The personal blog of Peter Attia, M.D.

Success versus Failure: A stark juxtaposition

Success versus Failure: A stark juxtaposition
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In April I was part of a panel at the Milken Global Conference, the title of which was something like, “Keys to a healthier and more prosperous society.”  The panel was moderated by Michael Milken, and it was great to meet him and his rock-star staff (especially Shawn Simmons, Paul Irving, and Nancy Ozeas). The other panel members were seasoned vets of the obesity discussion: Troy Brennan (Executive VP and Chief Medical Officer of CVS Caremark), Tom Frieden (Director of the CDC), Lynn Goldman (Dean of the School of Public Health at the Milken School of Public Health, at George Washington University), and Dean Ornish (president and founder of the Preventive Medicine Research Institute). I was the pauper in the group—no big credentials and zip-zero “panel” experience.

A few weeks before panel, we all jumped on a conference call and Michael set the stage for the discussion he wanted to moderate. He pulled no punches. “If you include the indirect cost—lost productivity, for example—the total cost of obesity and its related diseases is $1 trillion per year to our economy. This is unacceptable.”

Who could disagree? Hell, I usually only reference the direct cost of obesity and its related diseases—about $400 billion annually.  But whether we talk about the direct or indirect cost of these diseases, I’ve always found the human cost even greater—every day 4,000 Americans die from four diseases exacerbated by obesity and type 2 diabetes: heart disease, stroke, cancer, and Alzheimer’s disease. Now that is really un-effing-acceptable.

So, back to the panel. The idea of being on a panel kind of freaked me out, even more than the sheer terror and vulnerability of TEDMed. No control. The possible need to be defensive. Sound bites over substance.

I don’t enjoy debates. Nothing comes of them. Just greater and greater polarization. The “winner” isn’t even necessarily the one with the best “facts.” Gary Taubes shared this quote with me recently, which I find really insightful. Dallas Willard, a well-known ecumenical pastor and theologian, was often invited to debate the existence of God and other matters. These invitations included Richard Dawkins himself.  His response: “I don’t debate, but I am glad to enter into a joint inquiry. We will seek the truth together.” That’s the attitude I like.

In the end, I decided to just tell a few (in some cases provocative) stories. Why? Because it’s easy to present reams of data, yet so few people remember the point. (If you want to read an amazing paper on the importance of storytelling, check out this one by one of my former surgical mentors, Curt Tribble. You don’t need to care one iota about training cardiac surgeons to realize the gems in this piece.)

I realized going into this that I would be the contrarian in the group. I don’t claim to know all (or even many) of the answers, but I’m willing to bend over backwards in search of them. I realize folks (from readers of blogs to members of the audience at the Milken Global Conference) want facts, answers, prescriptions. I think we need to know more, first.

Below are the notes I made for myself in the days leading up to the panel. Basically, I wanted to tell a few stories, plus summarize it all (if given the chance). I didn’t actually “practice” this or even take notes up on stage (which I regretted when I realized everyone else was smart enough to bring notes), so if you decide to watch the actual video of the panel, you’ll note that I only vaguely followed what’s written below.  But in my mind, here’s how I thought about it. (I haven’t watched the video and I’ve pretty much forgotten anything I said, but I’m sure what’s written below is better than anything I said. I did send the video to two of the best speakers I know to get their feedback. Their feedback: could have been much better, but not the worst job ever. Lots of work to do for next time. Duly noted.)

How did I find myself interested in this problem?

My arrival at this place is really a coming together of two revelations. First, during my surgical residency at Johns Hopkins, not surprisingly, I was often dealing with the complications from diabetes and obesity in my patients. It slowly became obvious that all I was doing was slapping on the surgical equivalent of Band-Aids without ever addressing the underlying problem. I was treating symptoms and not the actual disease. When I would amputate the leg of a diabetic patient, which I had to do, regrettably, all too often, I knew that my patient was more than likely to be dead within five years anyway.

The second revelation was five years ago—September 8, 2009—to be exact. I remember it so clearly. My sport of choice was marathon swimming, and I followed what I believed to be the iconic healthy athlete’s diet. I had just completed an especially difficult swim into the current from Los Angeles to Catalina Island, becoming one of a dozen people to do that swim in both directions.  After more than 14 hours in the water, I got on the boat to begin the long ride back to Long Beach Harbor, and my wife looked at me, in my speedo, 40 pounds heavier than I am today, and said, “Honey, you’re a wonderful swimmer. But you need to work on being a bit less not thin.”

And not only was I, well, fat, despite all this maniacal exercise, but it turns out I was also pre-diabetic.

Her comment launched me into a series of nutritional self-experiments. I was already working out three to four hours a day, so the problem couldn’t be sedentary behavior. It had to be what I ate. Over the next year I manipulated my diet until I found what worked for me, which paradoxically didn’t involve eating less, just eating very different from the food pyramid. Along the way I became obsessed with reading the nutrition literature. What I learned was that the evidence supporting our dietary guidelines was ambiguous, at best, and occasionally contradictory. There was a real dearth of evidence to support what seemed like the obvious questions.

I realized then, that if the guidelines didn’t work for me and if I can’t figure this out, with my background as a doctor and someone who studies healthcare, maybe they don’t work for a lot of people. Maybe there are systemic problems here. Maybe these problems were at the root of the ongoing epidemics of obesity and diabetes. Lots of maybes…and not a whole lot of clear, solid, unequivocal answers.

Since then, I’ve made a personal and professional commitment to finding the answers. And if the studies don’t exist to give us unambiguous evidence, then raising the funds and enlisting the researchers necessary to do those studies.

What does success in public health look like?

When trying to understand complex problems, I like to start with success stories, identify patterns and work backwards—reverse engineering success. Consider the following graph.

AIDS

It shows the death rate from AIDS in the United States between 1981 and 2010. The point of this graph isn’t subtle. Death from AIDS rose steadily and monotonically through the mid-90s and since then has declined steadily. Though people still die from AIDS, this still represents a success story in health policy and science. For those experiencing the personal tragedy of AIDS, this is salvation.

So why did it happen? Well, first, the cause of the disease was correctly identified—the HIV virus—in the mid-80s; and second, by the mid-90s highly active anti-retroviral therapy, or HAART therapy, was able to effectively treat the virus and prevent progression to AIDS.

Again, two things happened: the cause of the disease was correctly identified, and an effective treatment was developed by an enlightened healthcare profession.

This is what success looks like.  Now, let’s compare this story to that of obesity and diabetes.

Do we have this situation under control? The case study of “failure”

Let’s take a look at this figure. It shows the prevalence of diabetes in the United States over the last hundred-plus years. (Thanks to Gary Taubes who dug up these stats while researching his upcoming book.)

Diabetes

In the early 1900s the leading figures in medicine, Sir William Osler at Johns Hopkins and Elliot Joslin at Mass General, did exhaustive analyses of the number of patients with diabetes based on hospital records and census data. As you can see, diabetes was exceedingly rare in the 19th century—somewhere between about 3 and 500 cases per 100,000, depending on the analysis.

By 1970, around the time I was born, that number was up to 2,000 cases per 100,000, and between 1970 and today—at a growth rate of nearly 4% per year—that number has risen to more than 8,000 cases of diabetes per 100,000.

Worse yet, type 2 diabetes is now spreading into demographics previously naïve to the disease, particularly children. I don’t think any of us in this room today would argue that we have this situation under control. So where are we failing? Many of you understand the world of business. If this were a business, we’d be asking a lot of questions at this point, or we would be out of business. Like any business, we have two possibilities. We either look at our business plan (the basic premise for how we’re going to succeed) or the implementation of that plan (the way we operate on a day-to-day basis).  When confronted with a runaway epidemic like this, we have to address the same two basic issues:

Either we understand the underlying cause of this disease and we have a good plan in place, but few individuals have the willpower or wherewithal to avoid the disease—whatever it is…In other words we’re not executing the plan.

Or, we don’t understand the disease in the first place and we’re giving the wrong advice. In other words, we don’t have the right business plan.

In this latter scenario, the failure is not one of personal responsibility, but of our assumptions about the cause of this disease. And these two scenarios have very different implications.

I am not certain which of these is more likely correct, but I do know the risk of ignoring the latter in favor of the former is not a choice we can make any more as a society.

So, maybe the question we should be asking is whether we are right about the environmental triggers of this disease—the underlying cause. Is it as simple as gluttony and sloth and a food industry that overwhelms us with highly-palatable, energy-dense foods, or is there something specific about the quality of the food we’re consuming that triggers these disorders? If we don’t answer this question about what is it in our environment that’s causing this disease correctly, just like we were able to answer it in the mid-80s with HIV’s role in AIDS, we can’t effectively treat the disease. Instead we’re stuck putting on Band-Aids.

Here’s another way to think about it: imagine this panel was on a new crisis in aviation. Planes are constantly crashing—falling out of the sky—and killing 4,000 people a day (just like obesity-related diseases are killing 4,000 Americans a day.) And you’re a pilot and you tell me that surely we understand the principles of flight. Right. Sure, we might suspect user error to be part of the problem. (Maybe the pilots aren’t flapping the wings hard enough!) But, maybe a better idea would be to go back to the drawing board to make sure we really understood this whole aerodynamics thing and we didn’t miss something important?

That’s how we think we have to look at this problem: 4,000 people in this country are effectively falling out of the sky every single day—dying—and we’re saying we’ve got it all figured out, and people just need to adhere better to our advice. I’m not confident that that’s the solution. Nor should you be.

Is there a policy-based solution to this problem?

Surely policy changes will play a necessary role in restoring our health. But it may be less about ‘how?’ and more about ‘when?’  I’d like to refer to this slide showing per capita cigarette consumption in the U.S. from 1900 until today—the number of cigarettes consumed is shown in grey with death rate from lung cancer superimposed in red.

Smoking and lung cancer

This is another success story. People in this room contributed to that success. The little colored triangles on the grey line are major milestones in science (red), market forces (green), and policy (blue). This is a great example of what one might call the “critical confluence”—scientific elucidation, policy action, market response, and behavioral shift—all coming together to save lives.

But, as in all things in life, algebra included, the order of events matters!

Which came first then? In the case of smoking and lung cancer, it was unambiguous scientific clarity, which in this case happened in the 1940s and 50s and resulted in the 1964 Surgeon General’s report. This information was absolutely necessary to drive the policy action, the market response, and the behavioral shift that followed. Without the knowledge that lung cancer is caused by smoking, no amount of policy or market response would have led to the necessary behavioral shift and so a meaningful reduction in lung cancer incidence.

When we consider the current situation with obesity and diabetes, we may still be missing the equivalent of the scientific clarity linking unambiguously the environmental trigger (smoking) that provided the obvious method of prevention (smoking cessation). And, again, if we think we do have that information, we have to ask why we’ve thus far failed to meaningfully prevent and successfully impact these disorders.

If the death rate from AIDS was still skyrocketing, I think we’d all agree we would either call into question our faith in HAART, or even the premise that HIV causes AIDS, if not both. Yet, in the face of skyrocketing obesity and diabetes, we play the who’s-on-first game all day long pointing fingers at people and industry.

Until we clearly identify the dietary triggers of obesity and diabetes, policies to shift behavior may be misguided and premature, despite their best intentions. Despite our best intentions.

I’m arguing that the policies so far may have been just that. Premature. And based on incomplete or faulty information. In other words, we may have the wrong business plan, but we blame our execution of the plan on our failure.

Parting shot

Today, we’re talking about a problem that touches, directly or indirectly, every single person in this room. It’s a topic that can be confusing and at times polarizing. We can’t lose sight of the big picture, which is easy to do when we just look at this problem through the lens of personal responsibility or will power. Remember, I used to think that “If people just learned to eat ‘right,’ (whatever that is), exercise and control themselves and their diet, everyone would be fine.”  Today I reject that logic and the hubris that fostered it.

In the business world we know that the wrong strategy, no matter how well implemented, gives us little chance of success. Similarly, the right strategy, if poorly executed, often fails. What we need is the right strategy first and then the right execution second. At the moment, it’s hard to argue that we’re not failing with at least one of these two tasks. The question is which one.

