitamins and minerals, and far more protein than any plant. This is why our ancestors evolved the way we did, so that we could go after better food: meat.

    Unlike most predators, we don’t have speed, fangs, or claws. However, we do have species defining characteristics that make us great hunters. Bipedalism, lack of fur, and sweat glands gave our ancestors the ability to run down fur covered quadrupeds in the hot sun. We certainly didn’t develop these tools to run down bananas. If we evolved to eat fruit and plants, we would have stayed in the trees like the other apes, or stay on all fours like baboons.

    We’re meat eaters. We should embrace it. Plants are fine, but they’re not the ideal food for our species. Like Taubes, I doubt if they’re even necessary. I’ve gone for week long stretches myself, to experiment, eating just meat and dairy and have seen no ill side effects. I know there’s been observational studies of populations that eat no plants, but I wonder if there has been any clinical studies on whether or not plants are necessary in the diet.

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    • Greg  February 15, 2012

      Just watch Survivor Man (Les Stroud). When he’s dropped into the reality of nature, no readily available plant substance can provide enough calories for a modern human. (Well, there was one episode on island survival where he kept eating coconuts.) You can’t even rely on small game, unless boiled to extract the fat from bone marrow – see “Rabbit Starvation” on Wikipedia. That right there is a prime example of how much we depend on calorically-dense fats, and should be a clue for anyone trying to understand a “natural” human diet.

    • Alan  February 1, 2013

      You are right. I know many people, myself included who eat nothing but meat (and the fat that goes with it) and water and have done for many years.
      http://www.zioh.net/
      You may also like to read about Owsley (the bear) Stanley at:
      http://www.zioh.net/library/theBear.pdf
      Good luck in your research.

  4. Michele  February 15, 2012

    Peter,
    You and Gary (as well as many other hard-working low-carb bloggers) are becoming LCHF rock stars!

    Please continue to use the diagrams and pictures. They are extremely valuable when you are trying to reach an aging, diabetic father because the message is more direct and succinct. I am sure you are aware that Dr. Eenfeldt posted a nice “poster” on how carbs make you fat. I find these types of charts/diagrams/pictures very far-reaching in terms of audience.

    Also, are there any diagrams out there showing fruit on a scale of least to most sugar? Perhaps such a diagram of certain fruit today superimposed over a diagram of that fruit, say 100 years ago, would tell a good story?

    Words cannot express the gratitude I feel for the information this blog gives me access to!

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    • Peter Attia  February 15, 2012

      Michele, thanks very much. I don’t know about being rock stars — I’m trying to stay below the radar, actually, since blogging is a very part-time endeavor for me. I don’t know of a diagram as you describe it, but it could certainly be done. One (easy) way to do it would be rank by GI, but I actually think that would not be the most useful way to do it.

    • Michele  February 15, 2012

      I had forgotten the site sugarstacks.com…I cannot remember if I found this through your blog or one of the other blogs you read. Either way, this is not a diagram, but shows the sugar-content in fruit in terms of stacks of sugar cubes, so a step closer to the diagram I’m looking for:

      http://www.sugarstacks.com/fruits.htm

  5. Garth  February 15, 2012

    Two edits:
    1.) Discussing your wife’s sugar response you write, “…, should could eat unlimited amounts of sugar…”
    2.) Discussing corn yields, “…200 bushels of corn per acre per year, up from less than 20 acres per year…” (Should be 20 bushels per acre per year.

    Onto my questions. Did you happen to read Denise Minger’s post a few months back about the fructose content of wild tropical fruits? They were surprisingly high, and she claimed they were eaten year round, or close to it. Do you think refined fructose is singularly capable of causing metabolic problems, or do you really think its just a matter of dose, keeping in mind the often pointed out fact that it’s easier to drink a glass of orange juice than to eat eight oranges?

    I’ve also recently seen more and more people claiming that vegetable oils lead to inflammation and metabolic problems, and that only with this trigger in place does carbohydrate consumption cause trouble. I don’t buy it – I think there’s compelling evidence that excess fructose alone can cause obesity, type 2 diabetes, etc. But do you think there’s any validity to the idea that the consumption of certain oils might contribute?

    Thanks for the great post.

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    • Peter Attia  February 15, 2012

      Garth, thanks for the fixes. Got ‘em. Great questions. Yes, I did read Denise’s post on this topic. As you probably can tell, I am a HUGE fan of Denise’s work. I think she is simply so smart and talented. I don’t actually think my post is contrary to hers, if you read both carefully. Sure, we may disagree on the margins, but I think our point is similar. When you read Denise’s post, and juxtapose it to mine, keep a few things in mind:
      1) While I use corn and Fuji apples as examples where size is an obvious morphologic change, there are many other subtle difference, as Denise points out (e.g., pulp, water content).
      2) Even though some (not all) prehistoric fruits may have had a modest concentration of fructose, it doesn’t tell us how much of said fruit people ate. Remember the dosage issue of fructose (and ethanol) — there is a very different metabolic outcome from consuming 20 gm/day versus 140 gm every 7th day. Dose and timing of dose really matters.
      3) It’s not actually clear how many folks were consuming large amounts of fruit in ancestral times. Certainly pockets of people may have been, depending on food availability, but it’s not clear this was a ubiquitous practice.
      4) TTX existed a million years ago, too, so my other argument is still important. We can certainly discuss exactly how much fructose was in the fruit, but the larger point remains — the presence of fructose does not mean is was (and is) “good for you,” especially in the quantities we consume today.

      To your second question, the high omega-6 oils (big 4: corn, safflower, sunflower, canola) are pretty horrible, especially in the quantities we consume, coupled with the dearth of omega-3 we consume. As to whether this, alone, is the root of our metabolic problems I don’t think we can definitively say, but I don’t think so. I think it’s an amplifying factor. In other words, n-6 to n-3 imbalance, coupled with high sugar/high carb consumption create a more-than-additive impact (deleterious, of course) impact on metabolic syndrome.

    • Edmund Brown  February 15, 2012

      To your point #3 – it is also possible that some peoples ate large quantities of fructose rich fruit and lived short, sickly lives because of it, but that could be better than the alternative (starvation). If the choice is between eating a bunch of sweet fruit or nothing at all during a dearth of other food options I believe most people would choose to eat fruit. The consequences of fructose consumption generally don’t seem to impair fertility enough to cause a strong evolutionary pressure against it. Starvation does provide a pretty powerful selective pressure. I have no idea if this hypothesis is a possiblility, but it strikes me as worth exploring…

    • Peter Attia  February 15, 2012

      Excellent point, Edmund, and I was actually thinking of this after I replied (while swimming this morning). If people look back at today in, say, 10,000 years, they will note that we had Snickers bars. But what can they conclude if they see no other information? Could they conclude Snickers bars were “healthy?” Nope. In fact, they could hypothesize (thought not conclude) that the population subsiding on Snickers bars did WORSE than the population not subsiding on them.

  6. Barbara Hvilivitzky  February 15, 2012

    Great post, Peter. So clearly written and backed up with undeniable stats that there is no question sugar is a huge culprit in our present health crisis!

    Can I ask a general question about thyroid and low-carb eating? It has been puzzling me. I’ve just been diagnosed with low-thyroid (on a scale of 0.35 to 5, I’m at 6.20). I’m taking meds for this.

    Under these conditions, in general, is it wise to stay on a higher fat, lower protein, low carb regime? Or should one eat a bit lower in fat so as to maintain weight until the thyroid is more in balance, then up fat once more?

    I know you don’t want to get into personal medical stuff – but just as a principle? There are so many folks out there who struggle to get thyroid balance – and many eat low-carb and get stuck!!

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    • Peter Attia  February 15, 2012

      Glad you like, Barbara. I will address the thyroid-carb issue in a subsequent post, and I’ve got it on the “coming soon” page. It might take a while, though. You definitely need to have your doctor help you with this.

    • Michele  February 16, 2012

      Hello Barbara,
      I am hypothyroid as well (my thyroid was removed, I hover between 0.37 and 2.00 – also “normal”). I am not a doctor but from my experience, if you are stuck it is due to your TSH and potentially one of the other related values (FT3, FT4). Until you sort out your dosage of hormone, eating more fat and weight training will help if only so that you do not gain more weight. Peter has mentioned the dangers of too much protein (which I have found makes me gain weight when I eat too much AND my thyroid values are not correct). I hope this information is helpful.

  7. Greg  February 15, 2012

    I was a vegetarian for 10 years or so, and interestingly enough, I think my vegetable intake has gone up on my LCHF, ketogenic diet. The simple reason is that before I would eschew the salads and choose low-fat, grain- based foods like rice, pasta, and bread as my staple. If not grains, then legumes, although that probably does class as a vegetable. Anyway, now the salad is my go-to option for many meals (topped with lovely bits of meat and cheese, of course). And might I add, broccoli and butter love each other.

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  8. Lisa  February 15, 2012

    Peter, nice post, and I agree with you 100%. However, I think there’s one point you’re not considering when you look at the recommendations from someone like Michelle Obama (I’m not including the USDA in this, since I believe their interests are entirely commercial), and that is, “the best is the enemy of the good.” Given the horrific state of the standard American diet, eating more fruits and vegetables, and even whole grains instead of refined ones, would certainly be a big improvement for the vast majority of people, even if it’s not the “ideal” diet. The problem we face now is that our current way of eating is no longer just a diet, it’s a culture. It’s embedded in everything we do, and in who we are. I think many people are past the point of no return when it comes to what they’re willing to sacrifice in their diet, particularly since many of them are now “habituated,” if not outright addicted, to sugar and starch.

    You face an uphill battle getting your message across. People believe things because they want them to be true, or because they fear that they’re true, and in this case, people desperately want to believe that sugar and starch are necessary, healthy components of the human diet, and they fear that the calories in/calories out model is correct. Add to that the huge commercial interests at play, the primary sources of funding for nutrition research, and the sheer volume and conflicting nature of “noise” in the media and on the internet regarding diet and health–and it seems next to impossible to create the sea change we in the low-carb community would like to occur. That’s not to say you shouldn’t fight the fight. Perhaps it will take a grass-roots movement like the one happening in Sweden (and led by people like you) for that sea change to take hold here in the U.S. But I believe high-profile figures like Mrs. Obama, Dr. Oz, etc. believe they can affect broader change by introducing more incremental adjustments to the diet that are “politically accepted,” and it’s not clear to me that they’re wrong.

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    • Peter Attia  February 15, 2012

      Lisa, you are absolutely correct. I hope I don’t suggest that Mrs. Obama or others are doing anything nefarious. On the contrary — they really want to help, and to your point, if the choice is between potato chips and a candy bar versus more fruits and veggies, it’s a no-brainer. But it doesn’t change the much broader and more important point (which is why we are forming NuSI): It’s time to put some science behind nutrition guidelines and food-based policy. I certainly have a hypothesis for what is right and what is not. But I could be wrong. Let’s stop the dialog and start the real science.

    • Lisa  February 15, 2012

      Amen! :)

    • Marilyn  February 17, 2012

      Lisa, I think you have a good point. When there’s nowhere to go but up, even small improvements are — well, improvements. I’m reminded of a friend of a friend who bought an old house in a poor neighborhood. She said most of her neighbors don’t even have stoves in their kitchens. There is little food preparation at home. People eat only the packaged stuff they purchased at the local store, and often as not that’s things like chips and candy bars.

  9. Fritz  February 15, 2012

    Dr. Attia,

    You’re leading me (perhaps unintentionally) to give up my daily “medicinal” alcohol permanently, which is good news to me, since I cut it out temporarily a while back to lose weight and still wonder if that is extreme or even ill-advised.

    Does anyone suspect that the apparently well-documented benefits of low daily alcohol use are minimal to LCHF people? The commercial interest driving that research would seem incredibly strong. Have you developed an opinion yet on whether the benefits of moderate daily alcohol vanish if one does LCHF? Or any research I can dig into on the subject?

    Not to neglect the central point of this excellent post. Sugar is long-gone from my diet, thanks to Gary Taubes, confirmed by your work. I’m grateful to you for this post, because I’ll be able to refer many friends here to help exorcise the “natural” demons efficiently.

    Thanks again,
    Fritz

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    • Peter Attia  February 15, 2012

      Fritz, as much as I LOVE my glass of wine with dinner a few times per week, I’ve never seen convincing data that it’s actually GOOD for me. I could argue that at small doses it’s not too BAD for me, though, which is what I do argue.

  10. Helga  February 15, 2012

    Wouldn’t it be great to really know what our ancestors ate? There is some archeological evidence, but it doesn’t seem as thorough as it could be. I’ve seen human evolution documentaries where bone protein analysis was done on Neanderthal bones, and they determined they ate no substantial amount of plant protein. They neglected to show the same results for Homo Sapiens bones. I would be interested to see those results. I’m sure there were great variations in diet based on what was available regionally. I got a great lesson in this a few years ago. I live in a climate that is similar to my ancestral climate. Cold, northern, little sun. I subscribed to a year round CSA. In my area the only plants that are available for 7-8 months out of the year are leafy green vegetables, mushrooms, and some really sad overwintered root vegetables. Fruit is only available for 3-4 months, and each fruit is only available for a week or two. We have become very disconnected from how food actually grows because we can buy bananas and apples every day of the year. I would guess that most of us would have no deleterious effect from fruit if we only ate it when we could actually pick it and put it directly in our mouths. Consumption of fruit would certainly fall. The other lesson the CSA taught me was counter to Pollan’s mantra about mostly plants. If I ate mostly local plants I would quickly die of starvation. So would anyone else who live in a climate with harsh winters. Food for thought!

    (reply)
    • Barbara Hvilivitzky  February 15, 2012

      Boy, Helga you certainly hit the nail on the head with your post. I too live in a cold climate, and to add insult to injury, what the squirrels don’t get the rabbits sure do. We could live off those furry little creatures, and pigs and chickens, and whatever greens we could grow, and the fruit that does well here – and then there are the lovely deer, and moose, and farther north, the caribou etc.

      But to eat tomatoes from Mexico, tender greens from California, grapefruit from South Africa, grapes from South America….well that seems a little crazy. Maybe the local food movements are the way to go – but as you say, limp carrots, dried out rutabaga, and mouldy squash does not appeal in February!!!! What about hydroponics? Is that the answer?

    • Helga  February 15, 2012

      I think not feeling like you doing the wrong thing if you don’t eat large amounts of fruits and vegetables every day is the answer. Don’t get me wrong, I enjoy these foods. But like exercising, I do it because I like it and not because I think it’s going to make for perfect health.

    • Matt Taylor  February 16, 2012

      I had my DNA mapped, and my ancestors are all from Europe going back 10′s of thousands of years. That time period includes the last ice age when I doubt they ate much fruit at all, and vegetables maybe only a few months out of the year, if they even bothered. My hunch is my genetic make-up is not suited very well for carbs.

