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If low carb eating is so effective, why are people still overweight?

If low carb eating is so effective, why are people still overweight?
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I find myself getting asked this question, or some variant of this question, with increasing frequency as I speak and write about the Alternative Hypothesis I find most compelling surrounding obesity and chronic disease.  One implication of the Alternative Hypothesis, as you probably understand by now if you’ve been reading this blog, is that many carbohydrates, especially if consumed at the levels most Americans consume them, promote fat gain.  In other words, overweight people are not the lazy, constantly grazing, weak-willed individuals many in the mainstream have led us to believe.  They just eat the wrong foods (rather than simply too much food).

Remember, I was one of those doctors in the mainstream once upon a time.  While I always tried (and hopefully succeeded most of the time) to treat overweight patients with respect, I silently judged them.  Why can’t you just eat less and exercise more?  Only when I realized, despite my diet which rigorously adhered to formal recommendations and my 3 to 4 hours of exercise per day, that even I was getting too fat for comfort, did I begin to question the Conventional Wisdom of why we get fat.  Of course, not everyone (fortunately) was born with my level of genetic susceptibility to insulin resistance (stated another way, not everyone is born with my level of carbohydrate sensitivity).  In my experience, about 10-20% of the population (my lucky wife included) seem resistant to carbohydrates and maintain exquisite insulin sensitivity, almost independent of diet.   Roughly 30-40% of the population are, conversely, very sensitive to carbohydrates and appear to be quite insulin resistant until nearly the last gram of sugar and most carbohydrates are removed from their diets.  Then there is the rest of population, which includes me.  To varying degrees, we’re somewhere between these two groups.

So back to this question — If carbohydrate reduction is so effective for weight loss, why are so many people still overweight?  Beyond being asked this question, personally (and frequently), one can see the same logic in the academic literature (see comment by George Bray in Obesity Reviews) and in the press (see comment by Gina Kolata in the New York Times).

George Bray: “I thus conclude that if any diet ‘cured’ obesity as their proponents often claim, there would be no obesity and thus no need for the next diet.  Yet the past 150 years, since the publication of Banting’s first popular diet*, have seen a continuing stream of new diet books.”

Gina Kolata: “Low-carbohydrate diets have been popularized periodically since the 19th century. Best-selling book after best-selling book promoted them. Yet if they work so well, why are so many people still searching for an effective way to lose weight?”

*If you have not yet done so, and you’d like to put yourself in the ‘low-carb aficionado’ club, you must spend time reading the work of Banting.

Dr. Bray is generally regarded as one of the most erudite authorities on obesity in the United States, while Ms. Kolata is one of the leading reporters on the topic – so we’re not just talking about “anyone” asking such questions.  Bray and Kolata are both smart and thoughtful people who have devoted much of their lives to thinking about this problem. In other words, we’re actually all on the same “team” – we desperately want to help people lead more fulfilling, healthy lives by improving their eating habits.  But we disagree on this point.

It seems Dr. Bray and Ms. Kolata (and many others) have proposed (implicit in their statements) an interesting “Principle,” below:

If a disease is prevalent, no treatment exists to eradicate it. In other words, if any condition exists, it implies there is no cure for that condition.  The reverse (and logically equivalent) statement is this: if a treatment exists for a disease, no one has the disease.

Is this a valid criticism of carbohydrate restriction?  Perhaps, but to be sure let’s consider a few examples of this Principle.

  • Polio no longer exists in the United States, thanks to the development of two types of vaccines to immunize people against the poliovirus.
  • Smallpox, a viral disease estimated to have taken between 300 and 500 million human lives in total, no longer exists thanks to two vaccines that eradicated the disease in 1979.
  • Breast cancer still exists, and in 2011 claimed the lives of 40,000 women in the United States alone. While there are many treatments for breast cancer (surgery, radiation, chemotherapy, and combinations of these) depending on stage of disease, no cure exists to eradicate it once it is systemic (i.e., spread throughout the body), which is consistent with the Principle. [Remember “logic 101” tells us that if A implies B, no-B implies no-A.]

So far the Principle seems pretty compelling.  Of course, to be an all-singing-all-dancing-universal-truth, there cannot be any exceptions to this Principle.  Do any such exceptions exist?

  • HIV, when progressed to AIDS, is responsible for nearly 2 million annual deaths worldwide (about 16,000 deaths per year in the United States), yet transmission of the HIV virus – the causative agent – is entirely preventable.  Furthermore, the current drug regimen for HIV can prevent nearly all patients with HIV from progressing to AIDS, thereby rendering HIV a chronic disease.
  • Malaria, a disease transmitted by mosquitoes, is responsible for about 1 million deaths worldwide each year, yet this disease can be prevented successfully via two broad strategies: prophylactic treatment with anti-malarial agents (this is typically what folks do when traveling to regions where malaria is prevalent) and use of anti-mosquito “technology” (e.g., nets, DEET).  Furthermore, when a person, despite these measures, contracts malaria, prompt treatment with anti-malarial drugs will cure most.
  • Polio, which has been eradicated in the Western world, is still prevalent in south Asia despite a clear method of prevention.

For the purpose of space and time I’ll stop here with examples, but it turns out there are far more examples of the Principle being violated than being upheld.  In other words, the Principle isn’t actually a Principle.  It’s an idea that is true less often than it is false.  Sort of like the idea dogs and children should never be together (which I used to believe after many years of suturing up the faces of children who had been ravaged by dogs).  I now realize that most children around most dogs are perfectly safe, and adult supervision can make the odds even better.

What is the common theme in each of these examples that defy the Principle?

It’s probably a combination of factors, and they differ across the examples, too. Let me use HIV as an example of this phenomenon.  I did my residency in general surgery at the Johns Hopkins hospital in Baltimore, Maryland.  For those of you not familiar with Baltimore, some background is warranted.  In the final weeks of medical school I took the advice of a friend and read the book, The Corner, by David Simon and Ed Burns.  This riveting true story was the single most valuable book I could have read prior to moving from posh Palo Alto to inner city Baltimore.  Through this book, other books, and eventually my own personal experience, I came to realize how Baltimore had become the heroin capital of the United States.  Furthermore, because of where Hopkins is situated in the city, I would come to spend many years taking care of patients in the emergency room and hospital wards who battled heroin addiction.

As a result of such high rates of heroin addiction, the number of patients walking (or being carried into) the Hopkins ER was very high.  If I recall correctly, and these numbers do change over time, approximately 60% of patients walking (or being carried) into the Hopkins ER were positive for HIV, hepatitis B, and/or hepatitis C.  Each of these diseases is transmitted through blood or other bodily fluids.   Needle sharing and sexual transmission are far and away the most common modes of transmission in the United States today.

Preventing HIV, hepatitis C, and hepatitis B is pretty straight forward today.  If you have sex, especially with “high risk” individuals, do so with a condom.  If you use IV drugs, do not share needles.  One could even go a step further and not use IV drugs at all and not have sex with high-risk individuals (e.g., prostitutes).  [Hepatitis B, while 10x more transmissible than hepatitis C and 100x more transmissible than HIV is the only one of these three viruses for which there currently exists a vaccine.]  While there are other ways these three viruses can get transmitted, practically all (>99% as of 2007) are contracted through these two routes of transmission in the United States.

Furthermore, the treatment for HIV using a treatment regimen called HAART (Highly Active Anti-Retroviral Therapy) has become highly efficacious at preventing HIV from even progressing to AIDS.   In other words, if one contracts HIV today, it’s quite likely to prevent HIV from progressing to AIDS.

How can it be possible, you ask, that anyone can contract a disease that is so easily preventable? Furthermore, for those who have contracted the disease, how can so many go without treatments that would easily render their condition a chronic one – a condition that will not lead directly to their death — rather than a condition that will lead to their death?

Information, infrastructure, and pain

One could (and I’m sure several have already done so) write an entire dissertation on this exact topic.  At the risk of oversimplifying, though, let me briefly explain why I believe a disease that has a preventable cause and effect can still exist.  There are three broad reasons, though they are not all equally contributory nor are they constant for all people (i.e., the dominant reason for one person might be less relevant for another person).

Poor information

While it might be “obvious” to many of us, it’s actually not clear to everyone that a virus can cause a disease like AIDS.  Heck, most folks don’t actually know what a virus even is.  Furthermore, some people do not know how the virus is transmitted or how, exactly, to prevent this transmission.

In the United States today, the group of people who contract HIV primarily because of what I call “poor information” is probably quite low. But in Africa, for example, this probably plays a significant role in transmission.

Poor infrastructure

Even if one realizes how the HIV virus gets transmitted and what the consequences are (i.e., “poor information” is not an issue), another feature – poor infrastructure – can play a role in facilitating spread of the disease.  While condoms and clean needles can greatly reduce the transmission of HIV, accessing them is not always easy, especially if one is on a tight budget, as many folks addicted to heroin are.   And while programs exist to literally give away needles and condoms, not everyone can access them in a time of need.

Pain versus consequence

Why do people use HIV infected needles when they can find clean needles at a shelter?  Why do people have sex with prostitutes without using condoms, even though they can access condoms for free?  I don’t think there is one clear reason or explanation.  Some of it is social support and surroundings.  Some of it is prioritization.  Some of it is pain.  Perhaps the pain transiently ameliorated by heroin or sex is deeper than the long-term cost?

What have we learned?

  1. A disease can exist despite a means of prevention.
  2. A disease can exist despite an effective treatment.
  3. The barriers to prevention and treatment are likely multi-faceted and complex (and highly dependent on the disease).

While I’ve only used HIV (and by extension, hepatitis C and hepatitis B) to illustrate this point, I hope I’ve given you some idea how someone can still “get” a disease, while living in the United States circa 2012, despite all of the good information and infrastructure to prevent it.

As you undoubtedly know, the problem is far worse outside of the United States.  In many parts for the world the people being afflicted with HIV lack even the correct information, let alone a shred of infrastructure to combat the problem.

Back to the original question

How does obesity stack up?  Let’s evaluate using this framework.

Information

Unlike HIV which, at least in the United States, is appropriately understood, the study of nutrition and obesity is a relative debacle.  The formal recommendation of the USDA, AHA, AMA, ADA, and others actually tell us to eat the foods that make approximately two-thirds of us overweight.

Try asking your doctor for help, and you’re likely told to eat less food, eat less fat, eat more grains, and exercise more, stupid.

Infrastructure

Since approximately 1972, U.S. food policy has almost monotonically been shifting further and further towards all but making it impossible to avoid carbohydrates.  Countless books have been written about this topic from many levels from agricultural subsidies to the lobbying powers of those who sell sugar.

The results of these actions are particularly devastating on those individuals who are not affluent.  If you wonder why the economically disadvantaged are more likely to be obese, ponder this:  one can buy ten boxes of ramen noodles for one dollar at most grocery stores.  On a per calorie basis, few things are cheaper than sugar and other carbohydrates.

If you’re hungry in an airport or a mall (or virtually anywhere out of your own home), how easy is it to avoid sugars and simple carbohydrates?

Pain

Like Dr. Rob Lustig has said on many occasions, I don’t believe anyone chooses to be overweight.  I do believe most people who are overweight are so because of poor information and poor infrastructure.  However, these two features are not the only reason.  Many people still smoke cigarettes today in the United States, despite good information (i.e., everyone “knows” smoking is harmful) and good infrastructure (e.g., cigarettes are very expensive and most places don’t allow smoking – the default action is not to smoke).  There’s another reason people smoke.  Similarly, some people will always turn to the wrong foods.  I guess, for some, the acute pleasure food brings outweighs the chronic pain it causes, even when information about food is clear and unambiguous and when infrastructure does not essentially force people to eat the wrong foods.

I don’t know how much of a role this feature will play when the former two features are one day corrected, but I’m sure fixing the former two will go a long way to reversing the epidemic we find ourselves living and dying in.

Should we be surprised that 67% of Americans are overweight and that nearly 10% have diabetes?

We are outright told to eat the foods that make us fat via all formal and informal recommendations. We are surrounded by food infrastructure that makes our “default” eating patterns in line with those (flawed) recommendations. And for those of us who decide to go against the grain and overcome these two enormous hurdles, we are almost assuredly not supported.  In fact, we’re often condemned and ridiculed.

While I greatly respect Dr. Bray’s and Ms. Kolata’s commitment to fighting obesity, diabetes, and their associated chronic diseases, I reject their reasoning for why reducing carbohydrates is not one of the most effective treatments.

p.s., when I wonder if my blog has any impact on people, I only need to see a picture like the one up top (from a loyal fan) to know I’m having some impact! [If you don't "get" it, check the video from this post a while back.]

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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. mem  March 29, 2012

    Thank you. I look forward to reading each new blogpost. And I very much agree with your thinking and experience as stated in this one. AS a an RN of about 30 years, with the first 15 or so in ER/Critical Care and the last in Public Health/Public Health Mental Health, I have struggled with these questions and spent much of my professional life working at forging solid relationships with patients and forging longer term coaching relationships to assist people in making and persisting in real behavioral change in their lives. I’m happy to say that I’ve seen lots of amazing change along the way, in many lives, and of course, none in some as well.

    I am also a long term low-carb weight-loss *maintainer* success story myself, having weighed 240lbs at 5’6″ in 1999 and weighing 145-148 by 2002. As of Oct 2011 I reached a new goal of 130lbs and will now maintain there for life. Stress and bio-rhythm dysregulation was, imo, the #1 factor in my becoming overweight in my early 30’s, losing it and then becoming obese – morbidly obese in my mid 40’s, as well as being a member of the 30% club and having a genetic predispostion (I am an adoptee and was only recently able to establish the familial obesity history as fact)to obesity. Even without the genetic predispostion, I think that the effects of chronic stress and the physiological dysregulation that shift work effects needs to be addressed more and in more detail. I spent years overworking and working 12-16 hour 7P -7A shifts. In my maintenance years, I have only returned to shiftwork or being on 24 hour call twice, and those were the only timse when I had a significant regain of 16lbs over two years, despite continuing workouts and little change in eating. It was MUCH harder to control my appetite (chronic effects of too little sleep and poor quality sleep and effects on appetite of chronically elevated cortisol which causes real, increased HUNGER at increased intervals!) My profession, about 50% of which is significantly overweight/obese, is illustrative of what I have written here, due, in large part, imo to the high rate of shift work, chronic overtime and inherent stress combined in the profession.

    I would also like to see more emphasis, in time, on *maintenance.* As you are well aware, big loss weight maintainers make up a 1% club. Of all losers, perhaps 3-5% keep it off for 3 years or morem most regaining a at least a 3rd back by year one, and all back by a couple of years or less, with more added on. The subject of maintenance needs much more emphasis. One of the “big secrets” among us maintainers is that to maintain, little to NOTHING you have been doing to lose, can change. There is nothing magical about “arriving.” In many ways, the herculean task is only just beginning because of the myths that everyone, including physicians and nurses believe about weight loss, the number one being that you can go back to whatever “normal” eating meant to you prior to the loss and just eat “sensibly.” This is a big fat lie. And it is essential on the weight loss road to establish a very workable plan that is *enjoyable for life* in the realm of exercise as well. For the vast majority, thinking that it is going to work to set up a weight goal that requires 60-90min or more of intense exercise per day, is a recipe for disaster and injury, with inevitable weight gain while that foot or leg or back heals. And then, an escalating hill of injuries as you come to dread the prison you’ve erected for yourself to maintain what *may* be an unreasonable weight to begin with, or an insistence or adding more and more carbs back in because “the book” said that’s what you do in maintenance.

    OK, I won’t bend your ear any more. But suffice it to say, I appreciate your work. And I’ll be waiting in the wings in hope that you might address some of these issues which are real saboteurs for healthy weight loss maintenance and life! Thank you.

    (reply)
    • Peter Attia  March 29, 2012

      Thanks so much for sharing your journey. I think your story and your comments provide a remarkable juxtaposition to the previous comment. I hope this gives people something to think about and contrast. Thanks for the inspiration.

    • Debbie  March 29, 2012

      I relate to so much of your story! I’m in the 1% club too, and it’s been a journey of changes in exercise routines, eating, weight – meaning, I had to realize I wasn’t meant to be really slender. I still struggle with this, secretly wishing I’ll hit the right kinds of foods for myself that will enable me to be thinner – and healthy. If I cut back on food amounts too much, I’ll lose more weight, but will feel horrible, have no energy, etc. – and that I don’t want. Years ago I even maintained a too-low weight, and had zero energy every single day, until I finally let up a little, and accepted a somewhat higher weight. So, yes, there is an emotional component to all this, perhaps especially for women. We feel the absolute need to be SKINNY! It’s definitely a journey – and this blog is fantastic, and a huge help!

    • LCG  April 8, 2012

      Mem,
      I too am an RN, who struggled with the same issues of circadian disruption, elevated cortisol, metabolic disturbances just as you did. I went from an 8 hr PM shift to a 12 hr night shift and gained 50 lbs in a matter of months. I ended up leaving that job since the toll on me was enormous, and culminated with me sitting in a empty room in CCU where I stuck my self on a monitor and watched scary PVCs scroll by. I was so totally stresses out by lack of sleep my heart conduction went haywire. I grabbed a passing cardiologist who sent me home with some ambien and orders to sleep. When I woke up 12 hrs later I turned my resignation.

      It took discovering the South Beach diet to turn my life around. Although not really low carb due to the tremendous amount of dairy, I got rid of the 50 lbs and then some. It stayed off with a quarterly phase one tuneup. Then I noticed that I felt better off all the carbs that phase two entailed, and I just stopped eating them, legumes, and dairy except grass fed butter, kefir, and heavy cream in my coffee. I woke up one morning and discovered I felt so good that I started crossfit at the age of 62. I now do diabetic education through a home health agency. Probably going to get fired for telling people to get rid of their bread, but I found my passion.

      I’m glad you shared your story. We all need to work to eliminate 12 shifts and to teach our fellow caregivers how to manage working bizarre hours. Some people can make the adaptation. You and I are in that category that cannot.

    • DH  April 8, 2012

      A graduate student and I have done an extensive meta-analysis on the effects of shift work on cardiovascular health. We found increases in myocardial infarction, stroke and coronary events which were fairly consistent across studies. The mechanism is likely as you suggested – circadian rhythm disruption, which drives cortisol over-exposure, which then drives overeating of carbohydrate-rich, convenient foods. Thus people get metabolic syndrome, type 2 diabetes, hypertension and acute and chronic vascular diseases. We now know that type 2 diabetes is actually a vascular disease more than anything else – it is also a disease of carbohydrate intolerance (perhaps the purest example we have; polycystic ovarian syndrome is another).

      For every 5 years that nurses perform rotating shift work, the risk of stroke goes up an additional 9%. Scary!

    • Peter Attia  April 8, 2012

      Wow, thanks for sharing Dan.

    • patty  April 16, 2012

      I am so grateful for these posts. I have struggled with my weight for years – increasing exercise, decreasing calories, logging my food.. only to see my weight climb. I have had 3 different doctors tell me I am ‘fat but fit.’ I guess that was supposed to make me feel good.

      About 8 months ago, I decided that all the mainstream information about weight loss didn’t apply to me & I must be different. I decided to take drastic steps & I started walking 20,000 steps per day (6-8 mile hiking, up major hills in any weather) logging my calories meticulously and the scale finally started to slowly go backwards. Unfortunately, I got sick twice and by February I had hit my highest weight ever…at 5’8” 215, I was shocked and terrified. I called to make an appointment with a lap-band surgeon when I ran into a friend (with a PhD. in Nuclear Chemistry from Berkley – he is no dummy). He was offering me a ride, but I said that I needed the steps to get healthy. He replied that walking was good for a lot of things, but if I was trying to lose weight, I should read “Why we get fat.”

      I felt so validated when I read that book. Finally, I realized that I can never eat sugar/carbs. NEVER. They are poison to me. I felt so relieved! I had tried for years to go low carb, but I thought it wasn’t healthy for the long haul….I can’t even imagine going back to that way of eating now.

      I weighed in at 185 today. I am eating like a queen, but still logging everything. I realized that I can eat protein, fat & low carb veggies to my fill, but I rarely eat over 1100 calories per day. When I finally accepted that the ‘calorie is a calorie theory’ is wrong, I have managed to get the weight off and feel better. I am comfortable with the knowledge that I will never go back to high carb/low fat eating, but I do feel like I am swimming up-stream.
      I wish there was a local support group or doctor who understands low carb lifestyle, but I am taking comfort from this blog.

      I thank all of you for sharing your experiences and expertise.

    • Peter Attia  April 16, 2012

      So glad your friend was able to introduce you to the alternative hypothesis of fat accumulation.

    • SP  February 21, 2014

      I would like to second Mem’s request for emphasis on maintenance. I’ve lost 25 kg over the last 3 years, by lowering my carb intake (and learning to enjoy exercise – who knew?), but the self-control war wages on. Some battles I win, some I lose. I would still like to lower my total body fat, even though my weight is now in the “normal” range. However, at this point, reducing carb intake any more seems like a daunting task, from the self-control perspective. I estimate that I consume between 150 and 300 grams of carbs daily, mainly complex. I also tend to wonder how much negative impact an animal-based diet has on the environment/eco-system, and if adhering to such a diet will not affect us negatively in the long run (from without, rather than from within).
      I recently started reading your site, after seeing your outstanding TEDMED presentation. You’re inspiring, yet in a way, difficult. I realize you have a love of numbers and facts, but I feel the need to point out that science is not the only way for you to help people “keep it off” (or just stay healthy). I think it would be extremely helpful to some of us if you wrote about the points you struggle with, and the way you deal with them (because in your presentation, you kind of let it slip that you’re human…). I hope this isn’t too personal a request.
      Thank you for doing what you’re doing.

  2. Lori  March 29, 2012

    Thank you, Peter, for this thoughtful post. You made a lot of excellent points here. Since it is hard to find good information from doctors, governmental agencies and the like and as you mentioned, support from friends and family tends to be non-existent, I get a lot of my information and support online.

    Lately, though, I am seeing a trend that I find very disheartening. Many bloggers that I formerly enjoyed following have decided that it is wrong to demonize carbs and are promoting the idea of adding them back into the diet. Not junk foods, but whole foods such as rice and potatoes. They report that they have lost weight, feel happier, sleep better. Most of the posters in the comments section applaud their decision and report that they, too, have lost weight and attained a sunnier disposition by eating more carbs. They often go beyond that to make derisive comments about low-carbing. It’s discouraging to read and neither informative nor supportive for me — I know adding in more starches will only cause my blood sugar and weight to go up — so I generally end up crossing that blog off my reading list. With so little support for low-carbing available anyway, it’s discouraging to lose these formerly good sources. Do you have any thoughts as to why so many people are changing their mind about the proper human diet? If carbs are the problem, how can so many people find good results through eating more of them?

    (reply)
    • Peter Attia  March 29, 2012

      Lori, I’ve seen this also, and all I can assume is that — perhaps — for some people, once they have “de-toxed” they can gradually add some carbs back. Would this work for everyone? I doubt it. Ultimately, of course, nothing matters for you more than what is best for YOU, not me, not other bloggers, not your family, not your friends, not your doctor. I’m 100% supportive of the idea that one should experiment to find what works best for them. My experiments led me to where I think I am at my aggregate best, but that might not produce the best results for you. Also, lost in this discussion is what one is optimizing for. Maybe it’s worth being a little less healthy if you can eat foods that give you more variety and pleasure? These are personal decisions. The one point I think worth stressing, though, is that for many people the slope is a slippery one. Once they re-introduce a bit, it becomes easier to add more. How much is too much? Depends on the person and on their goals.

    • tim  March 29, 2012

      I’ve seen this as well. The other thing is that some of the low carb sites are bashing Gary Taubes also. I don’t understand why, isn’t he promoting low carb which is what they advocate as well? Is there a point he/you bring up that is anathema to the “mainstream” low carb community?

      I just had a conversation with my brother about lc paleo etc; I think our whole family is going to go Low Carb btw!

      Great points in your post as well.

