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How do some cultures stay lean while still consuming high amounts of carbohydrates?

How do some cultures stay lean while still consuming high amounts of carbohydrates?
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Many of you have asked this question over the past few months, and I’m sure many more of you have at least contemplated this question at some point.  I know I did.

 

For the sake of this discussion, let’s ignore the fact that the “historically” lean countries (e.g., France, Italy, Japan) are catching up to our levels of obesity and metabolic syndrome, especially in certain affluent subsets.  After all, we did get a 40 year head start on how to eat poorly.   So, let’s ask the question this way:

How does the average person living in, say, Japan stay leaner and healthier than the average American while still consuming >70% of their caloric intake in the form of carbohydrates?  

I don’t claim to know the answer this question, but I’ve got a few ideas.

Before getting to this question I want to mention that I have reorganized a page on the blog, Media, which now has a lot of videos and interviews.  A lot of the questions I get asked are addressed in these videos and interviews (both of me and others), so please check there for answers to your questions. Last week I was interviewed by Ben Greenfield. Ben asked a lot of great questions which many of you have also asked over the past few months. Take a look here and see the questions Ben posed.  If you’re interested in hearing my thoughts, listen to the audio clip from the interview.

Back to the question at hand

These data are a bit dated, but you can see the point: the United States is leading the way in the obesity race, while other countries (including those eating at least as high a total percent of their intake from carbohydrates) are not.  How is this possible if insulin – stimulated by carbohydrate intake – is an important hormone in the body’s drive to accumulate fat?  

This problem has many layers to it, but for the purpose of simplicity (always a danger when aspiring to explain complex phenomena) I’ll limit the discussion to three main points – think of them as the “higher order terms” – in their order of importance.

  1. Lower consumption of sugar
  2. Lower absolute consumption of carbohydrates
  3. More favorable consumption of polyunsaturated fatty acids (PUFA)

These reasons are not independent.  In other words, they are highly correlated and linked to each other, which actually amplifies their effects.

One other point to keep in mind: There is no definitive experiment I will point to that can prove my assertion beyond a reasonable doubt – for that I would need a prospective, well-controlled experiment comparing the eating habits of these countries over decades.  Many things I’m discussing are observational in nature, so you’ll have to really scrutinize my thesis on your own.

 

Reason #1 — Sugar intake

There is a great disparity between U.S. sugar consumption and the sugar consumption of countries like France, Italy, and Japan (and most countries, actually).  When I say “sugar,” of course, I mean sucrose, high fructose corn syrup, beet sugar, cane sugar, and liquid fructose (e.g., fruit juice) to name just a few forms.  Why does this matter?  If you’re not currently up on the why-sugar-is-bad-for-you data, it’s worth reading this post, and watching the lecture by Dr. Lustig.  For a quicker answer, watch this video from 60 Minutes.

Think of sugar as a “metabolic bully” or the proverbial Trojan Horse of metabolic syndrome – you let sugar in, and before you know it, you have diabetes, heart disease, and cancer.  Consumption of sugar makes us metabolically inflexible as part of a vicious cycle I’ve diagrammed below.  The more sugar you eat, the more insulin resistant you become.  The more resistant you are to the effects of insulin, the more insulin your pancreas needs to secrete in response to all carbohydrates, including the not-so-bad “non-sugar” ones. The more insulin your pancreas needs to secrete to manage your glycemic load, the higher your average insulin levels, which is manifested by higher levels of circulating insulin at all times – fed and not fed. Higher levels of insulin lead to less fat oxidation and more fat storage (from both ingested fats AND ingested carbohydrates – de novo lipogenesis).  This, not surprisingly, leads to greater insulin resistance, and so the cycle continues.  There is a reason “vicious cycles” are called “vicious.”

Vicious cycle

 

Reason #2 — Total glycemic load

It’s important to keep in mind that the percent of carbohydrate consumed is nowhere near as important as the absolute amount of carbohydrate consumed. Failure to understand this point may be one of the most significant reasons for the calories-are-everything-argument.  Recall my post on why Weight Watchers and most commercial diets are actually low-carb dietsVirtually any diet that reduces caloric intake also reduces glycemic load.  Worth repeating: Virtually any diet that reduces caloric intake also reduces glycemic load. That is, cutting calories almost always means cutting carbohydrates, cutting insulin, and cutting fat storage.  So what does this have to do with folks in Japan eating rice?  While these cultures may consume a higher percentage of their intake from carbohydrates, their actual glycemic load is lower. In other words, they actually consume fewer total carbohydrates in most cases than a typical Westerner (and in the presence of much less sugar!).  Contrast “typical” carbohydrates consumed by these “high” carbohydrate societies:

Non-American eating

Sure, they eat rice and bread and pasta.  But how much at one time?  And what are they eating it with?

Compare the figure above with that below, showing “typical” American carbohydrate consumptive patterns:

American eating

Are we eating the same amount of pasta per meal as the folks in Italy?  Perhaps, though I don’t think so.  Furthermore, while they make their own pasta sauce out of home-grown tomatoes, garlic, and olive oil, we dump a pound of Prego on ours (the second or third ingredient is nearly always sugar).  While the French are eating baguettes, we’re eating sugar-filled bread.  While the Japanese are eating a small bowl of rice, we’re stuffing our face with a plate of fries and breaded onion rings.

Why does consuming more glucose matter, notwithstanding the point that the glucose we consume is virtually always linked to sugar?  The human body can only store a finite amount glycogen, so any excess glucose we ingest actually does 2 harmful things:

  1. Continues to raise insulin levels, which inhibits fat mobilization,  and
  2. Gets stored as fatty acid, and ultimately ends up as triglyceride in fat cells.  Remember, this is a one-way metabolic street.  When your body turns glucose into fat (technically, we turn acetyl-CoA into malonyl-CoA into palmitate), you can’t turn that fat back into glycogen.

More absolute glucose, regardless of the relative percent, still leads to more fat accumulation.

 

Reason #3 — Inflammation

While insulin is certainly near the top of the list of pro-inflammatory factors in our bodies, it’s important to keep in mind the role of some other factors whose balance plays a role in inflammation such as eicosapentaenic acid (EPA), docosahexaenoic acid (DHA), and arachidonic acid (AA) to name a few.  I will, in a separate dedicated post, compose a thorough discussion on the metabolism of omega-3 and omega-6 fatty acids. To be clear, the science around this is not fully worked out, and much of what we speculate is based on indirect cause-and-effect inference, coupled with “sound” mechanistic reasoning and, of course, strong observation.  In other words, this is not close to bulletproof logic.

What is known is that diets high in omega-6 polyunsaturated fatty acid (PUFA) (e.g., mostly plant oils like sunflower, canola, safflower, and corn oil) relative to omega-3 PUFA (e.g., fish and fish oils) create a disproportionate ratio of AA to EPA and DHA. When I go through the biochemistry of this (which is super-cool!) it will be obvious why this is true: Eat a huge excess of omega-6 PUFA relative to omega-3 PUFA and your blood and tissues will show a lot of AA relative to EPA and DHA.  Same logic holds in reverse.

What does this mean?

Here’s where the story goes from being “clear” to “less clear,” at least to me. There is reasonable evidence that too little EPA and DHA (omega-3) predisposes us to certain diseases, in particular, cardiovascular disease.  There is some evidence that the relative amounts of EPA to AA and DHA to AA matter, too (i.e., what happens when you eat too much omega-6 PUFA relative to omega-3 PUFA).  What is not clear is if too much AA relative to EPA and DHA (i.e., much more omega-6 than omega-3) leads to clinically significant inflammation in the body that fosters other disease states.  In fact, a case can be made that high amounts of omega-3 PUFA are outright protective from many diseases including the disease spectrum of metabolic syndrome (e.g., diabetes, heart disease, cancer, Alzheimer’s disease), independent of omega-6 PUFA intake.

Observationally, this seems “clear” – societies whose ratio of omega-6 to omega-3 consumption are lowest (e.g., 3-to-1 or better) have far less disease than societies whose ratio is much higher in favor of omega-6 (e.g., 30-to-1).  Of course, this does not prove anything, since uncontrolled observations are just that.  This is how folks like Ancel Keys and Colin Campbell have caused so much trouble and confusion in the field of nutrition.  It is possible that some other factor, beyond this, is resulting in the differential disease pattern.   In other words, it is not clear if this observation is correct because of the relative amounts of omega-3 and omega-6, OR if it is true because of the absolute amount of omega-3, OR if it is true for some other reason? I don’t know (yet), but will continue to work on this.

That said, there is some indirect evidence linking differential consumption of PUFA (i.e., relative differences in omega-3 versus omega-6) with actual disease states.  A paper published in 1993 in the New England Journal of Medicine showed that patients with more EPA/DHA precursors than AA precursors in cell membranes had greater insulin sensitivity and less heart disease (though, obviously, these are linked).  I will review this in much greater detail in a dedicated omega-3/omega-6 post, but I want to point out that there is some evidence beyond just the observational data suggesting more omega-3 and less omega-6 in your diet leads to better insulin sensitivity:

Eating more omega-3 and less omega-6 may lead to more EPA/DHA precursors in cell membranes than AA precursors, which is correlated [not causally linked] with less insulin resistance.

Hence, Western diets, where we don’t consume much omega-3 PUFA, and it is very difficult to avoid omega-6 PUFA (they show up in virtually every processed and packaged food we touch, not to mention all sauces and dressing, and even our grain-fed meat), may predispose us to greater insulin resistance and inflammation.  As you can see in the figure below, a (historically) typical Japanese diet was nearly equal in omega-6 to omega-3, while our diets are typically much higher in omega-6 than omega-3 – BOTH because we don’t eat much omega-3 AND because we eat much more omega-6.  The same is true of a traditional Mediterranean diet.

Let me reiterate: I do not know if the relevant issue is the denominator (i.e., absolute amount of omega-3 consumed) or the ratio (i.e., relative amount of omega-6 to omega-3).

[Personal note: Pending resolution, I do both: I maximize my omega-3 intake and minimize my omega-6 intake to a ratio of about 1:1 with lots of EPA and DHA and little omega-6.  What is not clear to me yet from current data is if I should be minimizing my omega-6 intake.]

Omega-3 vs. Omega-6

 

What can we learn from this?

I alluded to how multifactorial this issue was, but I hope it’s clearer to you now.  Let me try to summarize why some cultures have historically been able to consume rice and pasta and baguettes but stay leaner and healthier than Americans:

  1. They consume a fraction of the sugar we do.  More sugar consumption leads to greater insulin resistance, more fat creation, less fat breakdown, and more fat accumulation.
  2. They consume less total glucose, AND the glucose they consume is accompanied by less sugar (and less omega-6 PUFA, if it matters).
  3. They consume a ratio of omega-6 to omega-3 PUFA that is much lower than we do.  This may further reduce any insulin resistance brought on by the glucose they do consume (in smaller doses and with less sugar).

Let me close with one personal and anecdote.  When I began my nutritional journey, for over 18 months I still consumed a modest amount of carbohydrate, probably on the order of what a typical person in Japan would consume.  The biggest elimination in my diet was sucrose, HFCS, and “junk” carbohydrates. The results were impressive.  I went from being about 200 pounds at 25% body fat to being 177 pounds at 10% body fat while still consuming some carbohydrates (by that point I was down to maybe 100-150 gm per day).   However, I was able to get leaner (170 pounds, 7.5% body fat) and further improve my risk profile for disease by going below 50 gm per day (i.e., entering nutritional ketosis).  Was this last step of nutritional ketosis necessary? Of course not, but it was a nice way to experience the full spectrum of carbohydrate restriction.  Will I ever go back to eating 100-150 gm per day of the “right” carbohydrates at some point? Probably, provided I don’t go back to eating sugar and stuffing my face with carbohydrates.  It will depend on what I’m optimizing for.

My point is this: Just modifying your diet by the 3 factors I mention in this post — elimination of sugar, less total glucose load, and improved omega-3/omega-6 profile — even if you are not genetically programmed to be lean, will probably deliver 80% of the value in terms of disease risk and body composition.

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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. Chris  April 18, 2012

    Thank you for reinstating the old font! That other font was impossible to read, Gary uses it on his website also. I have excellent vision, and I still found myself squinting. This one is so much more accessible. A real relief!

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  2. Mason McClellan, LAc  April 18, 2012

    It is hard to get good data on Indonesia and Vietnam but I thought I saw in a WSJ article that their rates of diabetes are going down…I am not certain if I am remembering this correctly. Also interesting to note that Indonesia is the biggest consumer of rice per capita, twice that of Japan. Curious to what auto-immune issues they have since I would consider them benign carbs compared to wheat. Purely speculating on these questions but curious if you can offer any insight…since you are discussing cultures. Great stuff as always!

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    • Scott  April 24, 2012

      Consider the populaton of Indonesia is twice that of Japan, then also consider that the poverty levels in indonesia would indicate that most of the population is on a “low food diet” and the correlation is very understandable. Unless you understand the culture it is easy to treat a country’s population as homogenous, and Indonesia is a prime example where there is no homogenity.

    • Ivan  December 3, 2012

      I’m from Indonesia and I was recently diagnosed diabetic. Hence I was looking into this diabetic issues and found that the rate of diabetic in Indonesia is actually rising sharply as shown in national TV news and many local health articles. Just google out “Indonesia diabetic rising” and you’ll see the news.

      I would also consider the poor health system here, and that majority of the people cannot afford the luxury of getting checked by doctors just for a symptom of diabetes which is so subtle anyway. Not to mention the low health awareness to do routine medical checkup. Hence diabetes here might actually already epidemic but not detected.

      Indeed rice is our primary staple here. There even goes a saying here: “You have not eaten if you have not eaten rice.” And are we lean? Who says that? I look around and what I see is belly fat.. belly fat everywhere :p

      By the way, this is my first comment in this great blog. My saviour to say the least.
      I have followed LCHF way of living for 6 months now.
      The changes I experience in this 6 months?
      I have my BG under control around 70-90 (fasting or 2 hrs after meal) from previously 240 fasting and 310 2 hrs after meal. My latest HbA1C 3 months ago was 5.8 from 10.1 when I was diagnosed.
      I have ditched my BP medication completely with my BP now around 110/70 from previously 140/110.
      I have lost 18 kgs of weight, and 20 cm of waist circum.
      I have finished a couple of 10 KM run race from only able to walk 3 KM when I start this journey.
      I lift weight daily with incredible increased strength and my body now looks.. well how do I say it.. just say that I’m not embarrassed anymore to go to the public swimming pool in my shorts :)

      All this thanks to people like Peter Attia here, Andreas Eenfeldt, and Mark Sisson. So thank you, Peter!

    • Peter Attia  December 4, 2012

      Ivan, not sure I deserve any credit, but delighted to hear your story. Keep up the great work.

    • Ivan  December 5, 2012

      Hi Peter, you’re being modest :)
      For people with similar personality type as you (I’m INTJ with ambiguous I/E and N/S but very strong TJ), we need people like you who “breaks the code” for us. If it were not for this blog which explained everything clearly but logically, I would not adopt this “crazy sounding” way of eating :)
      Not to mention that you use your personal time to do all this self-research and blogging. You Sir deserve every credit :) Cheers.

  3. David Nelsen  April 18, 2012

    When I visited Japan in 2000 & 1989 I found that their supposedly sweet pastries had very little sugar in them. I was craving something sugary at the time and their sweets didn’t do it for me. I have been to all 3 of the countries in your post and on the negative end of the scale they tend to smoke much more than in the US. In Rome I was in a local market and they did buy a lot of pre made spaghetti sauce, but it no doubt has less sugar in it than American brands. A lot of seafood in the Japanese and Italian diets as well. They had smoked fish in the traditional Japanese breakfast (that plus salad and rice). What type of oil do you use for cooking? Flaxseed? I didn’t see much of the healthy Omega 3 types in my local grocery store. I got some cold expelled Safflour oil, but now I’m thinking this was a poor choice.

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    • Peter Attia  April 18, 2012

      I only cook with coconut oil and butter, but this has to do with the idea that it’s a bad idea to heat up a double bond. Hence, only heat saturated fats.

    • Travis Koger  April 18, 2012

      We only cooking with Beef Dripping due to myself being one of those types that dairy doesn’t do well with. Beef Dripping is pretty cheap also.

    • KevinF  April 18, 2012

      Just about every other reference I’ve seen to fish oil and Flaxseed oil says DON’T USE FOR COOKING — evidently heat oxidizes the Omega 3 to create a lot of free radicals, making them harmful instead of good. Seems to be a similar problem with the Omega-6 polyunsaturated oils — “vegetable”, corn, canola, the seed oils, soybean — don’t cook with them, and in fact pretty much avoid them altogether because they’ll skew your desired Omega 6 to Omega 3 ratio.

      A lot of people do cook at lower heat with the monounsaturates … olive, avocado, macadamia. But certainly saturated is a good choice — coconut oil and butter (and ghee works especially well for cooking).

    • jake3_14  April 18, 2012

      To flesh out this discussion, I’ll cite a comment by Dr. Mary Enig: “The idea that cooking with heat damages the oils that are highly polyunsaturated is true and the warning against cooking or frying using fragile oils such as flaxseed oil is valid, but not because trans fats are formed. What is formed under harsh circumstances such as high-temperature cooking and frying is a polymerized oil, and this is because the heat has helped to form free radicals and then various breakdown products. (Flaxseed oil that is still in the ground seed can be heated in baking and it does not become damaged.)”

    • Constance  November 4, 2013

      Hello everybody. Just thought it would be interesting to share what i know about the effects of high carb diet among Italians. I work as a registered nurse in Montreal, Canada. And I have noticed over several years of working with elderly patients in Montreal’s Italian community that all of them (with no exception) are diabetic. And this situation of course, is caused by high intake of pasta, pizza, bread, pannetone, cantucini,risoto, gelato, cheese etc. I have understood that dairy products are not good for humans health either.

  4. Tom  April 18, 2012

    Keep up the good work. It is nice to hear you not talking in absolutes about issues not proven yet. Thanks for being out there being the voice of uncommon sense

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    • Peter Attia  April 18, 2012

      This is a funny issues, actually. I spent all of yesterday with Gary. Gary is even more skeptical of the omega story, so he was giving me a very hard time for the 3rd point of this post…

    • Lisa  April 18, 2012

      Peter, It’s interesting that Gary doesn’t buy into it. I just read an article in which Walter Willet was quoted as saying the whole Omega 6/3 story is a “myth” with no supporting evidence. Looks like those two can finally agree on something! :)

      Just out of curiosity, is it the ratio Gary doesn’t buy into, or the benefits of Omega 3, or both?

    • Peter Attia  April 18, 2012

      The irony of WW calling it a myth…I’m not exactly sure what Gary’s opposition is, as we spend all of our time talking about NuSI these days. I think Gary’s point which is valid, is that science is not as robust as one would like to make formal recommendations.

  5. Matt  April 18, 2012

    Hi Peter. Loved this post (and the pictures). Suggestion/Request- You might consider adding a pdf link for some of these great articles. I, as an internist, would love to hand this sort of thing out to my patients rather my usual “stop eating sugar” and “take fish oil” diatribes.

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    • Travis Koger  April 18, 2012

      Matt,

      It is pretty easy to make your own PDFs of a web page using something like CutePDF. (Native on Macs) It might be a better options and increase Peter’s traffic (might not be good for his bank balance though) if you handed out cards with eatingacademy.com written on it. :)

    • jake3_14  April 18, 2012

      Speaking of handouts, you could give your patients a copy of Massive Health’s infographic on how carbs make you fat, based largely on Taubes’ work.

  6. Mike Hurley  April 18, 2012

    I hear the argument a lot that “carbs can’t be bad because a billion Chinese people eat rice every day”. I don’t think the average American truly understands the extraordinary amount of sugar and starch they are eating in a typical day. A half cup of white rice with a meal is nothing compared to typical “heart healthy”, carb loaded American meals. My typical breakfast before going low carb: 1/4 box of granola cereal drowned in skim milk and a tall glass of grapefruit juice.