Much of the discussion around this topic focuses on the execution; little attention is paid to the strategy or underlying insights that form the basis of the intervention.

Just 40 years ago the prevalence of obesity in this country was about one-third of what it is today, and that of diabetes about one-fifth. Is this all because Americans have become too gluttonous and slothful and the food industry figured out how to make food cheap and addictive enough? That they simply are too lazy and stubborn to do what we’ve been telling them to do—eat a little less, exercise a little more—for fifty years. Maybe. And I trust many good minds are already working on solutions to address that hypothesis.

However, what if the problem isn’t about non-compliance but about the nature of the advice we’re passing along. Maybe it’s our failure in that we have a simple idea about what causes these diseases, and like many simple ideas—paraphrasing Mencken here—it just happens to be wrong. It’s hard to fathom that two out of three Americans are simply too lazy to be active and too stubborn to eat healthy, despite losing their lives and their loved ones to the negative sequelae of these diseases.  I find that hard to believe.

So, what if the problem is that our dietary advice is wrong in the first place? And incorrect dietary advice has resulted in an eating environment where the default for most people is a diet that causes obesity and diabetes?

If HIV or lung cancer were still spiraling out of control—as they were thirty and fifty years ago before the causes were unambiguously identified—the great minds in this country and the world would be leading investigative teams of scientists to figure out what we may have missed in our understanding of the cause of these diseases. We would not be complacent, perhaps because it would be harder to blame these diseases on the victims and their lack of will power. When we fail completely to prevent two devastating disorders for half a century, isn’t it time to investigate what we might have missed—what is it about these disease states that we do not understand? If nothing else, shouldn’t we hedge against the possibility—however slim you think the odds are—that we’re not as smart as we think we are. Those of us who are here today because of our business acumen know the importance of hedges in business. Isn’t it time we did that with obesity and diabetes?

GC14 - Monday med panel - Attia

 

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About the Author:

Peter Attia, M.D., is a physician in private practice in NYC and CA. His practice focuses on longevity and healthspan. His clinical interests are nutrition, lipidology, endocrinology, and a few other cool things.

Discussion

  1. Mark Williamson  June 16, 2014

    Great post Peter. I often find myself thinking about the strategy issue in a similar, but slightly different way. For many of societies largest issues, I wonder what portion of resources get spent on treating the symptoms of the problem vs. understanding and treating the root problem. I can’t seem to find a significant societal issue where it feels like we are investing proportionally enough resources into understanding root causes. Which leads me to wonder if this is *the* root problem.

    Maybe for every societal issue we face (health, financial system risk, climate change, etc.) we would be best off fixating on trying to get a meaningful proportion of resources devoted to investigating the root cause of the problem vs. constantly trying to simply treat the symptoms of the problem.

    (reply)
    • Peter Attia  June 16, 2014

      Thanks, Mark. I agree, sadly, with your observation. I do think we’d be better off, at least for the persistent problems, going after the root vs. just the symptoms. If we only fixated on giving tylenol to lower fevers without ever thinking maybe the fever was caused by a bacteria, well, you know…

    • Hazel  June 16, 2014

      Well people don’t go to doctors much. Forgive the cynicism, but if patients make themselves well without help from their doctors, or if the doctor knows why the patient has symptoms of type 2 diabetes and has a cooperative patient who gets well on the doctor’s program, the annual earnings of the doctor is going to go down.

      If doctors know patients have type 2 diabetes but never mention the word, they have a chance to increase their annual earnings.

      It took me 40 years (in the Chicago area!) to find a doctor who knows and cares enough to confirm my plan for recovery. Now in my fourth year of recovery and still see that doc, usually only once a year. Thank heaven for the ones who know and actually help; they’re rare.

  2. Larry Istrail  June 16, 2014

    What an amazing post. So thoughtful and reasonable without the decisive rhetoric that taints so much of this debate. It reminds me of how elon musk describes innovation: you must utilize ‘first principal thinking.’ Break it down to its most basic, fundamental parts and question each one. Could this be improved? Is this here just because our predecessors chose it?

    (reply)
    • Peter Attia  June 16, 2014

      Thanks, Larry. Flattering comparison!

  3. Kevin  June 16, 2014

    Wow blast from the past but I’m reminded that Milken himself wrote a diet or cookbook around 1999 – 2000, rebounding from his colon cancer (I think) pretty much promoting all-soy-all-the-time. Soy bacon, soy shakes, tofu this and that. Wow I really really wish I’d never been exposed to that book!

    (reply)
    • Hazel  June 16, 2014

      Yes, and now beware the madness of crowds… especially when there’s marketing and money at stake.

  4. Steve Parker, M.D.  June 16, 2014

    Average daily energy expenditure from physical activity in the US over the last half century has declined by 100 calories.

    At the same time, average daily per capita calorie consumption is up by 200 to 500 calories over the last 40 years. It think the lower end of the range is probably more accurate.

    If those numbers are true, they could certainly contribute to the prevalence of T2 diabetes and obesity. Willpower and discipline may play a role in reversal.

    -Steve

    References:

    Church, T., Thomas, D., Tudor-Locke, C., Katzmarzyk, P., Earnest, C., Rodarte, R., Martin, C., Blair, S., & Bouchard, C. (2011). Trends over 5 Decades in U.S. Occupation-Related Physical Activity and Their Associations with Obesity PLoS ONE, 6 (5) DOI: 10.1371/journal.pone.0019657

    Swinburn, B., et al. Increased food energy supply is more than sufficient to explain the U.S. epidemic of obesity. American Journal of Clinical Nutrition, 2009 (90): 1,453-1,456.

    (reply)
    • Peter Attia  June 16, 2014

      These numbers don’t tell the story. When you look at error bars on them, it becomes clear we have little idea how much more or less we eat today than 40 years ago. Data are based on food availability and, at best, sometimes include waste. The expenditure data may be even less reliable. But given that we are indeed more overweight today than 40 years ago, it’s a given that (on average) people consume more than they expend relative the past. That’s merely a descriptive modifier. What’s missing is the explanation one. If I told you Bill Gates was rich because he “made more money than he spent” would that be saying another beyond the obvious? It’s true, sure, but it doesn’t say why. That’s what we should be asking ourselves.

    • Hazel  June 16, 2014

      Blaming the patients: “Average daily energy expenditure from physical activity in the US over the last half century has declined by 100 calories. At the same time, average daily per capita calorie consumption is up by 200 to 500 calories over the last 40 years. It think the lower end of the range is probably more accurate. ‘

      Read Taubes: Good Calories, Bad Calories

      http://drhyman.com/blog/2011/08/04/new-research-finds-diabetes-can-be-reversed/#close\
      New Research Finds Diabetes Can Be Reversed
      by Mark Hyman, MD

      I have recently spent more time in drugs stores than I would like helping my sister on her journey through (and hopefully to the other side of) cancer. Rite Aid, CVS and Walgreens all had large diabetes sections offering support for a “diabetes lifestyle”—glucose monitors, lancets, blood pressure cuffs, medications, supplements and pharmacy magazines heavily supported by pharmaceutical advertising. Patients are encouraged to get their eye check ups, monitor their blood pressure, track their blood sugars, have foot exams and see their doctor’s regularly for better management of their blood sugars—all apparently sensible advice for diabetics.

      But what if type 2 diabetes could be completely reversed? What if it wasn’t, as we believe, an inexorable, progressive disease that has to be better “managed” by our health care system with better drugs, surgery and coordination of care? What if intensive lifestyle and dietary changes could completely reverse diabetes?

      A ground breaking new study in Diabetologia proved that, indeed, type 2 diabetes can be reversed through diet changes, and, the study showed, this can happen quickly: in 1 to 8 weeks. That turns our perspective on diabetes upside down. Diabetes is not a one-way street.

      If we have a known cure, a proven way to reverse this disease, shouldn’t we be focused on implementing programs to scale this cure?

      We used to believe that once cells in your pancreas that make insulin (beta cells) poop out there was no reviving them and your only hope was more medication or insulin. We now know that is not so.

      Continuing misconceptions about what causes diabetes and our unwillingness to embrace methods know to reverse it have lead to a catastrophic increase in the illness. Today one in four Americans over 60 years old has type 2 diabetes. By 2020, one in two Americans will have pre-diabetes or diabetes. Tragically, physicians will miss the diagnosis for ninety percent with pre-diabetes or diabetes. (Below I tell you exactly what tests to ask your doctor to perform and how to interpret them).

      From 1983 to 2008, world-wide diabetes incidence has increased 7 fold from 35 to 240 million. Remarkably, in just the last 3 years from 2008 to 2011, we have added another 110 million to the diabetes roll call. And increasingly small children as young as eight are being diagnosed with type 2 diabetes (formerly called adult onset diabetes). They are having strokes at 15 years old and needing cardiac bypasses at 25 year old. The economic burden of caring for these people with pre-diabetes and diabetes will be $3.5 trillion over 10 years.

      If we have a known cure, a proven way to reverse this disease, shouldn’t we be focused on implementing programs to scale this cure? Unfortunately despite this extraordinary new research, the findings will likely be pushed aside in favor of the latest greatest pill or surgical technique because behavior and lifestyle change is “hard.” In fact, with the right conditions and support, lifestyle diet and lifestyle change is very achievable.

      What did research show?

      Reversing Diabetes: Can it Be Done in a Week?

      The study, entitled Reversal of type 2 diabetes: normalization of beta cell function in association with decrease pancreas and liver triglycerides, was exquisitely done. The bottom line: A dramatic diet change (protein shake, low glycemic load, plant-based low-calorie diet but no exercise) in diabetics reversed most features of diabetes within one week and all features by eight weeks. That’s right, diabetes was reversed in one week. That’s more powerful than any drug known to modern science.

      We know from gastric bypass patients that with rapid changes in diet right after surgery, within just a few days, without significant weight loss, diabetes goes away—fatty livers heal, cholesterol levels plummet. Some theorized it was because of changes in the stomach hormones related to the gastric surgery. Others, including the researchers of this new study surmised that maybe it was just the drastic change in diet. So they went about studying just the diet change without surgery.

      They studied 11 people with diabetes and compared them to a control group. Through very sophisticated techniques including MRI imaging, they measured their blood sugar and insulin responses, cholesterol levels and fat in the pancreas and liver (some of the hallmarks of diabetes) before and after diet changes at 1, 4 and 8 weeks.

      What they found was revolutionary. The beta cells—the pancreas’ insulin producing cells—woke up, and the fat deposits in the pancreas and liver went away. Blood sugars normalized in just one week, triglycerides dropped in half in one week and reduced 10-fold in eight weeks. The body’s cells became more insulin sensitive and essentially, in just 8 weeks, all evidence of diabetes was gone and the diabetic patients looked just like the normal controls on all the testing.

      While this may be surprising to most, it is something I see regularly in my medical practice. With focused, strategic, scientifically based nutritional intervention, combined with exercise, stress management and sugar and insulin balancing nutritional supplements, many of my patients completely reverse their diabetes. And the side effects—more energy, better sleep, improved sexual function and weight loss—are all good.

      What most don’t realize is that pre-diabetes and diabetes exist on a continuum and both dramatically increase the risk of heart attacks, stroke, cancer, infertility, sexual dysfunction, depression and dementia. You don’t have to get diabetes to be at risk for all those problems. That is why it is so important to get your doctor to diagnose pre-diabetes early and implement an intensive lifestyle program to help you reserve it.

      You may be at risk if you have extra belly fat, have a family history of diabetes, gestational diabetes, are in at risk ethnic group (Asian, Hispanic, African American, Native American, Middle Eastern), have high triglycerides (> 150 mg/dl) or a low HDL (< 50 mg/dl) or have high blood pressure.

      If any of these apply to you or you have other cause for concern, here is what to do.