    • Barbara Hvilivitzky  March 29, 2012

      And don’t forget that bloggers, and the crowd that follows them, get bored with the same-old, same-old. Kurt Harris has just about stopped posting. Now potty-mouth Richard (Free the Animal) has indicated he’s about to change his tune too. And some of the others are just going around in circles – what’s left to say really? The change is usually from low-carb, to Paleo, to Primal, to “more hard core evolution” to “whatever we can think up next.” I say let’s stick to the science, what works for most of us, a life-plan and get on with it.

    • Susan  March 29, 2012

      Lori,

      I agree totally with both you and Peter. Some of us cannot tolerate more than small amounts of carbs, and probably will never be able to do so.

    • Al  March 29, 2012

      Isn’t the “trend” to add back “complex” carbs limited to subset of bloggers who are using it for a very specific purpose related to weightlifting / strength training? The way I understand it, if you’re looking to bulk muscle and shred stubborn fat, loading up (moderately!) on carbs in a periodic “re-feed” after a period of low-to-no carb eating appears to be beneficial allegedly due to the interplay between insulin, ghrelin and leptin hormones. In other words they’re still trying to manipulate hormones and metabolism through diet but for a specific purpose not necessarily driven by maximizing weight loss.

      The amount of carb loading you can safely engage in seems to be proportionate to the amount of lean muscle you have, so a fat, soft weakling would be advised to use this as a finishing touch, not the cornerstone of a new diet. This too is not new as it is basically a cyclical ketogenic diet that has been around in the bodybuilding community for some time. I don’t know that adding carbs without the intense weight training precursor would do much for one other than fat mass gain but your mileage may vary.

      Peter, if you’re ever stuck for topic ideas, I’d love to hear an erudite and researched take on this “re-feed” strategy. I believe it is something Mark Sisson also recommended at one point as strategy for attacking stubborn fat loss, could be wrong.

    • Peter Attia  March 29, 2012

      I’d love to write it, but I would need to spend some time doing the research, including on myself. The self-experiment Mark Sisson and I have been discussing lately is fasting. I’m actually doing a 24 hour fast today as part of an experiment. I’d also like to talk with some of the other folks who know a lot about this, like Mike Eades, Robb Wolf, and others. I’m all about doing the self-experiments.

    • Marilyn  March 29, 2012

      I know, Lori. It occurred to me the other day that the new crop of bloggers seems to be moving surely and not so slowly to the food pyramid. If they continue in their current direction, I wonder what will distinguish them, eventually, from the status-quo/party line/politically correct thinking already in place.

      Peter, thank you for this blog. It’s one I check every day.

    • Ash Simmonds  March 30, 2012

      I’ve recently done a couple self-experiments in fat-loading and fasting.

      Basically, I eat as much fat as possible in one meal (90%+), and see how long I’m sated for.

      The first time I ate until nausea, and wasn’t hungry again for over 2 days. The second time I just ate until sated, and didn’t feel like eating again for 28 hours.

      These weren’t fasting periods per se – as there was no willpower requirement on my part – I was just legitimately not in need of food for extended periods.

      Details here: http://www.reddit.com/r/keto/comments/rb1j4/fat_loading_and_fasting_self_experiments/

      I intend to do this once every week or two.

    • Peter Attia  March 30, 2012

      Ash, keep us posted on this experiment. I’m doing a variation of this myself, though for a different reason. Too soon to comment on exactly what I’m learning, but I find this idea very interesting.

    • Sheri Hunt  April 18, 2012

      Thank you Peter,
      I don’t intend to fast on many of my open water sailing trips but find that when on the ocean, water is the only sustenance I need now that I am ketoadapted. My most recent trip required 24 hours sailing while on a 44 ft boat in 35 kt winds and 10-15ft swells with a short handed crew due to sea sickness (brought on by food consumption). One had taken prophylactic meds and the other had not. The others that ate food, simple carbs in particular, suffered also some form of indigestion. I was able to maintain my strength and focus for the entire time with only water.

      So perhaps a blog topic not related to physical performance:
      Does the ketoadapted state offer a mental performance advantage?

      [Literature on MCT supplementation (especially triglycerides of caprylic acid) suggests improved cognitive function (in a mentally compromised population). Reference available.]

    • Peter Attia  April 18, 2012

      Will do.

    • Michael  May 10, 2012

      You should talk to Martin Berkhan from leangains.com if you want to know about fasting.

    • Peter Attia  May 10, 2012

      I’ve read his stuff. Very interesting.

    • Cpilutti  September 18, 2013

      Once your weight is where you need it to be, why not add 1/2 cup of quinoa, rice or whatever once in awhile ( while dining out for example). If you start gaining weight dont do it anymore. Everyones different.)

  3. Dave Nelsen  March 29, 2012

    I think changing the food & fat paradigm is like turning around a super tanker. It’s going to take a long time. The embedded dogma is deeply engrained. I know carbs are bad for me and I’m working hard to permanently change my lifestyle to avoid them. The hardest part of low carb is the temptation of wanting to eat the carb’s you’ve known and loved for so long. I find strength in reading your blog and others like it. I’ve read both of Gary’s books and have ordered some others to help educate myself. My HDL’s went from 40 to 45 when going to low carb. Everything that generally happens when going HFLC – happens for me – weight loss, better lipid profile. I’m also able to get off my blood pressure medicine after losing 20 lbs. I’ve lost 20 lbs in a little over 6 weeks and am continuing to lose. Ideally need to lose another 30 to get to where I want to be. On no other diet plan can you lose weight this rapidly and have your health improve. For the past month I haven’t even been able to work out due to foot surgery, so the weight loss is all diet. Thanks and keep up the good work.

    (reply)
    • Peter Attia  March 29, 2012

      Glad to help, Dave. Keep up the good work.

  4. Mar  March 29, 2012

    Something you said in your recent podcast really struck a chord with me. When you transitioned into VLC you were not low enough to get into ketosis and not high enough to fully satisfy glucose needs. I have been trying to play it safe and hit a carb intake range of between 60 – 80 grams per day. For the first time I am wondering if some of the struggles I am having are from eating in a ‘grey zone.’ I am sure I’m not alone in the approach I have decided to take. After listening to your podcast I decided to try nutritional ketosis again and to at least stick it out for 8 weeks. I am on day two and I can cope with the fatigue and the mild but nagging headache, but the insomnia that could be he a deal breaker.

    (reply)
    • Peter Attia  March 29, 2012

      For me this was absolutely a problem. When I got to be really low carb, but not low enough in combined carb+protein, I was MISERABLE! I was constantly in a state of about 0.2 to 0.3 mM of B-OHB, and that just wasn’t enough to fuel my brain (and I didn’t have enough carbs to do the job, either).

    • Dave  March 30, 2012

      Peter,

      Do you think this was an issue just because of the duration of exercise you put in? So its either go full ketosis or go high carb? I know for me in marathon training and I run about 5-6 hours a week, and while generally very low-carb, I am not consistent enough to stay in ketosis, but I haven’t hit any problems with being in this limbo state. I feel great all the time.

    • Peter Attia  March 30, 2012

      Possible. It’s clearly not something everyone experiences.

    • John Dawson  March 30, 2012

      Hi Mar Where can I find this podcast?

    • Kayla  March 30, 2012

      I followed the Carbohydrate Addict’s diet for about a year and a half and it scared me off VLC for years! I’m sure I experienced the same thing, too many carbs/protein to enter ketosis fully, too few carbohydrates to supply enough energy (especially to my brain). I lost weight and my blood lipids were better, but the depression and anxiety just weren’t worth it. Now I’m VLC-HF and have never felt better physically, mentally, and emotionally.

    • Joshua Wardrop  April 20, 2012

      I had the same experiences, I had the mild headache, the fatigue, etc for maybe 3-4 days. After that, the energy rush I was feeling was actually creating the insomnia, because I would lie in bed with my brain a buzz. After 5ish days, it all came together, but again it coincided (coincidence?) with me reanalyzing my diet, slightly lowering protein, dramatically raising my water intake, and increasing cream intake. The breakthrough to me was making a glass of 50% unsweetened almond milk, 50% heavy whipping cream, and drinking it as a meal replacement.

  5. Per Wikholm  March 29, 2012

    Thanks Peter for focusing on this important question!

    This is the very reason why low carb diets only score marginally better than low fat or calorie restricted diets in RCT:s based on an “intention to treat” concept.

    It is hard to follow a low carb diet if all the media, your doctor/dietitian, your family, your workmates, friends and neighbors all the time bombard you with messages that this diet will kill you.

    And that is why I think a study on the altenative hypothesis should be conducted in Sweden rather than in the USA. Here we have a much greater acceptance for the LCHF-koncept (about 5 % of the population, a criticall mass adhering to it strictly and another 20 % somewhat adhering to it).

    And the HF-part of the LCHF concept is important here…trying to go low carb without increasing fat intake will almost ever fail.

    (reply)
    • Peter Attia  March 29, 2012

      That’s a great idea. I think we will probably start here, for the purposes of logistics, but ultimately these questions should be tested in other countries, on different genetics, also.

  6. Travis Koger  March 29, 2012

    Peter,

    Great article… again! Like other posters here, I am finding myself checking your blog every single day, multiple times per day. I know you only post once per week, but I am checking for new comments and make sure that I read every one.

    Praise the LARD! Or in my case, the Beef Dripping! :)

    (reply)
    • Peter Attia  March 29, 2012

      Travis, wait till you see the new t-shirts I just ordered…

    • Travis Koger  March 29, 2012

      I have been meaning to ask where you got your Praise the Lard T from. Look forward to seeing pics of the new t-shirts.

    • Tom  March 30, 2012

      The only place I found that sells the t-Shirt is a place in San Fran. I had a friend swing by and pick one up. Right now I don’t think they sell online.

      Prather Ranch Meat Co.
      Ferry Building Store #32
      San Francisco, CA 94111

  7. Brac  March 29, 2012

    With your blog posts, you demonstrate that you believe that the advice given out by the establishment is wrong.

    You mentioned HIV in this article a rew times.

    Have you read “Inventing The Aids Virus” by Peter Deusberg.

    Another example of where the establishment are wrong as to the causes of a disease.

    (reply)
    • Peter Attia  March 29, 2012

      I have not read it, but I’m familiar with the anti-HIV-causes-AIDS argument. Nobel laureate Kary Mullis is (or at least was) a proponent of this argument, and I’ve read lots of his stuff. I won’t pretend to be an expert, but the evidence I see for HIV not being the causative agent in AIDS is pretty low. Either way, it’s not really the point of this post, so I’d prefer not to dwell on this point.

    • RadiantLux  March 31, 2012

      Thank you for bringing up Duesberg. Ever since 1992, I have read news stories about him. There are a lot of politics in AIDS science. It is very interesting. I’m not sure if there ever is one single story of a disease. Even flu shots are controversial.

  8. Ukan  March 29, 2012

    I have been following blogs about Low carb for just over two years.

    Once thing I keep seeing is peoples reported improvement in triglyceride levels.

    If someone was to follow a low carb diet (<30 gm pd) what reasons might there be for not achieving the anticipated improvement.

    (reply)
    • Peter Attia  March 29, 2012

      Hmmm. Good question. Reduction in circulating TG is one of the first and most pronounced changes in removing carbs. Hard for me to “diagnose” like this but I agree, this is unusual.

    • Jeffrey of Troy  March 29, 2012

      While reducing bodyfat on LC, trigs may go up temporarily, as FA’s are released from their cells. Should drop as you approach a healthy bf% (10-15% men, 15-20% women).

  9. Mark Deevy  March 29, 2012

    Peter,

    Great Blog(s). A difficult topic to discuss – very well done. Keep up the excellent work.

    Mark

    (reply)
    • Peter Attia  March 29, 2012

      Thanks very much. The reason I was a day “late” on this one is that I couldn’t quite write it down the way it sounded in my head. I hope it still came across ok.

  10. Bob  March 29, 2012

    Thank you for the posts. I wish I had a link to an article I read about AIDS. (new Yorker I think), it seems relevant. According to this article:

    Aids cases in different countries in Africa went up as life expectancy went down. And vise versa. The hypothesis being that if you think you are going to die young anyways, why bother. I definitely know people who think they will get fatter and be fat for the rest of their lives – why bother. So many reasons why people don’t act in their best interest.
    Thanks.

    (reply)
    • Peter Attia  March 29, 2012

      Wow, interesting hypothesis.

  11. Brad  March 29, 2012

    I’ve been reading “Switch: How to Change Things When Change is Hard,” by Chip and Dan Heath (one of the most useful books I’ve read in the past 20 years), and one of their key messages is that “knowledge doesn’t change behavior.” They back it up with plenty of evidence, but more precisely it’s “knowledge ALONE doesn’t change behavior.” Changing behavior requires first appealing to the emotions in order to give us the momentum and power to change. Knowledge is used to steer that change in the right direction. Another key point they make is that you have to shrink the change by breaking it down into small enough parts so that it no longer seems overwhelming.

    The relevant point here is that teaching people why they gain weight and how they can lose it is only half, or even one-third of the solution. The bigger issue is how to motivate them to change and to sustain that momentum and motivation over time. The Heath brothers point to the need to “script the critical moves,” which means identifying the times of weakness when people tend to lose motivation and slip back into old patterns, and focus on techniques to get people past those hurdles.

    All the knowledge in the world isn’t going to help people to change their behavior. Change is a complex process and we’re resistant to it. Chip and Dan Heath spent years studying successful examples of change to figure out the keys to their success; I highly recommend reading this book if you’re interested in changing your own behavior, making changes in your workplace, or making larger changes in the world.

    (reply)
    • Peter Attia  March 29, 2012

      Very sage advice. Just ordered a copy on Amazon. Thank you.

    • lupo  March 30, 2012

      I read it, too. Great you put it on your reading list, Peter. You will like it and maybe improve the way you deliver your/our message.

    • Tom  March 30, 2012

      Try Made to Stick by the same authors about marketing. Sounds funny but i think the blog is about marketing health. easy read and some great tips. I work in IT and it has been invaluable in getting my points across in an easy way for other to understand.

    • Alexandra M  March 30, 2012

      I, too, ordered the book on your recommendation.I’ve already gained some useful insights in an hour of reading – though I wanted to scream when they talked about the successful effort in W Va to get people to switch to 2% milk from whole by telling them a glass of whole milk contained as much saturated fat as 5 slices of bacon!

      You just can’t get away from this stuff!

    • Anthony Peters  April 2, 2012

      Switch is a good book, and I do recommend reading it, especially because of all the concrete examples it gives on enacting change, and simple methodology. However, when it comes to the science of willpower it will teach you very little.

      For that I recommend “Willpower: Rediscovering the Greatest Human Strength” by Roy Baumeister and John Tierney. There you actually get some of the science of willpower as well as overviews of some of the popular techniques of personal change. The one topic that I saw brought up in the book that virtually no low carb blogger has picked up on is the role of glucose in willpower. Maybe Peter would have the time to take a stab at it one day.

    • Scott B  April 11, 2012

      Brad – thank you for the recommendation. I loved “Switch”, and it helps explain why the most popular post on this blog is Peter’s “What I Actually Eat”. People who are trying to implement a LCHF “Switch” need to get crystal clear on what to actually do, thinking in terms of specific behaviors they will change, like salad for lunch, and eggs for breakfast. What Peter actually eats is a call to action, to eat fat shakes and hard cheeses, coffee ice cream and coconut oil – all so we can be lean and healthly like Peter. Mark Sisson’s video on the 2 minute salad is in this same vein – exactly the kind of information most helpful. See http://vimeo.com/1425810.

      I think most of us are sold on the “why”, given how compelling the science is (thank you Gary). What we need to get all of this from the TBU category (true, but useless) to the “this changed my life” category is Chip and Dan Heath’s excellent counsel to “shrink the change”, “build habits” (purchasing and eating), “tweak the environment”, etc. etc.

  12. Mark.  March 29, 2012

    I’ve been a type 1 diabetic for over forty years, and switching to a low-carbohydrate diet has reduced my need for insulin, provided better control, and stopped a slow but seemingly inexorable weight gain — yet I’m still about sixty pounds overweight and can’t seem to stay under 250 pounds for long. I can’t see myself returning to an ADA style diet, and I now seem tolerant of fasting and hope to be able to eat less without hunger. I have yet to meet a doctor who approves of what I’m doing. There seem to be no resources whatever, on or off line, for the obese type 1. Low-carb has been great help but hasn’t been a magic bullet for me; I hope that I’ll be able to keep eating less and perhaps lose weight that way.

    (reply)
    • Peter Attia  March 29, 2012

      Mark, I can only imagine how frustrating this is for you, on so many levels. I wish I knew the answers to these questions. I’m sure there are things you could do to lose at least a portion of the extra weight, and hopefully this blog gives you some ideas, but I can’t be sure you can be completely lean. As far as your doctor goes, though, I wonder if it’s worth finding a doctor who supports you? I feel this is an important relationship and one that needs to be supportive, rather than judgmental.

    • nonegiven  June 6, 2012

      Dr Bernstein http://www.diabetes-book.com/
      varies protein amounts for type 1s to lose or gain weight.

    • Antje  December 20, 2012

      I would recommend, to check “wheat belly blog”.
      Category: Thyroid

  13. Bill  March 29, 2012

    The argument made by Bray and Kolata is hard to take seriously. The more interesting question is why some, perhaps many, people who radically restrict carbohydrates remain overweight, either plateauing or even partially regaining. Of course Jimmy Moore is the most well known example, and he is trying to figure it out for himself, but one hears these stories fairly often.

    I know Gary has said that low carb allows one to become as lean as one can be, not necessarily truly lean for everyone. I wonder how you would answer this question, or if answers even really exist at this point.

    (reply)
    • Garth  March 31, 2012

      This is something I have also wondered. But more important to my mind is what percentage of people experience this. After the question of how effective carb restriction is for weight loss, I would like to see a good study of how effective a reduced carb diet is at sustaining it. Fingers crossed that NuSI will get the ball rolling on some good studies to answer this sort of question

  14. Megan  March 29, 2012

    Thanks again for such a great post.I live in the UK where we are also bombarded with messages of low fat and high carb (albeit whole grains) diet solutions. However I recently found a solution to my own weight problems and embarked on a ketogenic diet which helped me to lose 42 pounds in 16 weeks. While the diet involves the use of pre-packaged foods, it also ensures that you receive counselling to deal with your food issues. I have found this combination especially useful.
    So, here I am at my goal weight and about to start the process of reintroducing “normal” food. This is taken at a very slow pace building up carb grams until you reach a plateau. At the end of this process I will discover to what extent I can consume carbs. I suspect that the level will be low for me.
    I agree with the above post, that the journey is really only just beginning once the weight has been lost. But I now recognise the failings of the food available to me.
    Despite reading Gary Taubes and others prior to losing the weight – I also needed the extra support I get in my weight loss group. Doing it alone was too hard.
    I suppose I fell into the third of your groups. I knew the science and the solution – but I lacked the right willpower, support and motivation to push past the emotional connections I had with some foods.
    I suspect that a lack of information is the least of our worries.The main focus should certainly be on offering support to follow through on that advice. After all, people still smoke despite knowing the dangers – as you quite rightly point out.
    Oh, by the way, I am a vegetarian and fully expect to be able to stick to a low carb diet. It really is possible with the addition of eggs and dairy. A post on vegetarians and low carbing would a great addition to your blog. There are plenty of us who believe in low carb diets despite our other ethical beliefs.
    Well done on your blog. You work very hard!

    (reply)
    • Peter Attia  March 29, 2012

      Megan, congratulations on your progress. I agree that a vegetarian can (quite easily) adopt low-carb eating principles, especially if they are able to eat dairy and fish. Here is my BIG warning: When you “reintroduce normal food” I get a bit worried. If you mean, “stop ordering my food and make it myself…,” great. If you mean, “start eating what I used to…,” not fine. If you return to your old eating habits you will, almost certainly, return to your old health.

    • Lise  April 1, 2012

      I agree that eggs and dairy are a great way for vegetarians to eat a low carb, moderate protein and high fat diet and it is not boring.

    • Claire  February 4, 2013

      This is ti Peter Attia. Vegetarians DO NOT EAT FISH!! So as a vegetarian, I could not incorporate fish into my diet. Pescetarians eat fish but not meat. :-)

  15. Jim Georgopoulos  March 29, 2012

    This is so disappointing. Dr. Bray and Ms. Kolata are actually arguing, what I consider, a silly point? “Why isn’t everyone thin if the solution is low-carb?” Do I understand their basic argument correctly? Doesn’t that imply that *everyone* has tried (and stayed) low-carb? The answer is ‘no’. Most people, in my experience, have not and have no intention to do so because “it’s a fad” and “it’s not healthy” and “my doctor told me…”
    It’s understandable in a way. Look at the “hit job” the mainstream medical community did to Dr. Atkins (and even continued to do so after his death).
    So this is the logic of these “informed” people of science?
    God help us.

    (reply)
    • Alexandra M  March 30, 2012

      I wish someone would ask Bray and Kolata, “If ‘eat less and exercise more’ is the solution to obesity why is everyone still fat?” After all, that’s a message that everyone has heard and that (sadly) most people accept, and that many, many people have tried. By their own logic –

      “If a disease is prevalent, no treatment exists to eradicate it. In other words, if any condition exists, it implies there is no cure for that condition. The reverse (and logically equivalent) statement is this: if a treatment exists for a disease, no one has the disease.”

      – their advice (eat less and exercise more) fails miserably as a treatment for obesity.

  16. Carlos Morales  March 29, 2012

    You didn’t answer your own question, though. There are many people who remain overweight while in ketosis, just look at Jimmy Moore. In Gary Taubes “Good Calories/Bad Calories” he states that it may be impossible for someone to remain fat while in Ketosis, but that doesn’t seem to be true.
    In anecdotal evidence, I did lose weight on a low carb diet. In fact, I lost 130lbs.
    http://www.marksdailyapple.com/how-i-lost-130-pounds-and-fell-in-love-with-bacon/
    Recently though, while trying to increase my exercise loads, I’ve felt tired and getting crap results. I raised my carb intake to 150 grams of carbs eating “primal/safe” starches, lowered my fat intake, and I’ve lost more weight and look better naked. I can’t understand how this works if the insulin hypothesis is correct.
    Also, you bring up that you eat dairy, but dairy raises your insulin level quite a bit.
    http://www.marksdailyapple.com/dairy-insulin/
    How does this suite the insulin hypothesis, if a raise in insulin causes weight gain?

    BTW, I’m not asking these questions while assuming I know the answer. I’m genuinely curious

    (reply)
    • Peter Attia  March 29, 2012

      I addressed your first question in a different response. Basically, just like hair (color, thickness, etc.), profound differences exist in body type and body response. Many people — but not all — do “best” on a diet that removes most carbohydrates. By “best” I mean, body composition and disease risk profile. But this is not true for everyone. If I knew exactly why, I would certainly share it. My frustration with the debate around this point (not your question, of course) is that the discussions around diet and nutrition look/sound/smell a lot like the discussions around religion and politics. It’s “all-or-none” with no effort to nuance and try to understand individual variation.
      A great example of this is your second question about diary. For some, yes, dairy kicks off a horrible cascade of inflammation and insulin secretion. For others, it does not. Even within dairy, there is a huge difference. For example, milk versus cream. Hard cheese versus soft cheese.
      I like what you’ve done — you’ve take control of what works best for you and you’ve been willing to modify and improvise. Keep it up!

    • Mandy  April 16, 2012

      I think I can shed some light on Jimmy Moore–at one time he maintained a blog containing his menus, which he discontinued last year because, in his words, “When I started this menus blog, the purpose was to show what the diet of a real low-carb dieter looks like on a daily basis. Now after three years of doing this diligently, it’s time to shut it down and spend time doing other aspects of the work I do with ‘Livin’ La Vida Low-Carb’.” Uh, no–the reason was because he ate crap and he HATED people calling him on it, which happened pretty frequently. The menus blog is still up but if you read his blogs these days they pretty much only deal with his upcoming podcasts. But since a lot of people listen to his podcasts and a lot of people want to promote their own sites (including Peter) and everyone’s like “oh, Jimmy’s such a nice guy” the fact that this guy is FAILING at “livin’ la vida low-carb” is ignored. Just as there are vegetarians who lord their “healthy” lifestyles while subsisting on tortilla chips, salsa and Morningstar Farms soy burgers, there are many like Jimmy who lord their “healthy” lifestyles while subisting on processed cheese, spaghetti squash and Atkins bars. I see now that he’s doing “Paleo” and has admitted to gaining weight. Like any addict–and I include myself in that description–he knows what to do. He just doesn’t want to do it.

