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Is sugar toxic?

Is sugar toxic?
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I remember one of my mentors in surgical residency made a very important distinction for me.  He said, “Peter, never forget what you are getting paid to do, and what you are doing for free.”  You see, there are some aspects of being a surgeon that are not particularly enjoyable.  The hours are long.  Sometimes you’re asked to intervene in a situation where there is no hope, and you feel you may only make things worse.  A lawsuit is just around the corner. But there are many aspects of surgery that are pure bliss.  Though I’m no longer a surgeon, some of my fondest memories in life stem from moments there.   Anastomosing a transplanted kidney into a patient (especially the renal vein anastomosis, which is the easiest to screw up).  Endartarectomizing a plaque-filled carotid artery.  Telling a patient and their family that you were able to remove the entire tumor in their colon, and that the lymph nodes were free of tumor.

What my mentor was saying to me was that those moments of pure bliss are not what we’re getting paid for.  In fact, we’d probably pay to do them!  What we’re getting paid for is the time we have to be away from our family.  The long hours, smelly call rooms, and bad hospital food.  The cost of medical malpractice insurance.

What does this have to do with the toxicity of sugar?  Well, nothing actually.  But I constantly remind myself of this when I feel my personal stress and anxiety mounting.  The past year has been a whirlwind of kinetic energy that makes my days in residency, 80 to 100 hours of work every week, seem tame and almost boring.  Most of what I do today is wonderful, but some is not.  I fly about 12,000 to 15,000 miles a month (in coach, no less) and spend about 8 to 10 nights a month in hotels.  Red-eyes are a regular part of my existence.  My day starts between 4:45 and 5:00 am and goes until 11 pm or later.  I can’t put in words how much I detest traveling and being away from my family.  So, I guess, that is exactly what I get paid to do.  (By the way, do not feel sorry for me.  I’m pretty sure all of this is self-imposed, but I still hate it.)

So, do you want to know what part of my role at NuSI gives me bliss that rivals the finest moments of surgery?  It’s exactly what I did a couple of weeks ago (and, fortunately, something I get to do often).  I spent a day with some of the best and most thoughtful scientists talking about their work and how we can make it better.

Can you imagine (assuming you’re as much a geek as I am) getting to pick the brains of the best scientists for hours on end?  Finding out why they are obsessed with the questions they ask? What keeps them up at night? What are the challenges they face?  What’s preventing them from resolving uncertainty?

I would pay to do this part of my job. This is the bliss described by Joseph Campbell.  And this meeting a few weeks ago was a great example of it.   This particular meeting focused on sugar research, specifically the metabolic impact of sucrose, high fructose corn syrup (HFCS), and fructose.  If you need a quick refresher on the distinctions, this should help. Spending so much time with this group got me thinking about a broader issue, which is actually the focus of this post:  Is sugar toxic?

What does ‘toxic’ mean?

Before we dive into the main focus of this post, we need to get crystal clear on our semantics.  Too much tomfoolery has already taken place for the simple reason that many people don’t understand the words they use.

For the purpose of rigor, let’s turn to the pharmacology literature for a clear understanding of toxicity.  Even though we all have an understanding of what “toxic” means, let’s be sure we’re understanding the nuance.  If you troll the medical textbooks you’ll eventually settle on a definition something like this (from Harrison’s Principles of Internal Medicine):

TOXICITY: The degree to which a substance can harm humans or animals. Acute toxicity involves harmful effects in an organism through a single or short-term exposure. Subchronic toxicity is the ability of a toxic substance to cause effects for more than one year but less than the lifetime of the exposed organism. Chronic toxicity is the ability of a substance or mixture of substances to cause harmful effects over an extended period, usually upon repeated or continuous exposure, sometimes lasting for the entire life of the exposed organism.

The first thing you may notice from this definition is that toxicity is actually subdivided into acute, subchronic, and chronic toxicity, based on how long it takes to progress from exposure to insult and the number of exposures necessary to cause insult.  This constitutes what I call:

Important point #1 – don’t confuse acute toxicity (what most people think of) with chronic toxicity.

Acute toxicity and the LD50

An example of acute toxicity is acetaminophen (abbreviated APAP, but commonly referred to by its trade name, Tylenol) overdose which, if significant enough, requires a liver transplant within days to prevent death from fulminant liver failure. (As an aside, this is particularly tragic because the liver, unlike the heart, lungs, and kidneys, can’t be supported extracorporeally; so if a person overdoses, and the liver is irreversibly damaged, they will need a liver transplant within days, or they will die.)

The question, of course, is what dose of APAP is toxic? (In this case, the toxicity is liver failure, which results in near-immediate death.)  Enter the LD50.  LD50 stands for “lethal dose required to kill 50% of the population.”  How is this quantified for a given substance, including APAP? Obviously, we don’t do randomized trials of increasing APAP doses in people until we definitively resolve this.  Instead, we (I’m using ‘we’ pretty liberally here – obviously I have never done this) do 3 things typically:

  1. Carry out the above experiment in animals to accurately estimate LD50 (in the animal);
  2. Mathematically model the best human data available and try to estimate LD50 (in humans);
  3. Compare the two estimates.

Not surprisingly, the answer to #1 is usually much higher than the answer to #2.  In the case of APAP, the LD50 in rats depends on age, but is probably somewhere between 800 and 1,500 mg/kg, suggesting a 75 kg human would expect toxicity (on average) between 60 and 110 gm (120 to 220 extra strength Tylenol tablets!).  Is this likely? Let’s go to step #2.  Below are data integrating known human toxicity with a mathematical model to estimate LD50, as a function of APAP dose (x-axis) and death versus survival over time (y-axis).  As you can see, this analysis suggests LD50 in humans is closer to 20 gm.  (These are data from humans who did not undergo liver transplant, except in the case of the yellow triangles.)

Acetaminophen Overdose Model

I’ve looked at several other models and they all appear to suggest about the same thing, The LD50 of APAP in humans is about 10 to 20 gm (10,000 to 20,000 mg or 20 to 40 Extra Strength Tylenol tablets), and most sources point to the lower end of that range.

So what’s my point of this?  My point is that there is a statistical distribution (see figure below) of the toxicity, which is why it’s called LD50 and not “LD” (which would imply everyone would experience toxicity from the same dose).  In other words (let’s simplify and ignore weight differences since this is in mg/kg and just assume I’m talking about a 75 kg human), some people will experience toxicity at 6 gm and others not until 16 gm. In the figure above, you can see one person lived, despite a dose of 40 gm (given that he received the antidote early enough) and another at 25 gm, without antidote.

Important point #2 – there is a spectrum of susceptibility to any toxin. 

LD50

What about chronic toxicity?

Sticking with APAP as our example, it turns out that much lower doses than the LD50, if taken day after day, are also toxic to the liver. How much lower?  As you’ll see below, the answer is highly dependent on the timing of these doses and other host factors.  In general, though, some authorities suggest repeated daily doses of more than 6 gm are toxic, while repeated doses below 4 gm daily are rarely toxic.  The point is that much smaller doses, if taken repeatedly, are still toxic.

Important point #3 – just because a dose does not result in acute toxicity does not mean it can’t or won’t cause chronic toxicity.

Complicating things a bit further…

There is no reason to expect physiology to be simple or binary, so adding one more layer of nuance to this already-longer-than-you-wanted-to-read-explanation is the following point. Factors such as alcohol consumption, underlying liver disease, viral infections, and genetic susceptibility are highly influential in both acute and chronic toxicity from APAP.  This shouldn’t be surprising, of course, though it complicates our discussion.  Since APAP taxes hepatocytes (liver cells), taking other drugs that do the same, consuming alcohol (uniquely metabolized by hepatocytes), or having underlying liver disease are invariably going to reduce hepatic reserve.  So, an individual’s ability to tolerate APAP is highly dependent on both measureable (e.g., cirrhosis) and idiosyncratic variations.

Important point #4 – host factors play a significant role in susceptibility to toxins.

Parting shot

I would be surprised if anyone reading this has not taken or used APAP (i.e., Tylenol or some generic equivalent).  In fact, most of us have experienced great relief from it.  That does not change any of the points above.

Important point #5 – the term “toxin” does not imply something is “bad” or universally harmful.

What does APAP have to do with sugar?

There must be some reason I’ve gone through all of this, right?  After all, the question of sugar’s toxicity is a somewhat polarizing one. On the one hand, folks like Dr. Rob Lustig have argued that fructose is harmful at the doses most people are consuming it today.  On the other hand, folks like Dr. James Rippe have argued the opposite.  Having read just about every paper and review article on this topic (I think) over the past year, I can say the debate has many facets, which I’ll outline briefly:

    1. The PRO sugar folks** argue that sugar, while void of any nutritional value, is no more or less harmful than a calorie of any other nature. In other words, it has no unique metabolically harmful consequence.
    2. Depending on affiliation, some of the PRO sugar folks debate back and forth about the advantages or disadvantages of sucrose (natural sugar from beets, cane, etc. composed of a linked glucose and fructose molecule) and HFCS (synthesized sugar composed of 55% fructose, 45% glucose mixture).   (There may be some merit to this discussion, though it would probably qualify as a “higher order” term. To a first or second order approximation, they are biochemically equivalent.) It appears this debate is a convenient way to avoid really confronting question/point #1.  The “natural sugar” producers can point at the corn growers, and vice versa, without really confronting the jugular question.  Both of these groups (sugar and corn) downplay research on pure fructose (which is pretty rare in nature and even our current environment), which is a valid point, though a distraction from the issue above.
    3. The ANTI sugar folks argue that sugar is indeed a “unique” macromolecule distinct from other carbohydrates.  Whether solely due to the fructose content, the combination of fructose and glucose, and/or the kinetics of the fructose (i.e., the speed with which the fructose requires hepatic attention when not accompanied by fiber) is a matter of debate and speculation, but those in this camp do agree that sugar is not “just” an empty calorie. The toxicity of sugar, they argue, is primarily related to its hepatic metabolism.  Specifically, “excess” (see below) ingestion of fructose increases VLDL production which increases apoB or LDL-P due to greater triglyceride load.  Additionally, at least at reasonable doses according to most literature, insulin resistance is worsened which amplifies the harm caused by other foods.
    4. Even among those who don’t subscribe to the idea that sugar is metabolically unique (and harmful), with or without a dose-effect, some argue that fructose consumption impacts subsequent food consumption in a way that glucose does not.  In other words, eating sugar may fail to satiate you and/or make you subsequently hungrier. These data are sometimes confounded, as are many data in this area, by the use of pure fructose, rather than the glucose-fructose mixture found in sugar.  Furthermore, evidence is emerging that sugar is addictive, much in the same way that a drug like heroin or cocaine might be, as suggested by functional MRI. So, while folks in this camp argue that sugar per se isn’t harmful, it does make you eat more (sugar and non-sugar, alike), and that is the harm.
    5. Perhaps the largest debate in this area stems from the dose issue.  The PRO sugar folks argue that at the doses most Americans consume sugar, there is no harm (even if there is a theoretical harm at very high doses).  The ANTI sugar folks argue that there is a dose-dependent (and probably a context-dependent – e.g., the insulin resistant person vs. the insulin sensitive person) deleterious impact of sugar, AND that current consumptive patients are indeed in this zone of toxicity. (This is probably the most comprehensive single review I’ve read on the entire topic, and I’ve discussed it point-by-point with 2 of the 3 authors.)
    6. Speaking of the dose issue, no area of this debate (in my opinion) has generated so much controversy.  How much sugar, defined as added sweetener (so this does not include the fructose found in fruit, for example) do Americans actually consume?  This is important, of course, if we want to know how applicable the above studies are to the question at hand.  Where to begin? (This topic alone is really a 3-part blog post.)  Estimating how much added sweeteners Americans consume is primarily done via two methods:
      1. Taking the difference between food availability data and waste data (ERS); or
      2. Using nutritional surveys (NHANES).

One of my colleagues, Clarke Read, looked into this recently.  Here is what he found (this was in response to a recent NY Times article suggesting sugar consumption is less than typically reported):

The adjustment to loss rates was done by RTI International in this report to the USDA Economic Research Service (ERS).  Section 4-1, which is an example calculation, is most useful.  RTI was asked to calculate estimates of loss, not estimates of consumption, and rather than working down from availability data, they in fact used NHANES 2003-2004 data to estimate consumption, then basically compared this to availability numbers (with a few adjustments) to find amounts of loss.  These loss percentages calculated from 2003-2004 then became the standard, and all other consumption data was calculated by applying this % loss to the availability data.

This means that all consumption numbers are effectively derived from NHANES data.  This is especially relevant for added sugars.  Since NHANES data tracks only consumption of foods, not ingredients, this availability-versus-consumption comparison initially leads to a 96% loss of cane and beet sugar (seen on page 95 of the 2011 USDA document — the “4 percent” referred to in the NY Times article), since NHANES data only reflects sugar added to foods directly, rather than used as an ingredient.  The judgment of a panel of experts was then used to determine the percentage of available sugar used as an ingredient, which led to their 34% loss estimate for sugars.  For HFCS, which is never consumed as a food and always as an ingredient, they simply gave it the same value as honey (15% loss between availability and consumption).  The ERS, however, overruled them (as described in the NY Times article — see the end of the Losses at Consumer Level section in the link for ERS evidence) and used the 34% loss estimate instead.

Page 10 of the 2011 USDA document shows who these 6 experts are.  The NY Times article asked 2 of these 6 about these sugar estimates, who don’t recall making them, though it’s implied that they simply don’t remember what happened back in 2008. In other words, while the overall trend in sugar data is determined by availability data (since % loss is assumed to be constant over time), the absolute amount consumed on any given year, as estimated by these loss-adjusted numbers, is entirely dependent on this RTI loss estimate which, for added sugars, is almost entirely dependent on an expert’s estimation.  All foods that are primarily consumed as foods rather than as ingredients have consumption levels that are based on an extrapolation of 2003-2004 NHANES data.

Translation: this is a complete cluster.  If you triangulate between the ERS and NHANES data, you wind up with an estimate of about 90 pounds of added sweetener per person, per year, or about 110 gm per day which, on average, works out to about 15% of total caloric intake.  Of course the actual consumption is much more nuanced (what isn’t?), since consumption varies a lot by age, gender, and socioeconomic status.  Furthermore, this estimate doesn’t include the fructose in fruit juice or fruit, though the latter probably isn’t nearly as high, or relevant, as the former.

Another very interesting point uncovered by colleague, Clarke, was that in a 2009 paper in The Journal of Nutrition, Dr. James Rippe (one of the leading proponents of sugar) noted the following:

“…fructose, as a component of the vast majority of caloric sweeteners, is seen to be particularly insidious.”

“It has also been shown to increase uric acid levels, which in turn promotes many of the abnormalities seen in the metabolic syndrome including hypertriglyceridemia.”

“There is considerable evidence of a detrimental effect on metabolic health of excess fructose consumption.”

Whether by accidental omission or otherwise, this paper is not listed on Dr. Rippe’s CV on his website.

**Sadly, it’s difficult to really interpret the data objectively from those in the PRO sugar camp because of the conflicts of interest.  Most of the PRO sugar scientists are heavily funded by the sugar industry.  For those interested in the historical context on science and the sugar industry, you’ll find this article particularly interesting.

Take home messages

What I find frustrating about this debate is that most people yelling and screaming don’t fully define the terms, perhaps because they don’t appreciate them (forgivable) or because they are trying to mislead others (unforgiveable).  The wrong question is being asked.  “Is sugar toxic?” is a silly question.  Why?  Because it lacks context.  Is water toxic? Is oxygen toxic? These are equally silly questions, I hope you’ll appreciate.  Both oxygen and water are essential for life (sugar, by the way, is not).  But both oxygen and water are toxic – yes, lethal – at high enough doses.

What did the APAP example teach us?  For starters, don’t confuse acute toxicity with chronic toxicity.  Let’s posit that no one has died from acute toxicity due to massive sugar ingestion.  But, what about chronic toxicity?  Can eating a lot of sugar, over a long enough period of time, kill you (presumably, through a metabolic disease like diabetes, Alzheimer’s disease, cancer, or heart disease)?

Even among a healthy population (i.e., people without overt liver disease), toxicity is a distribution function.  What’s toxic to one person may not be toxic to the next.  This is true of APAP and it’s true of sugar.  It’s true of most things I can think of, actually, including tobacco, alcohol, cocaine, and heroin. Ever wonder why “only” about one in six smokers dies of small cell lung cancer? Maybe it’s the same reason some people (e.g., me) get metabolically deranged from even modest doses of sugar, while others (e.g., Jill, my wife) can mainline the stuff and not appear to suffer many adverse effects.

I posit that Jill and I are both outliers on the distribution of susceptibility, probably driven mostly by genetic difference (rather than, say, exercise as we both exercise a lot).   So, I offer you a framework to consider this question.  I know some of you just want an answer to the question, Is sugar toxic or not? But I hope this slightly more nuanced response can help you figure out what you should be asking: Are you like me? Like Jill? Or like an Average Joe somewhere in between us?

This is what you will need to figure out on your own.  You could play it safe, assume you’re like me and eliminate all sugar from your diet (I eat no more than about 5 gm of sugar per day, almost exclusively in 85%+ dark chocolate – so less than 4 pounds per year).  But if you have Jill’s genes, maybe this is overkill.  (Though, I would argue, and may do so in a later post, that even Jill has noticed a change in her energy levels and a number of biomarkers by reducing her sugar content somewhat over the past 3 years.)

Sugar toxicity

It’s pretty easy (conceptually) to figure out where you are on this spectrum, but it does involve a few deliberate steps:

  1. Without making any adjustment in your current eating habits (i.e., fight like hell to avoid the Hawthorne effect), record everything you eat for a week and, using a database like this one (or something fancier like Nutritionist Pro), calculate exactly how much sugar you consume.
  2. Collect blood work (paying special attention to lipoproteins, triglycerides, glucose, and insulin among other things) and other measurements (e.g., DEXA if you want to assess body composition, waist measurement).
  3. Get intimately familiar with all the places sugar shows up that may seem counter-intuitive (e.g., “healthy” cereals, sauces, salad dressings, bread).  To do this experiment, you need not restrict your complex carbohydrate intake, but you’ll have to substitute products without added sugar.  For example, before I was in ketosis but beginning to discover my own susceptibility to sugar, I had to make my own spaghetti sauce from scratch rather than pour it out of jar.  I had to make steel cut oatmeal rather than eat Quaker oats.  I had to buy bread made with zero sugar (at $7 a loaf!) rather than my usual “whole wheat” bread.  You get the idea.  It takes time, and you should expect to spend a few extra dollars on food. But, it’s actually possible to find foods that contain minimal to zero added sugar.
  4. With this information in hand, begin the intervention: aim for a reduction of at least 50% from step #1. (In my first experiment I did 6 days per week of zero sugar, and one day of all I wanted.  Ultimately, this became too difficult, and it actually became easier to just go zero every single day.)
  5. Repeat the measurements (i.e., step #2) after about three months.  If you’ve seen minimal effect, assuming you were methodical and consistent, you’re probably in the Jill camp.  If you’ve lost fat, seen a reduction in your triglycerides, fasting glucose and insulin levels, increased your HDL-C, and decreased your apoB or LDL-P (assuming you were able to measure them), you’re probably in the Peter camp.

Last point I’ll make, as I suspect at least some of you are wondering.  How do two genetic outliers treat their genetic hybrid (i.e., our daughter)? I’ve written about this previously.  In short, we limit the sugar she eats in our house, but not so much outside of the house (e.g., birthday parties).  I estimate she eats about 25% of the sugar a “normal” kid does.  There is no doubt she loves it, and even a week ago when we went on a daddy-daughter date, I got her ice cream with sprinkles for dessert (the irony of me carrying a bowl of sprinkle- and Oreo-covered ice cream through a crowded restaurant was not lost on me).

What does amaze me is how it seems to override her senses.  That night, she had a big plate of salad, a bowl of soup, and even a large slice of pizza (if you’re wondering, I had 3 large plates of salad with chicken). She claimed to be absolutely full, and I believed it.  But when I brought that ice cream out, it was like she had never seen food in her life.  She simply devoured it.  The best part?  When she looked like she was done, I said, “OK sweetie, looks like you’re done, time to get going…” only to have her say, “No daddy!  I’m still finishing the chocolate broth!”  She literally left not one drop of melted ice cream (“chocolate broth”) or one single sprinkle or one single crumb of Oreo behind.

This does not seem “normal” to me, and for this reason I guess I refuse to accept, personally, that sugar is just a benign empty calorie.  But, one day our daughter will have to decide for herself where she lies on the distribution and how much she cares to do anything about it. Until then, we’ll save the chocolate broth for special (and not too common) treats.

Sarah's wedding

So, in response to the question, “Is sugar toxic?” it seems to me the answer is, “yes, sugar is probably chronically toxic to many people.”  And so is water. And so is oxygen.  My sincere hope, however, is that you now understand that this is probably the wrong question to be asking.  The better question is probably “What dose of sugar can I (or my child) safely tolerate to avoid chronic toxicity?”  The goal should be to figure out your toxic dose, then stay well below it.  (It’s probably not wise to consume 95% of the toxic dose of APAP just because you have a really bad headache.) What makes this important, of course, is that with water and oxygen, the toxic doses are so far out of the range of what we normally consume, it’s not really necessary to expend much mental energy worrying about the toxicity.  But with sugar, at least for many of us, the toxic dose is easy to consume, especially in world where sugar resides in almost everything we eat.

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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. Julie  May 28, 2013

    You know, I’ve inadvertantly done this experiment on myself and I am, unfortunately, on the “Peter” end of the spectrum. I guess my question for myself is how low to go in carbohydrate consumption without sacrificing nutrients from vegetables? How high in fat? Or does that even matter? How high in protein since it has the potential to cause an insulin response if you eat too much? I don’t know the answers to these questions. Although I could not figure out what Tylenol had to do with sugar toxicity, I got it by the end. Pretty powerful analogy, Peter. I got the point. Thanks.

    (reply)
    • Peter Attia  May 28, 2013

      Julie, there is little reason to limit non-starchy vegetables and low-GI fruit, even in ketosis. By extension, of course, if not trying to be in ketosis, there is little reason to restrict these at all. If you’re in the Peter camp, though, high GI fruit are probably best if minimized.

    • Liza  September 6, 2013

      Julie,

      Have a look at http://www.dietdoctor.com. In regards to a Low Carb High Fat diet, the answer to your nutrition question – how low to go in carbohydrate consumption without sacrificing nutrients from vegetables?

      The answer is: NONE. Veggies will still be the quantifiable bulk of your meal, but avoiding or minimising the ratio of certain carb high root veg. (Simply: if it grows over ground – eat it!, if under ground – don’t!) Your protein intake should probably stay pretty much the same as any normal diet allows, but with one simple difference – you don’t need to cut the fat off your steak! The final component – and the most important will be fats. Eat until your full and supplement your meals with butter, oilive oil, full fat dairy and nuts in moderation. In simplification, it’s a Paleo (stoneage) diet with no added crap. If the food you hold in front of you has a ‘contents’ list – avoid it.

      Dr Enfeldt (Diet Doc) has a tonne of analogies and own studies on his page, and I warmly recommend all related content. My dad has followed and lost a tonne of weight on LCHF – he’s now approaching 73 years old and is as healthy (and slim) as ever!

  2. Nathan Young  May 28, 2013

    The example you use at the end concerning your daughter eating her ice cream when she was already “full” is a great one. This is an anecdotal piece of evidence almost everyone can related to! I know I have been to the point where I couldn’t possible choke down another piece of meat or take another bite of broccoli, only to destroy some sweet treat moments later.

    I look forward to your continuing posts on this issue. Perhaps an important thing to address is how people who can’t afford all the blood work can assess their tolerance to sugar…

    I’ve been low-carb for a few years now, and experimented with ketosis last year. Long story short, it seems I’ve fixed myself metabolically. Recently I’ve added some sugar back in my diet and have seen a slight increase in lean muscle. However, even on days I eat sugar, my carbohydrate intake is still below 150g. Even with the muscle gain I’ve seen no fat gain (in fact I look leaner) and my waist size has not increased (even with going from about 155lb to 165lb).