  11. Conni  February 15, 2012

    Hi Peter,

    I think this is a great post, your points about what is and isn’t “natural” are absolutely spot on. I do have one concern. I see no reason to paint vegetables with the same broad brush as fruits. One can eat MOST vegetables and get nowhere near a problematic level of fructose. One can only eat a few fruits, by contrast.

    It’s a great idea to eliminate high fructose or high GL vegetables like corn and potatoes from our diets… but there are a great many vegetables that are perfectly fine and healthy to eat, that don’t adversely affect insulin and have the benefit of adding vitamins, minerals, fiber and – a point not to be excluded – more variety to a truly healthy diet, which helps to change it from just a diet to a lifestyle. “Limit fruit and vegetables” is, in my opinion, much too broad and sweeping a statement (i.e., the title of this blog), without qualifying it to mean most fruits and some vegetables.

    Best,
    Conni

    (reply)
    • Peter Attia  February 15, 2012

      Conni, you are absolutely correct! Of course, if I try to explain everything, my already-too-long-blog-posts turn into, well, you know. The nuances you’re describing are very important, and when given enough time, I like to communicate them, also. Thanks for helping me out. The important point is that folks need to evaluate each food type individually and within the context of their own genetic predisposition. All fruits are not created equal, either. While I don’t eat Fuji apples or bananas, I do still eat raspberries, blackberries and strawberries. HERE IS THE IMPORTANT PART, though. I don’t eat them because they are “good for me” or “necessary” for good health. Same holds for salad. I eat salad because it’s an awesome way to eat fat. I eat berries, because they are a treat.

    • Conni  February 16, 2012

      I’m very glad you saw it as helping, and not nitpicking, because that was my intent – helping to keep the message clear. There are more and more people every day getting interested and trying to understand what they’re supposed to eat, and it can be confusing in the beginning. My husband and I do eat apples – but we split them, and each have a half. Tastes great with pork sausage for breakfast. Keep up the great work, and thank you.

      Conni

  12. tivoboy  February 15, 2012

    One should not that without the ability to increase yield on farm land and for agricultural products, over at least the last 100-200 years, the planet population would most likely NOT be able to sustain itself.

    (reply)
    • Peter Attia  February 15, 2012

      Certainly not the way we live today, I would agree. But that begs the real question, doesn’t it?

    • tivoboy  February 15, 2012

      I’m not really sure I understand the question? But, here are some data points.
      In the last 200 years, population has risen from roughly 1 billion to over 7 billion. That’s a lot.

      50 years ago, crop yields were increasing roughly 3.5% a year, which was comfortably more than a global 2% population growth. But, today that number is closer to 1.5%, just about the rate of human population growth. When the production growth rate goes below the population growth rate-that’s when the problems will begin. not to mention the fact that VERY LARGE percentages of the worlds population-specifically 3rd and 2nd world are moving to consume ever greater quantities of foods stuffs, far more than they did in that past 20-30 years.

      I’d love it if WE ALL consumed less, across the board. It would probably do everyone good. I’m concerned, however, that without continuing growth of production we could run into a commodity production wall and demand spike. Historically, that hasn’t proved a good environment for populations.

    • Peter Attia  February 15, 2012

      Yes, agree with your analysis. I’m just asking a broader question: Are we (humans) better off with a planet of 7 billion people, some large fraction of which are not healthy? I don’t know the answer, actually, or even have a strong point of view. Just an observation. Think of an extreme case: what is better, X people living in perfect health or 10X people living in misery? I don’t know that the number of people is the best metric. What about quality of life?

    • Barbara Hvilivitzky  February 15, 2012

      We have no idea what would have happened if we had not added all the technology to farming. And I’m wondering if the tradeoff was worth it. We’re doing our best to reduce the population (in fact Europe is past the tipping point in that it will NOT be able to sustain itself in 50 years) and we don’t seem any better off in any areas of measurement!!

    • Logan Quinn  August 17, 2013

      Following along the thread of emerging 3rd and 2nd world consumption habits. Wouldn’t it be great if the 1st world could mentor them about the mistakes we’ve made, and help them avoid the pollution and obesity issues?

      All the more reason to really work on the science and figure it out sooner than later. :o)

  13. Alexandra M  February 15, 2012

    Thanks for addressing the “natural” fallacy!

    At the moment I’m reading “Wheat Belly,” and the author makes some interesting speculations about how repeated hybridization has changed the wheat genome so much that its gluten proteins are quite different from those of its ancestors, einkorn and emmer wheats. I imagine the same thing could have happened with corn – after all, the ancient peoples of Mexico called themselves the “People of the Corn” and didn’t die out from eating it. Is there any way to find out how much the proteins have changed with intensive selective breeding, and whether those changes ARE actually harmful, except by observational studies?

    (reply)
    • Peter Attia  February 15, 2012

      Alexandra, I am sure there is a way of at least getting some insight into this, but I do not personally know the answer.

  14. Marilyn  February 15, 2012

    I’ve always considered the all-wild-fruits-were-tiny-and-sour idea to be somewhat of a myth. If you’ll Google “wild plums” you’ll see some good information, with pictures. When I was a kid, we had wild plums growing on our farm in Nebraska. Yes, when they weren’t 100% ripe, they were hard and sour. (So anyone with the preconceived idea that all wild fruit was hard and sour could easily find “proof.”) But when fully ripe, those plums were the sweetest, juiciest, most succulent fruits you could ever imagine. Nothing in the grocery stores today even comes close. I’m sure there were other wild fruits just a wonderful.

    (reply)
    • Peter Attia  February 15, 2012

      Perhaps. But it doesn’t change the point I’m trying to make. Just because it tastes good, does that mean it’s good for you? Does it mean eating it (now or 7,000 years ago) improved health?

    • Marilyn  February 16, 2012

      OK. Thanks. Please kindly remove my comment.

    • Peter Attia  February 16, 2012

      You sure? It was a great comment.

    • Marilyn  February 16, 2012

      Leave it up. I think my point was missed as well, and maybe I need to be more specific. My point is that although most of the current “wisdom” that I read about wild fruits states that they were small and sour, I happen to know from personal experience that that observation isn’t completely accurate. Generalizing from that: I think we need to be careful about drawing hard and fast conclusions about much of anything, since in most cases we probably don’t have all the information.

      Do I think eating sweet wild plums would be detrimental to the health of a person 7000 years ago? Again based on my personal experience, I’d say that eating sweet wild plums once a year in the years the plums didn’t freeze would probably be insignificant one way or another.

      Cheers!

    • Conni  February 16, 2012

      Marilyn, I hope you decide to leave your comment, because this is something I’ve thought about also. I believe that you’re right, that there were fruits that were deliciously sweet before they were genetically modified. It is worth noting that in many climates, these fruits were not available year-round. It’s quite likely that our ancestors very much enjoyed eating these sweet fruits when they were available, and also quite possible that they put on a few extra pounds as a result. Those pounds probably came in handy to burn as energy during the winter months. I also think that the availability of fruits year-round in some climates could have caused those populations to evolve differently. It would help explain why some of us can eat more carbs than others, and maintain comparable health. Who knows what genetic soup we’re each handed?

      Your comments are quite valid, and a worthwhile part of the conversation. I think. :)

      Conni

    • Marilyn  February 16, 2012

      Thanks, Coni. I just read your comment after I put up my “leave it there” message. :-)

    • Marilyn  February 16, 2012

      Oh, dear! I left an “n” out of Conni. Sorry!

    • Conni  February 20, 2012

      Usually people add an “e” to my name, so the deletion of an “n” instead is a refreshing change. Haha!

  15. Brad F  February 15, 2012

    Hi Peter
    Can you help me with something. I am fairly evidence driven, and hold others to the same standards I hold myself.

    Having said that, can you help clarify something? When you invoke apple eating and use terms such as “toxic” and “harm”…

    At the macro level, I know exactly what you mean (sugar, fat, etc). However, I am unclear how an individual assesses toxicity in the context of a varied diet, using foods that might comprise <10% of daily caloric intake. Tall order, especially without elegant measurements and daily diet tweaks beyond the capacity of usual and customary.

    More a theoretical discussion than practical, no?

    Brad

    (reply)
    • Peter Attia  February 15, 2012

      Sure, Brad, but don’t think in terms of caloric input. If you got 10% of your calories from certain wild mushrooms, you could also be causing significant toxicity. Same thing with ethanol.
      I don’t think % of calories occupied the food is the best metric to assess. There are no calories in tylenol, yet 10 gm would destroy your liver.

    • Bradley Flansbaum  February 15, 2012

      I was using % calories only for illustrative purposes and as a stand in. Another way of saying it–these items (like fruit), only comprise a fraction of our diet. For someone like yourself, and I would include myself as well, dietary regularity with minor changes might give useful signals, ie, what is “toxic” and not. Although, even as a I write this, I dont know if I can identify these signals. Feeling “low energy today” does not count.

      However, most folks cant utilize that kind of instruction to determine “toxicity.” How can individuals determine if an apple is good or bad, or cherries, or peanuts, etc.

      Hope its clearer

      Brad

    • MITBeta  September 12, 2013

      The poison is the dose.

  16. Alex Carvalho  February 15, 2012

    Great post. The Laura Schmidt’s article you referred to claims that high sugar consumption can lead to fatty liver disease. I have already had a fatty liver (and other metabolic syndrome symptoms) when I started my ketogenic diet a few weeks ago. One of my concerns is whether the fatty liver won’t get worse with a fat rich diet. Is this a real risk or, to the contrary, a ketogenic diet should improve the condition of my liver?

    (reply)
    • Peter Attia  February 15, 2012

      Fatty liver is not driven by fat consumption. It’s driven by de novo fat production. This is, obviously, very counter-intuitive, hence so much confusion.

    • Ellen Davis  February 16, 2012

      Alex, I’ve done some research on fatty liver conditions and how a ketogenic diet helps here:

      http://www.ketogenic-diet-resource.com/fatty-liver-disease.html

      Saturated fat consumption actually improves fatty liver syndrome. Hope that helps.

    • Alex Carvalho  February 16, 2012

      Ellen, thank you. Very nice resource. I’ve already added it to my favorites.

  17. Robb  February 15, 2012

    Dr. Attia,
    I can’t recall if was you or Gary Taubes who noted that when tribes who are isolated from civilization have been studied by anthropologists they found that their preferred foods were animals and the choice parts were actually the organs. So I definitely think this view of the sort of “noble plant eating savage” is more fiction than fact. I have noticed after reading a lot of different diet and nutrition books in most of them the common thread is to drastically reduce or eliminate white flour and sugar. The problem is in a lot of cases the authors expand their scope and attack every aspect of the Western Diet with minimal evidence to justify it. (It would be like a fire investigator blaming everything in the house for the fire rather than just the candle left burning). When I read the books “Eat to Live” by Joel Fuhrman and “In Defense of Food” by Michael Pollon I get the impression that these two authors were in favor of plant based diets going into this and are trying to find evidence to prove it to be true. Where as in your and Gary Taubes case you didn’t have any preconceived preferences going in you were just trying to determine what the evidence was and where it lead. Unfortunately I think a lot of scientists have gotten into the business of making a hypothesis and trying to find evidence to prove it rather than refute it.

    (reply)
  18. DHackam  February 15, 2012

    The key question seems to be: “What did our ancestors eat while their genome was evolving?” This can then be contrasted to the standard North American diet.

    I actually posed this question to a retired anthropologist in my clinic. He stated that our paleolithic ancestors consumed a diet consisting of at least 80% meat, and surprisingly, most of it was in the form of carrion (dead animals or carcasses on the ground, particularly small furry mammals such as squirrels and the like). We had such a limited tool set that we could not really carry out much in the way of agriculture or vegetable growing – essentially what we had we used to scare off other scavengers by throwing rather hard, solid, sharpened objects at them, so we too could dine at the feast. I don’t know if this is the latest consensus academic opinion – my informant retired a number of years ago. But it does pose a marked contrast to those who state that we subsisted on a fruit/vegetable/grain diet.

    Just thought I would share this as it may be interesting for your readers.

    (reply)
  19. Edmund Brown  February 16, 2012

    Apples are a good example of selective breeding concentrating a trait in plants, in this case sweetness, i.e. fructose. Potatoes are another good example – They are much maligned in Paleo circles, and in my opinion some of the bad mouthing should really be directed at the variety grown less than the generic crop. I never enjoyed potatoes on my plate until I grew a high protein variety in the home garden. There are varieties of potato that lay in large amounts of protein (about 1/3 by weight), but one almost never finds them in a supermarket for two reasons that I can see.

    1. Building proteins is more metabolically taxing than building carbohydrates. That disadvantage means the yield of a carb rich crop will be higher than that of a protein rich crop, all other things being equal. Since farmers are paid by the volume they grow not the quality, the incentive is to grow whatever variety provides the “greatest” yield, not what promotes the greatest health.

    2. Protein rich potatoes do not keep nearly as well. No middlemen want to be stuck with a truckload of rotten potatoes, so they too exert pressure on the system toward the carb rich, flavorless crap on offer at your local neighborhood store.

    (reply)
  20. Ellen Davis  February 16, 2012

    I think one of the main myths of the “vegetables are healthier” argument is that they are “full of vitamins and minerals”.

    If you compare a 3 ounce serving of any lower carb vegetable to the same size serving of beef or pork, the vitamin and mineral content of the meat is much higher. But you don’t hear how meat is “full of vitamins and minerals” very often.

    (reply)
    • Peter Attia  February 16, 2012

      Great point, Ellen.

    • Matt Taylor  February 16, 2012

      Yes, and I believe there is evidence that a low-carb diet allows the body to use the vitamins/mineral better. I seem to remember Taubes specifically mentioning calcium as an example. Wouldn’t be surprised if Peter has post on this somewhere (or in the works), since he’s a blogging machine.

    • Peter Attia  February 17, 2012

      Matt, you are correct, but I have not yet explicitly written about this. Vitamin C is a great example of this. In the presence of glucose you require a great amount as a co-factor for the amino acid proline, but in the absence of glucose, you require a fraction of the amount. Hence, I consume virtually no vit C, yet have no scurvy.

    • Jon  March 24, 2012

      Peter,

      The sooner the post on this vitamins and minerals issue comes the better, as that is the most frequent argument I get in response when talking about your views with people who find them outrageous. Specifically, that we “need” to eat fruits and vegetables (and to some extent complex carbs/whole grains) for the vitamins and minerals they contain in order to be healthy and not die of some other problems separate from the metabolic disease associated conditions. I know there is a a difference between fat soluble vitamins (found in animal products and some oils) and water soluble (found primarily in plant-based sources), but I don’t have enough information about this to explain why you don’t “need” to eat fruits and vegetables and whole grains.

    • Peter Attia  March 24, 2012

      I will get to it. But in the interim, everyone time someone *insists* that you need X or Y in your diet, just ask them to show you the data? Simple request, right? I need X mg of this or Y mg of that. Great. Where did that recommendation come from?