  17. Anu  March 29, 2012

    Another thing that is important to keep in mind is a recognition of where people are coming from i.e. what is the baseline we’re comparing against. It may never be possible for the person who was 350 lbs to be “thin” by mainstream standards. Sometimes I see mocking comments at the bottom of blogs like yours and Gary’s by people who say things like, oh so if low carb is so wonderful, how come Jimmy Moore is still fat? Even Gary was once asked by a commenter what his weight and height and waist size were, with the implication that he still looked pretty “big.” Personally I’ve lost 60 lbs and gone from a size 16 to a size 6, yet I still wouldn’t say that I was skinny by mainstream standards, and it has become harder and harder to lose weight. I wonder if this is my low-carb setpoint and what determines that, since it seems clear we can’t lose weight forever. I think part of the reason it’s so hard for low-carb to get traction in the world is that the only people who people are willing to listen to when it comes to weight problems are those who’ve never had weight problems themselves — who are ironically probably the ones for whom carbs do the least harm and for whom a low carb eating plan would probably yield the least benefit.

    (reply)
    • Peter Attia  March 29, 2012

      The problem with comments like this is that they assume (erroneously) that humans are a homogenous population. Obviously, this is not even remotely true. The questions should NOT be, “Why is so-and-so still overweight if he’s eating a low-carb diet?” The question SHOULD be, “Which diet will help so-and-so be the most healthy he can be (even if that’s not remarkably lean and healthy on an absolute level)?”

    • Debbie  March 29, 2012

      I think there are 2 reasons the low-carb way of life is relatively unpopular: 1) the media demonizes it and 2) Carbs are addicting and delicious, and most people just do not want to give them up. Admitting the truth about carbs and health is just too tough for people to do, AND STILL continue to eat carbs, so – denial happens. I can understand it.

    • Matt Taylor  March 31, 2012

      A few years back I remember seeing a blogger talking about how “doughy” Gary Taubes was. Even had a picture with his midsection circled. In fact here is a link to it: http://www.diseaseproof.com/archives/diet-myths-the-doughy-gary-taubes-big-fat-lies.html . You can tell when somebody is losing an argument when they resort to childish ad hominem attacks. Pathetic…

    • Donna  December 21, 2012

      A recent article in the Cleveland Plain Dearler (Dec 18, 2012) about a CWRU professor who disputes claims that there is an obesity epidemic raised some interesting observations that may have some relevance here. One is that the BMI tables have been revised to the point where currently healthy people fit into the overweight obese category even though they are healthy, fit and lean. He pointed out that Brad Pitt would fit into the category of overweight. Too much reliance on these tables makes everyone a little bit crazy about whether they are fat or lean. For myself I am signifcantly overweight with health problems. That can easily be seen by anyone. But I have looked at other people who are active, look good by any standards and the BMI tables rate them as overweight. They are healthy with good cardiovascular health, liver health and brain health. If they are overweight by these tables should they diet to try and get leaner. I don’t think so.
      In the Art and Science of Carbohydrate Living, the authors discuss the issue of diet and diabetes. I’m going on memory here so I hope I’m getting this right. They say that diet may help the diabetic condition but the individual may still be overweight. Further tweaking may allow the person to get leaner. This is where the need for low carb nutritionists are needed. (I haven’t found any in my area) It takes a good eye to see what needs tweaking and it is different for everyone. The thing is they caution that once health or weight loss occurs, the carb intolerant cannot go back to eating carbs like they did before. Restricting carbs is a lifelong endeavor not a temporary one.

      If the blood work is good and you are healthier then you want to stay that way. Going back to old patterns would undo all the good. The bug is that the weight may or may not go down and that is dependent on so many things besides insulin resistance that it becames easier to give up because weight is tangible, ie you can see it. Good health isn’t so tangible so it becomes easier to focus on weight loss rather than good health as a goal. Society puts enormous pressure to look thin. The never too rich or too thin syndrome.

      I know the pressure as I deal with it almost every hour of every day and I’m exhausted by it. Yet what I have been doing has lowered my blood pressure, sugar levels and raised HDL so why don’t I focus on that instead of focusing on I only lost twenty five pounds in the last few months. (Maybe because I have a lot more to lose before I look good :) ) Frm what I’ve read above there are people who ought to be high fiveing themselves for doing so well. But I know the demon of weight and how hard it is to shake it.

      Peter, as always a great post. I read these studies with a much more critical eye now. I just wish people who write stuff in magazines like Prevention and Health did a better job in understanding what is good science and what is questionnable.

    • Peter Attia  December 22, 2012

      Donna, this is very important point, which I won’t do justice in my response. Short answer: obesity is actually the wrong target. MetSyn is what we should be worrying about. Obesity is a descent, but far from perfect, proxy.

  18. Deborah Gordon  March 29, 2012

    Thanks for this post Peter. I am going to be presenting on “Weight Loss” at the Weston Price Conference this November and just the chore of thinking of the title for the talk, I am stumbling over the paradox that while the instructions, the information, the rules to follow may be simple, the compliance with those rules is actually quite difficult for many people.

    I loved switching to more meat and more fat, with a little backwards look at bread and a regular lapse with a beer, but I know others who actually have a very difficult time (taste, energy, digestion) making the switch even moderately so. A large factor I believe is remnant fat phobia — it’s hard to digest a heavy protein program, much easier if you eat fat — as well as out-of-shape biliary function. Some folks have just grown up eating veggies and brown rice and lots of fruit and between their nostalgia, accustomed tastes and downright disbelief, weight loss is very challenging for those folks because the dietary switch is difficult.

    (reply)
    • Bruce Berry  March 30, 2012

      I have a farmer friend who has observed that the feed an animal is raised on, will be highly favoured by it forever. I have to wonder if this applies to humans also – the taste of home might forever be something sugary and carb filled for some. With most mammals, the maternal caregiver teaches the youngster what foods to eat; it then avoids these at its peril in most scenarios in nature.

    • Matt Taylor  March 31, 2012

      This is a very interesting point about favoring the food we are raised on. I know I love my mother’s cooking more than anybody else on the planet. When I visit it is impossible to remain VLC while I’m there, and I don’t even try anymore. So I gain 10 lbs in less than two weeks…

  19. Krisna  March 29, 2012

    Excellent and articulate post! Thank you for your effort and insight, which is so desperately needed. In my work, as a worksite wellness consultant, I see one additional missing piece. While bad information is certainly all encompassing and pervasive in the US, I believe individuals lack the “skills” to accommodate any new or relevant information. The low-fat diet has become the default system and in order to change that, new skills must be developed. It’s much like learning a new language. A gradual process of words, then sentence structure, followed by grammar and eventually comprehension. It takes time and as we know our society expects immediate results, with little critical thinking. Individuals need assistance now in how to build skills around, shopping, meal planning, cooking and actually the “how to” not the “what” of the low carb life. It is challenging, because they also have to have the will, like you, to go against the grain.

    (reply)
    • Peter Attia  March 29, 2012

      Great point! You’re absolutely right. A subset of the “bad information” problem is that most people don’t have the training to think critically about how to assimilate information overload.

    • Jan James  March 29, 2012

      I would add that people (I’m thinking diabetics specifically) don’t have the tools, either, to help them learn at an early stage. If your doctor gives you a pat on the head, says watch your diet and exercise it’s not sufficient. Once I bought my own glucose meter and a nice big supply of strips and started experimenting, it became very clear which foods were bad for me. I suspect that many obese people might also benefit from seeing what foods actually do to them. I’ve been low carbing for 5 years. It brought my blood sugar down to normal range and keeps it there. I haven’t lost weight on this diet since the first year, but I know if I started adding carbs I’d lose my blood sugar control and gain weight quickly. I wish meters and strips were more accessible for everyone.

    • lorraine  April 3, 2012

      Jan, it’s even worse than a pat on the head for diabetics. The codified instruction they receive from their diabetes educators in hospital diabetes self-management programs involves a dietary protocol of high carbs (certainly much higher than anything we consider low carb, and managing the effects of that with medications), calories in – calories out mentality, and an absolute assumption that their diabetes will progress to reliance on insulin. These *are* the tools that are given to diabetics. It’s crazy, and diabetes educators are at high risk of losing their jobs if they diverge from the protocol in any way.

      On better accessibility of meters and strips, Walmart brand of Reli-On meters and strips is quite reasonable. Strips cost less than half of most others, and sometimes they just give the meters away. I’ve checked their accuracy against my other meters and they’re the same. I was led to them by a doc who posted on a blog, maybe Dr. Eades’ blog, that he’s found them valid.

      I’ve been on the fence in the last few months, tho, if BG is really a valuable number, especially for prevention. It seems a whole host of things go wrong (insulin resistance, for example) before glucose starts to go up. I know some docs, like Dr. Bernstein and Dr. Davis (Wheat Belly) rely on BG, but I think it’s often too hard to tell what exactly is causing any particular BG reading at any particular time. I also know that the medication protocol that diabetics use is a direct gram carb for unit of meds relationship, but I don’t buy it because of the variations I see. I also have to try and evaluate BG in complicated scenarios where a lot of variables are at play – people who are on meds including insulin who see me in a post-prandial state usually, of who knows what kind of mixed meal. I always have them do a pre and post exercise BG, but it’s mostly to make sure they’re not hypo and also to condition them on the extremely positive benefit of exercise if their numbers are high (exercise is always good for a drop of 100 points if blood sugar is high, but by that, I mean diabetic high). But I don’t see any direct relationship usually between a particular meal and a particular BG, which is how the diabetic is trained in their medication literature, and also how many non-diabetics use blood sugar readings to track their reactions to certain foods. I’m not making the claim that self-monitoring of blood glucose is not effective for non-diabetics, I’m just saying that based on the diabetic readings I see, I’m unable to determine any efficacy in looking at a meal and a reading.

      I’m pretty much of the belief now that as long as a person’s insulin resistance isn’t too bad yet, the insulin concentration will rise high enough to keep the blood sugar pretty normal, so post-prandial blood sugars will look pretty normal in someone who’s not already diabetic no matter what. Peter’s situation with his OGTT is an example of this. I’d love to hear details about what you found regarding specific foods (or meals) and specific variations in your blood sugar to let you know which foods weren’t working for you. And I’m always looking for information to challenge any conclusions that I’m on the way of drawing, so your input would be helpful to me.

  20. Andrew  March 29, 2012

    Great stuff, as usual. I am one of these folks you refer to that needs to find a happy medium with carbs. I originally dropped from 215 to 155 (at 5’10”) using a strict CRON (caloric restriction) type approach. The weight loss was easy and my hyper-obsessive personality make the calorie counting, etc. fun in a perverse sort of way. However, I could never understand why I would then GAIN weight so easily if I spent a few days eating 1700 calories instead of my typical 1500. I am pretty active, so there should have been plenty of calorie burning going on. After reading Lustig, Taubes, yourself, and then a bunch of stuff from the Paleo community, I quickly realized that my CRON diet was so high in carbs (even if they were usually not highly processed), that I must have been in a major storage mode when my insulin levels went up. Now I have the opposite problem. I am eating high protein, low processed carb, no sugar (somewhat paleo in my approach, so I eat plenty of whole fruits and veggies) and I cannot stop losing weight! I am down to 153 without caring about calorie counting – that is too light for me, so I gotta add some more carbs back in, I think. As a PhD chemist, I am all about doing good experiments, and like you, I don’t mind doing them on myself. However, it is turning out to be way harder to find my metabolic happy place than I thought!

    Anyway, thanks for dropping knowledge on us – I look forward to the next post.

    (reply)
    • Jeffrey of Troy  March 29, 2012

      You sound like the ideal candidate for the rice and potatoes modification that the paleo sphere is doing recently.

      Just avoid wheat (and sugar of course) like the plague.

  21. Lisa  March 29, 2012

    The problem is one of “moral equivalence.” What the Kolatas and Brays of the world are saying is, because people can’t seem to stick to any “diet,” whether it’s low-fat, low-carb, or low-cal, then they’re effectively all the same, so just forget all of it and eat less and exercise more. That’s what it always boils down to, and since reporting and “science” seems to be almost entirely observational these days, there’s never any real data to challenge this belief. What they tend to do is point to someone like Jimmy Moore and say, look, he’s followed low-carb religiously for years and is still obese, while vegans like Alicia Silverstone are lean, so obviously no one diet works for everyone and it’s just about finding something you can stick to. That’s why what you and Gary are doing with your new initiative is so critical—until we have some hard science to back up these claims, conventional wisdom will always default back to eat less/exercise more. I couldn’t agree with you more that until there are widespread structural changes that make it easier for people to eat low carb, along with a supportive environment to do so, we’ll never win this war. Frankly, I’m not very optimistic that this is achievable. There’s simply too much noise out there, along with too much financial incentive to maintain the status quo.

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    • Peter Attia  March 29, 2012

      Lisa, I think you make some excellent points. I do hope, in time, we can course-correct. The foundation of this change will be “real” science, but good (real) science is not enough.

  22. Bob Johnston  March 29, 2012

    I’ve read the objections of Bray and Kolata before and my immediate reaction was “What a bunch of sh#t.” Responses like theirs are obvious rationalizations to mend the cognitive dissonance they so obviously feel.

    I don’t doubt that my response was typical for low-carbers as a whole but I imagine for the uninformed and misinformed out there that argument may seem to have merit. It’s truly unfortunate that your excellent rebuttal will most likely only be seen by the people who don’t need convincing and not by the people it could help. It’s a shame your blog doesn’t have the readership of the NY Times. But hopefully someday…

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    • Peter Attia  March 29, 2012

      Bob, ANYTHING you can do to spread the message to those who may benefit most from reading it, would be great.

  23. Lucas Reis  March 29, 2012

    I agree with everything in this post, but one thing I would like “low-carbers” to stop talking is “it’s easy to lose weight in a low-carb diet”, because it isn’t.

    It certainly is the easiest route, and I believe it’s the only one (and that people on other diets lose weight because they are eating less carbs also), but saying it is easy is wrong. I’ve seen many not being able to lose any weight, and many getting fat again. Maybe Kolata has a point here, saying it’s simply impossible to get thin…

    So, I believe that low-carb is the way to go, but let’s not delude people saying it’s easy! ;)

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    • Peter Attia  March 29, 2012

      Great point, Lucas. I’d through one nuance on it…it’s not easy for all people. Maybe not even most people. There are some (I’m not one of them) for whom the path to weight loss is as easy as breathing.

    • Travis Koger  March 29, 2012

      Lucas,

      Totally agree. It is definitely not easy, but once you get the system it indeed becomes very easy. Having said that, for the last four weeks for me it has not been easy, first losing 6lbs, then putting it all back on, then slowly taking most of it off again. The roller coaster makes it difficult, even though I believe I have the system worked out. However, over the last 16 months I have lost 80lbs, and technically that was lost very easy, considering how very very hard it was to try and lose it when I was still eating carbs. :)

    • Paul  September 17, 2012

      I think that is a really good point. I want to tell people that loosing weight on low-carbs is easy because in general it was much easier than counting calories and coming to terms with hunger. But carbs are addictive. Though I am quite happy about my weight, health and general sense of well-being, I have a yearly holiday carb relapse (thanks family!) due to the availability of fresh baked goods.
      I think it might be helpful to be realistic/specific about the experience, i.e., specify what is easier about low-carb and what are the challenges.
      Advantages: You never have to feel hungry.
      The bookkeeping is much simpler.
      In at least one sense, you get more enjoyment out of food.
      Others can fill in the Disadvantages.
      Btw, it is counter-productive to make yourself or anyone else feel bad about relapses. IIUC, the research on addiction shows they are to be expected. The point is to move point them as quickly as possible.

  24. Alexandra M  March 29, 2012

    Many excellent points, as usual.

    The “healthywholegrains-arterycloggingfat” paradigm is so deeply embedded in the American psyche at this point that even people who have heard about low-carb diets can’t wrap their heads around what it means.

    For 10 years I’ve been explaining low carb dieting to the woman who cuts my hair, while I watched her get fatter and sicker and unhappier every year. The last time I saw her a couple of weeks ago, she said she was finally going to try it, but she had some questions: “What kind of bread should I eat?” and “Should I drink Gatorade if I get dehydrated?”

    *facepalm*

    I really don’t think I was that inarticulate in explaining the basic concepts! But people mostly don’t know what’s in their food, let alone how to avoid it. But she still has the Atkins book I gave her 7 years ago, so I’m hoping…

    (reply)
    • Peter Attia  March 29, 2012

      Oh boy…Information! Infrastructure! And probably Pain… Stick with it. Hopefully this blog and others, coupled with your haircut frequency, can help her.

    • Matt Taylor  April 4, 2012

      I went out to eat tonight. There was not a single thing on the vast menu I could eat as-is. I had to pick it clean of sugary dressing, tortilla chips, toss the side of bread (no butter!?!?), etc. The waitress liked my “artistic” (her words) pattern of 3/4″-square tortilla chips I placed neatly along the outer rim of the enormous plate completely circling it almost touching…

      I gave the bread to my dog when I got home. I felt guilty… like I was poisoning him (and rightfully so to some extent). He seemed to enjoy it though. Poor bastard…

    • Peter Attia  April 4, 2012

      Matt, too funny! Yes, you are getting an idea of what I mean by “poor infrastructure” fed by “poor information.” I’m really shocked at how little people appreciate this vicious cycle the impact it has on American health.

  25. CS  March 29, 2012

    Dr Attia,

    Another medical parallel, and perhaps in some ways a more apt one, is alcoholism. Before the advent of AA and the eventual recognition that alcoholism is a disease and not just weakness and a bad habit, the advice to the alcoholic was similar to that now given the over-weight: just drink less, or stop. Moreover, we know that if one never drinks alcohol, one cannot become alcoholic. We also know that for a great many, if you become alcoholic, a 12 step program has a very good track record of controlling the disease. So why are there still drunks? Is it because we do not understand what alcoholism is or how to prevent or treat it? Who would argue such a thing? And incidentally, like obesity, not everybody who ever drinks alcohol becomes an alcoholic, any more than everybody who eats cookies becomes morbidly obese. Does that mean, therefore, that there is no such thing as addiction to alcohol? Moreover, even within addiction, some cases are far worse than others. The more you think about this, the more parallels come to mind.

    The addictive nature of sugar, and perhaps of other carbohydrates, is often alluded to in passing–Gary Taubes certainly suggests it, and I believe you have as well–but then it is simply ignored. I find this odd. Addiction is not simply a bad habit. So perhaps one of the answers to Kolata and Bray et al. is that as long as there are addictive substances in the environment, and as long as they are cheap and, as you rightly point out, nearly inescapable in the environment (and while the powers that be encourage people to eat them), then some people having a correct analysis of the problem and effective ways to deal with it are simply not enough, particularly while most are in denial. As the sugar addiction becomes more and more widespread with the massive increased ingestion of sugar, which is easily quantified of course, then more obesity can be the only outcome.

    Finally, prior to the 70’s, the advice on weight loss was generally to reduce carbs: back then serious obesity and a whole population overweight was not the case, as you know. It changed at the same time, not just in the US but in the UK as well (and perhaps elsewhere? It would be interesting to know) when carbohydrates were no longer seen as the issue, and as sugar became more and more prevalent in the diet. So when “Banting” ruled, the “problem” was less wide-spread and severe. When “Banting” was turned on its head….well, we see where we are now.

    How about a post on addiction?

    Keep up the good work.
    Cort

    (reply)
    • Peter Attia  March 29, 2012

      This is a great point, which I had not considered. I wish I knew more about (clinically) about addiction so I could write about this specific topic with some credibility. One of the studies we envision NuSI doing involves the use of functional MRI (fMRI) to better understand the neurological impact of macronutrient swaps.

    • Debbie  March 30, 2012

      I agree with you completely, Cort, and would add that – I think – the community that views overeating as an addiction, doesn’t see it quite as a substance abuse issue. In fact, here we’re saying overeating isn’t even the cause of obesity – in other words, it’s complicated. When obese, I certainly overate; I binged, constantly. But, If I’d never been fed carbs, would I have had a problem at all? Maybe not. But, once hooked – as any alcoholic will tell you – you’re an addict for life; you never lose your love of alcohol. My guess it’s the same for true food addicts, or carb eaters, overeaters, whatever you want to call us. And, because we must eat, it’s difficult to separate the substance from the behavior. Anyway, I’m trying to also say that the addiction community might benefit from realizing that carbs play a huge role in the food addiction problem, and that the type of food one eats in recovery matters greatly, that one would probably have a better chance of achieving what is known as abstinence (in OA – Overeaters Anonymous) if the issue of carbs in the diet were addressed. I’m not suggesting OA change, just that the addiction model of overeating/obesity widen to incorporate looking at the foods that are actually causing – probably for most of us – our food addiction and obesity.

    • Barbara Hvilivitzky  April 2, 2012

      “We also know that for a great many, if you become alcoholic, a 12 step program has a very good track record of controlling the disease.”

      Unfortunately this statement is completely false. AA has a 5% success rate after one year. So just like “eat less, move more” is wrongheaded, telling alcoholics to simply stop drinking is not the answer. There are several drugs however that are very effective. Naltrexone and Topamax are two of them. My point is that the SAD is full of addictive foods – and the obese may be just as hooked as drunks are to their tipple! But once they get their supply of drugs (aka “meat/fat/butter”) they will be on the road to recovery. To repeat: don’t expect addicts (to SAD) to just quit – they need a substitute that satisfies their addiction – or rather they must be given a food that satisfies the need that they hungered for…Peter does this make sense?

  26. Diana Attuso  March 29, 2012

    > “when I wonder if my blog has any impact on people”

    Stop wondering; your blog has an enormous impact. This is one of the few incredibly intelligent interactive SUPPORTS available. In fact I’d love to see more video from you, perhaps a lecture.
    I have found a few that have been really informative. Weston Price, Dr Davis. Those are the only ones that come to mind.
    This blog is a HUGE help!
    Thanks, Diana

    (reply)
  27. Scott B  March 29, 2012

    Peter – incisive, penetrating, and devastating response to a boneheaded critique of low carb (not to mention charitable). I would have been tempted to say the problem is ignorance and lies, but you’re a better man. Bring it Bro!

    (reply)
  28. jake3_14  March 29, 2012

    Thanks for elaborating on the logical flaws in G. Kotala’s and Darth Bray’s statements. The photo of the child flipping a tire was adorable!

    (reply)
    • Peter Attia  March 29, 2012

      Gotta start ‘em early!

  29. KevinF  March 29, 2012

    And to state the obvious: one good reason that there are still fat people despite the possible efficacy of low-carb diets is that there are people like Bray and Kolata constantly telling fat people that low-carb diets don’t work and are probably hazardous.

    (reply)
  30. maureendoug  March 29, 2012

    I’ve switched to a very low-carb diet, in an attempt to lose the 30 lbs I’ve added in the last 30 years. I love the diet, even though I had to give up my favorite food, pasta, but the satiety and freedom from worry about hunger more than makes up for it.

    Two comments: (1) I think one reason that people fall off the diet, or don’t continue it, is the fact that everyone else in your life is horrified and tells you how incredibly unhealthy it is. My peers, well educated women in their 50s, eat a “healthy” diet almost exactly the opposite of mine — whole grains, legumes, fruit salads, etc. My husband’s family has a lot of heart disease and are all about low fat. So to avoid criticism I basically conceal my eating pattern, sticking to salads and salmon, etc., around them, supplementing with fattier things later to keep my hunger down. But the social pressure against this diet is enormous.

    (2) I don’t think enough is said about the effect of the diet on the brain. Frankly I feel so much better mentally that it occurs to me that I was probably battling the negative effects of high insulin all my life without knowing it. I recently read a patient’s description of having received insulin shock therapy at a psych ward in the bad old days, and thought, wow, that’s just how I used to feel when I was hungry. I also wonder, since ketosis is used to for certain seizure disorders, perhaps there are some brain chemistry effects that the rest of us who are simply moody, cranky (as my parents always described me) could benefit from.