    1/2 cup of white rice has 18g of carbs, 0g of sugar. My typical breakfast had 122g of carbs, 59g of sugar.

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  7. Joey  April 18, 2012

    Thank you, for you willingness to provide all this well thought out and supported information for free.
    It is greatly appreciated.
    When you have gotten through your current list of posts to come, would love to see a post on alcohol addiction and how it relates to sugar addiction.

    Also for me – and I know this isn’t a money making venture – I would happily donate to the running costs of the website etc, because I have gained so much information and direction over the last few months. Just a thought.

    (reply)
    • Peter Attia  April 18, 2012

      Joey, I really appreciate it. The blog currently costs me about $5,000 per year run (that number keeps going up). I’m willing to provide that for free for now. If circumstances change, it’s nice to know there are a few folks willing to help. I’m deliberately keeping ads off, also. Hopefully that makes it easier to enjoy.

    • Travis Koger  April 18, 2012

      Count me in for that also. Would love to be a subscriber to the site. The information you provide easily gives me the feeling that this is worth paying a subscription for.

    • Travis Koger  April 18, 2012

      Peter,

      Why not move your blog to something like Glogger where you don’t pay the types of fees you are talking about here? Are their limitations with a platform like blogger that you get the benefit of self hosting. (I understand you use a service provider for the blog. Alternatively if you wanted more control, why not consider something like Squarespace.com?

    • Peter Attia  April 18, 2012

      I originally used a less expensive hosting service, but I was not happy with quality and had 2 crashes… you get what you pay for I guess…

    • Travis Koger  April 18, 2012

      Glogger….. dammit. Blogger!!

    • lorraine  April 18, 2012

      Joey, if you haven’t yet seen Robert Lustig’s infamous youtube video, Sugar: The Bitter Truth, you should take a couple of hours and sit through the biochemistry of how the liver deals with sugar, fructose and alcohol. It derives a thesis that sugar/fructose is toxic in the same way as alcohol, but it doesn’t discuss the addiction of it. The 60 Minutes segment from a couple of weeks ago, which Peter linked maybe in last week’s post, is also an interview with Dr. Lustig, but includes a segment on the sugar/cocaine/alcohol addiction effects. It’s fascinating work.

      I, too, would happily lend financial support blogs like this one. You can see the glaring need for large, well-controlled prospective human studies that ask the right questions and present all the findings (unlike Keyes and Campbell) in the difficulty in writing a post such as this one in which the topic is so important but the data is not all clear. In the meantime, careful discussion in blogs such as this, including the value of shared self-experimentation and the experience of what clinicians see with their patients, is vital to the discourse of figuring this all out (plus your graphics are always so good!).

      I’ve been getting close to a more comfortable fatty acid profile by purchasing bulk organic grazed beef, eliminating commercial salad dressing and making my own, buying bulk well-sourced wild fish, and limiting chicken. But it means biting the bullet on the up front costs (including a freezer) that many cannot afford. (Although I have to say that buying this way lowers the serving cost of meals well below supermarket factory farmed cost) I’ve been taking high quality fish oil for years and have never used vegetable seed oils. Because our food supply is so problematic on this fatty acid issue, though, it takes a fair amount of work (and rarely eating out), and it poses some issues for me regarding the sustainability of wild fish. And I often wonder, when suggesting people reduce their carbohydrate with the substitution of increasing fats, including that in fattier protein, if I’m not creating the trading of one problem for another – insulin inflammation for omega-6 inflammation – as most folks are not going to purchase beef or fish other than corn fed factory farmed. It’s a conflict for me, mostly because I see the fatty acid thing right up there with insulin as a first/second order priority.

    • Peter Attia  April 18, 2012

      Once we launch NuSI everyone will have the opportunity to contribute (tax deductible, too) to funding REAL nutrition science.

    • Chris Graffagnino  April 19, 2012

      A single banner ad top (or bottom) of page is unobtrusive. Very effective if you find advertisers directly. One website that has done this is gearslutz.com, (audio-engineering messageboard with 168k registered user). By my math they gross at least $20k/mo

      Just a thought. ;-)

    • Peter Attia  April 19, 2012

      Chris, I appreciate the thought. Perhaps, if the costs start to really go up, I’ll consider trying to remunerate.

  8. Trish  April 18, 2012

    I remember reading in “Good Calories, Bad Calories” that the Japanese had the highest rate of stomach cancer in the world. Just another reminder that leanness doesn’t equal health.

    (reply)
    • dave  April 23, 2012

      Trish,
      check out what else they eat.Bracken fronds are not exactly health foods but are eaten in Japan.Study the whole diet.

    • Jean Bush  January 18, 2014

      That’s mainly because they eat a disproportionate amound of pickled vegetables and fish.

  9. Scott  April 18, 2012

    Great post as always. Especially looking forward to the Omega 3/6 article; I keep PUFA low because smart people (yourself included) say so, but it will be nice to know the science underlying it.

    Speaking of PUFA, I’d be interested in your opinion on Conjugated Linoleic Acid (CLA). I know its theorized to lower total adipocyte number, but I haven’t seen any definitive studies confirming/refuting this in humans. This seems potentially quite useful in normalizing Leptin for people who have lost lots of weight.

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    • Peter Attia  April 18, 2012

      I’ve done an experiment on myself with CLA, but I was unable to detect a difference. Not much to report on, unfortunately.

    • jake3_14  April 18, 2012

      Two good reference books on dietary fats:

      Fats that Heal, Fats that Kill, by Udo Erasmus
      Know Your Fats, by Mary Enig

  10. Kathy  April 18, 2012

    Thank you, Peter – excellent post.
    I’m curious why you didn’t address the potential for genes to play a large role in response to carb load. For ex, Asian cultures were so isolated for so long from other cultures, there have to be some DNA-level issues at hand here. Even if it isn’t about actual NEW genes, there could be an epigenetic factor at play – DNA methylation brought on by the “dance between nature and nuture.” If all of my ancestors over countless generations ate roughly what I eat, chances are my body will have figured out ways to deal with it, even if my actual DNA sequence is exactly the same as someone in northern Vermont.
    That’s not to say the food combinations, lack of sugar, etc, aren’t critical – as you note, this is complex and no doubt our body’s responses to food come about as the result of a correspondingly complex interplay of factors. But given the broad continuum of response we see in US population to food (your wife vs. you, for ex), there has to be some deep, underlying factors as well, don’t you think? (And sorry if I’m being too exacting – you are doing an amazing job of addressing so much complicated material – it’s a tremendous service you’re providing here.)
    BTW, is that picture of the boy with the stack of sandwiches you? ;)

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    • Peter Attia  April 18, 2012

      Not sure genes play a role. It seems even Asians are not immune to “our” diseases once the eat “our” food. I have never seen credible evidence for genetic protection by race (obviously it exists by person). Today, some children even in Tokyo need gastric bypass for morbid obesity, almost certainly because they are eating like our kids.

    • Bob Mauri  April 18, 2012

      Actually, even eating our food, those Japanese that retain their culture have less heart disease then those who eat our food but adapt our culture.

      As for genes, it makes sense to me that genes may play a role per race, but proving that might be complex. For instance, American Indians tend to be very susceptible to obesity, heart disease, etc., but is this caused by living conditions/culture or by genes?

    • Peter Attia  April 18, 2012

      The data are pretty sketchy, though. The best data I’ve seen were on breast cancer in Japanese women in the US vs. Japan. Same genes, but higher breast cancer in the US. It was more complex, of course, but that was basic idea. Agree, this is complex.

  11. Brian Salazar  April 18, 2012

    Another great post and I couldn’t agree more. I’m currently in Florence for training, my first time since going LCHF, and the first thing I noticed was the difference in portions. As you said, they might eat pasta and breads but they tend to be a much higher quality and the amount they eat is more akin to a child’s portion in the US. Now if I could only find a way to bring some of the great meats and cheeses from over here back home.

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  12. Morgan Mallory  April 18, 2012

    Fantastic job with this, Peter! I’ve been eagerly awaiting this post.

    When I pitch a low-carb diet to friends and they throw the “If carbs make you fat, why are Asian people so thin?” question at me, I almost always point out the error in their logic. Here are my claims (albeit oversimplified):

    If you are overweight or obese, then you are insulin resistant.
    If you are insulin resistant, then carbohydrates make you fat.

    If both of these statements are true, it does NOT hold that carbohydrates make ALL people fat, but it’s a very common logical fallacy people make. In fact, the contrapositive of the chain of conditional statements above explains the observation of thin Japanese people:

    If carbohydrates do NOT make you fat, you are NOT insulin resistant, and you are NOT overweight.

    Therefore, you cannot make a logically sound argument against the statements above by pointing out that some people are NOT made fat by carbohydrates. That’s true! Doesn’t make the statements above any less true! (Can you tell I’m studying for the LSAT?)

    Thanks again for addressing this, Peter!

    (reply)
    • Olivier Ramirez-hernan  March 14, 2013

      I really think that you’re all wrong about that, the fact that japanese people are thin and eat 70% of there caloric intake with carbohydrates really well explained an other thing, the fact is that you can have the most of your calories out of carbohydrates but that has nothing to do with the amount of food you can eat, that stipulate that the 30% of the calories intake can be a massive quantity of food with no “negative “impact on the glycemic and insulinemic response but have a favorable effect by decreasing the glycemic index and load of the total meal. That’s also why “the percent of carbohydrate consumed is nowhere near as important as the absolute amount of carbohydrate consumed”

  13. Al  April 18, 2012

    Wait, so Canola is not that bad after all? Confusion reigns.

    (reply)
    • Peter Attia  April 18, 2012

      I’d say we don’t know…In the mean time, I do not consume canola oil.

    • mokshasha  May 14, 2012

      canola is “bad” for another reason – it’s a seed oil, high in omega 6 and with lotsa nasties that are in all seed oils to one degree or another – antinutrients and the like.

      why consume it when there are sooo many wonderful other good fats to eat?

  14. John Dawson  April 18, 2012

    Thank you so much for this great blog.

    In your own diet, where are the omega6′s mostly coming from?

    (reply)
    • Peter Attia  April 18, 2012

      Mostly in meat, and a bit in nuts. Very little directly from oils.

  15. Andy  April 18, 2012

    Using occcam’s razor we could simply say the carbohydrate insulin hypothesis is false. There’s so much information to the contrary of CIH that only those with a vested financial interest continue to defend it (such a low carb product pedalers, ahem-Eades *cough* Moore). For example. Carbohydrate intake has remained stable in the US since 1910: http://1.bp.blogspot.com/-pAXaQJgkPpY/TkR6gZOX96I/AAAAAAAAAz8/hXW8cuW0QPg/s1600/US+macro+intake+%2528kcal%2529+1909-2006.jpg

    Yet obesity epedemic really started in the 80s. How do you account for this using the CIH?

    I do think you’ve identified the key issue, food toxins, in the form of excess sugar (fructose) and linoleic acid (omega 6 oils) but certainly not carbohydrate! Excess energy intake (mostly in the form of added sweatners) also plays a role.

    Personally I can eat well above Mark Sissons carbohydrate curve (of high glycemic carbs including bananas, rice and potatoes) and still remain lean (visible abs), as do the kitavans, as do high-carb bodybuilders.

    (reply)
    • Peter Attia  April 18, 2012

      Andy, thanks for your comments. Carbohydrate intake has absolutely not been constant in the US since 1910 (or even 1970 for that matter). Look at NHANES and CDC data (and keep in mind, total caloric intake is also rising, so the absolute amount of carb intake is actually going up FASTER than the curves of relative intake show AND then couple this with the QUALITY of carb issue…you get the idea). Also, look specifically at sugar consumption. Your claim that you and some bodybuilders can eat carbs, therefore carbs are not fattening is not relevant and I wouldn’t dispute it. My wife is the same. Read this post for a discussion on this exact fallacy: http://eatingacademy.com/nutrition/gravity-and-insulin-the-dynamic-duo. It’s like my 110 pound wife eating Oreo’s, not gaining an ounce of fat (which she does not), and asserting that Oreo’s are good for everyone. Not at all…she’s just one of the lucky 10-20% of folks with profound carbohydrate (and sugar) resistance.
      Finally, I completely agree with the idea that Occam’s razor explains the obesity epidemic. The simplest change between 1900 and today is the quality of food we eat and the quantity of bad food we eat.

    • Martin Levac  April 20, 2012

      High carb bodybuilders use the standard bulk-cut method to grow muscles. You know what it means, right? They eat tons of food to grow fat, then they cut total food intake to grow lean, all the while listing heavy weights. When they try it with a low carb diet, they can’t grow fat no matter what.

    • Bob Johnston  April 21, 2012

      Yeah, it was a sickening amount of fluid but the amazing thing was my body just seemed to want more and more of the stuff. Sixty four ounce Double Gulps was the typical serving size; it just gradually grew to that amount over time.

      Since then all I drink are iced tea and water and I’m happy to say my consumption has decreased quite a bit. I threw away my old 64 ounce cups and am quite satisfied with a 16-20 oz serving. I probably still drink more fluids than the average person but I’m not peeing all the time so I think I’m drinking the right amount.

  16. Sam R  April 18, 2012

    Dr. Attia,

    Thanks very much, I really enjoyed this article as well as the others you have written on the effects of sugar. For those of us trying to cut down on our sugar consumption so it is more in line with the Japanese or European diet, or so that we become keto-adapted, what advice can you give on overcoming sugar addiction (which I believe from personal experience is real and dangerous)? Even after 3-4 months of fairly strict low-carb dieting (mostly under 50g/day, always under 100g) I still have extremely large sugar cravings. I’ve tried cutting down on cheat days and artificial sweeteners so my brain doesn’t miss the sensation of sweetness but the cravings are just as intense. When I do allow for a cheat I become ravenous in my sugar consumption. How can I (or we, as Americans) overcome this impulse?

    (reply)
    • Peter Attia  April 18, 2012

      I found also eliminating non-sugar sweeteners (e.g., sugar-substitutes) helped, but it’s certainly going to be tougher for some folks. Curious to the experience of other?

    • CS  April 18, 2012

      My experience with sugar addiction–and I resisted the very word for a long time, thinking it entirely bogus until I actually looked at my own behavior and history–is that one can no more “cheat” with a sugar addiction than any other sort. “Addiction” is a real word, not a metaphor. If it is very very difficult for an addicted smoker to have just one cigarette and then just stop again, or an alcoholic to have the occasional drink, why should this “addiction” be any different? Of course, not everybody who eats a lot of sugar is addicted. That goes without saying. But if one finds that having started, it is very very difficult–or impossible–to stop, well, there you are. And the answer is the same one would come to in discussing addiction to cocaine or heroin, or anything else: one cannot use at all. My own experience is that it extremely hard to quit sugar. [I remember one acquaintance who had kicked heroin saying that her struggle with heroin was nothing compared to her struggle giving up sugar.] After a month or so, for me, the cravings (though not always the desire, which is different)start to go away. A few months in and I am OK, but ever vigilant. Were I to have an Oreo cookie today, however, just one little one, I know from my own experience what would result. I have tried that experiment, alas. It might be months or years–this has happened–before I can put it down again. I find artificial sweeteners somewhat problematic as well, though not to the same degree. As Peter points out over and over again, we are all different, and it takes a lot of rigorous honesty to face the reality of how OUR bodies really work. If one Oreo is too many and 1000 not enough, well….There are programs for addictions.

    • Stephanie  April 18, 2012

      I would suggest looking into the possibility of yeast overgrowth. Seems to be a controversial topic, but do your own digging and see if and what may apply to you. Look for “Candida” and yeast overgrowth. Having cheat days with this problem will absolutely 100% nullify all of your low-carb efforts in one go.

    • Johannes Oecolampadius  April 19, 2012

      I had to cold turkey it. NO added sugar or artificial sweeteners at all. Takes about a month to like coffee again. My goal is under 20 carb grams day. That’s taken me from 238 to 188 in 15 months. No juice, no grain, no potato, no corn no sugar. What I like about low carb living is I can understand it. It’s simple. DOn’t do this. Do whatever else you want. That works for me. And I’m never hungry.

    • Michele  April 19, 2012

      CS…I truly appreciated your reply – especially “[I remember one acquaintance who had kicked heroin saying that her struggle with heroin was nothing compared to her struggle giving up sugar.]” This comment I believe!

      Oddly enough, I find it corelates with the level of thyroid hormone I am taking. If I am over-dosed then the cravings for fast energy like sugar get worse. I’m waiting for the post “Relationship between hypothydroidism and insulin resistance” like a kid for Christmas!

    • Luc Lauzon  April 19, 2012

      My experience with Sugar addiction lasted until I turned 45. I quit all added sugar and it took me about a year to start feeling comfortable around sweets. I stopped in March 2010, and the first Christmas with my entire family was hell, as my mother always has a table full of sweets. The last Christmas was easy, smell will get me dreaming once in a while, but not to difficult to resist even though my wife and kids still enjoy it every day. I keep eating my own jam on toast with PB (Only Carbs I have kept beside Veggies), but I make my own jam with Xylitol. I do enjoy diet drinks once in a while, and they don’t trigger any sugar needs. Did it work, well went from 309 to 188 pounds and taking part in my first Triathlon this summer.

    • Bob Johnston  April 20, 2012

      My experience is that artificial sweeteners were really holding back my fat loss.

      In early February I was eating low carb but my weight loss was stalled and my energy levels were crashing in the afternoons after eating a low carb lunch. At lunch I was drinking a massive amount of Diet Pepsi (> 100 oz) and I began to wonder if that was the problem. So I quit Diet Pepsi the next day.

      The results were pretty amazing – in 6 weeks I’d lost 14 lbs of fat and gained 6 lbs of lean muscle mass. Additionally my energy levels were consistent throughout the day and the texture of my stool improved (gross but true).

      While I know Aspartame doesn’t cause an increase in blood sugar I wonder now if it does cause an insulin response. I would drink the stuff throughout the day but was really heavy at lunch (free refills). I think perhaps my insulin levels were consistently high as a result and would actually cause low blood sugar after my lunch binge.

      I haven’t checked out my theory with my glucose meter because I really don’t want to drink any more of the stuff (the “cold turkey” headache was pretty bad). Regardless, I feel much better these days without it and I think it might be something to try if your fat loss has stalled.

    • lorraine  April 20, 2012

      On sugar/carb addiction, there are theories that come from alcohol addiction and eating disorders regarding the role of sugars and carbs on the brain, and when they are withdrawn, the brain experiences a depleted state of the neurotransmitters that the sugar/carbs/alcohol were masking. There aren’t any good studies that I know of, but amino acids are widely used among recovering individuals with good results from self reports. Can’t say if this is placebo effect, or that people with addictions just like taking stuff (which they do), but do some research on L-glutamine and L-tryptophan for sugar and carb cravings.

    • KevinF  April 20, 2012

      @ Bob Johnston — wait a minute. You’re saying you were drinking more than 100 ounces of diet soft drink just at lunch? As in, the equivalent of 8 cans of soda? How could you get that down? I’d wonder if the problem wasn’t the use of artificial sweetener per se but, you know, such massive quantities of ANYTHING.

    • Travis Koger  April 20, 2012

      Bob,

      Did you try replacing the 100oz Diet-Pepsi intake with the same amount of water or non-sweetened fluids?

      I am trying no-sweeteners at the moment, where I used to have around 1.5ltrs per day of diet lemonade (no caffeine at all) per day. So far after a week I have not noticed any differences though… unfortunately.

      I will try it for another week anyhow.

    • Matt Taylor  April 21, 2012

      At my business I have many gracious customers who like to bring us treats as a token of appreciation. Yesterday alone we had people bring doughnuts, 6-pack of beer, Reese’s Peanut Butter Cups, and frozen yogurt (“oh, don’t worry it’s not fattening like ice cream”… sigh…) I appreciate the thought, but sometimes I feel like a heroin addict in a world where 90% of the population are drug dealers.