    • Travis Koger  March 24, 2012

      Zoe Harcombe has a great article regarding the Five A Day marketing campaign and details some of the myths surrounding vitamins. It is a good read if you wonder about how to get vitamins when not eating fruits & vegetables.

      http://www.zoeharcombe.com/2012/03/five-a-day-the-truth/

  21. Dorian  February 16, 2012

    Hi Peter,

    Great post! Sorry if this is a bit off topic, but I’d enjoy hearing your thoughts on “the Mediterranean Diet” (which as far as I can tell is low sucrose, so maybe not too far off topic…).

    For starters, there are many “cuisines” around the Mediterranean: Italian, Greek, Spanish, Croat, North African… and even within these broad groups, Ligurian is different from Tuscan; is there a city/culture which best fits the Mediterranean Diet?

    Next, is it your opinion that some elements of this diet are good; while minimal elements are bad — i.e. lots of meat, fish, olive oil, vegetables with minimal sucrose? Or, even stepping back, perhaps your opinion is that this diet, while perhaps better than fast food, isn’t really that great (bread, pasta, fruit, etc.).

    Curious to hear your thoughts. Thank you.

    (reply)
    • Peter Attia  February 16, 2012

      Dorian, I don’t really like to speak in generalizations like this, because there is so much variation and nuance. Is a “typical” Mediterranean diet healthier than a “typical” American diet? Sure, but think more of what is being eaten and avoided, rather than just nomenclature around diet, if that makes sense.

  22. Matt Taylor  February 16, 2012

    Peter, you are so much better at getting this point across than I am. Whenever people try to tell me that because it’s “natural” it is good for me, healthy, etc… I usually say something like, “Well, dog crap, snake venom, and cockroaches are 100% natural too, and I’m not eating those either.”

    (reply)
    • Peter Attia  February 16, 2012

      I don’t know Matt. You just managed to say in about 15 words what I needed 2500 words to say. I think you’re the one doing it right :) I might need your help with next week’s post…

    • Matt Taylor  February 17, 2012

      Haha. Seriously though, when you deliver the anti-sugar/pro-fat message/lesson you are very positive, patient, humble, and never condescending. When I try to deliver the same message I end up seeming like a smart-ass, know-it-all, self-righteous, engineer/scientist type… which I kinda am. Our cause, if you want to call it that, is better served by your message delivery. I think you build a fine bridge between the science and the laymen.

    • Peter Attia  February 17, 2012

      Matt, VERY kind comments. Thank you. I hope to be part of the transformation that is about to take place.

    • Eddie Friedman  February 16, 2012

      Ha! Sounds like a horrid list of ingredients or a list of substances that some government agency would “allow” for in food safety regulations, in “permissible” quantities.

    • Jason Clements  February 20, 2012

      Cliffs and wolves and hurricanes are “natural” too. Haw haw!

  23. Robb G  February 16, 2012

    Peter,

    Great post!

    While reading about what domestication has done to the productivity and morphology of plants, I began wondering about the same thing related to the animals and animal products that we include in our diets.

    While your post refers to domestication of animals for cuddling on the couch, it does not go into detail on whether our domestication of farm animals has caused them to be very different from animals that we co-evolved with over millions of years.

    Do you think that the animal-based products we now eat suffer from the same issue as many plants, in that they are so different genetically from where they started, that humans may not be as well-adapted to digest and thrive when eating these products?

    While I seek out grass-fed and pastured meats and eggs, is this really not much different than the minimal benefit of organic and non-GM in plants (notwithstanding the potentially more humane farming methods)?

    Thanks!

    (reply)
    • Peter Attia  February 17, 2012

      Robb, this is very interesting question, and one to which I can’t claim to definitely know the answer. Here are the few things I do know. The domestication of crops and that of livestock followed a different time course. Crops underwent the majority of their domestication from about 3,000 years ago until, say, 20 years ago. Certainly, huge improvements are still being made today (e.g., nitrogen utilization, crop protection), but these impact overall yield and agronomics more than morphology, which is really what you’re asking about, I think.
      Conversely — and admittedly I know MUCH less about livestock — their domestication for consumptive purposes seems to have taken place over the past, say, 100 years. If I’m wrong on this (I don’t have time to read a book on this topic right now), hopefully someone will correct me.
      So we don’t really have a good “control” period to look at. Yes, it would be observational, but we don’t even have that. So we’re sort of stuck with the dilemma…what do we eat? Certainly, if you an afford it, there is reason to believe grass-fed over grain-fed offers a better omeag-6 vs. -3 profile. It also seems logical (but I don’t have supporting data) that livestock grown without copious antibiotics might be better. It’s not clear to me that non-GM would necessarily be better, but it would be nice to know…
      So where does this leave us? Here’s what I do know: I’m much better off eating a steak than eating a potato. Did humans eat either of these in their exact form 5,000 years ago? Nope. But I’m pretty my steak is much closer to theirs than my potato would be.

    • Alexandra  February 17, 2012

      “…their domestication for consumptive purposes seems to have taken place over the past, say, 100 years.”

      Well, there was that little fratricidal dust-up in Genesis. I think one of the brothers was a shepherd. ;-)

      “Shepherding is one of the oldest occupations, beginning some 6,000 years ago in Asia Minor. Sheep were kept for their milk, meat and especially their wool. Over the next millennia, sheep and shepherding spread throughout Eurasia.”

      And the Maasai have been herding cattle for a very long time.

      All herders practice selective breeding to some degree, culling out the weak and prizing especially robust males for breeding.

    • Peter Attia  February 17, 2012

      Yup, great point. I guess I was thinking more of the “industrialization” of it, but you make a good point. The real question is when did domestication of animals change the composition of their nutritional composition? One could argue it did not, at least as much as changing what they ate.

    • Alexandra  February 17, 2012

      Feeding corn to cattle didn’t start until the 1930s. I read recently that at one point they tried feeding them coconut oil to fatten them up quickly, but it had the opposite effect! Hmmm…

      As soon as grain feeding started, the meat changed. I assume you know that grain fed meat contains a highter proportion of omega 6s than grass fed. Also the gut of grain fed animals is more hospitable to the nastier strains of E. coli.

    • Guillaume Belanger  February 26, 2012

      Hi Peter,

      I really liked the post, especially the bit about sugar consumption and its metabolic effects in comparison to those of ethanol from Lustig et al’s paper. But also the world map of sugar production/consumption: it’s quite revealing to see it in this way.

      About the domestication of animals: Sheep, goats and pigs were domesticated for the first time about 8000 years ago, cows about 6000 years ago, and horses and donkeys about 4000 years ago. All in or near the Fertile Crescent.

      I’m sure you will find two of my last articles interesting: We were never meant to eat simple or starchy carbohydrates and Eliminating insulin-stimulating carbohydrates.

      Ciao
      Guillaume

  24. Helga  February 16, 2012

    I have a question for Peter and the readers. Has any experienced dry eyes and mouth, usually at night, as a side effect of carb restriction? I apologize that this isn’t on topic with the current post. I plan to discuss it with my GP, but I’m not confident he has extensive knowledge of “transition symptoms” with carb restriction. I know there is a pretty horrifying autoimmune disease that causes these symptoms, but I would rather not jump to the worst possible conclusion if there is a simpler explanation. Anyone?

    (reply)
    • Matt Taylor  February 17, 2012

      I had to increase my water intake to prevent dry skin and mild dehydration. On a low-carb diet we don’t consume as many food items that contain water, like fruit, milk, soda, beer, etc. If you haven’t done so already I would try that. Helps with the nighttime cramps too.

    • Helga  February 17, 2012

      Thanks Matt. I’m pretty well hydrated. I’ve found a few claims online that low carb diets cause decreased mucus production, which is critical to our eyes and mouth. Though sadly, I’m not sure the sources are credible. The only treatment recommendations are to eat more carbs or to use eye drops. I guess the question I’d really like answered is, “If anyone has had this issue, was it a transition effect, or permanent as long as carb restriction continues?”

    • Ed  February 28, 2012

      I’ve been LC but not ketogenic (75-100g/d) for the past six months. I do think my eyes (particularly wearing contacts) feel drier than the past, but its more of a nuisance than a problem. And I do steal my wife’s eyedrops (something I didnt do a year ago). Mucus seems fine, though.

      Perhaps it’s the power of suggestion, but after listening to Paul Jaminet (of the Perfect Health Diet), I started noticing the symptom. I believe he mentions glucose is necessary for this function. Maybe you are a candidate for experimenting with adding back a little bit of “safe starches”.

    • Mary  February 18, 2012

      oops, didn’t hit reply, but my reply is #27 below

    • Ellen Davis  February 18, 2012

      It’s possible you aren’t eating enough protein. Lyle McDonald writes about this. During the first 3-4 weeks of carb restriction, the body requires extra protein to compensate while it creates the enzymes it needs to burn fat for fuel. Also, Lucas Tafur writes that protein malnutrition will cause a decrease in mucus production, which can lead to dry eyes. (http://www.lucastafur.com/2011/03/ketomyths_08.html)

      I had the same issues, and eating more protein resolved it for me. There’s more info here on my daily protein requirements page: http://www.ketogenic-diet-resource.com/daily-protein-requirement.html

  25. Alex Carvalho  February 16, 2012

    Nice job at tackling “natural”. You write very well. May I suggest that you put tackling “balanced” and “moderate” on your to do list? All these are very poorly defined terms against which we’re constantly tested….

    (reply)
    • Peter Attia  February 17, 2012

      Sure. You may recall I have a t-shirt that reads: MODERATION — the only thing worth doing in moderation!

  26. Chris  February 17, 2012

    I would love to see an article like this destroying the “heart healthy whole grains” myth. Any of that on the radar?

    (reply)
    • Peter Attia  February 18, 2012

      Chris, I will definitely be writing about this topic in the future. I think you’ll definitely enjoy next week’s post. Just finished it up. Sadly, it’s the same story over and over again…

  27. Kypros  February 18, 2012

    Hi Peter,

    Great post. Only last week I was having trouble explaining to a colleague why a glass of apple juice can be unhealthy – apparently counter-intuitive for most people.I’d like your view on the following:

    Is a high fat diet beneficial even if combined with carbs? So if you are addicted to carbs and cannot cut them should you still aim to increase your fat intake? So if you cant cut bread for breakfast should you also spread butter on it?

    Thanks again! Keep up the good work.

    PS: Why Gouda?

    (reply)
    • Peter Attia  February 18, 2012

      Great question. As far as I can tell, eating a lot fat IN THE PRESENCE OF SUGAR is not a good idea. The best data I have seen on this comes from John Yudkin (you can check out his prophetic book on my list of recommended reading). Why? Probably because sugar is such a “metabolic bully.” In other words, in the presence of sugar, our body basically prioritized only the oxidation of it, and ignores everything else. Fat gets stored as fat, and excess sugar get stored as fat. This is probably an oversimplification, but Yudkin’s data certainly suggested it.

  28. Mary  February 18, 2012

    Helga, I developed “a pretty horrifying autoimmune disease” (rheumatoid arthritis) 8 years ago and dry eye was one of the many other symptoms that went with it. I refused all treatment and instead researched foods that caused flareups in others and changed my diet accordingly achieving complete remission 3 years later with essentially a low carb diet. As far as I’m concerned all inflammatory degenerative diseases are the same with the names just indicating individual genetic weaknesses (irrelevant). Even more so than RA, dry eye is a dusk to dawn phenomenon thought to be due to cortisone levels which are at their lowest around 3 a.m. While this doesn’t answer your specific question (whether it is due to low carbs), I hope it sheds some light on dry eye and the much dreaded autoimmune dis-eases generally.

    (reply)
    • Helga  February 18, 2012

      Thanks Mary. I’m glad you’re feeling well.

  29. Mike Grove  February 20, 2012

    This post isn’t showing up on my ipad??

    (reply)
    • Peter Attia  February 20, 2012

      Mike, I think it might be a caching thing, as it seems (please confirm) other posts are showing up. Installed a new plugin, so let’s hope this fixes it. My sincere apology.

    • Emily  February 22, 2012

      Thanks. I’ve been checking for a new post for days now, but couldn’t see it on my iPad either. Having blog-withdrawals. This post definitely worth the wait. Wonderful job!

  30. Anu  February 20, 2012

    Hi Peter,

    I would first like to express my heartfelt appreciation for what you and Taubes are doing. It can be really frustrating to see everyone else in the grips of the low-fat, whole grains dogma. Since I first learned about the low-carb way of eating, 8(!) years ago, there have been many times when I’ve wanted to grab a megaphone and take to the rooftops! You are doing that now, and with great patience, for which I thank you.

    I read a lot of low carb blogs and forums, and while it is nice to see the focus shifting from low-carb substitutes to eating unprocessed, more “natural” foods, I sometimes feel that these blogs miss the forest for the trees i.e. focusing on 10th order effects rather than 1st order ones, to borrow your terminology. That why It’s so wonderful that you and Gary are putting the focus back where it belongs — on insulin and its effects on fat cells. Towards that end, I wonder, are you going to do a post to rehabilitate Dr. Atkins? I feel that he’s been unfairly vilified. I credit him, almost solely, for saving my life and preventing the onset of diabetes (I was prediabetic at age 18, and both sides of my immediate family have diabetes). It is so unfortunate, that at least in the US, Atkins is synonymous with fad diet, because the minute I try to explain the way I eat to someone who is interested, I get oh that’s Atkins isn’t it? and I instantly get shelved into the crazy-person-following-a-fad-diet category.

    Sincerely,
    Anu

    (reply)
    • Peter Attia  February 20, 2012

      Anu, thanks so much for the kind comments and praise. You’re going to love this week’s post…
      To your point, I do plan to write a post, in time, addressing Dr. Atkins. I agree with your suggestion about he probably does not get enough credit for his pioneering work (though, he certainly was not close to the first – just the most commercially successful).

    • Anu  February 20, 2012

      You’re very welcome! I look forward to the post, as always.

      I agree, Atkins was certainly not the first and I don’t mean to suggest that he was. I guess I’m motivated not only because I feel he did good work, but because as long as LCHF is associated with Atkins and Atkins = fad, it’s hard to make headway, especially with American friends. I’ve noticed that non-Americans are often quite receptive to these ideas, but Americans tend to be dismissive, probably due to watching friends and relatives attempt Atkins, often incorrectly. As you say, Atkins was quite a commercial success, and probably had no need for my (possibly excessive) sympathy.

      Regarding being too commercial though, I’ve often heard Taubes being derided as a mercenary hack, only out to make a quick buck from selling his books. This boggles the mind, as I can think of few more painful ways to make money than spending five years researching one non-fiction book, on the off-chance that it will become a runaway bestseller…

    • Peter Attia  February 20, 2012

      Anu, I did not mean to suggest that commercial success is a bad thing – not at all. It’s laughable to think of Gary being viewed in that light. Clearly these people don’t know Gary at all, let alone as well as I do. As you point out, there is probably no *lower* ROI than writing a book that requires so much research…

  31. Crystal  February 20, 2012

    Great post!
    I’ve got a special situation regarding fruit consumption: I’m 22 weeks pregnant. Before pregnancy I didn’t eat fruit and I was at about 10 percent carbs per day. I, like you, finally had success in my fitness and physique (after many unsuccessful years running half marathons on a low fat/calorie restricted diet)…not to mention that changing my diet to HFLC brought my fertility back…which leads into my current predicament: I feel like I’ve been bullied into eating a lot of fruit by the conventional wisdom. These ketosis fearmongers say that I’m going to hurt my baby if I don’t eat at least 70-100 carbs per day. What do you think, doc?