    I fast most days, and my eating window is usually 6-10 hours long (I never fast for entire day). My metabolism dosen’t seem to be affected by the increase in sugar consumption (from what I can tell), and my muscle gain has plateaued.

    Having said all of that, I don’t consume much added sugar. But, before, I was consuming almost none, and eating only 50-75g of carbs per day (on average). Now I eat 75-150g per day. The one thing I guess I can’t even be somewhat certain about, is whether or not this increase in sugar/carbohydrate consumption has increased my LDL-P…

    (reply)
    • Peter Attia  May 28, 2013

      Interesting question. To your first question, absent the “fancy” blood work, even a simple lipid panel and metabolic panel (very cheap) will give lots of info.

  3. Luke  May 28, 2013

    Peter,

    Just wanted to say thanks for the work you do. I really enjoy the detailed explanations to some very interesting and complex (for me anyway) topics. I’ve spent hours on your blog reading and rereading your posts trying to wrap my little brain around it all ;)

    Your statement “this does not seem normal” to me, really hit home. While I am in a fact a “Jill” and could handle higher levels of sugar I too choose not to because I feel/function better without. I realize I’m eating more for psychological desire than physiological need when I eat sugary foods.

    Working as a personal trainer clients often ask “what do you think about eating____?”

    I’ve suggested they’ve ask themselves if that food will pass the “Dessert Test?” Essentially would you still eat that food if you were already full? If you you answer Yes, you should NOT eat that food. If you answer NO, it’s probably an okay “treat.” I think it’s a pretty easy way to find those foods that have the affect that “does not seem normal.”

    I’m like your daughter, I could be full and still hammer in the ice cream, chocolate broth and all! Thanks again for all the work you do, your cholesterol post is my go to guide when the cholesterol questions are asked!

    (reply)
    • Peter Attia  May 28, 2013

      Nice way to think about it, Luke. Next time you have some ice cream, just think of the broth!

  4. Albie  May 28, 2013

    Hi Peter

    Nice thoughtful article. Your points are well made. Have you given consideration that each person’s “toxic” level might also be influenced by age and hormonal and other imbalances like excess PUFA ingestion, which might be corrected. Lastly, you say you have talked to a lot of pro sugar scientists. Have you talked to Ray Peat, PhD yet, or read his work ?

    (reply)
    • Peter Attia  May 28, 2013

      Yes, Albie, I do believe that for most people there is a trend toward lowering the “LD50″ over time (i.e., as we age). Not sure about the role of PUFA, because the data as so conflicting, but it’s a very important idea to be explored.

  5. James Roman  May 28, 2013

    Another Great article. Thank you Doctor. Interesting that your distributions are severely right-tail skewed (higher “tolerance”). Clearly I wouldn’t expect the distributions to be “normal” however do you think all the tails are in the same direction?
    One other question…You mention that the toxicity of sugar is a polarizing topic among scientists. Is there general agreement anywhere? Any common ground on the role of sugar in the obesity issue emerging?

    (reply)
    • Peter Attia  May 28, 2013

      Good points, James. The figures are just schematics, and I think it’s unlikely the are normal. My guts says they skew the way I’ve showed them. I will say this, MOST scientists who really study this are closer to the ANTI camp than the PRO camp, but the devil is always in the details: dose? empty calorie vs. specific metabolic harm? specifics of liquid sugar?

  6. Stephan Guyenet  May 28, 2013

    Hi Peter,

    Nice post. I suspect that refined sugar isn’t the healthiest food to eat in quantity (with large variability in effects between individuals), though I’m not convinced that fruit is fattening or metabolically harmful.

    I wanted to expand on the example of your daughter eating ice cream. How would she have reacted to a pile of plain sugar cubes on a plate? If it were me as a child, I might have eaten one or two and then lost interest, despite the fact that I would happily wolf down hundreds of calories of ice cream. The point is that the ice cream is a reward/palatability superstimulus because it combines sugar, fat, calorie density, a pleasant flavor, and a pleasant physical sensation. This nexus of palatability/reward factors, often but not always including sugar, characterizes all hyperpalatable foods. Sugar is a big one, but it doesn’t act alone. I’ve tried fat-free ice cream and it doesn’t do it for me.

    (reply)
    • Peter Attia  May 28, 2013

      Stephan, this is a great point. I think “mode of delivery” really matters. Lumps of sugar…maybe not so palatable. Though, I suspect a big cup of a sugar beverage — pure liquid HFCS — would have been gulped down without regard for actual satiation in the case of my daughter. Personally, as we’ve discussed, the combination that seems to override my ability to control myself is: salt + n-6 PUFA + “roasting” + some sweetness. This combination makes salted, roasted cashews a personal heroin. As you know, I have literally consumed an entire Costco tub (nearly 7,000 kcal) in one sitting. And felt sick doing it! To really put a nuance on this topic, different people seem to have different “heroins.” I know many people who could not care less for nuts, but for me… (the other thing I can’t get enough of, by the way, is dill pickles and olives). Clearly salt is an issue for me. But nothing compares to the cashews, and I believe it’s their sweetness combined with saltiness.

    • lorraine  May 28, 2013

      So glad that Stephan chimed in here. I’ve often wondered if the palatability superstimulus, as he describes it, in the combination of sugar + fat blows out dopamine and drives craving in a similar manner as ecstasy on serotonin.

    • David Nelsen  May 29, 2013

      Peter, I’m with you on the Costco tub of Cashews. I could eat them all day. Of course, I could eat a box of Vanilla wafers as well, so I just don’t let them in the house. The personal space I’m in is that I strive to eat LCHF but have occasional lapses in judgment (or temptation by sweets). I think I fall prey to boredom as much as anything at times. Sugary foods definitely have a heroin like effect, although the withdrawal probably isn’t as strong. I do get what I call Sugar headaches when I stop eating it. Cheers, Dave

    • Peter Attia  May 29, 2013

      Damn cashews…

    • Stephan Guyenet  May 29, 2013

      Interesting thoughts Peter. I also find that salted nuts go down much easier than unsalted nuts. I only keep unsalted nuts in the house now, because I’ll stop eating them when I’m full. For the same reason, I keep roasted cocoa nibs in the house but not chocolate.

      Also, I wanted to add that although sugar isn’t the only palatability factor, it is a big one, and very deeply ingrained in the reward/hedonic circuitry. Infants (human and rodent) respond to sugar with stereotypical expressions of pleasure. We are deeply hard-wired to like sugar from birth, and there seems to be brain circuitry specifically dedicated to sugar seeking, as opposed to some other pleasurable things that we have to learn to like over time.

      My view is that sugar seeking probably performed a valuable function in the ancestral environment and therefore was strongly selected. Sweetness was associated with fruit, and less frequently, honey. Sweet fruit is usually non-toxic and nutritious, but has a relatively low calorie density so it’s intrinsically hard to overeat. The problem is that today, we add concentrated sugar to all sorts of other foods that have properties that would not be associated with sweetness in the wild. We refine and concentrate sugar, then add it to starch and fat, or drink it as a beverage. This takes the brake off consumption because you skirt around the qualities of fruit that intrinsically limit consumption (fiber, low kcal density, moderate palatability).

    • Peter Attia  May 29, 2013

      Stephan, thanks for weighing in again. This makes a lot of sense, and I’m sure most folks can at least personally related to what you are describing.

    • Donna L.  May 30, 2013

      When I was a young girl and even one not so young, I would eat just plain sugar cubes. I didn’t stop at one or two. I ate more. I also ate spoonfuls of sugar if there were no cubes. I did at times combine shortening with sugar (sort of like lard frosting). While some children would back away from sugar in pure form after a few cubes , not all would. Palatability only answers the question for some not all. And you may not believe that I actually didn’t like the taste after the first cube or teaspoon but continued to eat until I felt a ping and not from feeling sick
      Why did I consume vast amounts of sugar this way (in addition to what is present in foods), I don’t know. I have read and thought about, worked on the whys for a very long time. My obsession with sugar began as a toddler. No one in my family ate sugar like I did. Sweets were present always but not in huge amounts. I am the odd one in my family with a need that feels like an addiction. After many years, I have come to the conclusion that there is a biochemical drive that was present at a very young age. Not an emotional one as so many have tried to make it into. Recently I read where a woman traced her sweets problem back to eating a cookie when she was young and her parents were divorcing. I have a hard time with the idea that a five year old can make the connection .
      This post is excellent. Gave me some things to think about. Thanks for taking the time to write it.

    • Peter Attia  May 31, 2013

      Thanks so much, Donna, for your input. Sure makes me wonder about individual variation on this specific variation. I know, personally, I found pure sugar very UN-appetizing, but really loved it in liquid form.

    • George @ the High Fat Hep C Diet  June 2, 2013

      Sugar may not act alone, but it doesn’t need much help from other macronutrients in the case of sodas. A bit of citric acid, CO2 and a pleasant flavour (with the appropriate colour) are usually enough. Could you do this with fat? I can’t think of any commercial examples other than dark chocolate, which is an acquired adult taste.

    • KimBoo York  June 26, 2013

      Just piping up in response to Stephen that while my personal kryptonite these days is any form of ice cream, as a girl I, like Donna above, could and did eat whole bowls of sugar cubes. Even now I kind of get a pleasurable chill up my spine remembering how they melted in my mouth. I’d make myself sick eating them…and then continue on.

      Great article, Peter. Thank you so much for this lucid and informative approach to a subject that seems to bring out the knee-jerk armchair nutritionist in everyone I know. ;)

    • Peter Attia  June 26, 2013

      Thanks very much, KimBoo. Glad it was helpful.

    • Walter Bushell  July 28, 2013

      Remember with cola beverages they include salt, caffeine and acid flavors to offset the sugar so it doesn’t taste especially sweet, and hops to beer to kill the sweet taste. And some fruit flavored sodas contain brominated vegetable oil. Even Whole Foods, (to give the Devil his due) uses unbrominated flour a small improvement in for example, a cinnamon sticky bun.

  7. Mark  May 28, 2013

    Very well done. Pro and Anti-sugar people should be happy, and that’s no easy task ;)

    (reply)
    • Peter Attia  May 28, 2013

      Or both pretty upset. Probably an easier task.

  8. Tom Welsh  May 28, 2013

    Great article, Peter – thanks! I really appreciate the time you put into writing it, in view of your hectic schedule. (Which is also due to the work you are doing on behalf of all us human beings – so thanks again!)

    A couple of items of feedback. I have never used any Tylenol – whether because I am British and live in England, or because I have a strong aversion to using any drugs (except caffeine and alcohol) unless it’s absolutely necessary.

    Also, if sugar really is addictive, I wonder how come I (and many others) gradually reduced sugar consumption over the years? When I was a teenager, I remember putting 4-5 teaspoonfuls of sugar into a cup of tea! For the past 30 years, the sweetness of the milk I add has been quite enough.

    Incidentally, if you can spare a few minutes to look it over, I would like to know your opinion of this article:
    http://www.spectator.co.uk/features/3212846/withdrawal-from-heroin-is-a-trivial-matter/

    I have read and thoroughly enjoyed many of Dr “Theodore Dalrymple”‘s articles and books, and I understand that he is a trained and experienced doctor of medicine. His statements about drug addiction and the relative ease of withdrawal seem plausible, but I don’t know enough to judge their correctness or otherwise.

    http://en.wikipedia.org/wiki/Theodore_Dalrymple

    (reply)
    • Peter Attia  May 29, 2013

      Not sure, Tom. I can’t speak to Dalrymple’s thesis. A bit out of my scope.

    • George @ the High Fat Hep C Diet  June 2, 2013

      He is quite right. No-one was ever killed by a psychotic episode either. No-one was ever killed by lots of things that doctors like to treat, and that patients want treated.

    • George @ the High Fat Hep C Diet  June 2, 2013

      Now that I’ve read the entire piece, Dalrymple is demented. I certainly wouldn’t trust him with my own care, as he would be perfectly capable of explaining away any pain or dysfunction I suffered as delusional. I’d be OK as long as I didn’t die.

      The only research he cherry picks from the entire field is some tests done on prisoners by one researcher in the 1930s. I’m sure that was fun for all concerned. Opioid withdrawal is manageable if you go to considerable effort, use a high-fat, allergen avoiding diet, and take the right supplements (and Ibogaine, better still), and addicts should never be discouraged from doing it, but with sadists like this around, no wonder most junkies relapse.

    • PhilT  June 23, 2013

      It’s known as Paracetamol in the UK Tom, as Wikipedia’s entry for Tylenol says :-

      ” it is commonly known elsewhere in the world by its international nonproprietary name, paracetamol. Like the words “acetaminophen” and “paracetamol”, the brand name “tylenol” is derived from the chemical name for the compound, N-acetyl-para-aminophenol (APAP)”

  9. lorraine  May 28, 2013

    Cluster, indeed. You’ve made very good sense, as always, of the current state of the art. I have to add my ‘heck yeah’ to the other observations here, both in myself and others, that a sugar fix seems to over ride all common sense and body feedback on food intake. Not only in the moment of indulgence but in the days following, my normal routine of what/how much/when, which is successful in making me not think of food much, is completely disrupted by my brain poking me with a desire for “something”. It’s also good to see the accumulating acknowledgment in the literature of the relationships among sugar, uric acid and metabolic syndrome. I know of two diabetics recently who’ve had gout attacks for the first time and each of their physicians went the low protein route. We needed to send them back to their doctors with research papers on gout and MetSyn.

    What an adorable photo of your family. Looking forward to your TED talk. Saw the mini-preview. It was pretty moving.

    (reply)
    • Peter Attia  May 28, 2013

      Thanks, Lorraine. I think the talk will go up on the TEDMED site June 5 or 6, I’m told.

  10. Surena  May 28, 2013

    Dr. Attia,

    I can relate to those “moments of pure bliss”. After chiropractic school, I decided to go to medical school (currently in my 4th year) and the hospital can be a frustrating place when I can’t give all of the advice I would like to. On a daily basis, I think back to your speech when you gave the example of “catching the eggs before they hit the ground and instead punching the guy who is throwing the eggs” and it makes me laugh every time. But, on the weekends when I see my few patients (as a chiropractor) and I watch the lightbulbs go off and I get to watch their progress unfold, it’s all worth it. That’s what I live for…and hopefully I can experience more of those moments after finishing school. It’s to help those patients in the hospital that need someone to guide them.

    Thank you for posting this. The idea of having a ‘threshold’ has always intrigued me. For example, a group of children will get exposed to Strep; some of them won’t be affected, some will get better with or without treatment, some will develop P.A.N.S. In the last group, did they have something predisposing them to having a lower threshold causing them to react differently to the bacteria causing other symptoms? That’s obviously just one simplified example but it’s an interesting concept.

    Thank you for your work; this blog definitely inspires me when I’m at the hospital.

    Surena

    (reply)
    • Peter Attia  May 29, 2013

      Surena, thanks so much for sharing your experience and story. Very exciting path you’re on. Glad to be a part of your journey.

  11. Mel Ona  May 29, 2013

    Wow, Peter, just another brilliantly-written, riveting post! I’ve been re-educating myself through your blog (…after 14 years of ‘formal’ academic/medical training, I–and likely many health care providers–still have so much to (un)learn…). I’ve thoroughly enjoyed every word. Keep it up and thanks for sharing your “bliss” moments with the world!

    (reply)
    • Peter Attia  May 29, 2013

      Thanks so much, Mel. Glad it’s helpful.

  12. Ben  May 29, 2013

    My personal “heroin” is white chocolate from Choceur with coconut crunchy bits .. super palatable hyper even..
    This is the main point with sugar, it is added to everything to make the item addictive, and it works.. same with salt..

    SO the toxic issue is now that we know it has this effect, should there be legislation to regulate it, like cigarettes we know the harm, it is not going to happen on its own as the victim is willing and the producer is mendacious. A higher power will need to be invoked to limit the damage. ( I do not mean the Almighty )

    (reply)
    • Peter Attia  May 29, 2013

      I guess the questions I’d ask before I could contemplate this is:
      1. How much more scientific work would need to be done to be as clear as possible on the effects?
      2. What is the best model for regulation improving a similar problem?

    • Colleen  May 29, 2013

      I am totally against the nanny-state solutions to sugar. Vote sugar out of school lunches or food stamps or stop sugar subsidies? Sure. Regulate “sugar” ala Bloomberg or the like? No. Let’s get the science, educate people, and then they can make their choice. The post is telling us you can figure out on your own if your level of sugar consumption is affecting you and act. Look at the great record of the last 30 years and often continued demonization of cholesterol or saturated fat. Think those regulators are always going to get it right? I’m sure many would have regulated butter or cream or eggs under the guise of preventing heart disease Likewise, my Grandfather (born 1910) always spoke about his father and the knowledge that smoking was bad for your health and the $100 he received for not smoking as a youth. This was not a mystery before the surgeon general’s announcement.

    • Walter Bushell  May 30, 2013

      Salt is self limiting. This limit can be overcome by adding sugar and sugar can be added by adding salt. In any event the anti salt campaign is likely to do far more harm than good as people will continue to eat processed food with much added salt and skimp on the iodized salt added at the table. (Not even bringing up the recommended level of salt being less than optimal for health.)

  13. steve  May 29, 2013

    The Tylenol example was very enlightening and made me think that perhaps being in nutritional ketosis for to long a period(years ?) might also not be so great for the liver. After all certain cells can use glucose only such as some of the cells in the brain, the red blood cells, cells in the kidney and retina. All these cells from what I understand use about 120G-150G of glucose a day. So, if there is a need for glucose, maybe eating some means less work for the liver, and maybe that is a good thing if the source of the glucose comes from fruit and maybe some glucose starch.
    Thanks for your great work

    (reply)
    • Peter Attia  May 29, 2013

      I don’t know…the amount of glucose needed by the RBC and kidney is very small, easily supplied the liver even when in the strictest ketosis. The brain, of course, does very well on ketones. Maybe even better than glucose. But this is getting away from the point…

    • George @ the High Fat Hep C Diet  June 2, 2013

      The trans-sulfuration pathway is upregulated when carbohydrate is restricted, this is what supplies glutathione, which detoxifies tylenol. On the other hand, glucose-6-phosphate is needed to reduce (recycle) this glutathione.
      The liver can do lots of things and it’s always making glucose. Most people need less Tylenol on a low-carb diet, we have to factor that in too. NAC is the antidote to Tylenol (called Parvolex in emergency wards, sometimes reduced glutathione is used), and is usually effective if given quickly enough, and for long enough.
      This (I am assuming its use is standard practice in the US) would surely influence the human toxicity stats; unless these numbers only represented cases where patients waited too long, or were denied proper care.

  14. Ash Simmonds  May 29, 2013

    I once brainfarted around with the idea that if you put together an LD50 list of foods/macronutrients/etc sorted from most benign you’d probably come close to a reasonably perfect diet, dunno.

    As to the “always room for dessert” issue, it is of course most likely ghrelin we’re talking about, it’s a completely different kind of desire – it’s certainly not hunger. Plenty of times now I’ve done self-tests where I overeat fat (like eating 300+ grams of pure fat from a pork belly) and there comes a very specific point where:

    a) you no longer feel like eating – the palatability of the previously delicious meal in front of you is suddenly gone
    b) in only 2-3 forkfuls of fat later, the mere sight of the food actually makes you nauseous

    At this point just the thought of cutting off another piece of fat almost makes me dry heave, but then the idea of having some chocolate is just fine.

    They touch on this here: http://www.psychologytoday.com/blog/cravings/200805/why-theres-always-room-dessert

    (reply)
    • Peter Attia  May 29, 2013

      Interesting point, Ash. Whether ghrelin, or some parasympathetic (i.e., vagal) signal, or even something purely in the CNS, is a hotly debated topic. I know Stephan Guyenet and others have been working on this. It would not surprise me if there existed redundancy in the system (unfortunately).

    • Walter Bushell  May 30, 2013

      Not that simple. Vitamins A and D for example are mutually protective of high doses of the other. I think K2 factors in there too along with calcium, IIUC K2 helps send calcium to where it is needed and removes it from where it is not needed.

      This happens all over the nutrient spectrum, so LD50 are not a valid approach.

      And then there is individual variation. Starch is fairly toxic in fairly low doses by SAD standards for many people particularly when they are not exercising.

      Oh Baby! Nutrition is hard, if you approach it from a nutrient viewpoint.

  15. Julia  May 29, 2013

    Another great article, Peter! I’ve been so inspired by your blog since i discovered it a few weeks ago and you succeeded in motivating me to cut out grains and (my own home-made) baked goods from my diet. It’s only been a week, but I’m down to <150gm a day of carbs and I feel so AWAKE every day. I've struggled with daytime sleepiness since i was a teenager, and I was recently subjected to an overnight sleep study where they found nothing physically wrong with me but gave me a CPAP machine anyways. the CPAP machine made no difference and I still felt like falling asleep every afternoon, so I gave it up and gave up on the medical community. But now, a week into low-carb, I feel like I could take on the world. So I could personally argue that 25+ years of unnecessary sugar did affect my lifestyle quite negatively, although not enough to be the direct cause of my death – unless falling asleep at the wheel counts.

    (reply)
    • Peter Attia  May 29, 2013

      Julia, last line = priceless (if not for the fact that it’s not entirely a joke). So glad to hear about your success.

  16. Liv  May 29, 2013

    Great blog post

    (reply)
  17. Stephan Guyenet  May 29, 2013

    PS:

    The reason the word “toxic” bothers me, as applied to sugar, isn’t a question of accuracy. As you explained, refined sugar may well be toxic in some people at some doses, in the sense that it causes some sort of harm. The thing that bothers me about the word toxic is that it’s an emotionally provocative, sensationalist term in this context. Why not just call sugar “harmful” or “unhealthy”? The word “toxic” evokes hemlock and cyanide in most peoples’ minds, even if technically it can be applied to sugar. It’s a calculated use of language to maximize impact by engaging the emotions.

    (reply)
    • Peter Attia  May 29, 2013

      Fair point. My use of the term was based on the rhetoric that seems to be floating around without a clear explanation of what “toxic” means, which is what bothers me. This is why I like the idea (admittedly a bit simple) of the LD50 and the point about Tylenol. Yes, it can be toxic (acute or chronic), but it’s dependent on dose and host susceptibility. But I agree with the point you’re making. I think most people don’t bring the level of understanding to the problem that you might, though.

    • Maximillion Cornelius Vanderhoff  May 30, 2013

      > The reason the word “toxic” bothers me, as applied to sugar, isn’t a question of accuracy.

      So then, would it be accurate to say that it’s more important to you for terminology to be unmoving than it is for it to be accurate?

      > As you explained, refined sugar may well be toxic in some people at some doses, in the sense that it causes some sort of harm.

      If it may well be toxic in the sense that it causes some sort of harm, then why would you object to the use of a term that may have a motivational impact?

      > The thing that bothers me about the word toxic is that it’s an emotionally provocative, sensationalist term in this context.

      Have you considered the possibility that there are individuals that are not at all emotionally impacted by the term?

      > Why not just call sugar “harmful” or “unhealthy”?

      What would you say to people who consider “harmful” and “unhealthy” wildly outrageous characterizations and who would instead prefer the usage of “nonnutritive?”

      > The word “toxic” evokes hemlock and cyanide in most peoples’ minds, even if technically it can be applied to sugar.

      How did you make the determination of what the term evokes in other people’s minds?

      > It’s a calculated use of language to maximize impact by engaging the emotions.

      What if it’s a calculated use of language to *minimize* impact being that the word “lethal” was not chosen?

    • Walter Bushell  May 30, 2013

      Unfortunaterly strong language is necessary to get people’s attention. Of course, if you’re Dr. Lustig and dealing with a procession of morbidly obese children; it’s not rhetorical at all.

  18. dRAwkward  May 29, 2013

    How do you find time to have ice cream with your kid when you are working 100 hours a week and flying 15000 miles a month?

    (reply)
    • Peter Attia  May 29, 2013

      I make the time. Highest priority.