    • Conni  April 28, 2012

      Sam, the only sweetness left in my diet is daily 85% dark chocolate, 3 – 6 grams per day, plus a packet (sometimes two) of Stevia per day.

      Sometimes out of the blue I start craving that chocolate, it is a nearly irresistible impulse. I found out by accident that having some fat instead made those cravings vanish. For example, I might have a cup of decaf coffee, add a tablespoon or two of coconut oil, with a few drops of Stevia. The chocolate cravings disappeared.

      Purely anecdotal, of course, but worth a try!

      If you ever just have a hankering for some chocolate, another treat besides the 85% is to add some unsweetened cocoa powder to a cup of coffee, add some coconut oil if you want to, add a packet of Stevia or 6 – 8 drops, stir well as you sip, and enjoy.

      Conni

    • Jeffrey of Troy  May 8, 2012

      @Sam R

      Is it possibly chromium debt? Chromium is used up in metabolizing sugar. May need to replenish body stores (200-400 mcg per day, give the body time to recover).

      Many people push chromium picolinate, but I find GTF just fine.

    • ProudDaddy  May 23, 2012

      There was an interesting study on artificial sweeteners that I commented on over at SuppVersity. Unfortunately, it was in rodents. It basically showed that the effect is on subsequent meal satiety. Also, unfortunately, such a study has not been done in humans, and I doubt that the lo-cal sweetener industry dares to sponsor one.

    • leslie  June 11, 2012

      Pregnant with my fifth child, I discovered I was anemic. I was eating pretty well considering I wasn’t low-carb at that point, but adding iron to my diet made a huge difference. Sugar cravings almost completely disappeared. Baby is 3 months, I’m still on iron, and virtually no cravings. I’ve been wondering if a lot of people on a “normal” American diet could be anemic.

  17. Eddie  April 18, 2012

    Greetings Peter & WOI Readers:

    Sincere apologies for an OT question! I did not know where else to ask.

    I would prefer (i.e., need,) to substitute Sea Salt for Bouillon. What would be an equivalent “dose” per meal and/or daily? Any other considerations for such an adjustment?

    Thank you very much !

    Eddie

    (reply)
    • Peter Attia  April 18, 2012

      Start with an extra gram and titrate to effect.

    • Eddie  April 18, 2012

      Thank you ! 1 Gram per meal (i.e., 2-3x per day,) or 1 gram per day? Thanks again !

    • Peter Attia  April 18, 2012

      I aim for about 4-6 gm/day, of which I get about 3-4 from food, the rest from my bouillon.

    • Patrick  April 22, 2012

      Please excuse if this is pedantic: “g a day” of what? Salt, or sodium?

    • Patrick  April 23, 2012

      Peter,

      I’m drawing attention to this because it’s a minor inconsistency in your table “Regular supplements I consume every day”, on the most popular post “What I actually eat”.

      In the column next to “Bouillon (chicken, beef or vegetable)” you say “2-4 grams per day”. Note, you don’t specify “of sodium”, which I infer from the context. (Surely you don’t mean 2-4g of bouillon, for example.)

      Some readers might find that insufficient (information, as well as too little sodium chloride), and I’m not sure it’s enough to direct the reader to “titrate”, which I take to mean, “take as much as you need, adjusting as necessary”. How do we know how much we need? Do we take as much as the palate allows? Take as much as makes the headache, or nighttime leg cramps, go away, for example? I recognize that a reliable “dosage” is not indicated for everyone–you are not acting as a doctor–and perhaps that’s why you offer a range. And perhaps a range of 4g-15.5g of sodium chloride [sic] would be fine too, and this is all moot.

      2-4g of sodium, supplementing your already salted food, to make a range of 4-6g sodium per day, represents quite a lot of salt (4-6g sodium is found in 10.3-15.5g of sodium chloride). That’s a little more than I would reach for, if proceeding by taste buds alone (I do all my own cooking, and rarely eat out).

      A minor detail, amid such a wealth of information on you site, for which I am profoundly grateful.

    • Peter Attia  April 23, 2012

      This is much more art than science. I use about 2 or 3 teaspoons of bouillon. Each teaspoon contains about 900 mg of sodium. My total daily intake of sodium, from bouillon plus food, is about 4 to 6 gm per day.

  18. Cassiel  April 18, 2012

    Thanks for this great post, as always, Peter! :) Sometimes I get tired of the old “but the Japanese eat all that rice and they’re not fat!” because it’s such a simplistic argument. I’m glad to see you tackling it so succinctly. (FWIW, after all I’ve read, I’m with you on the omega 6/omega 3 thing, even if Gary isn’t! ;) )

    I spent three and a half years recently living in Japan and working in a company where I was the only white chick and nobody spoke English. (I speak Japanese – I was their translator.) I essentially integrated as much as a white person can, and got a lot of insights about how the Japanese live in general, including how they eat. The last 6 months or so of that time was when I first went low-carb, and I didn’t try to hide it or anything — I made a point of being happy to talk about it. Most people were open and curious, but it was interesting to see some people’s reactions to me suddenly cutting out rice, amongst other things! (One colleague told me point-blank “oh, we Japanese are different, we need our carbs” while filling her bowl with rice. :))

    What I found interesting to observe though is that the Japanese are catching up on the obesity rates, and I see this as being directly related to diet. A friend of mine once joked, “we gave Japan milk and they got taller, and then we gave them McDonalds and they got fatter” — but it’s kind of true.

    The traditional Japanese diet has lots of fresh vegetables, lots of fish and seafood in general, is more accepting of organ meats, and has a decent amount of fermented foods. Even today most young Japanese know how to cook a variety of traditional meals and prefer to eat at restaurants that serve Japanese food when going out. Yet at the same time, there are more and more fast food restaurants (McDs, KFC, and Japanese equivalents like Moss Burger) and more and more convenience stores (“conbinis”). At a conbini you can buy a prepackaged dinner for like 500yen and they’ll heat it in the microwave for you on the spot, so you can eat it right away. You can guarantee the quality of those is crap, not to mention a great deal of them these days are pasta based (ie Western style). Also, there’s been a huge surge in bakeries and other Western style desserts, meaning suddenly there’s a lot more bread products available — and the Japanese eat bread as a luxury, not a staple, so they’re usually sweet products laden with sugar. (Think cinnamon sugar rolls or maple syrup sugar bread, not sliced bread, although they’ll eat that too.)
    Couple that with the ever increasing workload, where everyone goes into work early, comes home late, and has little time to do anything, and the end result I see if that often people grab a bread product from the conbini and eat it at their desk for breakfast, and then get a conbini dinner or fast food meal on the way home from work. If they’re lucky and their office has a cafeteria they might get one good traditional freshly cooked meal a day (we did, but our company was good in that regard) or else they’ll do the conbini for lunch as well. Traditional foods get relegated to dinners with co-workers or friends (which may often include a lot of alcohol) or maybe weekends when they’re less tired.
    And, like America and other Western countries, more and more tasty snack foods are being made available all the time, meaning more people are getting addicted to them in just the same way; everything from chocolates to cookies to chips. The Japanese are fast veering away from everything traditional, and it’s not doing them any favours.

    I lived in a generically suburban area, and I had a lot of time to just look at the people living around me, and I like people watching anyway, and I found it striking to look at the generational difference of weight — the younger a person was, the more likely it was that they were overweight or obese. The older population was still overwhelmingly lean, but as soon as you got down to the 40-somethings, then the 30-somethings, then the 20-somethings, then the teens… each generation was more overweight as a whole, and I can’t tell you the number of overweight babies I saw. It still was nothing compared to America or Australia (my home) but it still was enough to stand out to me.

    To make a broad generalisation, the Japanese used to all be either skinny or sumo wrestlers. But that’s not true any more, and I blame the encroaching Western diet. I imagine this is true in any of these supposedly “skinny” countries — the more they introduce the Western love of sugar and refined wheat products into their diet, the fatter they get. To me, this just brings home the message once again that it is sugar and refined carbs that are doing the biggest damage.

    (Also, coming home to Australia after three years in Japan was a shock — when the hell did everyone HERE get so damn fat? XD)

    (reply)
  19. Carol  April 18, 2012

    Peter, after a year of gradual sugar and starch reduction, I’ve moved to a very low carb diet for the last 3-4 months and feel great. I eat mostly eggs, nuts, avocado, salmon, vegetables, cheese, full-fat yogurt, some meat, and some (but not too much) fresh fruit. I lost about 10 pounds (down to 137 and 5’6″, 30-year-old female) and am down to a size 2-4 from a 6-8. I just had a cholesterol test, and my LDL and total are somewhat elevated (total 264, HDL 86, LDL 165, triglycerides 65). I’m guessing that LDL is probably the good kind (large fluffy), but still, do you think I should be concerned about the high LDL?

    (reply)
    • Peter Attia  April 18, 2012

      Sorry, Carol, I’m trying (not always well) to avoid giving direct medical advice, as I’m not permitted. However, I’d ONLY recommend having a lipid NMR done. The test you’ve done does not give any relevant information.

    • Scott  April 18, 2012

      worth remembering that statistically, LDL cholesterol has never correlated with heart disease risk in women. HDL/trig ratio is probably the best predictor based on the standard panel, and your ratio is excellent (note I’m not a doctor legal blah)

    • Peter Attia  April 18, 2012

      But guys, if I only teach you 2 things, please make sure one of them is that LDL-P is all that really matters. Everything else is a guess. Some guesses are ok (e.g., TG/HDL-C) and some are not as good (e.g., LDL-C). Why gamble with a life?

    • lorraine  April 18, 2012

      If LDL-P is one of them, what’s the other? (kidding)

    • greensleeves  April 19, 2012

      Engrave this on a plaque, Carol, & give to your doctor: “The standard LDL recommendations do not apply to pre-menopausal women. They may have some application to post-menopausal women who already have demonstrated heart issues. Women exist and we are different.”

  20. Glaurung-Quena  April 18, 2012

    Another factor may be cultural approaches to food — if one group of people tends to eat only during meals (eg, as traditionally in France, according to Michael Pollan), while another group tends to eat a lot of snacks between meals (as in the US), and if the food industry manages to define “snack” almost exclusively in terms of carb-heavy foods (bread or candy rather than cheese or nuts) then the second group is going to never really have many hours during the day when their insulin levels drop.

    (reply)
  21. Michael J. O'Neill  April 18, 2012

    First, thanks for taking the time to write this. Work like yours can have profound effects on people’s lives. It certainly has on mine.

    Second, like many others, I’m psyched to read your upcoming post on Omega 3′s and 6′s. (If you get a chance to update your Omega 3 and 6 oil chart for that post, you might want to add coconut and olive oils to it, since they are so popular in paleo, keto and low carb communities and many don’t know what they provide for in respect to omegas)

    Third, your anecdote about how your BMI changed when you reduced carb consumption to <50g a day is interesting. I cut my carb load to <20/day about a year ago and have dropped approx 108lbs so far. It's still a work in process, but clearly it managed to help reverse a trend that was only growing more and more dire under the supervision of standard nutritional orthodoxy.

    Keep it up!

    (reply)
    • Peter Attia  April 18, 2012

      Thanks, Michael. Olive oil is virtually all monounsaturated (so very little PUFA, therefore little omega-3/6). Coconut is all saturated, so all not omega-3/6 component.

  22. Andrew  April 18, 2012

    I think that Lustig et al.’s emerging research–and the accompanying shift of public concern away from fat and toward sugar–will open a fresh window of opportunity for mainstream study of the full carbohydrate/insulin hypothesis. The researchers profiled in the 60 Minutes piece appear to be conducting rigorous, controlled research–real science. When and if that research convinces the overlords of epidemology that added sugar/refined carbohydrates are primarily responsible for CAD and the other infirmities for which fat was previously blamed, we might finally be able to broaden the conversation (and the science) to a consideration of the effects of all carbohydrates. That’s my hope, anyway.

    Peter- I appreciate the work that you and Gary and company have done (and that NuSI will do) to move that ball down field.

    (reply)
    • Peter Attia  April 18, 2012

      Thanks so much. Really look forward to launching NuSI this summer.

  23. Vytas  April 18, 2012

    Another wonderful article, though I must admit that I’m becoming increasingly more baffled (not by anything you wrote, but just by my own personal experience). Your last two paragraphs are the trigger that hit home. Although it’s my own situation, I’m pretty sure others are in the same boat. The net effect is that I believe things are even more complex than anyone realizes. And that’s what makes shaping a solution difficult.

    Here’s the very real scenario that truly muddies the waters:

    Last May 2011, I started a primal lifestyle. No breads, starches, grains,sugars. I eat grass fed meat, wild salmon, poultry, plenty of green leafy veggies, and a limited amount of fruits (strawberries, raspberries, apples), olives, macadamia nuts, and pumpkin seeds. That’s pretty much it. I dropped 50 pounds, having started at around 260 on a 5’11″ frame (male, 58).

    And then the weight loss stopped in November. NoAnd then all of a sudden, beginning early November,
    the weight loss abruptly stopped. I had changed nothing. My total carb (all from veggies and fruit) is well under 50 grams. Protein is around 90 to 100 grams. The only oil I use is olive and the only added fat is butter.

    Testosterone levels are normal. Blood lipids are fantastic. I exercise 3 to 4 days per week, with light aerobic (80% HR, no chromic cardio) and progressive resistance. Absolutely nothing in my diet, routine, and life has changed, other than being frozen at my current weight.

    What’s frustrating is that this makes no sense (to me) whatsoever. I sense that this is one of the reasons people give up and go back to eating junk.

    Someone told me that my problem is the need to gain more muscle mass. That, as well, is easier said than done. I just can’t seem to succeed in getting that regardless how much weight I lift or pushups I do.

    Since there are so many variations among people (and personal challenges as the result of genetics and metabolic differences), is it any wonder that there is so much debate about what works, what doesn’t, and why?

    If I can no longer lose weight eating virtually no easily-digestible carbs, starches, or sugars, what’s left?

    (reply)
    • lorraine  April 18, 2012

      Vytas, I don’t know if this helps in any way, but I know someone who’s experiencing the same as you. Her inflammatory markers are way high, and we’ve been wondering if this could account for her intractable plateau, so she’s going to have an omega-3 profile done.

      For you, though, are you sure you’re getting 50 g or less of CHO? I find that eating fruit makes it hard to stay at 50 or below. You might also experiment with changing the amount of calories. Sometimes you’re not creating a sufficient caloric deficit, or conversely, sometimes you’re in a sort of metabolic stasis and an increase in calories can get you going again.

    • greensleeves  April 19, 2012

      Lorraine is wise! Drop all the apples. If that doesn’t work, drop all fruit. If that doesn’t work, cut calories by 200 a day. If that doesn’t work, ask your doctor about metformin. :) You may still be profoundly insulin resistant.

    • Vytas  April 19, 2012

      Greensleeves, that doesn’t explain why I lost 50 lbs effortlessly. If I were that insulin resistant, it would seem that I would not have been able to do so.

    • Anu  April 19, 2012

      It’s just generally easier to lose the pounds at first and then it becomes harder. I lost 60 lbs fairly easily over six months but have been struggling to lose the 1ast 15 or so. I have to be extremely strict to lose weight — no apples, little fruit, count the carbs etc. So what works for 50 lbs may not necessarily work after that — you might need to be stricter.

    • Chris Graffagnino  April 19, 2012

      Vytas, my condition is somewhat similar to yours. One thing that helped me through a recent plateau was to limit artificial light after sunset; particularly, TV/computer/phone screens. Reason is that your metabolism is yoked to light cycles via suprachiasmatic nucleus. Bright light too close to bedtime=high cortisol=no REM sleep=no weight loss. I will go as far as to wear sunglasses at night if I have to. You will be surprised how quickly you start yawning if you do this.

      Here is an Oxford Univ. lecture re: suprachiasmatic nucleus

      http://www.sms.cam.ac.uk/media/1229403;jsessionid=2643280616B0DCAB467C506FF1F79049

      Best of luck!

    • KevinF  April 19, 2012

      If I may say so Vytas, OF COURSE it’s more complex than anyone realizes. Only the calories-in-calories-out crowd believes it’s easy, and no one coming to this website believes them. All people can do is give you suggestions that anecdotally worked for some others at times. The low carb community seems to accept that the body is a bagful of wet chemicals and hormones with a mind of its own, and the best we can hope for is to reign in the most dominant forces. There are no straight trendlines … forces in the body react to everything. For all the people who insist this is the best way to lose weight, no one I’ve seen actually guarantees you can necessarily become skinny per se, especially after you’ve spent years corrupting your metabolism.

    • Vytas  April 19, 2012

      All very good comments and much appreciated.

    • Pierre Legrand  April 20, 2012

      I am 6′ and started at 245. Stalled at 205 for 6 months. Decided I was still having problems with insulin resistence. Did a bit of reading and found out that Intermittent Fasting is one of the ways to “fix” that problem. Four months ago decided to try it for a month…still doing it and am now 192.

      I eat once a day. Usually at night with the family…this might be an easy thing for you to try. I got results within a week.

      Make sure to eat lots of saturated fat when you do eat and don’t worry about how much you eat.

      Btw I eat less than 20g of carbs a day.

    • lorraine  April 20, 2012

      Vytas, that’s a good question about how could you have already lost 50 pounds if you’re still insulin resistant. It’s something I’ve been wondering about, too, in folks I know who have significant weight to still lose after a pretty big weight loss and who then get stuck. In most, there’s a big stress factor in their lives (including sleep as mentioned by Chris), but doesn’t all that just go back to effects on insulin? In some, HOMA_IR is still high, but not in everybody.

    • Vytas  April 20, 2012

      Pierre, How are you getting enough protein with just one meal a day? I’m considering the 16 hour (Leangains) fast which I heard about on Mark’s Daily Apple.

      I’ve now stopped all fruit to see if it helps. My only carb now is essentially from lettuce and a single small tomato.

    • Cindy C.  April 21, 2012

      Have you tried adding coconut oil to your fats. Its different mix of fats may make a difference in your metabolism. Also for me, any nuts would always cause me to gain, even if their carbs were low. Nuts also mess up my digestion. I don’t eat fruit, as they cause too many cravings with me.

  24. Dave  April 18, 2012

    With regards to Omega-3s, I eat fish oil supplements each day. I always take the recommended dose on the container. Does it make any sense to eat more than the recommended dose? Also I know I still get too many omega-6′s, because while I am on a low-carb diet, I still eat some processed foods and dressings.

    (reply)
    • Peter Attia  April 18, 2012

      This question is a second order question, really. The biggest question, which I hope to get some better data on, is does it matter at all, and if so how much?

  25. Nicole  April 18, 2012

    This is a very minor part of the post, but I’m curious about it: “Will I ever go back to eating 100-150 gm per day of the “right” carbohydrates at some point? Probably, provided I don’t go back to eating sugar and stuffing my face with carbohydrates. It will depend on what I’m optimizing for.”

    Do you think being ketotic for years is not sustainable in some way? Or not optimal for long-term fitness or health? Do you miss particular carbs (rice, starchy veg, fruit) that you’re doing without now to stay ketotic? What do you think would motivate you to shift your diet away from ketosis?

    (reply)
    • Peter Attia  April 18, 2012

      No, I just think some aspects of my athletic performance have suffered and I may want to optimize around them. Also, sometimes I miss eating more fruits and veggies – NOT because they are “healthy” – but because I just miss eating them in higher quantities.

    • Nicole  April 18, 2012

      Thanks for answering, Dr. Attia, I’ve been low carb-very low carb most of the past 2 years and have lost 65 lbs. I miss some of the variety of having my carbs in the 50-80 g range, definitely more fruit and veggie quantity at that range. But right now I’m trying to stay under 30g until I get the last 30 lbs off. I feel great, my running endurance is improving, but I do miss the variety in my food. I do struggle more with the “zone of misery” when my carbs are in that higher range, especially for exercise, my body struggles to know if it’s a sugar burner or fat burner. Is that because I’m still 30 lbs overweight? Is that likely to be better when I’m at my goal weight (level of leanness)?