    (reply)
    • Peter Attia  February 20, 2012

      Crystal, unfortunately, I can’t provide personal medical advice through my blog. I can tell you that countless women carried and delivered countless babies while in nutritional ketosis (keto-adaptation) for thousands of years. Why we are different today, I don’t know. However, unlike my own eating habits which have ample evidence suggesting efficacy and safety, I am unaware of such data for pregnant women. So while I remain confident for many reasons that (even) a pregnant woman can consume next to no carbs, I don’t have data to point to. I do plan to address this in a full post at some point, but I know you want an answer now! Sorry I can’t provide more direct advice.

  32. Anu  February 20, 2012

    I have some more questions :). Thanks so much for your quick responses to these questions!

    You mentioned in one of your posts that your wife is one of the lucky ones, and doesn’t get fat despite carb consumption. I guess my question is, does this metabolic advantage also translate into some amount of immunity from insulin resistance related diseases? Or could years of eating lots of sugar and carbs do away with any advantage?

    I ask because my boyfriend is one of the lucky ones too, and remains effortlessly lean no matter what he eats — and I don’t mean just skinny fat, he is wiry and muscular. He has no history of diabetes in the family and only one member of his immediate family is overweight. His diet is not low in carbs but it is fairly high in fat — if we don’t eat meals together he defaults to a ham, tomato and cucumber salad dressed in sour cream for breakfast, sausages and some type of vegetable (could be starchy or non-starchy) for lunch and pasta with lots of butter and parmesan cheese for dinner. He doesn’t have a sweet tooth, though he will eat muffins and cakes from time to time, as well as fruit, dried fruit and fruit juice (about once a week). He dislikes chocolate, sweet cream/ice cream and nuts so that rules out a lot of desserts anyway. When we eat meals together, I tend to dictate the menu as I love to cook and he tends to lose a bit of weight. He sometimes supplements my meals with a slice of bread but often does not.

    My question is: is eating high fat, but not completely low carb hurting him? If it ain’t broke, why fix it, you know?

    (reply)
    • Peter Attia  February 20, 2012

      It’s tough to say. About 20% of people with metabolic syndrome are not obese (or overweight), so being lean does not guarantee health, that’s for sure, but being non-lean makes it much more likely to be unhealthy (i.e., have the diseases associated with metabolic syndrome).

  33. Elena  February 21, 2012

    Thank You for an excellent post. Let me preface my comment by saying I agree with 99% of what you are saying. In the interest of clarification though feel the need to point out that Michael Pollan (and others like him) are not making general health claims but rather trying to expose the lack of sustainability in our current “meat” crop farming standards. There is evidence to suggest that our standards have not only altered the quality of foods (meat specifically) as well as harming the environment (ie more antibiotics used) as to make reliance on meat unsustainable. Hence the preference for plant protein over meat protein. So while I continue to advocate a low sugar/low carb lifestyle I always preface it by saying that factory farmed meat isn’t necessarily a better choice.
    Thanks.

    (reply)
    • Barbara Hvilivitzky  February 24, 2012

      Oh, but factory farmed meat is not the only option. Do a little digging and you’ll find that just regular old ranching is the way to go. It’s better for the land than agriculture, is self-sustaining, and produces more food than mono-cropping in the long run.

      We’ve been told it’s a choice between mono-crops and factory farms – not so. (sorry I can’t do links – don’t know how – if there are others who can, please jump in!)

  34. Robert I  February 21, 2012

    Fructose may not be one of the culprits in the obesity epidemic that it’s been made out to be, Canadian researchers are reporting.

    Read more: http://www.ottawacitizen.com/health/Fructose+main+villain+behind+weight+gain/6182554/story.html#ixzz1n1NGmbgM

    summary and link below:

    Fructose consumption not linked to blood pressure, finds review

    Prolonged consumption of a fructose rich diet does not lead to increases in blood pressure, according to the findings of a new systematic review of the evidence.

    http://www.foodnavigator.com/Science-Nutrition/Fructose-consumption-not-linked-to-blood-pressure-finds-review

    (reply)
    • Peter Attia  February 21, 2012

      Robert, please tell you’ve critically read the actual article (Review article, to be specific) in the Annals of Internal Medicine and not just the bumper sticker newspaper reports.

    • Robert I  February 21, 2012

      Thanks for the quick response Peter,

      I’ve only seen the abstract. The researchers’ credentials, publication and funding source appear to check out. I lack the training to evaluate the methodology. That’s where you come in! :-)

      Robert I

    • Peter Attia  February 21, 2012

      No problem, Robert. Just trying to make a broader point. I’ll try to read the paper in detail in the coming few weeks. Super back-logged right now. This paper is a meta-analysis, though, which means it’s an analysis of other other papers, many of them pretty poor. As my brilliant adviser used to always say, “A hundred sows ears makes not a pearl necklace.” By the way, don’t sell yourself short. I bet you could read through this is and find the issues.

      By the way, here is the list of “disclosures” from this paper. Does this look legit?

      The researchers reported relationships with Coca-Cola, Abbott Laboratories, International Life Sciences Insititute North America, Archer Daniels Midland, Pulse Canada, BDSK Consulting, Glycemic Index Laboratories, McCain Foods, Temasek Polytechnic, Dairy Farmers of Canada, CreaNutrition AG, Almond Board of California, International Tree Nut Council, Barilla, Solae, Unilever, Saskatchewan Pulse Growers, Danone, Kellogg, Haine Celestial, Loblaws Supermarkets, Sanitarium Company, Orafti, Advanced Foods and Material Network, The Peanut Institute, Oldways Preservation Trust, Quaker Oats, Procter & Gamble, The Canola and Flax Councils of Canada, Soy Advisory Board of Dean Foods, The California Strawberry Commission, Alpro Soy Foundation, Herbalife International, Nutritional Fundamentals for Health, Pacific Health Laboratories, Metagenics/MetaProteomics, and Bayer.

    • Robert I  February 22, 2012

      You may have seen a different source than I Peter. Thanks for the insight. From what I gleaned the Canadian Institutes of Health Research (Canadian government)funded the study. University of Toronto was involved. The researchers have received unrestricted grants from the Coca-Cola Company to fund other research. HFCS was not part of this research. If it had been and if a soft drink manufacturer had funded or otherwise controlled the study, I would have discarded it.
      That said I sometimes find it hard to decide just how clean a researcher’s hands have to be before a study warrants recognition.

      Robert I

    • Peter Attia  February 22, 2012

      I have a whole stack of papers in my office “proving” that sugar is actually not bad for us. Unfortunately, every one of them is sponsored by the sugar industry, at least in part (or done by someone in the sugar industry). It’s definitely tough to know some times.

    • Jim Bowron  February 23, 2012

      From the ‘bumper sticker” newspaper reports; (i) says study in rats shows fructose leads to obesity, metabolic syndrome etc.’ but does not necessarily mean it applies to humans (ii) looked at 41 trials with 780 people, didn’t say how long trials lasted (iii) used isocaloric diets and hypercaloric diets and found fructose had no effect on weight compared to diets that provided the same amount of calories from non-fructose carbohydrate sources and (iv) when fructose was added to a ‘usual diet’ there was a consistent and strong weight increase but that fructose is not the issue, its the calories.
      In my opinion, not much useful in that meta study.

  35. Pierre Legrand  February 21, 2012

    Peter what do you make of the studies showing caffeine adversely acting on insulin sensitivity? At this point I am practicing very low carb along with fasting. I eat one meal a day at night. But I do drink caffeine and am wondering if that too is gonna have to hit the road.

    Seems like I spent all my youth gathering up bad habits that I am spending all of my middle age giving up.

    (reply)
    • Peter Attia  February 21, 2012

      Pierre, I’m just starting to dig into these a bit now, but haven’t read enough to have a proper opinion. I’ve added this topic to the “coming soon” page.

    • Matt Taylor  February 24, 2012

      Caffeine gives me hunger pangs similar to what sugar does. Seems to me something is going on there. I should look into it, but I do not like the idea of giving up my morning coffee…

  36. Beverly Slavik Rodriguez  February 21, 2012

    Peter, brand new to your blog but I find all of this fascinating. I’m going to try NOT to rant or sound preachy but I’m curious as a medical professional if you would like to see this style of eating become mainstream for the general population based on your assertion that the standard American diet is making us sick? I’ve been on many many “diets” over the years and have tried everything from low carb/high protein to vegetarianism. I’ve recently eliminated gluten from my nutrition plan because I believe I’ve developed an intolerance to it, possibly Celiac’s disease. So I’m with you on that. I’ve also taken to eating as many whole foods as I can since most processed foods are loaded with gluten and sugar. So, there again, I totally agree with you. I have this one nagging problem with the style of eating you’re offering here – agriculture sustains this country. I just cannot get past the problem that if we (nearly) eliminate all of the foods from plant sources available to us from our diets, that we would be unable to sustain ourselves for long. In order for Americans to switch over to a lifestyle like yours would have to mean sweeping changes to the way we farm and grow food. Population growth follows food availability and it would seem that the advent of “modern agriculture” is the reason we the nation we are today. Even if it is killing many of us, I’d like your thoughts on the average person changing over from the USDA recommended diet to this style of eating. Thanks!

    (reply)
    • Peter Attia  February 21, 2012

      Beverly, this is a VERY interesting comment and certainly one worthy of great discussion (So I hope others join in!). It actually poses an ethical question, rather than a scientific question. The US grows nearly 100 million acres of corn. What if we grew 100 million acres of tobacco, and doing so supported the livelihood of a million Americans. Should we keep doing it? I suspect that many of the farmers (or at least farmland) who (that) once grew tobacco now grows non-tobacco agriculture. But the broader question is, what is the most important feature we should consider? Economic prosperity? Health? Something else?

    • Beverly Slavik Rodriguez  February 22, 2012

      It is an ethical question and considering that it is agribusiness that dominates the marketplace, sets pricing, and has destroyed the family farm and I would also guess companies like Monsanto are the ones funding most of the research to support a cereal based standard American diet. My only hesitation in supporting it outright is, could anyone live on this diet, sustainably for years. If this were to become mainstream and corn, rice, and wheat production slowed or the medical community as a whole came out and said, this is the new diet we should all follow (unlikely as that may be), would the environment support it, could we afford it, and what is the long term prognosis for such a change in our diet?

    • Peter Attia  February 22, 2012

      You’re asking great questions, Beverly, and no doubt there would be a reallocation of resources and even broader infrastructure. But we would need to contrast this with the alternative: in 2030, as many as 50% of Americans will be diabetic or pre-diabetic according to the CDC. We already send $2.45 trillion (nearly 18% of GDP) on healthcare. On our current trajectory, this discussion could be moot, as we will be too collectively sick and bankrupt to worry about other issues of sustainability. My gut says let’s fix this problem, and in that context work to make it sustainable which, as you suggest, may “look” different than the current model. Love to hear other thoughts, too.

    • Helga  February 22, 2012

      It is unfortunate that farming animal products is so much more resource intensive than plant products. We started growing so much grain to feed the masses. I’m afraid the real elephant in the room for resource management vs. ideal diet, is world population. No one really likes to talk about what it would take to reduce the burden of so many hungry mouths. Perhaps eventually we will find a natural balance, but the earth in it’s current state is not really cut out to feed so many humans well.

    • Debbie  February 23, 2012

      Eating meat and fish has become a political issue given more weight on the anti-meat side by the general belief that meat is bad, fish a little less bad, and that vegetarianism is probably best. Change in thinking if it comes at all will be very slow! But, in some utopia, couldn’t we have humane raising of animals for slaughter, for instance, replacing all the corn? The animals rights movement is quite strong and has made an impact even on those who do happily eat meat – there’s a sense that somehow it’s morally wrong. This attitude really has to be challenged head on.

    • Guillaume Belanger  February 26, 2012

      Hi: If we are concerned with the use of resources and the impact on the planet, (rather than somehow generating work for people), then I am supremely confident that a mostly raw, meatless version of a high-fat, moderate protein, low-carb diet is more than sustainable. In fact, I think it is ultra-sustainable.

      It combines the consumption of animal products that do not require killing nor intensive farming: eggs, butter and cheese, with the plant-based, super-healthy, saturated fat from coconut oil, and the low-impact foods such as nuts, seeds, and easily grown leafy greens and other vegetables. Finding nearby sources from small farms for almost all of these, (coconuts only grow in the tropics), which is usually possible in most places in the world, makes this a super-low impact diet because there is hardly any industrial overhead: no chemical pollution; no energy expenditures for large-scale processing, either to plant, grow and harvest, or to transform the grown product into some derivative, (think of the hundred of things we make with corn, none of which are healthy nor necessary); no transportation issues, with all the implications that has; and on and on.

      So, for me the point is pretty obvious. Here is what I mean by a “mostly raw, meatless version of a high-fat, moderate protein, low-carb diet”: in general and more specifically, what I eat on a daily basis.

    • Peter Attia  February 26, 2012

      Yes, I didn’t make this point earlier, but it is quite easy to consume even a ketogenetic diet with minimal meat consumption, especially if you still consume dairy and fish.

    • Matt Taylor  February 22, 2012

      I guess you are worried that if the high-fat/carb-restricted diet is the right answer, then can we sustain it as a society once everybody is eating that way? My intuition tells me that the benefits to knowing and acting on the right overall diet will outweigh any problems that arise because of it. There is a huge monetary upside to this, not to mention the reduction in human suffering and the increased productivity of a healthy society. It also wouldn’t surprise me if the healthy way is more efficient at feeding a population than the unhealthy way from the standpoint of land use, resources, energy, etc. There is a whole lot of wasted energy stored in the US population right now in the form of adipose tissue. Fat is stored energy. That fat represents food that did not need to be grown, processed, packaged, and eaten. That represents wasted energy and resources that could be used in a more positive way in a more healthy society.

    • Barbara Hvilivitzky  February 24, 2012

      There is so much land not used for agriculture right now because it’s not suitable for mono-crops – that animals could graze on. It’s a myth that we could not raise enough animals to eat – that could feed every man woman and child in North America….and guess who’s perpetuating the myth? Big Business, Big Agriculture, PETA, Vegans, etc. and this mis-information is pushed by the very powerful media, aided and abetted by the population control people. With proper ranching and farming techniques ALL could be fed.

      Just a few generations ago there were millions of bison roaming the plains in North America – MILLIONS!!!!!! Not saying we could go back to that, but it surely seems that with our know-how, and a little THINKING we could go from eating corn to eating meat, no?