  19. Michele  May 29, 2013

    Peter, I can’t thank you enough – enough and them some to negate the negative feedback you sometimes get – for yet another article that encourages me to think for myself and change the sometimes “black and white” way I feel about nutrition in the United States. It’s a bone of contention between my family and myself which can bring out the shouting and screaming you mentioned above. It’s hard for me not to feel extremist about this stuff. Your post and the comments of others (i.e. the “junkie effect” of ice cream) relativized a lot for me.

    In the meantime, I dropped the ball on the cholesterol series because I was just feeling mentally lazy. I will promise myself to get back to that and read it. Thank you.

    As for the little powerpoint – Carbohydrate Intolerance – I once sent you for a check, it is getting previewed or downloaded weekly and this makes me feel I’m making a little difference. Thank you again.

    Thank you thank you thank you a gazillion bazillion times!

    (reply)
    • Peter Attia  May 29, 2013

      Wonderful to hear, Michele.

  20. Cindy  May 29, 2013

    Finally! A clear explanation about sugar detailing the science and applying some logic (as well as common sense). I can attest to the acute toxicity of sugar myself. In my 20s my vision suddenly changed. Rather than assume it was genetic ( a few of my siblings wore glasses) it was my ophthalmologist that suggested I quit eating sugar. He was right! My vision returned to normal within a month. Anyone familiar with diabetes would attest to the affect of blood glucose on the lens of the eye.
    I’m now interested in both the acute and chronic ‘toxicity’ of sugar in oncology. Should I advise our patients with rapidly growing tumors to abstain from all sugars? Can I advise their families to remove sugar from the diet as a preventative measure?
    I would really like to see you address these 2 questions with an equally insightful blog.
    By the way – I think (hope) you might have finally taken the sting out of the word ‘toxic!’

    (reply)
    • Peter Attia  May 29, 2013

      Interesting, presumably you were diabetic at the time (even if not formally diagnosed)? This is a not uncommon presentation for people with T2D. Fortunately, it is usually reversible if caught early enough and addressed immediately.

  21. Luc  May 29, 2013

    I might be in a good position to contribute to this discussion. I stopped eating added sugar on March 01, 2010. Not for medical reason, just to gain control over my life. So I became my own experiment. I only went low carbs on November 01, 2011, so spent 20 months with only sugar reduction. In the fall of 2011, I realized I was no longer getting sick. A cold would be half a day of very slight sore throat, and a flu would be aches and slight chill for two days. I have 3 young children, so in the winter one of those hits the house every 3 weeks. My wife would still feel the full impacts of those infections. My only sources of sugar were vegetables, fruits and dairy products. I would still drink an occasional diet soft drink or chew sugar free gum.

    On a side note, researching the reason for this effect, is how I discovered Gary Taubes in October 2011. 130 lbs lighter by the summer of 2012 and running triathlons.

    In the last few months, around the 3 years mark, a very strong transformation has happened. This from someone who was obviously highly resistant to insulin, although not yet diabetic. Someone who love sweet to the point of skipping a meal to get to desert faster.

    - I no longer have any craving for sweet food.
    - I can no longer drink diet sodas or chew sugar free gum – too sweet.
    - I can no longer eat fruits – also too sweet.
    - The smell of something sweet cooking, actually makes me slightly nauseous.
    - My immune system is still much stronger than it used to be (Did not see any more changes after I went Low carbs).

    I eat a lot of vegetables, and no problems with those, although I really taste the sugar in onions and sweet peppers. I always loved fruits, but am quite happy to let them go, if it means no more addiction or craving.

    Is sugar toxic? If my immune system received a major boost to fight viruses and bacteria, what chance would it have had to fight something like cancer.

    So in my case, yes, sugar is very toxic.

    (reply)
    • Peter Attia  May 29, 2013

      Thanks for sharing your story, Luc.

  22. David  May 29, 2013

    When I saw that you had a new blog post, I was hoping that you would be addressing the red meat/ TMAO study that was recently publicized (here, for example, http://www.nytimes.com/2013/04/08/health/study-points-to-new-culprit-in-heart-disease.html?pagewanted=all).

    Have you looked into this at all? Any comments?

    (reply)
    • Peter Attia  May 29, 2013

      David, see EA FB page. I posted 2 links to very good assessments of these papers, one by Chris Kresser, the other by Chris Masterjohn. NY Times, unfortunately, not so thoughtful on this topic.

    • David  May 29, 2013

      Facebook! So that’s where you’ve been hiding! :)

  23. Read  May 29, 2013

    Much of what I have read on this subject is confusing and contradictory. This article is one of the few I have read that is frank and well-reasoned. It troubles me when science is hijacked for whatever reason and it appears to me that the sugar industry has corrupted the field. In any event, I doubt the average person can sort through the debate on sugar even if they have the time to learn the biochemistry.

    I prefer any argument that can be put to the test and that is what you suggest. Use your body as a laboratory and find out if ingesting sugar/carbs makes any difference. It sure did in my case.

    Thanks for a beautiful piece. I look forward to the rest of it.

    (reply)
    • Peter Attia  May 29, 2013

      Read, I’m glad this was helpful. Though I didn’t go into it in this post, there are a lot of experiments out there that need doing which can shed much more light on this topic and resolve much of the ambiguity.

  24. Kelley  May 29, 2013

    Thanks for another wonderful post, Peter. Just some anecdotal (n=1) observations. Like your wife, I don’t seem to be especially carb-sensitive. I used to always have a sweet tooth. Then, about 15 years ago, at age 33, I put on about 12 pounds in about three months. At first I panicked–clothes didn’t fit; for the first time ever I wasn’t “Hollywood thin,” etc. But then I realized that I felt better overall. Whereas before I would get headaches that lasted for days, those had disappeared, my mood swings disappeared, and my sweet tooth was greatly reduced. (I was eating more food of all kinds in general, not more sweets.) Bottom line: before, I literally wasn’t eating enough to support my metabolism. I felt better at 145 pounds than at 132 pounds. I came to believe that, for some people, thinner doesn’t necessarily equal better health. Also, my sweet tooth has proven to be about habituation. Before I got involved with my now husband, I was a fairly accomplished baker. But he’s a lifelong diabetic (type-1, diagnosed at age four). He didn’t care about my skills as a pastry chef. I stopped keeping sweets around, and, over time, my sweet tooth kind of faded. Now most times, I’d rather have a few extra bites of dinner than “save room” for dessert. Don’t get me wrong: if sweets are around I will probably indulge–one of my favorite things about Thanksgiving weekend is pie for breakfast on Friday morning. But I don’t feel compelled to seek sweets out or to buy them when I’m shopping, etc. Plus, when I eat something sweet for breakfast, I don’t feel great for the rest of the day, so I only do so very rarely, and I’ve learned to throw away “special-occasion” sweets after a couple of days. It has taken time (like everything, right?). But, in my case, the sweet tooth faded once it wasn’t being indulged.

    (reply)
  25. Roger Johnson  May 29, 2013

    Thank you for another great post. I get so tired of the masses of uneducated and unqualified who espouse the use of a certain supplement to rid the body of “toxins” or who are antagonistic towards certain foods because they are “toxic” to the body. Undoubtedly some of these claims are true, but even a blind squirrel find a nut occasionally. Your thorough, reasoned approach and sound science are a rare commodity these days. Even better, I like how you break down the prognosis for certain segments of population. Rarely does one size fit all and the medical community is way behind the times on this point.

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    • Peter Attia  May 29, 2013

      Roger, glad this framework was helpful.

  26. John  May 29, 2013

    Peter, great corelation and what a beautiful family you have.

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  27. Nan  May 29, 2013

    If I intellectually don’t want sugar, yet can’t seem to keep away from it if ever I once start, then the answer for me is a resounding “yes!” That, and the fact that I feel so horrible after having any, then yes again, it must be toxic for this body.

    (reply)
    • Peter Attia  May 29, 2013

      You’ve got to figure out what works for you. Sounds like you’re well on that path.

  28. Eric U.  May 29, 2013

    OK, this is asking for rampant speculation, but…what do you think the effect would be of switching from HFCS/sucrose to glucose as a sweetener, across the board? It’s still not likely to be a great thing to eat huge amounts of. However, there have been societies that ate lots of high-GI starches but had far lower diebetes, obesity, etc., than we do, and there’s little chemical difference there. As a straight substitution you’d use more of it to get the equivalent sweetness, but if it really is more satiating, perhaps not all that much more.

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    • Peter Attia  May 29, 2013

      For starters, glucose isn’t really that sweet, so there are at least 2 variables that are changing, one in the brain, and the other in the body, based on site of metabolism. Look at the work of Kimber Stanhope, who has done this experiment. There does indeed appear to be a significant difference, at least at the doses she looked at.

    • Eric U.  May 30, 2013

      Thanks for the pointer to Kimber Stanhope! For others who are interested, here are a few links to relevant papers:

      Consumption of Fructose and High Fructose Corn Syrup Increase Postprandial Triglycerides, LDL-Cholesterol, and Apolipoprotein-B in Young Men and Women http://jcem.endojournals.org/content/early/2011/08/11/jc.2011-1251

      Consuming fructose-sweetened, not glucose-sweetened, beverages increases visceral adiposity and lipids and decreases insulin sensitivity in overweight/obese humans http://www.jci.org/articles/view/37385 with easy-to-read translation at http://www.ucdmc.ucdavis.edu/ctsc/documents/CTSCNewsletter_Spring_2012.pdf which also talks about a subsequent study.

    • Peter Attia  May 30, 2013

      I know Kimber personally, and she’s done some very good work on this topic. More to come from her, too.

    • Eric U.  June 3, 2013

      An anecdote from a friend who tried swapping in glucose for sucrose: he found that it worked great for homemade jam, which he usually finds too sweet anyway. However, for dessert-type things, they just never seemed sweet enough for him, no matter how much glucose he added. So it might not work for everyone, but given how little sugar I eat, I may try it for occasional treats. Or I might try glucose + some high-intensity noncaloric sweetener.

  29. Christine Germain  May 30, 2013

    Thanks for a great article! I have been in ketosis for the past two years and it feels really great. I have a brain tumor that has totally been shrinking. I wanted to know if you knew anything about the psychological aspects of sugar. I like you have children and while I do try to limit their sugar intake it is impossible to try and eliminate it. So I know of all of the physical aspects of sugar consumption but what about what it does to the mind. How my child’s behavior will change from eating some fructose, in terms of some fruit. It’s interesting but his sense of his limitations totally changes and he becomes down right naughty. Might it have to do something with the gut-brain connection?

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    • Peter Attia  May 30, 2013

      Christine, this seems (purely based on experience, as I’m not familiar with this literature) highly variable by individual. For what it’s worth (probably not much…), even when my daughter gorges on sugar, she’s still behaviorally fine. Conversely, I have friends who report the opposite with their children. So I suspect it’s more complex than a binary issue.

    • James  May 30, 2013

      Prepare a reserve of pemmican and eat that during your trips :)

    • Dave Nelsen  May 31, 2013

      I have 4 daughters and 1 son. All of my daughters can eat as much sugar as they want and have no effects. My son on the other hand used to have severe behavioral issues when he ate too much sugar. When I used to drink Coca Cola I would be ok for a week or so then get massive headaches. It wasn’t always this way but seemed to get worse as I got older. I’ve never heard of meat headaches, so I’m not worried about too much fat or protein.

      Cheers,
      Dave

    • Surena  June 2, 2013

      Christine, I have a background in functional neurology and functional medicine and although the gut-brain connection plays a role, that’s only 1 piece to the puzzle. I work with children with neurobehavioral disorders and in my experience, they not only have a reduced level of cognitive, motor, and sensory abilities, but also a reduced level of autonomic and immune regulation abilities. Coincidence? Absolutely not. The desynchronization and ineffective interhemispheric communication (ability for the right and left hemispheres of the brain to communicate) is the bigger picture that explains all of the abnormalities. For instance, a child with an underactive right hemisphere of the brain may present with social deficits since the right side of the brain is primarily responsible for the development of social skills but that child may also present with decreased gut motility, decreased barrier functions, increased heart rate, decreased insulin sensitivity, and increased insulin surges, etc. The right hemisphere of the brain plays a role in all of those functions, too. Of course it’s more complicated than that but it’s important to understand the influence the brain has on our body.

      Give 5 children the same amount of fructose, and you can get 5 very different responses. Apart of that reason is the gut-brain connection as you mentioned…how effective the gut is in processing the fructose. However, if the brain has some type of deficit, (even if it’s not major enough to have the traditional symptoms of a child with a neurobehavioral disorder) it can influence the gut, insulin sensitivity, etc. (all the things mentioned above). We all have a threshold…give anybody enough sugar and they will react to it in some way. The question is: how can we heighten that threshold so that we aren’t as easily affected by sugar or any other substance for that matter? (That’s my personal goal to figure that out).

    • Ali  July 12, 2013

      Hi Chris (it’s Ali from Bee’s group). I have thought long and hard about this one. My grandsons both turn into Tasmanian Devils if they get too much sugar.

      Every food in nature comes packaged with a complete array of nutritional elements. Not only do they distinguish the foods from each other, but they also provide elements that help the body digest the food, and support the body in general. Processed sugar is lacking these elements. It has nothing in it to tell the body what to do with it. That I believe is where the toxicity lies. Because the body then has to call on its own resources to try to process it, that means those elements are diverted from other important processes, including neurological.

      So, that may be the case with sugar but if fruit comes with an array of nutritional elements, why would that affect your son? There are many factors that unbalance the ecology of the gut. Even one course of antibiotics can apparently deplete 50% or more of the gut flora. High sugars in general can change gut flora favouring yeasts over other more beneficial microbes. Eventually it may get to the point where it just becomes one huge fermentation tank! The fermentation process involving sugars produces alcohol.

      Is your son’s – and my grandson’s reaction, whether fruit or processed sugar just a response to a form of intoxication?

      When I was riddled with Candida, because it triggered constant fermentation in the food I ate, my body could not process alcohol at all (and I do wonder if this phenomenon could well explain the existence of NAFLD – as my body readjusted and the Candida went away I had several weeks of my liver clearing out debris and very probably fat globules!). I avoided it for years. Now, after being relatively low carb for over 5 years I can consume a little without any problem (i’m not a lover of alcohol anyway).

  30. steve  May 30, 2013

    Hi Peter,
    This is one of the best blog posts I’ve read about sugar. Thanks for putting this together.

    Slightly off topic, with all the traveling you do, do you have any advice on how you maintain a decent diet? I often travel for work and wonder off the reservation with my diet. Apart from all the sugar lots of restaurants put in their dishes and salad dressings, I also have trouble finding real cream for coffee, getting enough saturated (as opposed to polysaturated) fats, etc. How do you do it with all the traveling you do?

    (reply)
    • Peter Attia  May 30, 2013

      It’s not as tough as it used to be now that I’m learning the tricks, but maybe worth a blog post at some point.

  31. Cecilia af Jochnick  May 30, 2013

    Thanks – what you write confirm my observational findings. I am heaviy overweight but claim not to be sensitive to sugar (I am fat on “cream and butter”) which always gets me into a lot of arguments with the LCHF people who refuses to believe my experience. Candy and chocolate do not trigger my cravings – I do binge on icecream but more on salty, fat foods. I am diagnosed with BED but it is not sugar that is my downfall. You put that discussion in perspective for me, thanks again (and I am swedish, hence the maybe weird language)

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  32. James  May 30, 2013

    I have 2 kids: 3.5 y.o. and barely 2.y.o. My youngest never experienced added sucrose in anything and she is very fond of meaty stuff (she might actually be addicted to salty food – but we only eat so-called “primal” foods). My oldest kid had experienced added sucrose at times before we removed most processed foods from our eating habits. Even though he has not had extra sucrose (i.e. added in foods) for a long time, he still talks about it. I explain to him that even if it tastes good in the mouth, it is not necessarily good in the belly. It seems to sink in. When grand-ma forgets that we don’t eat sweetened stuff and proposes something with added sucrose, he refuses it. I am not naive enough to think it will last but my kids won’t get it at home as long as they live with me. I do use xylitol once in a while when I bake for them, which seems to be non-addictive.

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  33. Bill Vincent  May 30, 2013

    Peter, you are spot-on with your blog, as I have come to expect. Coming from the world of pharmacy and chemistry, I often say that everything is toxic. Every drug is a potential toxin. The only question should be: “How toxic is the drug (or chemical compound) and under what conditions?”

    At first glance that might seem to undermine the meaning of the word “toxic,” but I don’t believe so. People in the US are told this is safe and that is unsafe, when there is always a degree of danger associated with everything. Toxic is not a black and white term. Some toxins have a large dosage range that will make you sick long before it kills you. With others, a small error in dosage is enough to kill. Some people will have a sensitivity to a drug that other people do not. Some toxins are eliminated quickly and others slowly. These are the nuances that the average person fails to grasp when the term “toxic” is used.

    Kings and other VIPs during the middle ages took small doses of arsenic, in increasing amounts, to build up their tolerance to arsenic. Indeed it worked, or at least until they increased their dosage one time too many and exceeded their absolutely lethal threshold. So our bodies can be quite forgiving of toxins under the right circumstances.

    I understand Robert Lustig’s reasons for declaring sugar toxic, but his usage comes across as extreme and exaggerated. His argument is soundly based upon the metabolic pathway, and as you so eloquently argue, much like the toxicity of Tylenol. Yes, both are toxic, but people will have varying degrees of response to the toxic effects of each chemical.

    So the problem with sugar is that:
    A) it is toxic to many people (but probably not everyone),
    B) the dosage for toxicity varies greatly, and
    C) the toxicity can be manifested in a number of ways with a multitude of symptoms, most of which are not obvious to people in the short term.

    Until we can find a way to quantitate an individual patient’s toxicity to sugar, and provide them with a dosage threshold, the term toxic is meaningless to them.

    People who know I have been in pharmaceutical research (although not a pharmacist myself) often ask me if some drug they are taking is safe. I give them both a yes and no answer. Every drug is safe, but every drug is toxic. Every drug will show bad reactions for some individuals, even if only rarely. So patients should contact a doctor or pharmacist if they have any misgivings about their reaction to a drug. However, every drug is considered safe, for most people, when taken as directed and in the proper dosage.

    Then real questions for a physician are…
    “What dosage regiment for sugar would you feel comfortable telling people they could follow without being at risk for toxic effects?” and “If there is no generally safe dosage that you could recommend with a clear conscience, should this drug (sugar) be declared toxic and withdrawn from the market?”
    Normally, withdrawal would be the FDA’s reaction to a serious toxic drug response. Viewing sugar in this manner would certainly validate Lustig’s utilization of the term “toxic.”

    Perhaps we should label sugar as a “drug”, before we label it as “toxic”. Referring to sugar as a nutrient is a meaningless argument. It is not an essential nutrient. Some people argue that sugars are essential, since our bodies use them in biological pathways, but we can make what we require and do not need to consume it. Any chemical that is not essential to our diet can just as validly be called a drug instead of a nutrient. Moreover, unlike basic, essential nutrients, sugar stimulates the same brain receptors as opiate drugs.

    I say we begin by referring to sugar as a drug. Then we can judge it by the same criteria as other drugs, including it’s toxic effects, addiction, etc.

    … Bill Vincent

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    • Peter Attia  May 30, 2013

      Bill, very well said. Thanks very much for sharing your experiences and insights with us. You’re obviously much more expert on this topic than I am. I think your idea of “drug” versus “toxin” is very interesting.

  34. Ron Wichin  May 30, 2013

    Another fantastic article. Your blog has increased my understanding of metabolism and physiology exponentially. Hardly a day goes by where I don’t use it in my office with our weight loss patients. I do have a question? I am much like you with my sugar reaction ( my fasting insulin is 10), i have lost 75 pounds on a low carb, adequate protein diet but now I am crossfitting 4-5 times a week and following the wendler 5-3-1 program 2-3 x a week. I fuel my workouts with superstarch (amazing stuff), I want to lose another 10% body fat which would bring me down to 15%. I know my protein and carb numbers per day and plan to fill the rest of my daily calories with fat. My question is can i best alter my body comp by eating total calories at a significant (1000 cal) deficit of my total daily expenidiiture and perhaps impacting athletic performance or by eating at my TDEE and building more muscle and allow the fat percentage to reduce that way.

    (reply)
    • Peter Attia  May 31, 2013

      Ron, I’m a big Wendler guy, too, so I’m glad to hear there is at least one other weight lifting geek out there who is into that nuance. In “theory,” yes the caloric deficit would ideally come from reducing fat to what might be termed a “hypocaloric KD,” thought the semantics can be misleading, because it’s really only referring to exogenous calories. IF might be another technique to experiment with.

  35. larry  May 31, 2013

    Peter,great discussion as usual. My understanding is that Dr. Lustig’s thesis is actually that fructose ( alone or as a component of sucrose) is effectively toxic due to its specific metabolism (which he explains in exquisite detail) . And he acknowledges it’s not acute; rather chronic and dose dependent similar to alchohol. I think he’s been making the toxicity argument to call attention to the problem, not to generate a debate over use of the word toxic.

    (reply)
    • Peter Attia  May 31, 2013

      Correct, Larry. Most of the discussiona round sugar pertains, specifically, so the fructose component and its unique metabolic requirements in the liver (similar to alchol). In fact, I think Rob suggests an “ideal” limit of the total alchol + fructose in a 24 hour period to minimize the effect of chronic toxicity. I suspect this threshold varies for all the reasons I discussed, but I do think there is really something to idea of NOT mixing sugar and alchohol. Simply too much for the liver to process.

  36. Chris  May 31, 2013

    Thank you. I was particularly interested in your observations about your genetic hybrid. I had gestational diabetes with both my sons and I often wonder how this has affected them and what their futures hold. The first time, the diabetes was not controlled [the screening test was high normal] and I had a 12 lb son by c-section. He had uric acid crystals in his urine (but normal blood work) for at least a year. The second time, I controlled with a VLC diet and then insulin, and delivered a very healthy 7.5 lb son. The older boy (now a young adult) is a “fruit bat” – loves sweets and takes a dim view of green vegetables. The younger boy loves savory food and salad. He won’t finish a slice a birthday cake since it’s too sweet. But he does love (full fat) ice cream.

    Life is interesting.

    (reply)
    • Peter Attia  May 31, 2013

      Chris, thanks so much for sharing this experience with everyone. I guess, for you and your family, the most important thing to think about is what you can do now, moving forward (vs. worrying about what you have no control over). I continue to see emerging evidence that what a mother eats and doesn’t eat during pregnancy has a significant impact on the life and metabolism of her child. What I don’t know is if this epigenetic overlay is greater than the genetic component. I suspect the answer is, “it depends…”

    • Ali  July 12, 2013

      This aspect interests me. The old adage used to be ‘eat for two’ when a woman was pregnant, but then the ‘establishment’ decided that was just an old wives tale. Well, believe it or not, the old wives were right.

      As a foetus is forming in the womb, the growth is driven by nutritional elements. If the mother doesn’t have enough of one or a few different elements for the two of them then where would the baby get them from? I think Weston Price adequately illustrated this when he related the ‘pigs and vitamin A’ experiment that he came across. We only need to be deficient in a small amount of any given element and it can have a profound effect on the growing foetus.

      The establishment does understand this in a limited way – they do furnish pregnant women with folic acid to prevent Spina Bifida, and some get extra iron, but that’s about as far as it goes. Maybe what we eat doesn’t affect the baby radically, but perhaps it won’t develop quite as many neurons in the brain, or nephrons in the kidneys. Maybe it may be more vulnerable to a particular health problem in the future. Maybe it won’t process certain elements as well as another person. So much about disease is put down to ‘genetics’, but what if these are familial issues driven more by nutritional deficiencies rather than genetic mutations?

      As Curtis H Wood wrote back in the 1950s, we are overfed but undernourished. There is a glut of nutritionally empty food out there that provides virtually nothing but calories. That isn’t good for us, and it certainly isn’t good for building strong, healthy children.