  26. jake3_14  April 18, 2012

    This statement caught my attention: “Higher levels of insulin lead to less fat oxidation and more fat storage (from both ingested fats AND ingested carbohydrates…” I thought that only insulin caused fat storage and that it acted in that role only on glucose (via GLUT4 transporters) and on triglycerides (via LPL) that have been created from excess circulating glucose.

    Can you please elaborate or point to a resource that explains this statement?

    (reply)
    • Peter Attia  April 18, 2012

      That is one way insulin makes you fat, but ingestion of fats in the presence of high levels of insulin also promotes fat storage rather than oxidation. That’s why fattening sweets are particularly bad.

  27. steve  April 18, 2012

    Dr Peter:
    Excellent post. Use your NMR results to gauge how much carb you can tolerate in light of your CAD concerns coupled with maximizing athletic performance. I have no doubt you can eat a greater amount of carbs,and be able to maximize both cardiac markers and athletic performance. You have to via NMR find out what your LDL particles look like based on diet experimentation.
    I am surprised at GT questions about Omega 6/3. Most of the studies i have seen in the past highlight the protective nature of the Japanese diet which many think is from the the 2-4oz of fish consumed per day.
    I would also add that increasing amounts of fish oil via supplementation carries with the risk via more poly’s in the diet and greater chance of oxidation. Far better to reduce the Omega 6 in the ton then to consume tons of fish oil daily. A gram or two probably ok, but beyond that one will raise their LDL cholesterol and possibly subject themselves to more oxidation.
    A+ for recognition of underlying patterns shared by different cultures whose diets clearly are more health promoting than SAD. Our problem in a nut shell whether you agree with CIH is carbage- junk and glycemic load as you have pointed out. Thanks.

    (reply)
    • Peter Attia  April 18, 2012

      I will definitely use NMR, glucose, insulin, NEFA, and TG levels to titrate.

  28. Maryann  April 18, 2012

    Olive oil is one of the top foods with fraud, unfortunately. The April Journal of Food Science is quoted as reporting : “Among the adulterants found in extra virgin olive oil: cheaper ingredients like hazelnut oil, sunflower oil, refined olive oil, palm oil, peanut oil, and olive oil from a “non-authentic geographic origin” (translation: not the country the oil is said to be from). The list goes on.”

    For anyone interested, there is a website (extravirginity.com) that is compiling a list of authentic olive oils. It is so important to be sure what we are consuming is not diluted with inferior oil and contaminants.

    (reply)
    • Peter Attia  April 18, 2012

      Yes, unfortunately, quality control, even with “extra virgin” is probably suboptimal. Thanks for link to get real stuff. I’ll check this out.

    • Chris Graffagnino  April 19, 2012

      The author of Extra Virginity recommended this source:

      http://www.californiaoliveranch.com/

      REALLY good stuff…I put this against another high-dollar estate from Sicily; equal, if not better taste. One year “younger” & quite a bit cheaper!

    • Peter Attia  April 19, 2012

      I’m going to give it a try.

    • Peter Attia  April 21, 2012

      Just ordered 6 x 500 mL bottles for $60 with free overnight shipping. Made my salad dressing with it tonight. VERY good! Thanks for the recommendation.

    • maryann  April 19, 2012

      We use California Olive Ranch. A Google search will give you a free shipping coupon.

  29. Paula  April 18, 2012

    Fabulous! Love this topic. Get tired of debating it with people though, the excess, the overload, the explosion of the carbs that are available was not fathomable in the 80′s and prior. Especially sugar! You simply did not have the variety or everywhere access or enormous sizes and relatively inexpensive too. Before long other overseas nations will face the same obesity epidemic if they mirror our situation.

    Remember when wearing Levi’s was the ultimate American fashion statement overseas? Soon, just like here, American sweatpants will be the height (or low) of overseas fashion…

    (reply)
  30. lockdownd  April 18, 2012

    Hi Peter,
    I didn’t realize flaxseed oil was so high in Omega 3. One of my “go-to” foods to ensure a high fat diet is olive oil. Gary’s skepticism aside, do you think it makes sense to incorporate more flaxseed and less olive oil to get more omega 3?
    thx,
    Eric

    (reply)
    • Peter Attia  April 18, 2012

      Only IF you believe absolute omege-3 (rather than conversion to EPA and DHA) matters. Flaxseed (linolenic acid) converts poorly to EPA and DHA.

  31. Debbie  April 18, 2012

    Below find a post from today’s NY TImes “debate” on vegan eaters vs. meat eaters. This post is typical of a pro-vegan. What I’m wondering is, are these people just the exceptions (probably)? The vegan “debaters” definitely were more strident and sillier sounding than the pro-meat; I say that with no bias whatsoever. Sorry, but they sound desperate to me.

    PatrickCalifornia
    My wife and I are long-time vegans raising a healthy vegan child. Our wonderful daughter is above-average in height and in the 95th percentile in head size. She has hit virtually every developmental milestone at least a month ahead of average, and she has been regularly declared healthy and above average by our pediatrician, who has decades of experience with thousands of children and who has declared that he is comfortable with our vegan choice. We know at least a dozen other vegan children who are healthy and high-functioning. That’s consistent with the findings of the American Dietetic Association, the nation’s largest organization of nutrition scientists, which has issued a position paper written by experts who reviewed the existing peer-reviewed literature and found that well-planned vegan diets are healthful for infants and children. The considered opinion of such experts–and of our pediatrician–are what we rely on to make decisions about our child. We don’t tend to factor in the opinions of cookbook writers.

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  32. Stephanie  April 18, 2012

    I agree with everything you’ve said. Add to your already well laid out post are the following contributing factors: Use and abuse of anti-biotics and general Western medicine disease management that is symptom-centered and clears beneficial gut microbia, over use of sterilization in general home life, and finally- use of non-natural food substitutes such as margarines and non-dairy creamers.

    Since moving to Germany and interacting with a very internationally diverse crowd, I’ve been surprised time and time again with the greater acceptance and wider use of traditional therapies and adherence to different life-style traditions by non-US Americans. Some of these include: herbal remedies and teas, not using dish soaps and cosmetic soaps, not bathing every day, and consumption of way more fermented foods. Obviously you can see I on a very “internal microbiota” centered theme and quite favor this etiological angle :)

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  33. J  April 18, 2012

    Good article, great blog Peter. I have a question about something not really related. Sorry if this is offtopic for this entry.

    Right now I have cut carb intake by a lot and I’m looking great and feeling great. Unfortunately, I’m not very muscular, and now that I’m losing so much blubber I’m getting a… kinda girly figure. Do you think gaining muscle mass will work on a low carb diet? And if so, when do you think is the optimal time to take in protein or fat, and from what sources?

    (reply)
    • Peter Attia  April 18, 2012

      You can, but you probably need to really focus on resistance training and adequate protein intake.

  34. Kenny  April 19, 2012

    Carol, I recall Dr. Eades saying that if your triglycerides are below 100, as in your case, and LDL is calculated (standard lipid panel) and not directly measured(NMR lipoprofile), which i’m also guessing is your case, then your total LDL number(while meaningless) is almost assuredly much lower than your test is showing. The Friedewald equation which is used to calculate LDL, tends to be way off for those with triglycerides under 100. With an HDL so high, and triglycerides so low, chances are you have mostly large fluffy LDL particles. But, like Peter said, best to get the proper test done (NMR lipoprofile).

    (reply)
    • Peter Attia  April 19, 2012

      Standard cholesterol testing calculates (i.e., estimates) LDL-C using this simple formula: LDL-C = TC – HDL-C – TG/5, because the assumption is that TG/5 is approximately equal to VLDL-C. This formula is reasonably accurate for LDL-C if TG are not completely out of line, when compared to a direct measurement of LDL-C. The larger point, of course, is that this number — estimated or directly measured — is not what we should be worried about.

  35. Rob  April 19, 2012

    The Glycemic load argument is so true. Only in the US did I travel and have to share a plate of food with my partner for every evening meal because it was too big for me (and I’m a big eater) and many restaurants get annoyed by this. I was ordering small coffees and they were still bigger than the large coffees in Italy. Portion control does not exist there.

    (reply)
    • Travis Koger  April 19, 2012

      Rob,

      Portion control exists, just they are used to people expecting larger portions.

      When I was in Chicago last year… on low-carb. I ordered a burger at a really good burger place. I requested no chips/fries and no other sides… the meal normally came with several. The very nice waitress literally asked me three times if I was sure after offering many, many alternatives to the menu item. In the end the meal came out with coleslaw on the side with the explanation that the waitress felt bad for only supplying the burger, therefore she added the coleslaw on the side. I still didn’t eat it, but to me it shows that normally they feel under pressure to provide more rather than less.

      Burger was still great, but I was still questioned if there was something wrong with the coleslaw… and the bun, as I didn’t eat either.

      Surprisingly enough, one of the biggest issues I had whilst in the US (I was there for for over a week), was getting food with enough fat in it and little carbs. In the end I almost had to abandon low-carb for several days because it was getting increasingly hard to find something to eat that didn’t seem like a returned meal. :)

    • KevinF  April 19, 2012

      Sad but true Travis, not enough of us low-carbers to make a market, I suppose. But here’s a tip if you can find one: go to a barbecue joint — the more shack-like the better. Can always get fatty brisket, ribs, and sausage and other meats. Skip the BBQ sauce and the side orders. Those are about the only restaurants I patronize any more; fortunately I’m in Texas.

    • Mark Jacobs  April 20, 2012

      Kevin, yes being in TX is a big plus for low carb, but so is North Carolina, pork and I can have the BBQ sauce here, as long as it’s Easten style sauce. The Eastern NC sauce is vinegar with red pepper flakes. Tasty fatty pork and vinegar is a low carb dream

    • KevinF  April 21, 2012

      Yeah Marc I’ve heard tell of that Carolina style sauce. There’s a great place near Austin called Salt Lick with a vinegar sauce, though I can’t say from experience if it’s exactly the same. Traveling the land and investigating all the BBQ traditions pretty much constitutes my entire bucket list.

    • Topper  July 10, 2012

      The Salt Lick is definitely my favorite BBQ joint here in Austin. I go weekly (Low-carbing for 2 yrs, ~200lbs lost and counting). If you ever do go, you have to get the “burnt ends” of the brisket. The sauce, however, is more sugary then vinegary.

  36. Lo  April 19, 2012

    “That is one way insulin makes you fat, but ingestion of fats in the presence of high levels of insulin also promotes fat storage rather than oxidation. That’s why fattening sweets are particularly bad”

    The way you put this surprised me.

    My IR is so high that my fasting insulin levels are 5-6 times what they should be–I always have high insulin even without eating anything.

    I have been stuck without significant weight loss for months now while eating very, very low-carb but relatively high fat.

    Looking for something to break me out of this rut, but I have been very opposed to the idea of PSMF diets because they also cut out fats. From your reply above, though, do you think it’s sometimes necessary for some people to severely restrict both fat and CHO?

    (reply)
    • Peter Attia  April 19, 2012

      No, just restrict CHO. IR goes away within weeks with strict restriction.

  37. greensleeves  April 19, 2012

    “My point is this: Just modifying your diet by the 3 factors I mention in this post — elimination of sugar, less total glucose load, and improved omega-3/omega-6 profile — even if you are not genetically programmed to be lean, will probably deliver 80% of the value in terms of disease risk and body composition.”

    Is this true for women, Peter? I wonder. The female metabolism is obviously so different than mens’ – insulin/leptin disorders just kill our fertility, for example. . . how do we – or should we – account for gender differences?

    (reply)
    • Peter Attia  April 19, 2012

      There are 3 distinct types of adults: men, pre-menopausal woman, and post-menopausal women, and unfortunately it seems this order is also true in the complexity of understanding fat regulation in each subset. I’m working hard to understand all groups, but it’s taking some time. Agree with your concern, though. I still believe all 3 groups are greatly helped – at least by factors #1 and #2 (and maybe #3).

  38. count bitcoin  April 19, 2012

    Disciplined carb avoiders like myself may accidentally enter ketosis (although now I’m purposefully in ketosis, because it’s the balls).

    So it’s ketosis + sodium = OK. Because I’m not a measurement person, or what one might call “organized”, I need simplicity for my brain not to detonate.

    If exercising or still feeling bad you add magnesium? Or if I already feel great I can stop obsessing?

    (reply)
    • Peter Attia  April 19, 2012

      Most people in ketosis do need supplemental Na and Mg.

  39. Michele  April 19, 2012

    Peter…THANKS for the Wolfram/Alpha link!

    It is FASCINATING.

    (reply)
  40. Kathy  April 19, 2012

    To the genetic issue – I don’t think the fact that Asians moving to the US and becoming obese disproves that there could be an (at least) an epigenetic component (not to mention that geneticists keep finding function among the so-called “junk DNA” that was once thought to do nothing – who knows what is contained there?)
    If you change the environment radically (such as Asians moving to the US, or moving the US diet to Asia) then the methylated genes, used to dealing with an entirely different diet (high carb, low sugar, high in omega 3s, etc)are likely to be overwhelmed. One poster made the point that his pre-low-carb breakfast drawfed the typical Asian daily carb-intake in one meal – it would most likely drawf the Asian’s carb-coping mechanism as well.

    (reply)
  41. Kathy  April 19, 2012

    oops – I meant to also say I would gladly pony up some funds to support your web-work, too!

    (reply)
    • Eve  May 1, 2012

      Your 3 points make better arguments than the link you gave here:

      1.”Low to insignificant consumption of refined sugar (fructose).”
      Both China and Japan leads in rice consumption. Let’s use Japan for comparison being closer to Western lifestyle.
      Japan is the leader in functional foods production. Many of the foods you will find in their supermarket are processed foods with some added nutrients to boast functionality. If you read carefully, you won’t miss fructose or its kinds listed as key ingredients on the packaging. Standing in the queue line, you will find more processed foods sit in the shopping trolleys than fresh foods.

      2. “Eating mainly unrefined starch (e.g. brown rice, root vegetables) that is slow to digest”
      Nope. Their typical diet – ramen (white processed noodles), white rice + glutinous rice (same like in sushi), miso soup, little vegetables, few pieces of meat or seafood. Japanese valued aesthetic more than they value nutrition. Brown food is hard to find in supermarkets nor in eateries. The best ramen is clear white, reflective like mirror, bouncy like rubber.

      3. “Traditionally more physical activity then sedentary western population.”
      By the late 90′s, Japan economy is fueled by industrialization. 9 out of 10 has work that is either desk or machine bound. They take LRT or train or drive to work. Most jobs are fairly comfortable that they do not produce a sweat in a day.

      Although I have no data off hand to offer, my observation tells me their calorie intake is so much less than typical American’s, their cuisine still as conventional as their culture could be without much frying or cooking with added oil. This resonates well with the theory that carbohydrate combined with oil=IR=fat accumulation? The key in why Asian eating so much carbo and still manage to stay thin is the disparity in the amount of oil used to cook and consumed. With the infiltration of American chain fast food restaurants in some part of Asia, we now have picked up scary jump in morbid obese children and young adults across all Asian continents. A portrait of fat kid was once hard to find in China is now a common scene when you walk the street of Beijing. Compare to Tokyo, much less seen simply because less such chain stores in the streets of Tokyo.

      For the record I am Asian and love Asian food. I practice Nutrition and help in community health screening once in a while. On the occasion that I picked up one family of 5 with the smallest and youngest member >100kg, I also found out that they used up 1 bottle of 5kg cooking oil in 3-5 days. How ironic is that?

      Why am I posting here and not at your link? I think it is important to talk about Nutrition responsibly which I agree to most of your posts here hence my point is please evaluate the link before adding them to your post. Other than that, please keep up the good work. Best regards.

  42. Dorian  April 19, 2012

    Peter, a bit off topic here, but both my wife and I have ventured into LCHF over the last 3 years with the most recent year being essentially sugar and grain free (with lots of sat fat from grass-fed cows). She has one of those executive medical exams coming up, where I believe we can request exams (and don’t have to pay for them). While she is in good health, we figure it couldn’t hurt to establish some baselines. We were planning to ask for the NMR (for LDL-P), Hg1Ac, and CRP. Any others you would suggest? Thank you.

    (reply)
    • Peter Attia  April 19, 2012

      Try to have your doctor go through Health Diagnostics Laboratory, who do not only these labs, but a great test on sterol absorption and synthesis, which can help guide therapy. Make sure to include a fasting insulin level, too.

  43. Ben C.  April 19, 2012

    Another fantastic post, Peter!!

    I have an additional thought regarding the question as to why some cultures stay lean while consuming high amounts of carbohydrates…at least as it applies to most Asian cultures:

    Traditionally, the staple carbohydrate of Asian societies is rice, which breaks down almost exclusively into glucose…virtually no fructose. As Dr. Lustig has suggested and some research corroborates (and you have laid out on this blog), fructose has a very different metabolic pathway from glucose and tends to promote insulin resistance and obesity to a much larger degree. So, one could argue that one simple answer to the question is the low overall fructose consumption in traditional asian cultures compared to modern western cultures.

    Additionally, most rice is naturally gluten-free. Current research and books like ‘Wheat Belly’ argue that gluten tends to spike insulin and promote insulin resistance even more so than table sugar. So low levels of gluten in traditional Asian diets as opposed to modern western ones might also significantly contribute to their relatively low obesity numbers.

    (reply)
  44. Tom  April 19, 2012

    Just out of curiosity have you run into Hans Rosling and/or his Gapminder software? They have a huge amount (albeit lots of breadth not much depth) of world data in an application (free) that lets you do some pretty amazing things in visualizing the data. Lost on health and nutrition as well.

    He might be a good resource/advocate for your new venture as well. You both share a similar pattern in destroying common myth’s. if you have not seen his TED presentation on YouTube it is phenomenal.

    (reply)
    • Peter Attia  April 19, 2012

      Tom, I’d love to discuss this with you. As you can see, I can use some help. Please email me.

    • lorraine  April 22, 2012

      WOW! Thank you, Tom, for sharing this. I watched two of his TED talks and can’t wait to see what one can do at Gapminder.

    • Alexandra M  April 23, 2012

      Thanks! Rosling is amazing – the first TED talk I watched was about poverty, and I’ve got to say that’s the first time I’ve ever seen a TED talk ended that way!

      http://www.ted.com/talks/hans_rosling_reveals_new_insights_on_poverty.html

  45. Marilyn  April 19, 2012

    @Travis Koger: “Surprisingly enough, one of the biggest issues I had whilst in the US (I was there for for over a week), was getting food with enough fat in it . . .”

    That doesn’t surprise me in the least. I live in the US. Hubby and I must have the discussion at least once a week about how good meats used to be. We’re old, so we remember the good old days. It’s quite a revelation to haul out some of my old cookbooks and see the fatty cuts of meat illustrated.

    (reply)
  46. Elna Cain  April 19, 2012

    Hi Peter
    I just have a quick question regarding your idea of going back to eat carbs again. If you go back to eating 150 gms of carbs, will you still eat the same amount of fat, or will you have to eat less fat? Or low fat? Just wondering. thanks

    (reply)
    • Peter Attia  April 19, 2012

      I suspect my fat intake will go down.

  47. tom  April 19, 2012

    Another thing that is killing you on bandwidth costs is you are saving line art (charts, graphs) as .jpgs, when they get much smaller without losing quality as .gifs.

    ie, the chart on this page…
    http://eatingacademy.com/nutrition/what-i-actually-eat

    …is 800kb as a .jpg, but 50k as a .gif.

    The rule of thumb is to save continuous tone photos as .jpg’s, and line art as .gifs.