    Thanks!

    (reply)
    • BostonLisa  June 6, 2012

      I wholeheartedly agree. I’ve been trying different approaches to low carb eating (higher protein/lower fat vs. higher fat/lower protein) and found that fat calms me down, reduces my anxiety and provides energy. I used to be on anti depressants and when I realized what they weren’t doing for me, I weaned myself off them. This diet combined with regular exercise works wonders for my mood.

  31. Jim Bowron  March 29, 2012

    As you note, everyone has a different reaction to carbs. For myself, I take a personal warning from my previous experience as a smoker. Like many smokers, I quit a number of times before finally ditching the habit, and my failures always started with “I’ve been doing so well for so long, I can have just one and not get re-addicted.” I found I couldn’t have that ‘just one’, and I worry that, after apparently getting rid of my addiction to sugar, that if I slowly re-introduce carbs as I near my goal weight I would hit that same ‘slippery slope’ and get re-addicted to sugar.

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  32. Margaretrc  March 29, 2012

    Awesome post! Love your blog. My FB friends get tired of me posting diet and nutrition stuff, but some day soon I am going to put up a link to this blog. I think people need to see that not all doctors buy the mainstream BS. You and the other doctors in this sphere (Dr. Eades, Wortman, Phinney, etc.) and scientists like GT give us all credibility. As more doctors and scientists move away from conventional wisdom and start pointing to carbs, instead of fat, as what’s making us fat and sick, the information arm, at least, will get stronger. The infrastructure and pain arms are going to be more difficult, but one arm at a time!

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  33. Marilyn  March 29, 2012

    Bray: “I thus conclude that if any diet ‘cured’ obesity as their proponents often claim, there would be no obesity.”

    Kolata: “Low-carbohydrate diets have been popularized periodically since the 19th century. . . if they work so well, why are so many people still searching for an effective way to lose weight?”

    . . . I dunno, Dr. Bray and Ms. Kolata. Maybe it’s because the experts keep spreading the word that low-carb diets are dangerous, ineffective, impossible to follow, missing vital nutrients, low in fiber, dangerous to the kidneys, toxic to the heart, softening to the bones, softening to the brain . . . ?

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  34. Sabrina Chase  March 29, 2012

    Any references available to people who hit the no loss/gain problem with low carb, and found a solution? I’m in that situation myself – low carb worked great at first, and I do feel a lot better, but I have more weight I need to lose. I’m running out of food groups to eliminate ;-) Agreed everyone is different and you have to find the solution that works for you, but how?

    (reply)
    • Marilyn S  March 30, 2012

      I’m with you, Sabrina. I have totally eliminated processed carbs and sugar and upped my fat and protein and veggies, but have totally stalled with weight/fat loss. I only lost about 8 lbs and see very little change in my shape. I do feel so much better and am happier overall. I just wish I knew what I need to still do to kick start some more fat-burning. I’ve cut back on fruit and dairy and now need to reduce nuts, I guess. Let’s carry on and keep trying to find our ideal foods and shape….

    • greensleeves  March 31, 2012

      Sabrina,

      Have you had your thyroid and hormones tested? Do you have PCOS? If the answer to both of these are negative, then you are possibly stubbornly insulin resistant, and may benefit by starting low-dose metformin.

      Talk to a low-carb friendly doctor.

    • Alex  March 31, 2012

      Here’s what I did… I had easily maintained my 120 lb loss for 3 1/2 years sticking to vlc (vlc/paleo eating for the last year) without tracking anything except carbs.. on March 1st, I decided to use fitday to track my eating and nutrition.. I learned a couple things: 1) My nutrition was rock solid! 2) I was eating a lot of protein, sometimes 200 grams per day. Within the first week, I upped the fat and lowered the protein, still keeping the carbs at about 20g…never more than 30g. The calories stayed in the range of 1900-2300 per day. Result: felt just as good as always and I lost 5 lbs in 30 days! I am going to continue the fussiness of weighing everything to see if this continues.
      Probably no way to know if it was the protein/fat change or simply the act of tracking that made the difference.

    • Peter Attia  March 31, 2012

      Great insight, Alex. I really believe a lot of folks eating low carb, but hitting a plateau would benefit from reducing protein intake. For a refresher on my story, look at part 2 of my personal journey where I document this: http://eatingacademy.com/how-i-lost-weight

    • Alex  April 1, 2012

      Thanks, I had assumed I was eating moderate protein so even when I read your post, and what Nora Gedgaudas has to say on the subject, I thought it didn’t apply to me. It was an easy tweak and now the protein is at 90-120 G/day and fat is 70-75% of calories. Even though tracking is fussy and makes me feel like I am “dieting” there is great value in doing it.

  35. Alexandra M  March 29, 2012

    I wonder if there is any data showing that “the LCHF revolution” in Scandinavia is making a difference in obesity rates?

    (reply)
    • Peter Attia  March 29, 2012

      Good question for the Diet Doctor.

  36. DHackam  March 29, 2012

    Great comments. I especially agree that the infrastructure for providing low CHO on the run is abysmal – think of any fast food restaurant (and I’ve probably eaten from all of them), airport or train station. The reason for this is simply the information bias. Industry will provide what consumers have been led to want – by nutritionists, health policy experts, doctors, advocacy organizations (ADA, AHA, etc), and so forth. The messaging there is so effective that I still see people who are terrified of saturated fat and dietary cholesterol (including family members of mine). In fact, that remains the default reaction of those who are being oriented to this diet – even by a physician.

    The other remark I wanted to make – judging by the above comments, you have some of the most intelligent readers in the entire blogosphere.

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  37. Dave Nelsen  March 29, 2012

    Sabrina, I don’t know the particulars of your situation but I can say the following: 1. When eating low carb and trying to lose weight, everyone has a carb threshold above which they won’t lose weight. My wife and I are both LCHF but she can’t tolerate as many carbs a day as I can.
    2. It is true you can eat until you are satisfied, but I find to lose weight you need to learn to eat less (and still be satisfied) over time.
    3. Peter has it on this site, but too much Protein can actually kick you out of Ketosis.
    4. Try mixing up the food you eat if you are in a rut.
    5. Educate yourself. I just ordered “The art and science of low carb living”. I find that the more I learn, the more there is to learn.

    Hope this helps. Dave

    (reply)
  38. Alexandra M  March 29, 2012

    Yes I know – I asked him in an email but I never got an answer. And he very rarely responds to any comments on his blog, unfortunately.

    I also suggested that people on low carb diets who are anxious to combat the conventional wisdom should get their blood work done regularly. I think a lot of people get fed up with their doctors telling them to eatlessandexercisemore and abandon their doctors altogether. But if doctors were to see a trend in improving lipid panels they might wake up to the fact that dietary fat does not go straight from the tongue to the coronary arteries.

    I’m going to start carrying a copy of my bloodwork results around with me because I get so tired of explaining that eating fat does not make you “a heart attack waiting to happen.”

    BTW, last weekend I had dinner with a group of people to whom I’ve been trying to explain things over the past few years. The two morbidly obese people ordered the same thing: potato soup and bread, whilst staring horrified at my bunless cheeseburger with bacon and avocado…

    (reply)
    • Bente  March 31, 2012

      The obesity epidemic has stalled in recent years in Sweden, according to the diet doctors blog. Sweden and Norway where I live has some of the lowest rates of obesity in the western world.

  39. lorraine  March 29, 2012

    Not to add even more buzz kill to this topic than it already has, but:

    Information – Even when it happens (and I know it will) that there is rigorous testing of the carb/insulin hypothesis, the conduit of information is still fundamentally broken. In my substantial experience, most – and yes I believe this is a majority – of people believe their doctors should be the source of all of their health information. Doctors, however, neither perceive themselves as, nor are trained to be, health educators, and they never have. This more recent trend in the last few years of doctors providing primary prevention in the form of diet advice is rarely if ever implemented in the office, and if it is, it’s a “handout”. If I had a dollar every time I hear, “Why didn’t my doctor tell me that?!”, I would be retired and living in the 1%. My answer is always the same, “Your doctor is trained to do one thing, and that is to treat diseases with prescription medication. That s/he has less than 10 minutes to interact with you in an appointment because of how crushed his/her practice is due to managed care means that any service outside of treating your illness with medication is an unreasonable expectation of them.” If, as the stories would have us believe, our young doctors are learning about nutrition, exercise and life style, they aren’t translating that into clinical practice. My most recent experience with this was just this week in the treatment room of my mother’s young, hot shot, orthopedic surgeon who convinced my mother (who has metabolic syndrome with obvious clinical signs) that her arthritis has nothing to do with anything except her genes, and that there’s nothing she can do to remedy that except have knee replacement surgery someday. She now refuses to hear/read anything I have to say because her doctor told her differently (ok, and also because I’m her daughter).

    Take home: NuSci needs to have a media operation to bypass the doctor as the expected primary provider of health education to the medical consumer. For now, a million n=1 media operations have created a groundswell. I just now decided to start inviting doctors to my seminars free of charge. I think you guys should hire a big time fundraiser, who may also have to be willing to work free of charge for awhile. But if and when that gets up and running, it would be my pleasure to make a contribution.

    Infrastructure – Medical schools and medical associations (AMA/ADA/AHA/ABlahBlahA) and nutrition programs are tools of the pharmaceutical (and food) industry. Period.

    Take home: See above.

    Pain: Speaking of food and pharmaceuticals, the reason why there will still be a substantial obesity problem even after the correct dietary solutions are assimilated into our medical and social cultures, is because food is still the cheapest, most easily obtainable and legal mood altering substance available. I speak from 20 years experience working in hospital obesity clinics and weight management programs, eating disorder programs, community education in diabetes/MS self-management, and private practice. Maybe my universe suffers from selection bias, but a LOT of people (my experience is the majority), once they have the best of information, are still unable to commit because food (carbs/sugar) serves as their primary coping strategy for stress, overwhelm, and emotional and physical pain. And it works – it increases serotonin levels and hits (and changes) dopamine receptors the same as any street drug.

    Take home: Solving the obesity problem and the diseases that arise from it also requires helping our fellow travelers learn more effective self-care to break from the addictive nature of these foods.

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    • Debbie  March 31, 2012

      I agree wholeheartedly, Lorraine; thanks for this post. I believe one slight flaw in the delivery of the low-carb diet message – I’m not referring to this site, obviously – is not addressing the difficulty factor. Peter puts it beautifully: it’s a trade-off, you give up some good stuff, but the rewards are well worth it. For him, he says staying on the diet is easy. But, it should be stressed that for many if not most of us, it may not be so easy – BUT, it’s not so hard either, once one gets the hang of it, and enjoys the benefits. Often the diet is promoted as a perfect fix, certainly for obesity. It seems to be close to that, but for the reasons you delineate, it’s flawed, because people, for whatever reasons, have trouble sticking to it. Admitting the difficulty factor at the outset, I think would prepare people, so that perhaps they wouldn’t be immediately thrown off track and ready to give up at the first signs of discomfort.

  40. Andrew  March 29, 2012

    I enjoy your blog and appreciate that this is not a commercial endeavor for you. Over a 6 month period I lost 50lbs low carbing. I still have 20-30 to go. In the past year I have regained 7 or 8 lbs. I exercise alot (which may have nothing to do with weight management I know) and I am still adhering to a low carb diet. I have read other places that low carbing “stops working” after 6 months and this has been my experience. I am wondering if others have noticed that low carbing seems to stop working….could this be a “more fat less protein issue”?

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  41. Jeffrey of Troy  March 29, 2012

    A couple recent posts of mine have dealt with this and a related issue:

    Why different people need different amounts of carb
    http://jeffreybrauer.blogspot.com/2012/03/low-carb-or-low-fat-it-depends.html

    Nutrigenomics
    http://jeffreybrauer.blogspot.com/2012/03/signaling-nutrigenomics-made-easy.html

    (reply)
  42. lorraine  March 30, 2012

    WOW! Dr. Lustig made it onto 60 Minutes! I guess it’s not so hopeless after all.

    (reply)
    • Alexandra M  April 1, 2012

      I’m looking forward to seeing the 60 Minutes piece tonight, though quite a few people seem to have seen it already. You wouldn’t believe some of the comments at the CBS website – everything from a conspiracy theory that this is being bankrolled by Aspartame manufacturers, to the belief that people have been eating sugar for thousands of years without ill effect and fat people should stop blaming other people for their gluttony and laziness.

    • lorraine  April 1, 2012

      That’s unfortunate about the CBS boards comments. I thought it was a really good piece. Dr. Gupta seemed sympathetic to the evidence.

    • Alexandra M  April 2, 2012

      Yes, Gupta did seem sympathetic to the evidence. But judging by the comments, the resistance to low carb is far greater than I thought. Or maybe it’s a self selected group. Every time I watch 60 Minutes I wonder if I’m too young/healthy to be watching it since every ad seems to be for a medication!

    • Peter Attia  April 2, 2012

      Think about the implications to the “average” person if what they portrayed is correct? This is a life-changing change. It’s like telling someone who smokes 2 pack of cigarettes a day — for the first time — that smoking causes cancer and heart disease. The first response, especially given the addictive potential, is profound denial.

  43. Samantha Evans  March 30, 2012

    Peter, your blog is one of the best anywhere. I’m grateful for your thoughtful care and wisdom.

    This article is particularly useful for explaining important things about low-carbing and the readers’ comments are important additional value.

    I have one quibble, however. In North America, prostitutes are not high-risk individuals when it comes to spreading HIV/AIDS and other STIs. We are not the source of these infections. In fact, a person is at significantly greater risk of contracting an STI by a casual encounter with a nice man or woman one might have met at a bar or a nightclub than by having sex with a prostitute. It’s true that prostitutes who are also injection drug users are the ones most likely to be carriers of blood-borne infections and so, to that extent, referring to prostitution in connection with heroin use in Baltimore may make sense. Nevertheless, over 85% of prostitutes do not work on the streets anywhere in North America and women who work indoors are no more likely to be injection drug users than other members of the general public.

    There’s a lot of literature that supports my statements, including this article.

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  44. John Dawson  March 30, 2012

    “For some, yes, dairy kicks off a horrible cascade of inflammation and insulin secretion. For others, it does not. Even within dairy, there is a huge difference. For example, milk versus cream. Hard cheese versus soft cheese.”

    How would I test/measure to see if this applies to me?

    (reply)
    • Peter Attia  March 30, 2012

      If you have the luxury of drawing labs, you could use that (i.e., actually check your blood for insulin levels and other markers). For most people, however, that’s not practical. Instead, you would do an experiment. Say, 4 weeks with vs. 4 weeks without (changing nothing else), and assess.

    • Edmund Brown  March 31, 2012

      In my experience key areas to assess when taking a break from dairy are

      -skin – acne, keratosis pilaris (often on upper arms, but elsewhere too), general luster, and flakiness

      – sinus/rhinitis – snot production (runny or sticky boogery), snoring

      – eyes – allergic shiners (from dark to just faint discoloration)

      – lymph nodes – palpate prior to cutting dairy and then after removing it.

    • lorraine  April 3, 2012

      Peter: AT HOME INSULIN TESTING FOR BOTH FASTING AND POST-PRANDIAL

      I’ve been using an at-home blood spot test for fasting insulin from ZRT labs to compare it to clients’ regular labs, just to see how close it runs. It’s pretty darn good. I am aware of other labs using blood spot tests for things like A1c, and I wanted to see how it stood up to regular blood draw values. I have considered using it for clients who’s docs won’t do a fasting insulin and/or for folks who want to do it more often than their doc will order, and then use it to calculate HOMA-IR. You use a lancet to place a blood spot on chemistry paper and then send it by mail to the lab. The test is only $35.00.

      So it struck me today to find out if ZRT is doing a serum insulin by ELISA, and therefore, would it matter if it was fasting or post-prandial; ie, could it be used to mimic the insulin results seen in a glucose tolerance test. I spoke with one of their physicians today, and in fact, it can. The only caveat is that they publish the results per the ranges for fasting insulin, so a user would need to know the ranges for post prandial insulin to know what they’re numbers indicate.

      So the question of course is, what’s the validity on the blood spot test vs. blood draw. The doctor there is sending me validity data on the test (not for the insulin per se, but the method of blood spot), which I will post here so people can chew it over.

      If sufficiently valid, it holds the possibility of allowing folks to look at their insulin response, not only to carbohydrate, but also to protein and dairy, without having to go in for an OGTT and for a very affordable cost.

    • Peter Attia  April 3, 2012

      This is very good to know. Can you please send me the information?

    • lorraine  April 4, 2012

      Peter,

      I sent you studies on the blood spot tests. Please just let me know you got them. Thanks.

  45. Fritz Ziegler  March 30, 2012

    Bravo, Peter! The voice of reason speaks. I really appreciate your respectful attitude, because it improves the discourse no end to avoid demonizing those who disagree, while being clear why you disagree.

    Your approach seems wise: viewing carbohydrate intolerance as the problem and reminding us all that it can vary markedly from person to person, using yourself and your wife as an example. That’s the same approach used by Phinney and Volek in “The Art and Science of Low-Carbohydrate Living”. The varying degree of carbohydrate intolerance explains why getting an answer to obesity that works for everyone is terribly difficult–so many variables to deal with, making it tricky to design useful experiments on a budget without introducing hidden confounding variables.

    I only wish I could have discovered this wisdom 40 years ago, when the low-carb movement was tiny compared to what it is now.

    Thank you for your work,
    Fritz

    (reply)
    • Peter Attia  March 30, 2012

      Thanks very much, Fritz. It’s never too later, though. I, too, wish I knew this 15 years ago.

  46. Joe Smith  March 30, 2012

    Peter:

    I am reading The Art and Science of Low Carb Living and note that they are recommending LCHF diets of up to 85% of calories, just as you have described. Meanwhile, I’ve been suffering from low carb gluttony, and have put on 25-30 lbs over the last 6 months on a very low carb diet (most days under 20g of net carbs). The diet was working well for a few years, but it’s just not working anymore. Yes, I’ve changed the amount I eat, but the problem seems to be that I WANT to eat more than I used to.

    If I eat even one egg, I’ll eat a zillion. The sweetness of them seems to get me going. On such a low carb diet, I’ve become highly sensitive to carbs and even the higher carb green vegs can taste to me almost like they’ve been sugared. In fact, if someone gives me even a tiny piece of candy or cookie or cake, I have to spit it out because it’s so aggressively and unpleasantly sweet.

    I of course have wondered whether there’s something I can do to get over such emotional eating. But after reading your blog and Art and Science I began to wonder: maybe the best way to deal with it is to model the problem as an insufficient fat/total_cals ratio instead of modelling it as a psychological issue.

    So yesterday morning, I got out a nutritional guide and a calculator, and instead of having my normal breakfast appetizer of two soft-boiled large eggs stirred with a tbsp of coconut oil, I increased the oil to almost 2 tbsps, in order to bring the fat/total_cals ratio up to 85%-ish, and lo and behold I didn’t want any other food afterward. It was so rich I couldn’t eat another bite of anything. (Delicious, like a very rich and sweet egg drop soup, by the way.) I don’t think I’ve had that sensation — of simply not being able to eat another bite of ANYTHING — for years.

    The trick of bringing the ratio up to 85% worked again at another meal yesterday, and I had my first successful “diet” day in months. Painless. I was quite grateful to discover that the “OMG, I can’t eat another bite” experince occurred long before the added fat tipped the calorie scales against me.

    I will keep you posted as to whether this trick works longer term or is just a fluke. Obviously, it’s a heckuva lot more effective to add some more fat to food, rather than to seek years of psychotherapy that may or may not address the purported “emotional eating”.

    Wish I’d thought of this before I put on all the weight!

    Question: I did a hypothetical calculation of how much fat it would take to bring a 1/2 lb of chuck roast up to the 85% ratio, and it turns out that it was in the neighborhood of 10 tbsps, an absolutely enormous amount of fat and added calories. I don’t even know that I could get through such a meal without barfing, and obviously such a large amount of calories seems, at least at first glance, like a questionable way to lose weight. (Yes, I realize that there’s debate on whether some people can lose weight on that amount of cals in a LCHF diet, including your own story and heavy cream smoothie recipe here on the blog. Though Mike Eades has written that if one eats too many cals, they simply won’t lose weight.)

    On the other hand, if I keep the chuck roast and added fats at the 85% ratio, and bring the overall portion size down to a more realistic size for my dinner, that would leave hardly any meat on the plate.

    If you weren’t burning up a zillion exercise cals and just wanted to stay trim, would you be more likely to cut protein in order to keep the fat ratio high? Or would you just cut fat? In short, I had a little trouble imagining the math that would result in sufficient protein AND an 85% ratio AND a diet-friendly bit of calorie restriction.

    Anyway, the bottom line is I’m hypothesizing, for the moment, that maybe the reason that at least SOME of us are chubby/fat on LCHF diets is because, no matter how much we read and think for ourselves and let go of our indoctrinated fear of fats, we semi-consciously resist experimenting with going all the way to the “extreme” fat/total_cals ratio that might somewhat magically solve the problem.

    Obviously, my research into this hypothesis will be n=1, but I thought I’d mention it and see if there are any comments on the idea.

    P.S. I’ve done some serious water fasting over the recent years — some very long fasts and a few periods of 1-meal-a-day intermittent fasting, so it’s conceivable that whatever I discover will be inapplicable to other because I’m not at all typical and have way over-sensitized myself to carbs in a way that most people never will.

    -Joe

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    • Peter Attia  March 30, 2012

      Keep us posted on the experiments. One thing I’d recommend, though. Try to only change one variable at a time for a period of time.

  47. Rob  March 30, 2012

    Great blog Peter. Really helpful and informative. Do you have thoughts on exercise and losing weight simultaneously with the low carb diet? In Gary Taubes’ most recent book he alluded to exercise perhaps being counterproductive when trying to lose weight. I’m not willing to give up my workouts, but I am willing to give up 20 pounds.

    (reply)
    • Peter Attia  March 30, 2012

      Like you, I was not about to stop exercising. I don’t think we have enough data to say either way. Keep up the workouts, but make sure your reactionary eating post-workout is from the good stuff.

    • Bradlee Clark  March 30, 2012

      I look at my workouts as a means to an end, Rob. I have a goal to get back into a fitness level that will support the hiking lifestyle that I used to enjoy. I imagine I could lose all the weight I could, but if I wasn’t physically prepared to hike down into the Grand Canyon, I probably wouldn’t be hiking back out! And besides, exercise is invigorating, and there is no carbohydrate that can produce the satisfaction I have after finishing a workout. Keep it up!

  48. JMarra  March 30, 2012

    CS, I asked Gary Taubes whether he’d consider writing a book about sugar addiction, and he answer via email that he didn’t at this time think there was enough solid science and/or research supporting it.

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  49. carolyn  March 30, 2012

    i haven’t read thru all the archives, but have you ever addressed the phenomenon of the largely rice-based diet in e. asia _not_ resulting in obesity there?

    i felt this was a great weakness in gc,bc. taubes never took that bull by the horns, although he did suggest obliquely that maybe different populations evolved different tolerances. (the example he used was perhaps scandinavians shouldn’t use the olive oil used w/o apparent harm by mediterannean folks.)

    and when i say rice-based, be aware that back in the day, that was almost the only source of calories for the poor, who certainly didn’t get to eat meat very often. and yet obesity was rare and still is there.

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    • Peter Attia  March 30, 2012

      I have not done this yet, but it’s on my list (“coming soon”). Lots to talk/write about on this topic. I have addressed this in an interview, once, which you can read here: http://asweetlife.org/a-sweet-life-staff/featured/the-ketogenic-diet-and-peter-attias-war-on-insulin/24184/

    • carolyn  March 31, 2012

      i read the interview which was very interesting.

      to expand on my question, while the groups you reference there, (italians, french and japanese) use little sugar, and when they do consume carbs, you claim they tend to be low glycemic-index. still the low carb community here advocates spurning consumption of even these carbs (rice, wheat, pasta)as dangerously obesegenic for many of us (20-30%).

      it’s certainly a puzzle. maybe back in the day, most folks weren’t getting enough of _anything_, (oppressed and pillaged by their version of the 1% perhaps) including carbs, which explains their maintaining their ‘slenderness’, or rather chronic semi-starvation. hopefully your and taubes’ initiative will settle the question. keep up the good work!