      How to Reverse Your Diabetes

      First, get your doctor to test the following:
      1.A 75-gram glucose tolerance test measuring BOTH glucose and insulin fasting and 1 and 2 hours later. Your fasting blood sugar should be less than 100 mg/dl and your 1 and 2 hour sugar levels should be less than 130 mg/dl. Your fasting insulin should be less than 10, and your 1 and 2 hour levels should be less than 35.
      2.Triglycerides should be less than 150 mg/dl and HDL (good cholesterol) should be over 50 mg/dl, and the triglyceride to HDL ratio should be less than 4. These ranges are meaningful only if you are on no medication.
      3.Newer cholesterol tests measure the size of your cholesterol particles and is very effective in diagnosing problems with pre-diabetes early. In fact, this is the only cholesterol test we should be performing.

      And here’s the program I use for my patients to reverse diabetes:
      1.Eat a low glycemic load, high fiber, plant-based diet of vegetables, beans, nuts, limited whole grains, fruit and lean animal protein
      2.Vigorous exercise (fast walking, running, biking, etc.) 30 minutes 4-5 times a week and strength training 20 minutes 3 times a week
      3.Take a good multivitamin, fish oil, vitamin D and blood sugar and insulin balancing nutrients (including chromium and alpha lipoic acid)

      Remember, pre-diabetes and diabetes is not a one way street and the solution is not at the bottom of a pill bottle or the end of an insulin syringe, it is at the end of your fork and in the shoes on your feet!

      Now I’d like to hear from you …

      Do you think diabetes can be reversed? If so, how?

      What methods have you tried to gain control of your diabetes or weight gain? How have those methods worked for you?

      Why do you think accessible, scalable, lifestyle solutions like these that actually reverse chronic illness are not more frequently prescribed in conventional doctor’s offices? How can we change this?

      Please share your thoughts by leaving a comment below.

      To your good health,

      Mark Hyman, MD

    • Colleen  June 16, 2014

      Social norms have changed which may help explain increased calorie consumption. One example a 4yo birthday party we went to yesterday. 40 years ago a party would have consisted of cake and maybe lunch. Yesterday, pastries, lunch (pizza and pasta), cake, free soda fountain, a giant table laden with sugary junk, a pinata more candy, and “Frozen” cotton candy. Other social norms – daily high calorie coffee consumption, free soda fountain at work, eating out instead of brown bag at work, etc. What is “normal” has changed in my view.

    • Kelley  June 16, 2014

      Hazel: For a different perspective on how to reverse diabetes, check out Richard Bernstein’s book “The Diabetes Solution.” Whereas Hyman advocates a plant-based diet, Bernstein recommends a more typical very-low-carb diet. He, too, maintains that type 2 diabetes can be reversed, and that the side effects of type 1 diabetes can be reversed.

  5. Larry  June 16, 2014

    Peter, based on the cover and article in current issue of Time, in which you are mentioned, looks like word is finally getting out in the mainstream re fat vs. carbs and some of the dietary issues you, among others, are raising. Must feel good to be part of that.

    (reply)
    • Peter Attia  June 16, 2014

      I think it’s a step in the right direction. But there are 3 mighty pillars of nutritional wisdom that still need to be tested and, if necessary, overturned.

  6. raphael711  June 16, 2014

    Hi Dr.Attia,

    I discussed the failure & successes of treating obesity/T2D with Dr.Guyenet. It seems to have “hit a nerve”, spurring him to write this post “Has Obesity Research Failed?” [http://wholehealthsource.blogspot.fr/2014/06/has-obesity-research-failed.html].

    In this post you use AIDS as an example of ‘success’, which I thought was all the more interesting considering Dr.Guyenet specifically says “Obesity is much more challenging than a simple infectious agent or nutritional deficiency that can be readily treated”.

    He goes on to say: “I hope it’s clear that obesity research has not failed– it has produced huge amounts of scientifically robust information, and a number of effective therapies. None of these therapies are the magic bullet we wish they were, yet there’s no reason to believe this is because our understanding of obesity is fundamentally flawed.”

    Your response would be greatly appreciated & likely enlightening to both readerships. Thanks!

    (reply)
    • Peter Attia  June 16, 2014

      Well, I agree to some extent with Stephan that obesity may be a more complicated problem than polio, AIDS, or smallpox (i.e., infectious diseases). But that is not the point of my post, if you read it *carefully*
      The point is obesity research has largely been a failure because the outcome has gotten better, not worse.
      If you’re a CEO and your job is to raise money for your company, you can’t say you’ve been great–you have a great pitch, you communicate well, etc.–if you fail to raise money. Even if those things are true, the final yardstick of your performance is against the initial objective.
      If there is another objective for obesity and T2D research beyond reducing their prevalence, fine, evaluate the research against that. But for me, that’s all secondary.

    • Kelley  June 16, 2014

      Peter: I just (this morning) finished reading “Mistakes Were Made (but Not by Me)” on the recommendation of your previous post. Fresh in my mind is the closing chapter, wherein the authors explore the value of making mistakes (so that we can learn from them), and of Americans’ cultural loathing of making mistakes (which leads to denying them and, often, to making more to cover up the original ones). They quote Edison on his thousands of initial “failed” attempts to create the incandescent light bulb. He famously said, “I have not failed. I successfully discovered 10,000 elements that don’t work.” Without having read Guyenet’s paper or knowing his philosophy, I wonder if that is the perspective he’s adopting: “We haven’t failed; we have produced reams of information, some of which is useful in addressing this problem and some of which we can discard.” (Of course, more is revealed in the last part of Guyenet’s quote: “…yet there’s no reason to believe this is because our understanding of obesity is fundamentally flawed.” Maybe he is indeed clinging to evidence that needs to be discarded.) Failure would be if we stopped now, having erroneously assumed we’d found the solution, or if we kept doggedly pursuing lines of questioning that obviously keep going nowhere. I know that individual researchers and even some significant groups of researchers no doubt are guilty of those very things. But I’m using the collective “we” here in the broadest sense possible. “We” haven’t failed yet as long as there are people who are willing to continue tackling the problem with fresh eyes. They (hopefully) will learn from and build on the mistakes that were made by their predecessors.

    • Peter Attia  June 16, 2014

      Glad you read it. Carol has become a close friend. She’s also become obsessed with nutrition and hopes to publish a 2nd edition which will include a chapter on nutrition. Lots of material to work with, unfortunately.

  7. Ash Simmonds  June 16, 2014

    “I’m arguing that the policies so far may have been just that. Premature. And based on incomplete or faulty information.”–

    What it all comes down to, making policies and telling people what to do when you aren’t even sure it’s right.

    This week’s Time Magazine cover story about fat/cholesterol being good after all is a great reminder of this – we have people in “our circles” rejoicing at the relenting of a major media influence, but what about their responsibility almost exactly 30 years ago when they outright said it’s not even up for debate – cholesterol and fat are killing us?

    Sorry, you don’t get a hall pass because you are now saying what you think is currently the right thing. The data even back when they published that BS was already pretty clear that sat fat/cholesterol weren’t the problem – but even moreso, there evidence that it IS a problem was completely non-existent, yet they were still willing to tell the world something so polarising based on this?

    And of course the other classic example is McGovern and his little speech back in ’72 along the lines of “we don’t have the time to wait for evidence, we need to tell people how to be healthy NOW, and we’ve decided that way is by avoiding animal fats and reducing cholesterol”. Well done fellas.

    I’m just glad I spent a life willfully ignorant of policy, and never once missed out on a juicy steak covered in butter.

    (reply)
    • Hazel  June 16, 2014

      Bravo!

  8. Ash Simmonds  June 16, 2014

    On a semi-related note, you are probably aware of the take-down of Demasi’s Catalyst program by the Aussie ABC channel. I think this program – and the whole clusterfk surrounding it needs to be seen by as many as possible to understand the suppression of sanity we’re up against.

    I’ve put together a host of resources about the program (the vids, transcripts, Cliff’s Notes, links to blogs talking about the behind-the-scenes stuff, etc) here:

    http://highsteaks.com/abc-catalyst-heart-of-the-matter-dr-maryanne-demasi/

    Cheers.

    (reply)
    • Hazel  June 16, 2014

      Bravo; I copied and saved the info.
      Cynical but true; if TPTB can keep the info under wraps, they profit.

  9. Moti Halpert  June 16, 2014

    Does HIV cause AIDS?
    Not everyone thinks so.
    http://www.duesberg.com/

    (reply)
    • Peter Attia  June 16, 2014

      And some people think the world is flat and that the sun orbits the earth.

    • Rachel  June 17, 2014

      Peter I am disappointed you dismissed this comment so out of hand. I do not think the world is flat or that the sun orbits the earth but I have listened to Dr Duesberg and he raises some difficult questions about the HIV/AIDS hypothesis. https://www.youtube.com/watch?v=pB8g0b-FkW0 With your intellect and medical knowledge I would love to hear your opinion on this.

    • Peter Attia  June 17, 2014

      How do explain the HAART-AIDS interaction?

    • Connor  July 11, 2015

      Hi, Peter.

      I also found your answer here unnecessarily blunt and sarcastically.

      I can totally see someone saying ‘Peter Attia believes that maybe diabetes causes overweightness through insuline resistance, haha!’ and then quickly replying, totally convinced of the available evidence on the contrary, the same as you replied.

      Personally, I believe your hypothesis is right and the AIDS denialists are wrong. But this is only because I read a lot about the arguments and evidence presented from both sides of both AIDS denialists and non-denialists, as well as lipid hypothesis denialists and non-denialists.

      My point here is not so much whether AIDS denialists are right or wrong (much probably wrong), but that the way you rejected the comment seemed hasty and irrational, as if just because the claim seemed a bit absurb (and contrary to the popular medical consensus) it didn’t deserve any thought. This is precisely one of the reasons lipid hypothesis and cholesterol skepticism don’t get wider attention: because it goes against decades-long medical consensus, so ‘it’s definitely nonsense’.

      I think your rejection is a true negative. But you seem to have arrived at it with a not-so-good process, which if replicated may yield to false negatives in the future.

      Part of it may be simply shortage of time: you were in a hurry and you don’t possibly have time to analyze everything everyone sends you. A better response would have been ‘No time to see it, but find very unlikely to be true, because HAART works based on the premise HIV exists.’

      Best.

  10. Robert Moser  June 16, 2014

    Interesting read, as always.

    The link you provided for “The way we talk is the way we teach” is behind a paywall. I would very much like to read it; do you know of anywhere else it might be found?

    (reply)
    • Peter Attia  June 16, 2014

      Hmmm, worked for me easily. Try to google the title of the article, “The way we talk is the way we teach” and “Tribble.” Hope you can find it.

    • Sean  June 16, 2014

      Yes, It’s about $35 to get the article.

  11. Chris  June 16, 2014

    Hopefully this is the beginning point where biases are laid off (even if just a little) and folks like you start thinking more scientifically…as you may precisely know than many studies appearing every day in medical journals poorly resemble the scientific method.

    Will post the panel on my support group to debate it. Thanks Peter!

    (reply)
  12. Lauren Romeo, MD  June 16, 2014

    Interesting! A good discussion.
    In my own practice I do inform the diabetic patients about eating a low carbohydrate diet and a simple walking practice daily. They often reject my help and continue to have elevated blood glucose and non-healing wounds. It is depressing. They won’t even try because they would have to “give up” beer, pizza, etc.
    I ‘ve noted the resistance seems to be related to their worsening disease. Can it be a circular problem?
    In the clinic we call it Sugar Brain.

    (reply)
    • Peter Attia  June 16, 2014

      Sad, indeed. A complicated answer sits in my head, but it would take another blog post to expand.

    • Hazel  June 16, 2014

      It must be immensely frustrating for doctors who know that a simple method of changed eating does work for many people but their patient or patients won’t try. I know many people who won’t, no matter how simple the change may be.