    Smaller file sizes also load far faster, and Google ranks fast sites higher, so you win on both counts.

    ok, enough nerdiness for today. Thanks for the blog! :-)

    (reply)
  48. Dave at the Y  April 20, 2012

    I see the Glycemic Index often used to indicate the relative level of glucose delivered to the blood. What do you think of the Insulin Index for quantifying the “typical” insulin response to a food?

    Wouldn’t be great if we could readily measure our individual Insulin Index?

    Thanks for the great site!

    (reply)
    • Peter Attia  April 20, 2012

      The two aren’t the same, of course, but what’s interesting is that the same foods have different “responses” in different people. The nice thing about the insulin index is that you get a better sense of the contribution made by protein.

  49. Pierre Legrand  April 20, 2012

    Peter another homerun…

    A comment of mine got dropped and was wondering if I should review the comment policies and if I need to where they might be located.

    (reply)
    • Peter Attia  April 20, 2012

      There is a delay between when you post and when they go up.

  50. Lardlad  April 20, 2012

    It’d be interesting to study a sumo wrestlers macronutrient intake.

    (reply)
    • Peter Attia  April 20, 2012

      Agreed. I’m sure it’s been, done, though I don’t know the answer. I have a guess, though…

    • Martin Levac  April 20, 2012

      I tried to find info on that and I couldn’t find the thing I wanted. This should be close enough:

      http://caloriecount.about.com/chanko-nabe-sumo-stew-recipe-r466579

      Look at the carb/fat ratio. It’s a LFHC diet. The protein content is rather high. But when we look at low carb studies, we find that all diets don’t differ much in the protein content. What matters for weight is carb/fat content and ratio. If we extend that single meal to the typical caloric intake of sumo wrestlers of about 20,000 kcals per day, we get a total fat intake of about 300g/day, and a total carb intake of about 1,900g/day. For 2,000 kcals, 30g fat, 190g carbs.

      The reality is that 300g of fat is a huge amount of fat, therefore has a huge effect on satiety. It’s doubtful that they actually eat that much fat. Therefore it’s doubtful that they eat that many calories. Overfeeding studies tell us 8,000-10,000 is about the maximum calories a human male can eat in a day. Our own situation tells us we can grow just as fat as, if not fatter than, sumo wrestlers by eating barely over 2,500 kcals/day. A more reasonable estimate is that they eat around 5,000 kcals/day, most of it coming from carbs. That info comes from the thing I couldn’t find. The info widely available is a myth (20,000 kcals).

      One anecdote I know of is a bodybuilder who tried to eat his maintenance calories but virtually no carbs. He couldn’t maintain his weight (280 lbs). He lost 9 lbs in a month eating 3,500 kcals of meat, cheese and bacon. He also said he had so much energy and just wanted to lift weights all day.

  51. Martin Levac  April 20, 2012

    Hi Peter, to your question, the simple answer is that we mischaracterize both their traditional diets, and our own modern diet.

    We believe lean meat is best, right? Where does that belief come from? The low fat dogma, of course. You and I know this idea is flawed. Nevertheless, it drove us to imagine all kinds of reasons we shouldn’t eat modern fat meat especially when they’re fattened up with grains. Thing is we used to prefer fat meat before. How did this fat meat got fattened up before our grain industry? Rather, what kind of fat did grain-free produce? Besides the o3/o6 aspect, it’s the same kind of fat found in grain-fed meat. This means lots of saturated fat.

    While o3/o6 quantity and ratio might be important, we’re talking about tiny quantities, milligrams. Changes in tiny quantities are important with micronutrients like vitamins and minerals. But when it comes to fat, macronutrients, tiny changes don’t matter much. It’s the big changes that matter. Just look at carbs. The difference between 250g and 300g is irrelevant. But going from 300g down to 50g makes the world of difference. It’s the same thing with animal fat vs vegetable fat.

    When we replace animal fat with vegetable fat, we do change the o3/o6 picture but we change the saturated fat picture even more. We barely eat any of that anymore. But we used to eat tons of it every day. The difference here might be something like 100g vs 10g or greater. Also, some populations eat tons of fish. That means tons of o3. Compare that to populations who eat barely any o3 yet still maintain good health. It’s not the o3/o6, it’s the saturated fat. It’s the fat meat.

    The fundamental aspect that lead to our mischaracterization is industry. Our modern high carb diet requires a huge industry. No industry to eat low carb. Just hunt and gather. Do these “healthy” populations have that kind of industry? If not, then they don’t actually eat a high carb diet.

    Other aspects. Indigestible plant fiber, therefore barely any carb absorption. No industry, therefore barely any vegetable fat consumption. Genetics: No immunity to modern high carb diets when traditional populations switch to it.

    (reply)
    • Peter Attia  April 20, 2012

      Really spot on commentary, Martin. Thanks.

  52. jason  April 20, 2012

    Peter,

    How do you explain that 30% of obese individuals have low fasting insulin levels and no evidence of insulin resistance? How does that fit into the carbohydrate insulin hypothesis?

    Thanks.

    Jason

    (reply)
    • Peter Attia  April 20, 2012

      I’m not sure 30% of obese individuals are not IR. Fasting insulin, while a good marker of IR, is not a perfect marker, either. Changes in VLDL particle size, number, and TG content within VLDL can precede changes in insulin and glucose levels by many years and therefore are much more sensitive markers of IR. So…I think most obese patients are, in fact, IR. That said, I’m sure a small subset of obese patients are minimally IR or maybe even not IR at all. There are other endocrine disorders that can cause obesity in an isolated setting with out IR, but they are not particularly common.

    • lupo  April 24, 2012

      Hello Jason!

      Excellent question. I had the exact reverse topic with my physician attending today. He said that there is a significant number of lean people with type II diabetes.
      The cause of obesity or leanness isn’t always about the amount of carbs or the type of carbs. One possible answer is “genetics”.
      Hope we can see good research on that in the future.

    • Peter Attia  April 24, 2012

      “Significant” needs to be kept in context. *Any* number of lean type-2 diabetics is significant, as it seems to counter our understanding of IR, but it’s not like 25% of T2D are lean (exact numbers are hard to come by because so many T2D are undiagnosed, and the lean folks may be disproportionately represented in this group).

  53. Anthony Peters  April 20, 2012

    This may be off topic but I have to ask, when you have an injury, what resources do you use diagnose it and figure out a path to recovery. When searching the internet I find a lot of contradictory stuff. I’m currently suffering from an elusive but persistent back/hip/leg injury (changes from day to day) I’ve quit all activity except for slow lifting once a week. I probably need to get an mri done but don’t have the money, and doctor’s have been pretty useless. If anyone knows of a good resource you’d certainly make my day.

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  54. Caro  April 20, 2012

    Damn. I’ve knocked out wheat, and I’m trying to limit other grains (and potatoes) as well, though I’ll probably make some exceptions for rice. I’m still not up to letting go of sugar. I often think about it, but I keep buying chocolate…

    (reply)
    • Peter Attia  April 20, 2012

      I’d knock out sugar before even wheat, but if you’re getting results you’re happy with, keep it up.

    • cancerclasses  April 21, 2012

      Chocolate cravings can be a symptom of ‘magnesium deficiency’, google that term & you’ll find lots of info.

      To kill sugar & carb cravings eat more butter, coconut oil & good saturated fats with or without protein but not with sugar & carbs, if you’re not eating at least 2 or more tablespoons of butter per day you’re not getting enough good dietary saturated fats.

      Also, recalcitrant & refractory carb cravings that will not resolve can be a symptom of a systemic fungal infection or cancer since they both use glycolysis, fermentation of sugars, to produce energy and thus cause demand for large intakes of carbohydrates.

    • Ben Gilsdorf  April 24, 2012

      I tried some of the commercially sugar free chocolates, but I was not happy with any of them. I make my own chocolate. I buy unsweetened chocolate(some call it baking). I buy virgin coco butter (the eating grade)and I mix it 50/50. I add stevia, erythritol and splenda to get the right sweetness. I started out using coconut oil but it melted to quickly. The coco butter gives it the right feel. I add a little sea salt and a touch of ground chiles. I have used ghirardelli, dagobah and scharfenberger. I don’t yet have a favorite. Enjoy

  55. David  April 20, 2012

    Peter, A bit off topic, but I bought the blood ketone/glucose monitor you have on this site. When do you test? Before or after meals? Thanks, Dave

    (reply)
    • Peter Attia  April 21, 2012

      All the time! Just depends on what you’re specifically looking for. For day to day consistency, I like a morning fasting level.

  56. Marilyn  April 20, 2012

    Caro, a Hershey’s kiss or two or three over the course of a day is pretty harmless sugar-wise. I’ve found that one or two of those leaves me just as chocolate-satisfied as a whole fistful. Plus, there are all sorts of things one can do with cocoa powder and sweetener (I use stevia/erythritol) mixed into butter or coconut oil or cottage cheese or yogurt or whatever. Add some chopped nuts and away you go.

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  57. Eric  April 21, 2012

    Great post, Peter, as usual. I couldn’t agree more with some of the contributors here: traveling is a bear! I’m in Chicago right now and simply can’t describe the odd stares I get when I order a 3-egg omelet with bacon, ham and cheese but no toast or potatoes but please add two pats of REAL butter and some full fat cream for my coffee. They think I’m nuts. I travel nearly every week and it’s hard to keep up with how many times I get responses like that. I ordered a tomato and mozzarella salad last night along with a 9oz filet with some butter. The waitress freaked and asked the doctor sitting near to me if what I was ordering was healthy. He said absolutely not….that’s a recipe for a quick death. Bless his heart.

    Basically, I would give a big fat hug (no pun) to anyone who can figure out a practical way of traveling LCHF that doesn’t involve intermittent fasting (convenient on travel days) or dehydrating your pet grass-fed cow.

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    • Marilyn  April 21, 2012

      Eric, you just have to be sneakier. If the menu says “choice of potato,” tell the waiter/waitress to skip the potato because you don’t like potatoes. (People who don’t like potatoes do exist.) Don’t say anything about the bread because with the inevitable bread/rolls comes automatically some butter. As the waiter/waitress is setting the butter on the table, ask “Is that real butter?” If not, you can then ask for some. If they ask what type of bread you want or if you want it toasted, go along with the game and pick one, then just leave the bread on the table. When it comes to coffee creamer, I just use the half and half. The amounts are so small, it really isn’t critical. Just be sure it isn’t a non-dairy creamer.

      P.S. Don’t you wish you’d asked the waitress if medical advice was included in the price of the dinner?

    • Matt Taylor  April 21, 2012

      When a waiter or anyone asks me why I don’t eat bread, potatoes, rice, fruit, etc. I am more blunt and ask them, “Do you want all 137 reasons or just the top five?” If they insist I usually say something like, “1) I would prefer not to die prematurely, 2) I don’t want to weight 50 lbs more than I do, which I did when I ate “low fat”, 3) I don’t want diabetes like many many men in my family, 4) I don’t want to get heart disease, like many men in my family have died from, and 5) I have more energy and feel better eating this way. Next question! “

    • Alexandra M  April 25, 2012

      Quite a few places – even my local diner – offer a “healthy” plate: burger on top of a salad. Of course the plate also comes with 2 cups of cottage cheese and 1/2 cup of coleslaw. But, hey. At least they got it about the bread!

      The Holiday Inn I stayed at in DC actually had a low-carb breakfast of eggs (I had them add cheese), grilled chicken, avocado, sour cream and salsa. It was good enough to have two days in a row. So that shows some progress!

    • Marje  June 12, 2012

      For my birthday last week, I asked the family to take me to Jimmy Johns Gourmet Sandwiches for lunch. I had just read that they will make any of their sandwiches WITHOUT BREAD… but wrapped in lettuce instead. We all agreed… their “unwiches” were delicious.

  58. Glenn Whitney  April 21, 2012

    Thanks for your interview with Ben Greenfield – very stimulating.

    I also posted this comment on Ben’s site:
    So this helps prove that humans can thrive on almost any combination of macro nutrients you can imagine. But thrive for how long? Is this an optimal diet for reproductive health? Evolution can only be understood in the context of reproductive fitness.

    A few other points to consider:
    - When it is cold in the Arctic, it is cold all day, all night and cold in the shelter, not below freezing but cold. The air people breath 24/7 is cold everywhere, in a way it rarely is below the Arctic
    - Even above the Arctic Circle, where Inuit and other Artctic people have lived, there is a warmer (unfrozen) season, in which a wider variety of foods (including carbohydrates!) are consumed.
    - If he hasn’t already read it, I highly recommend to Peter (as a Canadian) the anthropology book “The Other Side of Eden” by Hugh Brody, who lived among the Inuit for many years
    - Also recommended is the BBC’s Human Planet. In particular, there is an episode on Narwahl wale hunting. The skins apparently is highly sought after because it’s one of the rare sources of Vitamin C in the native diet

    (reply)
    • Peter Attia  April 21, 2012

      Many of our ancestors were in ketotis for long periods of time. Not only would they be in ketosis from eating relatively few carbs, but more importantly any time they would go 24-48 hours with out a meal — not too uncommon in our evolution — they would be in ketosis. If we didn’t have the ability to make ketones when our livers ran out of glycogen we would not exist (for an example of this, look at the natural history of children with glycogen storage disease, type I). So it’s not clear to me how ketosis is not sustainable or how it fails to foster reproductive fitness?

    • Martin Levac  April 22, 2012

      @Glenn,

      “Evolution can only be understood in the context of reproductive fitness.”

      Nicely put. I’ve been looking for a way to say that as simply as you did. I will add that the context must include the ability to feed the young until it becomes fit to reproduce as well. Though I guess that’s implied anyway.

  59. Rosalee  April 21, 2012

    Thanks for this article, it’s nice to feel better prepared to respond to concerned friends and family.

    I just wish more people knew about why fat is not the enemy. I’m probably being too sensitive, but I can tell my classmates are looking at my eggs and bacon breakfast thinking no wonder she’s fat. I get little comments like oh wow I’d only eat that on the weekend while they practically gloat over their bowl of fruit salad and oatmeal. I guess once I’m lean people will see what I eat and think she must have a crazy active metabolism.

    I know I shouldn’t care what others think, but it is hard not to. I guess I will just have to work hard to reshape myself to be an example to help people rethink their assumptions about nutrition.

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  60. count bitcoin  April 22, 2012

    My Epileptic-Ketogenic Hot Dog and my experimental findings (for the animal lovers on this site)

    Although this is on topic, it is off species. My dog, Dolce, became epileptic when my daughter was born and I have spent the last 3 years researching the subject while adapting to her condition. Dolce is an adopted black lab-faced hot dog who is sweeter than the sweetest high fructose corn syrup.
    I don’t want to get into details because the post will get too long so I will get right to the important findings, which I only found based on my response to her 2 acute episodes of pancreatitis which almost killed her.
    Finding 1: The literature about the benefits of restricting food in regards to life span and health in all sorts of test animals seems to hold up in the case of my dog (feed the dog less food and it is healthier, except reproductively).
    Finding 2: I switched her from “EVO (low carb) red meat”, to “EVO herring and salmon meal (also low carb)” after the pancreatitis episode, while simultaneously restricting her food intake (fish probably dissolves in her stomach more quickly, easing the strain on the pancreas).
    Finding 3: The switch in food type and quantity was the only change made after pancreatitis, and dolce has not seizured since (8 months now). Dolce had seizures once a month, every month (like an epileptic clock), consistently for a solid year before the pancreatitis episodes. She is treated with phenobarbital, the same drug epileptic humans are treated with.
    Finding 4: Dolce lost 6% of her body weight since switching to the new food/quantity, which has allowed my vet and I to reduce her phenobarb dose by 25% to account for new mg/kg ratio. This is important if it works out as extended exposure to phenobarb can eventually force me to supplement with bromide which is prohibitively expensive compared to just pheno, which is only $25/month or so.
    Conclusion: For you dog (and cat) lovers who are on this site who still believe dogs (or cats) were practicing agriculture at some point in their evolutionary heritage, I figured I’d remind you to consider your dog’s health in the same way you have re-considered your own. Your dog will face-lick you for it.

    (disclaimer) – in case anyone reads this and isn’t aware already, xylitol is deadly to dogs, but great for home made ice cream.

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  61. Doug  April 22, 2012

    Also, the French never adopted the low fat message and as you alluded, never jumped on the vegetable oil bandwagon but rather continued to use traditional fats like lard and butter, no margarine or Wesson corn oil in those nasty clear, plastic bottles…God knows that toxins are leached from those

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  62. Anne Staunton  April 23, 2012

    Hi Peter,

    Great blog and great post. I am really interested in genes/culture/environment questions and enjoyed your analytical approach here. Having lived in France and Japan among other places, I agree with your points and what others have added re: unpacking carbs here and there as well as other factors. I also think the point is worth making that the American diet contains far more protein also compared to what is eaten in your three comparison countries. But maybe that will be the topic of another post.

    Regarding genetic factors that could be examined re: glucose or carb tolerance – if there is such a thing – I would be curious if some pathway similar to alcohol sensitivity might yield results (polymorphism of alcohol metabolizing enzymes). I read a presentation by Christopher Gardner, PhD that talked about multi-locus genotype patterns associated with obesity/weight management suggesting evidence of a gene-diet interaction leading to “personalized” nutritional intervention.

    Regardless, I guess there are easier ways we can assess individual susceptibility to carbs and food sensitivities in general by just doing elimination diet then adding back in carefully while repairing gut then striving for total volume, quality and proportions of nutrients that are right for each of us.

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  63. kadkins  April 24, 2012

    Peter,
    I wanted to thank you for what you do and give you some words of encouragement. You have been an inspiration and a wealth of knowledge, and a source that I have been able to utilize to slowly change the minds if friends and family. Keep up the good work!

    (reply)
    • Peter Attia  April 24, 2012

      Thank you so much. Very kind of you to say.

  64. Jim  April 24, 2012

    I’ve lived in East Asia.

    For many of them, the only simple carb they really eat regularly is white rice. They’ll eat noodles which replaces the rice at a meal. The rest is usually complex carbs in the form of veggies, and protein in the form of soy and meat, eggs, fish. They don’t really eat much of other simple carbs like bread, sweets, pastas, cakes, etc. And not many sweet drinks either. Mostly water and many varieties of tea.

    So they’ll eat a bowl of white rice with every meal. But this often means that the only simple carb they’ll eat in a day is about 2 or 3 servings of white rice. Everything else will be veggies and protein. I’ve lost weight when I’ve lived there eating like this because my overall carb intake and especially my overall simple carb intake goes down drastically from the standard American diet.

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  65. steve  April 24, 2012

    Hi Dr. Peter: Be interested in your thoughts on this:

    “Our studies have focused on a common, genetically
    influenced metabolic profile, characterized by a predominance of small, dense LDL particles (subclass pattern B), that is associated with a two- to threefold increase in risk for coronary artery disease. We have found that healthy normolipidemic individuals with this trait show a greater reduction in LDL cholesterol and particle number in response to low-fat, high-carbohydrate diets than do unaffected individuals (subclass pattern A).” -from http://www.ajcn.org/content/71/6/1611

    I believe this explains my family history of CAD in light of TRGS in my case of only around 60. Am not sure if it is the low fat aspect of the diet used in the study, but think it may be the carbs since i do not follow a low fat diet. Any sense of why metabolically this takes place? Could it be insulin spikes or sensitivity and not BG?
    My BG is only 80-83 and if i did a very large carb load as an experiment,(potatoes for dinner followed by bowl of berries) my blookd sugar after an hr doesn’t go above 120 which is considered a normal response. Maybe the underlying insulin reaction affecting the size of the LDL particles? Am normal weight and exercise. NMR results show high level of insulin sensitivity- in bottom 20%- most insulin sensitive group. Age:61 Thanks and interested in your views!

    (reply)
    • Peter Attia  April 24, 2012

      This study is interesting, but the results as they stand are kind of irrelevant. Since they did not (at least to my quick reading) quantify the change in the number of particles, we don’t actually know if this observation is clinically relevant. Particle size is not important. Particle number is. Neither peak particle size nor particle phenotype has any association with atherosclerosis. Incredible they did not at least do an apoB. Yes, it’s true small particles are at times *associated* with more of them, but the size is not causing the problem. Since there is no particle measurement in this study, it’s not clear if this study and its conclusions matter.