    • Kevin Mobley  March 31, 2012

      Here is a great entry from Mark’s daily apple on an young Asian guy who gave up rice and what it did for him in 6 weeks — http://www.marksdailyapple.com/quitting-rice/#more-28275

      This is intended for Carolyn who asked the rice question. I posted my reply to the wrong entry.

  50. Bradlee Clark  March 30, 2012

    “If low carb eating is so effective, why are people still overweight?” caused a great deal of confusion with a few folks who chose not to read on past the headline.

    (reply)
    • Bradlee Clark  March 30, 2012

      They thought maybe you abandoned the eggs and bacon :-)

    • Peter Attia  March 30, 2012

      I can’t help people who are that uninterested in reading more than two lines…

  51. carolyn  March 31, 2012

    i was wondering where the financing for your nutritional study group would come from. i suppose mostly from the fda, that stalwart guardian of the public health. i suppose you can easily embarrass them to give generous grants to test your hypothesis since that august body has been so disgracefully negligent in the past. (forgive my cynicism of that craven industry-compromised agency.)

    do you expect any funding from conagra or other big ag heavy hitters? my guess is no, since your findings may be most inconvenient for their bottom line.

    sorry for the snark, but it must be said.

    (reply)
    • Peter Attia  March 31, 2012

      We expect NuSI to be primarily, if not exclusively, funded by private citizens and private foundations — everyday people who tired of being told what to eat without an science supporting the recommendations.

    • lorraine  April 1, 2012

      As mentioned above, please let us know when a mechanism for making a donation is in place. Maybe you should get Colbert involved (lol!). He got his super pac funded to around a million dollars in a few months. Any projections on how much a first study would cost? And has a specific hypothesis/study design been decided?

    • Peter Attia  April 1, 2012

      Will do. We’ll probably start grass roots fundraising in the summer and every dollar will go to research. We’re working on the budget right now for the first study. Depending on many factors, I expect it to cost between $4 and $8 million.

    • David Nelsen  April 3, 2012

      It’s great that you’ll get the ball rolling soon on your own study. I would assume the Alternate Hypothesis would be the 1st target. It’s going to be critical that everything is done right so that the naysayers won’t try to blunt the results with mindless nitpicking. On the face of it a study by a group who believes low carbs are good for you that does indeed prove that low carbs are good for you can be interpreted by non “believers” as a self fulfilling prophecy. In this case, I don’t see a huge risk as proving the Alternative Hypothesis is correct has already been done, just not properly. You’ll know going in that the patients on a low carb diet will lose more weight, suffer fewer dropouts and will have significant improvements in their blood chemistries. A parent in my son’s Boy Scout troop is a Dr. (Internal Medicine) and he’s currently on the HCG diet. I get the impression from talking with him that a lot physicians know low carb works and why and he’s backing it up by doing essential a low carb and low calorie diet. The best study you could possibly produce won’t sway Dean Ornish, but it could very well give rank and file Dr.’s a leg to stand on when prescribing a weight loss or heart healthy diet for their patients. At my work we are provided free health coaching and I talked with Mayo clinic rep today. I asked her if their health coaches can and would work with someone who is eating low carb. She had to check and get back to me but in the end they can and do support it. That actually surprised me a bit. I won’t know until I actually meet with the coach to see if they think I’m a nut and need to be talked back into carbs. If you’re ever speaking in the Phoenix area let me know. Thanks, Dave

    • carolyn  April 3, 2012

      i volunteer to be one of the first experimental subjects. (just don’t put me in the control group!)

      my requirements are few. is it too much to ask for the accomodations granted to the ‘the biggest loser’ crowd? is the news blackout strictly necessary?

      =)

  52. Peter  March 31, 2012

    Peter, when NY Times headline that a study concluded that stomach stapling as standard cure for T2D, are the researchers suffering from cognitive dissonance or something more pernicious. As one who had eaten based on the conventional dogma and changed after learning about macronutrients and insulin from books and blogs, why can’t the Ornish, Esselyn & Oz camps see the science and clinical data? It’s only logical that when knowledge prove me wrong, I should adapt them to improve my health. Why are they defending the fat-hypothesis so ardently still?

    I think the their side, along with big pharmas, food interests, medical establishment, and gov have critical stakes to perpetuate the current paradigm.

    Two personal anecdotes on how corrosive and damaging the current paradigm is:

    While waiting in my doc’s office, I leafed thru a magazine targeting at diabetic patients, published by American Diabetic Association. Inside the issue was a healthy banana bread recipe; ingredients included banana, whole-wheat flour and ½ cup of brown sugar. Healthful for who? What would happen if ADA declared to their T2D readers to ditch carbs to improve and possibly cure their affliction. Would ADA’s advertisers and memberships rebel and cut off their ad dollars and dues? Money talks louder than the their T2D readers.

    While observing our kids taking swimming lessons at our local YMCA I overheard a rotund mom, handing a Juicebox to her slightly rotund son, hair still wet from lesson, now famished, to drink. She advised him,” Look, no sugar added. Just apple juice, concentrated pear juice and grape juice. Pure, natural. Good for you.” Later at a vending machine, son asked what items he should buy. “Animal crackers, granola bar, low fat non-fried chips and fruit roll.”, she said. The fat-hypothesis is spell-bounding.

    Besides educating myself and altering my habits accordingly, I let my relatives, friends and co-workers know about my self-experiment. Perhaps in seeing my personal results, it will arouse their curiosity and motivate them to invest the time to learn about LCHF to better their health. That’s the significance of 1, as in n=1 experiment.

    Against the fat-hypothesis establishment, I will let the credentialized ones, like yourself, Eades, Taubes, Vortman and others to fight. No wonder you train like a Spartan.

    (reply)
    • Peter Attia  March 31, 2012

      I wish I knew the answer to your question, but we can’t just sit around and do nothing while nutritional dogma is dictated by bad science and epidemiology. Right?

    • Travis Koger  March 31, 2012

      Right! Spread the word… Praise the LARD!

    • carolyn  March 31, 2012

      i read that nyt piece too. the treatment, a very dangerous operation with a daunting mortality rate, strikes me as overkill. like using a hammer to swat a fly.

  53. Stan  March 31, 2012

    I see I am not alone with my mixed results from low carb eating. I dropped 40 lbs easily, and then hit a plateau. Unfortunately, I wanted to lose 55-60 lbs.

    I tried increasing the percentage of fat in my diet, and severely limiting carbs. This left me feeling like crap (lethargic, brain fog) AND I did not lose any more weight. That wasn’t a very rewarding result.

    I understand that individual mileage may vary, but it has left me with a tendency to get annoyed with those who over sell the notion that you can be as lean as you want by religiously cutting carbs from the diet.

    Carb restriction certainly helped me, but hasn’t provided the full answer.

    I also agree with others that I’d like to see a better explanation for the existence of these primitive cultures that subside largely on high carbohydrate diets, and yet remain quite lean (essentially no fat individuals). When these populations get exposed to western diets and lifestyles they get heavier start to exhibit all the diseases of civilization. I’m sure some probably have gone from food shortage to food abundance, but is that universally true? I suspect that there are other things going one (stress, activity level, type of carbohydrates used, etc.)

    (reply)
    • Peter Attia  March 31, 2012

      This is the million dollar question, but I’ve only got a few $20’s in my wallet. There are SO many variables involved and they vary from person to person in magnitude and order of importance. As far as what to eat, there is probably no universal truth, as I’ve said many times. What works for me does not necessarily work for you, and vice versa. There is so much to comment on here, but I just can’t do this question or topic justice in a quick response. Please stay tuned and I will work to address these points in subsequent posts.

    • greensleeves  March 31, 2012

      I feel your pain Stan – and I want to ask you if you are insulin resistant.

      If you’re counting carbs strictly, then you should be ok, and lose. If not losing, then check your calories to ensure you’re not eating 5,000 a day or something crazy. If carbs and calories are fine, then you should add exercise. After that, check your blood sugar, thyroid, and sex hormones. That will tell you the next step – what medicine you may have to take, be it synthyroid, metformin, a testosterone patch, what have you. :)

      As for these vaunted “primitive cultures” who eat tons of carbs – they are eating tubers, not Pringles and Pepsi. And they are also all tiny tribes who live in remote areas, long separated from the rest of humanity. They most likely have unique genetics as a result. But what do they matter? You don’t have those genetics. Eating the SAD didn’t work for you, why would living on a diet of 60% sweet potatoes magically work better? :) Would you really want to trade in bacon for boring ‘taters?

      Some of us just lose the genetic lottery, and it sucks. Hope you find what works for you soon.

    • Paul  September 17, 2012

      After loosing a substantial amount of weight, I did hit plateaus. Calories counting helped, and frankly it was much easier to restrict calories once I was keto adapted because it didn’t really feel that much different (though not enough sodium did make me feel crappy). low-carb eating mainly ensures you won’t put on weight (or only very slowly – protein does produce insulin) so calorie counting/VLCD can be a useful short term strategy.

  54. Eddie Friedman  March 31, 2012

    I am grateful for many of the benefits eating low carb has helped me realize. (Good health, etc.) I would like to be leaner, and I see that is somewhat of a theme with others who’ve posted above. This reminds me of this quote: (I remembered the quote, but rather than grab the book, I googled, found it online, and cut & Pasted. So, the added emphasis is neither mine nor from the original, IIRC.)

    “Gary Taubes…warned us all of this phenomenon in his book, Why We Get Fat…The following quote is from pp. 204-205 of the 2010 hardback edition of his book:

    “The fewer carbohydrates we consume, the leaner we will be. This is clear. But there’s no guarantee that the leanest we can be will ever be as lean as we’d like. This is a reality to be faced… [I]f you are not actively losing fat and yet want to be leaner still, the only viable option (short of surgery or the prospect that the pharmaceutical industry will come through with a safe and effective anti-obesity pill) is to eat still fewer carbohydrates, identify and avoid other foods that might stimulate significant insulin secretion–diet sodas, dairy products (cream, for instance), coffee, and nots, among others–and have more patience.”

    (reply)
  55. Pam  March 31, 2012

    Thx Peter for all you do. Weight loss stalls are a reality for many people. But persevere b/c our bodies are not machines that work on the calories in/ calories out calculations ore even the “carbs out/ lose lbs weekly” every week.

    As someone mentioned above, when you hit a stall, lower carbs even more. If that doesn’t work lower calories also. Someone on another forum was stalled for 2 years. She finally started losing again by doing a low carb version of Up Day/Down Day Diet.
    http://www.johnsonupdaydowndaydiet.com/html/how-to-do-the-diet.html

    Which is really just another way to do Intermittent Fasting. But they have a calorie calculator based on age, weight, and activity.

    (reply)
  56. Matt Taylor  March 31, 2012

    Peter, thanks for another great post. I am also one of these fans who checks this blog almost daily not just for a new post, but for the comments and the follow-up. The intelligent comments and your responses more than double the value of the post itself. If you ever want to change careers you should go into teaching, Peter.

    (reply)
    • Peter Attia  March 31, 2012

      Thanks very much. I like it more when the readers do the talking. I already do too much in blogs that keep getting longer and longer…

  57. Marilyn  March 31, 2012

    Peter, I’d be interested in your thoughts on this.

    I know a couple of people with “autoimmune” diseases. One has fibromyalgia. She told me she had recently read that — true to her experience — people with fibro often have greater than average difficulty keeping weight off. The other person has MS. She’s still walking, but her “bad” leg is noticeably fatter than her “good” one.

    Which causes me to wonder. . .might there be a nerve damage component to fatness? And taking that idea one step further, might a lot of people who have been eating excessive carbs for years have enough minor nerve damage throughout their systems to now make it more difficult than would be expected to lose weight?

    Am I way off-base here?

    (reply)
    • Peter Attia  March 31, 2012

      Hmmmm. I don’t know the answer to your question, but I do suspect inflammation is playing a role in the process (rather than nerves, per se). Of course, there are many ways to reduce inflammation, of which reducing sugars and simple carbs is one. Trimming omega-6 and increasing omega-3 is very important also.

  58. Alex  March 31, 2012

    I agree… I would wager that many people simply don’t know which foods are carbohydrates and do people know that carbs=sugars?.. what percentage of people have no understanding of wheat, or any grain, actually being sugar?
    It would be enlightening, I think, to create a test, maybe on youtube, etc. asking folks to classify their foods.

    (reply)
    • Peter Attia  March 31, 2012

      I sure hope this blog and others can start to put a dent into that (very solvable) problem.

    • Matt Taylor  April 1, 2012

      I tell people that soft tasty white bread starts to turn to sugar as soon as it hits the inside of your mouth. Chew it for a while and see if it doesn’t turn sweet. Also http://www.sugarstacks.com/ is pretty illustrative for other food items and I have asked them to add bread, rice, potatoes, etc.

    • Alex  April 5, 2012

      The way “Whole Grains” and “complex carbohydrates” are talked about, as if they are somehow magical food, makes me cringe.
      Whole grains and complex carbohydrates (all of them) = SUGAR, no dietitian or even Dr. Oz can change that fact.

    • Spheniscine  August 3, 2013

      Unfortunately, Matt Taylor, that site only seems to be interested in counting sugars, not starches, despite it all ultimately breaking down to glucose.

  59. Elna Cain  April 1, 2012

    Alex
    I totally agree with your comment. I am interested in watching Dr. Lustig’s interview on 60 minutes touting that sugar is toxic.
    I am primarily doing LC (along with my hubby) for fertility reasons and I am really wondering if diet is linked to fertility. I’m finding it harder and harder to believe it does when I see lots of pregnant women on a LFHC diet..

    (reply)
    • KevinF  April 2, 2012

      Just saw 60 minutes — pretty cool. They abbreviated some of the physiology but that was OK. Bottom line, fructose quickly leads to LDL, at least in good looking young people stuck in a metabolic ward. One annoyance was the line “Turns out sugar may be as bad for you as those fatty cheeseburgers!”, then they actually showed video of Sauron and the Nine Nazgul — excuse, me, the McGovern Commission. Now if only they’d do a story on THAT travesty.

    • Alexandra M  April 2, 2012

      “Now if only they’d do a story on THAT travesty.”

      Part of the tragedy here is that some of the people who have figured out that the information they were given about diet is wrong have extrapolated that to thinking that science itself is useless. Hence all the conspiracy thinking in the CBS website comments.

    • Anu  April 2, 2012

      Seeing a lot of pregnant women on a LFHC diet is not in itself evidence that diet doesn’t have any effects on fertility. After all, I see plenty of skinny people eating LFHC diets, yet I know for a fact that eating that way causes me to put on weight. Genetic factors play a big role in determining which people will be fine on a LFHC diet and which people might benefit from a LCHF approach.

    • Alex  April 5, 2012

      Keep at it Elna, great health can only help improve fertility.. I feel better now at age 51 than I have all my life, that alone makes it worth it. I have read so often about just how fertile the paleo diet makes women that I am VERY careful in the birth control department.. no more babies for this old broad!

  60. Dave  April 2, 2012

    So I’ve read GCBC and Taubes was probably one of the first to open up my eyes to the idea that ‘eat less, move more’ is nonsense. Although the one thing that I didn’t agree with is that he sees to downplay the role of infrastructure (as you define it above) as having an impact on obesity. Maybe I read into it wrong, but does his opinion on infrastructure differ than yours? Does Taubes not think that our environment influences our eating behaviors, meaning our choice of foods?

    (reply)
    • Peter Attia  April 2, 2012

      Hmmm. I’m not sure and I don’t want to speak for Gary. Maybe you should post the question on his blog?

    • Dave  April 2, 2012

      Thanks for the suggestion. I actually left a question for GT and he responded already. To clarify what I meant, my question had to do with his lecture talks where he debunks conventional wisdom’s purposed reason for obesity being due to a toxic environment with soft drinks, candy bars, cheese curls, and fast food joints so easily accessible, along with internet, video games, smart phones, etc. allowing us to be sedentary.

      So his context was that it isn’t toxic because of an abundance of calories and promoting a sedentary lifestyle, but because of the carb-heavy nature of the environment. Here is the quote:

      “You got it right. Definitely the environment is toxic, but what makes it toxic is the sugar and refined grains, not the fast food joints, labor-saving devices, video games, etc.”

  61. Kindke  April 2, 2012

    Re: Marilyn,

    It seems that the brain via the sympathetic nervous system plays a large role in determining the lipolysis rates for fat cells.

    Each fat cell throughout the body should be considered in isolation, the size of the fat cell will ultimately be determind by the rate of lipogenic vs lipolytic stuff acting on that particular fat cell.

    “A similar blockade of lipid mobilization in humans was seen incidentally nearly one hundred years ago when a hemiplegic patient also presented with cancer cachexia resulting in a mobilization of lipid only from the neurally intact leg”

    http://ajpregu.physiology.org/content/275/5/R1488.full

    (reply)
    • Marilyn  April 3, 2012

      Thank you, Kindke. That explains a lot. My hunch is that there is a lot of work that could be done in this area.

  62. Eat Less Move Moore  April 3, 2012

    Low carb jumped the shark years ago. It’s not a lifestyle that can be sustained for most – or even one that continues to work to goal for many. Richard Nikoley and Dr. Kurt Harris and Stephan Guyenet and CarbSane and Matt Stone (among literally dozens of former ‘low-carbers’) are RIGHT. The only people who keep insisting that it works are stubborn cases like Jimmy Moore – and we can all see how well it’s working for him.

    (reply)
    • Peter Attia  April 3, 2012

      I disagree with your comment entirely, but I doubt anything I say will convince you. I’m sure you’ve found a balance that works for you, which is great. But to assume only a stubborn person would stay on a low carb diet…really?

    • KevinF  April 3, 2012

      Wow, there are DOZENS of former low-carbers? Well. Can’t argue with numbers like that. You have changed my mind sir.

    • Alexandra M  April 3, 2012

      “…among literally dozens of former ‘low-carbers’…”

      Dozens, you say? Well, who knew? I guess I’d better change my ten-years-and-counting “unsustainable” lifestyle right away!

      Actually, I won’t. Call me stubborn, but I just can’t give up my improved health and energy no matter what “dozens” of people say.

    • Matt Taylor  April 4, 2012

      Low carb worked pretty well for humanity for a couple hundred thousand years. I know during the last couple ice ages my ancestors in Europe were seriously-stubborn low carbers.

    • Barb  April 4, 2012

      I have come to believe that one approach does not necessarily work for everyone; I do know that low carb works for me.

      I also happen to believe that, at some point, calories do count. I read some of the posts on other forums and shake my head in disbelief. I see people eating enormous quantities of food in a single day, but because it is low carb, expecting to lose weight. I am curious as to where it is written that this way of eating is a license for gluttony.

    • Tim  April 4, 2012

      Regulation of Food Intake, Energy Balance, and Body
      Fat Mass: Implications for the Pathogenesis and
      Treatment of Obesity
      Stephan J. Guyenet and Michael W. Schwartz

      I just downloaded this from the JCEM. Mssr. Guyenet seems to discount low carb out of hand, say Mediterranean Diet works just as well. Have you read this yet, does he make any sense? It’s a little too technical for me to completely understand.

      Thanks and great work as always

    • Trish  April 17, 2012

      I read Free The Animal and while it’s true Richard is eating higher carb he’s sticking to tubers, he’s not falling face-first into a bowl of pasta every day. Even with potatoes I doubt he’s going over 150 carb grams a day and considering the RDA for carbs is 300 that’s still low. I don’t read the others enough but I do know that Dr. Harris and Matt Stone were never overweight. As for Jimmy Moore, no sane low carber should ever hold him up as a success story. Yes, he did lose 180 pounds but by many accounts he’s gained almost a hundred back because he is addicted to “low carb” frankenfoods, this is no secret. And he is gaining weight on “paleo.” He is the classic example of someone who is failing because he’s trying to recreate the way he ate before with low carb. Low carb crap is still crap. I frequent a couple of low carb boards and I can guarantee that if you visit the recipe sections the majority of the recipes will be for bread substitutes, candy and desserts. Everyone raves about how delicious they are … and then whine about their stalls or gains. “B-b-but it’s low carb, I don’t understand!”

      It’s not just about low carb. For me, I still have to watch calories and exercise too and I tell people on the boards that. It’s still work to lose weight, no two ways about it. My main reason for doing low carb, though, is because I’m not raging hungry all the time, which is what killed me on every other diet even when I was losing significant weight. It’s pretty easy to restrict calories when you’re not hungry.

    • erinb  September 16, 2012

      Jimmy Moore? I find that interesting, because Jimmy has been very upfront about his struggles and is now breaking through with changes in his diet and doing great again, by adding more fat. I think that was not even fair to judge someone without walking in his shoes or even following him closer…ASSUMPTIONS are not a good thing. What works for one may not work for another. Good luck in your own journey.

  63. Claudia  April 3, 2012

    Wow!I just measured my ketones: 3.1 mmol/L!
    I bought the Precision Xtra ketone monitor you mention in the books and tools section here and got the test strips (boy are they expensive!). Seven weeks on <20g carbs a day plus 80% cal from fat. I haven't lost any weight but I feel great. The mental energy and clarity make it worth it for me. I didn't go through the miserable phase you refer to, just very mild headaches occasionally. I work out with weights 3/wk. Count me in the "I wish I'd known 20 years ago" crowd. Very cool, indeed.

    (reply)
  64. Megan Hansen Kenimer Harvey  April 4, 2012

    Hi Peter. Just wanted to comment on the possible neurological effects of macro alteration…I am no stranger to the VLC routine, but for the past two weeks I have switched to VLCHF. Although my results are moderate so far, my daughter decided to join me in this eating experiment and has lost 15 lbs in 16 days, and she is basically sedentary. My ex also wanted to try the VLCHF experiment and has lost nearly 20 lbs in two weeks. What is interesting about this is that my ex has ADD and has been able to completely quit taking his Adderall since day 2 of our experiment….he says he now feels like a “normal person.” My daughter was informally dignosed with ADD and after hearing about my ex’s results, I asked her if she had noticed any change in focus and she replied, “TOTALLY! And I noticed I feel the need to move a lot less!” So…if this is common effect of the VLCHF diet among ADD/ADHD dieters, just imagine the implications…no wonder the pharmaceutical industry wants to discredit/suppress VLCHF!

    (reply)
    • Peter Attia  April 4, 2012

      Megan, I have heard this a lot. I am sure (and I will ask him today) that Dr. Lustig would agree that ADD is probably on the rise for a number of reasons, but sugar consumption is on the list. I really believe the brain was meant to optimally work on B-OHB, rather than glucose, given the constant supply versus highly variable supply. Thanks so much for sharing this incredible news.

    • Rosa  November 20, 2013

      Hi Megan and Peter,
      thanks for bringing the topic of ADHD/ADD up. This “disease”, is not one disease with a singular cause but a complex of symptomes of which we often do not know the actual cause. However, increasingly doctors all over the western world prescripe methylphenidate (Ritalin) to children from a really early age. I do not want to say much about the drugs except that it has a lot of very unpleasant side effects including sleeplessness, stunning growth and lowering motivation. Despite the heavy and frequent side effects they are the standard protocol in use for any child diagnosed with ADHD. When my son was diagnosed with ADHD five years ago, innitially we started on medication but somehow it really didn’t feel good to swap my super intelligent, witty, lively, happy, driven, curious and playfull son for a sleepless, slightly depressed, innitiative- and apetite-less child, who was only easier to handle for his teachers because he felt nautious all day long. So I started exploring the endless information internet provides us with, TOO MUCH!! But some points were really interesting for me to find out:
      1. ADHD can have many causes only one of these is really “cured” by methylphenidate supplementation.
      2. A plethora of different food related intollerances and allergies can cause all the of symptomes of ADHD
      Based on a few research papers I decided to stop the drugs and start following a total allergy restriction diet to find out if this could help my son. We actually told school and the doctor he was taking his drugs to prevent opposition and to get an honest judgement of his behaviour, which is very difficult in any case. To make things easy me and my daughter also followed the diet. Two weeks into the diet (it’s a bit a very naked LCHF regime, because you start with also almost no veggies, no fruits, nuts, dairy, eggs, fish or any other food that could cause intolerance, leaving you pretty much with beef, turkey, spinache and turnip) the result was incredible; obviously all the side effects of the drugs were gone, my son was feeling happy again but also not at all agitated anymore and he could focus much better in class. After four weeks we asked his teachers how they felt he was doing and anonymously they replied the drugs were working miracles and that he was doing very well.
      Slowly we started to reintroduce some products every two weeks to see which of them was the cullprit and (not surprisingly, since this is the site it is) we found that any food with high carbohydrate content and lowfat dairy products, triggered a total relaps.
      One very nice side effect of this food voyage was that my daughter who has her fathers metabolic genes (storing reserves) finally also started to lose some of her fat reserves without being hungry and being allowed to eat when and as much as she wants, she loves it. And I myself having always been a skinny but total carbohydrate junkie, always looking for quick fixes, finally feel content and can run my marathon without carrying around kilo’s of raisins.
      So what was the point I wanted to make?
      1. the connection ADHD/ADD and carbohydrate hypersensitivity exists and it is sure worth the trouble to at least try a LC(HF) before putting your child on drugs with some serious side effects.
      2. LC(HF) diet works for children very well as long as there is some flexibility and room for wishes and experiments also from their side
      3. Not being obese (actually slightly underweight) does not mean I am not just as much profitting from a LC diet when it comes to health and well being, in my opinion much more important then the circumference of your waist anyways.
      Thanks Peter for this site it is very informative!