  37. Jane  May 31, 2013

    Hello Peter an all,

    I am surprised you did not mention the area under the curve of total sugar (and glucose too) consumption in connection with the causation of metabolic syndrome, insulin resistance, carbohydrate intolerance, sugar addiction, carbohydrate addiction, however you want to characterize the problems.
    Many of us are not encountering this problem until later in life and need help with alerting our children to the risks of their chronic exposure to sucrose. I read that Jane Brody article downplaying the sugar risks Taubes mentioned when my kids were little, ans even used her cookbook. The area under the curve of total sugars consumption would be helpful part of an explanation.
    Despite knowing that at least one grandfather who had diabetes requiring insulin, and despite knowing that I had spilled sugar during my second pregnancy (not diabetes though), and despite two of three children who weighed more than 9 pounds at birth, . . . I failed to grasp the risks with enough sense of urgency to try to change my way of eating.
    In retrospect, perhaps I should have been more alert, but understanding the chronic effects seems to have eluded even most physicians, apparently. Certainly none has ever mentioned them to me, despite the gradual onset of the signs of metabolic syndrome — never including obesity or too high tryglycerides, or even waist measurement!
    Now it is not at all clear to me that any of the chronic damage is reversible. It is not even clear that I can get intoketosis, or that I wantto, considering this zone of misery problem!

    Perhaps you could post a graph illustrating an example of lifetime consumption of sugars?

    (reply)
    • Peter Attia  May 31, 2013

      Good point, Jane. I don’t really know the answer, but the AUC might be a helpful model of chronic risk. It is almost certainly the case for most people that aging increases susceptibility to this particular molecule. Is it this the result of something else (i.e., an independent change in insulin sensitivity)? Or a direct result of some change in hepatic processing? Not sure…

  38. Chris  May 31, 2013

    Peter, I started reading your blog about a week ago and find it fascinating. I think my wife is actually starting to get annoyed with me talking about it so much. What initially drew me in is your analytical approach to nutrition. I like to think of it as the moneyball approach to nutrition. I just started trying to eat similarly to how you’ve described and it is going well so far.

    My question though is this; when I start to describe what you eat to people, they usually say make the comparison to Atkins. I don’t actually know much about Atkins though. Can you highlight some of the differences in philosophy between your approach and the Atkins approach?

    (reply)
    • Peter Attia  May 31, 2013

      I’d prefer to let others address. Hopefully someone can jump in.

    • Ash Simmonds  June 1, 2013

      Atkins is all about calling to the appeal for fat loss whilst also being able to indulge our acculturation.

      90+% of the online discussions to do with Atkins/ketogenic are like whining kids going “mummy can I have a cookie?” and struggling with the social eating culture they were raised with, in this way Atkins provides a framework which is essentially a coping mechanism that you can fall back on – a “diet” that is both effective and maintainable in the long run.

      The way to internalise “healthy” eating is to forget about food as an energy source, and remember that it’s really a hormone stimulant/suppressant – what you want to do is minimise the (detrimental) hormonal fluctuations which are at the root of every modern disease.

      All we need is a bit of protein, some trace vitamins/minerals, and energy. The big stupid nutrition war is on where to get the energy, and people will go to enormous lengths to justify getting it from poor sources (which mess with your hormones on the way to becoming energy).

    • Jane  June 1, 2013

      Well, one difference is that Peter started with cutting sugar, then . . Refined flour, then fruit? I do not recall the details that he mentioned. I would describe his approach as working his way down the carb ladder as Westman calls it in the newest edition of the Atkins book, instead of immediately severely restricting carbohydrates to 20 g by eating only protein and low carb vegetables.
      Peter also supplements with lots of fish oil and MCT oil,which are not mentioned by Westman, but not a multivitamin. At least that is what I recall. I also do not recall him mentioning salt requirements or eating broth on a daiy basis.

      My question for Peter is why do you believe that you can get by without vitamin supplements, such as B vitamins, without plant sources? I worry about folate for women of child bearing age, for example,

  39. jw  June 1, 2013

    Is exercise toxic?

    When Exercise Is Too Much of a Good Thing
    http://well.blogs.nytimes.com/2011/03/09/when-exercise-is-too-much-of-a-good-thing/

    None of the younger athletes or the older nonathletes had fibrosis in their hearts. But half of the older lifelong athletes showed some heart muscle scarring. The affected men were, in each case, those who’d trained the longest and hardest. Spending more years exercising strenuously or completing more marathon or ultramarathon races was, in this study, associated with a greater likelihood of heart damage.

    Study: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3119133/

    (reply)
    • Peter Attia  June 1, 2013

      I’m pretty familiar with this literature, and I desperately want to believe it’s wrong! James O’Keefe has been discussing this for a while, and we’ve had a number of discussions about it. In humans most of the data are observational, so we need to be careful not to over-interpret. But the mechanism of action makes sense, as far as atrial stretch and atrial arrhythmia.

  40. Jennifer Elliott  June 1, 2013

    Hi Peter.
    Thank you for the great posts. My own story is as a dietitian whose understanding and approach to nutrition completely changed over 10 years ago because of the personal experience of having a child with quite a severe weight problem. Two of my children as youngsters could eat what they liked and stay lean, whereas my middle daughter always carried weight around the middle. She was less active, more interested in food, didn’t like meals to be delayed and at times could eat quite large amounts of food in a sitting. She gained a lot of weight at around 12 years of age and even with 20 years experience in nutrition, I found it difficult to explain why this was happening. Luckily I met a GP who suggested she be tested for insulin resistance, which she was found to have. But that was just the start of it. I knew little about IR and how to treat it, so had to go back to study. We trialled different eating plans and found a lower carb plan that she has followed for the last 6-7 years. She is very sensitive to all carbs, not just sugars but knows how much she can tolerate. My clinical practice has changed because of this. I now explain to clients with IR/Met Syn how the way they process carbs can result in excessive hunger, cravings, snoring, high BP, low energy, high Tgs, fatty liver, anxiety, low moods etc. Often after a week’s trial of lower carb they feel different and that’s a huge motivator for change. A major problem for me is undoing peoples’ beliefs about diet and health. 30 years of Aust Dietary Guidelines promoting a diet based on carbs has a lot to answer for!

    (reply)
    • Peter Attia  June 2, 2013

      Jennifer, I wish every RD out there was as curious and thoughtful as you are.

    • Jane  June 2, 2013

      Ash,

      Great comment! Clearly that is a very helpful way to think about it.

      I am reminded that Peter has a very good short list of recommended books.

      The Atkins book by Westman et al is a very helpful step-by-step guide losing fat, but I learned more about the hormonal effects of food choices from Taubes’s books, and from Lustig’s book and online talks.
      Now, this website seems to be an excellent resource for better understanding the effects on our lipoprotein markers.

      The quality of the commentary here is quite a draw.

    • Jane  June 2, 2013

      Oops
      This most recent comment of mine belongs above, in response to Ash and Chris.

  41. PhilT  June 3, 2013

    I think some of the anti-sugar opinions and studies deserve a ** footnote too, as that camp is probably more fanatical and devious than the industry itself.

    Sugar or indeed fructose is seldom consumed alone, and the RCTs looking at differential effects of different sugars in the context of the whole diet don’t really seem to show any significant difference in outcome, do they ?

    How do we handle the fruit paradox. Lustig says that the vehicle is irrelevant, so how does the 16% sugar solution that is Welch’s grape juice fit into the picture compared to the 10% HFCS or sucrose sweetened full fat cola ? Sure, there a vitamin or two in the juice but I might not need them, maybe some beneficial polyphenols I already get from red wine, who knows. Is fruit juice toxic ? For that matter, as fruit is just juice soaked into fibre – is fruit toxic ?

    All of a sudden the argument is two orders of magnitude more controversial and less acceptable by society.

    (reply)
    • Peter Attia  June 3, 2013

      Well, the difference is probably that the anti-sugar folks are generally (though some might be) not funded by an industry that wants to see a specific outcome. I’m only pointing this out because it complicates the science. Maybe I’m missing your point, but I think Lustig would be the first to point out that grape juice and Coca Cola are, from the standpoint of the liver, very similar. He’d say eat grapes, but don’t drink grape juice.

    • PhilT  June 7, 2013

      “Well, the difference is probably that the anti-sugar folks are generally (though some might be) not funded by an industry that wants to see a specific outcome.”

      The anti-sugar folks *are* an industry that wants to see a specific outcome.

    • Peter Attia  June 7, 2013

      Define “industry?” Does this mean all scientists are part of an industry?

  42. Dr. Richard H. McSwain PhD PE  June 3, 2013

    Dr. Attia,
    I heard your presentation last week at the IHMC in Pensacola and found it to be profound. I have had a nerve issue in my foot for a number of years. Two years ago I had a nerve bisection in hopes of terminating the pain. Instead of curing the pain, it resulted in a hypersensitivity to sugar. Any sugar intake in my diet results in severe nerve pain in my foot that lasts for hours and usually results in loss of sleep.

    So my question is: How can sugar intake result in nerve pain?

    Richard H. McSwain PhD PE

    (reply)
    • Peter Attia  June 3, 2013

      I really don’t know. If it’s temporally related that would suggest it’s not caused by changes in Hb A1C.

    • Lori Hogenkamp  June 4, 2013

      Stephen and Peter:

      So why wouldn’t we rather say sugar or fructose in refined form is more “stressful” to the system when in isolation (why fruits don’t have the same impact b/c of their antioxs, polyphenols and fiber buffers the stress of the sugar/fructose —- Oxidative stress drives VLDL, not to mention insulin resistance, metabolic distress, etc) Would that be equally (if not slightly more) scientifically and technically accurate? Although it would have the same lack of nuanced defintion and understanding from both general and scientific communities, which is the same problem with the word “toxic”. We tend to have an “outside” linear impact instead of the more nuance nonlinear internal systems interaction balancing act starting with the “host factors”. Which are aptly (and impressively, way to go Peter) not only significant but essential for the delineation of impacts. So host factors are the way in which one handles stress and typical coping pathways (the distribution curve). Which depends on which systems (based on experience, expressed in epigenetic mechanisms) are engaged and what other stressors (and resources) are present. So while toxic is adequate (sorry Stephan I think “harmful” and/or “unhealthy” are without the meaning and would be variations-on-the-tune of “when are they stressful and how is that stress balanced” which takes a conserted effert to tease out cost/benefit situations). I would think “stress” although currently lacking proper definition by our general and even more professional audience is the most accurate term.

      So I’m very curious why we do not use the word stress?

      “Palatable foods” also have a complex stress interaction depending on the system. On one hand they counter stress, on the other they can create stress. Depends on the system and the other resources required at that time. Palatability of high density caloric resources are great for handling stress, but if they don’t actually contain resources or counterbalances (ahem, junk food) they create stress… depending on the antioxidant systems, jobs, counteractions, system engagement, alterations, level of adaptation (to respond in more “toxic” degrading fashion) etc. involved or otherwise engaged. Since Peter mentioned Tylenol that would be the CYP2E1, tylenol, alcohol, glucose all overlap this same pathway and interact with the same type mechanisms, stress/toxicity mechansims.

      So “stress” would be some kind of “dirty” (?) word (or oblivious hidden gorilla maybe?) that nobody uses because……

      Effects of early life interventions and palatable diet on anxiety and on oxidative stress in young rats.
      Marcolin Mde L, Benitz Ade N, Arcego DM, Noschang C, Krolow R, Dalmaz C.
      Physiol Behav. 2012 Jun 25;106(4):491-8. doi: 10.1016/j.physbeh.2012.03.025. Epub 2012 Mar 30

      Consumption of a palatable diet by chronically stressed rats prevents effects on anxiety-like behavior but increases oxidative stress in a sex-specific manner. Krolow R, Noschang CG, Arcego D, Andreazza AC, Peres W, Gonçalves CA, Dalmaz C. Appetite. 2010 Aug;55(1):108-16. doi: 10.1016/j.appet.2010.03.013. Epub 2010 Mar 27.

      Chronic ethanol and high glucose inducible CYP2E1 mediated oxidative stress leads to greater cellular injury in VL-17A cells: a potential mechanism for liver injury due to chronic alcohol consumption and hyperglycemia Kavitha Swaminathan,a S. Mathan Kumar,a Dahn L. Clemensbc and Aparajita Dey*a
      Toxicol. Res., 2013, Advance Article

      Combination treatment of epilepsy with ketogenic diet and concurrent pharmacological inhibition of cytochrome P450 2E1. Palmer M.Med Hypotheses. 2013 Apr;80(4):481-5. doi: 10.1016/j.mehy.2013.01.011. Epub 2013 Jan 28.

      UT Southwestern Medical Center (2011, April 19). Limiting carbs, not calories, reduces liver fat faster, researchers find. ScienceDaily. Retrieved June 4, 2013, from http://www.sciencedaily.com­ /releases/2011/04/110419003651.htm

    • Peter Attia  June 5, 2013

      Lori, I can only speak for myself. I don’t find semantics to be my forte. I like to describe processes, as best I can, and uncover the nuance. I leave it to the smart folks to come up with the perfect nomenclature. While I don’t have any philosophical opposition to the word “stress” and I agree it’s better than “not healthy,” I’m more interested in trying to define and test this hypothesis.

      Is smoking a pack of cigarettes each day unhealthy? yes. Toxic (chronically)? yes. Physiologically stressful? yes. Bottom line…you’re more likely to live a longer, disease-free life, if you don’t smoke a pack of cigarettes a day than if you do (all other things equal). That’s what I want to understand.

    • Lori Hogenkamp  June 4, 2013

      Oxidative stress and diabetic neuropathy: pathophysiological mechanisms and treatment perspectives.
      van Dam PS. Diabetes Metab Res Rev. 2002 May-Jun;18(3):176-84.

      Combination of alpha lipoic acid and superoxide dismutase leads to physiological and symptomatic improvements in diabetic neuropathy.
      Bertolotto F, Massone A. Drugs R D. 2012 Mar 1;12(1):29-34. doi: 10.2165/11599200-000000000-00000.

    • Ali  July 13, 2013

      What is interesting about the body is that pains in certain areas aren’t necessarily emanating from that area. The feet and hands are full of nerve meridian endings and recurring pains and discomfort in the feet can often correlate with issues elsewhere in the body.

      For instance, for some years I have had a very itchy left heel. Checking the reflexology chart, it equates with the colon. I have had some issues in my colon, so that ties in well. Also, not long after I dumped gluten and most carbs over 5 years ago, my liver suddenly had a big clear out. I could feel lots of stuff going down my hepatic tubes in my right side, it became very sore, and immediately it started a very sharp and intense regular pain started in my left foot. Lo and behold, checking the chart, the area of the pain equated with the liver.

      For many years prior to dumping gluten-based grains I would get raging restless legs, kicking about the bed uncontrollably for hours. If I get ‘glutened’ the restless legs resurface with a vengeance. Why? Because the gluten and other foreign proteins in the modern wheat triggers neurological issues in my gut. It’s basically a form of ‘gluten ataxia’.

      Our feet (and hands) can tell us a lot more about what is going on than we realise. The reason you developed sugar intolerance after the surgery was probably because the nerve pain in your foot was actually telling you there was an issue elsewhere, possibly in your gut (not knowing where the pain actually was). Surgery trauma like any major stress or trauma depletes the body of a huge amount of nutritional elements and that can have a long-term effect on people that in the main are already very nutritionally deplete. Surgery is also often followed by antibiotic or other drug courses, and that all has a major impact on the health of the bowel, and therefore the person.

      Whilst I do believe that a lower carb diet is always going to be beneficial for most people, it’s as much about what is removed, as what it is replaced with. Most low-carb regimes remove grains. It is well documented how modern grains, especially wheat can rob the body of far more nutrition than they give – the joke that with many cereals you’d probably be better off eating the cardboard box is sadly not really a joke at all. A lower carb or ketogenic diet concentrates mainly on all-natural real food so people are always going to be getting more nutrition. The more nutritious the food, the healthier we will be. Much emphasis is placed on probiotics these days to help the gut. However, it’s not the microbes per se that are the important thing, but what they do. Lactic bacterial fermentation makes food far more nutritious. It draws more nutrition out of the food, and adds more too. B vitamins are increased, which helps digestion, and things like vitamin K2 are generated.

      Life really is all about nutrition. The better and more abundant the nutritional elements – the elements we are made from, the healthier we are. Unfortunately these days, much of the food out there, including much of the commercially grown fruit and veg may look like food, and taste like food, but isn’t food at all. You can’t Improve on perfection. The more mankind fiddles and meddles with their food the less beneficial it becomes. How far will they go before its too late to change it back? Has it already reached the point of no return???

  43. Hakim  June 4, 2013

    Hello Botros,

    I’m desparetely waiting for ur post on caffeine. I’m very appreciative of all the work your doing in the field. Thank you

    (reply)
  44. Lori Hogenkamp  June 5, 2013

    Peter stated: “Is smoking a pack of cigarettes each day unhealthy? yes. Toxic (chronically)? yes. Physiologically stressful? yes. Bottom line…you’re more likely to live a longer, disease-free life, if you don’t smoke a pack of cigarettes a day than if you do (all other things equal). That’s what I want to understand.”

    Semantics is not my forte either, I’d say physics and neuroscience is more my thing. You are unfortunately in this statement making the same mistake as most and looking at stress as a variable. Something that is stressful. I am referring to it as a model. HOW stress works, which is through complexity dynamics that require us to think differently about the questions we ask, the evidence we see and the evidence we seek (framework to put it together).

    I’m not fighting here for semantics, but language is important (as it leads to research terms and pathways). When is smoking cigarettes “healthy”? Depends on the system right? What are you trying to accomplish and what is being accomplished on that individual. You have to break down the stress (balancing) mechansims and trade-offs. And how and on who stress would re-regulate a system that would make potentially unhealthy resources a viable healthy brain balancer (and address this balance so the “unhealthy” balancing crutch is no longer necessary). When you take a systems thinking stress approach you look at how stress has impacted the system and also how nicotine may become a regulator of that stress for some (which can be caused by multiple different things, a nonlinear stress mechanism means there is overlap and cross-over).

    One exposure (or combination of exposures and lack of nutrients or resources at that time, in particular individuals) can create problems we may not seem to think are associated (or were mediated by ‘choice’). when if we address from a systems approach via stress mechanisms of nonlinearity we may find getting the outcomes, and understandings, we are looking for, may become more feasible.

    I can give you thousands of examples and the starting points (genetic-neuroendocrine) i currently suspect (needed for chaos patterns). If you’d like to discuss sometime Peter, please give me a call, my website is “The Meal Matters Most” on wordpress.

    http://themealmattersmost.wordpress.com

    Smoking, Genetics and Schizophrenia: Evidence for Self Medication. Sherry Leonard, Sharon Mexal, and Robert Freedman. J Dual Diagn. 2007 November 1; 3(3-4): 43–59

    Oxidative stress might be a mechanism connected with the decreased alpha 7 nicotinic receptor influenced by high-concentration of fluoride in SH-SY5Y neuroblastoma cells.Gao Q, Liu YJ, Guan ZZ.Toxicol In Vitro. 2008 Jun;22(4):837-43. doi: 10.1016/j.tiv.2007.12.017. Epub 2008 Jan 15.

    Alpha7 Nicotinic Acetylcholine Receptors Modulate Motivation to Self-Administer Nicotine: Implications for Smoking and Schizophrenia. Darlene H Brunzell, J Michael McIntosh. Neuropsychopharmacology. 2012 April; 37(5): 1134–1143. Published online 2011 December 14. doi: 10.1038/npp.2011.299PMCID: PMC3306875

    .

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    • Peter Attia  June 5, 2013

      Appreciate your thoughts, Lori. I guess my issue with the term “stress” to denote something negative is that stress is actually quite beneficial in many circumstances. I’m somewhat myopic/obsessive in my view of exercise, for example, where I constantly focus on stress and the adaptive response it brings in strength, endurance, and explosiveness. This is true in many other instances also, so I’m also not sure stress is the best word choice. My original point still stands, of course.

  45. Bryce  June 5, 2013

    Love your blogs. My comment is a personal one unrelated to the sugar essay. I’m a 55 year old male; exercise 6-10 hours per week with moderate intensity resistance training and moderate-to-high intensity aerobics; follow a low carb diet (meat and veggies, primarily; there are periods when I consume fruit and nuts; no starch; no sugar (other than in the fruits, veggies, nuts); several cups of coffee per day; have always had very good lipid panel results. Baseline toal chol is 135-140; trigly ~25; HDL >55; VLDL <25; calc'ed LDL 175.

    What the heck happened to me?

    (reply)
    • Bryce  June 5, 2013

      My msg above somehow got truncated….
      Component//11/2009//5/2012//3/2013//5/2013
      CHOLESTEROL, TOTAL/137/ 144/ 257/ 280;
      TRIGLYCERIDES/24/67/81/73;
      HDL CHOLESTEROL/52/50/66/55;
      VLDL CHOLESTEROL CAL/5/13/16/15;
      LDL CHOLESTEROL CALC/80/81/175/210.

      I’m not after your medical advice, although I’ll take it. Just trying to figure out if there were/are other variables at play beyond a simple dietary change. Bryce

  46. Jeremy Tyler  June 5, 2013

    Dr. Attia,

    Another excellent post. I saw where you mentioned that this might turn into 3 posts. Look forward to it if that is the case as I could read a new post of yours everyday it seems. On sugar tolerance I actually have a question that hopefully you can help with or possibly point me in a good direction (book or person). Can carbs and insulin affect people only in certain smaller ways while everything else seems fine? My wife, like yours, is very sugar/carb tolerant when it comes to the obvious symptoms like fat gain, and not as obvious symptoms when it comes to blood pressure, apoB count, etc….. She is a pure Ectomorph and doesn’t have any of those problems.

    There is one issue though that she has that correlates heavily with carbs and insulin resistance, and that is Polycystic Ovarian Syndrome. To actually be more correct, she does not have PCOS as she doesn’t seem to have insulin resistance, is nowhere near overweight, and has normal cycles. But she does have hirsutism, back acne, and polycystic ovaries (which her doctor refused to believe she could have since she was not insulin resistant till the scan came back showing polycystic ovaries, at which time the doctor seemed to be irritated because she was wrong). So since my wife was constantly having these problems associated with polycystic ovaries but she did not seem to be able to get any help other than being told to get on birth control, I decided to look into it.

    I read the parts Gary Taubes wrote about in Good “Calories, Bad Calories”, looked up what I could find on Dr. Michael D. Fox, looked up studies where those with PCOS tried VLC and their symptoms disappeared and came across this scientific article http://www.medscape.org/viewarticle/562712_3 . I then had her get on a keto diet with me and for her last 3 cycles and the results so far have been her back acne has been going away, hirsutism disappearing, and she has not felt any growth of cysts the past 3 cycles.

    The best diagnosis that I could come up with is that she must be genetically predisposed to have very insulin sensitive theca cells on her ovaries that cause the cysts, hirsutism, and acne, while at the same time not experience any other insulin problems such as weight gain, bad lipid profile, insulin resistance, or anovulation. While most who have polycystic ovaries tend to have anovulation as well, she does not and the I think the reason is that she is not insulin resistant, therefore has a constant source of calories for her body to feed off of and so the body never feels as though it’s starving in any way so it keeps her having normal cycles. Yet she still had cysts on her ovaries and all the side effects and pain that goes along with it.

    I know that was quite a bit to read, but what I would like to know first is, do you plan on posting about PCOS anytime soon? Do have any additional sources on the subject you could point me to? Lastly, as stated at the beginning can she really have problems with the insulin affecting her theca cells (which seems to be the problem as I can diagnose it) but not the rest of her body? Basically could the rest of her body be insulin sensitive and not react negatively to carbs and insulin, with only the theca cells on the ovaries reacting badly, or do you think there could be something else causing it? Also what do you think of the hypothesis I came up with? Sorry if I asked too many questions, I’m just so damn curious. Look forward to your response. Thanks.

    (reply)
    • Peter Attia  June 5, 2013

      Certainly a variable response exists. I’m not knowledgeable enough about PCOS (yet) to write anything meaningful, unfortunately.