    • Alexandra M  April 25, 2012

      “Particle size is not important. Particle number is.”

      Really?? No more Pattern A / Pattern B? No more “protective, large and bouyant LDL?” So, I learned all that stuff about ApoB numbers in relation LDL-C and now I have to dump it all out?

      *sigh*

    • Peter Attia  April 25, 2012

      Correct. Pattern A vs. B is irrelevant. Apo B matters *IF* it is really measured, but VAP does not do that, it estimates Apo B.

  66. steve  April 24, 2012

    How low should particle numbers be? I have heard under 1000 for low risk individuals, and under 700 for high risk. Is 300 better than 500 or 600 for example? Have not seen how low is really best. Thanks

    (reply)
    • Peter Attia  April 24, 2012

      1,000 is 20th percentile. We’ll get to this soon. Tonight’s post begins the discussion.

  67. steve  April 25, 2012

    Looking forward to it. My particles were last at 568, but need Crestor 10 and Zetia to get there. Over 50% were small particles per NMR. Going for another NMR in couple of weeks. Genetics: hyper absorption and synthesis.
    Thanks for your great work!

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  68. Dominique - €€€  April 25, 2012

    Interesting post.

    As French we like to eat real food and tend to eat en famille, (but that is changing with modern life) not in front of the TV, and are proud to eat regional – food that is produced where we come from. We have set meals, try not to snack, or wash down our food with soft drinks. We have such a proud heritage of food, that we don’t see the point of eating unreal or over-processed food. It’s a matter of national pride. At the same time what we call “la malbouffe” (processed food) is catching up and levels of obesity are rising. And there is the impact of the recession on nutrition, more and more people can’t afford what they used to eat (animal protein) and replace it with calories laden but nutrition poor because that kind of food is cheaper and fills you up. Nothing like sugar to make you feel good when you feel down, more addictive than crack. Where I go on holiday to the Med, fish (once an affordable protein) is now more expensive than meat, and that is not even in places where fleecing the tourist is expected.

    As a French woman there is something else as well, a social pressure to be thin for health but also for the norm in a very sexist culture. French doctors have been churning diet books for decades, in women magazines, the diet season is perennial and course there are the ubiquitous pictures of a perfect women’s figure selling you cellulite cream (as if). When I was younger and heavy, men told me off for being fat, for my own good of course. Serge Gainsbourg, a venerated singer, ugly, chain-smoker and alcoholic labelled Marilyn Monroe “ a boudin” (sausage) and I thought – Lord, is there no mirrors in your house!
    Now days if a French man tells me off for having “over developed arms” ( from weights and rowing and therefore too manly ) I usually say : In my experience, men try to conceal deep sexual inadequacies by trying to make real women feel bad, what do you think? And I stand back, in my walking stance. I once was in a bus in London, a French man in his late 40’s loudly said in front of his teenage children that “ English women have ugly bottoms”, I told him that at his age and with his girth (he was overweight) that he was too old and fat to sport the Tom Cruise look from Top Gun. That did not go down too well.

    In the UK of course, things are really bad:

    http://www.guardian.co.uk/society/2012/apr/25/diabetes-treatment-bankrupt-nhs-generation?INTCMP=SRCH

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  69. Malibu K  April 26, 2012

    Hi Peter, great article as always.

    I have one question about LCHF diets that I can’t find the answer to: When in a hypo-caloric ketogenic diet, what happens to the excess [unused] calories?
    since they are not stored are they just expelled as waste?

    thanks!

    (reply)
    • Peter Attia  April 26, 2012

      What excess calories? By definition a hypo-caloric diet is creating a deficit.

    • Malibu K  April 27, 2012

      Ah, sorry, I meant HYPER-caloric!
      yeah, with ‘hypo-caloric’ that sure was a dumb question ;)

      With a hyper-caloric ketogenic diet, where do the excess calories go? Expelled as waste?

      Sorry for the mistake in the first question, and thanks!

    • Peter Attia  April 27, 2012

      Read the post, Do Calories Matter?

  70. Dana  April 29, 2012

    France, Italy, and Japan still eat critter guts. Read your Weston Price.

    We ate a lot of crap at the beginning of the 20th century but one of the big differences between then and now is we will not even eat liver anymore.

    France, Italy, and Japan also eat lots of seafood. See again Weston Price.

    I’m not saying it’s good to have your diet as 70% carbohydrates, because it’s not. Someone eating 70% carbohydrates but also eating critter guts and seafood is fighting a neverending war of balance between nutrients and antinutrients. It just so happens they’re eating enough nutrients that the antinutrient damage does not matter quite as much.

    Let ‘em all drop the critter-gut foods in the name of being cool and modern, and the seafoods in the name of sustainability and watch them all balloon up the way we do.

    By the way, they still suffer chronic health problems. For instance, the type 2 diabetes rate in Japan is climbing.

    (reply)
    • Peter Attia  April 29, 2012

      Why do you think rates of diabetes and obesity are rising in Japan?

  71. Stuart Buck  April 29, 2012

    Anecdotal of course, but apparently Japanese sumo wrestlers try to gain weight by eating as much rice as possible: http://www.cnngo.com/tokyo/none/secrets-sumo-wrestlers-diet-067161

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  72. Gary C Castaldo  May 1, 2012

    So my question is why wouldn’t you promote grass-fed beef? A grass-fed beef doesn’t lower the Omaga-6 fatty acid with in the meat but increases the Omaga-3 fatty acid to about equal.

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  73. Cindy C.  May 7, 2012

    I have been reading a lot on Nutrigenomics. It is the science on how nutrients affect and change our gene expressions. Here is one article.
    http://physiolgenomics.physiology.org/content/16/2/166.full.pdf+html

    I have read most of this article, and some of it more than once. It reads to me that an optimal diet can prevent, and even in some cases cure some diseases. It seems to say that the diets of our ancestors changed their gene expressions, and those are passed down to us. So we can vary in how we react to carbs(like your wife can seem to handle more without too much of a problem). It does seem to say that optimal(high nutrition) can get the body producing enzymes, and thus getting even more nutrients from the foods. It is hard to know my precise makeup, and needs. My ancestors as far as I have been told, are French, English, and Irish. I do take basic supplements-B complex, C, A from fish, cod liver oil, E, gray sea salt, calcium and magnesium citrate. I eat some low carb veggies every day, and try to eat liver once a week. If anyone looks up any vitamin deficiency symptom, we most likely can see it in ourselves.

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  74. Stan  May 25, 2012

    So they are eating a low carb diet, despite the composition being 70% carbs. But that necessarily means much lower calories than in the US diet, and also much lower fat. So why does it follow that the absence of obesity is a consequence of lower carbs? Seems like the experience from traditional Asian cultures could equally well be used to validate calorie/fat restriction as a weight loss strategy. Oh, I forgot, calorie restricted diets don’t work for Americans, people just can’t deal with being hungry all the time. I guess the Japanese must just be mentally tougher, more disciplined, since they apparently have traditionally been able to manage on lower calorie diets???

    Also, I see more than a few messages in the thread from people who have stalled on low carb diets. Your response tends to be: “watch your carbs, it should work”. Well, it should work if your alternative hypothesis is correct. And perhaps they aren’t getting the results they should because their compliance is poor. But that is a harder sell for someone who lost a bunch of weight and then had the process stall too early, wiithout changing anything.

    The other possibility, the elephant in the room is that maybe these people have hit plateaus because there are problems with the alternative hypothesis. Doesn’t a science based approach eventually require that you modify or abandon a theory or hypothesis if it can’t accommodate all the evidence?

    (reply)
    • Peter Attia  May 25, 2012

      Stan, you’re more than welcome to take over any time if you’re not happy with the content on this blog. Sorry I can’t take a few hours per person to troubleshoot every person’s plateau. That’s the minimum time required to help, in my experience, and obviously not at all the purpose of this blog. That is, I am not in any way trying to be a health coach to 10,000 people per week. Also, read a little more closely before you utter this kind of sarcasm. When you write a comment like this is only shows me you’ve internalized about 7% of what I’ve written. I don’t expect anyone to read as much as I much as I have written, let alone what I have read, but show me some courtesy in the tone of your questions, rather than demonstrating how little you’ve attempted to internalize it. I’m a patient guy, if you can’t tell. But when I’m working for free, I don’t suffer folks too kindly who strike your tone. Fair enough?
      To your last point, that’s exactly why NuSI is being formed. If you think my anecdotal experience or yours or that of someone who has stalled is “science,” and somehow disproves a hypothesis, well, I think we have a different understanding of science, my friend. Speaking of science, every minute I spend typing this response is keeping me from preparing for our scientific kick-off meeting next week which will be the beginning of testing the alternative hypothesis and trying to get to the bottom of a problem that I don’t claim to know the answer to. But I’m pretty sure a calorie is not a calorie is not a calorie.

  75. Brian  May 25, 2012

    Peter you get a LIKE for that one – keep up the good work.

    Can’t wait to see some results from NuSI !

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  76. Ekaterina Tabakova  June 8, 2012

    Thank you very much for this post, Peter. I love your blog and share it with all my clients and gym members (i’m a personal trainer). I have to say that growing up in Russia I have never witnessed such levels of obesity as i now see in my country of residence (New Zealand). And every time i go back for a visit, despite eating like a horse (when i go in winter it’s -40 celcius outside, so you gotta eat meat) i always came back slimmer, which used to puzzle me as a student. now i know why and i’m so glad that you are sharing your scientific knowledge and experience with the world. My clients really appreciated the cholesterol series too. thank you! they are reading you now :)

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    • Peter Attia  June 8, 2012

      Having at least been to Australia (though not NZ, unfortunately), if you think the people there are overweight…have we got a show for you!

    • Travis Koger  June 8, 2012

      Peter,

      Being Australian, currently living in the UK and regularly visiting the US, most recently two weeks ago, I think I can safely say that the UK is trying its best to take the obesity crown from the US. Though it appears to be more in the 40 and over age group. The majority of children and teenagers are still pretty lean, despite the junk that they shovel into their bodies. They are however just starting the cycle and the future is in front of them with the way their parents and grandparents look.

  77. Lisa Osowski  June 15, 2012

    Hi Peter -
    Would appreciate your professional opinion regarding the current Medicare enteral nutrition regulations. I’m an RD working with folks at home with enteral nutrition orders. Here is my dilemma. Folks with a dx od DM (and who will thrive on an lower carb diet) are not allowed an DM-specific enteral formula (35-45% carbs) without a trial and failure on a standard enteral formula (50-65% Carbs. So the majority of Medicare enteral patients are on higher carb formulas with more hypoglycemia medications than might be required on a lower carb formula. Would be interested in hearing your thoughts. Do you happen to have a working relationship with the medical director of Medicare? It would help me to understand why the Medicare regulations are as they are.

    (reply)
    • Peter Attia  June 15, 2012

      This is tragic, of course, but speaks to the essence of why NuSI is important. Not in my lifetime can my dinky little blog address this fundamental problem. Only with robust and rigorous science, ultimately leading to a revisit of official guidelines, can this problem be addressed. Until then we need folks like you, on the front lines, advocating for the best possible treatments based on current science (which, obviously, I believe means the least glycemic load possible).

  78. Richard  June 28, 2012

    I enjoy your posts on these topics. I have been on a low carb diet for about three years now, starting out at about (I think) 5’8 and 165, and then dropping quickly to 155 or so. So I was never obese, and I am fairly muscular. I don’t think I want to get any lighter. I think, however, that I have some sort of issue with wheat, and when I stopped wheat altogether my gastric reflux issues ended quickly, as did my IBS issues, but more slowly.

    Both before and after the switch to low carb I was doing weight training and tennis each three days per week. I cannot say I noticed any great improvement, but it does help in tennis to be ten pounds lighter.

    I am also 67 now, but I have no idea about the effect of that on the whole issue. I continue to gain muscle, but I really do not want to look like a weightlifter; I was a gymnast in college, and I just want to look like that.

    What leaves me utterly perplexed is that my friends who are still on the low fat and Lipitor approach all think I am quite strange and that I must be crazy, despite the weight and health issues they all have, which I do not share. I gave up trying to preach to them, I just tell them to do their own research. Last night I heard one fairly chunky guy tell another that the best approach was to eat only the leanest pork.

    The low fat ideas seemed to have reached the realm of religion, where it is heresy to question the accepted wisdom and orthodoxy.

    At this point I have increased my carb consumption slightly, but still people ask why I don’t even eat rice (I live in the Philippines), and I tell them I do, just not very much.

    It seems to me after three years of doing this that what is missing in this discussion is the role of NOT EATING: that is to say, not eating for extended periods, more than say 8 to 10 hours… Because just about everyone does that every night. Instead, have a little cream and coconut oil in the morning with coffee and no solid food until noon or 1PM. It is quite do-able, and what it achieves, I think, is to allow your body to switch from taking energy from constant digestion and force the body to function as it was meant to, taking energy from internal sources. What the body was never designed to do is simple enough: it was never intended to be constantly supplied with food, every four hours or so, so that hunger would never be experienced. What I notice here, and what I think is happening in the US, is not just excess calories, but a constant stream of “nourishment” and the body producing the different substances needed for proper digestion, using that energy “source” and dealing with those digestion related substances in the bloodstream, rather than using the energy stores existing in the body.

    I would also propose that drinking a lot of water is very helpful. Not eight glasses each day, which is silly, but maybe slightly more than what feels like enough. Otherwise it is possible to have unpleasant stroke-like events due to the blood vessels being unhappy from lack of water.

    And in doing all this I would recommend getting enough Vitamin D, from sunlight if possible, and K2, and magnesium. Lots of sunlight here in the tropics….

    Thanks again for your continuing posts.

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  79. Nutznseeds  July 21, 2012

    People in Japan WALK a lot more than we do…

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  80. Nico  August 30, 2012

    Hello, I just discovered your website from Mark’s Daily Apple, and your guest blog on cholesterol.

    In response to the above three main points, it is clear to me that if you 1. decrease sugar intake, 2. decrease carbohydrates and only consume from non-grain foods, and 3. improve your omega 3:6 ratio, you will get weight loss results and health, be it reduced blood pressure, improved immune function…

    I have observed my clients success with this method, combined with exercise of course. Thanks for the post.

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  81. Dan  September 6, 2012

    You stated: “Olive oil is virtually all monounsaturated (so very little PUFA, therefore little omega-3/6)”

    However, in http://en.wikipedia.org/wiki/Omega-3_fatty_acid , it is listed as 13:1. 6 to 3. In this case, should I regard olive oil as highly inflammatory??

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    • Peter Attia  September 6, 2012

      Correct. If wiki says otherwise it’s either wrong or you may be misinterpreting. Using the best database money can buy (ok, maybe that’s an exaggeration), Olive oil is 13.8% SFA, 10.5% PUFA, and the remainder (about 73%) is MUFA. Of the PUFA, virtually all is 18:2 linoleic.

  82. Alex  September 12, 2012

    Given the focus on carbohydrate intake, I wonder if something we may perhaps miss in evaluating the diets of these relatively long-lived populations is their overall protein consumption.

    There is some conjecture that restricting protein intake too can prevent age-related disease.

    For example, a brief clip of the studies they have carried out at UCL:
    http://www.youtube.com/watch?v=6NoCgr2w_Gg&feature=plcp

    I do not have much evidence for this query, but it is perhaps worth thinking about what effect protein intake has on the body.

    Also, if one did find that even protein should be eaten restrictively, as is the case in the mediterranean diet, then would it lead to the conclusion that in fact we should restrict many areas of our diet: in effect, caloric restriction?

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    • Peter Attia  September 12, 2012

      Possible. Needs to be addressed with controlled experiments, of course.

  83. David  September 13, 2012

    You appear to be in disagreement with the work of Dr. T. Colin Campbell, a well respected doctor with over 40 years of research, yet you offer no proof his research is flawed. As far as what you feed your child, I have 3 kids so I can relate, you obviously take great care in her diet with much thought and discipline, which makes me wonder why you would ever feed her animals milk, which is reported by so many doctors and nutritionists to be one of the worst foods humans ingest. Animals milk is for animals, not for humans. I don’t have animals milk in the house and I never feed my kids bacon, but to each his own. I do wish you the best at NuSI and I hope you are open to finding the TRUTH whatever it may be.

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  84. David  September 13, 2012

    Thank you for the links. I am sure you are well aware of Dr. Campbell’s rebuttal to Denise Minger and as a Doctor yourself you probably saw through her so called critique, which appeared impressive upon first perusal but couldn’t stand up to the light of day. http://www.tcolincampbell.org/fileadmin/Presentation/finalmingercritique.pdf
    I am also sure you have considered the source with regards to Denise Minger versus much more accomplished and experienced doctors and researchers such as T. Colin Campbell, Esselstyn, McDougall, Ornish and Barnard who have come to similar conclusions about the healthiest diet following decades of research.
    You are also likely aware Bill Clinton has adopted the diet promoted by Dr. Esselstyn and he is the healthiest he’s been in years. Our ex Presidents have access to the best healthcare in the world and Bill Clinton finally turned to a low fat vegan diet when all else failed and he’s had great success.

    I know I’m not going to convince you here about the benefits of a plant based diet, I just ask that you as a doctor in charge of significant Foundation monies from which to benefit and enlighten the American public on diet that you keep an open mind and always seek the truth. T. Colin Campbell didn’t set out to prove a plant based diet was healthiest, he grew up on a dairy farm in support of the standard American diet, but he went where his research lead him, which he believes to be the truth. Many other well respected doctors have come to the same conclusion on the plant based diet.

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    • Peter Attia  September 13, 2012

      David, I have a rebuttal for each of your comments, but I think we (and all readers) realize there is no “point” to even a polite exchange on the topic. Let’s agree to disagree. But let’s also agree (unless you disagree) on the following: The reason seemingly smart folks can disagree so much on what should be a simple question (What should we eat to be healthy?) is *exactly* why we need NuSI. Nutrition should not be debated like politics or religion, where there is no “right” answer.

      Obviously the Ornish or Campbell diet is MUCH healthier than the standard American diet. The burning question is WHY???

      Let’s move forward with the science and find the truth once and for all. Perhaps at some point I will address your questions in more detail on a blog post. They are absolutely worthy of thoughtful response. In the interim, though, ask yourself the following question: Pick the 2 diets at the furthest end of the spectrum, say, Atkins and Ornish. Notwithstanding the work of Christopher Gardner in JAMA in 2007, what do they have in common? Amazingly, they have more in common that most people realize! Both discourage sucrose, HFCS, and flour! Is it possible that much of the benefits Mr. Clinton has experience have to do with the removal of these agents rather than the removal of something else? When one switches from burgers and fries to tofu and salad, there a LOT of changes going on! To say it was the meat and dairy is not accurate. It COULD BE, though I don’t think so, but we haven’t proved it. Check out this post I wrote which peripherally touches on this point: http://eatingacademy.com/nutrition/why-weight-watchers-is-actually-a-low-carb-diet

  85. David  September 14, 2012

    Thank you for your thoughtful reply. I’ll look forward to following your progress. Based on my own research I believe I have found the healthiest diet, i’ve seen some incredible results from family and friends as well as myself, but I am always seeking the truth.

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    • Peter Attia  September 14, 2012

      Thanks, David. We all stand to learn something fantastic from this. We all want the best, and I’m confident NuSI will play a vital role in helping elucidate this. Stay tuned!

    • Bob West  September 14, 2012

      Peter and David, this exchange is why I have hope for the future…. whatever direction we go.

  86. george  October 14, 2012

    What’s your opinion of lack of sunshine or vitamin D and the health connection?

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    • Peter Attia  October 15, 2012

      Still working this out, but I do elect to assume until proven definitively that low levels of vit D are not helpful.