    • Peter Attia  November 20, 2013

      Great points, Rosa.

  65. Ruby G  April 4, 2012

    Thanks for the info Peter. Much of what is being written about any diet is by non-menopausal women and men. When I was younger, pre-menopause, it wasn’t so hard to lose weight. I have cut the carbs down to a little avocado and some lettuce and cucumber and my weight refuses to budge. Lack of weight-loss has been true even as my activity level and strength have increased. I feel much better and no longer have to take that afternoon nap (unless the personal trainer half-kills me in the morning)or need to snack throughout the day. Nonetheless, it is disheartening to be stuck with the excess pounds. Gary Taubes mentions the role of estrogen in fat accumulation, but what can one do when the estrogen is on the wane?

    (reply)
    • Peter Attia  April 5, 2012

      Yes, it really seems that menopause has a significant impact on fat metabolism in some (but necessarily all) women. Definitely worth working with your doctor to be sure everything (e.g., thyroid, Vit D, estrogen, progesterone) is in order.

    • Kindke  April 5, 2012

      Ruby,

      Sex hormones do make a big difference, estrogen for women is critical in managing bodyfat. Men undergoing castration without androgen supplementation experience significant changes in metabolism. CICO need not apply.

  66. Deb  April 10, 2012

    I have a question about blood ketone levels. My husband and I have been eating low carb to very low carb for at least 5 months. We do not eat any sugar or grains. I would say my carb level is even lower than his, as he eats more fruit than I do. We decided to get the ketone monitor you suggested in your Books and Tools section. It arrived yesterday so we took a reading after dinner, which consisted of Bison cheeseburger (no bun of course), a salad with hard boiled egg, sweet red peppers and bacon with high fat dressing, and mashed cauliflower with butter and heavy cream. My husband had about a 3/4 Cup of frozen blueberries with heavy cream for dessert. His reading was .3 and mine was 2.5. We did another reading this morning when we got up, this time his was .2 and mine was .6. I read from your blog that the reading for keto adapted people ranges from .5 to 3.0, which is a wide range. Is that because it will depend on when you check your ketone level, what time of day and before or after a meal? We aren’t sure what our goal is to be, is the lower number better, or the higher, or as long as you are in that range does it matter? What factors come into play as to whether the reading is closer to the .5 or to the 3.0? My husband is below the .5, what does that mean? I should mention we will both be 60 this fall, in good shape, on no meds. Our exercise consists mainly of a 3 mile brisk walk (with hills)5 days a week and we are now starting some resistance workouts. We also did our blood glucose levels this morning (fasting, before coffee or eating anything) and our readings were 105 and 106. That is high for us, would dairy be a factor? We eat a lot of eggs and we do eat cheese, mostly hard cheeses like cheddar and colby and also cream cheese and heavy cream. Or, too much protein? We haven’t been tracking that but I would say we would both be below 100 grams a day. We also wonder if it is common to have a higher glucose level at age 60. I guess it would help if we tracked what we are eating, I should start doing that again, but after counting calories religiously for many months last year I have enjoyed the freedom of not counting anything! I could go on with some more questions about dietary fat but will ask that question in another post!

    (reply)
    • Peter Attia  April 10, 2012

      Deb, congrats on your great progress. You’re doing exactly the right thing if you’re interested in experimenting with ketosis. A lot of things impact hepatic (liver) production of B-OHB (what you measure with that device): carb intake, protein intake, exercise/activity, and specific fat intake at the least. I can’t really troubleshoot without a lot more very specific info, but I’d keep doing what you’re doing. I know what works for me (e.g., max protein and max carb consumption in one sitting), but this may be irrelevant to you. Iterate on the right amounts and keep testing pre- and post-meal, plus morning fasting.

  67. Deb  April 10, 2012

    Thanks Peter! We have just recently found your blog after hearing you on Jimmy Moore’s program and we are really learning a lot!
    Can you explain what you meant by max protein and max carb consumption in one sitting?
    I also have been wondering about dietary fat. I would say I get most of my fat from coconut oil and MCT Oil, but I am wondering if I should be getting more of my fat from saturated fat in the form of butter and other animal fats. I don’t have much body fat to lose, maybe 5lb, which I think is harder to lose that when you have a lot! And, I don’t care what the scale says, if I see loss of inches. This might sound silly to be concerned with only a few inches or pounds but I am only 5’1″ and 5 pounds on me is 10 pounds on others. Anyway, my question is, if my diet is high in fat, will my body burn that for fuel instead of the stored fat I would like to get rid of? From what I understand, the MCT and coconut oil cannot be stored so they are used right away. I am not sure how much fat I should be eating, if I can be eating too much and therefore this stubborn last few pounds is hanging on, or am I not eating enough, or perhaps it is more about how many grams of carbs and protein I am getting, in relation to the fat. I guess my question bottom line is, what should be the main source of my dietary fat or if it’s a combination, what ratio of animal to the coconut oil and how can I know how much, without counting calories?

    (reply)
    • Peter Attia  April 10, 2012

      Max meaning how much protein and/or carb can be consuming in a one sitting without inhibiting the liver’s ability to make B-OHB. Correct on MCT oil. They can’t be stored, so they are either immediately oxidized (or converted to B-OHB) or excreted in stool.

  68. Dan  April 11, 2012

    Possibly a stupid question (given all you’ve covered on the website) but for healthy non-diabetics who aren’t really looking to do endurance exercise or other physical training, is it strictly necessary to monitor ketones closely for achieving a ketogenic diet? Why not just drive daily carbohydrate intake below 20 g/day by eliminating carb-rich food sources. Wouldn’t this have the same effect and be far more cost-effective?

    I can understand a possible benefit of ketone testing is trying to increase carbohydrate intake levels up to a threshold that still puts you into ketosis but still lets you enjoy your food choices (carb intake <20 g/d is equivalent to the induction phase of Atkins and so pretty rigorous – perhaps too rigorous for everyone). I can't exactly prove I am ketotic but a constellation of things – dropping weight, ketotic breath and the fact that I eat less than 20 g/d of carbs does tend to tell me that I very likely am.

    Maybe I've missed something here. Thanks very much!

    Dan

    (reply)
    • Peter Attia  April 11, 2012

      The only reason to check is to confirm you’re eating correctly. Keeping carbs below 20 gm/day is not enough if you’re eating too much protein, for example. It’s certainly not necessary to check, though.

    • Alexandra M  April 13, 2012

      I think I asked this before (didn’t see an answer): Shouldn’t you be fasting (12 hours) to see ketones that are the result of burning body fat? I read (can’t find it now) that if you test ketones shortly after a high fat meal the ketones will be the byproducts of burning the circulating triglyderides. I looked this up because for a while I wasn’t testing positive when I woke up in the morning, so I tested in mid-afternoon and turned the stick dark purple!

      I see a lot of people celebrating dark purple results in the afternoon, thinking they’re in ketosis. But perhaps they’re not? This would be really good to know!

    • Peter Attia  April 13, 2012

      When one is in a state of nutritional ketosis, you don’t need to be fasting to “see” ketones produced from internal fat stores. This is also true of fasting, of course, but the point is that when you’re ketotic, your body is doing this all the time.

    • Peter Attia  April 13, 2012

      This is embarrassing. Whoever wrote it should be ashamed of their inability to fact check.

    • Travis Koger  April 13, 2012

      Exactly what I was thinking. Apparently Brynne has written a bunch of TV episodes, so clearly she is an expert… but then there is nothing in the article to indicate she is an expert writing comment about a topic she clearly has no understanding of. Instead she just spews out rhetoric from Health Professionals.

      It is sad though as this was in the top 10 search results when I looked for Ketone level recommendations.

      What it does do is make me question the accuracy of any of the articles on Livestrong.com, which is a shame.

    • Alexandra M  April 13, 2012

      “According to Kansas State University’s Housing and Dining Services…”

      Are they kidding? That was unbelievable!

  69. Megan  April 20, 2012

    I’m sort of new to the low-carbing way… I’ve done it on and off for about a year. I’m back on the “on”, but doing more research this time around (I have read tons of online stuff about the Atkins diet, read Sugar Busters (which is what prompted me to go low carb in the first place), Good Calories, Bad Calories AND Why We Get Fat… by Taubes, and countless other online articles). Here is my question:
    At this point I am eating no sugars or starches. Only meat, eggs, heavy cream w/ 1 cup of coffee in the morning (and about 1/2 to 1 tsp. Truvia), meat, more cheese, salad a few days per week, and that’s it.

    You talk about aiming for protein between 120-150g/day. Does that apply to women as well, or should I aim for less? I have been testing my urine with Ketostix for the past week, and I am always in the Moderate or the level just above. My problem is that for the last month, I haven’t lost any weight! And I haven’t “cheated” at all. Sniff.

    My understanding, from reading you blog for the last 4 hours, which may have caused me slight brain damage ;), is that if I’m in ketosis, then obviously too much protein isn’t an issue, but after the huge serving of prime rib I had today, it sparked the question.

    (reply)
    • Peter Attia  April 20, 2012

      Right, “moderate” protein consumption is necessary in you’re in ketosis.

  70. Megan  April 20, 2012

    I guess the real question for me is if I am in ketosis, does that mean that I am not consuming “too much” protein. Or could I be in ketosis and still be eating too much protein.
    THANKS!!!

    (reply)
  71. Joshua Wardrop  April 20, 2012

    Dr Attia, do you have any info or opinions on 7-Keto? My doctor recommends it, but its so new to the scene, I cant find any solid information on WHAT it is, or why it works, just a bunch of “this stuff works great!”.

    (reply)
    • Peter Attia  April 20, 2012

      Sorry, Joshua, I have no experience with this product.

  72. David Ma  May 2, 2012

    Hi What happens when you’re on the ketogenic diet, and then have a ‘rest day’. E.g. you’re going out with family and friends for a big dinner (and you’d rather face death than explain to them what you’re doing).
    Will consuming >50g of carbs at that one sitting or say lunch and dinner reset all your efforts and you have to try and get into ketosis again? Will you also experience all the side-effects of lethargy, muscle cramps and weakness and also decreased mental acuity until you’re in ketosis again?

    What has been your experience?

    (reply)
    • Peter Attia  May 3, 2012

      In my experience, you bounce out of ketosis and even when when immediately returning to a ketotic diet can take a few days to get back. You see an almost immediate reduction in B-OHB levels, signalling a return to obligate neuronal dependence on glucose.

  73. Elle  May 3, 2012

    Well, people are still overweight while eating low carb because…

    Low carbing is an easy way to also under eat. And when you under eat, your body’s metabolism slows down. The problem is that the “low carb” trend tells you it’s not necessary to count calories. So while you may not need to count calories out of fear of over-eating (a good idea anyway), the greater concern is *how little* one might be eating. Proteins and fats keep you satisfied longer, so it’s much easier to underestimate your daily food intake.

    Besides the obvious rebound when you re-add carbohydrates, the metabolism is slowed.

    And people can get over this – if you want to reap the benefits of low-carbing, eat at your daily minimum (usually 1200-1300 for women and 1700-1800 for men)…. do a small ‘carb refeed’ every 3rd or 4th day to avoid actually going into ketosis… or do a ‘cheat day’ one day (the weekend perhaps?).

    NUMBERS are what it comes down to. Count, do your math, save your time. Only Ectomorph body types can get away with under-eating while still losing weight.

    (reply)
  74. sugaraholics  May 16, 2012

    My own experience, like many other low-carbers, especially of the non-paleo type, is that I lost weight for a while, but discovered the faux-foods that were low carb, but loaded with artificial sweets, and I ate too much protein, especially cheese. Even the paleo folks go crazy with making desserts with nut meals that can easily lead to a stall. Such foods make for an easy way to stall, or even gain. Once I became more conscious of the effects of these faux foods to trigger cravings, things became much easier–especially once I went serious paleo. For lots of us, the hardest thing is to believe we will one day not really crave sweets if we give them up for a few months. My surprise was how bad lots of foods now taste to me that I once was crazy about. Like all good things, low carbing requires some sacrifice, on the front end, for the eventual wonderful benefits.

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  75. Andrew Van Cleve  May 17, 2012

    I have followed the high fat low carb lifestyle for many years off and on and now lose weight over a six week period followed by months where I maintain that weight while adjusting my wardrobe. I find that by lowering my fat intake while remaining on low carb I can lose weight, but with corresponding debilitation and discomfort. So then I raise my fat intake again so my weight loss stops but stay on low carb so the health benefits continue to accrue. I estimate if I continue as I am I will no longer be obese in 10 years or so.

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  76. Anne Richardson Richardson  July 7, 2012

    I’ve come across a webite, Low-Carb Luxury, that talks about the “One Golden Shot.” They get at least one letter/day from someone claiming that going on and off a low-carb diet makes it subsequenly harder and harder to lose weight. How could this make a difference, assuming it true?

    Anne

    (reply)
    • Peter Attia  July 8, 2012

      It’s not clear this is true for everyone, but certainly there is a lot of empirical evidence that multiple bouts of recidivism (e.g., cycling on and off a low-carb diet) makes each subsequent attempt more and more difficult. Like most broad claims, there is probably great individual variation to the hormonal response and adaptation that plays a role in this. My advice: when you make the switch, stick with it.

  77. Susan  July 25, 2012

    I liked this article. I have read other articles on your website and your view seems to echo a common (and tragic) Western medicine mistake of treating the physical apart from the mental or spiritual. Humans choose bad actions as much for psychological reasons as physical ones, maybe even more so.

    I would offer that while American food has seriously deteriorated over time and definitely added to the obesity problem, American culture has deteriorated even more, producing a collective mental health that is in rapid decline, a decline that I believe it out in front of the physical health decline.

    The addicts you reference here likely have or had varying amounts of low regard for their own lives. Humans who live in chronic hopelessness get trapped by that and the way out becomes the slow, nearly unnoticeable “suicide” of choosing the bad stuff. This trap is real and quite powerful. I would posit it is more powerful than the body mechanics you are keenly investigating — I believe it to be a first order item.

    I know this trap firsthand. I’ve witnessed it many many times in others, often to a fatal conclusion. With that going on, it calls into question labeling their fatalities unavoidable. Western medicine folk need to watch the excellent film “Leaving Las Vegas” repeatedly until they can break out of their own denial. Otherwise they will remain ineffective as healers. Humans are complex and to address the physical out of context of the spiritual or mental is a mistake.

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  78. Sonja Stendera  August 26, 2012

    HI, unfortunately, this post does not answer the question. I think it is because that it has to be admitted that low-carb is not the magic diet for weight/fat loss and maintainance itself, but in combination with calorie restriction., it would be a miracle if you could eat whatver you want, just w/o carbs or very low carb and not getting bigger. dream life, but an utopia. bc even people like me living low carb and get a fair amount of exercise everyday have trouble loosing weight or maintain it. low BF% requires calorie restriction, carb and fat restriction and a ton of exercise (weight liftiung and cardio), and if you have ‘bad’ genes like I do, I still have trouble to get below 30%BF besides doing all that. give me meat and spinach forever and I would not loose fat if I overeat in calories every day..

    (reply)
    • Paul  September 17, 2012

      Wrong. Maintaining weight low carb has been very easy, personally. Whether it is easy to stay off carbs for some people (or even for me) is a different question. Though even for me, an occasional relapse doesn’t phase me, I get right back into it because I don’t regard eating carbs as either necessary or healthy.

  79. elaine  September 2, 2012

    OK I am really confused. I spent time this morning reading comments on your site and you VERY much advocated low carbs and went to great length telling your story. Now I come back to you site, and read this blog, only to find you say limiting carbs isn’t the answer to weight loss…huh???????

    (reply)
    • Peter Attia  September 2, 2012

      Not sure where you’re drawing that conclusion.

  80. mdingo98  September 12, 2012

    what is a good carb counter app. where you enter the food, the amt and it gives you carbs in grams. I don’t need a fancy graphic, just a reliable database

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  81. Will  September 17, 2012

    Peter, I am glad to read that you’re starting to experiment with fasting. I have found this to be one of my single best tools for health. I assume you know quite bit about autophagy at this point, being mediated by B-OHB and all. This also seems to be a key cellular defense against microbes, and I find that a 2-3 day fast can cure most infections if I start as soon as I notice symptoms.

    Once I got keto-adapted, I found that my energy levels increased into 3 days of fasting, dipped in 4-5 days, and then leveled out indefinitely. Exercising within my aerobic capacity was effortless even long into a fast, and given the adaptation I could even hike uphill at a reasonable pace this way. This is also a great way to keep emptying the glycogen tank, to soak up much more glucose than I could with a constant stream of (even low carb) food. I particularly like to begin a fast with sprint intervals, to deplete liver glycogen quickly and get deeper into ketosis, plus maximally ramp up HGH production.

    I’ve collected a handful of citations over the years if you’re curious and haven’t already read them. Keep up the great work! :)

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  82. David  September 23, 2012

    I find it interesting that many of the low carb doctors and book sellers are over weight while many of the top plant based doctors and promoters, high complex carbs, are thin and fit. Atkins died from a heart attack 60 pounds overweight on a low carb diet. Here’s a 2 minute YouTube video showing pictures of some of the top promoters of each diet. http://www.youtube.com/watch?v=2zVxA6yipv4

    When we look at some of the healthiest cultures in the history they ate high complex carb diets, not low carb diets. And is a persons diet all about losing weight or is it about being healthy? How does the low carb diet stack up against Americans top disease, heart disease, versus a high carb diet such as Bill Clintons diet where he is having great success treating his heart disease just as thousands of others have been doing for years. Some high carb doctors have decades of research and working with patients to prove you can prevent and reverse heart disease with a high complex carb plant based diet. Dr Caldwell Esselstyn is one of the leaders in this research and one of the Drs. Bill Clinton relies on for his diet advice. If low carb was the best diet Bill Clinton would be on it. If there was a drug or procedure to avoid changing his diet to allow him to continue eating meat and dairy BIll Clinton would have done it, afterall he has access to the BEST healthcare in the world, better than any of us could ever hope for.

    When you look at the pictures of the diet promoters and you do your own research you just might find that Bill Clinton has found the answer to the healthiest diet and it’s not low carb.

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    • Peter Attia  September 24, 2012

      David, I’m sure you’re a smart guy, but comments like this — strange ad hominem attacks — certainly wouldn’t lead anyone to conclude you’re a bright guy. Atkins died of a heart attack 60 pound overweight? At least get your facts right. That is patently false. Not “a bit misinterpreted,” no, categorically false. Of course, even if it were true, would it nullify the science behind the approach? Does the fact that me and a hundred other low carb doctors are thin validate low carb? Of course not. This is such an overly simplistic argument, I’m almost embarrassed for you bringing it up.
      Of course, you may want to ask *why* Bill Clinton is healthier today than he was 10 years ago. List out every change he made in his diet. Start with the elimination of sugar, flour, simple carbs. Sure, he’s eliminated most meat, too. But how do you know which of these changes is the driver of his new found health?
      This is why we rely on things called “clinical trials” not stories of people who are thin or fat or healthy or sick. Stop focusing on what’s irrelevant and get your head into the literature if you are at all serious about this topic.

    • JohnK  April 24, 2013

      Hi David –

      That’s exactly what I thought about a year and a half ago – Bill Clinton’s a really smart guy, cares a lot about his health, and will get the best advice available. So I spent a few days figuring out what he’s doing, and decided I would revert to a no grain, low-ish carb, low fat vegan diet to lose weight and reduce my risk of cardiovascular disease. While I was adapting to this new diet (which was not exactly new to me because I had been a vegetarian for almost a decade and had tried a low-carb, no fat vegan diet (very hard to maintain due to the level of effort necessary to feed oneself)), I continued to research and came across the blog and youtube posts by Dr. Greg Ellis (www.byebyecarbs.com). His posts completely changed the direction I was going in and I’ve been LCHF since then, have lost 50 pounds, have improved functioning in all aspects of my life, and have confounded my cardiologist, who can’t argue with my results, although we’ve had our differences.

      Now I do suggest that you go to Dr. Greg Ellis’s website and take a look at what a moderate protein and fat diet has done for him. Compare how he looks to the China study doctors, and decide who you’d prefer to look like. Read his story. He’s a bit too much of a self-promoter for my taste, but his heart is in the right place. He’s done decades of independent research, read the studies, has an excellent and appropriate education to assimilate this information, and has come to the same conclusion as Dr. Attia.

      We’re all entitled to our own opinions and conclusions. Live and let live, I say. I’m LCHF forever, it’s changed my life in a positive way I never could have imagined possible.

  83. David  September 24, 2012

    I am interested in what the leading low carb doctors and spokespersons look like, do they appear healthy? Many of them appear to be overweight. Anyone who sells diet books should be fair game.

    “Stop focusing on what’s irrelevant and get your head into the literature if you are at all serious about this topic.”
    Perhaps you can offer more literature from highly qualified 23 year old bloggers such as Denise Minger, a self described tutor, freelance writer, website designer who is neither a doctor, nurse, nutritionist or scientist to prove which diet is not best. Is this the type of relevant literature you are referring to? Do you consider Denise Minger to be a qualified professional? I’m sure you are smart, very smart, but referring Denise Minger’s rebuttal to decades of serious scientific research given her obvious lack of qualifications doesn’t exactly reflect well on you.

    You are seeking the truth, which is admirable, so I’m fairly confident you are open to posts which provide views in opposition of the low carb diet, which appears to be the predominant diet supported in this blog. If this is a low carb diet only blog please say the word and I won’t post again.

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    • Peter Attia  September 25, 2012

      David, first of all, anyone is welcome to comment on this blog, regardless of views. So feel free to comment. However, if I may be so blunt, the reason I’m getting short with you is that we’ve already had this EXACT same discussion over a different post a few weeks ago. And I thought we came to a mutual agreement to “agree to disagree.” I explained how epidemiology is not a substitute for clinical trials and referred you to a series of posts (here’s one more, written by a *doctor* since you don’t think Denise is worthy of your time: http://www.proteinpower.com/drmike/cancer/the-china-study-vs-the-china-study/). [By the way, you're criticism of Denise due to her "obvious lack of qualifications" is a bit disconcerting...it's not like getting an M.D. or a Ph.D. guarantees someone is smart or critical thinking in nature, both of which Denise has in spades.]

      We then had a long back and forth about Bill Clinton. I won’t repeat it, as I hope you at least remember the point — I’ve now made it twice.

      Finally, out of nowhere come these bizarre ad hominem attacks on Robert Atkins (which, by the way, are 100% incorrect and suggest you’re not doing your homework very thoroughly) and overweight diet book authors. At this point, in my mind, you start to stray from a healthy (but confused) skeptic into the realm of heckler who is uninterested in anything other than wasting my time.

      My time is very valuable. I don’t tolerate people who I perceive to be deliberately wasting it. So consider this your final notification. If you comment again about the China Study, Denise Minger, Bill Clinton, Robert Atkins, or overweight people — don’t expect any response, just a swift “delete.”