    • Heather  July 8, 2014

      That’s my brother. I have given him the 2011 version of the Diabetes Solution and he hasn’t touched it. I send him articles, posts, studies from scientific journals. But he’s fine. All his numbers are “normal”. Thanks to medication. He won’t “deprive” himself. He came to visit me and had a foot long meatball sub (white bread) and a HUGE serving of french fries. Then gets on the phone to his friend and says he’s doing more cardio now. He still thinks it’s fat that is keeping him fat. He still calls it “grease”. His doctor tells him about 10g of sugar a day is okay. But keep eating that high-carb diet. Thanks to his doctor he thinks he’s doing a great job of controlling it. Our Dad is on dialysis, barely walks, has a pacemaker, is in and out of the hospital and this is at 72 – my Mom has to put his pills in his mouth because he can’t feel his fingers anymore. My brother honestly doesn’t think that will happen to him. My Dad was never obese – he just had the carb belly. My brother is obese. He also has a huge carb belly.

  13. Jack  June 16, 2014

    Peter,

    I watched the panel discussion and I think your message was quite clear. I’ve talked to so many people who believe that exercise is the answer along with eating a “balanced” diet. I think if people avoided sugar and carbs like they avoided fat, cholesterol and tobacco, we’d see a drop in metabolic syndrome like in those charts you showed above. The problem is, people already have their preconceived notions of what healthy eating already and with all the differences in opinion even in the scientific community, how can there be any effective policy implementation? Like you said, we need to get rid of the noise with hard scientific data that the scientific community, and by extension the policy makers, can come together around.

    What are your thoughts about the artery picture, where the top showed an artery of a person that eats whole foods, the middle is a person who eats refined carbs and the bottom is someone who eats low carb high fat diets? I know you’re a supporter of low carb and high fat at least for yourself. Are you worried at all that your arteries are clogging? (My guess is no, but could you talk a bit about it?)

    Thanks,
    Jack

    (reply)
    • Peter Attia  June 16, 2014

      Jack, you watched the whole thing? Even I don’t have the patience to do that! Most of those pictures are in mice. Also “high fat” diets in mice contain about 20-25% sucrose by weight. So I don’t think we’re learning much. The ones in humans are comparing a low fat AND low sugar/low flour diet to a standard American diet high in fat, sugar, and simple carbs. So, again, no new insight. In short, few people have the insight of what’s going on inside their arteries as much as I do. So for me, at least, I’m not worried.
      But I don’t know universally if this is true across the board. Hence my plea for more of the right kind of studies to elucidate this.

    • Ash Simmonds  June 16, 2014

      I watched it too, the message as outlined in this post got across just fine, the girlfriend picked it up easy enough.

      Funniest part was the bit about how the eat less/move more thing is an utter failure, and right on the back of that another speaker tries to reconstruct the house of cards with exactly that approach, how we’re eating 100 calories a day more and exercising less with dramatic pictures of pushbikes dwindling etc.

      Ornish has GREAT monologues on how bad the situation is and how to go about fixing it in general that are almost worth a standing ovation – but I just wish he’d stop there. He always stuffs them up by suffixing his personal “hearthealthywholefoodsplantbasedlowfatdiet” dogma to the end of it and somehow constantly slotting in that one time he magically reversed heart disease by getting people off junk food (which is the same as animal protein I guess).

      Compelling panel overall, worth a watch to anyone who’s reading this blog.

  14. Elizabeth Vincent  June 16, 2014

    Dr. Attia,

    I am very much interested in your theories as I am one who has developed Type 2 diabetes in the last 7 years. I am 60 years old. I don’t have a lot of information on my heredity, since my mom passed at age 27 with melanoma. However, neither of her parents had diabetes, and neither did any of her siblings. As far as I know, I have one cousin (out of 12) who is 2 years my junior who has developed Type 2 diabetes. I hate this disease! I find my energy down, my depression is up, and I hate constantly trying to figure out what to do to improve my “condition”. I am not looking for an excuse. I am looking for results! I have often thought that the major causes of some of our prevalent diseases was the way our food sources have been “human” contaminated with GMO, pesticides, overuse of land that causes our foods to lack nutrition, and perhaps other things not yet identified.
    I cried when I saw your TEDTALK because I had felt the same way before I got diabetes! I think you are definitely on to something!

    (reply)
    • Peter Attia  June 16, 2014

      Elizabeth, the books by Steve Phinney & Jeff Volek, along with that of Richard Bernstein, are great resources.

    • Kelley  June 16, 2014

      Elizabeth: I second Dr. Attia’s recommendation of Richard Bernstein’s books. Bernstein says that type 2 diabetes can be reversed with a very low carb diet (and that the complications of type 1 diabetes can be reversed with a VLC diet). Like Dr. Attia and his colleague Gary Taubes, Bernstein is no-nonsense. His only agenda seems to be discovering and disseminating the truth. His personal story as a type 1 diabetic is also intriguing. His website provides a wealth of information: http://www.diabetes-book.com

      I came across Bernstein’s work because my husband is a type 1 diabetic, age 51, diagnosed at age 4. He’s in great health, but a few minor complications started to crop up a couple years ago. They improved within about a month of hubby dialing in his blood sugar control a bit more by reducing (not even eliminating) carbs.

      Good luck in your journey. I wish you the best. Stay strong!

    • Steve Odom  July 11, 2014

      Elizabeth, I’m 60 and was developing Type 2 Diabetes, according to doc and blood tests and 3.5 years ago started following the diet Gary Taube recommended in his Reader’s Digest article. I lost 40 lbs the first 6 months and have kept it up and have lost 65 lbs. I’m 5’10”. I decided then that it wouldn’t be a “diet” but just a permanent change. I eat pretty all the fatty food I want to, and eventually found myself just eating twice a day because I wasn’t hungrey. The first two weeks are difficult, as the sugar/carb craving comes after you but after that you feel great! I aim for zero carbs, which is nearly impossible, but don’t go any “middle of the road” methods, i.e., only carbs on weekend, only whole grains, etc. Believe nothing that comes from the USDA, FDA, etc. Meat, (of all kinds. Enjoy the fatty cuts), nuts, cheese, whole yogurt, berries (not other fruits), whole cream and milk, peanut butter, green vegetables, other kinds of greens, any kind of fatty dressing, but always check carb content on prepared foods. Absolutely no sugar in any drinks. Believe me it works! Never been so pleased! When you lose the first 5 lbs., it’s so encouraging you just want to keep doing it!

  15. Cathy  June 16, 2014

    Thank you for another excellent article. I find that the ‘calories in/calories out’ model is firmly ingrained in the psyche of most who have ever tried to lose weight or studied weight management. It takes a lot of effort to relearn what is actually the truth and that is hormones rule.

    (reply)
    • Hazel  June 16, 2014

      Bravo! Hail to glucagon.

  16. Tim C  June 16, 2014

    “The ‘winner’ isn’t even necessarily the one with the best ‘facts.’…I realized going into this that I would be the contrarian in the group.”

    It hardly ever happens that debates change anyone’s mind, and they’re more of an intellectual p**sing match than anything else. It takes a lot to overcome the “conventional wisdom” about what food is healthy versus unhealthy, and to undo the paradigm that is so locked in and reinforced via government and corporate interests.

    6 months ago, someone could have shown me the dozens of scientific studies showing better weight loss results from low carb diets, or they could have described the problem of insulin and its role in fat accumulation, or they could have shown me all the statistics that demonstrate our current paradigm isn’t working, and my response would have been some dimwitted logical round-robin that would have exposed my ignorance and cognitive dissonance.

    I think (some percentage of) people entertain alternative hypotheses when it becomes impossible to ignore the faultiness of the conventional hypothesis. I believe most people are ignorant of this dichotomy, and that’s half the problem.

    (reply)
    • Peter Attia  June 16, 2014

      If you don’t mind me asking, what changed (for you, personally) in the past 6 months?

    • Tim C  June 16, 2014

      In my case, it was sort of a “brute force” process of overcoming my ignorance

      I’ve always had a tough time maintaining weight. And I have a family history of pretty major heart problems, diabetes 2, cancer, etc. Like most people, I’ve always thought that if I just had more will power, more inclination to exercise, and a willingness to eat fruits, veggies, and “heart healthy grains”, I would have good health outcomes. After all, weight change = calories in – calories out.

      Year after year, I would start an diet/exercise program, get discouraged (and hungry), and give up. Then I’d feel bad about myself, consider my fate if I didn’t do something, and the cycle would repeat.

      My real catalyst was a little silly and anticlimatic…after eating a 850 calorie piece of red velvet cake, I asked the question: will my body “use” all those calories? In other words, was I going to have to do 120 minutes of cardio to “burn” those calories that took me all of 120 *seconds* to eat?

      The question got me started on an exhaustive journey to better understand cellular metabolism, and each question I answered left me wanting to know more about it – adipocytes and skeletal muscles, insulin, HSL and LPL, etc. I was quite ignorant about all of it.

      Google led me to your site, and its treasure trove of information. It’s really been a great tool in helping me to understand the science of it all. So, thanks for that!

    • Peter Attia  June 16, 2014

      Very interesting journey. Appreciate you sharing it, Tim.

    • Kelley  June 16, 2014

      Although your question was posed to Tim and not to me, I can tell you what changed MY mind two years ago. I hold a BS (ha!) degree in nutrition, from 1984 (but I never completed the additional training to become an RD). I edit health-oriented self-help books for a living. So I’ve been a student–formally and informally–of nutrition, health, and fitness for 35 years. Like Tim, I was committed to the calories in/calories out theory (aka the “gluttony/sloth” hypothesis). As someone who has never had a weight problem, and who can eat a LOT without gaining much weight, but who has always eaten a fairly “healthy” diet (never indulged in much junk food and cooked mostly from scratch), I sort of wondered, “What’s so hard about this?” I also am a fitness instructor (Jazzercise) and teach 4-5 classes per week. I haven’t read popular diet books obsessively, but I have read a few, and of course have stayed aware of the most popular diets (via cultural exposure, with a bias on my part toward absorbing nutritional info) and could summarize most of them more or less.

      About two years ago I heard a 10-minute radio interview with Gary Taubes. I was like, “Great…another ‘expert’ who thinks he’s discovered the magic bullet. And he’s not even a doctor.” But something about his measured tone and his logic caught my attention. Still, I was resistant to having my paradigm challenged.

      Shortly thereafter, a vegan friend of mine posted on FB a link to an article by John McDougall, whose book “The Starch Solution” was just coming out. I looked at the article. It was compelling in certain ways, but mostly I found McDougall’s argument based as much on rhetoric as on facts. Remembering the interview with Taubes, I felt some cognitive dissonance, but wrote it off to “There are so many conflicting theories out there. What are you gonna do? I guess I’m one of the lucky ones.” (I still think I more or less lucked into my metabolism.) Then I was shopping at my regular grocery store, walking down the “popular books” aisle (which I never really pay much attention to) and noticed GT’s “Why We Get Fat” at eye level. I thought, “What the heck?” So I bought it. And I immediately went home and ordered McDougall’s “Starch Solution.” I read the two in quick succession. It was Gary’s obvious commitment to finding the truth that won me over. His tone (“I think I’m on to something, but lots more research needs to be done” rather than “I’ve discovered The Truth and now I just need to convince you”–ie, McDougall’s tone) was just right.

      It’s not precisely accurate to say that I’ve become a staunch devotee of the low-carb philosophy (although I find that if I minimize carbs in my diet, I don’t have to think about my weight at all). Mostly, I’ve returned to my questioning ways. So, thanks GT and PA and NuSI. This journey of exploration has been among a handful of life-changing ones for me.

    • Kelley  June 16, 2014

      Correction: On re-reading Tim’s comment, I see that he didn’t specifically talk about hewing to the “calories in/calories out” theory. Yet in my comment I mentioned his doing so. My mistake. Sorry, Tim.

  17. Jack  June 16, 2014

    I have not had a chance to see the video. Before approaching a “problem”, you have to have the “right” people, with the “right” mentality.

    Keep up the great work!

    (reply)
  18. NitrousOx  June 16, 2014

    Even Luc Montagnier, directly says HIV infection alone is “not enough” to cause AIDS. If you find a scientific paper that proves that HIV causes AIDS let Kary Mullis know. He’s been looking for it for 20 years! Haha!