    • Lori Hogenkamp  June 6, 2013

      I know miniscule about PCOS as well. But I do know a bit studying Autism and PCOS does come up in the inflammatory pathways of those predisposed on the estrogen side of the spectrum. So a reasonable hypothesis, for that side, would be of estrogen-insulin relationship with epigenetic modification with stress regulating exposure (endocrine disruptors and estrogen resources like sunlights, aka Vitamin D). So I am PURELY theoretical science, but if I were to nudge your investigation for a spell, it’d be toward Paleo Diet trends that include the elimation of gluten-casein, addition of probiotics (the HPA skin) and of course the relationship of Vitamin-D (sun, butter, antioxs), insulin and androgen modifications (avoiding endocrine-disruptors and adding nutrition contributing to it’s balancing, aka phytoestrogens). But again, I know really nothing about it, just hypotheses generating.

      Effect of soy phytoestrogen on metabolic and hormonal disturbance of women with polycystic ovary syndrome
      Behnaz Khani, Ferdous Mehrabian, Elaheh Khalesi,c and Azadeh Eshragh. J Res Med Sci. 2011 March; 16(3): 297–302. PMCID: PMC3214337

      Vitamin D in the aetiology and management of polycystic ovary syndrome. Thomson RL, Spedding S, Buckley JD.Clin Endocrinol (Oxf). 2012 Sep;77(3):343-50. doi: 10.1111/j.1365-2265.2012.04434.x.

      The role of HPA axis in metabolic derangements in PCOS. Djuro Macut. Endocrine Abstracts (2009) 20 S1.3

      Genome-Wide Methylated DNA Immunoprecipitation Analysis of Patients with Polycystic Ovary Syndrome
      Hao-ran Shen, Li-hua Qiu, Zhi-qing Zhang,2 Yuan-yuan Qin, Cong Cao, and Wen Di.
      PLoS One. 2013; 8(5): e64801.

      Pervasive developmental disorders in children of hyperandrogenic women with polycystic ovary syndrome: a longitudinal case-control study. Palomba S, Marotta R, Cello AD, Russo T, Falbo A, Orio F, Tolino A, Zullo F, Esposito R, Sala GB.Clin Endocrinol (Oxf). 2012 Dec;77(6):898-904. doi: 10.1111/j.1365-2265.2012.04443.x.

      Autistic Traits in Women with Polycystic Ovary Syndrome. Herguner, Sabri; Harmanci, Hatice; Hergner, Arzu; Toy, Harun. Research in Autism Spectrum Disorders, v6 n3 p1019-1022 Jul-Sep 2012

      Inflammation in response to glucose ingestion is independent of excess abdominal adiposity in normal-weight women with polycystic ovary syndrome. González F, Sia CL, Shepard MK, Rote NS, Minium J. J Clin Endocrinol Metab. 2012 Nov;97(11):4071-9. doi: 10.1210/jc.2012-2131. Epub 2012 Aug 17.

      Vitamin D is a membrane antioxidant. Ability to inhibit iron-dependent lipid peroxidation in liposomes compared to cholesterol, ergosterol and tamoxifen and relevance to anticancer action.
      Wiseman H. FEBS Lett. 1993 Jul 12;326(1-3):285-8.

    • Peter Attia  June 6, 2013

      Thanks Lori.

    • Jeremy Tyler  June 6, 2013

      Thanks Lori, I’ll take a look into those sources and see what else I can find out. Hate that there hasn’t been many true scientific inquiries into PCOS because between 1 in 10 and 1 in 20 women of childbearing age has PCOS.

    • Ali  July 13, 2013

      I really am one of those people who believes that modern grains are pretty evil. Before you even get into GM, they, and particularly wheat, have been subjected to incessant hybridisation. It now contains foreign proteins that interfere with hormonal functions in the body. Personally, although I am no doctor, I am very analytical, and I see no reason why IR and PCOS have to be bed-mates.

      We are all individuals. Each of us comes from different ‘genetic’ and nutritional directions. My body’s weakness or vulnerability isn’t necessarily going to be your body’s weakness or vulnerability. Whilst I have IR, I don’t have PCOS.

      The medical profession always strives to fit us into neat little boxes. When we don’t fit, instead of changing the box, they send us packing. Um. Last time I looked, none of us were clones….

      Although nutrition is considered of little importance, we are actually made of the elements that are in the food we eat. So what we eat is always going to have a good or bad effect. If we remove the insidiously damaging ‘food like substances’ as Michael Pollan succinctly describes them, and replace them with REAL food, the body then has the tools with which to sort itself out. It really isn’t rocket science. Or maybe it is – if we want to rocket!

  47. Maistas sportui internetu  June 6, 2013

    There is no such thing as toxic…there is only the toxic amount of it.

    (reply)
  48. JJ  June 6, 2013

    Thank you again Peter for another platinum grade post, based on science, carefully considered, and relevant i.e. not normally what you find in an article linked to nutrition. I see how much you have thrown yourself into this and the sacrifices you are making and it is incredibly inspiring. I have completely backed your approach close to 100% (my fiance thinks I have taken up some crazy ‘fad’) adopting as much as I can subject to a few practical constraints. The main reason I did this is your credibility, your lack of preachyness and the fact you have nothing to gain from me doing so.

    Sugar can have so much impact on day to day quality of life, it is hard to watch loved ones sometimes suffering the effect of this especially when you feel unable to really influence their behaviour. My fiancé ironically is concerned about my own health since changing my diet and to try and reassure her I have asked for a basic lipid profile from my GP (this will be the cheap version referred to above as NHS in UK – I tried to ask for ApoB but my Doctor stared at me blankly). I have no idea how to even interpret the results and am even more worried my Doctor might misinterpret or over interpret them especially if he subscribes to conventional wisdom (which I am sure he probably does).

    I know the basic lipid stuff tells you very little but is there anything I can look for, any ratio or meaningful indicator at all?

    (reply)
    • Peter Attia  June 6, 2013

      JJ, if only having access to conventional labs, non-HDL-C (= TC less HDL-C) is probably a better predictor of risk than LDL-C. Also, TG to HDL-C ratio and fasting glucose and insulin pretty helpful to understand insulin resistance.

  49. Clair Nielson  June 6, 2013

    All of these individual variations in peoples’ response to nutrients makes me wonder if general health advice is possible at all. Doesn’t this high variability make most “controlled” trials worthless? If the response of half the people in the trial just cancels out the response of the other half, how can one learn anything at all from the trial?

    (reply)
    • Peter Attia  June 6, 2013

      I hate to use smoking as an analogy again, but I think it helps. Many people who smoke will not go on to develop lung cancer, emphysema, or heart disease, yet a great number to, presumably because they are genetically or epigenetically susceptible. So how should we handle this? Well, I think what we do right now is exactly the way to handle it. We explains the risks clearly and unambiguously. Everyone is free to smoke, but if you choose to, you know you’re taking a risk. Will it cost you? Hard to tell. Once “nice” thing with sugar is that you can get quicker feedback on your susceptibility than you can with smoking.

      That said, you do make a VERY important point about the utility of most clinical trials: they are almost without exception focused on mean response with little attention paid to variability. This is one more reason to read any study very carefully and try to see the data whenever possible.

    • Lori Hogenkamp  June 7, 2013

      This concept crossed my mind 20 years ago in school when I asked the innocent question of my stats professor “where does the bell curve come from and how is it it exists”. The answer “no idea”. At the time I thought, “whoa dude, you mean we base our entire scientific premise on an assumption we have no idea how or why it exists?” Sounded fragile to me, but I let it go. However, 5 or 6 years ago studying the mind (information processing) and physiology I suddenly thought “holy crap, what if we got it wrong?: So erase everything you think you know, change your thinking and rebuild it.

      To answer your question Clair Nielson, I would say they are not useless. RCT are clinical snapshots, singular points that assume the system could be controlled out or that our systems are static. They are valid “points” of information. So we now need to put those studies together (instead of thinking they ‘cancel’ each other out like you say), knowing they do not apply to everyone, but particular patterns under certain circumstances. Linear science is fact finding (and our current model) its an outside action that will repeatedly come up with the same outcome because we hold all other variables constant. The problem with the human body is that the variance isn’t random (where we could take an average distrubution) but rather particular patterns for particular reasons. So in nonlinear science it’s about the system it is put into, nonlinear science is about interactions, the interactive dynamics of those singular facts put into active systems. So instead of the outside action as the primary focus on outcome (our current model), rather the system becomes the focus (systems dynamics). And the system can change. It can be different people, but even your physiology can change your response at different times. Our current medical science assumed we could factor that out, we now know we can’t. The problem is is that changes the scientific thinking we have to use. It’s difficult for people to do that, but it can be done because the science we have to use instead using very specific spelled out rules and you still follow very well trooded out physiological facts. So no they aren’t useless, but we do need a new model to understand them.

  50. JJ  June 6, 2013

    Thanks again Peter.

    (reply)
  51. Sylvie  June 7, 2013

    The take-home message seems to be that nobody can go wrong following a low-carb diet for life (maybe with one day a week off). Otherwise, one must constantly monitor the effects of hire carb consumption through life. Or is it uncharitable to lump all carbs (wheat, spelt, oatmeal, high GI fruit) if you’re looking to maintain/lose weight and be in good health?

    (reply)
    • Peter Attia  June 7, 2013

      Sylvie, a rigorous answer to this question would require at least a (long) blog post. Maybe a book. I’m sorry I can’t provide either at the moment, because it’s a fair question.

  52. Marcy  June 7, 2013

    The story about your daughter and the ice cream reminds me of my niece when she was a child. She would push her meal away saying she was full. She would then ask for dessert, and when we would say, ‘we thought you were full’, her answer was, ‘my food stomach is full, not my dessert stomach!’.

    (reply)
    • Peter Attia  June 7, 2013

      Hilarious. And not hilarious. Simultaneously.

    • eh  September 1, 2013

      My son (8) says much the same, running his fingers down the center of his torso, “dinner side full; dessert side not full!”

      Mercifully he is in perpetual motion, so no obesity related morbidities evident yet …

    • Peter Attia  September 1, 2013

      Hard wired…

  53. Linda Morken  June 7, 2013

    Hi Peter:

    Wonderful work you are doing! I’d like to add a source of invaluable information to your nutrition research. The book, “Nutrition and Physical Degeneration” by Dr. Weston A. Price documents just how devastating the introduction of sugar (and other refined westernized foods) to healthy, remote peoples of the world was to their health and well-being. The non-profit Weston A. Price Foundation publishes fully referenced outstanding articles on the very topics you are interested in. A return to the nourishing traditional foods of our great-great grandparents is what they advocate. Here’s a link to an article from their most recent journal that shows the quality of their research: http://www.westonaprice.org/environmental-toxins/violent-behavior-a-solution-in-plain-sight. Although this article concentrates on behaviour and nutrition, it applies broadly to the fact that we are what we eat. BTW, Dr. Price was born and raised a Canadian, too.

    Linda Morken
    Volunteer Chapter Leader
    Weston A. Price Foundation
    Vancouver Island

    (reply)
    • Peter Attia  June 8, 2013

      Thank you, Linda. I don’t think I knew Dr. Price was a Canuck.

  54. Grant  June 7, 2013

    Great work there Peter. As a pharmacist I’m reminded of the adage that came up often during my training – the only difference between a drug and a poison is the dose. As this can be the case with nutrients such as the fat soluble vitamins, it looks to be true for sugar. I think Stephen really hit on it in one of his earlier replies regarding fruit consumption.

    (reply)
  55. Nguy?n V?n Tu?n  June 8, 2013

    So while we are debating whether sugar is toxic or not, we are overlooking the other catastrophe bearing down on us, to wit the rising epidemic of degeneration of the brain.

    http://people.csail.mit.edu/seneff/EJIM_PUBLISHED.pdf

    And to add insult to injury, we have been told to remove saturated fat from our diet, despite the fact that the lipid hypothesis of CVD has been thoroughly debunked.

    I do wonder whether medical doctors remember their Hippocratic Oath: “Never to do HARM to anyone”.

    (reply)
  56. Evelyn aka CarbSane  June 8, 2013

    Hi Peter,

    I am curious if you recognize the dripping irony in the following statement:

    >>>**Sadly, it’s difficult to really interpret the data objectively from those in the PRO sugar camp because of the conflicts of interest. Most of the PRO sugar scientists are heavily funded by the sugar industry. For those interested in the historical context on science and the sugar industry, you’ll find this article particularly interesting.<<<

    The article in cited is: Big Sugar's Sweet Little Lies How the industry kept scientists from asking: Does sugar kill? — Co-authored by none other than Gary Taubes. Gary's bio there, http://www.motherjones.com/authors/gary-taubes, includes this line: "He is currently writing a book about sugar". He is being paid to reasearch and write that book by the Robert Wood Johnson Foundation and his bias against sugar is longstanding.

    Would this not be a blatant example of conflict of interest on the ANTI side as well?

    One of the problems here as well is saying that any science that doesn't support the sugar=toxic side of things is thus "pro" sugar consumption. This is a good way to polarize the debate because it allows one to paint anyone who "defends" sugar as someone suggesting we should all live on Pixie Stix and Sierra Mist. That's just silly, would you agree? There can be a happy medium there somewhere … one where the term toxic really has no rightful place. It is a needlessly inflammatory term and clouds the issue. If you are serious about personal toxic limits, I hope you extend that to all foods and components that are isolated and consumed in high levels. After all, we can induce far greater toxic effects in rodents with lower doses of various fats than sugar (and not just trans fats).

    The ANTI science, when held up to the light of scrutiny, doesn't stand up very well. Make no mistake there are financial stakes in that game too.

    (reply)
    • Peter Attia  June 8, 2013

      Interesting point, Evelyn. I think the real question is if Kimber Stanhope, Peter Havel, George Bray, and others in the ANTI camp have the same degree of conflict — financial conflict — as John White, James Rippe, and others in the PRO camp. There is no doubt that bias will always play a role in science. We are all biased despite how hard we might try to not be biased. But a conflict of interest may be a separate issue.

      Perhaps the more important question ought to be, what can be done about it, if our goal is to know the truth? How can science overcome its inherent bias due the fact that people, not robots, do the work?

    • Evelyn aka CarbSane  June 9, 2013

      (I did not see a way to reply to your response Peter, so I am replying to my comment and hoping it goes in the right place. )

      In my past life I researched both in academia and industry and I’m well familiar with how funding works. I am really not sure that just because funding is from a public source or purportedly non-interested private source doesn’t mean it won’t influence the outcome. Moreso, it may influence the study that gets done at all. Try getting funding for a study not designed to show man-made global warming for example.

      So since you mention Stanhope and Havel, the study design of the one where they took obese subjects and intended to replace 25% of calories with glucose or fructose sweetened beverages is questionable to me. Since nobody is drinking fructose-only beverages, the 125g/day of pure fructose (with no balancing glucose) is physiologically aberrant (this alone renders the results to be of questionable relevance off the bat.) Secondly, if the goal was to replace calories with fructose or glucose, why didn’t they attempt to control for calories in the rest of the diet? These subjects did not compensate fully for the liquid calories and as such were in a chronic hypercaloric state and gaining weight. Considering that the effects of fructose have been hard to elicit in isocaloric states might that have been considered?

      I don’t see how this science is any more OR less suspect than had the same study been paid for by PepsiCo. In other words, the science is what it is, and there are problems with this study that could be due to bias by the researchers and/or could have been influenced by the funding source and needing to get a predicted result.

      What if Pepsico had done the same study, replaced 50% of calories with Sierra Mist (sweetened with sucrose) or UCAN (grin) and controlled the rest of the diet so that 25% of their weight stable calorie intake was fructose or waxy maize Superstarch. Had this shown no difference, everyone would be shouting bias because PepsiCo funded the research. Would that change if Jeff Volek did it? How about Richard Feinman? How about if NuSI had funded the study?

      This study would be an improvement in that it tested physiologically relevant “foods”, but it would still be of limited relevance in the “real world” where mostly I see numbers like 10% bantied about in terms of calories from SSBs. So lets say PepsiCo chooses instead to use 20% or even 25% Sierra Mist (and keep total calories constant) and they can compare to 20-25% glucose-superstarch mix. The results of such a study would have far more relevance to the causes of metabolic dysfunction, don’t you think? And again, if PepsiCo vs. NuSI or NIH or whatever sponsored such a study, would the results have any different meaning? Havel v. Volek? I don’t think so.

      The science is the science, so the issue becomes one of study design, implementation and interpretation. Stanhope & Havel provided extensive supplementary information with the first publication from the study I’m talking about here. Even as extreme as it was, there were some very surprising “no differences” that went not noted in the publications. Were PepsiCo to pay some researchers to publish that analysis up, would it now become tainted?

    • Peter Attia  June 9, 2013

      Not necessarily, but the probability is greater. There are solutions to this. These questions that remain unanswered can be answered. To quote the late Basil Rifkind, “the data are gettable.” How to do so is what I suspect is the most important set of questions to be asking. And, yes, I agree with your comment about the lack of utility about fructose-only interventions. While they may be mechanistically interesting, they don’t appear clinically relevant.

    • Evelyn aka CarbSane  June 10, 2013

      I agree, the data are gettable. In some cases we do already have it. I’m not sure there’s a solution to the problem of “no result” being seen as an outcome not worthy of investigation/publishing. It certainly influences what studies get done to begin with, and it’s not conducive to further funding to find nothing conclusive.

      Thanks for allowing me to comment here Peter, and your considered responses. It’s refreshing and much appreciated.

    • Peter Attia  June 10, 2013

      I think all data should be published, including so-called “negative” data (I’m not sure this term makes sense). I’ll share an anecdote. Early in my post-doc/fellowship I did a series of experiments on human cancer and immune cells looking to modulate reg T cell response. This was follow up work to something I did that was very promising and I expected this to work (and to be published in a high-impact journal). The experiment didn’t work. The toxin I was using to modulate the immune system didn’t work. I repeated the experiments two more times. Nothing. I was bummed and didn’t want to go through the trouble of writing it up, only to publish it in a 2nd or 3rd tier journal. My mentor, who is simply a giant in the field, said, “Peter, this must be published. One of the biggest problems in science is people not publishing negative work. If your publishing this alerts others to the problems, that is as valuable as had it worked.”

      Talk about a valuable lesson in scientific integrity. I went on to publish many more papers in that field — some ‘negative,’ some ‘positive’ — but I never forgot what Steve Rosenberg taught me. I think this culture can expanded to all of science, and certainly nutrition could benefit from it. I think it would also raise the bar on the types of experiments people would do. Pre-registration is one step in this direction, but ultimately, it has to be driven by the scientists themselves.

    • Evelyn aka CarbSane  June 11, 2013

      Preregistration might work if all that is required is to make the data public. Otherwise I think the unintended consequence of research not being done at all may occur.

  57. David M Driscoll  June 9, 2013

    “some argue that fructose consumption impacts subsequent food consumption in a way that glucose does not. In other words, eating sugar may fail to satiate you and/or make you subsequently hungrier. ”

    The study you quoted actually shows that glucose stimulates eating more than fructose
    Gender Fructose Water Glucose Glucose-aspartame
    Female 703 960 1328 1088
    Male 1035 1231 1474 1501

    And later “pooling across sex, subjects in the fructose condition ate, on the average, 225.9 calories less than subjects in the water condition, who in turn ate, on the average, 252.7 calories less than subjects in the combined glucose conditions” and “It is noteworthy that subjects ingesting 197 keal of fructose showed almost perfect regulation, reducing food intake by about 225 kcal relative to subjects who had the 0 kcal preload of water. On the other hand, subjects with the glucose preload showed potentiation of intake, leading to about 450 more calories overall than water subjects, after ingesting both the preload and the buffet meal”.

    “So, while folks in this camp argue that sugar per se isn’t harmful, it does make you eat more (sugar and non-sugar, alike), and that is the harm.”

    We now have confirmation from the authors themselves (via the letters published in the Journal of the American Medical Association) that the much misquoted study “Effects of fructose vs glucose on regional cerebral blood flow in brain regions involved with appetite and reward pathways” from January 2013 with regards to fructose and hunger – has been largely misrepresented.

    http://www.ncbi.nlm.nih.gov/pubmed/23632711
    “We underscore that the study found no statistical difference between glucose and fructose ingestion on hunger, fullness, or satiety. Thus, while we also reported pre-drink vs post-drink changes in fullness and satiety for each drink separately, we did not interpret this as demonstrating a difference between treatments.”

    We also know from the supplementary data from the Stanhope 2009 study, that although MASSIVE doses of fructose resulted in a similar levels of fat gain (admittedly it was the more problematic visceral fat) that people taking in 25% of their calories from fructose vs glucose, didn’t eat any more calories under free living conditions. http://www.jci.org/articles/view/37385/sd/1

    With regards to Dr Lustig and his fringe views on fructose, while theories and evidence may seem convincing to the general public and reporters, the real test is how well he performs with his fellow scientists!

    He was certainly called out for overstating the evidence and poorly extrapolating rat research at a conference he spoke at last year – check out the Q and A video in the attached article by David Despain (as well as the other lectures)!

    http://evolvinghealthscience.blogspot.com.au/2012/04/sugar-showdown-science-responds-to.html for a full review and links to all lectures – if not just watch the Q and A at http://www.youtube.com/watch?v=ypWe6npULUQ and http://www.youtube.com/watch?v=cnGhfX2yaU4

    What research shows that it is fructose that causes addiction? The study that you quoted certainly doesn’t show that ” Furthermore, evidence is emerging that sugar is addictive – http://ajcn.nutrition.org/content/95/4/810.long

    At the Q and A at the Sugar Symposium, Dr Lustig was called out on this and one researcher showed that rats liked glucose based carbohydrates over sucrose, and another questioned the applicability of rat research to be extrapolated to humans!

    Also a recent rat studied suggests that it might be the sweet taste and NOT the fructose (as they used an artificial sweetener) although this article has been largely misquoted also!
    http://www.plosone.org/article/info:doi/10.1371/journal.pone.0000698

    (reply)
    • Peter Attia  June 11, 2013

      David, excellent catch. A friend pointed this out last week (that I had linked to the wrong paper), but I need to revise it. A better study to illustrate the potential (though conflicting) role of fructose vs. glucose on subsequent appetite and feeding behavior is probably the 2004 by Karen Teff et al in The Journal of Clinical Endo & Metabolism. But even this study doesn’t look at what needs to be studied (if you know of such a study, please send link, but I’ve been looking for a month…). The “ideal” study would pit isocaloric levels of glucose vs. sucrose (or HFCS), which is far more interesting in my mind than isocaloric glucose vs. (pure) fructose for the obvious reasons.

      To your point about the Stanhope and Havel data, including 2009 and 2012 data using 25% is understandable, but still represents ‘efficacy’ data (though not necessarily ‘effectiveness’ data). A big part of the problem is what I address in the sidebar about NHANES and ERS databases. I have seen numbers reported as high as 140 pounds per year per capita of added sweetener! When one uses more conservative numbers, 73 pounds per year per capita seems to be the convergence, which is about 14-15% of total calories, not 25%. However, and this is crazy part, while the AHA recs (2009, Johnson, Appel, et al.) recommend no more than 150 kcal/day, the DGAC (“The report of the Dietary Guidelines Advisory Committee) in 2010 recommended up to 25% of total energy from added sugar! I had to read it to believe it. That’s quite a range, 5% to 25%. So, in this setting, I think the work of Kimber S and Peter H is warranted to explore the boundary conditions.

      To your last point, I have seen data in press (but still in review) that show the impact of glucose + aspartame vs. HFCS vs. glucose (all isocaloric) on all biomarkers available including TG, TG AUC, apoB, etc. There was a some difference between glucose vs. glucose + aspartame, but HFCS stood out very clearly. However, since unpublished, best to wait until they are out to really comment.

  58. Jane  June 10, 2013

    Hello again Peter,
    Are you familiar with the books: Body by Science? Or Slow burn? Or Power of Ten?
    Or the literature about strength training to reduce visceral fat and reverse incipient metabolic syndrome?
    Specifically, Is high intensity necessary? And how can we tell If we have allowed enough time for recovery?

    I am particularly interested in reversing the metabolic damage of IR, but also injury prevention, to avoid surgeries for joint problems.