      Just because we’ve been told a lie for a long time doesn’t mean we can’t start to believe the truth.

  37. Al  February 21, 2012

    Peter: is it possible to be in ketosis AND have excess insulin production? According to my CVS-brand Ketone Care (TM) Ketone Test Strips, I’ve been in ketosis for about 3 weeks now, nearly four – I test my urine 6-7 times a day and I’m always in the range of small (15mg/dl) to moderate (40mg/dl) ketosis, yet I’ve been gaining weight and about an inch around my waist! I’ve gone from 208 pounds to nearly 220. I’m eating no processed foods, almost zero carbs a day, plenty of fats to go with the protein, am lifting weights at least twice a week and doing interval sprints twice a week too. To say I’m distraught would be an understatement as I was trying to reach 185 and a “normal” BMI for a 6″1 guy. Is it possible that I’m secreting insulin (and hence gaining waist flab) even though I’m not taking in any glucose and consistently maintaining ketosis? I’ve heard of insulin-producing tumors but am not sure what the symptoms would be. On the other hand I have frequently disrupted sleep with 2 small children and a high pressure job – could cortisol be to blame? A friend recommended trying a 24 hour fast but I’m too afraid to space out at work. Any thoughts?

    (reply)
    • Peter Attia  February 21, 2012

      Can’t really diagnose this way. Really tough to diagnose from a distance. Maybe too much protein? Maybe too much dairy? Maybe too much artificial sweetener?

    • Al  February 22, 2012

      I know, am at wit’s end.

      If anything I’ve been cutting back on protein since reading of experiences similar to yours but it does not seem to be reversing the gain (been about 2 weeks). To be clear, if the weight gain were all lean muscle mass and I was losing belly fat I would just chalk it up to the weight lifting and not worry about the increase. It’s the increase in belly fat that has me freaked.

      If too much protein were the culprit, would that not kick me out of ketosis completely? If I understand the process correctly, excess protein would be converted to glucose thereby releasing insulin but how could one (consistently) remain in ketosis in that case? (Which is why I ask if its possible to be producing ketones in urine and still be producing enough insulin to add fat?)

      The only dairy left in my diet is two spoons of heavy cream for coffee (50 out of 50 calories are saturated fat according to the Organic Valley nutritional label – some days I have two coffees), two spoons of sour cream with breakfast (50 out of 60 calories are saturated fat), and the odd small piece of cheese (maybe two bites a day?). The only other place I’m getting any carbs are a few spoons of green veggies (cooked in butter or coconut oil), olive oil slathered green salad, and a handful or so of salted dry roasted almonds. The rest of my diet is meat and fish. I’m not cracking 20 grams of carbs more than once a week, if that. By the accounts of most people I should be shedding at least a pound a week.

      Pre-ketosis I was drinking milk and kefir and eating a lot more cheese so it would seem odd that it would have this effect only after I reduced dairy intake substantially (and I don’t have a dairy intolerance). I don’t use sweeteners of any kind and only drink seltzer water, water, coffee or unsweetened tea.

      I’ve heard of people on atkins type diets stalling and doing things like fasting to break a stall but I’ve gone beyond stalling to actually gaining. The worst part is what do I go back to? Any amount of carbs is going to be an increase at this point and it feels like I’m destined to keep gaining weight no matter what I do at this point. Very frustrating.

    • Peter Attia  February 22, 2012

      Al, I’m sorry I don’t have an answer for you. I can imagine your frustration. I wish I had an answer, but it’s very hard to troubleshoot without really digging into the data. Please be patient. If you haven’t done so, ask your doctor to check all of your metabolic labs.

    • John K  February 26, 2012

      Check the ingredients of the “dry roasted” almonds, as they may have additional ingredients and you may be eating more than just salt and almonds.

      For a snack, I make my own buttered pecans in a skillet with raw pecans, butter and salt. There’s a high fat content there, and I know what I’m eating.

    • Matt Taylor  February 22, 2012

      If you are eating almost zero carbs per day (so I assume you mean <20g), I would expect your ketone strips to be dark purple, not just the moderate range (though everybody is different of course). Are you sure there are no carbs you are missing or that are hidden? Maybe up your fat intake and cut back on protein (to 100g or less). Also could try cutting back on alcohol or caffeine if applicable. I tried fasting for 1-2 days to kick the weight loss back into gear, but it did nothing for me. It is relatively easy for a low-carber to fast though, as we don't have that heroin-like sugar addiction gnawing at us. I doubt you will "space out" or anything. What worked for me when my weightloss stalled and started creaping back up was to add fat, cut protein, and give up a daily dose of bourbon or two, but YMMV…

    • Al  February 22, 2012

      Matt: that’s a good observation, it’s been bugging me that I never seem to get in the dark purple range, even after gobbling raw coconut oil. YMMV indeed.

      I guess the greatest source of anxiety is this: Have I, by going very low carb for a while now, somehow INCREASED my carb or protein sensitivity? Is that a hidden danger of these diets?

    • Michele  February 22, 2012

      Hello Al,
      I have tried to read through your post as carefully as possible but I did not see you mention how much water you are drinking. Have you considered this aspect? Also, I have to go back an read the posts but I thought that it is not necessarily a good thing that your ketone strips would be purple – meaning that if if there is such an over-supply spilling into your urine, it could be because your body is not making proper use of the ketones as fuel. I am rooting for you. Please don’t give up hope. What is Matt’s take on what I said about the ketone strips?

    • Matt Taylor  February 22, 2012

      That all does seem odd, Al. I am no means an expert, and only know from mine and a few other’s experience, but if I were eating your diet my ketone strips would show in the high range consistently. But those strips are not really the most accurate anyway, and I also know that it is possible to be in the small-medium range and not lose weight. Maybe it is time to talk to a doctor, preferably one who knows and advocates low-carb. You should not worry yourself though. Sounds like you already have other things on your plate. Keep doing the right things and you will be better off no matter what the weight, and things may turn back around or at least even out.

    • Matt Taylor  February 22, 2012

      Al, since you mentioned weight lifting, another thing to consider is that your ideal BMI weight may not be as low as 185lbs. If you have a large frame and are very muscular then maybe your goal weight is not realistic. Think about some NFL players who are 6′-1″ and ripped but weigh 200+. Anyway, if you are very carb sensitive like I am, as you approach your “ideal weight” it gets exponentially harder to lose weight. I am 6′-1″ also, and I have not been able to drop below 190 yet, and if I add carbs back in I can shoot up to 200+ quite quickly.

    • Scott  February 23, 2012

      Its worth noting that ketosis does not guarantee fat loss. If you are consuming more energy than your body uses, you will still generally gain weight. We fight calories in/calories out a lot in the low-carb world, but it is still ultimately true. So I’d consider looking to your total caloric intake, as it might be just too high.

    • Al  February 23, 2012

      I can understand how and why ketosis does not guarantee fat loss (since all the fat you’re burning could be diet-sourced), but doesn’t the presence of ketosis preclude fat GAIN? That’s what I don’t understand in this whole insulin hypothesis – if insulin is what triggers or causes de novo fat accumulation shouldn’t the absence of insulin imply no fat gain irrespective of caloric intake? And don’t ketones mean an absence of excess glucose and by extension insulin? How (biochemically?) is fat being accumulated then? Either some other hormones are involved in doing the same thing (cortisol?) or some amount of insulin is present despite being in ketosis? (Would that I could live on nothing but fat for a while to figure it out) Presumably this is caused either by excessive protein intake (which for someone of my size would have to be what, more than 300 grams a day or roughtly three pounds of meat?) or hypersensitivity to even the smallest amount of carbs. And if this is the case why would it matter what your total caloric intake is? Put another way, if i’m secreting insulin, it would create fat because that’s its job, right? Why would the insulin care (act differently?) if it’s whacking 500 calories out of an intake of 2000 rather than 5000? A fixed amount of insulin creates a fixed amount of fat – or does it create twice as much fat just because I ate twice as much fat? The insulin hypothesis does not say that insulin goes up or down in accordance with total calories in, right? only that it will increase in relation to glucose? But I’m not spiking glucose if I’m still in ketosis, right? Am I accumulating fat and mass from eating 20g of carbs and 150g of protein but simultanously staying in ketosis thanks to 250g of fat? (Rhetorical, nobody seems to know).

      To answer some earlier questions: I drink water when I’m thirsty, don’t force feed it. In my beginning low carb phase (last April) I found myself drinking more water than usual as my body adjusted but don’t feel as thirsty these days unless its post workout. I realize that 185 may not be possible for me though I must have been that weight at some point before I hit 257 at the height of my fat days. If I was 215 and ripped I wouldn’t care but I’ve gone from 203 last summer to 218, could never be mistaken for ripped, have never shed my sizable love handles and relaxing my gut muscles reveals a belly which would indicate that most of my visceral fat hasn’t gone anywhere, plus the ultimate fit or fat test: my upper thighs still touch.

      Weirdest observation to date: some of the lightest urine stips come after I wake up and have effectively fasted for 10 hours or more.

      Thanks for all the encouragement.

    • Matt Taylor  February 23, 2012

      My Ketone strips are lightest when I wake up also. My hypothesis is that you are burning very little energy while asleep, so the ketones are not necessary.

    • Matt Taylor  February 24, 2012

      Al, two more thoughts… First… you say that you have a high-stress job and your sleep is not the greatest. That cannot be helping your weight loss (or your general health). I have trouble with the same issues, and it is definitely counterproductive, but I cannot remember the biological reasons why. Maybe dig into that to see if it is a significant factor there. Second… and this is a long shot… Since your ketosis is lowest when you wake, are you eating late in the evening and/or eating your carbs and protein late? A friend claimed success with limiting carbs and protein after 4pm. I think the idea is that the body is more likely to store these as fat when you are inactive and asleep. Dunno myself, but just trying to help.

    • Scott  February 26, 2012

      While this is probably something that Peter would be better situated to answer, I think your understanding of Ketosis is a little off. I know personally that even in ketosis I can still gain weight very easily if I’m not careful. Ketosis is valuable because it sort of forces us to eat foods that will ensure our insulin levels stay low, (along with many other health benefits), but that doesn’t mean we stop secreting insulin, and it certainly doesn’t mean we stop storing fat. While I doubt it would be possible to become obese in ketosis, it is certainly possible to gain weight. The true advantage of ketosis (in my experience) is that it makes our bodies much more efficient at weight loss when in a calorie deficit. But you need to have that calorie deficit to see any effect. I’d say if nothing else try experimenting with a lower calorie intake.

      As for the ketone strips, I wouldn’t pay much attention to them. The urine strips are rather unreliable, and our body generally gets better at producing the appropriate amount the longer we are ketotic, which would reduce the amount of excess that we excrete through urine. Not to mention that you can reap the benefits of low carb without being in ketosis.

    • Al  February 26, 2012

      Scott: if that’s the case then I’m not sure that the benefits of ketosis outweigh the risks once you’re down to the short strokes. If I’m having to start reducing protein as well as fat then I’m effectively counting calories again and battling to stay in ketosis is just an added stress. One theory I’m starting to develop is that the real impact it has is what type of activity you prefer or are able to do on a daily basis. Being glycogen deprived and in ketosis seems to favor low intensity continuous activity and being out of it favors shorter duration high intensity drain the liver stuff. It might just come down to figuring out what kind of activities you have time/inclination for and how much fat you need to clear. If high intensity intervals clears more fat for you then you’re probably not disadvantaged by not being ketotic (assuming calorie consumption is reasonable in either case) whereas if daily hour long hikes is your only feasible activity then you’re only going to have a shot a clearing any fat if you’re also in ketosis.

    • Scott  February 28, 2012

      Al: As for the “risks” associated with ketosis, I think its a non-issue. For exercise, I honestly don’t think exercise is necessary for pure weight loss. Having said that, I personally am ketotic and perform relatively high intensity weight lifting workouts, it just takes some time to adjust.
      Admittedly, if ketosis is causing you undo stress, it may not be worth it, but that’s your call. Ketosis maximizes efficiency at utilizing body fat stores, so a calorie deficit will result in the most fat loss. But you will ultimately need a calorie deficit.
      As a side note, I seem to recall a study showing that frequent exercise actually induced mild leptin resistance; aka exercise makes you hungrier.

    • Al  February 28, 2012

      Scott: While everyone is entitled to an opinion on the matter, I’m not sure how one can conclude definitively that ketosis risks are a non-issue. For one, the harder it is to get into and maintain ketosis, the more reductionist and less diverse a diet becomes which necessitates reliance on supplements. Second, if any one of us walks into our GP’s office and says “I’m about to embark on a long-term period where 80% of my diet is fat, is this safe?” I’m willing to bet the answer is “no” most of the time. Not many lay people are willing to take the risk that their doctor is wrong when the downside could be coronary catastrophe a few years down the line. There seems to be a lack of definitive research to call the game one way or another. If ketosis “maximizes” fat loss, why are some fat deposits more susceptible while others are more stubborn? How do some people seem to lose weight without being in ketosis? If a calorie deficit is ultimately needed, why do many people (myself included) lose the first 25 pounds while indulging in total food porn with no regard to input quantity as long as we’re not chugging carbs? Why does the ease of fat loss then change for some poeple but not for others. Either we’re “doing it wrong” (which is what the standard food pyramid and “move more” crowd that Taubes takes issue with has said all along) or there are some significant gaps in this insulin hypothesis.

    • Peter Attia  February 28, 2012

      Al, I think it’s important to separate perception (of risk) from risk. You both make good points, but 90% of GP’s saying nutritional ketosis is “risky” does not mean it is. It only means 90% of GP’s are unfamiliar with it (to put it kindly). My GP thought I was *crazy* 2 years ago. Today’s he’s the biggest supporter, so never forget the educational component of this.

      Let me be clear, I am NOT suggesting everyone should be ketotic. Carb restriction is a spectrum, and ketosis is at one side. It all comes down to what I call “where you start from” and “where you’re going” to determine the optimal eating strategy. Losing weight is just one part of this, and people can lose weight on any diet that creates a deficit between energy consumed and expended. The magic is doing it sustainably. If being in ketosis is not sustainable for someone, I would never encourage them to do it, BUT I would agree strongly that it takes about 12 weeks to give it a proper shot before drawing that conclusion. 5 weeks into my 12 week experiment I would have told you I would NEVER stay in ketosis for 1 day beyond my 12 weeks…but here I am today.

      This week’s post should shed some more light on this. Stay tuned guys…

  38. Paul  February 21, 2012

    Argggghhh! The New York Times is at it again:

    “But anyone exercising for two hours or more does need to get carbohydrates, the muscles’ fuel, according to the position statement. That means eating before, and perhaps during, the workout.

    Those who try to skimp can end up with a poorer performance, said Dan Benardot, a sports nutrition researcher at Georgia State University. A long workout, like a run that lasts more than two hours, is “an enormous drain on blood sugar,” he said.