    (reply)
    • Peter Attia  June 16, 2014

      So what’s your answer? Kary Mullis is definitely a smart guy, but if that’s your benchmark for truth you should get familiar with his other positions rather than just say, “he’s been looking at it for 20 years.” That means nothing.

  19. Brian  June 16, 2014

    Thanks for all you are doing to change the world. Sounds hyperbolic, but it’s true.

    When is Gary’s book coming out?

    (reply)
    • Peter Attia  June 16, 2014

      I don’t know (and I don’t think he knows either!).

  20. Fredrick Hahn  June 16, 2014

    Good post Peter.

    Trouble is, when you have doctors like Ornish, Essylstein, McDougall, etc. spewing forth their unscientific BS, it’s a tough road ahead. These people are not interested in the science behind the issues, they are only interested in their own agenda.

    When these people are taken seriously as Ornish always is, so too are their ideas and this is unfortunate. In our efforts to seem fair, reasonable and accepting of other viewpoints – viewpoints that are absolutely wrong – we shoot ourselves in the foot. Ornish shouldn’t even be on that stage.

    (reply)
  21. Lynn  June 16, 2014

    Great post Peter. Indeed, the advice to, “Eat right and exercise” plus the one that really gets me, “Everything in moderation” is clearly not working. I admit to viewing the overweight / obese in our society as lazy over-eaters, having the deadly sins of gluttony and sloth, plus a dash of stupidity to have gotten in to that situation in the first place. Now I find myself much more compassionate. Not to say there’s no personal responsibility in the matter, but I certainly accept the notion that people are being misled, remain confused and feel lost as to how to solve the problems they are facing with their failing health.

    (reply)
  22. Mark  June 16, 2014

    Peter, I also watched the whole panel discussion. I thought that you were quite clear when delivering your message (great job!), but that the other panel members just didn’t want to hear or understand it. You clearly explained the scientific process; the other panel members just vamped on “we know ever so much.” A strong dose of Karl Popper would benefit some of these folks!

    (reply)
    • Peter Attia  June 16, 2014

      You felt my pain, Mark…

    • Kevin  June 16, 2014

      I’m thinking more Kuhn and Planck.
      “…a new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.”

  23. james  June 16, 2014

    Haven’t seen the discussion yet. Sort of thinking about it, am not even sure if it is worth it. From the comments so far it appears there is a wealth of cognitive dissonance and some eminence based information. Not to say that your time was wasted. It never is when you spend time defending what should be so obvious by now.
    I fully agree with you that we have to get at the science behind it. I am getting a bit tired of yet another observational, an other large cohort, controlled for all sorts confounders, or not, because half the time we don’t even know what the confounders are . It is one of the reasons I always enjoy Art Ayers’ posts. And now with the recent research coming out of Sweden about the possible negative impact of antioxidants, because we don’t even know to what extent we are upsetting the delicate balance in the production of ROS where our system is probably more than adequately equipped to intervene when and where needed.
    I think I mentioned it before, I came to this not completely unlike so many here, except in my case it was a couple of angina attacks and subsequent verdict , arteries clogged, need double by-pass and statins for life. I did none but started my own research because obviously something was wrong with what we had been doing, eating even though we had both followed the nutritional advice from the experts. Actually my wife is a graduate in Health and Nutrition from Wageningen University. And thus we discovered the ‘alternate universe’. Malcolm Kendrick, Gary Taubes, and of course “there are no safe starches” Ron Rosedale, etc. etc. Which basically set us on a more primal path.
    Never went back to my cardiologist, never used a statin in my life and BP went down from 150-160 / 100 to 135/87. I am 72, stand 6 tall (small) and weigh 65kg. No matter how much fat, or how many eggs I eat, I seem not to be able to gain any weight.
    Thanks for the clear and for everybody understandable information. Always enjoy the e-mail notification come
    Keep it up Peter, NuSi is desperately needed.

    (reply)
  24. Andrew H  June 16, 2014

    Dr. Attia,

    I look forward to new content here as it’s a wealth of information, but I do fear the answer is that it depends; it’s the chicken or egg argument. Is this a cause or side effect or both? What are lacking are large unbiased double blind studies. We need studies that are performed without an agenda, The USDA provides us nutritional guide lines, they are interested in protecting/promoting agriculture, not that they are being malicious, but it isn’t helping the population. To paraphrase you, the idea that the business plan is wrong or the implementation of said plan is wrong is a fair assessment, we have the numbers and what we are doing isn’t working, the problem is increasing.

    I just feel that without a ground up look at this we have far too many policy makers or experts stuck in a mode of stagnation, They are misinterpreting data or ignorant to new data or ideas that contradict their beliefs.
    Now the “why” the statement a calorie is a calorie is true, but not all calories are processed in the same way. The human body processes a calorie or carbohydrate, protein and fat all differently, why don’t we start from there. The identification and solution from this point is going to be rough, there a decades of bad info and poor responses to address the bad info.

    (reply)
  25. Hazel  June 16, 2014

    Dr. Attia, this is an excellent site. Thank you for maintaining it.

    (reply)
  26. Digby  June 16, 2014

    I really enjoyed this post. I find that in my late middle age I don’t want or need a “magic” solution, but want to see good science (not funded by those with an agenda or bottom line) so people have good information. As one who tried to live by the AHA and USDA guidelines, only to get heavier every year, I know what people lack is reliable information they dan trust. I am so glad I stumbled on to Atkins, Taubes, and you, which finally allowed me to get control and avoid diabetes which I was clearly headed for. I have nothing but sympathy for people who are obese, for they in the main don’t understand what’s taken control of their bodies. If I hadn’t found out about the power of carbs I would be there myself.

    (reply)
  27. S. White  June 16, 2014

    Hi Peter,

    I am Tom Bilyeu’s assistant and he wanted me to find your Reversing the Smoking Trend Graph so that I can get the important moments from it, however I cannot find it online. He let me know that you showed it to him personally. Is there any way that you can send me an email with the graph?
    Best,
    S. White

    (reply)
  28. Norm  June 16, 2014

    As usual great post Peter! I don’t think there can be any better way of highlighting the problem as you did by using business model and the airplane analogy. I would quote the great poet Dr Iqbal here: “Although my group has idols up their sleeves, my job is to keep calling towards truth.”

    High blood pressure was quoted as leading cause of death, I wish they knew how effective low carb is for high blood pressure. Good to hear from Ornish in his concluding remarks, …”a diet low in refined carbs…” I was expecting him to say low in fat.

    (reply)
  29. Tom Kirkendall  June 16, 2014

    Peter, I thought it was interesting in the panel discussion how Ms. Goldman failed to grasp the point you made with regard to the lack of emphasis being placed on determining the true causes of obesity in the face of the obesity-related death toll in comparison to what resources would be spent if that same death toll were the result of airplane crashes.

    I made the following observation over at Art DeVany’s blog years ago: Saying that expending more calories than you ingest is the key to controlling obesity is sort of like saying that gravity causes airplane crashes — true, but it doesn’t tell you much.

    (reply)
    • Peter Attia  June 16, 2014

      Tom, glad you noticed this. I was worried I did too lousy a job explaining the analogy (which I may have). I like your gravity one, also.

  30. Mark Z  June 16, 2014

    I have nothing of substance to add, just want to say I’m new to your site and feel like I’ve just discovered a veritable gold mine in terms of what the future of nutrition is going to look like.

    All too rare these days to find someone who practices the scientific method with absolute purity, if I had a complaint it is that you don’t write often enough.

    Mark in Canada

    (reply)
    • Peter Attia  June 16, 2014

      Thanks, Mark. Not sure I can do much on the writing frequency problem, though.

  31. P  June 16, 2014

    How you must have suffered. Was it billed as a debate? The rest of the Milken panelists, made up of industry, academic, governmental and medical establishment types, were there to pontificate the current paradigm: eat-less and burn-more. As you rightly pointed out in your slide, the reason the anti-tobacco public policy reduced incidences of cancer is because tobacco causes cancer. The SAD pyramid diet promoted by the establishment in last 40 years got us an epidemic of obesity. Their fix is to hand them more of our tax dollars money and let them pile on more governmental regulations ( all buildings designed w/ Goldman staircase) and social coercions, ala the cigarette model.
    Bad ideas beget awful results. People died. Instead of seeing the flaw and resulting damage their policies have wrought, perhaps due to cognitive dissonance, they double down w/ more of the same policies.
    I sensed your reticence to declare the fallacy of the SAD paradigm, because you didn’t want to offend the esteemed (credentialized w/ gazillion degrees) panelists. You can’t afford to burn potential funders at confabs. Sensibly, you held back, sounded agnostic and played nice as the pompous Ornish’s kept bloviating about his clinical trials, arterial slides and snarking at Dr. Atkin’s hypothesis.
    You are one calm hombre!

    (reply)
    • Peter Attia  June 17, 2014

      P, you’re kind in your praise. It wan’t billed as a debate, but as you can see, these things are sometimes set up as such.

  32. Lavinia  June 17, 2014

    Well done, but your argument lost strength with me when you used the analogy of 4000 people falling from the sky daily to create the sense of urgency in recognizing 4000 obesity-related daily deaths in the US. I instantly thought, “How many people are alive today in US and how many people fly daily? Those can’t be the same numbers. The answers: 318,253,000 alive in US today (rounded off) and, using a 2010 figure, 6,575,343 persons fly per day. If 4000 people die in US per day, that means .00126% of our population dies each day from obesity-related causes; .00126% of 6,575,343 (the number of people flying daily) equals 83.

    Eighty-three people falling from the sky daily is a more accurate proportion in creating your intended comparison. Still absolutely alarming.

    As for my personal experience of weight and health, I lucked into the Specific Carbohydrate Diet eight years ago (Paleo-like, but with the addition on non-liquid dairy and homemade yogurt; based on monosacharrides vs di- and poly-) due to deteriorating health after ten years of ulcerative colitis. More and more meds, yet getting sicker and sicker. It definitely takes will power to resist all the ‘yummy’ food around me, but luckily I feel the literal pain of poor choices within a couple of days if not hours, so it’s easy to re-set my course and be, for the most part, incredibly healthy. I think choices are most often based on motivation and I lucked into a condition that grabs me and throws me on the toilet in a ball of pain in short order if I don’t make the right choices. My weight is great, I exercise and am strong as a horse, and all my numbers are stellar. I am extremely active. But making the right choices has taken me years (I didn’t want to believe that my diet had to be that ‘restrictive’) and I still stumble despite my motivation and exposure to a wide range of information. I don’t even know where to start when speaking to my 85-year-old mother about nutrition. It’s as though she hasn’t read anything about nutrition since 1993, still believing that fat makes people fat and that rice cakes count as breakfast. So, yes, people are confused as to what to eat, but I also know that it’s pretty clear that cake and ice cream is not what you should eat if you want to lose weight and yet my friends do exactly that. To me it seems more like we are all battling addictions more than anything else.

    (reply)
    • Peter Attia  June 17, 2014

      I was going for a simpler message, but I actually like your analysis more. May I modify it and use it next time I make this case?

    • Lavinia  June 17, 2014

      Peter – But, of course. Nice of you to ask.

  33. Teresa  June 17, 2014

    Peter-
    I listened to your panel discussion you posted.
    I am just so stinking proud of you! The female who disagreed with you was off base
    But oh well- you handled yourself well! I am always
    Encouraged by you! Incidentally, we had a ‘biggest loser’
    Competition at wrk- I ate mostly ketogenic and won the competition.
    Always inspired by you! Thank you.

    (reply)
    • Peter Attia  June 17, 2014

      Yup, she sort of missed the point…

  34. Samuel Burkeen  June 17, 2014

    Nina Teicholz apparently does a good job of telling a story. It was so good I read it twice. Things were bad, but I did not realize how bad. Basically, the business plan has been very questionable, but investments have been made, careers made, and reputations established based on a particular dogma.