    • Cynthia  January 24, 2013

      I spend most of my time out of doors. I wear a sunblock on my face. That said 3 years ago I was diagnosed with severe Vitamin D deficiency. I take 100,000 IUs of Vitamin D a week. After I reached a therapeutic level of 50 great things began to happen. I wasn’t as tired, I lost 15 lbs, my skin cleared up, my gums improved so much my Dentist was amazed and my blood sugar returned to normal. I am a 56 year old female. I am a nurse and have a MS in Fitmess and Human Performance. Absolutely there is a health connection.

  87. yuma  October 16, 2012

    Dr. Attia, there is no doubt in my mind that the low carb ketogenic diet is the way to go. Doctors Phinney and Volek – in their book “The Art and Science of Low Carbohydrate Performance” – provide the facts.

    However,based on available statistics, the Japanese – a slim population with a high carb diet – consume 66 lb. (30kg.) of sweeteners per person per year.

    http://usda01.library.cornell.edu/usda/ers/SSS/2000s/2002/SSS-09-10-2002_Special_Report.pdf

    Americans consume 150 lb. per person per year.

    http://en.wikipedia.org/wiki/File:Usda_sweeteners.png

    Wouldn’t you agree that if Americans reduced sweetener consumption and calories to Japanese levels, they would be as slim as them?

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    • Peter Attia  October 16, 2012

      Hard to say…there are some genetic differences, too, which I did not go into in this post. The topic, of course, is interesting enough that it actually warrants a re-visit of this topic.

  88. AT  November 1, 2012

    Hi Peter,
    I’ve lived in Japan for the past 8 years, so some observations from everyday life:
    -The low-fat trend is lagging here compared to Europe/US. In some of the more local supermarkets (apart from milk) it’s almost impossible to find low fat dairy.
    -The red meat consumed is extremely high fat (ex. wagyu beef). It’s very hard to find lean cuts. Same with chicken (always consumed with skin) and pork (always eat the fat). Fish is consumed almost daily including breakfast (ive never seen a Japanese kid or adult eat Frosties or any cereal for breakfast).
    -Goes without saying that green tea consumption is big here (substitute for soda elsewhere), green tea is a known anti-oxidant which could possibly interfere (purely my opinion) with the oxidative stress produced by elevated uric acid on the mitochondria.
    -Unfortunately sugar and low-fat is slowly penetrating everyday life, beer consumption is also steadily overshadowing the more traditional alcoholic drinks such as rice/potato wine.
    -Another point worth noting is how much more resistant the Japanese men seem to be to the growing western trend of male baldness. Life here is no less stressful for average salary men than it is abroad so it’s questionable how much stress has to with the phenomenon. It is my opinion that sugar is likely the culprit there while lifelong daily consumption of green tea-type antioxidants can’t hurt either. Male baldness here is interestingly on the rise along with the penetration of sugar in the Japanese diet.
    Congratulations on your blog, always thought provoking.

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    • Peter Attia  November 1, 2012

      Very interesting. Thanks for sharing real-world data!

  89. Mary  December 1, 2012

    I just sat down to exercise on a stationary bike and watched your interview on FOX. I have only spent the last hour looking at your site so please excuse me if answers to the following questons have already been written.

    - What is your opinon of T.Colin Campbell’s “The China Study”? (I spent 8 weeks reading his book and reviewing points in PubMed indexed research; your explanation can be detailed.)

    - What is your opinion of Barry Sear’s “Zone Diet?” ( It appears you are targeting the same population and using similar methods that Barry Sear used.)

    - Finally, controversy exists over high protein/ low carb diets; what is your opinion of these diets? (Deaths have been attributed to these types of diets.)

    Thank you in advance for your response.

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    • Peter Attia  December 2, 2012

      All addressed elsewhere. Start with Denise Minger’s critique of the China Study. Given that you’re well versed, you’ll definitely appreciate the nuance of her analysis.

  90. Taylor George  December 10, 2012

    I am seeing that it is difficult to get a good reading on which foods are high in PUFA6′s. In fact, this site http://180degreehealth.com/2010/02/omega-6-content-of-common-foods

    differs quite a lot from the foods you’ve given. Where should we go

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    • Peter Attia  December 10, 2012

      Stay tuned until I a post on this topic.

  91. Edward  December 27, 2012

    Anyone who hasn’t actually read Weston A. Price’s book, ‘Nutrition and Physical Degeneration’ definitely should do so as soon as possible. Price spent years traveling around the globe examining the teeth and general health of “primitive peoples.” In every case from Switzerland to Pago Pago, he found that as late as the 1930s, isolated people could be found that had never had a Western diet. Invariably, his findings were that less than 1% of the teeth examined had dental decay, usually less than 0.5%. The people of the same “race” however, that lived in contact with Western diets had horrible decay, even when under the care of dentists. The isolated peoples had no problem with wisdom teeth growing in, no need of orthodontic care and had no rheumatic fever, scurvy or any other degenerative diseases or cancer.

    I’m posting this here because the diets of the people he visited varied so widely. The Swiss in isolated high mountain cantons consumed whole grain rye as a coarse bread and milk, both raw and as cheese almost exclusively. The Masai of central Africa ate milk, blood and some meat. The Inuit ate fish and seal and very occasional berries and Spring green shoots. Other tribes of Central Africa ate fresh water fish and swarms of ants during the season when the ants would fly about. In the islands north of Australia, the natives ate coconut and coconut crabs and fish. And so on.

    His primary conclusion was that it is primarily a deficit of fat soluble vitamins that cause problems with tooth health and general health, including stature, head shape, and intelligence. The book is profusely illustrated with side by side photos of people who were isolated and their brethren from nearby towns. He was aware of the benefits of only eating butter that was from green grass fed cows, something some people think is a recent discovery. He also was aware of water soluble vitamins, of course.

    After his travels he was consulted many times when the mothers of children with seemingly intractable illnesses would come to him for help. It always occurred that the children had been eating mostly white bread with jam in large amounts and were helped with weeks if not days by receiving cod liver oil and grass fed butter. He even found that he could reverse tooth decay with this kind of diet, because the dentin beneath the cavities would re-mineralize and harden to the point of keeping bacteria out of the pulp of the tooth.

    The .pdf of his book is available here:
    http://www.edwardbe.info/uploads/NutritionAndPhysicalDegeneration.pdf

    I downloaded this from an Australian site, if anyone owns the copyright, and sees this as a violation, let me know at edward5brode [at] yahoo.com and I will remove the file immediately.

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  92. Nigel  December 30, 2012

    I have been successful in keeping lean for the last couple of years following the paleo/primal diets (in fact I think I found this site via Mark Sissons Daily Apple site) which has been pretty low carb – I’m guessing 50-100 g of carb a day. But for the last few months I’ve become interested in the idea that a healthy diet, one which keeps me lean and strong, is not necessarily low carb. The lean gains protocol of combining Intermittent Fasting with higher carb consumption after resistance training seems to produce amazing results of keeping people both very lean lean and strong. For the past few weeks I’ve been restricting my training to three days a week and in the eating window after exercise consuming around 450 g of carbs (in the form of sweet potato and/or white rice). On those days fat consumption is very low. I’ve not gained any fat (or weight) and have lost a small amount of fat around my abdomen. I’ll keep with this for a while yet to see how it works out, but I think the notion of low carb as being the route to health are not necessarily correct per se. The originator of Lean Gains is Martin Berkman, but I’ve been following a Japanese web site where an English trainer is trying to introduce the Lean Gains concept to the Japanese rice based culture with some success, and has more detail on calculating ones own figures for the required carb/fat/protein consumption.

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    • Peter Attia  December 30, 2012

      Interesting. Please do keep us posted. I’m very interested in what Martin is doing.

  93. Cynthia  January 24, 2013

    Wow, what a great article ! I have been a nurse for 20 years and have a MS in Exercise Physiology. Your article was easily understood and brought to me new ideas that I hadn’t considered before.

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  94. Gregory R.H.  February 5, 2013

    Dear Peter. I greatly appreciate the work you have put into this website. I am amazed how well you can deliver scientific matters to the general audience. I am doing a lot of nutrition studies and came across two pretty big and conflicting ‘hypotheses’, it is the ratio of Omega 6 against Omega 3. Here is the link to the Brian Peskin’s hypothesis: http://www.brianpeskin.com/efa-analysis.pdf
    I really hope you can have a look at what he says and perhaps improve his your your own opinion on that matter. It seems your recommendation is quite the opposite of his. There are some other big claims Brian makes but so far I mostly understand the reason behind his and your claims, yet the EFA issue bothers me. Perhaps your expertise may help us in our quest for perfect nutrition.

    Best regards, Greg

    (reply)
    • Peter Attia  February 6, 2013

      Greg, to be honest, it will a year before I can read this guy’s 55 page document. I can’t even make time to kiss my daughter goodnight right now. I can’t even believe I make a few minutes to respond to comments on the blog. Sorry…

    • Amy  February 6, 2013

      I skimmed the 50 page document and poked around his website for 15 minutes.

      Take away analysis of a busy, unqualified stranger on the Net:

      1. He’s selling something. That is, is “special” magical blend of seed oils that will save us all. When I downloaded the PDF I was frustrated by the mountains of testimonials and lack of specific recommendations on what to eat. There’s maybe 3-5 pages out of 50 of real data. The rest is filler and meant to get everyone excited by the concept.

      2. That said, he may have a point about ODing on fish oil. I know that in the presence of enough meat by-products, Vit C is unnecessary to produce collagen. If we’re eating plenty of good fats (defined as naturally occurring with some provisos), I could see regular fish oil supplements at least being redundant. Fish oil might greatly improve a situation where someone is eating carbs at the expense of fat.

      Since fish oil is wicked expensive and it doesn’t make sense that we’d need it in huge quantities, I’m planning a personal experiment to cut back our intake. No big plans on buying the snake, err, “seed” oil, though.

    • Peter Attia  February 7, 2013

      Amy, thanks for doing the heavy lifting on this one.

  95. Alia  April 22, 2013

    I am Malaysian, 5’7 , 53 kgs, very lean and muscular. I eat rice 3-4 times a day everyday but the things we eat with are really really beneficial for health and are mostly organic because we grow them in our backyards. A typical Malay meal everyday is white rice, variety of dishes made from all sorts of flavourful ingredients, fish,meat or chicken and the most important side dish of all, raw vegetables such as parkia speciosa, archidendron pauciflorum,pennywort leaves,winged bean,asiatica pennywort and more. Please check out the health benefits of these herbs. They are mostly bitter and tastes really bad if eaten alone, we normally eat them with rice and other dishes. My grandmother is 82 and so healthy and active, she eats rice and these herbs everyday too. A lot of Malays in Malysia are diabetic but I dont think its from the food we consume but the drinks, we are notorious for drinking exceptionally sweet drinks e.g rose syrup+4-5 spoons of sugar. But other than that Im pretty sure the food we eat are mostly healthy, maybe that is why we don’t really have to alter our diets when we exercise to lose weight. I know I don’t and my body is the same as people who eat clean to get their dream bodies. Most of my friends and family too. Maybe its genetic or maybe our system is just used to rice. Im not sure. But just to et you guys know, this is what we normally eat.

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  96. George  May 23, 2013

    Peter,

    What about the gut microbes as an answer? See Michael Polan’s NYT article here: http://mobile.nytimes.com/2013/05/19/magazine/say-hello-to-the-100-trillion-bacteria-that-make-up-your-microbiome.html

    Like you, I’ve been keto adapted for several years. Reading this article makes me want to consider more diversity as a parameter in the non-starchy veggies I consume.

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    • Peter Attia  May 23, 2013

      Sure, reasonable hypothesis. What’s driving the change in gut biome?

  97. Grant  May 29, 2013

    Could a fourth reason be more amylase in their spit? Predigests starch and shrinks the glucose spike. I googled something like “amylase content in saliva by ethnicities” or something. It seemed to suggest that Middle-easterners have more amylase than Native Americans and Af-Ams.

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    • Peter Attia  May 29, 2013

      Yes, quite possible. Chris Masterjohn spoke about this at AHS last year.

  98. Grant  May 29, 2013

    And if the amylase hypothesis is true, it might explain why Oz is thin while his patient Oprah isn’t. Note to Oprah: People with low-amylase spit shouldn’t take diet advice from a guy with high-amylase spit.

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  99. Mark  May 31, 2013

    Hi Peter,

    I am eagerly awaiting your blog post on Omega 3 and Omega 6 fatty acids (I love your site and have found it to be possibly the most useful nutrition related site on the internet). I’m curious if you limit yourself to grass-fed meat. Presently I have all but eliminated carbohydrates, outside of vegetables, from my diet and don’t consume vegetable oil (although mayo and canola oil have begun to creep back in). I’m curious if you know how much Omega 6 one would be getting per ounce of conventionally farmed meat?

    Thanks,
    Mark

    (reply)
    • Peter Attia  May 31, 2013

      Mark, whenever given the choice, I prefer grass-fed, but I’m not super-strict about. I do supplement n-3 (EPA and DHA) to a very specific levels of about 8.5 to 9% by RBC level, and my n-6 intake is pretty much confined to nuts and meat. I don’t really consume veg oils, largely because I think they taste like toilet water compared to a good olive oil. I don’t know the answer to your question, but I’m sure someone has done this calculation.

    • Bill  May 31, 2013

      With no n-3 supplementation, just eating normal portions of fatty fish twice a week or so and avoiding vegetable oils, my RBC n-3 level is 10.9%. Some would suggest that’s too high, but I’m banking on the idea that if it results from real food in reasonable portions it’s probably OK.

      I heard Dr. Lustig state in an interview recently that if you consume farm-raised salmon fed grain-based pellets you might as well eat chicken since the n-3/n-6 ratio will be bad. My n=1 here would seem to contradict that, since (unfortunately) the great majority of the fish I consume is farmed.

    • Peter Attia  May 31, 2013

      Wow, that’s a pretty level absent supplementation. I have never seen that before. I think your hypothesis is probably right.

  100. Chris  June 10, 2013

    From my own experience I find it easier to maintain my 6 to 8% bodyfat on a highcarb diet. Everything from fruit to starchy and very simple sugars. When I actually cut to 5% I would do a big carbload once a week. Carbs have a better effect on leptin levels. I tried a keto diet. I lost a lot of muscle. Felt lethargic and my hormones were out of whack. It was hard to sleep and hard to focus. The moment I changed my macros to carb my training sessions were again intense. I could sleep again and felt happier. From serving in the navy and being stationed in countries that consume a lot of carbs like Japan, you definitely notice a higher NEAT. A lot of people moving around more. Which without carbs would be impossible to pull off. We’re more of a sedentary convenient society. Plus, maybe this is only ancedotal, but in my experience when I overconsume carbs I’m more more active the next day. A professor once told me that storing carbs as fat is a very costly process from an energy standpoint, but will stop the body from oxidizing lipids. My point is we live in a very lazy society that praises convenience. I’m not a genetic freak by any means. I was obese for most of my life. The last five years I’ve been able to maintain low bodyfat levels, plus compete in bodybuilding shows. Fat is burned in the fire of carbohydrates.

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  101. Tate Metlen  June 10, 2013

    I think everyone focuses on the macro-nutrients too much and ignores the micro-nutrients. I think the “paradox” of high carb cultures that don’t have the same problems of western civilizations can be explained in three ways:
    1. PUFA. The only major thing that has change in diet worldwide. And there ARE studies that show this causes or helps cause the metabolic issues the western world has… Or try this thought experiment: How did farmers make pigs fat before the advent of grain based feeds?
    2. Look at grains for a moment compared to other sources of carbs such as squash and potatoes. Grains are about three times more calorically dense. It is just plain easier to overeat. Now white rice… high caloric density, but it IS low in anti-nutrients, so less damaging than other grains. Wheat is the worst of all the grains, the genially modified are even worst as they have more anti-nutrients to act as natural pesticides. They help strip out required nutrients, which cause the body to require more intake of food to get those nutrients, but when the food is wheat, the vicious cycle continues.
    3. Liver function. Long story short, the liver needs certain dietary intakes to function properly. namely choline or the precursors. The best sources of these? Eggs, milk, and liver. (Any one of which is sufficient qualities solve the issue.) How much of those are eaten in the SAD? How much of these are eaten on the typical VLC diet?

    I think the low carb diets address most of these concerns on accident, but also induce other problems due to a glucose deficiency. That is why most people feel a lot better with a little more carbs. The paleo group also is almost there… but they still eat a lot of PUFA’s in the form of nuts. BTW, that was the answer to how farmers use to make pigs fat… they would feed them nuts in the fall. Specifically acorns and chestnuts.

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  102. PJ  June 18, 2013

    As someone in their early forties who is battling type 2 diabetes, I would like to point out something no one ever talks about: the brainwashing and mindgames American’s have to deal with in order to eat better and improve their health. Personally, it makes me incredibly depressed to hear what I now have to eat to feel & look better. All my life I was barraged with ads telling me to eat high-sugar cereals & sweet breads for breakfast. To drink soda instead of water. To eat delicious fast food. And that’s exactly what I did. My point is..why isn’t anyone addressing the mental issue beyond hunger? Why is everyone expecting American’s to just wake up one day after decades of brainwashing and being told the wrong things to eat and drink and just start eating low carb and avoid sugar? Don’t forget that when you raise an animal to eat and drink a certain type of food or liquid, that this then becomes ingrained in that animal, and will always be considered the “norm”, no matter what else is introduced in the future. And that’s exactly what many people like myself are now dealing with. Yes, I do everything I can to eat & stay healthy. I avoid sugar & carbs as much as possible, eat plenty of veggies & moderate fruit, take supplements, take my medication, and occasionally exercise if I have the time (I’m being honest here). But am I happy eating this way? Do I look forward to meals like I used to? At the end of the day do I feel satisfied and pat my belly because I ate good? No..not even close. As a matter of fact..I’m frickin’ miserable. And depressed. I miss Coca-Cola like a crackho who can’t afford another hit. I miss my mexican sweet breads with my loaded-up sweet coffee & cream. I miss being able to just pour me a big bowl of sweet cereal..instead of eating this healthy omelette with mushrooms. Food is now just sustenance..it doesn’t give me pleasure anymore. And when your brought up to believe food isn’t just food..but is happiness..well..that really affects your quality of life. So I can’t wait until researchers start developing ways to counteract all these years of brainwashing my generation had. Maybe create some therapies to counteract that and brainwash us into believing this veggie burger & carrot fries meal tastes as good as one made with angus beef and potatoes. But I think the chance of that happening in my lifetime is as good as science being able to create a “holodeck” like on Star Trek -in other words..fat chance.

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    • Peter Attia  June 18, 2013

      PJ, few things upset me more than this…at some point I’m going to write a post about this titled, “Defaults matter.”

    • Donna S.  June 19, 2013

      PJ
      You are not alone in what you have described. Since I was small (quite awhile ago) I saw all sorts of food ads for sugary foods which my parents brought home. Plus treats galore that were touted as being healthy. Casseroles and other similar foods that were cheap, filling and crowded out more healthy food. Now I try to eat better with all I know and I can’t get past the ‘wanting’ of the foods that filled my younger days. I’ve done the 21 days or more routines in the hope the cravings would go away as others have claimed happened to them. Never happened to me. I always relapse like an ‘addict’. I’m looking forward to Peter addressing this as it is a major issue for many of us.

  103. Jeff Johnson  June 19, 2013

    …………………………..
    …………………………….
    …………………………………………

    A couple of things………..
    …………..