    If the body runs out of glucose for fuel, it will start breaking down muscle, which is counterproductive. Dr. Benardot’s research indicates that athletes do best when they never let themselves have more than a 400-calorie deficit during the day. That is, if you expend 1,500 calories on a two-hour run, you offset it with at least 1,100 calories in food that day.”

    http://well.blogs.nytimes.com/2012/02/20/workouts-may-not-be-the-best-time-for-a-snack/?hpw

    (reply)
    • Peter Attia  February 21, 2012

      Just awful…a very sad state of affairs, indeed.

  39. Kypros  February 23, 2012

    Hi Peter,

    Dr Wahls talkes about reversing MS and minding your Mitochondria. Interesting she puts more emphasis on consuming large amounts of certain vegetable groups rather than on good fats. Are you familiar with her research?

    http://www.youtube.com/watch?v=KLjgBLwH3Wc&feature=youtu.be

    (reply)
    • Peter Attia  February 23, 2012

      Yes, I am very familiar with her work and her very moving and compelling story. Did you read my post this week: http://eatingacademy.com/nutrition/why-weight-watchers-is-actually-a-low-carb-diet
      The phenomenon I describe in this post is exactly what Dr. Wahls is confusing. Is it really the leafy greens? Maybe. But how do we know it’s not all the stuff she is removing from the diet?

    • Kypros  February 23, 2012

      HI Peter, yes I have read your most recent post! Excellent as always!I think that you are right..it is inconsistent to say that you follow a gather hunterer’s diet (especially the Innuits’) and then go on to recommend two plates of specific vegetables everyday (year round. Btw what do you think about creatine and its posible effect on preventing degenerative disorders of the central nervous system?

    • Peter Attia  February 23, 2012

      I’m not familiar with the data on that point.

  40. Matt  February 24, 2012

    Hmm… interesting! I can’t say I’ve read Dr. Lustig’s research but I have watched the “Sugar: The Bitter Truth” video. I don’t remember the exact details why but I remember him mentioning that the fiber found in fresh fruits has a nullifying (maybe not completely) effect on the toxic effects of the fructose. This, and the relative much smaller quantities of fructose found in fruits compared to sugar products, is why it’s okay to eat fruit, but not okay to eat refined sugar and HFCS. Do you have thoughts on that?

    (reply)
    • Peter Attia  February 24, 2012

      The hypothesis is that eating fruit is less harmful than drinking fruit juice because of the dose response. The fiber in the actual fruit delays the amount and time-course of the toxin reaching your liver.

  41. Mike  February 27, 2012

    Hi Peter,

    Just curious to know what your thoughts are on dark leafy greens as a whole? To me they seem to be in a whole different nutritional category than say a potato. Every morning I usually have a smoothie with half a pound frozen spinach, handful of almonds, a cup of blueberries and water.

    Also I just found this blog today and I’m really enjoying it!! Thanks for putting this kind of information out there, especially with all the hype and pseudoscience regarding diet and nutrition.

    (reply)
    • Peter Attia  February 27, 2012

      Mike, absolutely! Lettuce is pretty benign, BUT this does not meet you need to eat it. I eat it – not because I think it’s necessary or even “good for me.” I eat it because it’s a great way to get more fat (via high fat salad dressings), which I believe IS good for me.

  42. Lucas Reis  February 28, 2012

    Hi Peter,

    Awesome blog you have here!

    As a fat person, I tried all kinds of dieting and exercising through my entire life. By reading Taubes’ books and your blog, the “low carb” hypothesis is the one that appears to be the most acceptable to me, with the most sound theory.

    But, another hypothesis that I find very acceptable is the “it’s impossible to get thinner”, because I can’t get thinner after months of low-carb eating, nor do I know anyone that has lost, let’s say, more than 20kg during or after adulthood and managed to stay thinner for more than one year.

    What do you think of this hypothesis? That some people simply can’t get thinner? Or that _most_ people simply can’t get thinner after adulthood?

    Keep up the good work! (and sorry for my english…)

    (reply)
    • Peter Attia  February 28, 2012

      Lucas, you’re asking a very tough question. I do believe there are so me people for whom getting thinner is very difficult, despite all measures. I’m not sure why, though. Also, it’s not clear if this results from dietary habits at an earlier time. For example, I have seen folks that have cycled weight up and down repeatedly struggle to lose weight later in life. But why? Lots of theories out there, but none proven in my mind.

      By here’s the more important point: what if you are one of the folks for whom weight loss is going to be tough. That does NOT mean you can’t improve other aspects of your health (reduce risk of disease, improve energy levels, be mentally sharper).

    • Lucas Reis  February 29, 2012

      Oh, of course! ;) I think my health has already improved a lot by not eating so much carbohydrate.

      But I really think that, in terms of getting thinner, we know very little. The science is hard to do, the data is hard to get and to interpret, and everybody (at least thin people :) has the certainty that they already know how to do it.

      Just my 2 cents…

  43. Russell Holtslander  February 28, 2012

    I have been eating more vegetables, but not eating corn, potatoes, beets, carrots etc. I aim for foods in the low G.I. range, like green beans. I actually eat more vegetables than before. I have stopped eating fruit, even berries.. I have been worried that this is unhealthy, since eating fruit is always said to be healthy. Now I am a little less worried. I tend to think of fruit as dessert. I might have some when I hit goal weight, but it seems counterproductive to eat dessert when I am trying to lose.Everyone keeps talking about cravings for bread, pasta, and fruit, but I don’t have those. It makes me feel weird. Maybe its because I stay over 60% fat, but I have no desire to eat these foods.

    (reply)
  44. Harsha  March 4, 2012

    What are your opinions on a vegetarian diet that cuts out potatoes, corn, and other “starchy” vegetables?

    I was raised as a vegetarian, and I honestly can’t eat meat, it looks off-putting and even it would help me out in terms of health, I don’t think I could stomach it. I do eat eggs on the other hand.

    (reply)
    • Peter Attia  March 5, 2012

      Harsha, no problem at all. It’s quite easy to eat like I do without meat, assuming you’re ok with eggs and dairy. You can get more than enough protein from these things (plus nuts and a few other foods). There is no need to eat meat if you are morally opposed to it.

  45. Fay  March 13, 2012

    Low carbing = consuming less processed food and I have noticed that although I haven’t cooked with sugar or salt in years (except for salt on eggs) my tastebuds are really really sensitive to both salt and sugar now. I do feel that I should eat more fruit and veg but a bowl of blueberries in double(heavy)cream makes me dizzy as do parsnips and potatoes literally make me sick now.

    (reply)
  46. Stoev  March 14, 2012

    Hi Peter,
    I have been into bodybuilding style of training for about 5 years. I have some experience with high carbohydrate diet and it actually worked for me to gain over 15kg of muscle while staying relatively lean (below 10%bf).
    However, since I started the high-saturated fat medium protein low-carb approach, I achieved a more impressive degree of muscle definition, far better digestion… actually my overall health and condition improved dramatically.
    I wonder if this way of eating is optimal for further muscle gain (granted i get enough calories) despite the anaerobic type of the bodybuilding and gymnastics training. Would i benefit if add some starch peri-workout while on high-fat diet. I don’t care if i lose some definition, as i know how to cut effectively. I am more conserned about losing the health benefits of low carb eating.

    So would you recommend using insulin spikes to induce some additional anabolic effect, or you think that the Atkins approach provides an environment anabolic enough to stimulate further muscle growth?

    Thank you in advance,
    L. Stoev, 20

    P.S. I am sorry if my questions are not clear enough, English is not mother language : )

    (reply)
    • Peter Attia  March 14, 2012

      Stoev, no need to apologize for your English, I understand exactly what you’re asking. It’s a good question, but I’m sure I know the answer for sure, as it probably varies a lot by person, timing, etc. I would suggest doing an experiment on yourself to figure out if the added carbs and resulting insulin increase muscle hypertrophy? I think everything comes at a cost. To be as lean as possible probably makes all anabolic processes more difficult.

    • Stoev  March 15, 2012

      So, ingestion of protein and raising the level of blood amino acids provokes minor insulin response. Amino acid transport to muscle is somehow insulin-dependent process, while the biosynthesis of muscle protein is more dependent of testosterone and STH levels.
      Pro bodybuilders often apply exogenous insulin with the idea to rush more AA into cells. I don’t know if they actually achieve better muscle anabolism that way, but that’s their goal for sure.

      So my question is, to what extent is AA transport to muscle cells dependent on insulin? Does more insulin always means more active AA transport or there is sth like a treshold? And most importantly – are the low insulin levels still optimal for AA utilization?

    • Peter Attia  March 15, 2012

      It’s a trade-off, and it varies by person. More insulin means more anabolic metabolism (fat storage, glycogen formation, and AA synthesis). Two of these three are good, one is not. Everyone has a slightly different “dose response” also, so I can’t really give a definitive answer. One CAN still utilize and synthesize AA in a low insulin environment, however. It just may not be as efficient.

  47. charles grashow  April 11, 2012

    Is sugar really toxic? Rebuttals to Robert Lustig

    http://paleodietnews.com/5202/paleo-diet-is-water-toxic/

    http://www.huffingtonpost.com/david-katz-md/sugar-health-evil-toxic_b_850032.html

    Your thoughts

    (reply)
    • Peter Attia  April 11, 2012

      Yes, sugar is toxic, assuming the folks who wrote these understand the meaning of the word “toxic.” I’m not going to comment on Katz, because he fails to actually address the actual issue (i.e., the science behind the toxicity of sugar) and reverts to the standard line of “just eat more plants and sugar in moderation because a calorie is a calorie is calorie…unless it’s meat or saturated fat,” but I’m a bit confused by the paleo blog, as he basically acknowledges what Lustig and others say (i.e., dose response). What are your thought?

  48. charles grashow  April 11, 2012

    I guess you could say I’m a moderately low carb diet person – I have a can of whole fat coconut milk as part of my fat bomb breakfast smoothie and add a banana and some frozen berries as well as a scoop of goat milk protein powder (a blend of whey and casein) and I have 2 or 3 cups of bone broth vegetable soup throughout the day as well – the rest of my diet is a pound of either raw grass fed ground beef, lamb or goat with lacto fermented sauerkraut and mustard and 4 pastured chicken or duck eggs fried in coconut oil with some more kraut and mustard and EOD a can of sardines.

    I’m also on doctor supervised testosterone replacement therapy

    My most recent blood work – blood was drawn on 3/16/12 on day 14 right before I reveived my testosterone injection and was sentg to Shiel Medical Lab

    T4 – 10.2 Ref range 4.5-10.9 ug/dL
    T3 Uptake – 32.4 Ref range 22.5-37.0%
    TSH – 3rd Generation – 2.24 Ref range .40-4.50 uIU/ml
    T3,Total – 79 Ref range 60-181 ng/dl
    T4,Free – 1.23 Ref range .80-1.80 ng/dl

    Enhanced Estradiol – 34 Ref range less than 52.0 pg/mL
    Estrogens, Total, Serum – 127 Ref range less than 200 pg/mL

    PSA – 0.38 Ref range less than 4.00 ng/dl

    GlycoHgb (A1C) – 5.2 Ref range 5.0-6.0% mg/dL
    Estimated Average Glucose – 102.5 mg/dL
    Fasting Glucose – 79 Ref range 65-99 mg/dL

    Lipids (VAP Test)

    Total Cholesterol – 324
    HDL Cholesterol – 84
    Cholesterol/HDL Ratio – 3.9
    LDL Cholesterol (Calculated) – 230

    Iranian LDL Cholesterol Calculation – 186

    Triglycerides – 54
    VLDL Chlosterol (Calculated) – 11

    Triglycerides/HDL ratio – .64

    Pattern size – A – large and bouyant

    Sub Class infomation
    HDL-2 (Large, Bouyant; most protective) – 31 Ref range >10 mg/dL
    HDL-3 (Small, dense; least protective) – 54 Ref range >30 mg/dL
    VLDL-3 (Small Remnant) – 10 Ref range <10 mg/dL

    DHEA – Serum RIA – 8.3 Ref range 1.80-12.50 ng/dL
    Testosterone, Total – 660 Ref range 300-890 ng/dL
    Testosterone, Free – 137 Ref range 47-244 pg/mL
    Testosterone %Free – 2.1 Ref range 1.6-2.9%
    SHBG – 30 Ref range 11-80 nmol/L

    (reply)
    • Peter Attia  April 11, 2012

      You should still check NMR. VAP is of very little, if any, value.

  49. Alan  April 19, 2012

    Heard your interview with Ben greenfield and have not stopped poking around your site since. Really great stuff!

    2 questions. First, it sounds like you are not against non starchy vegetables like broccoli and asparagus, correct?

    Second, from reading your work it sounds like my issues have been subbing additional protein for the reduced carbs. I eat eggs fried in coconut oil and a bison hash for breakfast. Big salad with chicken, lots of oil/vinegar, blue/feta cheese, walnuts/pecans, asparagus/broccoli, bacon for lunch and then chicken/vegetable for dinner. I eat almonds as snacks. Sometimes protein shake with chocolate whey, oatmeal, kefir and a few raspberries. How can i get more fat and less protein in my diet? Do i need to change anything radically? I don’t react well to dairy (Hives and hayfever symptoms) so that is not a great answer for me.

    (reply)
    • Peter Attia  April 19, 2012

      Correct. The protein-vs-fat-substitution issue is only important if you’re in (or aspiring to be in) ketosis, because of the gluconeogenic nature of protein.

  50. David  April 23, 2012

    On your point about what is natural: sure there is an evolutionary selection and genetic modification, but does that make processed food natural?
    A can of corn vs corn on a farm are two different things and have undergone different processes. And nutritionally they differ. Can food be isolated into its macronutrient components?

    I notice you eat a lot of processed and cured meat (which is carcinogenic) and also use MCT oil and eat a few selected foods – prob limited by the fat: protein or carbs.

    Is limiting your diet to a few food choices and including processed and cured meats bad for your health in the long run?

    (reply)
    • Peter Attia  April 23, 2012

      I think corn in a can vs. corn on cob, notwithstanding if they add sugar to the can (which they often do), is a 2nd order term. The point is this, how “healthy” is corn? Does it bear any resemblance to teosinte (that which we evolved to eat)?
      Not sure, but it’s not actually clear the salami I eat is carcinogenic. Data suggesting this often suffer from methodological flaws of observation.

  51. Anthony  May 3, 2012

    I have certainly benefited from increasing healthy fats and reducing my high GI carbs. When looking at your diet I look at Salami and Cheeses as being just as processed as your corn example if not worse. I have tried to live via a “real food” lifestyle. I would love to see you put together a “real food” – found in nature diet. thx!

    (reply)
  52. Bryn  May 10, 2012

    Dr Attia,
    I saw that this was on the list of “coming soon topics,” and I apologize for jumping the gun, but I’m wondering if you can recommend any key studies or other sources addressing the vitamins and minerals issue. I’m fighting my own “war” with my fiance who is very concerned about my health given my new dietary changes, and I need some solid scientific evidence to win him over. I do have access to most major medical journals.
    Thanks in advance!