    The food industry responded, and people basically eat what is offered in the local supermarket. Most of what is sold is low fat, no fat, high carb. If you have to ask the dairy guy to go search in the back for a plain, full fat yogurt that has not been injected with jam, you don’t need to do a study to find out what most people are eating. It is in plain sight, and you have to make a real effort to do something else. In fact, you probably have to violate what your doctor is telling you to do.

    Unfortunately, most people who can’t tolerate what is presented as healthy in their local supermarket, and blame themselves for not jogging enough everyday, or suffer severe calorie restriction are just going to get worse. The situation is so bad in the research community I don’t expect things to change until they just die off.

    (reply)
    • Colleen  June 17, 2014

      Ditto on the difficulty at times of finding plain full fat yogurt!

    • DonnaS.  June 19, 2014

      I am in the process of reading Nina’s book Big Fat Surprise. It’s a must read which I’m sure as probably been mentioned elsewhere here. I’m at the part about Crisco and how it came to the forefront. It got me to thinking that I became a Crisco/margarine kid with lean steak and skim milk and so forth. Makes me wonder if my weight use has been compounded by these items I ate as a kid.
      What a panel to have been on. You actually had one of the better credentials, Peter You actually worked on yourself. You had health issues and you tackled them. One of the panel I don’t think has ever had weight issues and he tells us to eat plant based and do this or that. It makes me wonder if he actually has thought as critically about these issues as you have. .

  35. Erika  June 17, 2014

    Good Morning Peter, et al…
    I’ve had the PLEASURE to peruse your site extensively over the past week and came across MANY a post that screamed for me to respond, but I’m just a ‘layman’ and needed time to put my words to paper without seeming like a total moron!
    Firstly… I totally understand your passion. It seems though, that the harder you try to explain it, the more you are faced with resistance. As is with me. The harder I advocate this solution, the more I’m faced with ‘but what about this… and what about that.’
    My story (if anyone cares)
    I jumped on the LC bandwagon 6 or so years ago after seeing a doctor about being “sick and tired of feeling … SICK and TIRED” After a general blood work up, it was concluded that (not only was I overweight/obese… but borderline Anemic as well” Otherwise healthy and strong (and stubborn). Don’t visit him but maybe once a year but in this case I just KNEW something wasn’t right! Of course his advice… lose weight, eat more frequently. Yaaa…ok!! I’m a ‘starve’ all day except for “IV” of coffee,cream and sugar that I tote around…. then come home and graze until bedtime. OK.. I get it… eat more frequently to ‘fuel’ your body all day long. Start with oatmeal.. “it sticks with you all day” … Gave it a try… and over a period of 7 months and lost 62 lbs! (From 248 to 186) Yay me!! Eating ‘lower carbs’ definitely was PART of the solution….
    Well… (trying to Cliff Note my post) managed to keep it off for 2 yrs and then, like many, LIFE just throws you a curve ball… and all went to hell. So.. in summation (is that even a word?) here I am today… back up at 220.6 as of last Tuesday (when my “$hit or get off the Pot” journey started once again) Down to 214 today! 🙂

    SO… eating low carb.. nothing new to me! It works AND I know it!
    Please don’t be offended when people ask you what you eat. We just want to make sure we are choosing the right ‘gasoline’ for the ‘tank’ (insert winky smiley face here) <—- More of a good vs bad foods education lesson. When I read it I took it as.. Oooohhh cheese…. ooohhhh butter… oooohhh… whipping cream. We know quantities and preference differ … we just are grasping at … well…. whatever roadmap that will inevitable guide us to our final destination. (cheesy, I know)

    There is a question coming, I promise…
    Ultimately… the bottom line (for me) is getting to the point of Ketosis. You mention that it could take up to 3 weeks to get there…. however I read another article yesterday that put it at '3-5' days? Is this possible?
    The reason why I ask (and why I frantically dissected many an article re: Ketosis last night) is that I experienced many of the symptoms/side effects yesterday morning) Extreme cramping/sweating/nausea in the morning and an 'out of body' feeling for the rest of the day. A 'foggy haze' so to speak. Alert and absolutely able to work but just a feeling that I was looking at my world from the 'outside' Was this in fact a possible result of Ketosis? A 6.6 lb loss in 1 week totally exceeded my expectation… 'stoked' none the less… and realistically not expecting those numbers every week… I just really want to get to the point of being in Ketosis but I'm unclear if I'm already there or not.
    I know you are followed by many informed and educated folks and know you are busy and 'have a life' (whaaaat?) so I'm happy to heed the advise or comments from any one of these fine folks. Have a SUPER day. And 'thank you' …. just 'thank you'

    (reply)
    • Rita  June 17, 2014

      Hi Dr.:

      Firstly, my extreme appreciation for your work, your passion, and your writing. Now, to piggy-back on Erika’s story/question, I am wondering what your current stance on a ketogenic diet is at the moment – that is to say, Richard Nikoley at Free the Animal has taken a turn away from low carb and away from ketosis as a result of his work with Tator Tot Tim and the mighty Resistant Starch/gut biome research. Thoughts? Thanks!

  36. Justin  June 17, 2014

    Hi Peter,

    my first comment over here… Been around here for a while now and thought it was time to share my thoughts and tell you how much i learned through reading your well-thought-out posts here.
    Your point of view seems so logical to me that it is hard to believe how our society is not able to implement the clear steps this implicates.
    It seems like we´re blind to the difference between root causes and symptoms.
    As a side note, your content always is enabling folks to form their own believes and hypotheses. I really like that.
    Have a nice day!
    Justin

    (reply)
    • Peter Attia  June 17, 2014

      Thanks very much, Justin.

  37. P  June 17, 2014

    All the Milken panelists, after prefacing that they remained open to new ideas on causes of obesity, rest of the time they focused on public policies for prevention and touted anti-tobacco as the perfect model to rid of obesity. As far they are concerned, root cause has long been settled. Simply hand over more power to these credentialized experts, the government(CDC director) , business(Caremark exec), academia (Dean Goldman), do-gooder (Milken) and medical(Ornish), to regulate and coerce the mass to eat-less, burn-more and de-stress ala Ornish. Like Galileo’s Inquisition for doubting geocentrism, your lone voice of skepticism never had a chance. Love your blog. Keep fighting!

    (reply)
  38. Juliet  June 18, 2014

    IMHO, the scariest part of the panel discussion is not that most of the panel favors a plant-based, low-fat, calories-in,calories-out approach — it’s that they all seem to favor using public policy ( i.e. Government) to mandate and/or force their ideas onto everyone else, as if this matter has already been settled….

    (reply)
    • Samuel Burkeen  June 18, 2014

      This has been done for forty years with disastrous results. It is not so much that there is a government nutrition policy, it is that the food manufacturers reverse engineer their foods based on the required labeling/policy. Additionally, product promotion, and even media careers have been made supporting that policy. The majority of what is presented to you in your local supermarket, or public media for that matter, has been a result of government food policy.

      The really obscene aspect of all of this is that if you faithfully followed the policy and it made you sick, then you are treated as a slothful, glutton who failed to adhere to the party line. A common variation of this is the knee jerk reaction of ” you don’t get enough exercise and you play too many video games.”

      I am probably not persuaded by the exercise argument simply because I am 67 years old, and anybody jogging in my inner city Detroit neighborhood would have probably been suspected of mental illness in 1955. When I tell people this the come back is that everybody worked out on the assembly line every day. Well, all those office workers didn’t
      work out, and “beer” bellies were far more prevalent among the assembly line workers.

      Up until the government nutritional/medical complex became afflicted with some kind of nutrition psychosis, and I am not using that term lightly, most people thought they got fat by eating too many sweets, or drinking too much beer. In fact, people thought meat was nutritious.

  39. Dominique  June 18, 2014

    (First off, Gary has a new book on the way? That’s one big rock I must have been living under of late…)

    Really thought-provoking insights here. The comparison to AIDS treatment is keen, as it illustrates the stakes and severity of the implications of the obesity and diabetes epidemics. As you pointed out, both strategy and implementation must be on point for any treatment to be effective. While Americans’ overall implementation of government-promoted nutritional standards has been fairly abysmal, I think it’s also safe to say that said standards and the current obesity treatment (“eat less fat and overall calories, exercise more!”) are equally abysmal. Whether those standards are causative of the implementation is up for debate, but seems likely. Either way, the situation warrants further study (by both the scientific community and individuals taking responsibility for their health) and stringent application of those treatments that have shown to be effective.

    I’ve recently started moving forward with pursuing my dreams of working in medicine, and sites like yours make me all the more excited about what lies ahead – particularly the opportunities to use lifestyle interventions to improve quality of life and promote healing. So, as always, thanks for sharing.

    (reply)
    • Peter Attia  June 18, 2014

      Happy to provide even a small amount of excitement about what lies ahead.

  40. Yossi Mandel  June 18, 2014

    Just happened to be reading about ghrelin, and came across researchers being hampered by buying into this exact mindset:

    In 2009 “GOAT links dietary lipids with the endocrine control of energy balance” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2789701/ “we also find that activation of the GOAT- ghrelin system is triggered by a specific lipid-rich environment rather than by caloric deprivation. These observations suggest that the ghrelin/GOAT system informs the CNS [central nervous system] about availability, rather than absence, of calories”

    Then picked up in a 2013 review “Peptides and Food Intake” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4005944/ “this mechanism [enzyme ghrelin O-acyl transferase] may act as a nutrient sensor by using absorbable fatty acids to signal to the brain that high caloric food is available”

    This because they see that ghrelin remains high in presence of lipids, so must be eating lipids that causes high ghrelin. So maybe do the experiment and see if ghrelin remains high under all conditions instead of just saying it is so? Well someone did, and in ketosis ghrelin drops: 2013 “Ketosis and appetite-mediating nutrients and hormones after weight loss” http://www.ncbi.nlm.nih.gov/pubmed/23632752

    Oops. Somehow that didn’t make it to the review. Vicious cycle of ignoring failure in real life application to creating failure in research which perpetuates the failure in real life application.

    (reply)
  41. JJ Bell  June 19, 2014

    Finally managed to scrape time together to make it through the video. Peter, you are a Saint and have the patience of a champion.

    Apologies in advance, this is going to be a bit of a rant……

    I commend the work the Milken Institute is doing but although they may be non-partisan, I think the common prejudice amongst many of the group was plain for all to see. How the hell you managed to get on that panel I will never know but well done!

    I hear your points on questioning what such debates achieve but I have to admit it was very entertaining if equally frustrating. Re the comments you made on your own performance, you are evidently self-critical (a man after my own) but although I felt you started slower than you could have (possibly 75%-80% Peter Attia), I felt you finished with aplomb.

    Frustration: You are extremely nuanced and devote limitless energy to the critical details. Lynn Goldman’s retort to your middle presentation made me growl internally. This is how I saw it.
    Peter:
    Lynn: We know it all. We have the answers (by implication, people are dumb/self destructive). Here’s how we implement them better i.e. more of the same (and probably the same results).

    Amongst the ‘here’s what healthy behaviour we need to promote’ slides I spotted a slide showing people how they could transition from the unhealthy to ‘healthy’ breakfast cereals. Isn’t amazing how deeply marketing penetrates? If you removed the heart healthy marketing claims from the bottom of the picture, what actual nutritional difference is there across the cereal spectrum?

    I am astounded that so many clever people, with access to and awareness of the same information to you are so closed minded. Did Dean Ornish really quote a mouse study basically saying that low fat = lower risk of heart disease? Forget the risk factors (in humans) he says, concentrate on the actual plaque accumulation (in mice!!!!)
    Although I thought Dean hit on a lot of important points (stress, reduce refined carbs etc.) I really think he suffers from thinking he knows more than he does. He plainly thinks high animal protein diets are dangerous but what type of animal protein are we talking about, what quality and what confounding corollary behaviours are packaged in with this high protein consumption?

    One of the speakers made a great analogy about a questionnaire Daniel Kahneman apparently carried out asking students why they smoked (they apparently had faith in the medical system’s ability to develop treatment to save them from lung cancer before it was too late). This faith in the system extends to diet and if we continue telling people we have all the answers and to live (& die) by the food pyramid/plate, they will believe us.