    Peter’s Ted Med Talk
    Peters taik has been online since day one – session 4 ——–1:14 into the video———— all the 2013 sessions are here and I watched them all- at —
    http://new.livestream.com/TEDMED/ondemand/videos/16718478
    Kroger’s/Smith’s grocery stores
    They sell low carb yogurt – 4 carbs per container – $00.40 cents a container – these are the only places I’ve seen low carb yogurt sold

    Winco Stores
    They have an encredible bulk section – cinnamon $2.00 per pound and many other herbs as well

    Neighbor Lady Next Door
    This lady had diabetes – a rotting foot – they wanted to cut it off – she killed herself instead as she didn’t want to walk around with one foot – can’t say I blame her -

    As Peter Seller’s say’s in the movie “Only Two Can Play’ ———————- The Price is just too High——————-

    (reply)
    • Peter Attia  June 19, 2013

      The talk will be on line “properly” next week on the TED and TEDMED websites. The streaming version is “raw.”

  104. Joyce  June 27, 2013

    I have just discovered your awesome website (through the Diet Doctor’s website generously mentioning you). What an awesome site. I myself follow Dr. Rob Thompson’s Low Glycemic Load Diet, and am now reading his Sugar Blockers Diet book. The difference in my health has been amazing since loweriing the glycemic load in my diet (and I still eat lots of veg and fresh fruit!)… Thanks for such a wonderful website and great information.

    Please write a book for us. Can you tell I like to read? Thank you.

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    • Peter Attia  June 27, 2013

      Joyce, it may be a while before I can get to it. Perhaps one day.

  105. Scott A  July 2, 2013

    Author Roger Mason states “the best source in the world” for DHA and EPA is flaxseed. He further says “fish oil has dangerous arachidonic acid”. This seems to contradict what I have learned from your website and other places. Please help resolve my confusion.

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    • Peter Attia  July 2, 2013

      Scott, I don’t know Roger Mason. I do know, from speaking with the experts on this topic and reading their work (e.g., Bill Lands, Bill Harris), that conversion of ALA to EPA is about 1-2%, and virtually 0% to DHA. So while it’s true that flax high in omega-3 (ALA), this statement about it being the best source of DHA and EPA is incorrect. The issue of AA is also misleading, if not outright incorrect. Don’t take my word for it, though. See the work of folks like Lands and Harris.

  106. Simone  July 8, 2013

    I feel very confused. Have read Dr. Dean Ornish and others who promote heart healthy eating through restricting junk food AND restricting/eliminating meats and full fat dairy. Have also read THE CHINA STUDY by Prof. Campbell.

    I know that Dr. Ornish has documented reversal of heart disease….and I’ve heard other docs on Public Television pushing vegan style diets. Then I read you and feel confused!

    Can you clarify?

    (reply)
    • Peter Attia  July 8, 2013

      Simone, the question we need to be asking is what is about these diets that may promote health? If you have the patience to read this blog in its entirety, I think you’ll have a better answer. I’m sorry that I can’t address this quickly in a short response.

    • Hemming  July 9, 2013

      Hi Simone,

      Jack Kruse, Mat Lalonde etc. have to some degree debunked Dr. Ornish’s studies supporting his diet and contributes it to some to other factors such as quit smoking and starting to exercise.

      I’m not saying that low carb/ketosis is the universal answer to all of our problems just that there is more to it than the diet guidelines advocated by Dr. Ornish.

  107. HeatherTwist  July 13, 2013

    I’ve been reading “The Fat Switch” and some of what Dr. Richard Johnson has published, and I think he may have found some common threads in the diets that “work”. I started a low uric acid diet because I was getting gout symptoms … Like my Dad did. He controlled his gout with diet, and when he did … he got skinny . The “low gout” foods seem to cause weight loss. It seems uric acid might be the trigger for fat storage.

    Now in my case, the foods aren’t connected by much else, except that “gout sufferers” recommend them.

    1. Drink vinegar-water. Vinegar lowers uric acid levels, for some reason.
    2. Avoid fructose. Fructose raises uric acid levels.
    3. Avoid certain meats and seafoods.
    4. Avoid beer (I drink wine though).

    Anyway, it’s working. Joints stopped hurting, and I have been losing weight.

    (reply)
    • Peter Attia  July 13, 2013

      Very interesting, Heather. I’ll be meeting Dr. Johnson in September and look forward to discussing all of the implications of the fructokinase in great detail. I’m reading his book now.

  108. Ann  July 20, 2013

    What are your thoughts on reasons why, even though Icelandic, Nordic and Japanese people eat a high amount of fish and have greatly reduced rates of heart attacks compared to US, they have a much higher rate of hemorrhagic strokes? I read somewhere that the high rate of strokes is not due to the omega 3 but rather due to the mercury and other pollutants found in fish. Is this correct? If so, what amount and what kind of fish is safe to eat per week?

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    • Peter Attia  July 20, 2013

      High levels of EPA and DHA significantly thin the blood. If too high, this results in easy bleeding. So while, while this would protective from embolic stroke or atherosclerosis, it would increase the risk for anything hemorrhagic, including stoke.

  109. Sean  July 23, 2013

    Peter, I tweeted you a few days back but I realise that twitter is probably not the best platform to discuss such big issues with their tiny word limits. I saw your talk on TEDMED 2013 and I thought it was intriguing but I have some questions on insulin resistance, diabetes, obesity and how they relate to one another. I apologise for any ignorance but your blog is massive and I didn’t really know where to start, despite trying your “start here” post which didn’t point me in any obvious directions to find the answer.

    I understand that your claim is that obesity and diabetes are both a result of insulin resistance, but I find this to be confusing. Insulin resistance, you say (as does most everyone else), is the reduction in sensitivity of cells to the effects of insulin. So what are the effects of insulin? Primarily, as you have noted, it is an increased uptake of blood glucose by muscle cells and fat cells, probably mediated by increased expression of some glucose transporters of some sort in the cell membrane. (Glut-4?) Thus, a reduction in this sensitivity should lead to a reduced ability of muscle/ fat cells to take up glucose for storage, whether in the form of glycogen (for muscle/ liver tissue) or lipids (via lipogenesis in fat cells). Doesn’t this mean that insulin resistance should actually lead to impaired fat accumulation rather than enhanced fat accumulation?

    Apologies if I have left my comments on an inappropriate post, once again I had difficulty trying to navigate to a relevant post dealing with this issue. Looking forward to hearing from you I enjoyed your TED although I wish you had explained your theory in greater detail.

    (reply)
    • Peter Attia  July 23, 2013

      DNL is a very minor part of the adiposity (see post on fat flux), so IR leads to more circulating insulin. Fig 1 in that post should make it more apparent why hyperinsulinemia increases adiposity.

  110. Lou  August 1, 2013

    Thanks for the excellent article. Your judgements are spot on IMO. Perhaps I can throw a little light on your question about the amount of omega 6 required.

    “Traditional diets contain nearly equal amounts of omega-6 and omega-3 essential fatty acids.” Weston A. Price Foundation

    “To reach optimal health, the ratio of omega 3s to omega 6s should be close to 1:1. When omega-6 fats predominate in your diet, as is common in the United States, this encourages the production of inflammation in your body. Since so many diseases have now been linked to chronic inflammation, this really is one of the most important nutrition concerns to get right. Many scientists believe that one major reason for today’s high incidence of heart disease, hypertension, diabetes, obesity, premature aging, and some forms of cancer is the profound imbalance between your intake of omega-6 and omega-3 fats.” Doctor Joseph Mercola

    “Health practitioners often suggest you use no additional parent omega-6 and that instead you use supplements exclusively with parent omega-3. This is incorrect because the omega-6 we do consume in our foods is highly processed, harmful and often loaded with cancer-causing transfats. You need the additional pure parent omega-6 to compensate for this. Because the parent EFAs are so much more effective than EFA derivatives, you need a much lower total quantity than other formulations.” Doctor Brian Peskin PhD, Note parent omega 6 is unprocessed food high in omega 6. In addition to ingesting GOOD omega 6s we need to ELIMINATE the denatured omega 6s

    “Recognizing the unique benefits of EPA and DHA and the serious consequences of a deficiency the US National Institutes of Health recently published Recommended Daily Intakes of essential fatty acids. They recommend a total daily intake of 650 mg of EPA and DHA, 2.22 g/day of Omega 3 EFA and 4.44 g/day of Omega 6 EFA.” Note IMO this is LOW I try to get between 5 and 10 grams/day of each omega 3 and 6 on average

    Avocados are my favorite omega 6 source. When I think I have found the end of its benefits a day or two later I find more.

    http://healthyprotocols.com/2_omega_6.htm

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  111. Carlos  August 12, 2013

    170lbs @7.5% BF
    Pictures/data to prove?

    (reply)
  112. jolie  August 15, 2013

    Although things are changing, I’d like to add that many Asians don’t eat as much meat as Americans. Usually, on special occasions, like going out to restaurant or birthdays, holidays; maybe they eat meat once a week or once a month. Some will go months without it. If you’re not getting protein, then you need energy from other sources. This is also a common thing I’ve seen among vegetarians: they’re all very thin, it seems. I live in a place where there are a lot of vegetarians.

    Other sources of protein I’ve seen consumed include: soy-tofu, silk worms, crickets, scorpions, and then basic meats and fish.

    So basically, what if it’s a metabolism thing? What if their bodies are wired to burn carbs first? If you’re not getting protein energy, then that’s gotta leave carbs. Rice and noodles are cheap, and easy to make.

    Also, as you said, they eat a lot of veggies, and not as much sugar; definitely smaller portion sizes than others. Although, again, things are changing. When I was in Seoul, I saw people eating fried chicken with chopsticks. People love western food there. I fear for their health, lol.

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  113. Darlene Specht Brehm  October 13, 2013

    Brian Peskin has been advocating discontinuing fish oil supplementation in favor of a biologically appropriate ratio of Omega-6 to Omega-3 for years.He has spent many years in the wilderness making his argument in print and at medical conferences around the world. Successfully withstanding continual attacks by those blindly defending the status quo, he is happy to report the changing of the status quo as it relates to fish oil and heart health.
    Remember, May 2013 as the time when the medical establishment embraced one of Brian Peskin’s fundamental discoveries. Specifically, the discarding of fish oil for heart health. First reported in the New England Journal of Medicine, a very large well-done study in Italy showed that fish oil was completely ineffective in preventing heart disease for a very large group of high risk patients. Soon after, Dr. Eric Topol, renowned cardiologist from Scripps Health (La Jolla, California) and editor-in-chief of Medscape, recommended discontinuing all fish oil supplementation for the prevention of heart disease. It doesn’t get any more main stream than Dr. Topol, so I gladly accept the designation of an advocate for a rational, now mainstream approach for combating heart disease. For more info re: Parent Omega 6 and 3 go to Brian Peskin.com.

    (reply)
    • Peter Attia  October 14, 2013

      This is a very interesting debate, Darlene, and not one I know the answer for. I do suspect the reality is somewhere in the middle. VERY low EPA/DHA = “bad” VERY high EPA/DHA (i.e., uber supplementation) = “bad” also.

  114. Paul  October 14, 2013

    Having reread this essay prior to a recent bike trip and vacation in France, I was alert to your theory that the “French Paradox” is explained by the lesser overall consumption of carbs and sugar by the French (compared with Americans.) I was convinced you were right.
    This is written long after you posted this blog and and I am not sure you check for current comments, but I feel compelled to report that I now think your theory is not fully correct.
    Most of the French I observed were indeed thin to just mildly overweight. The many Chinese tourists looked soft but not heavy. There was the occasional bulky Brit or German. But, yes, the truly big –bulging!– people were invariably American (further identified by their universally abysmal standard of dress.)
    Yet, yet, yet… never have I seen as many French fries (frites) served and consumed as I did in France, by locals. Even 40-Euro steak dinners in high-class restaurants came with mounds of frites. Asked for a salad substitute, French waiters seemed horrified — what, substitute rabbit food for a delicacy? I watched an American vegetarian ask for vegan cuisine … utterly stumping the waiter until with a sudden smile he left and then returned with a huge metal bowl filled with…. frites! Yes, there were vegetarian-friendly cafes scattered here and there but not many. Further, Parisian cafe tables groan under the weight of baguettes (whole or chopped) served at every meal! And don’t even start on the constant flow of desserts. Or the espresso sipped through cubes of sugar.
    Yes, I saw plenty of salads — usually arugula and lettuce– but otherwise, green vegetables were limited to the occasional dish of green beans, usually in fancier places. I never saw spinach or broccoli — except the latter, once, on a pizza at the next table.
    Speaking of pizza, Paris and Bordeaux seem to have more pizza places per square kilometer than I have ever seen in the States. At a cafe I watched two perfectly thin Parisians consume 14-inch pizzas — each! — for lunch.
    So what could account for the “French Paradox”? Red wine? Maybe. The higher quality of ingredients and preparation? Perhaps. But here are a couple other things to consider:
    At any given moment, it seemed half the city residents were on the sidewalks. Each side of Champs-Elysees was filled with pedestrians, seemingly 24/7. So were side streets. Merely by emulating the French, I soon found myself averaging nine miles per day. (My smartphone app credited 500 to 600 calories burned this way each day.) In public buildings (other than hotels) going to higher floors almost invariably meant climbing staircases rather than taking elevators or escalators.
    And another, less positive, factor: smoking. It looked to me like slim and fashionable young women nearly all smoked, and nearly constantly. Empty cigarette packages (even Camels!) and butts were the main component of debris at curbside.
    Despite the reported popularity of the “Dr. Dukan” diet in France, (a low-carb variant), no waiter I mentioned it to had any idea of what I was talking about. The French do not seem to share Americans’ obsession with “health food” (and generally don’t appear to need it, judging strictly by appearances) but their relative slimness, I suspect, is explained more than just by their food choices. Partly –perhaps — but not all.

    (reply)
  115. Salim Morgan  November 18, 2013

    You questioned whether the apparent observed benefit came from improved Omega-6 to Omega-3 ratio or simply from increased Omega-3. Logically, you left something out. What about the benefit coming directly from REDUCED OMEGA-6?

    I happen to believe this to be the case and read about a study in India which seemed to bear it out. Just a population study and no “proof” of course, but pretty compelling.

    I don’t believe that humans need large amounts of Omega-3s, period. I DO believe that the vast majority of people walking around today, after decades if intense Omega-6 poisoning could probably benefit from it. However, I remain convinced that reducing Omega-6 addresses the real problem more effectively and directly. J

    ust curious how you left out one glaring logical possibility, while discussing the others in some detail.

    (reply)
    • Peter Attia  November 19, 2013

      Isn’t your suggested mechanism logically consistent with a reduction in the ratio of n-6 to n-3, ceteris paribus? (no need to respond, Salim, that was a rhetorical question)

  116. Alice  November 18, 2013

    I have lived for 19 years in Italy and, to me, the most important difference between the Italian and the ‘Western’ diet I am experiencing in the UK is that (traditionally) Italians cook their food from scratch, even takeaways are what we call a ‘gastronomia’ ie homemade food sold to the public. Still, weight is not the only issue here and in the last few years, despite remaining comparatively lean, Italians have started to develop all the conditions linked to methabolic syndrom. Moreover, society is changing, more women work (true for all the 3 countries considered here) and ready-meals are becoming increasingly popular, hence the ‘westernification’ of our diet.

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  117. Jim Valance  November 25, 2013

    Hi Dr. Pete, great blog. I love this post. It was well written and totally comprehensible. The people taking part are very knowledgeable too and I got some great info here (BTW I’m new to your site). I’ll be checking in more often. Thanks and keep up the great work.

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  118. dr cate  December 8, 2013

    Great line of inquiry here. One thing that has not been mentioned is that the idea that just b/c the folks in Japan eating all that rice look thin, that they’re healthy. While I worked in HI I worked with a HUGE population of Japanese and other Asians who tended to eat rice for breakfast lunch and dinner. Many of them had diabetes in spite of normal BMI. (I did not have a body comp scale.) Cutting rice dramatically improved their numbers. So I don’t see any evidence that this population of people tolerates higher amounts of carbs any better than the rest of us, all else being equal.

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    • Peter Attia  December 9, 2013

      Excellent point, and one that causes great confusion. Today, the prevalence of T2D in China is reported at about 11.5% — higher than even the U.S. How is this possible when their prevalence of obesity (according to BMI > 30) was reported in 2010 to be even lower?! Well, the answer almost certainly lies in your point, which is yet another example of the point I tied to make in my talk at TEDMED.

  119. Phillip Madonia M.D.  January 13, 2014

    Peter,
    I came across your blog while researching for a talk I am giving next week. Nice job. What a tremendous amount of research and review distilled into easily digestible bites. Thanks for your effort.

    I am an obstetrician/gynecologist and about three years ago we (8 partners in a suburban practice) decided to offer our patients a healthy eating plan. The design was not exactly a ketogenic diet but it stressed the low glycemic load carbohydrates and modest protein and fat. We have had tremendous results with weight loss, improvement in insulin levels and lipids. Our diet is about conscious eating and changes for a lifetime. Not just lose the weight and gain it back. We do not use pills and shots which are so popular. Enough about our program. I have a question.

    Do you have any thoughts on why the obesity epidemic in this country (evidenced by the percentage of the population is overweight and obese and the percentage of diabetics) started in the Mississippi valley and spread east and west? Interesting in this is the fact that Nevada was years behind the rest of the country in achieving the same diabetes and obesity rates. If you look at a map over time it looks like an infectious disease.

    Was there something in the environment? Bacteria in the food? Something is (was) going on that has not been addressed.

    Please keep up the good work.

    PM

    (reply)
    • Peter Attia  January 13, 2014

      Very interesting question, Phillip. It could be a cultural difference (e.g., cultural affinity for certain foods), a socioeconomic difference, or a genetic predisposition. Those would be my starting guess.

  120. Charles  April 20, 2014

    At this point, it’s hard for me to feel that any analysis that doesn’t include looking at gut microbiota is going to be incomplete, and find things that can’t be explained. (Not to say that the kinds of studies you’re doing aren’t valuable!)

    Given that studies show when we transfer fecal bacteria from lean mice into obese mice, the obese mice get lean. And given studies showing that foods high in resistant starch (which influence gut bacteria balances) decrease glucose response from meals containing carbohydrates, I have to hypothesize some aspects or tranches of the obesity epidemic has something to do with changes in gut bacteria. And I’ve been basically LCHF for 40+ years, since the 60s, so I’m not anit-carb-hypothesis.

    You asked above what might have changed the gut microbiota. I’d note that you can also correlate the rise of obesity and diabetes, etc. with the rise of antibiotic use, especially if you factor in a generation delay between the introduction of antibiotics into meat. As that rose, the next generation was the generation that started to see obesity levels rise. Why might that be? Because you get your initial set of gut bacteria from your mother at birth, and if the mothers’ guts started to become bacteria-deficient, that would be passed on.

    And certainly the fact that we started eating more simple and processed carbohydrates rather than more complex carbohydrates (with more soluble fiber), would change gut bacteria, and probably not for the better considering that adding resistant starch seems to improve the health of gut microbiota. It also seems to significantly improve satiety signaling, and there are a couple of potential reasons for that. I would bet you a dollar or two that carbohydrate resistant people like your wife (and some other friend of mine that drive me crazy for the same reason) have very different gut biomes than carb-sensitive people.

    And I bet we’re going to find industrial oils and sugars damage the balance of gut bacteria, possibly beyond the fact that we lose important nutrients by substituting them for good fats and safe carbs. (Though maybe the latter is more significant in the long run.)

    Again, I’m not arguing against the value of the carb-insulin hypothesis, only to say it might be a big part, but only part of the answer. I’ve often said that there isn’t one reason we get fat, and carb-sensitivity can be intrinsic or acquired. And without taking into account a system containing 99% of the DNA in your body, where 90% of the neurotransmitters in your body are produced among other things, it’s going to be hard to get a complete picture.

    Here’s an interesting article I just found that seems to speak to this: “Comparison with ancestral diets suggests dense acellular carbohydrates promote an inflammatory microbiota, and may be the primary dietary cause of leptin resistance and obesity” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3402009/

    And this one: “The gut microbiota suppresses insulin-mediated fat accumulation via the short-chain fatty acid receptor GPR43.” http://www.ncbi.nlm.nih.gov/pubmed/23652017

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