    (reply)
    • Peter Attia  May 10, 2012

      Suggest she read Good Calories, Bad Calories.

  53. Cindy  June 30, 2012

    Hi Peter,

    Thanks for your site…and sharing your life…..its really very much appreciated, particularly with your strong clinical background as a physician. I’m a Registered Dietitian/nutritionist, have a private practice and have been seeing clients for over 20 years. I realize RDs can invoke fear in more progressive nutrition minded people, though i think there are more and more of us who think out of the box, while also trying to maintain a strong science based approach to health. And those of us with a master degree usually have a strong background in metabolism. And Jeff Volk is an RD so we can’t be all bad :). Although I don’t know him, I did interview Jeff back in the 90;s (he and Stephen Phinney made up the bulk of my references for a protein chapter I wrote for Sports and Cardiovascular nutritionist. Based on their research I still figure protein needs for my patients based on their ideal weight and usually 1-1.5 g/kg body weight. I cringe as I read online the misrepresentation of low car diets as high protein…..really metabolically misses the boat!

    Anyway, I’m onboard with most of the low carb, mod protein, high fat philosophy and its various branches including the Paleo diet. I see a lot of celiac and non-celiac gluten sensitive people in my practice. For some time now, I’ve sort of intuitively been insulin cautious and teach carbohydrate restriction on a continuum. But a couple of questions I have:

    1. One of my concerns/questions with a 50 gram carb diet is the reduction of phytochemicals. Maybe with the reduced inflammation and reduced free radicals produced with less carbs, fewer phytochemicals are needed….but the whole field of phytonutrients is compelling with regard to preventing cancer. I understand obesity, inflammation etc. and its connection to cancer, but I wonder the risks having to limit so many phytonutrients to keep to 50 grams. I realize it does come down to prioritizing your carbs….berries and broccoli vs. lactose in milk. What are your thoughts on this?

    2. Another question is potentially the effect, if any, on the pancreas because of the high fat…..this is rarely talked about. I realize the reduction of insulin helps the pancreas in other ways, potentially preserving beta cells, and we’re talking different systems in the pancreas. But just curious, have you heard of any increase in pancreatitis etc. Pancreatitis may be the effect of other factors in a poor diet. but just curious if gal bladder or pancreas issues ever come up, considering they are the organs that help break down fat. I suppose depending on total calories, the fat load may not be an issue but with higher calorie intakes, such as yourself, was the high fat ever an issue? Ever the need for digestive enzymes?

    Again, many thanks for the effort and time you put into your blog!

    Cindy Carroll

    (reply)
    • Peter Attia  July 3, 2012

      Cindy, thanks for your comments. Fortunately, there are a lot of good RDs out there, too, as you point out. The fully elucidate the independent value of phytochemicals is very difficult, as there is often a confounding set of variables and, as you know, the reliance on observation is strong. That said, I think you’re getting at the right point. How necessary are their potentially protective benefits in the absence of significant inflammation, ROS, etc.?

      As far as the pancreas goes, it’s an amazing organ. It’s both an exocrine *end* endocrine organ in one! Most people focus on the endocrine part (e.g., the role of insulin, glucagon), but by mass, the cells that carry out the endocrine function are only 5-10% of the pancreas, so much more pancreatic mass is dedicated to the exocrine side, which you allude to. I see the point you are making, thought I’m not aware of long-term data suggesting it’s a problem that can’t be adapted to. It’s likely that someone immediately status post a cholecystectomy may need to ease back into full fat consumption, though.

  54. Cort  July 22, 2012

    If it is of any interest, here is my recent experience with carbs and with fruit.

    On 1 June, having just turned 68 (5 ft. 10, 213 lbs) and having read Taubes and you and been convinced by the argument, I embarked on yet another low carb diet. A year ago I failed to loose weight by not only eliminating sugar (I gave that up 4 years ago) but most carbs (stayed below 20 most days for a couple of months), but I decided to give it one more shot. Perhaps, I thought, there comes a time in life that, short of starvation on a desert island or being bricked up in a basement one can no longer loose fat, period. But maybe this time….

    This time my rules were: very low carbs, 1500 calories/day (because a year ago I averaged perhaps 2300 and lost nothing; relying on my appetite to regulate my intake is, for me, a flawed strategy), and no dairy (last year I ate cheese, cream, greek yoghurt and have since read enough to raise the question of dairy in my mind, mostly from the paleo community) and no artificial sweetner, which seemed to have loomed too large in my thoughts and about which someone on this blog had interesting things to say.

    I hoped to loose four or five lbs/mo, which is about the best I have ever done in a lifetime of yo-yo dieting since the age of 14. I would eat green veg to my heart’s content, moderate amounts of meat and poultry and fish (4-6 oz per serving), olive oil, lard, coconut oil, an ounce or two of nuts, and a small amount of fruit–a few berries, the odd apricot. I hurt my shoulder badly at that time, so no gym, nothing but walking perhaps 30-45 minutes/day in various batches. I kept rigorous records.

    Results were astonishing.

    I lost 18 lbs in 6 weeks. Absolutely nothing had prepared me for that sort of result. Nor was I hungry (3 meals/day, life in between) or weak or lethargic or cranky. I know I know. I sound like one of “those” weight loss commercials, which had NEVER been true for me in a long life of trying. I figured folks were either genetically very different, or lying.

    This morning was interesting. For the first week since the outset, no loss of weight, no loss of inches.
    Looking at the last week, I exercised the same amount, ate slightly more calories than the week before (when I had lost another 4 lbs)–1550 instead of the previous week’s 1400–but the only other difference was an average of 3 serving of fruit per day (a serving being 1/2 cup of blueberries, 1/2 cup of strawberries, or 1 medium apricot) up from less than 1 per day the previous week. So it would appear that the fructose in fresh fruit is not without problems–at least not for me. Given how few calories and carbs are involved, I find it surprising. Once again, it seems to be a question of hormones.

    Like you, Dr. Attia, I am an experiment in progress. But I cannot tell you how grateful I am that you and Gary Taubes and Rob Wolf and the others are out there. I would never have stumbled on this on my own, and of course society tells me I am crazy. So I just send them to you and to Taubes and to Lustig and I continue to loose weight. At my age this is a matter of life and death. I owe you.

    (reply)
  55. Tom  August 17, 2012

    One question: in books by folks such as Dr. Fuhrman, Esseltine and so on, they recommend a mostly plant-based diet, based on the notion that plants contain huge amounts of valuable micronutrients – phytochemicals and such – many of which have positive benefits for humans. According to these experts, we are discovering every day more and more about these micronutrients in vegetables and their health benefits. Dr. Fuhrman posits a high nutrient-dense diet consisting heavily of plant foods and small amounts of meat, claiming it’s much better for you. In truth, I’ve noticed that a food such as kale is very high in nutrients. How do you reconcile such “plant-based” experts with the low-carb recommendations?

    (reply)
    • Peter Attia  August 19, 2012

      Tom, it’s really a question of scientific evidence. Where is the clinical data — not mechanistic or “intuitive” explanations — that phytochemicals are necessary for health in the doses suggested by some? I’m not saying a eating vegetables is bad, but I have not see real experimental data proving it’s necessary. Many of the proponents of this (Esseltine, Campbell) rely on observational epidemiology to make their case, but we can’t confuse this type of work for experimental science. I have to recommend you devote some real time to this, and there is no better place to start than Denise Minger’s work on this topic, which you can read here: http://rawfoodsos.com/2010/07/07/the-china-study-fact-or-fallac/ and here: http://rawfoodsos.com/2011/09/22/forks-over-knives-is-the-science-legit-a-review-and-critique/

      I know what you’re thinking…this guy wants me to read for the next 4 hours? Yes, I do. If you’re serious about learning this stuff, you’ll need to be serious about understanding the lack or presence of the scientific method used in espousing such recommendations. Only when you do this can you make an informed decision for yourself.

    • Justin  July 2, 2013

      Peter,
      I’d find it very helpful to have an FAQ that gives a clearer explanation of how you choose the vegetables and fruit that you eat.

      I can see: the pictures of raspberries, avocado, and green salad, and references to these in the example meals; references from other people in comments to starch free items like broccoli; examples you list of fruit and fruit juice that you don’t recommend; negative references to peas; etc. However, what is the criteria and how could we check it?

      Thanks for the site, and for the balanced way that you and the team are approaching this. It’s all new to me, but I’m impressed and grateful!

      Justin

    • Peter Attia  July 2, 2013

      Justin, I can’t really do this. It’s very context and individual specific. There aren’t “rules” like this.

  56. Ilanit  August 24, 2012

    Hi Peter,
    One of the reasons I eat lots of fruits and veggies is for the fiber. When I low carb I get constipated. Aren’t fruits and vegetables important in a diet for their fiber content? Also what is your position on legumes here?

    (reply)
    • Peter Attia  August 24, 2012

      Great question, and worth of it’s own post. It’s on the “Coming soon” list…How soon is another story, of course.

  57. charles grashow  August 28, 2012

    @Peter

    If you believe that we should eat a diet like our paleo ancestors – correct me if this statement is untrue – then why doe you consume so much dairy?

    How far back on the evolutionary time scale should we go to determine what we should or should not eat? 10,000 – 100,000 – 500,000?

    After all – dairy is not paleo. Lactose tolerance only developed within the past 7500 years or so.

    http://eatingacademy.com/nutrition/what-i-actually-eat

    Breakfast: “Fat shake” (In a blender: 8 oz heavy whipping cream, 8 oz sugar-free almond milk; 25 gm sugar-free hydrolyzed whey protein, 2-3 frozen strawberries)

    Lunch: About 4 or 5 oz of assorted cheese (Gouda, Swiss, Manchego), 2 or 3 oz olives, about 4 oz of particularly fat salami and pepperoni

    Breakfast: Scrambled eggs (6 yolks, 3 whites**, with added heavy fat cream) cooked in coconut oil, 3 or 4 sausage patties (be sure to look for brands not cured in sugar).

    Coffee with homemade whip cream (heavy fat cream hand whipped)

    Lunch: About 4 oz of especially fat salami and pepperoni, about 2 oz Parmesan cheese

    Dinner: Ground beef sautéed with heavy cream, onions, broccoli, and melted cheese

    2 large cups of decaf coffee with homemade whip cream (heavy cream whipped with a touch of xylitol)

    (reply)
    • Peter Attia  August 28, 2012

      I used think I was profoundly lactose intolerant and avoided dairy like the plague. Interestingly, once I removed wheat and most fruit from my diet (I only eat modest amounts of berries), voila, I’m not lactose intolerant. In reality, I doubt I ever was.

  58. Brad Elabdi  March 25, 2013

    Peter,
    Since we’re borrowing on Lustig in this blog post we should also mention he absolves the fructose contained in fruit with his quote, “When God made the poison he packaged it with the antidote”. This is a reference to the fiber contained in fruits & veges which offset the ill effects of fructose.

    Fiber aside I refuse to believe the fructose content in something like a carrot or handful of blueberries carries the same toxic punch as the same dose of granulated sugar or HFCS…I’m just not buying it.

    (reply)
    • Peter Attia  March 25, 2013

      I know Rob personally. I can assure you that he does not view peas, carrots, and blueberries in the same category sucrose or HFCS, even molecule for molecule of fructose. That’s his point.

  59. Nathan  March 31, 2013

    Am I wrong to be annoyed when Lustig keeps trotting out easily misunderstood slogans such as “eat real food” and appealing to nature fetishism or beliefs in a benevolent god (e.g., “God would never give us anything bad”)? Obviously he’s not telling his patients to drink lots of “natural” fruit juice or to gorge on God’s gift of honey, and he often provides examples wherein fruit consumption causes adiposity.

    So I’m really curious about why he takes this “eat real food” tack. Is God and nature his way of selling his message to Americans? Is exchanging Twinkies for watermelon some kind of compromise position?

    BTW, I’m really not trying to run Lustig down. Most of what he does is awesome. I just think your message (and that of Taubes) is both clearer and cleaner, and I don’t understand why Lustig can’t do the same.

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  60. Diana  June 30, 2013

    Peter,

    This post is an example of what is driving people crazy. You seem to be a sincere and well-meaning man, but your writing could stand to be cleaned up.

    For example: “Most people assume the fruits and vegetables we eat are “natural,” but in reality fruits and vegetables of today bear little, if any, resemblance to their original form” is a meaningless sentence. There is no such thing as an “original form” of an apple. I get the point you are trying to make: that since the AR, we’ve been developing strains of fruits and vegetables that are higher in sugar content than in the past, but the sentence is meaningless.

    Second, and this is the more overarching point, the beleaguered public listens to people like you and turns off because you are not making clear that eating fruits and vegetables isn’t the same thing as eating fat-carb bombs full of refined carbs and sugar. An apple is NOT the same thing as apple pie.

    Does your wife eat lots of desserts, refined carbs, etc? or does she eat “sugar” in the form of fruits and vegetables?

    Did you see this?

    http://well.blogs.nytimes.com/2013/06/27/how-carbs-can-trigger-food-cravings/?_r=0

    Do you really think that eating apples has the same metabolic effect, and the same effect on the gut flora, as eating apple pie?

    (reply)
    • Peter Attia  June 30, 2013

      I think you’re missing the point, Diana. At no point have I suggested an apple = apple pie. You may be confusing something else or taking commentary elsewhere out of context. When I talk about not consuming fruit in an unlimited manner, it’s in the context of nutritional ketosis. If one wants to be in NK, one can’t have too many apples. As to your question about the NY Times article, yes, I’ve seen it, though reading the NYT for ‘science’ is pretty limited. You’ll get more out of reading the actual paper by David, who I know very well and have been discussing this point for about 12 months.

    • Diana  July 1, 2013

      “As to your question about the NY Times article, yes, I’ve seen it, though reading the NYT for ‘science’ is pretty limited. You’ll get more out of reading the actual paper by David, who I know very well and have been discussing this point for about 12 months.”

      Peter,

      This was a horribly condescending thing to say. I don’t have access to the entire paper. I read the abstract, the full item “requires a subscription to The American Journal of Clinical Nutrition.”

      Does it really make a difference? Did I point out something incorrect in citing the NY Times blog item? Can we agree that sugar addiction is real, and that apples don’t contribute to it?

      Regarding the rest of your points, let me hasten to add, I AM ON YOUR SIDE. I get what you are trying to do. I just don’t think you are making your points well, sorry.

      You go into a long explanation about how fruits today aren’t the same as fruits 10K years ago….then you admit that apples aren’t the same thing as apple pie. But the way you phrase it, you make it sound as if modern apples are unhealthy, because they have been bred to be big and sugary.

      Like it or not, this is the message you are propagating. Sugar kills, fruits have sugar, don’t eat fruit.

      Do you want to communicate with more than just an elite few? Or do you want to communicate with the general public?