    I can’t accept the argument that the main reason for the obesity epidemic is that people make irrational decisions or somehow reach for toxic foods to self-medicate other stressors (though I am not ignoring this completely). If for arguments sake, we carried out 10,000 close to perfect studies and they all vilified carbs, are you telling me that if people knew they could eat as much butter/cheese/ as they liked with minimal damage and in fact this could help them lose weight/improve health, they would not do it? It’s all about the information.

    I thought your closing section, with the analogy to smoking, was a brilliantly crafted argument (and really a knock-out blow). I watched the film Rocky at the weekend at an outdoor cinema with a few friends and the crowd’s reaction when he ran up the Philadelphia Museum steps was similar to how I felt when I watched that part (I am sad possibly I know). I know it should but it never fails to amaze me how difficult it can be to progress science.

    Well done for sticking in there Peter, Haggler (grit) and Feynman (belief in science) would be proud 🙂 ?

    Ps Thanks for the Haggler, Hearns recommendation & unbelievable coffee recipe. I feel like I owe you something.

    (reply)
    • Peter Attia  June 19, 2014

      JJ, you owe me nothing for the recs. You’re very thoughtful response and commentary are more than enough. I appreciate your thoughts greatly.

    • jw  July 5, 2014

      I used a Youtube to mp3 converter and also looked at the slides, but I did not see any of the reactions that might have been on thevideo. That being said:

      It is becoming clear that Ornish is the new Keys. He must be aware that mentioning questionable mice studies was grasping for straws. And following it up with a strawman criticism of a LCHP diet, which was as disingenuous as one can get with a leading LCHF researcher on the panel. As stated above, it must have been very hard to hold your tongue.

      He gave a tepid “while I support the research that Peter is doing”, he then went into a typical and presumptive “the science is settled” stance for the rest of the talk. These are high school debating tactics, but they work surprisingly well even today (and especially in politics, whether nutritional or otherwise)..

      Repeating others’ criticisms of Ornish’s research, there were many confounding factors, the sample was small, there was no statistical power, and my personal pet peeve – it has never been independently replicated in the 15 years since publication (AFAIK).

      With the caveat that he has produced some positive changes in some areas in his patients, and I am sure that there are some people who benefit more from LFHC than LCHF, I don’t understand how he continues justify his arrogance.

  42. JJ Bell  June 19, 2014

    Thanks Peter!

    (reply)
  43. Vanessa  June 19, 2014

    It is amazing how much of modern medicine is still the same wretched Greek science that Western society has been following for thousands of years. “A balanced diet” is not unlike the balance of the four humours redux.. Medicine by analogy: eat fat and you get fat. The appeal to “common sense” in eat less/exercise more. The Greeks didn’t experiment, but rather thought about a problem and used analogy to arrive at a solution. We mock blood-letting and emetics, but we (i.e., the modern age) are not so far from it, it seems. Next we will be returning to the theory of the Wandering Womb (you have to read it to believe it!) to explain all things wrong with the female body. Nutritional science has become a kind of religion, in which people believe what they want to believe, ignoring or deriding evidence, because it points in the contrary direction. Whatever happened to the scientific method? It is held only by the minority, it seems, like you and Gary Taubes.

    I get angry because after years of stable (though a bit heavy) weight and tons of exercise, I dutifully followed my doctor’s advise to eat less fat, and I gained 35 pounds. Low carb has taken 10 off, but I sit here in solid ketosis, on a seemingly endless plateau, despairing of ever losing the rest. Thank you, modern medicine.

    (reply)
  44. John U  June 20, 2014

    Hi Peter. Very interesting blog again, right on the heels of the last one, and related in some ways.

    I find the quote you mention by Dallas Willard – “I don’t debate, but I am glad to enter into a joint inquiry. We will seek the truth together” to be a fine goal, one which suggests honourable pursuit of what is right. Unfortunately, I think it is misplaced in the present situation, that is, in the context of the panel “debate” which you attended. Not all were interested in finding the truth.

    You say “I realize folks (from readers of blogs to members of the audience at the Milken Global Conference) want facts, answers, prescriptions…”. This is probably true for the audience and the majority of those who take an interest in this subject. However, I believe it is not true for the majority of the panel members nor is it true for those in policy making processes in government, academia, and big business involved in producing carbohydrates for human consumption.

    Logical and persuasive arguments such as those you used to highlight the AIDS success story are nice, but they will not help much. The cigarette debacle ended well but how long it took! Look at how much push back came from the tobacco industry which for decades resisted any change in legislation to discourage smoking. Every legal avenue (even illegal ones) were tried to scuttle government interference. The reason it took so long was because cigarettes did not kill you fast enough. When the results of actions are clear and indisputable, things move quickly. The nutrition problem is similar and even slower.
    .
    Unfortunately, most people do not understand science or the scientific method. They do not understand the need to constantly question our beliefs (hypotheses) if there is even a small amount of evidence which puts them in doubt. Since most people do not have knowledge of science to guide them, they default to those trusted professionals in the medical profession to be honest and right, and to tell them what to do. How many times have you heard someone say “ My doctor said that …….” . Now. as a non-medical doctor, try to convince this person that perhaps their doctor is misinformed. Not going to happen. Then there is the media which provides all the information the average person really needs. Why question such reports when they are coming from highly recognized sources in academia?

    The main problem is that this whole process of developing the “correct” nutritional advice for the country has been politically and financially driven by business interests who stand to either make or lose a lot. Science is not going to win the war. Good science will not stand in the way. We have already seen examples of science being marginalized and ignored if it did not support the status quo. Remember the case of Helicobacter pylori. The establishment ridiculed this notion that a bacteria was responsible for stomach ulcers. It finally took the good doctor to infect himself and cure himself to make an impact and win some support for his discovery. That is what I call drastic action.

    This was not a debate in which rationallity or good science prevails. There already exists tons of credible evidence which at least should make a true seeker of truth question the validity of the nutritional advice which we are given by the government, and which is supported by the professional medical institutions. There is no sign that these institutions are looking for the “truth”, but there are all kinds of signs that they are “in bed” with those who stand to lose a lot of cash if the truth gets out. We will not win this war any time soon if we cannot get the majority of the population to question the conventional wisdom. So how will this happen? As I already surmised, the vast majority do not understand science and simply trust their medical advisors, the majority of whom are plain ignorant on the subject of nutrition. This is very troubling, and I don’t have a neat solution. What I do believe, however, it that it will not happen by being polite and a “team player” (as I am sure you are) with those who are part of the problem. I think it will take dramatic and drastic action (such as publically calling some folks liars and idiots perhaps, or publically trashing someone’s research if appropriate). The media has been part of the problem, but now media is much more diversified. We need to enlist the media’s help in sensationalizing the process of ridiculing the conventional wisdom, just as those who have ridiculed good research in the past. It will take some serious leadership skill to move the population in the right direction, not through science, but through down and dirty persuasion of the traditional kind – appeal to the basic instincts of people – long life, good health, and good sex. We need to be on the offensive.

    Rational scientific arguments are fine for the vast majority of the scientific community. Unfortunately, too many of the leaders of these communities have been corrupted with money and advancement issues. It will take to long to reverse this situation. Drastic and politically visible action which garners media interest is required to shake up the status quo. If I sound like someone who believes in conspiracy theories, well I do in this case.

    I join the others who applaud you for being such a fine advocate of this cause. This is a tough battle and it needs tough people, and I believe you are a very tough guy.

    (reply)
    • Peter Attia  June 20, 2014

      Agree with a great deal of what you’ve suggested/proposed. How can people like you help? For organizations like NuSI to succeed, funding exceptional and rigorous science is necessary but not sufficient for change. We need an “irate and vocal minority” to set brush fires for change.
      I’d like to better understand what that looks like over the next decade. This will not be a simple petition or campaign contribution. No bumper stickers here.

      So what does the movement look like?

    • Yossi Mandel  June 20, 2014

      Personally I think that the movement looks exactly like what you’re creating: Fomenting distrust of doctors and health experts and fomenting trust of science and experimentation.

    • Peter Attia  June 20, 2014

      Ok, but how does this movement leverage the passion of those of you reading this?

    • Yossi Mandel  June 20, 2014

      It would have to have a goal first – x amount of people with x amount of knowledge and/or doing xyz. If Nusi has a brief for organizing people for science or health, you might be able to do it through that. For online activism it would require more robust forums to create communities. Look to how Jimmy livin la vida and others organized communities for specific targets – low carb, paleo, etc and look for specific health goals among their communities. You see much further than that, you might want to have 1000 people with ability to comprehend 50% of a research paper or ability to parse statistical values, you might have those people crowdsourcing reviews of science papers, which are worth looking at which not etc. Since Denise Minger is self taught, she might have some ideas on how to get people to teach themselves. Lots of others ways to go about this with more thought.

  45. Read  June 20, 2014

    We are bombarded with advertisements for cheap high carbohydrate/sugar foods presented through targeted ad campaigns and marketing strategies designed to convince us that certain foods are highly desirable and even “healthy.” Large corporations fund “studies” and even the government presents a food pyramid that includes massive amounts or sugar. I recently noticed a wheat cereal company marketing a “protein” breakfast cereal that of course is packed with carbohydrates so they see the trends and develop a very sophisticated strategy to fool the public into thinking they are eating something healthy. In other words, the truth has been buried behind a massive misinformation campaign and a lot of junk science. Many in the medical profession are complicit or ignorant so there is no authority figure or consensus for the ordinary citizen (most of us are “followers” as you noted in another post) to find the truth.

    Trying to discuss the “facts” in such an environment is very difficult but I think it might be necessary to “debate” or confront the corporate machine and misinformation in order to change minds on a large scale. I do see a sort of slow turn in progress, hence the protein cereals and “low carb” breads etc., so I think the science may be winning out on some level. However David is trying to bring down Goliath and it is going to take a while to dismantle years of misinformation about diet and health.

    Best wishes,

    Read

    (reply)
    • Peter Attia  June 20, 2014

      Hard to disagree with the thrust of your argument. See my response to John U. Same questions posed to you.

    • Read  June 20, 2014

      That is a really good question Peter. My thought is that NuSI is on exactly the right track. Serious people with the science to back up their conclusions. I would not engage on a Madison Avenue level, no TV commercials, no charismatic doctors with talk shows, no bumper stickers, just serious people talking clearly to the media about the science.

      Maybe more important than the media because of the scope of their influence are the trade organizations, the AMA, the American Heart Association, etc. and the medical schools. First, I think all physicians should be required to learn about the biochemistry of nutrition in medical school through a non-dogmatic course emphasizing the best new science . Courses and textbooks on the cutting edge of the field should be part of such a program and need to be written. Second, the professionals themselves must engage in the debate with their fellows in these trade associations to try and change the paradigm.

      I am just throwing out ideas here as I am no expert. I hope we will reach a tipping point eventually. I see this happening with statins for example. My guess is that in a decade or less the medical profession will be forced to to admit that they recommended and prescribed this drug too broadly and thus caused more harm than good. Many of these doctors simply did what their associations recommend for patients so perhaps they are a significant lever to effective change.

      At least for me the movement looks like Taubes, Attia and others who have put themselves and their careers on the line to try and bring about the kinds of changes that in time will increase health and decrease health costs on a large scale. I will be very interested to see where this goes and who wins the war for public health.