    Thanks again.

    (reply)
    • Peter Attia  June 10, 2013

      A little bit, but not enough to comment with any credibility.

  59. Jane  June 10, 2013

    More Qs, prompted by comments to me from a dietician.

    Why do not feel any need to supplement with B vitamins?
    And, what about pastured meats, chicken, dairy, . . . .? Do you believe your fish oil supplement provides adequate balance?

    Do you know of a good online site, or book, that would provide more guidance, valid guidance, for aging women trying to reverse metabolic syndrome?

    Your website is fantastic.
    Again, thanks so much.

    (reply)
    • Peter Attia  June 11, 2013

      I think supplements should be person specific, and based on some baseline. Some people need B supplements, others don’t. Same with EPA, DHA, folic acid (which can be based on MTHFR mutations), etc. Point is, I don’t think there is a one-size-fits-all approach.

    • Linda Morken  June 11, 2013

      Jane:

      I’m an aging woman (nearly 60!) that has had success in reversing pre-diabetes, obesity, IBS, and GERD by learning and applying the information I found on the following sites. I believe that our ancestors had food right and if we want to regain our health we have to go back to eating whole, unprocessed, nourishing foods. My food list includes pastured meats and eggs, plenty of animal fats, naturally fermented homemade kefir and sauerkraut, bone broths, organic veggies and some fruit – mostly berries, and a little real sourdough rye bread. It’s basically the food we would find on our great-great grandparents’ small farm, before food became industrialized processed concoctions. Eating like this is working (4 years now) for me and many others. Here are the links to sites that have helped me so much:
      http://www.westonaprice.org/basics/dietary-guidelines
      http://www.dietdoctor.com/how-to-cure-type-2-diabetes-2

      I wish you wellness.

    • Jane  June 12, 2013

      Thank you, Peter. That makes sense, of course.

      Linda, thank you very much for reminding me about Jay Wortman’s excellent story, and about the helpful website by Andres Eenfelt.

      The westonaprice.org approach certainly has a lot of appeal, and has a ring of truth to it, but I have not yet learned to enjoy all that food prep. I am still working, always, toward the optimum personal balance.

      Cheers.

  60. Razwell  June 11, 2013

    Hi Dr. Attia,

    Great article.

    Since we are still unravelling how cells work and how nutrients affect them, I realize the unknowns about nutritional science are enormous. From my conversations with my friend Urgelt, I know we have absurd amounts of sugar in the modern diet. This , I think, is likely a very bad thing.

    Take care,
    Raz

    (reply)
  61. Phil Washlow  June 12, 2013

    Peter,

    I have been fascinated by your blog for quite some time and frequently send links to friends when they tell me what I am doing is wrong. I have been eating a low carb diet for quite some time but never felt great with it until I read some of your advice and really upped my electrolytes and fat intake. With that said I CAN NOT SLEEP lol, I find that I have nearly unlimited energy at all times. I have tried cutting out coffee but that has not helped. I take 3mg of melatonin every night to help me get to sleep, as I have had trouble falling asleep in the past but the melatonin has never failed me before. This has been going on for about a week. Any advice? Thanks in advance.

    (reply)
    • Peter Attia  June 12, 2013

      Phil, I have heard this from several folks. I wish I could say I knew why, but I don’t. In addition, I’ve heard some folks (this happened to me, too) complain of transient vivid dreams. It is possible that your brain is “adjusting” to the new substrate of B-OHB (in addition to glucose).
      Sounds like you’re doing the right stuff re: sleep hygiene, but I suspect it takes a while. Full sleep regimen would be: no caffeine or alcohol after, say, 2 pm. No exercise late in the day. Stop desk work after dinner, etc. Hopefully this effect is transient.

    • J  June 13, 2013

      Phil,
      Could you say exactly what you’ve been eating to up the electrolytes and fat? I’m just wondering because I feel quite fatigued on the low-carb diet (and I keep trying but eventually give up and later try again), although I do try to have broth every day and lots of fat. I thought if I try exactly what you did maybe I could get all that energy, too! But I hope you start sleeping well soon–good luck!

    • Lori Hogenkamp  June 17, 2013

      This may be from the ketogenic effects on adenosine (it can kick the switch caffeine too inhibits). I don’t know the counters off-hand, whether it’s transient or just a sign ketogenic diet is not for you (sleep is kinda important-sarcasm alert). What came to mind as natural forms (there’d be pharmacological ones too) would be valerian and/or hops, however, there is no medical literature on the interaction of these two pulls on adenosine, so I would use caution and a fantastic doctor. There may be other strategies if investigated, or again there may be subtypes or times when/where ketosis is not a well suited strategy, in my understanding.

      Adenosine, Ketogenic Diet and Epilepsy: The Emerging Therapeutic Relationship Between Metabolism and Brain Activity. S.A Masino, M Kawamura, Jr, C.D. Wasser, L.T Pomeroy and D.N Ruskin. Curr Neuropharmacol. 2009 September; 7(3): 257–268. doi: 10.2174/157015909789152164

      The fixed combination of valerian and hops (Ze91019) acts via a central adenosine mechanism. Schellenberg R, Sauer S, Abourashed EA, Koetter U, Brattström A. Planta Med. 2004 Jul;70(7):594-7.

  62. Dan Hackam MD, PhD  June 12, 2013

    Peter, extremely brilliant posting. Thank you for your comments. Your distinction between acute and chronic toxicity is very important.

    I stopped measuring my lipids quite some time ago, because they had all reverted to normal after carbohydrate reduction. The thing I track now is my weight and waistline. I would also like to say that it is possible to be carbohydrate-reduced on a strict vegan diet, whether for ethical or health reasons. No need to throw out the baby with the bathwater there! The only sugar I consume is from vegetables or very small amounts of fruit. As with you, I am highly sensitive to (dys)metabolic syndrome.

    I have had some success with coaching patients to cut down on their sugar and starch intake, with impressive reductions in body weight, plaque burden (though a few deteriorated), and lipid measures. I believe you use LDL-P. We don’t have much access to that here in Canada, although I understand Atherotech has recently added it to their battery of tests.

    I would appreciate hearing what you think, in a nutshell, about fruit consumption. Or is that somewhere else on this site?

    Many thanks,
    Dan Hackam

    (reply)
    • Peter Attia  June 13, 2013

      Low GI fruit are fine for all, and most fruit (incl high GI like banana) for some. Even in ketosis one can consume a modest amount of berries.

  63. Mike McGee  June 13, 2013

    Hi Peter

    Your site is great.
    My question is: Do you know or know of any research in regards to how carbs impact hyroid hormone (T4/T3) production within the body.

    I’m an Endurance guy, Triathlon. My Thryroid was removed in 2005 due to Thyroid cancer and I take synthetic T4. My perception is that carbs somehow influence T4 conversio to T3 but have not been able to find any research.
    If I reduce my carbs it seems I need more T4. So I am trying to figure out the science to validate what I experience. Thanks……..Mike

    (reply)
    • Peter Attia  June 13, 2013

      I suspect it’s not about carbs influencing conversion of T4 to T3 and perhaps more to do with ATP sensing in the liver and those changes driving TSH, which in turn drive T3 and T4.

  64. Michael Trumper  June 14, 2013

    I was thinking of your blog as I read this disaster http://www.huffingtonpost.ca/jane-dummer/sugar-myths_b_3417321.html and this nice little bit of information at the bottom
    “Jane Dummer is a registered dietitian and expert in nutrition. Jane serves as a consultant to the food and beverage industry, including The Coca-Cola Company.”
    Last week I took my boys to a movie and was subjected to a 2 minute Coca-Cola propaganda piece that dovetails nicely with the message in this article.

    (reply)
    • Peter Attia  June 14, 2013

      Funny. But not funny, too.

    • Michael Trumper  June 15, 2013

      Yes, it is one of those head scratchers where you are not sure whether to laugh, cry or get angry.

  65. Bob West  June 16, 2013

    Peter, this is not directly about your post, but have you noticed that the “Recent Comments” list has started to have links to apparently unrelated posts on other web sites, that definitely are not comments, and that do not reference your blog?

    This morning I am seeing an entry in your comment list for http://excellentjourney.net/2013/06/15/primal-summer/ and another for http://healthylivinghowto.com/1/post/2013/06/why-the-body-needs-saturated-fat.html

    These actually look like interesting reads, but they’re not comments and they’re not on your site. Looks like a peculiar bug in your blog software. I first saw this a few days ago and assumed you would fix it, but maybe you haven’t seen it on your end (?). Hope this will help (and I hope I’m not the only one getting this!)

    Bob.

    (reply)
    • Peter Attia  June 16, 2013

      I think these are links from other sites to this one. The 3 I looked at are not spam and do make an actual reference. I’ll keep an eye out.

  66. Pam  June 16, 2013

    Those are called “trackbacks”. Others linking back to your site, usually a good thing.

    http://en.wikipedia.org/wiki/Trackback

    (reply)
    • Peter Attia  June 16, 2013

      Yes. I get about 10 a day, however they usually don’t show up as comments. Maybe they have all along and I’ve just missed it.

  67. Judy  June 25, 2013

    What a relief to find this blog and the topics you are discussing. Granted, there will always be parts that are over my head, but it is very thought provoking.

    I’ve been involved in various types of self-experimentation for many years, not necessarily by conscious choice.

    I do want to add one point to what you say about finding alternatives to foods with added sugars. Yes, it is possible. Be prepared, though, in our culture of many choices, to discover that many, if not most products wind up being off your radar. You wind up being surrounded by people puzzling over what foods to choose in a supermarket or restaurant while you are scanning around for what (or whether) there is anything there you CAN eat.

    Granted, in my case, I have sensitivities to MSG and for some bizarre reason, to citric acid, which is a common preservative, which basically means that if I want to eat it, I need to prepare it myself, and NO, I do not always have the energy to do this!

    In any case, I am so happy to have found this place where this discussion is happening and to following along as new information comes along.

    In the end, each of us needs to get to know their own metabolism and its quirks and since our bodies change throughout our lives, this learning has to continue as well.

    (reply)
  68. CD  June 25, 2013

    I’m tempted to think some of the difference in sugar tolerance between you and your wife comes down to sex-based differences re carb metabolism. I think pre-menopausal women do better with carbs than do men. Indeed, many women of reproductive age cannot healthily sustain a true VLC (or “paleo”) diet.

    (reply)
    • Peter Attia  June 26, 2013

      Probably not in her/my case, though these differences do matter over time.

  69. Mary  June 25, 2013

    I’m glad someone is looking into this. Someday there will be recognition that sugar addicts need opportunities for help rather than judgement about the resulting obesity and diabetes. Unfortunately, there is no such official recognition of foods/sugar being addictive “drugs” and there is no such thing as sugar rehab.

    (reply)
  70. Darlene  June 26, 2013

    Your article/blog post is very interesting to me. Two years ago, I had “perfect” cholesterol levels, great HDL/LDL ratio, but my Dr. noticed my fasting glucose was at 103. (It’s always been around 95-100 anyway) Then 6 months later, labs again, crept up to 109. Dr. said cut carbs and exercise. I weighed 155lbs at 5’8″, not obese. So, I went on the “Atkins diet” for 6 months. I exercised some. I do not RUN. :) I do have to tell you that I did not eat much chicken or fish (not a big fan of either in great amounts) but I cut carbs enormously. 50-75 max a day. I lost 15lbs -20lbs without exercise. Felt FABULOUS. I was 46.

    Labs again to see the results at about the 6 month mark, new Dr-other left private practice- fasting glucose had only fallen to 106. I was VERY disappointed. I had cut the sugar out of my diet tremendously. I love sweets! :) But I did it. Diabetes runs on both sides of my family and this is a concern though my mother’s was elevated (but not diagnosed diabetic) up until she died at 79.

    So that makes me wonder what camp i am in.

    I cut massive amounts of sugar out of my diet and saw little change in my fasting glucose levels.

    And the biggest disappointment was that my LDL/HDL went wonky on the Atkins. My good cholesterol went up (it was already good to start out with) but so did the BAD. My triglyceride level DROPPED. It was good before but it had a 30point drop! but now my LDL was over the legal limit! The ratio stayed the same but I received a phone call from the nurse with a call-in for Lipitor.

    I unofficially fired my Dr. at that moment.

    That Dr. just called in a cholesterol med and never once asked any questions about my diet!! I will get with a new Dr. and hopefully have an intelligent conversation about what’s going on with me and how to avoid having to take cholesterol meds and exactly HOW I need to modify my diet!

    ALL MY LIFE I have had fabulous cholesterol levels. GREAT LABS. Except that stinkin’ fasting glucose. And then the elevated cholesterol after following some version of the Adkins Diet!

    I’m very confused. I had a “normal diet” and had great HDL/LDL levels, but slightly elevated glucose. Went low carb, now wonky 225 cholesterol and still slightly elevated glucose.

    Ugh. Thanks for listening.

    (reply)
    • Peter Attia  June 27, 2013

      The ‘straight dope on cholesterol’ series may be interesting for you to read.

  71. Darlene  June 26, 2013

    Sorry that comment is so long. Perhaps you can edit it? I’ve had a lot of coffee today. ;)

    (reply)
  72. J Michael Hayes  June 26, 2013

    My wife talked to you about lipids in Boston at the AHS conference last year.
    I, a lawyer, was also present. Below is part what I got out of the conference & what it has led to. You will find it interesting:

    http://buffalo.ynn.com/content/top_stories/670200/buffalo-lawyer-files-lawsuit-against-makers-of-high-fructose-corn-syrup/

    (reply)
  73. Paula  June 28, 2013

    I wanted to put in Jay Wortman’s comments from Richard Feinman’s post on “Fructophobia”.

    “What is the downside of making sugar less accessible? You argue that in the current climate of lipophobia, the only place to go then is more starch. Yes, technically true. But in the real world, possibly not. When my 11 year old son leaves our sugar-free home and goes out into a sugar-soaked world, he is not tempted by pizza, rice and potatoes (well, maybe chips), it is the soda, juice, cookies, candies, etc that he is bombarded with that challenge his resolve to eat according to our wishes. If those are gone, will he then over-indulge in pizza, rice and potatoes? I don’t think so. And, even if more starchy things become available, they are usually combined with fats when eaten (eg pizza) which, I believe, mitigates the harms of refined carbs by reducing post-prandial hyperglycemia. If they are not combined with sugar (eg cakes, cookies) what will people eat instead? Excess starch consumption in the absence of sugar would be not that appetizing, methinks.

    “It is for these reasons that I think a pogrom against sugar is perhaps not a bad place to start.

    “My son at 11 already thinks he’s 14. And he has put us on notice that his first act after emancipation will be to return home and consume a chocolate bar in front of his father. To which I reply, “if you want to damage yourself, why waste your money, why not just hit yourself on the head with a rock? And why wait?”.

    My son and I have a great relationship and he has a wicked sense of humour. ”

    By the way, the documentary made regarding Jay Wortman’s Big Fat Diet in Canada is worth watching.

    (reply)
  74. Candace Fuller Pfau  June 30, 2013

    Refined sugar, I think is toxic regardless of whether you are a Jill or a Peter. Whole foods, preferably raised without antibiotics, pesticides, or GMO’s. We don’t need it. We can get plenty of natural sugar from fruits in our diet in moderation. I come from an alcoholic background that goes back three generations. I remember when my Father quit all alcohol that he suddenly started sucking in anything with sugar in it. I.E. cakes, ice cream etc. Well, he was just replacing his alcohol with pure sugar. Growing up I was a Jill.
    I sucked in deserts but I had a very high metabolism and was very active. I stayed slim. Fast forward to age 45 to 50. Slowly eating anything I wanted was no longer working. And I started to gain weight eating the same way I had always eaten. So, I started trying every kind of diet. Atkins, no carbs, raw foods. The hardest thing to eliminate were salty chips, and fresh bread. I easily gave up the sweet desserts. I could bake a loaf of bread and consume the entire loaf. Of course bread is starch is sugar. Same Same Same. Fast forward to age 60. Suddenly a cancer crops up on tonsillectomy scar tissue. After seven weeks of horrid radiation (it was stage one) And refusing all tube feeding. I then weighed 104 pounds. Having started at 150 pounds (before treatment) and I am 5 feet 6 inches tall. I refused tube feeding because I knew that if I accepted it, then I would not continue to eat food by mouth and eventually I would have to wean off the tube feeding plus I saw the infections that could result from leaning on tube feeding. So began my battle to gain back to a healthy weight. I found that now sugary foods held no joy. I had lost the ability to taste sweet. The best foods were pure, simple foods. Like fresh tomato (which I was advised not to eat but I have anyway, in fact craved them) I also could not now eat the salty dry foods because of lack of saliva. So, in fact, it took supplementing with protein Carnation to gain to 120 pounds. I imagine I was in ketosis without even trying since I had to eliminate all breads, and sweets. The best foods when you have no saliva are juicy fresh foods. Ie berries, avocado, peaches, tomato, etc. Meats were also difficult. A group of octogenarians who are on the CR slowing aging plan helped me to understand why I could not gain weight. Here is what they told me. Also this very low calorie diet is very good at reducing re-occurence of cancer cells. Cancer loves sugar in any form. This was a life saving email for me. I cannot thank the CR group enough. Also know that they thyroid can have great influence on cholesterol. Too little thyroid hormone and cholesterol will go up, as will weight gain. For me, I think sugar is poison. We don’t really need refined sugar. Be careful what you wish for. Life is strange.

    Hello Candy,

    My wife and I are on CR 8+ years now. She is 5’6″ and weighs 120, age 60.

    Wound healing is very slow when on a CR diet.

    You can add protein via protein powders added to smoothies. Whey and rice protein powders are frequently mentioned by our members. Be sure to do weight bearing type exercise so you add muscle instead of body fat.

    CR will inhibit the return of cancer based on lab animal evidence. Be sure to use diet tracking software to assure all essential nutrition. Those vitamins, minerals, and amino acids are what your body uses for maintenance and repair.

    You are finding it hard to gain weight because your body has established a new set point and will defend that set point. Continue eating additional calories from all sources and your body will finally accept that it cannot keep burning off the excess calories to defend the set point. It is similar to people reaching a plateau when losing weight. There are plateaus during weight gain as well.

    Alternative medicine is a sound approach to health maintenance, but modern medicine is where you want to look when you become ill. The best preventative approach is a diet high in vegetables and fruit. Restrict saturated fat and use olive oil as a healthy source of fat as well as fish and fish oil capsules. Regular exercise is also wise for age related disease prevention.

    Good luck and email again if you have further questions.

    Bob Cavanaugh
    Managing Director
    CR Society Intl.

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  75. Teresa  June 30, 2013

    I found this fascinating. Here in the UK the BBC ran a series a short while ago called ‘The Men Who Made Us Fat’, which closely mirrors what is being suggested in this blog. A precis can be found here: http://www.bbc.co.uk/news/health-18393391

    I went through the menopause at 32, then almost doubled my weight in a couple of years. I was thoroughly beaten down by docs saying ‘eat less, exercise more’. I have kept a food diary for the last six years and rarely go over 1800 calories & 50g of fat, walk continuously at work and do 30mins a day exercise. Still I’m seen as just a fat woman who’s lying to herself.

    I’m going to follow your suggestions and see if this helps. It does make sense!

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    • Peter Attia  June 30, 2013

      I’ve seen parts of it, Teresa. Very interesting.

  76. RL  June 30, 2013

    maybe all the ideas are correct?
    in the early 2000s i worked for an integrative medicine clinic. serving a primary population of cancer patients. they manipulated chemo to minimize the effects with heavier dosing at night, gave high dose iv vitamins, herbal supplements, psychotherapy, biofeedback, body therapies like massage. and of course diet. every patient was told they were getting an individual program but the diet was almost the same for everyone. a modified macrobiotic diet. no sugar, very minimal eggs, minimal to no dairy, cold water fish, lots of vegetables, beans, tofu tempe seitan. one of the personalizing factors was if a patient had an estrogen receptor positive tumor they were steered away from soy.
    i believed in the clinic and the diet & brought the diet home. no sugar (yes brown rice syrup, barley malt and agave). from few eggs to no eggs, from occasional dairy to no dairy and then no fish.
    i got sick. always freezing in the summer – from my bones. losing weight. constant fatigue unable to exercise, molluscum. my cbc bmp thyroid all normal. one of the clinic dietician / researchers deviated from the party line and told me my genetic background was not allowing me to follow this vegan diet, the best thing i could do was return to my omnivore roots or at least eat some chicken soup from time to time. i did and the molluscum went away i could run daily and lift weights. At the time i could not leave a meal feeling full without bread or pasta. recently life has changed, over a decade has passed i started putting on weight. now i feel best with bread once a week, mostly vegetables, meat – high fat – which has had multiple positive effects.
    is it user specific and time specific too? maybe all the researchers are correct – for some people some time – no fat or no sugar… could it be that the optimal diet based on stress, environmental exposures, sleep availability, physical demands and genetics at age 30 may not be appropriate for the different environment, other demands and the same genetics at age 50.

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  77. Joe  June 30, 2013

    Peter, I arrived here through your ted talk. It was quite compelling, and I impressed very much by what you shared there. I strive to grow that much in my own life.

    On sugar: I am relatively sure that I react poorly to sugar as well, when I went cold turkey I went from about 220 to about 200 in a few months (I am 6 1 and am fairly dense). I started doing crossfit and loosened up my diet a little (partially due to added calorie burn from the intense cardio) and my weight has shot back up to the 220 range.

    My trouble is that I actually have a reasonably hard time figuring out what is/isn’t on the “converts to sugar” list. Rice is bad, bread is bad? I guess? I can safely assume Ice Cream/Candy are bad, but that “Not obviously sugar” list is harder for me to find in a way that I can easily remember. According to some people it seems like nearly everything converts to some form of sugar, and I should be eating close to paleo if not actual paleo. Can you recommend a resource for finding an easy to understand list?

    Thanks!

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    • Peter Attia  June 30, 2013

      I think you may be confusing 2 ideas… when I say sugar I really mean sucrose and HFCS. Rice, etc. gets converted to glucose, which is not the same. The speed with which a carbohydrate gets converted to glucose is loosely proxied by its glycemic index (GI).

    • Joe  July 1, 2013

      Thanks for the reply!

      I guess the clarification to my question is that I don’t know what words I should be triggering on avoiding. I know sugar in all it’s various forms (Cane, evaporated cane juice, HFCS certainly, etc etc). What I don’t know is what else is on the list, I guess I sort of thought that all bread was inherently sugar, maybe that isn’t true. You are telling me Rice isn’t on your list of foods to avoid? Or it is?

      That sort of starts to get at the fact that I don’t know how to look at a food label and tell if it’s carbs are simple or complex, (Unless they are specifically labeled simple). Maybe that’s just internet research for me to do. I looked around your site and didn’t find anything like a discrete list.

      Thanks!

  78. Belle  July 1, 2013

    Hi Peter,
    I have found your post very interesting and educational to read. Recently I have been diagnosed with IBS and we have been trying to work out triggers and also if it could be food and my doctor had recommended the LowFODMAP diet. Information about the diet from Monash Uni – http://www.med.monash.edu/cecs/gastro/fodmap/.
    As part of the diet you cut out Fructose and Sugar Polyols to see if these can cause issues. I have found that this isn’t the only issue – the next step is a low carb diet, because we have seen a trend in carb heavy foods causing issues even within the limitations of the Low FODMAP diet.
    I also have been reading information from Sweet poison (http://sweetpoison.com.au/) which I thought you might find interesting.
    Thanks for an interesting post and I am off to read some more of them.
    Belle

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  79. Barbara  July 1, 2013

    limiting intake of this addictive substance makes so much sense. In regards to children, is it possible their bodies metabolize sugar differently so that its effects are less harmful until they are full-grown – (mother’s milk is high in sugar)

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  80. Valerie  July 1, 2013

    Hi Peter,

    Sorry if this comment doesn’t quite go along with the topic of the post, but my brain says it does, sort of.