      If you’re hear to learn, welcome aboard (even if you question me and remain skeptical). But if you’re here to bicker and snicker and waste my time, see you later. Go some place else. I can assure you others will be far less civil in their responses (check out AC if you’re looking for a verbal colonoscopy…not recommended).

    • J  September 25, 2012

      David,
      Have you read Denise Minger’s critique of the China study and really thought about it? I think it would be great if you did that and then posted your thoughts about what she really has to say. Ad hominem attacks are considered a logical fallacy for a reason, because the important thing is what a person is saying and doing, not their age or how many degrees they have. The ability to think rationally is part of being human and it belongs to all of us. She thinks that the conclusions people are drawing from the China study are unwarranted by the data. If you disagree maybe you could show us where you think she’s mistaken instead of saying that she is too young to pay attention to. Lots of people with greater qualifications make big mistakes. If you read about Ignaz Semmelweis you can see that the professors of medicine of his time were making a big mistake in not believing that doctors needed to wash their hands in between patients. There’s no reason to think that the big names of our time are infallible either. It’s hard to try to see the world in a different way than you’e used to; I’m a healthcare provider and I spent years counseling patients to cut down on saturated fats, and I spent years as a vegetarian, and for me, reading Taubes’ book Good Calories, Bad Calories was fascinating but also horrifying because I had to think about how my well-meaning advice, all those years, had been bad. I doubted his conclusions at first but I read some (about a hundred) of the many studies he cites. Maybe you could print out Denise Minger’s critique and really think about it, and let us know. Because I would really be interested to hear what you think of her critique, but it’s kind of mean and irrational to just deride her because of her youth.

  84. David  September 25, 2012

    Regarding my “ad hominem attacks” I was surprised by your response to my initial post on this page here given the blog page title is “If low carb eating is so effective, why are people still overweight?” I thought the Youtube video I had seen recently was on topic, perhaps I misunderstood the topic. Regarding a certain well known low carb doctor and his health, the information I provided I got directly from a doctor who says he knew the man for more than 10 years.

    Now if we can move on, why did I come to this blog? I wanted to gain useful information. I changed my diet just over 4 years ago because of the information I obtained on how it helps the body to fight disease, especially heart disease. Do you have any information on trials that indicate the low carb diet prevents or reverses heart disease?

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    • Peter Attia  September 25, 2012

      There are many studies that have examined this question, the largest of which I review in detail in my presentation at UCSD (you can see this is the post “How did we come to believe saturated fat is bad”). To date, also studies that have specifically asked the question you’re asking have not been powered sufficiently to demonstrate hard outcomes (e.g., death, MI). So instead, we look at trials that compare biomarkers (e.g., CRP, apoB, TG, HDL-C). There are plenty of these, many of which I’ve reviewed in detail. Start with Part IX of my cholesterol series.

  85. Mer  October 11, 2012

    I think a lot of people who find their way to low carb are those who are already seriously metabolically challenged, and who who have tried and failed so many times that they are willing to buck the “conventional wisdom” to try a diet that is far outside the mainstream. I hate seeing Jimmy Moore called a failure. He started at 410 pounds, clearly not a normal metabolism. He has struggled with weight up and down, but has continued to keep at least 100 pounds off for 8 years, a pretty remarkable achievement. I can empathize with him as I started from a similar spot – nearly 400 pounds. I first did low carb back in the late 90s, and got down to about 275 where I stuck for a long time. With a lot of struggle and starvation and very low carb and tons of exercise I fought my way down to 248 where I stayed for about a day or two, and then in the space of about 3 weeks bounced back up to 275. And there I remained for nearly three years. Over that I tried – more carbs, fewer carbs, more fat, less fat, more exercise, less exercise, no dairy, more protein, less protein …. and the scale never budged. So finally – since at the time it was all about the weight loss for me – I just gave up and fell face-first back into the SAD.

    Until 2006 when I started to develop some health issues and decided to try again. I went back to LC as it was the only diet i had *ever* been able to stick to for longer than 2-3 weeks (about my max with Weight Watchers for example) or lose more than a few pounds. I didn’t even KNOW what I weighed. My scale didn’t go up high enough to register me. After a couple months on the diet I went to the doctor for something unrelated, and they weighed me in at 375. That was in early 2006 and I have been low carbing ever since, nearly 7 years now. Once again I got down to the mid-270s and stayed there a long time. I made an effort and once again fought my way down to the 245-250 range and managed to stay there for a couple months, and then bounced back up to 275 in an 8-day period where I suddenly gained about 3 pounds a day every day for 8 days, no matter what I was eating. And then stopped, and now I have been stuck at 275 ever since. I’ve mostly been around this weight for 3 years again this time around. I’ve done all the things I did before – more fat, less far, more carbs, fewer carbs, more protein, less protein, etc. I take metformin and Armour thyroid (was DXed with hashimoto’s in 2009). And nothing seems to work.

    Yes I’ve managed to lose 100 pounds, but no one can say that 275 pounds is a good weight for a woman of 5’7″. I stay low carb because I enjoy the food and it’s the only diet I’ve ever been able to say that about. Right now I’m trying to keep my carbs lower, my protein lower and my calories lower (though not super-low, and I get about 75% of my calories from fat). Still nothing is budging.

    I think there are a lot of low carbers like me out there, mostly (like me) post-menopausal women. But I’d hate to use me as an example that low carb doesn’t work. But I have to admit I get pretty discouraged these days.

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  86. Ellen Urciola  October 12, 2012

    Dear Mer,

    Do not get discouraged. I too am a menopausal woman of 54 ( and a tall 5’3). I started at 257. After 22months I am down to 210 and stuck. Gain two, lose two. More fat, less fat. Dr. Attia suggested ( for me) to try 70 – 75 gm Protein, 50grams carbs(which I cannot seem to get past 15-25) and as much fat as I need to not feel hungry. I have found that I need to meticulously keep track of my food, calories, protein, fat, and carb intake. I find I need to keep my intake at or just under 1000 calories, with 25-30% of that as Protein, about 65% fat an the rest carbs.
    Lately, I find I am getting hungry when I didn’t before and I am doing that yo-yo 1 pound – 2 pounds up/down.
    I also have not been faithful about recording my daily food intake. In my case, I think I need to push through the initial hunger and see what happens. I do know one thing, I love eating low carb. I wish you the best, stick with it. I just wanted to let you know you are not alone.
    Ellen

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    • Mer  October 12, 2012

      Ellen, it sure can be a struggle. We need a support group for menopausal women stalled on their diets! I’ll say quite frankly if I had to limit myself to 1000 calories a day I’d just plan throw in the towel. Even 1500 calories feels like “starvation rations” to me. I’m relatively comfortable in the 1700-2100 calorie range. But again, I’m not losing weight! Maybe I do need to cut calories. I’m actually obsessively weighing and measuring every bite I take right now. I feel like a total freak when I take an olive from the fridge and then carefully place it on the scale betore popping it in my mouth. LOL. My goal has been to keep net carbs under 50g daily, my protein under 100g (and preferrably under 90g), and the rest from fat. Although I’ve been low-carbing for 7 years and periodically weighing and measuring my food this time it’s been three weeks straight. The first week I made and effort to cut back on my calorie count and averaged about 1700 calories/day and I did lose 7 pounds (but I had recently gained some weight in a short period so thing I had a lot of water weight to lose. The second week I ate more to appetite and averaged 2000 calories/day – and lost 4 more pounds, probably the rest of the water weight.

      This week my average has been 2100 calories and I’ve lost nothing. I guess the water weight is all gone. I just can’t get my head around the idea of having to starve myself to lose weight. I was listening to Dr. Eric Westman on a podcast last night and he said for stubborn cases people over have to go below 20g of total carbs (not net). I might have to give that a try but it depresses me also as it leaves room for so little variety in the diet, especiall for someone like me who is not crazy about meat in general.

  87. Ellen Urciola  October 13, 2012

    Hi Mer,

    I totally agree, we menopausal Women tend to be the exception to any rule and need support from others like us.
    You must take into consideration that you have 5 inches more of height than me. Also, I do not take thyroid medication. A thousand calories works for me, but I can certainly see where it would not work for you.
    The water retention is driving me crazy, I weigh myself in the morning, after dinner, and just before I go to bed.
    Sometimes I show a 2pound gain in the 2hours from dinner to bed! Then it is gone in the morning! This can go on for weeks, then suddenly I will drop 2-4 pounds all at once. Then the cycle begins all over again. I am finding that because I do not have cravings anymore, I only occasionally miss the variety. Having been a professional chef for 32 years (before making a career change) I am constantly trying to create new ways to work with the food I eat.
    Good Luck, keep reading Dr. Attia’s blog , I am sure there are others who might have even better advice than me.
    Ellen

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  88. Geralyn  October 25, 2012

    I didn’t read all of the comments, there were so many, someone may have said this already. I have heard that sugar, the highly refined type you have on your cereal (to be specific but not to discount other sugar from the statement). Sugar is highly addictive and causes similar brain responses
    as recreational drugs. Last I heard this is still being tested on mice . I think any parent who has witnessed their child going from angelic to demonic in the space of a lollipop can guess how this will pan out.
    I wonder if carbohydrate intolerance is apparent during childhood. I personally was a hyperactive child, now I’m a fat adult.

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    • Peter Attia  October 26, 2012

      Geralyn, you are correct. There is a growing body of evidence suggesting this is true.

    • Donna  October 26, 2012

      Recently, 60 minutes discussed sugar. You can find links to it on this blog (I think). One researcher is looking at how sugar affects the brain. It is remarkably similiar to a person on drugs which didn’t surprise me. Nor did his other statement where it takes more and more of the sweet stuff to get the response first had with only a little bit. Personally, I find that to be very true. My ‘need’ not desire for sugar increased as my tolerance to the effect increased.
      As a child I was normal weight up until the time that puberty started. I ate the same amount of food as my weight increased as before when I was of normal weight. Hormonal changes start long before they are apparent. If you have a defect with regards to carbohydrates then any carbs consumed will add to weight gain since the energy is parceled out to the fat cells and not available for use. I did not overeat. That came much later. You do not become fat by overeating, you overeat because you are fat. I have an idea as to why and I can’t point to any study to back me up Regardless of body size, if you are carb intolerant, the carbs consumed will be directed to the fat cells and not for use as energy by the body. However the body needs a certain amount of energy to keep the body functioning. It will nudge you, demand, yell, entice whatever in order to get you to consume more at one sitting or to eat sooner than needed. It will get the energy needed to continue living but it will also direct most of it to the fat cells. The cycle continues to grow no matter the desire lose the excess weight until the underlying problem, carbohydrate intolerance is addressed. As a growing up child I ended up eating more than necessary in order to give my body enough to do the necessary growing.
      What are the things most readily available to fulfill the need? Carbohydrates in many forms. It isn’t just sugar that is the villain for children and adults. It’s rice and potatoes and corn and bread and high fructose fruit etc. Does this have a deletorious effect on the functioning of the brain. I’m not sure. We know the affect of alcohol and drugs. Sugar, honey, molasses, syrup, etc… do they have the same effect? I think yes but not to the same impairment level as the other two mentioned items.
      I disagree with the idea that children and adults can go from angelic to demonic by eating sugar in form of candy, cookies, cake, etc. Most likely the effect is due more to excitement from a party or trip or anticpated treat not from the ingestion of the sugar. Yet….. Being someone who has big problems with sugar consumption and as a person who tears apart her own reactions in order to understand them better, I think sugar has an effect that I think is akin to a dry drunk. Impaired thinking. Why did I do that thinking. Carbohydrates may be responsible for less ideal thinking in a person who has sensitivity to the effect of this food group. I find it amusing that we all make many attempts to make sugar into less of a poison than it is. Those who don’t have the problem with sugar I hope are grateful they don’t have the problem.
      Because we humans vary so widely in our response to food, it is hard to grasp that what one person does may have a deletorious affect on another. The current state of our government and many medical practitioners to insist we eat more whole grains, fruit may have a disastrous effect on those who are carbohydrate intolerant, insulin resistant, etc. The encouragement to eat more fruit may not bode well for those who are sensitive to the effect of sugar. Even low glycemic fruit may be bad news for some of us. What if vitamin supplementation is needed because we consume carbs. If we didn’t maybe we don’t need to take in that daily vitamin.
      I got off track here in my comment. To consume carbs(sugar, rice, bread, fruit, cakes, donuts, juice, etc.) at a young age and your body has an abnormal hormonal response, you may start to gain weight. Since there are other factors involved in growing up (activity level, food availability, type of food, etc.) a significant weight gain may not happen until early adulthood. Your brain chemistry knows the easiest fix to get is carbs and with sugar in many forms so readily available guess what is easiest to consume. Once on the treadmill it takes more and more of the sweet stuff to get a result. As Dr. Lustig pointed out fructose (part of sugar) goes to the liver first where it has a good chance of being shuffled off to fat cells before it gets to the brain. Then the brain demands more to function.
      Catch twenty two.

      Long winded as usual. Sorry, Peter.

    • Peter Attia  October 27, 2012

      No apology necessary.

    • Donna  October 27, 2012

      As usual was mulling what I said in my post above and it struck me that I forgot to say something that I consider crucial. So hopefully I can make this short and sweet. I see two different issues in how obesity occurs and sugar addiction. The former is a hormonal response to carbs in all forms which can result in the development of obesity. If the body needs more fuel which it can’t get from what ends up stored in fat cells and wont’ be released then the urge develops to overeat and carbs, simple and complex, are the easiest to get, to digest…..though excess protein is also welcome if no carbs (simple or complex) are available.
      The second issue is sugar addiction which, I believe, should be a separate issue from carb intolderance and obesity. Where the former is in the biochemistry of the body and the body doesn’t care where the carb comes from, the brain takes special consideration. It is also responsible for the psychology of being human. It is concerned with thinking and emotions. In some individuals sugar (as sugar or as alcohol) becomes a problem. For some the ingestion of sugar is like being a little bit drunk. There is a subtle alteration in thinking annd acting where with illicit drugs and alcohol it is far more pronounced and deadly. More of the ‘poison’ is desirable because of the chemical response in the brain.
      Sugar, in all its forms, is a double whammy in that it works on the body increasing the likelihood of obesity in prone individuals and it also acts on the brain derailing emotional stability in susceptible individuals. An individual may have one or the other or the double whammy of both. And it seems if you have both, the difficulties aren’t doubled but seem to become tenfold making it much harder to deal with.

      Thanks for reading.

  89. Donna  October 28, 2012

    Hi Peter,
    I’m not sure where this question might fit in if at all. In rereading Gary’s book he has a sentence that postulates that even someone following low carb might not lose the weight but may experience better blood test results (better health overall even with the weight still present?) I was wondering if you knew of any study or of anyone investigating this idea. After all, I’ve read several posting where the person laments that the weight doesn’t come off in spite of adhering to a low carb diet. I’m supposing their frustration is compounded because they are still being met with the demands from society and the medical establishment (not only doctors) that they have to lose the weight to increase their level of health. I believe it is possible that certain individuals may experience no weight loss (a hard ‘pill’ to swallow for anyone wanting to lose weight) but if they can be given proof through clinical study that their health would improve if not the weight it may be the key to helping them find it easy to keep adhering to the chosen food plan. It may help the medical establishment to be more open to continue helping individuals who find weight loss nearly impossible but can increase their health fitness without the message that ‘you are doomed to ill health because of the weight’.
    I suspect that sounds like an oxymoron (?) to many who focus on weight being the indicator of fitness and health. By no means I am suggesting that this ‘entitles’ a person to give up as has been suggested in some postings. What I would like to see is health encouraged for all irregardless of size. Don’t jump to the conclusion that a person who is overweight is not healthy. They may be healthier than the lean person internally.
    I read somwhere back in the eighties that certain experts considered overweight and obesity to be symptoms and not the precursor to health issues. Something like obesity does not cause heart disease but rather that obesity occurs along with heart disease or you can substitute diabetes for heart disease because they have a ‘defect’ in common, not that one (obesity) is a cause of the other (diabetes). It’s too bad that this idea never caught on. I think it would ease the self guilt many have and allow them to focus on living life with joy.

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  90. Has  November 3, 2012

    Primrose oil has GLA; and the long list of benefits esp. to the skin, that I don’t want to miss. However it is omega-6. Would you say that the benefits outweigh the negative effect of the omega-6? I appreciate other related info on the oil. The one I am taking is cold pressed with 10% GLA.

    (reply)
    • Peter Attia  November 3, 2012

      Can’t comment on this formulation, but I will write in the future about the omega-6 issue.

  91. sten bj  November 9, 2012

    To Donna. Oct 28.
    Donna, how are your blood tests developing?
    You can always get a calcium score scan, which at least by trackyourplaque is regarded as gold standard for heart disease. Most likely Dr Davies (WheatBelly) is right here!
    In the US (Denver) CSS is available for $99.- and repeating after 1 year would tell you if the calcium score goes down or up (bad). The more calcium in the heart of course the worse. Muscles and blood vessels require zero calcium deposits for optimum functionality. Here in Europe I have not yet found any for less than 300 Euro.

    The deposition of fat is a survival mechanism for harsh winters or starvation in general. Yet keeping the same fat on year after year was hardly the intended way. And if earlier diet contained lots of polyunsaturated fats the deposits could now be rather rancid and the body may therefore be reluctant to re-process it? (Ray Peat surely have a view on this!) Is it a reason younger people has it easier to lose weight?
    Yet you may still be right in the thought that body fat is not a symptom of disease at all.
    Although we know that visceral fat is.
    LCHF is said to reduce that first, so you may need to get a ketone meter to get the weight loss on the right track. The only proven method? After Jimmy Moore’s recent success it looks that way. Good Luck!

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  92. Heather  November 11, 2012

    When you were asking the rhetorical question, why do people eat carbs when they are bad for them, I immediately equated it to: 1) lack of knowledge, 2) lack of money; 3) addiction; 4) culture; 5) brainwashing by the “experts”. I work in public health and one thing that is asked with our health navigators (case managers) do checks on our clients is about fresh fruit and veg and the people invariably say they can’t afford them and they can’t afford to go out of their neighborhoods (no cars or bus passes) to go to a store that sells them even when they do have a little extra money. It’s very sad. I’m in that 30-40% of people – I can do LCHF religiously for weeks and lose 1/2-1 lb a week, but I have one cheat weekend (and I’m talking eating 2 pieces of toast for breakfast with my eggs and meat and a hamburger bun for lunch) and I’ll gain 5 lbs. :P 1-2 months of LCing down the drain in 1 day!

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  93. Julie Hopkins  December 4, 2012

    Dr. Attia, you should paraphrase G.K. Chesterton to Bray and Kolata:

    “It’s not that low-carb diets have been tried and found wanting: it’s that they’ve been found difficult and left untried.”

    Thanks so much for all the great information here!

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  94. Catherine  December 23, 2012

    Hey have you seen the website gnolls.org? He says the amount of fat in a carb based food lowers the g.i rating. This means people should have a lot of fat with their carbs if they decide to combine them because it slows the release of insulin. It doesn’t just end up storing more fat because the insulin decides to store more calories.

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  95. Donna  January 26, 2013

    Peter, I’m not sure where this belongs or even if it is a question that belongs on this blog.
    Recently I read that gastric bypass patients have a four time greater chance of ending up with a substance abuse problem mostly from alcohol. This got me to thinking about low carb eating.

    Gastric bypass patients are instructed to eat high protein and very few carbs. Fat is another issue. Usually the diet has to be low fat becasue of what the bisecting of the stomach accomplishes. I’m wondering if those who adhere strictly to the high protein low carb eating plan and have a problem with carb ‘addiction’ don’t end up needing to find a way to get the carbs hence the choice of alcohol. Some bypass patients (not all) have trouble with the disgestion of carbs after the surgery so they tend to follow the doctors recommendation that carbs be avoided. But alcohol seems to be another matter. Alcohol is considered a carb.but I wonder if the way it is metabolized in the liver makes a difference and therefore some bypass patients find a way to get high carb ‘satisfaction’. I’m not talking a psychological satisfaction but a bio-chem satisfaction no matter what the intention may be by the patient.

    What little I’ve seen about this indicates that the professionals want to treat it as a substance abuse problem. I tend to think that it is a bio chemical problem that has not been addressed by the resulting dietary requirements after surgery.

    My question or rather questions would be if a change is needed to the dietary regime neede by bypass patients which would make it closer to a ketogenic diet so that the body could make the switch to burning ketones rather than glucose. This question is outside the realm of this blog I think. But my other question may be more pertinent to the topic in hand. Do some who go low carb find themselves drinking more alcohol? Using alcohol more liberally than before the changeover to low carb eating. Is the body (brain) so physically demanding carbs in any form than it will sabotage a person’s dedication to eating well to get it? Obviously not everyone who goes low carb develops the problem just as not all bypass patients become alcoholic. I’m wondering if developing a subastnce problem is more an indication of bio chem prolems in the body and not a psycological problem.

    I’m wondering if some of us have a carb ‘addiction’ that is not readily identifiable by current methods except the tried and failed or tried and succeeded method. .

    What bwilders me is that the response to the study that bypass patients may develop an abuse problem is to assume that it is psychological only. I lean more towards thinking it is a biochemical issue that becomes a psychological issue with repeated dosings. And if some individuals frind themselves straying back to carbs, is it not mor likely a physical response rather than a pyschological one.

    I’m just not sure where the line should be drawn. I’m tired of being told my eating habits are emotional issues when I feel more certain they are biological in origin first with the emotional part coming later.

    I hope this makes some sense. I’ve been ruminating about this since I read about the study. Maybe some of your readers can shed some insight.

    Thanks.

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    • Peter Attia  January 28, 2013

      Donna, these are really great questions. I must admit, my bias is leaning more and more towards biologic/physiologic drivers (versus emotional), and this even includes eating disorders. Check out the work of Leslie Simm at Mayo Clinic. The bigger question I struggle with is the “division of labor” between with periphery and central system. Is the body in charge of the brain? Still not sure.

  96. Hamze  March 17, 2013

    People get fat on low-carb diets because they eat stupid stuff like mayonaisse or bacon and decide to take in over 300 grams of fats.

    In all reality, if you keep protein and fats the same and not overcompensate, you can easily cut calories from carbs and lose weight. I don’t think you should be scared of carbs, though especially since insulin sensitivity is relatively easy to increase.

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    • pjm  July 2, 2013

      Mayo maybe stupid (and often it is sweetened) because many versions contain large quantities of vegetable oils. The problem with these is that polyunsaturated fat in biochemical studies seems to be the biggest factor in causing LDL to degrade into form that are likely infilitrate the walls of blood vessels. I don’t think bacon is the cause of anyone’s weight gain by itself (though would be happy to self experiment ;>). One way you can put one on weight eating low carb is , I suspect, because of excess protein.

      The point that Taubes in WWGF that I think is important is that the alternative hypothesis is not that “low carb” is “the answer” but that the correct scientific paradigm (aka the alternative hypothesis) is that weight and appetite and activity are all complexly regulated systems (hormones like insulin but certainly others being key components of these systems). Perhaps the most common disregulator is dietary carbs, but
      1) it is not the only one and (stress, lack of sleep, etc all show in the literature,
      something CICO doesn’t explain vary well )
      2) once the addressing the low hanging fruit of carbs,
      it may be much more complex to reduce weight past
      the new, healthier equilibria (aka set points).
      3) These further reductions may, in fact very likely is my guess,
      may have limited impact in terms of improving health/reducing risk
      factors.

      Besides all the good comments on adequate fat intake, salt, calorie
      counting, thyroid function, etc. for all those doing “advanced” low carb
      dieting, I would add the issue of choline. Chris Masterjohn has an interesting
      post on this. Iiuc, choline is essential to the liver’s metabolism of fat.

      As for thyroid function, I have a suspicion that since most people by default assume
      vegetables are always healthy, we may get ourselves into trouble. Many vegetables
      – especially raw – are goitrogenic (i.e. suppress thyroid function). The same is true of
      nuts (again, especially if raw). Something to keep in mind.

  97. Maryann  March 26, 2013

    Is garcinia cambogia safe to add into a low carb lifestyle to achieve weight loss?