    • Peter Attia  July 1, 2013

      Diana, first off, I appreciate your support for this issue and your point. I think something is being lost in translation. I do not disagree that fruit is not equal to sugar. I am very if my point about reading that article came across as condescending. This was not at all my intention. I was trying to make a broader point that it is nearly impossible to glean from a newspaper, even a reputable one, the truth in a study. In this particular case, the writer (Anahad O’Connor) did an excellent job reporting on the outcome and implications of the Ludwig study. This caliber of reporting in the press is the exception, not the rule. Anahad is, in my opinion, the most reliable science reporter on nutrition. Regardless, I see your point. I apologize for offending you. Not at all my intention.

    • Diana  July 2, 2013

      Peter,

      No problems. I agree that science journalism on the topic of nutrition is mostly awful. The NY Times has great science journalism, IMO (Nicholas Wade is awesome), and this particular article was great because it had an interview with the scientist.

      It is true that eating too many carbohydrates – even good ones – will inhibit lipolysis. In fact you might say that that is the purpose of eating carbs and this was a good thing back in the day when people were skinny animals hunting other skinny animals and we needed fat. It’s not so good now. If you have to lose fat, you must control carb intake, including fruit.

      But you don’t get fat eating fruit. This is not the way we get fat, sorry. People are binging on huge amounts of junk food and no one wants to call them on it. I got fat that way, and I got relatively lean by cutting out that behavior pattern.

      I walk around where I live, NYC, where people are supposedly thinner than in most of the rest of the country, and I am seeing obese young people (mostly but not all young women) and it kills me.

      That is why I am very fanatic about good information getting out there, to the general public. They need a simple clear message. Not dumbed down, but simple and clear.

      Confusing the issue with disquisitions about what apples were like 7K years ago is not the way to go. Look at modern American’s (and Brits and everyone else’s) food intake and you’ll see a lot worse than some fruit.

    • Peter Attia  July 2, 2013

      Agree.

  61. Jeff Johnson  July 2, 2013

    …………………..
    ……………….
    A matter of Context……..

    There are certain realities involved here that don’t really care about people’s feelings or opinions one way or the other -

    !. You can eat 1000 calories of apples or apple juice a day and lose weight without any problem – in this context – apples would be compatable with your weight loss goal or up it 1800 calories and just mantaian weight -

    2. Converesly – eat four big apples a day( 320 calories or so – 80gr carbs) – and combine this with 700 calories fat and within a short time you may start looking like porky the pig – up the fat calores to 1500 and almost certainly you will start resembling old porky – and very quickly

    3. The statements above above are equaly true – and they should be something that people know – say any one older than three -
    4. A high carb diet needs to be low fat( below 10% of calories) -

    5. A high fat diet requries just the opposite( extremly low carbs)

    6. It’s little wonder many people when finished dieting gain weight – they sinply start combining fat and carbs together and binge eat ever now and again – and they get fat again – - what a mystery
    7. The above statements apply to everyone on the face of the earth – including people who write for New York Times and all those who killed themselves with there diet and are now dead – so everyone should be happy now

    (reply)
  62. Devra Mattes  July 3, 2013

    Diana said, “But you don’t get fat eating fruit. This is not the way we get fat, sorry. ”

    Though I understand she is referring to a cultural tendency (we get fat because we are eating so much junk, most people are not getting fat just because they are eating sugar in the form of fruits) rather than biology, this struck a chord for me nonetheless & I have a comment. :)

    Somehow I did gain weight & increase the amount of fat on my body by increasing the amount of fruit I ate. Large servings of fruit, every day, for breakfast, for several months = a 5 lb weight gain on a very small frame. That was the only change. Was it the fruit itself or was it the insulin response to the fruit? Does it matter which, in the scheme of things? Maybe, maybe not. Maybe there is no real distinction. The important thing, to me – the outcome – was that I was eating a seemingly healthy ‘non-fattening’ food … and I got fatter. I had to stop eating fruit to stop getting fatter. I was not eating pastry, I was not eating junk. I was eating fruit.

    Does your body store fruit as fat? Maybe not. Maybe technically it was not the fruit making me fat, maybe it was the insulin making me fat. But if the insulin response is the cause of the fat gain, not the specific food itself, then what matters is the insulin response I get from the food, yes? So any and all foods raising my insulin *might* make me fat, yes? So, yes, maybe I (& others) get fat eating fruit despite the ‘fact’ that supposedly we don’t get fat eating fruit. If fat gain is primarily about hormonal responses to food (and it certainly seems to be), then the specifics about the food are secondary, except that they have the right ingredients to create that hormonal response. So maybe sugar is sugar – apple or apple pie, your body may well have the same hormonal responses to both. Yes, the ‘natural’ sugar combined with fiber in fruit will probably have a less dramatic effect than the ‘unnatural’ sugar of a fruit pie, but insulin rises nonetheless. And all it takes is an insulin rise, regardless of source, to engage the fat-storage mechanism, yes? So I think, technically, fruit can indeed make you fat – maybe the fruit itself is not stored as fat (but are we sure about that, really?), but the insulin rise starts storing SOMETHING as fat . I’m guessing that SOMETHING would be everything else eaten that is above current energy needs, and if that SOMETHING is fruit why wouldn’t it be stored as fat (I honestly am asking)?

    Please tell me if I am off-base.

    – I’m not anti-fruit, but I do think fruit gets a free pass as some kind of magical food, despite it being basically nothing more than sugar + water + fiber. fruit is a treat. it’s nature’s dessert :) and like all dessert, best on occasion, not 6 times a day. give me one perfectly ripe mango in season & I am in heaven. I was vegetarian for 20 years, vegan for portions of that, raw vegan at one point (and very malnourished!), and I was told again & again how fruit was healthy, fruit was perfect & magical & so nutrient-rich that the human body can be sustained in perfect health with a fruit-only diet. that information is wrong. if you want to give people good information, keep it real: how does the human organism function, what is in the food we eat, what reaction does it provoke in the body, and no sacred cows. –

    I do think that that the changes in the fruit we eat compared to the fruit of our ancestors makes a difference – if the fruit we eat now is higher in sugar than the fruit of our ancestors (and we eat it year-round now, not just seasonally), that DOES change how our hormones respond. If we are designed to eat low-sugar fruits occasionally, in season, and that is not the current paradigm, we are not eating optimally. It is a valid article of information to include when making decisions about what to eat & how much. Is discouraging the eating of fruit a higher priority than discouraging the eating of Big Macs? No, of course not. It’s like triage – you work the priorities in order of importance. But fruit is not without problems, and it’s worth talking about.

    a question: what is the actual difference between levulose & fructose? d- form vs. l- form? since I’m a non-science-y type, I don’t necessarily grasp the distinction. how is it that fruit sugar is chemically better than man-made sugar, as far as the body is concerned?

    thanks for all you do, Peter.

    (reply)
    • Peter Attia  July 3, 2013

      Levulose is fructose to my knowledge, just a historical name. The important distinction is between glucose and fructose, and how they interplay (described elsewhere on this site and many others). When people say “man-made” sugar, they usually mean HFCS, which is effectively the same at sucrose.

    • Devra Mattes  July 4, 2013

      That was pretty much my understanding (re: fructose) – as far as the body is concerned, fructose is fructose, glucose is glucose. I am weary of magical thinking around nutrition. :)

      Thanks for the follow-up, Peter.

      Take care.

  63. Tina Adkins  July 11, 2013

    Hello! I am so happy to have found your site – as a research scientist myself, I am *always* trying to go to the source and read scientifically valid articles – as you have already pointed out, it’s a bit of a mixed bag out there and I can’t spend too much time on it (as I am due to finish my PhD this year!). I have read most of these comments, but not all, so forgive me if you have already answered this question. I was wondering about the “scientific” connection between plant fiber and reduction of disease, particularly with regards to diseases like colon cancer (and the added idea that excessive red meat contributes to this disease)??

    Thanks,
    Tina

    (reply)
    • Peter Attia  July 11, 2013

      Tina, the cancer issue, at least via fiber (one study) and saturated fat (another study) has been addressed. No reduction in colon colon cancer with increased fiber intake (both shown prospectively and in meta-analyses), and no reduction in many cancers, including breast, with reduced saturated fat intake (when sat fat replaced with fruits, vegetables, and whole grains).

      I’m not sure these give red meat a pass, but as I write in another post about red meat, much of the bad rap it gets is based on ecology and observational epi.

  64. Olga  July 17, 2013

    Hi Peter,

    I am really enjoying your blog and considering making the changes to my diet that you advocate. However, I am linking professor Colin Campbel’s presentation below. lt claims that animal protein, which is heavily present in your diet, is harmful. Can you please explain to me the radical differences in your views of nutrition?

    “Celebrated Cornell University professor T. Colin Campbell Phd, presents the overwhelming evidence showing that animal protein is one of the most potent carcinogens people are exposed to. Here is his presentation: https://www.youtube.com/watch?v=yfsT-qYeqGM&feature=related “.

    (reply)
    • Peter Attia  July 18, 2013

      Olga, I’ve been asked this question or a variation of it probably 50 times in the past year, which suggests I need to a blog post on it, I guess. The reason I have not done so is that two others (or countless folks), have so very eloquently. If you’re interested, here are the links to them, below. VERY short answer is this: I have no doubt that the diet promoted by Dr. Campbell is better than a “Standard American Diet,” however, there is no scientific (read: prospective, experimental) evidence that is superior to all modes of eating. I’m really loathe to write about in this, because it only seems to turn into a discussion as mindless as one on abortion, same-sex marriage, and stem cell research — in other words, it seems impossible for many people to have a scientific discussion on this topic, without it turning in a near-religious one, which is tragic. The morality of eating animal products should under no circumstance ever be confused with a very important scientific question: is it healthy or harmful?

      http://rawfoodsos.com/2010/07/07/the-china-study-fact-or-fallac/
      http://rawfoodsos.com/2011/09/22/forks-over-knives-is-the-science-legit-a-review-and-critique/
      http://www.proteinpower.com/drmike/cancer/the-china-study-vs-the-china-study/

      I know this is more than you want to read, but I’m also doing this partially so others with the same question can decide for themselves.

  65. Hazel  November 13, 2013

    http://www.connectwell.biz/pdf/comment_truth_about_sugar.pdf
    The article published in Nature

    (reply)
  66. Patricia  February 2, 2014

    I have been devouring your information, I have given up all refined foods, grains and fruit except for berries once a day. I am restricting carbohydrates. I eat nuts, non starch veggies, full cream butter, bacon, coconut oil and protein. I do use about 10 drops of stevia a day. I must say my husband has lost weight but I haven’t I would be really disappointed if it were not for the fact that this eating is anti inflammatory and the pain in my ankles, knees and back have greatly decreased. YEAH! I still need to lose weight. Can you help?

    (reply)
  67. Cooper  February 13, 2014

    I just saw the video of your presentation to @ JumpstartMD. The last question on the video had to do with fiber and how we may not need as much of it as we’re told. I figured this post was the best place to give an idea. I remember hearing something on “The People’s Pharmacy” about the role of fiber and their guest doctor that day was advocating fiber because of it’s role in regulating sugar.

    The short of it was that insoluble fiber acts to absorb sugar, specifically fructose, in the GI track and therefor prevents its absorption in the small intestine. Eventually the sugar would pass out of the system with the fiber. soluble fiber did a similar job in the blood stream acting like a vacuum cleaner for the sugar, and lowing the glycemic load of foods. So my connection is, maybe we’ve been recommended to increase our fiber consumption not because of the fiber, but because of the harmful effects of sugar, and the reduction or elimination of sugar would lead to less need for fiber in the diet.

    (reply)
    • Peter Attia  February 14, 2014

      Fiber helps with bowel transit time, but beyond that, there is no evidence it prevents cancer, though such claims are touted as dogma. Of course, fiber is but one component of the diet that impacts digestion. Amount and type of meat, amount and type of fat and oils, hydration status, genetics, gut bacteria, etc., call play a major role.

  68. Tim Claason  March 5, 2014

    FWIW, the Nature article now costs $18, not $32 as you mention early in this post

    (reply)
  69. Dana  April 20, 2014

    Actually? People in Asia are not healthier than we are. That’s a myth, and part of the problem is we seem to believe that you’re only unhealthy if you’re fat. People, the reason there aren’t as many fat people in Asia is because there are more *starving* people in Asia. You wouldn’t be as fat either.

    They don’t get the exact same diseases at the exact same rates we do but they do get a lot of pancreatic cancer, a lot of diabetes and a lot of heart disease (especially in India, that mecca of vegetarians everywhere). And, oddly, a lot of nearsightedness. “That’s not from diet, though,” you’d reply. Wanna bet? Diet has some effect on your eye health, and can definitely affect your visual acuity. I’ve heard from people who went Paleo and suddenly their eyesight improved. Including an Asian guy who posted his success story on Mark’s Daily Apple, and several of his commenters.

    Also if you look at Denise Minger’s critique of the China Study you will find not only that the data don’t say what T. Colin Campbell claims they say but they also point to wheat as a major driver of chronic disease in China, which has been using wheat for a very long time now. They were the ones to introduce pasta to Italy, you may recall from history class.

    Where people consume grain and don’t make themselves immediately or chronically sick in Asia I think several factors are involved.

    1. They’re eating rice, not gluten grain, and rice is less hazardous to your health, though you still don’t have a blank check to eat as much as you want (“Perfect Health Diet” claims about rice notwithstanding–that crap jacks up my blood sugar and, being Cajun, it pains me to say so).

    2. They’re still eating lots of animal, especially animal fat, bone broth, and organs. They also eat lots of seafood. These all have protective effects vs. chronic disease.

    3. They get enough sun. Sounds nonsensical until you do a little investigating and discover there are links between lack of sun exposure and chronic disease. If you’re preventing minor skin cancers (melanoma can show up on unexposed areas of the body, so I doubt the sun is the sole driver of its development), you’re still making things worse for yourself in the long run, and not just because you aren’t making sufficient amounts of vitamin D.

    If you are going to insist on eating grain carbs then you need to take other steps to protect yourself because from what I can see, carbs take away from health more than they contribute to it.

    That goes for fruits and vegetables. Their seasonality alone should tell you that we don’t depend on them for basic survival–we can’t, because they aren’t available at all times of the year. They have their uses in the human diet when utilized properly but they can’t be a *consistent basis* of a healthy human diet. Or at least no one fruit or vegetable can. What we really need to be looking at is animal-based nutrition, making sure that is all dialed in, and then we can have plant foods in their proper context–a possibly helpful addition to the diet, not its foundation.

    We’re not other primates. We’re different. We have way more small intestine and hardly any large intestine compared to the other great apes. That means much less tolerance of or ability to process plant matter. Something to keep in mind.

    (reply)
  70. Tyler  August 14, 2014

    Dr. Attia,

    Can you comment on the micronutrients in these fructose containing fruits and vegetables and the implications of leaving these out of a diet?

    (reply)

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