    My husband and I started a low carb (<20g) diet over a month ago. We both lost 10 or so pounds of water in the first two weeks. He has continued to lose weight, about 1 pound a week. My weight has been another story. Starting the low carb diet seemed to expose another condition in me. It all started when we went for a hike on a Saturday two weeks ago. As soon as I started to feel the exertion from the hike, I noticed my hands starting to tingle, like they were losing circulation. Then it began in my feet, legs, and face. The tingling was leading to numbness until I told my husband I had to stop and rest. At this point I had already formed several hypotheses as to the cause and ruled out them all except low BP. To confirm, resting and squatting seemed to help, as well as guzzling water. After I drank about a liter of water, I was able to continue the hike with only minor tingling in my hands (I kept drinking water throughout). Since then, I've been trying to drink at least 80 oz of water everyday (even though I don't "feel" thirsty and often feel like I'm forcing it down) and get adequate electrolytes. However, my body is retaining the water like crazy (up and down 2-6 lbs everyday), but even though I'm urinating like crazy too, I still have symptoms of dehydration (dry lips/skin, lethargy, const., headaches, etc). Doing some research into the matter, it seems that probably I've been chronically dehydrated the majority of my life, but it somehow was always masked and mitigated by the water I retained with my glycogen load. My hope is that if I continue taking in a lot of water, my body's cells will stop acting like I live in a dessert (even though I do) and the retention and symptoms will cease.

    All of that to say this: My research led me to the book "Water for Health, for Healing, for Life: Your Not Sick, Your Thirsty!" by F. Batmanghelidj, M.D. In the book, Dr. Batmanghelidj makes claims that almost all of our chronic diseases (asthma, allergies, obesity, diabetes, hypertension etc) are caused by an underlying chronic dehydration and that 75% of Americans are dehydrated. These claims are based on his clinical and personal experiences (healing peptic ulcers by having patients drink water etc) and his own research, but he rarely cites scientific literature in the book. So, while the concepts are compelling, they might should also be taken with a grain (or pinch?) of salt.

    Here is where my brain connected with the posted topic: One of the claims he makes is that in the case of diabetes, dehydration and subsequent low sodium/potassium levels cause the brain to "peg up the glucose threshold so that it can maintain its own volume and energy requirements." This would explain why "stressed people resort to eating sweet food." Se essentially, people crave sweet food because they are dehydrated.

    But here is my real reason for posting: He also says that when water, sodium, and potassium levels are low, "the responsibility for holding water in the body and outside the cells falls onto the sugar content in the blood" and that insulin is a water regulator because it forces potassium into cells. He doesn't ever really touch on a dehydration-cause of insulin resistance. In fact, he claims that dehydration causes insulin to not be secreted, which causes diabetes. However, we know that in most individuals who end up getting diabetes, there is a hyper secretion of insulin and resistance to it before the pancreas gives out. However, assuming the above quotes are true, what if dehydration IS the root cause of insulin resistance? The logic would be as follows: the volume of water in the body is lower than optimal as well as sodium and potassium levels. The individual is eating excessive sugar because she is misinterpreting thirst signals. The pancreas pumps out insulin because the glucose load is too high. The cells, however, reject the glucose that the insulin is trying to usher in because they "sense" the body's dehydration level and are rejecting it in order to maintain adequate blood volume in the circulation.

    Do you have any insight in regards to this or chronic dehydration?

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  81. Mainstream Mom  July 2, 2013

    I’m new to your blog/web page but came across this post first. Regarding your daughter eating ice cream after being full. It seems pretty normal to me as far as what is typical with kids, even adults. Wouldn’t it have something to do with sensory specific satiety? Perhaps I’m understanding this term incorrectly, but it’s like eating at a potluck or a buffet. Because there are SO MANY enticing foods, it is easy to overeat because you’re not just eating ONE thing. I am not part of the low carb lifestyle. My family prefers oatmeal every single day. We add nuts and dried fruit to it, various milk options. But I get bored of it and can’t eat enough of just that to have it stick with me for more than a couple of hours. However, give me some savory foods and fruit and protein-rich items and I’m bound to eat more total calories because of the variety.
    The other thing that was brought to mind is a study I remember glancing at that showed that until children’s leg bones are done growing (or was it growth plates?) they have a huge tolerance and preference for sweet.
    When we serve dessert at our house, I tend to serve child-size portions WITH dinner, rather than at the end. The goal is to keep kids from learning that dessert is eaten on a full stomach. They often eat their dessert first and fill up til they are full from the rest of the offerings on the table. But then again, I sometimes let them eat as much as they want of a sweet (cookies for instance) during a snack time. I just make it a rule that they have to stay seated at the table. This way they feel like they have some control over portion and don’t feel unnecessarily deprived. But I don’t serve sweets frequently (more than you, probably).

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  82. Peter Duerksen  July 2, 2013

    Like some of your other readers, Peter, I arrived here through your TedTalk:
    http://www.tedmed.com/speakers/show?id=18028

    I just wanted to tell you I really appreciate the way that you are going about your research: no “gut-feels”, no “knee-jerk-reactions”, and questioning each assumption and before researching your own conclusion. You are taking the long, hard route toward the answers we are looking for, but it’s far more trust-instilling than diet books and nutritionists who build their business on emotional responses and unproven, unfounded research.

    I come from a family of overweight sugar-holics, multiple stomach bypass surgeries (which ultimately did not solve the weight problem for ANY of the 6 of them), Type-2 diabetes, and lots of dietary assumptions. The end result for me is that I’ve decided I did not want to mess with any of it, so I’ve been eating whatever I wanted to including loads of sugar for the last ten years, and am now about 50lbs overweight.

    I look forward to hearing the conclusions you come to as a result of your research, and maybe losing some of the weight I’ve gained.

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    • Peter Attia  July 2, 2013

      Thank you, Peter. Apologize in advance that science can only progress so fast (which is to say, not fast enough…).

  83. keith littlewood  July 3, 2013

    Hi Peter

    I really enjoyed your video on TED. It’s something i have been mulling over for a while now. When we talk about cellular dysfunction we can see so many issues occuring. What are your thoughts on thyroid function and the implication on all of the problems that you are seeing and how simple sugar may enhance cellular function particularly when hypothyroidism is present. Sugar may also be the current target of nutritional hate but I found that this article provides an interesting balance to the arguement.

    Would be great to hear your thoughts. keep up the good work.

    Keith

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    • Peter Attia  July 3, 2013

      Keith, I really like David Katz, though I don’t know him personally. The article is reasonable, and I think he’s asking good questions, but it’s actually the wrong question (though I understand why he’s doing it). The question should never be is X “the” harmful food that causes Y; it should be is X “a” harmful food that causes Y. By focusing on the former, rather than the later (until the very end), he spends a lot of time arguing about a null space that is irrelevant.

  84. Yvonne Shakti Mireau  July 6, 2013

    Finally!!! A critical look at the complex questions we should be asking about…well, everything! I’m so excited about discovering your blog and TED talk that I hardly know where to start…!
    First, I have often wondered why I can also “mainline” ‘sugar’ without gaining weight or becoming diabetic. I am concerned about my use/ “addiction” however, especially since having breast cancer in 2007 (NED now) and hearing about how ‘sugar’ “feeds” cancer. (Even the terms sugar, addiction, cancer-food need to be defined further, which brings me to my next point).
    Secondly, I love that terminology and hegemonic assumptions are being critically challenged and discussed, in both scientific and vernacular ways. When I wrote my MSW thesis about eating disorders in 1997, I almost drove myself crazy examining every possible assumption… language itself is so loaded! And the questions we ask, or don’t ask, also need to be carefully examined for biases.
    Thirdly, as a former nurse (NICU) I am delighted to see you addressing the diversity among patients with such compassion and curiosity. Why DO some people become obese, insulin resistant, diabetic, while others just don’t? Why do some smokers get lung cancer, while others don’t? Why do some people gain weight by eating relatively healthy foods, while others can ‘get away with’ eating a poor diet? What role, and how much of a role, does genetics play in all of this?
    There are so many more questions than answers! Keeping an open mind, questioning our assumptions, paying attention to nuances and discrepancies can open the door to so much more insight than trying to prove a vested interest or favoured theory. Thank you!
    Keep up the good work!

    (reply)
    • Peter Attia  July 6, 2013

      Thanks very much, Yvonne. I appreciate your feedback.

  85. Zack K  July 7, 2013

    Hi Peter,

    I also arrived here through your TED video and I’m glad that you are researching this topic, I believe it could have a large on our society, no pun intended. I also have encountered some questions that I think you would have the insight for. I agree with your stance and I would also hypothesize that one of the sugar side-effects could be “a” cause of bad dental development/health, and could be an indicator for people who don’t seem affected, like the Jill Camp.

    I have done some research regarding Nutrition and centered a diet plan around macronutrients (protein, fats, carbs), while striving to avoid unnecessary simple carbs (sugars) and “bad” fats. The only time I used sugar, more specifically Dextrose and MaltoDextrin (about 40-50 grams total), was after intense weightlifting. The reason I supplemented Dextrose and MaltoDextrin was to boost the metabolization of protein, improving the speed of delivery to muscles and jump starting the recovery phase. By using this simple sugar supplement, it would cause the body to react by increasing insulin levels which does two things: first it helps deliver the protein to the muscles by increasing uptake caused by the elevated insulin levels and secondly, mitigates the effects of cortisol, which is released during weight-training, further breaking down muscles and inhibiting the rebuilding phase. I have seen great results and no bad effects, although I am concerned about a few things.

    So here are my questions: Would/Could using Dextrose/Maltodextrin to boost Insulin levels be detrimental to overall health in the mid/long run? For example, causing an individual to be more insulin resistant? or despite the boost in muscle growth, could the sugar be causing harm to dental health via the bloodstream? is there “a time and place” for sugar in a peter’s camp individuals’ diet?

    Another concern of mine is consuming HFCS and other processed carbs, and I am disappointed because it is economically difficult for many to avoid HFCS or sugar substitues, perhaps there is an underlying effect that exacerbates the effects related to sugar consumption? I have read that particular sugar forms are metabolized in different ways physiologically and have different effects. Should I be concerned despite the claims stating that sugar is “chemically the same structure” etc.?

    I really appreciate your experiences and research, I hope that your findings are able to find their way into our culture for the health of many who suffer from dietary diseases.

    (reply)
    • Peter Attia  July 7, 2013

      Zack, I’ve never seen compelling evidence that sucrose and HFCS are biologically different, though I guess it’s possible in some settings. So if you’re worried about sucrose, be worried about HFCS, and vice versa. If not you’re not, nothing to worry about, enjoy the cheaper version (HFCS).

    • Threonate  July 7, 2013

      I would favor plain sugar (sucrose) and cane sugar over HFCS, since the latter can be contaminated during production and processing, such as when it was found that about half of all tested samples of HFCS in 2009 were contaminated with mercury.

      Besides, and I’m not sure how this is possible, but drinks sweetened with HFCS have a hint of “corn” in their flavor compared to drinks sweetened with white sugar. Not sure why, but I can definitely taste the difference. I remember sweet iced teas and sodas in the Middle East surprised me with their superior flavor; a more “sugary” taste if you will. It was hard for me to ignore the subtle corn flavor in U.S. sweet teas and sodas, especially with brands such as Arizona.

  86. Threonate  July 7, 2013

    Peter.

    Not sure how you’re able to do so much research and write many serious, thorough articles, but it’s welcomed and refreshing!

    You probably wrote the best series on cholesterol (The Straight Dope on Cholesterol) that I, or anyone, has ever come across.

    Again, thank you for all the work you do and information you share. It’s not in vain, that’s for sure! Just wanted to let you know.

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  87. Marcia  July 7, 2013

    Peter – great blog and your TED talk was amazing. Beyond amazing. Should be required watching for everyone in the medical profession . . . including patients.

    Question (relating somewhat to this post): how would you handle a teacher (grade 2) who rewards all her students’ successes with candy. Or – how deal with a school that allows such an insane practice?

    Thanks – again – for all you do and for that brilliant talk.

    (reply)
    • Peter Attia  July 7, 2013

      Marcia, that’s a tough question and I guess at some point I’ll have to address it head on when it’s my child in that situation. I guess, and I may be overly naive here, I’d ask the teacher why he/she thinks candy is a great “reward” for a student?

    • Mainstream Mom  July 10, 2013

      Spoonfed blog has some resources on talking to teachers about food in the classroom: http://spoonfedblog.net/wp-content/uploads/2012/Spoonfed%20School%20and%20Junk%20Food%20Handout.pdf

      The link is not the one I was looking for but you could do a search on the blog. Also The Lunch Tray blog. One of those has another nice handout about food in schools. Ultimately if you can help your teacher see that food rewards (of any kind) are inappropriate at school that might help. Seems like most organizations that deal with children’s health state quite clearly that food rewards should not be given to children. Maybe print out some things like that.

    • Commprof  July 13, 2013

      As someone who has worked in school setting for many years, I would recommend following the excellent suggestion to find some credible written material about how inappropriate it is to use food for rewards and give it to the principal. I would ask the principal to bring this to the attention of the teachers but not say that a parent (or which parent) initiated it. This way your child is less likely to be identified by the teacher or other students as the person who made the candy go away.

  88. Denise  July 7, 2013

    Hi Peter,

    I don’t know if this is the right place to share this (and you may well already be familiar with this); my husband and I have been discussion much of what you have written -with great interest!- and have been bouncing questions back and forth about the American/Western phenomena involved in context with the global (my husband is not American, so these types of discussion are the norm around our house). Anyway, a quick Google search pulled this up, and I thought to share it with you –on the off-chance you may not have already seen it. http://www.noorderlicht.com/en/projects/the-sweet-and-sour-story-of-sugar/ — in reading more about this project, the question of “toxicity” can (and does!) go beyond American consumption…WELL beyond it.

    Thank you SO much for all that you are doing. :-)

    Cheers,
    Denise

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    • Peter Attia  July 7, 2013

      Denise, though I had not seen this particular link, I’m unfortunately familiar with this issue.

  89. Tim  July 7, 2013

    Peter – Thanks for the interesting article. Interesting that you begin with using APAP as the basis for your discussion. And I guess my question goes to both APAP and sugar. Is there a point of chronic toxicity that you will not end up with a chronic medical condition that can not be reparable. My concern is more on the lines of APAP. I had an anterior/posterior spine reconstruction with about 10 levels of fusion. After 2 weeks in the hospital I went home on Vicodin 10mg with 375mg APAP. For the first month I was taking 2 tablets every 4 hours. And then tapered to close to none after another 2 months. Lot of both, huh. I think I fell just under the LD50 for APAP for an extended time. Question is – after that amount is the liver able to repair itself? I know that Tylenol is in almost everything like sugar is, and I avoid lots of OTC meds like the plague. Just finished the Clean diet by Dr. Alejandro Junger hoping the detox would help. Incidentally I lost about 30 lbs. in that three weeks, and am going to continue with the diet, only adding a few more calories as it is very restrictive. Tim

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    • Peter Attia  July 7, 2013

      Fortunately, Tim, the liver is one the few organs in the body that is completely able to regenerate after injury, provided the injury does not scar the hepatocytes or liver architecture. You doctors can definitely do a quick blood test to determine the health of your liver.

  90. EbonTheStudent  July 8, 2013

    Hi Peter.
    I came here after seeing your talk on TEDMED. My question is about sugar replacements. My theory is that while our bodies are built to deal with sugar to some extent (though not refined sugar, I concede). Is it plausible that the modern rise in obesity/insulin disorder could be in relation to the exponentially increased use of sugar replacement chemicals? What I mean to ask is, do you think that one cause of this damage to insulin receptors etc could be the unnatural/manufactured additive we have in todays diet?
    Anecdotally I notice a high number of people who have problems with health turn to sugar replacements, diet options, and “fat free” foods, and I wonder what the correlation/causation relation might actually be?
    I have often worried that, because we all “know” that sugars and fats are bad for us, and that the majority of the research we have focuses on those items, we overlook the damage that may be caused by the things that we replace them with. The packet says “80% less sugar!”, and that’s what sells. Nobody really notices the rest, or if they do, they place a smaller importance on it due to the public conception of sugars and fats…

    I was just curious to your thoughts and if you’ve come across similar theories in your research?

    Thanks!

    (reply)
    • Peter Attia  July 8, 2013

      I wrote a post on artificial sweeteners that sort of addresses this question.

  91. Mary S.  July 11, 2013

    I listened to your TEDMED talk today and was greatly affected. Thank you so much for your compassion and understanding. I am a 67 year-old woman in excellent health, but 11 years ago I was headed in the wrong direction, weighing 262 lbs. and completely out of control with my eating. I have no idea what my glucose reading was at that time since I didn’t have the courage to see a doctor until many months later, after I had made major changes to my diet and lost a considerable amount of weight. I joined Overeaters Anonymous in August 2002, something I recommend with all my heart to anyone who is having difficulties with food. Since October of 2002 have not eaten anything containing sugar in any of its forms as an additive. Ditto for flour (the word can’t appear on an ingredient label). Today I weigh 137 lbs. on a 5’6″ frame. At a medical screening this morning my fasting glucose level was 77. The miracle for me is that since eliminating these foods from my diet I have not had a single compulsion to binge or even to overeat. I know this is a mere anecdote, but I believe my experience supports your theory, especially the part about hoping to make it possible for people to do the right thing. First we need to know what the right thing is, since I fear that many of us are getting bad advice from the nutrition experts. I am very familiar with the heartbreak and degradation which come as the result of obesity, and the contempt which many of us have experienced from members of the medical profession. My very best wishes for success in the work you are doing; I’d like to think we will see some results in my lifetime! Maybe you are too late to make amends to that woman in the ER, but I accept them gratefully on her behalf. You and she are both in my prayers today.

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    • Peter Attia  July 11, 2013

      Mary, this is a very impressive journey. I hope others read this and find solace in the struggle so common to beginning a journey like this one.

  92. Michael Hirasuna  July 13, 2013

    Sugars, both glucose and fructose, are toxic. Their exposed oxygen atoms will react with protein if given the chance. It is our ability to convert sugar to glycogen or fat that keeps it from harming us. Sugar is not a natural nutrient, humans have to adapt to it. Two million years of evolution has given humans a fat based diet. So when glucose from grains became readily available ten thousand years ago, the human digestive system began to adapt to the increased glucose load. Ten thousand years is short in evolutionary terms but not insignificant. It should not be surprising that some people can thrive on a whole grain diet, but those people probably could also thrive on a fat based diet. But people who thrive on fat based diets, may not thrive on whole grain diets. We only had 40 years to adapt to fructose from a sugar based diet, so it is surprising, but not impossible, to find individuals who can thrive on sugar.

    Possibly an interesting experiment for NuSI would be to take advocates from the China Study and the Paleo schools and have them switch diets. It might even be funded by a television network looking for a new reality show.

    If both groups thrive, then Lustig was right; it is the sugar. If both groups get sick, then diet is genetically based. If one group thrives but not the other, then we can finally recommend a diet that is good for everybody.

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  93. Dorothy  July 13, 2013

    Hi Peter,
    I quit eating sugar ages ago after reading Dr Perricone say (in not these exact words) sugar makes you look OLD. I didn’t need any research, that did it for me…;) although I did finish his book and his research is compelling. I am wondering, is Stevia ok? Not the ones mixed with maltodextrin or anything like that but a high quality stevia with no additives. Does this count as “sugar” even thought it has no calories and is a plant? Green tea is a little strong without it! ;)….plus he recommends cinnamon to keep insulin levels in check, what is your opinion on that? As well as alpha lipoic acid to increase glutathione…I’d love to hear your take on these things.

    (reply)
    • Peter Attia  July 13, 2013

      I don’t really know, Dorothy, but I would guess stevia is less metabolically taxing than sucrose, if for no other reason that one consumes lower “doses” to get the same sweetness “effect.” Probably a similar argument for the typical non-nutritive sweeteners. This, of course, says nothing about the impact they may play on your brain.

  94. Lara  July 13, 2013

    Great article – I just watched your TEDMED talk and was very impressed by your approach of questioning convention. In this same vein, what are your thoughts, or have you done any research into the role that synthetic chemicals play in the onset of insulin resistance. There are a number of chemicals (now classified as “obesogens”) which are linked to metabolic disease through various pathways (hormone disruption, suppression of leptin, altering production & development of fat cells, and even triggering insulin resistance).

    Many of the chemicals in our personal environment, from pesticides on our food, to chemicals in our cleaning products, household items, are “obesogens” and follow a totally different dose response curve than is found in traditional toxicological research. Obesogens are all endocrine disrupting chemicals, and are/can be bioactive at extraordinarily low levels in the body, resulting in a “non-monotonic dose response curve” rather than the monotonic one you’ve shown above… meaning very low levels of these chemicals, WELL below the LD50 tests, can me more toxic than larger exposures.

    I’m fascinated by the intersection of synthetic chemicals (and some natural ones) that are able to interfere with our bodies hormonal system, many pre-natally, that can result in insulin resistance leading to obesity, or other metabolic diseases, and the obesity epidemic.

    Would love to hear your thoughts on this side of the research!

    Thanks for all your work and helping to shift the conversation away from blame!

    (reply)
    • Peter Attia  July 14, 2013

      Lara, Unfortunately, I don’t have enough expertise on this topic to offer anything beyond a trite response. Hopefully there are folks doing the type of research on these chemicals that will be done on the food side in the coming decade.

  95. Paul  July 14, 2013

    Hi Peter, thanks for the amazing work you are doing. I wonder if you could address why you supplement with magnesium and potassium. I have experienced cramping more often on a highly carb restricted diet but have never seen those supplements recommended. By what mechanism do you think the low carb diet depletes Potassium? Again, the website is incredible and I can’t wait to see what NUSI has in store for us.

    (reply)
    • Peter Attia  July 14, 2013

      Mg is a co-factor in how we process K. Also, the renin-angiotensin system, which leads to K depletion, is kept in check with sufficient sodium.

  96. Corrie Ann  July 14, 2013

    Thanks for this post. I stumbled across your TED talk tonight, which led me here. As a health/nutrition coach I am often posed the question about the impact of sugar on the body. It’s interesting, because so many people just want a yes/no answer. They don’t like the “it depends on your body” answer, whether it is about sugar or anything else health wise. Thanks again.!

    (reply)
  97. arantxa  July 14, 2013

    Dear Peter,
    thanks for your great blog and all the great job you are doing, i form part of the Spanish PCOS community a 6% of the women have this Syndrome which is believed to be generated by the insuline resistence, it is quite difficult to cope with it due to weight gain, androgin obesity, hirsustism and infertility, acanthosis nigricans, as you can see a whole miriad of symptons..We are carboaddicted but it seems doctors (at least in Spain) does not want to give us a low glycemic diet but the classic 1200 calories one which makes no effects on us, we only loose around 6 to 8 kilos at the beginning but then our bodies seem to stuck on this and despite our efforts no more weight loss, therefore we quit as we see no results. You are talking about kethosis, are you doing Dunkan diet? here is forbidden, endocrins say if the prescribe this type of diet they will be rejected from the Endocrine Association..
    In my oppinion a Dunkan diet is a bit strong for our bodies, we promote to avoid simple refine sugars and flours, eat more vegs and fiber which slows the glucose metabolism in our body, eat complex carbohidrates instead such as wholegrain bread and pasta (moderate) and what is more important to exercise.
    In the old times in my country people had no car or other vehicles and walk from their town to other towns, they ate heavy casseroles with legumes such as beans, cheackpeas, mixed with meat and they were lean and healthy. Nowaday with the stress of our daily lives we have no time to walk and also the stress is a key factor to eat, the more anxious we feel the more we eat , if you are a sugaradict the situation gets worse as you eat sugar to feel energetic but 3 hours later you feel down and tired and have to eat sugary things again to have energy.. it is a yo-yo situation¡¡
    i hope that one day you can find a good and healty dietary programme and we can have the great luck to try it¡¡
    many thanks for your great job¡¡

    (reply)
  98. Susanne Biro  July 15, 2013

    Hi Peter,
    I came across your TED Talk and then this article. You mention eating chicken. What are your thoughts on the work of John and Ocean Robbins, Kathy Freston, Dr. T. Colin Campbell, Dr. Joel Furhmanm the documentary “Earthlings” regarding the many benefits of a plant-strong (vegan) diet – for weight-loss, disease-prevention and sustainability of our planet? Thanks in advance for any response. Warmly, Susanne Biro.