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  98. David Ortiz  April 23, 2013

    I went to the supermarket yesterday and couldn’t find real plain yoghourt (all the fat and no sugar added). Everything was 0%, “low fat”, etc. Sugar content in a 6oz bottle: 23 grams. Who was buying that? overweight people. No comments.

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  99. paul  July 2, 2013

    Peter,
    It is my understanding that one of the reasons we require as much water-soluble vitamins as we do is because of the glucose-based metabolism. E.g., glucose inhibits vitamin C metabolism in cells; many B’s are important for glucose metabolism.

    Since seeing your IMHC talk and having a better since of the details of ketosis (particularly that the body
    is still using – actually trading off between ketones and glucose) does this mean that mean that vitamin C
    metabolism is also cycling contrary to glucose levels? Just curious.

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    • Peter Attia  July 2, 2013

      I don’t know the specific answer(s) to your questions, but it has been well documented that Inuit, despite not consuming much vit C, did not have scurvy, probably due to lack of glucose interference, though it’s possible there is something else going on (though the role of vit C and proline in collagen synthesis is well understood).

  100. Steve Beisheim  July 17, 2013

    What helped me gain a tremendous amount of muscle, lose weight, and feel amazing was a low carb version of The Blood Type Diet. I just eat red meat as a type 0, I’m in ketosis 24/7, and i feel amazing.. For vegetarians, the trick is… greens, salads, vegetables. Also a lower frequency of eating is very important.

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  101. Mohammed Ashgar  July 19, 2013

    Excellent framework Peter. I’ve something to share from my career in the Economic Development arena. As a development professional, whenever we want to start a development project in any low-income country, we consider many economic factors. One of these factors is food security. For some reason, we tend to assume that the less carbohydrate (i.e. Rice and wheat) cultivated/imported in a certain country, the more important it’s to invest in food security. Usually, this investment translates to more rice or wheat. So, building on your point of infrastructure, ministries/governments/development institutions actually tend to measure their success based on how much carbs they can feed!! Consequently, obesity, presuming that it boils down to carbs, may become much more widespread globally as we try to alleviate poverty!!!

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  102. Lissa  July 27, 2013

    Left this on your Facebook page as well ….

    I too just watched your TED talk – it was shared by . Very nice. I also made my way over here and found this article. I was really hoping for some answers here as to why I not only cannot lose weight on low carb, but I have gained about 25 pounds. (Most of that gain happened when I was treated for hypothyroid …. unsuccessfully.)

    I feel better on a high fat, low carb natural food diet. I have varied the ratios of macronutrients. I have tried eliminating foods that could be allergens or to which I could be intolerant. I am not sure that I am insulin resistant – my levels have always tested low, when I monitored my blood sugar, it was completely normal, and I lack other indicators of having insulin resistance or metabolic syndrome.

    I am at my wits’ end now. Is there any hope?

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    • Peter Attia  July 27, 2013

      I believe there is, Lissa, but it’s probably beyond the scope of this interaction to provide any meaningful insight. If it were “obvious” I am sure you would have implemented it successfully already.

    • Lissa  July 28, 2013

      Well, thanks for your reply. Such as it is …. last ray of hope, gone.

      I know that I will never be able to get back to where I was 10 years ago … slender, healthy, energetic. Something changed in me and 50 pounds just appeared seemingly out of nowhere. And they aren’t going to leave. I have been holding on to the vague hope that I would at least be able to lose some of it, to get to a point where I am no longer scolded by my doctor, looked on with pity by those who knew me back when I was thin and healthy, and judged harshly by everyone else.

      Oh well … might as well go have a pizza and an ice cream sundae, right? No sense in being fat and deprived, at the very least I can enjoy food again.

    • Peter Attia  July 28, 2013

      Not sure that’s the conclusion I would draw. In fact, it’s not.

  103. Jeff Johnson  July 28, 2013

    …………..
    ………….
    ……….. Injestested Fat

    Lisa – I wish you’d cheer up a little

    The body does not like to store Carbs or Protein as body fat – body fat comes from injested fats plus high Insulin – or in some people just from the fat it-self as their body is adept at storing it – but not releasing and burning it –

    If this applies to you – a standard low carb diet will only make you hungry and the more fat you eat – the hungrier you will get until youv;e reached too many calories to lose weight =

    You might try a very low carb and very low fat approch – 120 calories fat -120 calories carbs and the rest of your calories from protein –

    Your protein choices cold be whey protein – or in my veiw less desirable tuna fish or George Foreman grilled meat –

    If you succeed in losing your weight – you can add a little mre fat back in the diet until the point where it starts to increase fat dependent hunger –

    I hope tommorow is a better day -

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    • Ellen Urciola  July 29, 2013

      Hi Lisa,

      I share your frustration, but Jeff is correct, I have struggled over the last two and one half years to find the ratio that works for me. Less fat for me seems to work the best. The longer I stay with it the more my body adapts. I too have to put up with a doctor that makes me feel miserable for not being able to lose weight fast enough for him, but I have managed to lose 35+ pounds, reduce my blood glucose to normal, and reduce my BP med. from 20mg. to 10mg. I also have to contend with the psychological aspect of eating. Being an emotional eater I have had to learn to distinguish between mouth hunger and physical hunger. Hey Jeff, your picture does not match your sage -like wisdom :). Thank you for such insightful advice! Hang in there Lisa, and find a more sympathetic doctor, I plan to.

  104. Lynne  August 21, 2013

    I just discovered your website and blog last night and have been reading through the tremendous amount of information on low carb weight loss. (I am a bit confused and overwhelmed but happy to have found this to study!) I wasn’t sure where to post my question, so please forgive if I have gone off topic.
    I have struggled with losing weight most of my life, although I have never been severely overweight, I have fluctuated between being 15-30lbs over what would be considered a healthy, and comfortable weight for me. I’ve tried all the diets from Adkins, (gained 1lb over the 3 weeks I did it), South Beach…never lost an ounce, and Weight Watchers using their old plan before carbs were even used in calculating points. I did have success with WW, losing an average of about a 1.5-2 lbs per month over a 10 month time period. I was able to, and did eat things like low-fat potato chips, bagels, etc., on the plan and exercised approximately 1-2 hours a day most days. Slow but steady, I lost almost 18lbs. That was the fastest and most consistent weight loss I have experienced as an adult woman. I was thrilled! It has been several years since I have followed WW, or any “diet” consistently as I seem to always become discouraged at how much effort and discipline I feel I have to put in, for very little result. (I know, poor me, right?) Since I am not looked upon as being considerably overweight, and I can fit into size 10-12 jeans, I usually just accept that this is it for me but I certainly would love to find an approach that would allow me to transform myself the way you did. I desire a fit looking and feeling body, yet my body fat percentage ranges around 37% right now. I exercise 5-7 days a week in various ways; weight training, biking, HIIT, walking, jogging, and I enjoy it most of the time although there are times when it feels like I have to force myself to put in more hours or increase my intensity because I have eaten a bad meal or two, been on vacation and have gained 5lbs etc. and then suffer with injuries from over-training. Anyway, my question is this: You mention that low carb eating may not result in weight loss for a certain percentage of people. I would like to sink my teeth right into this low carb thing and transform my health and gain the fit body I have always desired. But, before I do so and possibly end up feeling as though I’ve spent a lot of energy, time and money on educating myself, buying and preparing meals, ect…(I can continue doing what I am doing and stay the same, I am looking for change) would you be willing to shed more light on why low carb eating doesn’t result in weight loss for some people. I don’t know if my recent blood work for my annual physical would be helpful, but my Glucose came back at 91 within the normal range of 65-99. Cholesterol total at 196 with HDL at 81 and LDL at 104. Triglycerides at 57 with the range being <150. So does all this normal stuff mean that I am not insulin resistant and a low carb diet may not work for me? By the way, I am a soon to be 50 year old woman, 5' 4.5" tall, went through surgical menopause at 37 y/o and take Levoxyl for hypo-thyroid Hashimoto's disease.

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    • Peter Attia  August 21, 2013

      It’s hard to tell, Lynne. It takes me a lot of work, unfortunately, to diagnose insulin resistance. Fasting insulin and insulin response to glucose challenge are probably the most helpful numbers.

  105. Lynne  August 22, 2013

    Thank you, that is all I needed to know. Long description to my question but a simple answer is perfect. I wasn’t sure if the normal levels meant “normal” or whether or not there were further tests to determine IR. I also watched your TED speech today. I was moved to tears, thank you for your work.

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  106. George  September 22, 2013

    Thank you for offering such great insight on obesity. I myself lost 70 lbs 20 years ago using the Atkins book (low carb) but gained it all back because it was so restrictive (i just couldn’t keep avoiding what everyone else around me was eating). I realized this happens to everyone, so I started looking for ways to make the low carb lifestyle work… and after many years of being fat, I have succeeded in losing weight while still eating what I want (not as much as I want, but enough to keep me from being depraved). I saw this amazing video series that explained it so well I started a website so others could see it and learn how I have been able to do it: It’s at: http://SmarterLowCarb.com/life-changing-video/ Hope this helps more people see it.

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  107. Dean  December 15, 2013

    Thanks for the well thought out argument. You are quite right about accessibility to the wrong types of food playing a major role in obesity. While there are ways around it, on the surface, any low carb diet is quite expensive comparatively (depending on your country of course). Like I said though, there are ways around it.

    One small thing I want to share is the extreme impact blood sugar plays on appetite. I went onto a low carb diet by changing nothing, except drinking water instead of soda, and having no rice/pasta or bread. Otherwise the meals stayed the same (same size meat, just no rice on the side). Even though I was eating far less, my appetite was less ravenous, and I had no cravings. Seems counter-intuitive to most, but it was the reality.

    My only concern was that my weight loss remained quite high, losing on average 1.5KG per week even on week 8. Only needed to lose 20 (18+2 water weight) so already trying to move in the direction of “maintenance” (lost 12)

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  108. Green Deane  December 30, 2013

    It is very easy to anwer why people are getting fatter if low-carb works so well: 1) The government has been pushing the wrong kind of diet for 40 years, 2) the medical community and related institutions are wedded to that bad diet, and 3) most fast and “convenient” foods are based on that bad diet. The anti-saturated fat American Heart Association and the pro-carb American Diabetes Association cannot overnight say “Our advice for the last 40 years has been wrong and just the opposite of what it should have been. In reality simple carbs are bad for you and saturated fat is good for you.” Their woefully wrong positions won’t change until those earning a living off this misinformation retire or die. It took at least a generation or two to put this lousy diet in place. It will take a generation or two to get rid of it.

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  109. Sarah  January 17, 2014

    Britain (where I live) just doesn’t seem to want to conveniently accommodate the low carb diet or even consider it as a sensible way to eat. You go to any ordinary supermarket or you eat out and carbs and sugar are the staples to pretty much everything. I live in a society obsessed with and addicted to carbs and sugar. It is very hard, especially as a low income person, to stick to this atkins diet I am on. It’s also very antisocial. My family want to go to JD wetherspoon or McDonalds and it’s very difficult to order something that isn’t labelled garden salad, even then it comes back with croutons or insulin rendering dressing when this wasn’t stated on the menu. If I request them to be removed I am looked at like a lunatic. I know that carbs are the reason why I am fat. For years they have been the staple of my diet and I have been doing low calorie and I am stuck at 5’2 and 137lbs with a 30 inch waist. It isn’t the fat or the cheese or the steak I sometimes eat, it’s the oatmeal, the muesli and the couscous and the pasta. Then try explaining all this to your typical Joe Public. They insist that cheese and bacon (luckily for them I don’t even like bacon) make people fat and have even been told by their doctors to reach for a bowl of vegetables with steamed rice if they want to avoid heart disease and a life of obesity, yet many of them are overweight. It must be the forbidden bacon and the fried eggs they have been having recently so they switch to meusili and get even fatter and make up for it with even more ‘complex’ carbs and blame their metabolism or their bone structure. They visit the doctor asking why they can’t lose weight and the doctor just gives them the same advice and assumes they must be stuffing their face all day with saturated fats. They go on to develop health problems, blamed on high fat foods. We live in a society fed on false information when it comes to maintaining weight and when it comes to diet and nutrition. As an apple shaped woman especially carbs and added sugar are literally toxic to me, yet my doctor does not even know this. I think that we should take Sweden as more of an example. They have realised that the low fat and high carb way of eating is unhealthy and ineffective and maintaining a sensible weight and waist circumference and that it’s actually the other way around.

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  110. Abby  February 1, 2014

    Having tried a variety of diets over the last five years with no real success (I’m about 200lbs and 5′ 5”), I decided last weekend that I was simply going to try and eat low(er) carb and see what happened. I’m not giving myself a headache food planning/ shopping, just avoiding the obvious and seeing where it takes me. Granted I’ve eaten quite a lot of eggs, but also plenty of low carb vegetables instead of rice, pasta or potato, etc.

    I’ve tried carb controlled diets in the past and found them restrictive and misery inducing. So my idea was to do what I can but not turn it into a big thing. Week one is always a bit deceptive I guess (five pounds down) but the real revelation for me has been that I’m suddenly not hungry and craving food all the time. In a matter of days my appetite has TOTALLY changed in a way that I’ve never experienced. It’s been really easy to avoid carb laiden snacks as I’m not feeling the ned to snack. I’ve rapidly come to the conclusion that I’m the type of person who just shouldn’t eat many carbs and it’s really interesting to see how many people have reached the same conclusion.

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  111. Jonathan  February 7, 2014

    I have a question, people talk about not being in ketosis, but still being in “fat burning” mode. Doesn’t fat always metabolize into ketones? If you’re burning fat, aren’t you in some degree of ketosis? Or is ketosis defined more by a certain threshold of ketone production?

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    • Peter Attia  February 8, 2014

      Nope. Look at fat flux post.

  112. Gabrielle Bauer  March 2, 2014

    I’m probably like your wife. I’ve always been able to eat a high-carb diet with absolutely no ill-effects. At age 57, I’m maintaining a 50-pound weight loss on a high-carb diet (300 g carbs, which is 60% of my 2,000 cal allotment). Knock on wood, I have no digestive or musculoskeletal symptoms whatsoever. I feel exactly the same as I did when I was 20. So when I hear all the low-carb this and low-carb that out there, I can’t help wondering if the premise is overstated. Granted, I don’t know if I’m normative or an outlier. Just saying.

    GB

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  113. cristina  March 4, 2014

    My doctors are a bit puzzled and me too, so I have a question out of curiosity for you. Could a 36 year old woman which has been all her life at the underweight limit could be insulin resistant? I had gestational diabetes with my second pregnancy (never been properly tested with my first pregnancy, but baby was normal weight) and realize after, by home testing, that I am glucose intolerant, I can go as high as 10mmol/l at 1 h post meals (my maximum was actually 12.5mmol at two months postpartum, but then there was some improvement). My doctors mentioned possible LADA and MODY, but somehow I don’t think this to be the case (hopefully). I actually got the chance to do two measures on my mom and dad last fall, dad seemed normal, mom seemed to be very similar to me, ie normal between before meals, but going high after meals. I read about PCOS and insulin resistance, but I am not sure I am a good candidate for this (my mom even less). I would bet on some genetical insulin resistance on my mother side of family, but my doctors seemed to think such a thin person has zero chance of being insulin resistant. I was educated since childhood to eat low fat and not too much meat because my mom had some gallbladder issues, which means I was on a high carb diet all my life (not sugar, but starches and visibly not really a lot since I never put much weight on). I now try to restrict to about 40g carbs per meal, because this usually keeps me under 6mmol/l at all times and I find this a good target, but I want to know more about what’s going on with me. Blood tests come out optimal, I have low blood pressure, it really seems I just have this glucose intolerance, but I want to understand where it’s coming from. Note that my OGTT came as 4.8 at 2h two months postpartum, but they did not want to measure at 1h and stupid me did not have my meter with me (never thought they will not measure at 1h…and if I eat 75g of carbs from starches at home my blood sugar will be high for 2-3 hours afterwards). I am actually not sure my moms anomaly has the same source as mine or if it’s not evolving faster in me. My mom it’s still very thin at 63 and seems in good health. I must say I have been really really severally sleep deprived for the last 4 years (my fist was a very poor sleeper and my second it’s still very young) and I know lack of sleep can play a big role, I also have very strong reactions to stress (got this from my mom) and I had a lot of emotional stress from family issues the year prior to my second pregnancy and lost a lot of weight, but I don’t think I will become ‘normal’ again when the kids grow older. Also since I had kids I seem to store ‘all’ the fat on my body on the front of my belly, it’s not really much, but compared to the rest of my body it makes a striking picture.

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  114. Sam  March 30, 2014

    I suspect this might be a missing piece of the puzzle as to why we make poor choices about our health (e.g. have unprotected sex). Dr Dan Ariely, a behavioural economist (Tedx Talk below, very informative, 18min) has done studies in how people make decisions when the pay-offs are immediate and the pay-back is far off in the future.

    An example from the talk to save time: He contracted Hep C through a bad blood transfusion. The treatment (he simply called it “interferon” and left it at that) involved self-injecting the medication, 3 times a week for a year and a half. Each injection would be followed by vomiting and high fever. It was extremely unpleasant in the short-term and the long-term pay-off was far off into the future as well as uncertain. His way around it was to give himself an immediate reward post injection (in his case watching movies – I would choose something else). After a year and a half, he found out he was the only candidate in the clinical trail who stuck it out. (He was also cured!)

    https://www.youtube.com/watch?v=PPQhj6ktYSo

    I am very interested in this topic because I help high school students study maths and an average 16 yr-old has a tough time making the right choice when faced with 20min math homework vs. 2 hours of TV. I have been looking for more constructive ways to help them deal with the problem than simply label them as “lazy” and yelling at them.

    On to a question only tenuously related to the the above: I think that people keep asking you what you eat for a very simple reason. They would like to try the ketogenic diet but lack the knowledge and the know-how to put together a plan of some sort. You say that every person is different and that the ketogenic diet might not be for everyone. Fair enough. You also say that it is necessary to educate oneself in order to make the right choices. Couldn’t agree more.

    From all the video-watching and blog-reading it is very clear that your intention is to make a positive difference in people’s lives…which you have done. I’ve pointed quite a few of my friends in your direction and they said it helped. What I’d like to point out is that this is an incredibly complex topic. The vast majority of people are not able to take principle into action very easily and they look for heuristics, sometimes in the wrong places (copying your diet to the letter).

    So my question is, what are the guidelines I could follow to give this diet a try? What I have in mind are questions like the following:
    How long should I try it to see if it works? Is a month sufficient? 6 weeks?
    What are warning signs I should look out for (reasons to stop immediately)?
    The “zone of misery” kicked my butt last time I tried, how do I get around it?
    What are the most common problems people encounter when they first start this diet and what are good strategies for dealing with them?
    What are the common mistakes people make?
    I’ve looked up a list of foods that are high fat, low carb as well as oily sources of proteins, worked out the amount of protein, fat & carbs I “should” eat (138g, 197g, 31g), thought about what might work with my lifestyle and set up a plan with which to start (adjustments to be made as needed). Is that a good approach? Any suggestions to build on that?

    Cheers

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  115. Teri West  April 19, 2014

    I found this page after watching your video and wondering if you weren’t telling my life’s story about the battle with diabetes and obesity. My battle with obesity as been lifelong. I think you are spot on that different people have differing metabolic makeup and what works for some may not work for others.
    I have been obese since my teens and developed type 2 diabetes about 6 years ago. I am 59, 5′ 10” and over 300. I have yoyo dieted all of my life. In 2010, I was at 420 lbs. and knew I had to do something, so I started with cutting down on carbs, particularly refined sugars and fast food, and I joined the Y to get exercise. I lost about 30 lbs over a year but stopped after that. In the fall of 2011, my hubby had a heart attack and I tried diet changes that would hopefully help both of us. I lost another 20 lbs and stopped. I maintained the weight loss, but I could not lose. In the August of 2012, I was diagnosed with breast cancer, the stress of which took 20 off of me, and 3 weeks after the diagnosis I was hospitalized for and AVM in my small bowel and had a bowel resection to remove it. During the 3 weeks in the hospital my diet was primarily ice chips, so that took another 20 off of me. The mastectomy followed the resection 5 weeks later. I did not do chemo because the risk was higher than the benefit it would have given me. I spent the winter recovering from all of this and the following February I began eating more healthily and I set a goal to walk the Strides Against Breast Cancer 5k in October ’12. By summer I had lost a total of 90 lbs (from the 420).
    I developed pain in my hips by mid-summer which put me into phyisical therapy and I had to stop walking. The week after the therapy ended, I began walking again and I broke my foot, (Two weeks before the Strides 5k) which put me in a cast for 6 weeks and a boot for 3 more months because it did not heal completely. I should have had surgery on it to begin with. In mid January of this year, after finishing with bone stimulation therapy on my foot, I joined the Y because I had gained 20 lbs over the winter and I wanted to begin losing again.
    This time, it has been much harder to do. I am working out 60 minutes, 5 days a week, swimming laps 3 days and doing strength and cardio on the other two. This is considerably more strenuous than the walking I did last year but it is tailored to keep the stress off of my joints and feet. I have lost 12 of the 20 I gained, about 4lbs. a month.
    My oncology nutritionist recommended a book entitled “Intuitive Eating” and although you do follow a “diet” of sorts it appears to me that yours has been an intuitive journey of finding out what works well for your body. I have been on the road at times where I no longer crave the foods that I give up, but at some point, that craving returns. It never truly stays away and I fall back into old habits easily. The thought behind Intuitive Eating is that depriving ourselves of what we like causes those lapses occur.
    I have changed from refined sugars to fresh fruit and I love it. It has essentially taken the place of the sweets that I craved. My glucose levels are now normal, but still with medication. I hope that if I can lose more weight that the glucose will drop even more and I can get off of the medication. I just don’t feel ready to give up bananas and apples so I don’t think I could do what you do at the level you do it. But I want to make more tweaks and see what happens.
    I especially like the fact that you do not present this as “the magic cure” for obesity. I too think that research is vital and hopefully there will be more findings in the future that will help us end this cursed problem.
    I know that genetics are a major key to it because I come from two families that are opposites. My mother’s family is plagued with metabolic syndrome and my dad’s family had very little of it. His mother died at 102 and ate lard, fried foods, sweets, almost anything she wanted. She was overweight at times, but not obese. Dad had more struggles than anyone in his family and I wonder if the diets he used did more harm than good.
    Anyway, I was delighted to hear that an actual MD was questioning the current thinking about nutrition and obesity. My breast surgeon hounds me about my weight and yet the oncology nutritionist frowns on “diets”. Hum….what’s a mother to do???

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    • Peter Attia  April 19, 2014

      Glad to hear you’re taking charge and figuring out what works for you, Teri.

  116. Itsthewooo  July 13, 2014

    Correct me if I’m wrong, Peter, but didn’t Carbsane debunk all of this years ago? (Shhh. Don’t tell anyone. Secretly she rocks my world.)

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  117. Alf  August 21, 2014

    Hi Peter. I read one comment you mentioned about fasting. Muslims fast 29-30 days during their holy month of Ramadhaan. Its not that I’m promoting my religion… its just because with many Muslims… they fast a great many days throught out the year. For instance… we are encouraged to fast on Mondays and Thursdays…. or if we’d like, fast one day, and not fast the next, and then fast the next day, and not fast the next. Etc. Etc. Maybe you can do an experiment on them, or maybe try it yourself to see the benefits.

    The Ramadhaan month just ended tho… We however don’t do 24 hours fasts. Its just from dawn to dusk (depending on the region of the world, this can be a very long time [e.g. summer in the USA] or a very short time [e.g. winter in the USA]). Just a thought… I myself would like to know to see what benefits might arise from that kind of month-long fast, or even the encouraged fasts (e.g. the alternate days and Mondays and Thursdays).

    Ok. have a good one and please keep up your excellent and unbiased work! :D

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  118. Robert Wheeler  September 24, 2014

    People are still overweight despite they are in “low carb” diet” because they think they’re eating the “right” food, when in fact, they are not. Great blog, Peter. It’s very informative. Keep up the good work! I really enjoy reading all your articles. I look forward to reading your future posts.

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