    (reply)
    • Peter Attia  July 15, 2013

      Susanne, sorry to ask this of you, but can you look through some of the comments in the blog (various posts), as I’ve addressed this several times. Too long to type out each out time. Sorry.

  99. Steven James Beto  July 17, 2013

    I have often times wondered why we consider sugar a condiment and not a drug. Sugar is derived from the plant source as is heroin and cocaine and the end result is a white, crystalline substance. In the book, “Sugar Blues”, it was stated that sugar in the 17th and 18th centuries was taken through the nose; consider also that sugar has been used to cut more dangerous drugs. Yet, we pack the substance into processed foods and feed it to our babies. Could there be a correlation between sugar consumption and disease? I am pleased that you are looking in to the problem, Dr. Attia, and I leave it to you to find the answer.

    (reply)
  100. Lucas  July 17, 2013

    Hi Peter,

    Maybe the missing link to insulin resistance is endorphin resistance. The endorphin receptor (MOR) regulates the quantity and the sensivity of insulin. http://www.ncbi.nlm.nih.gov/pubmed/19221053

    kind regards

    Lucas (Epigenetic therapist)

    (reply)
  101. Erica Lynn @ Optimal Health Consultant  July 24, 2013

    I loved this article. Everyone seems to desire a “one diet fits all” plan and it just doesn’t exist. Each one of us were created uniquely, not equally.

    If I eat sugar within 12 hours I will become an emotional wreck; angry, sad, depressed. My daughter however can have a moderate amount without it affecting her at all.

    In my house we eat based upon our personal body’s needs.

    (reply)
  102. BobM  July 31, 2013

    Peter,
    I have been an Eating Academy reader for almost two years now. I credit your low-carb program with my 35 pound weight loss as well as correcting my lipid profile. I am a big fan of your work and this site. I do have a related question though. I notice that in many of your articles you write that a carb rich diet leads to metabolic syndrome. This in turn leads to Alzheimer’s , cancer and heart disease. Can you share with us how sugar and carbs in the diet lead to Alzheimer’s disease? I ask because I recently had my DNA tested through 23andme.com. I learned that for the APOE gene, I am ?4/?4. For men with this variant, 23andme.com calculates the odds of getting Alzheimer’s by age 79 at 43.5%. This compares to 7.2% for and average person.

    I realize this is probably too large a topic to cover in comments section of this article. It probably would require at least an article of its own.

    I’ve done some article searches on my own and found the article: Nutrition and Alzheimer’s disease: The detrimental role of a high carbohydrate diet:

    http://people.csail.mit.edu/seneff/EJIM_PUBLISHED.pdf

    Is this a good article to for me to read to get the understanding I seek? Does it look like good science?

    Thank you in advance.

    Bob

    (reply)
    • Peter Attia  August 1, 2013

      I hear your concern, Bob, and have worked with a number of people who have the apoE 4/4 alleles. I have lectured on this topic, and am familiar with the literature, but I have not been able to sit down and put a post together. This is a reasonable paper to read, but I hope to deliver a great post at some point. Short answer to your understandable concern: apoE 4/4 does NOT “ensure” you will have AD. You can, I believe, do much to combat this risk.

    • Pam  August 1, 2013

      Good morning Peter. This is a request for clarification of your answer here to Bob.

      “Short answer to your understandable concern: apoE 4/4 does “ensure” you will have AD.”

      Did you mean that having the apoE 4/4 _does_ mean you’ll end up with AD? I have read other places, such as Dementia Today, that it does _not_ mean one will absolutely develop AD. Or perhaps there is some nuance here I am missing….very possible.

      I join the chorus here of thanking you for spending precious time with us here with your “hobby.” Blessings to you and your family.

    • Peter Attia  August 1, 2013

      GREAT catch, Pam.

    • Maryann  August 1, 2013

      Hi Bob,

      Gary Taubes has a great chapter (Chapter 13) in “Good Calories, Bad Calories” that I believe has the answer you are looking for. It is a great chapter and I think you will like it.

    • BobM  August 7, 2013

      Thank you Peter. I will look forward to that post. In the mean time, I will continue with my LCHF diet and be particularly vigilant about fructose.

      Thank you Maryann for your suggestion too. I’ve seen many good comments about “Good Calories, Bad Calories”. I think it is time for me to read it.

      Bob

  103. Rob Weiner  August 9, 2013

    Another excellent article. Thank you for putting this together. As a former health and safety professional, I can tell you that your explanation of LD50 is the best I have ever read. I also believe your explanation of individual dietary tolerances is also spot on, based on my comparisons of my own health/diet to that of my four siblings (I got the short genetic straw).

    One question: does it make sense that the toxicity of sugar would also be dependent on the overall caloric load of the rest of the diet? For example, if a person ate 2oz of sugar as part of their 1500 calorie diet wouldn’t their body process that differently than eating 2oz of sugar as part of their 2400 calorie diet?

    Thank you, thank you and thank you again for this profoundly helpful website.

    (reply)
    • Peter Attia  August 9, 2013

      Yes, completely. Sugar may be more detrimental in the context of being “over-fed.”

  104. Reiner  August 15, 2013

    Peter

    Fantastic blogging! I spent three days reading (just read 10 or 15%!) and learning and getting information to criticize. Congratulations, just excellent!

    I would like to translate some topic for Portuguese (Brazil). I can (with appropriate citations)?

    (reply)
  105. James Page  August 15, 2013

    Hey Peter I really appreciate the transperancy of your journey that you provide here! It is very helpful and keeps me constanstly driving for more information and knowledge. I have a few questions I am hoping either you or someone on here with more experience can help me with, really just looking for ideas. I recently transitioned into nutritional ketosis, going on my 4th week. I opted to purchase the nova max to monitor my levels , my initial reading after intense circuit training prior to refueling was 1.6mm/ket after fueling up and 30 min I jumped to 2.1mm/ket which was odd I thought initially, but realizing the intense workout actually causes blood sugar to go up as muscles release glycogen from what I understand??? Lastly after another intense workout last night and dinner I tested about 20 later and my level was an astonishing 3.7mm/ket, I was a bit alarmed as that seemed to high, as I am not diabetic I am concerned about the level? I quickly ate some almonds/cashews/cream to raise my blood sugar in order to get below 3.0. I guess I am just looking for someone with more experience here that could hopefully chime in and provide some insight into my recent experiences.

    (reply)
    • Peter Attia  August 15, 2013

      I’m not familiar with the units you’re referring to. I work in mM. BTW – muscles can’t release glycogen, but the liver does.

  106. James Page  August 15, 2013

    Sorry i was referring to mM, and I was confused on the glycogen mainly because I was trying to ascertain how my blood sugar would be higher and ketones lower directly after a workout, then after eating a meal they reversed my blood sugar down to 77 from 92 and ketones from 1.3mM to 2.1mM on that particular night. Then last night after a meal my levels being 3.7mM just trying to make sence of it all. I have read levels above 3mM are not optimal.

    (reply)
    • Peter Attia  August 16, 2013

      I would not conclude that. Read post on fat flux. Blood measurement is a snapshot in time. Don’t infer too much.

  107. James  August 19, 2013

    G’day Peter! I recently stumbled across your stuff after listening to your recent TED talk… interestingly it is something I have been more recently reading about whilst away from home on a medical elective, and then I googled and found this site and all the gold you’ve written on it! Keep up the great work!

    Anyway, being an Aussie I thought I might give a wrap to another aussie doing something you may be interested in following. Damon Gameau, is a young film producer making a movie following his journey of eating 40+ teaspoons of sugar in “healthy” food after a few years of low/no sugar diet.. He is up to day 18 and already blogging the effects it’s having on him. I think by day 40 he will have lost the plot! I am keen to see how he goes! If you get the chance check out this site

    http://gameauland.com/that-sugar-film-teaser/

    Cheers, and looking forward to some new material from you.

    (reply)
  108. Daniel J ShenSmith  August 26, 2013

    Peter,

    I’ve been reading your posts and articles, watching your medical talks and TED talk for weeks now, and obviously still have much to go!

    I’m sure you’ve received a ton of comments like this, but I’ll make it anyway as you deserve every one of them; Your TED talk in particular showed that you have true compassion for others, and that you are not afraid to speak out for something that you truly believe is in the REAL best interests of others’ well-being.

    Just like everyone else, I’ve grown up with beliefs that dietary fat is bad, followed the guidelines and nutrition rules whilst being very fit and active. Alas, I developed the same “fit-fat” body you describe in my early 30s.

    I’d been increasingly aware of ‘rubbish’ in the processed and pre-packed foods we eat, but your talks and blog gave me the proper confidence to kickstart some REAL changes in my diet. Within just 6 weeks of changing my diet I’ve lost around 5kg of mostly fat, whilst taking on an additional gymnastic strength building programme, and I’ve never felt fitter / stronger! From morning to night, I don’t feel hungry, I don’t feel tired, I feel fitter and stronger than ever.

    I have a 3 year old, and I will certainly be mindful of not allowing the same pitfalls most of us have had from standard ‘guidelines’

    Please count me among the people giving you a true ‘thank you’ for your work, it is well deserved.

    I do have one question currently that I’m struggling to find a definitive answer to;

    I note from your writings and podcast that the carbs in most dairy products are converted immediately so do not truly count in the carb intake, however I’ve been wondering about milk in particular. I have always drank full-fat milk, but lately have been wondering about the carbs within it, and how much of it would be converted, and whether I should limit consumption of milk?

    Thanks and kind regards

    (reply)
    • Peter Attia  August 26, 2013

      Daniel, thank you so much for the kind words and for your support. The main sugar in milk is lactose. Different people process this differently. For many, some of that lactose gets converted to lactate, which the liver turns in glycogen down the line, while the other half works more like glucose via insulin secretion, etc.

    • Daniel J ShenSmith  August 27, 2013

      Thanks for the reply, pretty much as I’d deduced from your resources, and had chosen the correct path in that case and limited my consumption to very little added to coffee!

      I had always known there was a huge amount of sugar, carbs and starchy foods on the shelves, but lately I truly feel enlightened having walked back through the same supermarkets and have to say that it appears 98% + of stuff on the shelves is just crammed with those highly refined culprits of insulin resistance!

      Having spoken with a number of people about this, some of them argue the case that ‘some people eat anything and are still skinny’ – but of course they miss the point that not everyone is the same, not everyone processes all foods in the same way, and skinny doesn’t mean healthy by any means!

      Thanks again

  109. Billy Williamson  August 30, 2013

    I have been thinking about switching to a ketogenic diet for quite a while now, but I have one very big problem. I am a college student, at Binghamton University, and the cafeteria food is not exactly composed of high fats and proteins. I have been thinking about making a meal replacement shake instead. I was thinking a protein drink with a scoop of peanut butter and some coconut oil that I would drink four to five times per day (I should probably include some sort of multivitamin). I guess my question is, is this practical, and more importantly, is this a safe thing to do?

    I should also add that I am a 20-year-old male and not over weight, but I would like this diet to complement physical performance as well as my studies.

    (reply)
    • Peter Attia  August 30, 2013

      The all liquid diet is certainly easiest, though not enjoyable for everyone. Is it really necessary, or can you get away with one liquid meal and one solid meal per day + snacks?

    • Billy Williamson  August 31, 2013

      I can probably get away with one solid meal per day, there is a salad bar. Snacks? I don’t think that is feasible for me, only because any snacks I could eat are usually fresh foods that spoil easily. I think I will try two liquid meals per day + one solid meal + a couple snacks.

      Thanks for the advice

  110. charlie  September 11, 2013

    LD50: http://xkcd.com/1260/ ;o)

    (reply)
  111. james  September 12, 2013

    Hey Peter, what does your Wife eat?!

    Your example at the end of where you and your wife sit on the genetic spectrum was cool – and very similar to what I’ve found with my girlfriend and I. She can pretty much live on Coke and Chocolate and not gain a kilo, whereas I would just ballon right up if I did that.

    So even if ‘weight’ is not an issue, (my girlfriend is quite thin and would actually like to put ON some weight), I’m curious to know what you see as a healthy diet for somebody on the high end of the genetic scale?

    Just because they CAN handle that much sugar, obviously doesn’t mean they SHOULD, for all the other health reasons you’ve explained, but could they also benefit from going to a NK diet?

    Thanks!

    (reply)
    • Peter Attia  September 12, 2013

      Pretty “normal” diet, except that it’s relatively low in sugar. I’d guess she’s at the 10-20th percentile of sugar consumption in the U.S. She’s probably 45/30/25 by CHO/Fat/Protein.

  112. Kyle  October 3, 2013

    Hello. If it’s okay to do this here, I would like help on this concern. I’m Filipino. Rice is so much essential to us as a culture here but is it evolutionary? I want to be fit, ripped and healthy. I’m currently 230 pounds and I consider myself diabetic with so much digestive problems. The books and research combined that I gained and most practiced in the book, Man 2.0: Engineering the Alpha by John Romaniello and Adam Bornstein, was a Intermittent Fasting, Very Low Carb, Paleolithic Diet with Metabolic Resistance Training.

    He calls this the “Insulin Reset” stage. As I pondered upon this, each one of these big words are books by themselves and here are these people combining them. I tried the first week and I felt really great but after the fourth day, I really craved rice and temptation to eat like normal was really beginning and I binged. Felt really bad.

    Then, I had e-mail conversations with author Stephen Lanzalotta who made The Diet Code and basically advocates a calculated 52% carbohydrate, 28% fat, 20% protein division focusing Fundamental Foods during the Renaissance. But then, reading the science of Man 2.0: Engineering the Alpha (Intermittent Fasting, VLC, Paleo, Resistance Training) it felt so bad to go back to a more relaxed carbohydrate state.

    But, both claim that people have gotten healthy with their totally contradicting methods (former heavily researched and up to date and the latter seemingly merging a golden ratio concept and working out an eating model using real food). Any advice or guidance regarding the merit of the two considering my gigantic weight?

    (reply)
  113. Mihail  October 8, 2013

    Hi Peter,
    I’ve read carefully what you wrote about sugary food.
    I am a diabetic type 1 since I was 30, now I am 33 years old. I am an very active person, I do a lot of sports and I try to eat as best as possible. But my food has a lots of carbs. Because of my sports, (I am doing some martial arts) I need to eat a lot. Main meals contains around 80g of carbs, lots a veggie and meat as well.
    I am thinking to switch on this low carb high fat diet. My LDL it’s a bit high and doctors tried to put me on statins but I just don’t want to take them. Even my diet doesn’t have too much fat I am still having this problem.
    Have you experienced someone like myself on this diet?
    Could you help me with some advices please?

    (reply)
    • Peter Attia  October 8, 2013

      The cholesterol series will help, especially as it pertains to the important (and unimportant) biomarkers of cardiovascular health. You may not need as many carbs as you think and I’d recommend looking at the book by Dr. Richard Bernstein, himself T1D.

  114. Mary Becker  November 6, 2013

    Hi, Pete.
    Thank you for sharing your blog.
    We noticed that you have thal minor as does my daughter who is a performance athlete. We are trying to help her maximize her performance. Any suggestions? How do you modify your diet, training and recovery plans to address your thal minor? Any further reading or consultants you could recommend?
    Thank you so much,
    The Beckers in Maine

    (reply)
    • Peter Attia  November 6, 2013

      If she’s not anemic, it probably has no impact at all. I run about 10% below normal Hb and Hct. Not much I can do other than train harder!

  115. Sheila Hoselton  November 15, 2013

    My daughter and I both have severe behavioral problems after ingesting sugar. So far mostly sugar cane sugar, but no one and i mean no one in my area will even listen, including the doctor’s that all insist she needs ADHD medications. I would like to discuss what is going on so I can get some intellectual information on where we may move to participate in studies, that I know would cut down on the ADHD med rx rate.
    Sincerely Sheila

    (reply)
    • Peter Attia  November 15, 2013

      What happens when you remove sugar, HFCS, etc. from her diet for 30 days?

  116. Richard  December 22, 2013

    Just stumbled across some youtube videos and starting reading your blog. Love the information. Keep up the good work.

    (reply)
  117. health-seekers  December 24, 2013

    Some of this was a bit complicated; but Still a good article.

    Sugar is threat to my health too. The fat-phobes threat to my health too (they restrict or ban good things like avocados, nuts, yolks of eggs laid by happy healthy hens, unsweetened bakers chocolate, & the delicious healthy unsweetened fortified coconut milk sold by Trader Joe’s)

    I reject white rice, white flour bread, sugar, white flour pasta, candy, soda, HFCS, juice, vegetable oil, and restrict dairy.

    I consume (as $$ & transport allow) vegetables, whole fruit, berries, nuts, unsweetened fortified coconut milk, stevia extract, virgin coconut oil, sweet potatoes, whole grains, beans, chia seeds and/or fish oil pills, eggs (yes the yolk is most nutritious part ), & occasionally some meat. I can go days or week(s) without meat. i avoid hotdogs and other processed meats.

    One problem in the food debate is the lack of honest compassionate logical dialogue. The judgmental vegangelicals on one side; the judgmental Paleovangelicals on the other side. Hard to figure which is worse.

    Unhealthy unfair rotten books like: ‘comfortably unaware’ & ‘the vegetarian myth’ ‘the end of food’ also come to mind.

    How about some good books? Good books like: ‘sugar shock’ & ‘ predictive health’ & ‘ what i eat around the world in 80 diets ‘

    How about a good video like: Food Fight!

    We need pragmatism, compassion, science, consequential thinking, & polite logical dialogue.

    Thanks for letting me comment!

    Have a healthy happy Christmas, Chanukah, Kwanza !

    May we all have a healthy, prosperous, honest, happy 2014 together!

    (reply)
    • Robin  March 1, 2014

      Unhealthy unfair rotten books like: ‘comfortably unaware’ & ‘the vegetarian myth’ ‘the end of food’ also come to mind.

      Just finished The Vegetarian Myth. It is quite a read and reveals some uncomfotable truths, so I would like to know why your use of adjectives?

    • Robin  March 1, 2014

      Hi again, I just spent the evening re-reading the book, “The Vegetarina Myth.” It should be on every human’s “must read” list. The ignorance of the vegetarian’s belief system and it’s selfishness (very egocentric) is a bit of a paradox as a vegetarian would not see it that way, I imagine. My son is a vegetarian (unhealthy, getting fatter by the year on his high carb diet) and with our family history of diabetes, I can see that I may outlive him. Protein and fat are my staples! Makes me sad but he has made his choice to sacrifice his health over that of caged animals and the cruelty that comes with that, instead of addressing the needs to change the way we do animal husbandry and farming. It is, in the end, not my problem though I will be sad to attend my son’s funeral, knowing that it was self-inflicted, and so, unnecessary.

      I do not see that “Unhealthy unfair rotten books like: ‘the vegetarian myth’” are, well, that!

      I have long since avoided grains but now I feel compelled to to tell every grain eater that they are driving the destruction of the planet. I am sure that will go down well but it is clearly true!

  118. Remedia  January 12, 2014

    For a recent interview with Dr Robert Lustig on the negative effects of sugar, REMEDIA spoke to him a week ago:

    http://remedianetwork.wordpress.com/

    (reply)
  119. Henry Van Horik  January 13, 2014

    Hello Peter,

    I was just listening to your podcast with Vinnie and Anna and he mentioned removing sugar from his diet due to his cancer, I recalled this study from Sept 2013 titled: “Specific Sugar Molecule Causes Growth of Cancer Cells”. I wonder if you have become aware of this study?

    http://www.sciencedaily.com/releases/2013/09/130916103646.htm

    Here’s a quick synopsis: “Sep. 16, 2013 — The process of glycosylation, where sugar molecules are attached to proteins, has long been of interest to scientists, particularly because certain sugar molecules are present in very high numbers in cancer cells. It now turns out that these sugar molecules are not only present but actually aid the growth of the malignant cells. In the long term this discovery is an important step towards a cure that can stop the growth of cancer cells.”

    (reply)
  120. Rawnaq khudai  January 24, 2014

    Hi Peter,

    This may not be the best place to ask, but I just wanted to quickly get your thoughts on this. What role does thyroid hormone free T3 play in the metabolism of the ketone adapted body of someone doing the standard ketogenic diet? Is free T3 important even after the muscles have developed the enzymes needed to use free fatty acids? Do brain cells need free T3 to be able to use ketones?

    Thanks!
    Rawnaq

    (reply)
    • Peter Attia  January 25, 2014

      I don’t know the answers to these questions. Stating the obvious, TSH (and therefore T4, and by extension T3) are important for many aspects of our existence, so it’s likely there is some relationship, though I can’t at this time describe it.

  121. Hazel  March 17, 2014

    Excellent artic Dr. Attia. Thank you for the work you do. I’ve sent this to several friends who with diabetes, and read the article closely myself because though I’ve been on low-carb four years, I’m experiencing a plateau and want to burn more fat. I don’t use sugar but do consume leafy greens (romaine, kale, spinach occasionally, beet greens and if beets are attached I eat them too… I discovered in the third year of low-carb that too many leafy-green carb grams give me problems. This is sad because I “could” consume them in quantity (I would like to) but gain weight if I do — and it’s not “lean muscle”. Accordingly I assume that although I fast most days, have coconut oil and/or other good fats in the a.m. and a moderate amount of protein for dinner, sometimes with “greens” and sometimes without, my metabolism judging from blood tests is balanced but is easily unbalanced if I’m careless. But this is better to know than not to know; your article confirms what I suspected, so thanks for offering it at this time, it’s a great help and I hope it will help my friends as well.

    (reply)
  122. Ilya  March 26, 2014

    Hey Peter,

    I don’t know if you read the following article, but I think it’s very applicable in many of your posts (specifically those regarding exercise):

    http://online.wsj.com/news/articles/SB10001424052702303949704579461381883678174?mod=e2fb

    As a marathoner and a hardline keto-er, this gives me hope that the days of pasta parties and carbo-loading are numbered. However, it’s tough to fault the article for being unable to make a definite conclusion regarding the link between sugar consumption and heart disease, as there are so many factors that go into marathon training that are really hard to control for.

    (reply)
  123. Jane T  April 20, 2014

    Peter -

    I am here because I am doing research about a bout of abdominal cramping. I think I had a toxic reaction to sucralose Splenda. I feel better today – 4th day. The 1st day, the doc said muscle strain. My hubby adamantly agrees. I went immediately to the doc because I never felt such a pain before. No fever, nausea, nor diarrhea.

    My background: I consider myself very healthy, I do not smoke, drink nor do drugs. I rarely use over the counter drugs or artificial sweeteners. I am 59 yrs, 5 ft 2, weigh 100 lbs. I do limited exercise. I have never needed to diet. BUT, I LOVE sweets – cookies, ice cream, chocolate, pastries, etc. (but the thought of eating sugar cubes is gross to me). I also eat a balanced diet everyday – meat, chicken, or fish, and rice, vegetables.

    Day 1 – At about 11am , I ate a Usana vitamin pack for the first time. Then at 11 pm, I ate at a potluck. At about midnight, my right side started feeling soreness. I ate lots of foods at the potluck, and I ate 3 or 4 cookies made with Splenda (sucralose). I didn’t find out until after I ate the cookies that it was Splenda

    So I stopped taking ANY vitamins, but otherwise I am eating normally now. The cramps had been very sharp at times and I expelled gas.

    My body can tolerate eating lots of sugar, but could the Splenda be toxic to me?

    (reply)
  124. Paula  April 22, 2014

    Dear Doctor,
    Please live forever.

    (reply)
    • Neal  May 13, 2014

      Peter,
      Good stuff thanks for the great information!!! I am training for a 100 mile race in October, and always looking for solid information to incoporate into my eating habits and my workouts. Please tell your brother and the rest of your family hello. I worked with him at Liberty.

      Thanx

    • Peter Attia  May 15, 2014

      Neal, I passed along to my bro who sends his best. Great to hear from you.

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