  46. NitrousOx  June 20, 2014

    RE: HIV/AIDS (off topic but VERY important)
    Peter,
    I consider you a brilliant person. I have you as having more in common with Mullis and Duesberg than with the Ornishes of this world. Haha!
    Check this out:: http://www.niaid.nih.gov/topics/hivaids/understanding/howhivcausesaids/pages/hivcausesaids.aspx
    The articles presented as “evidence” in my view are as good as all the trash presented in the nutrtion science universe. The discussion (see link above) even states this “fact”: “Chimpanzees experimentally infected with HIV have developed severe immunosuppression and AIDS” If you notice NO REFERENCE is provided.
    Compare that statement with this: http://www.dailymail.co.uk/news/article-2034439/Lab-chimps-freed-caged-fior-30-years-injected-HIV.html
    Something’s off…
    Also, just like statins may prevent a second heart attack in certain populations (unrelated to lowering cholesterol levels), HAART is believed to stabilize certain parameters due to its ANTI INFLAMMATORY effects.
    Watch the documentary “House of Numbers”. All the top players of the AIDS field were interviewed (on both sides of the debate). It’s a great starting point. Will put some healthy questions in your mind just like Gary Taubes’ book did for the diet debate.

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    • Connor  July 11, 2015

      Hi, NitrousOx and Peter.

      I used to think that those arguments sounded reasonable enough to justify doubting mainstream consensus, but I now think they’re mistaken. Check this big article, Duesberg is there under ‘HIV is not the cause of AIDS’: http://en.wikipedia.org/wiki/Misconceptions_about_HIV/AIDS.

  47. John U  June 20, 2014

    Regarding what to do to tackle Goliath (a good anolgy btw), we absolutely have to have the media involved. After one’s own family physician, most folks listen to the radio commentaries by nutritionists and read the newpaper columns on health and diet. When these sources offer “bad” advice (not supported by good science and research studies), they need to be taken to task in possibly an arrogant way, no mincing of words. The question then is how to make this happen. In fact it is already happening on a whole bunch of good web sites, hosted by well qualified and credible bloggers. The problem is only one of exposure. Note enough of the general public read these blogs. So, what if Nusi or a similar organization (I am thinking here of something like Thincs, the network of cholesterol sceptics) would start a web site devoted to bashing the conventional wisdom, using facebook, twitter, and written communications to news media after some crappy study is published in their pages. This organization’s main purpose would be to attack all public and psuedo-public (such as medical journals) publications and news releases which require debunking. Such an organization would have to be staffed by full time employees who devote their time and energy to meeting this goal. Such an organization would have to be associated with a number of prominent medical professionals (much like NUSI) who would also write articles and critiques and provide the element of high credibility. I suspect that we already know many names who might be wiling to associate themselves with it, but I confess that this part might be a bit trickey. The existence of such an organization would have to be publicized in the media and its mission would have to become well known to the general public, hence substantial funding would be requried. I suspect a lot of the general public would be interested to follow the editorial comments of such an onganization, because people like to read about controversy and discention. Attacking the traditional advice of your government makes for very interesting reading and listening, especially when the subject matter is about your own health and well being. So I believe that it is doable. If I were a medical professional with good credentials, I would certainly try to form such an organization, so I suspect there must be others with the appopriate credentials who think similarly and are not afraid of the political and professional repercussions, and there certainly will be many.

    The existence of all the blogs on the web devoted to this subject is a good start, but these blogs wil never achieve the results which most of us would like to see in any time soon. What we need is powerful people who are well connected and with access to substatial funding and who truly want to do the right thing.

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  48. P  June 20, 2014

    Open up multi-front battles, used by other winning causes successfully, to defeat the forty-plus years alliance of government, big business, academia and media that has thrived from SAD paradigm. To protect their own self-interests, the SAD alliance will crush any dissent.

    Short-term (such as Greenpeace)
    1. At conferences and PR events, such as Milken conferences, confront the authorities’ personal conflict of interests. Point out the lack of proof, fallacies and collateral damages of SAD. Shame and stigmatize the SAD promoters and experts.
    2. Publicize the debate, via mainstream and new media to the general public that the current dogma is faulty.
    3. Organize, promote and publicize the benefits of keto.
    Medium-term
    1. Deploy legal strategies to tie up current regulations promoting SAD.
    2. Defund SAD researchers.
    3. Instant war-room rapid responses and detailed rebukes to flawed pro-SAD studies.
    4. Coordinate an alliance of anti-SAD groups (government, big business, academia) for actions.
    Long-term (anti-tobacco)
    1. PACs to promote keto.
    2. Fund research for legitimate clinical experiments.
    3. Usurp establishments (AHA, ADA, medical societies, gov agencies) from within their power structure, similar to how Ancel Keys drove his agenda once he became a director of AHA.
    4. Coordinate and organize disparate keto entities’ actions to define plans, actions to achieve goals.

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    • Peter Attia  June 20, 2014

      Agree with some, but not my question. My question was not “what is the strategy to do X, Y, Z?” My question is more about the role of folks who aren’t stupid enough to give up their day jobs, but still want to help a movement change the face of nutrition and human health? In other words, what should the readers of this blog and folks like them, with “normal” lives, be doing?

    • Boundless  June 22, 2014

      > In other words, what should the readers
      > of this blog and folks like them, with
      > “normal” lives, be doing?

      * Be an example. Make sure that what you are doing nutritionally actually works. Be able to explain why you’re doing what you’re doing.

      * Share but don’t preach.

      * Keep in mind that we don’t yet know what the ideal diet is for everyone (and it’s apt to be a set of diets matched to a long list of variables). What we are certain of is that the USDA MyPlateOfMetabolicSyndrome is a disaster for anyone.

      * Join the health committee where you work, or find out who’s on it and kibitiz from the sidelines. I’m the token SAD dissenter on mine.

      * Donate to nusi.org or just shop through it’s amazonsmile link (Peter smiles).

      * Sign the “Attia for Surgeon General” petition (Peter frowns).

      All seriousness aside, there probably is some maximum rate at which the culture can convert to what is likely to be a set of diets featuring lower carb, higher fat, lower n6 fat, no grains, no soy, favoring organic, favoring grass-fed/finished meats, avoiding GMO and it’s entourage, etc.

      I frankly did not expect to see that Time “Eat Butter” cover this soon.

      It’s going to take some time for the food industry to respond to radical changes in what people eat. I work in ag machinery. I eat almost nothing that our equipment plants. That’s a sobering situation.

    • Vicente  July 10, 2014

      Hi Peter,
      I think we, laypeople, can’t provoke big changes in the way other people think about health and nutrition:
      1) Everybody thinks they are doing the right thing. And when we say that almost all the public health institutions in the world are wrong, they think we are talking nonsense. “How could that be?” It is incredible.
      2) We are neither medical doctors nor registered dietitians. Why should people listen to us? They won’t. They don’t.

      In my experience only my family and close friends are open to new ideas: they know how fat I was one year ago, they can see me now and they know I am no moron. They know “first-hand” this way of eating works. AFAIK only my wife, my parents and a friend (he is a T2D) have changed their diets because of my success.

  49. Read  June 20, 2014

    My mistake, I misunderstood your question. I suppose the answer to that is to become informed, to engage in the debate, to experiment on themselves and find what works, and to support those individuals and organizations that promote a reasonable approach to nutrition. I suspect real change will happen from the top down not the bottom up but as voices are heard the marketplace will respond so there is value in speaking up.

    Mostly the individual should take responsibility for his own nutrition and become informed enough to make sound decisions. Correcting the rest of the world is an incremental process that will eventually tip toward significant change when the marketplace realizes it makes economic sense because enough people have “put their money where there mouth is.”.

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  50. John U  June 21, 2014

    Peter, re what we readers could be doing to help this movement, I think that the working masses who just read the blogs and write comments would be able to so on a site which would be well publicized and therefore hopefully read by the masses. Its mission (provide credible information regarding science and health and debunk the bad advice offered by conventional wisdom) should be, and hopefully would be, interesting to follow by anyone who has doubts about his or her health status and what his or her medical practionner is advising as corrective action. The usual fare which is currently offered on so many blogs would now appear on a site which is read by a lot of people. These readers and commentors should also write to their political representatives and ask pointed questions refering of course to the (counter) information on the blog. Big business lobbies are only successful if they have the govenmental policy makers on their side. We need to rock the boat and create mass concern about our health so that these policy makers realize that to stay elected they need to respond. Creating a national health scare might be good, especially if the masses realize that it is not their fault that they are in bad health.

    All this may be wishful thinking, but I do believe that competing clinical studies will not make enough of a difference. Loud and abundent bombardment of the authorites in the NIH,AMA,congressmen, senators, etc. might provided a bigger bang. This can only happen if there is a well oiled machine in place which can drive public policy changes. We, the masses, can only provide the science and the anectotal evidence to support it. Even anectodal evidence cannot be ignored if there is enough of it.

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  51. P  June 22, 2014

    For the big pic strategies to fight against the SAD alliance, I leave that to the pros, such as yourself. As for myself and family, we eat keto primarily and abstain from junk and carb rich food. To make this into a movement, be an influencer and share , without being obnoxious, knowledge with our families and friends, one person at a time. The most important thing parents can do is to have their kids bring their own food to school, instead of eating federal mandated low-fat-high-carb fare served at the public school system. Educate our own kids. Get them to correlate the obesity epidemic in shoppers and what the items in the grocery cart. They must have the knowledge base and courage to stand aside from the herd, dismissing the SAD propaganda. We may not be able to change the older generations; but we have a chance to try to save the next.

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  52. Ellen Urciola  June 22, 2014

    I think a grass roots movement is beginning to create a stir. I see more and more papers touting the evils of sugar and carbohydrates.  This is do to your contribution Peter. You need to do exactly what you have been. You are are providing a well crafted pathway through education. 

    Peter, you have taught us what the problem is. You have provided us with evidence to back up what you say. Then you have shown us how to interpret it for ourselves, how to recognize the fallacy from the logical in the conclusions of the research. You have provided us with the tools we need to talk to our physicians in ways they will respect our opinion.

    You have offered the counter argument and not only shown us the bad interpretation but have given us the tools to find it for our selves.

    This is a passionate debate that incites emotional (and irrational) responses from I’ll-informed naysayers whose only tools for debating are to scream and yell thinking that those who yell loudest are right.

    I am an educated lay person (who has earned my masters in other than science). I see more talking (by myself and others) taking place, some quietly, some not so quietly. I can now talk intelligently about low carb because of you and this blog. 

     I notice two things, the quiet agreers are nodding and joining the conversation and people are beginning to listen (of course Dr. Oz being lambasted before the Senate helped. Sorry, couldn’t help that one).

     I  agree, the “squeaky wheel does get the oil” but, we need more refutation of the bad science not only by organizations like NuSci, but by researchers, without agendas, who loudly speak up and say, Hey, wait a minute that argument  doesn’t make  sense for these reasons.

    We need to keep talking, with the tools you have provided us, sometimes loudly, sometimes quietly (and perhaps with a big stick?).

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  53. Jonathan Christie  June 22, 2014

    What’s wrong with bumper stickers? We need memes to combat “Artery-clogging saturated fat.” Keto is King. LoFat -> Fat. LowCarb for Diabetes. Sugar kills. A calorie is not a calorie. Carb/Insulin/Fat. Fat is the new carb. If the controversy won’t fit into a bumper sticker, it won’t fit into people’s attention span.

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  54. Ralph Doncaster  June 27, 2014

    2:25 into the panel video: “More than 50% of all economic growth in the last 200 years” has come from public health and medical research? I really doubt that. It’s hard to take someone seriously when they start with unscientific BS like that.

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  55. K. Duncan  June 30, 2014

    You are my hero, Dr. Attia. Not only because of the tireless effort you make to truly help people, but for your ability to stay calm and thoughtful during that discussion! I have to admit I got quite angry with a couple of those panelists! But as I reflected on the massive success (this is not an overstatement) I’ve had in the 5 weeks since discovering your blog (through your wonderful TED Talk!), it just made me sad. You truly have your work cut out for you.

    The fact that these health professionals still tout the conventional wisdom despite all evidence to the contrary is just plain depressing. It would’ve been a better discussion if they would have shown the maps charting the increase in obesity in the US at the beginning of the discussion instead of the end. It would take an unrivaled set of cajones to make some of the assertions the panelists were making in light of that information!

    All I can say is thank goodness for NuSI. It’s crystal clear that if we want any meaningful scientific studies done on this topic we’re going to have to do it (and fund it) ourselves!

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    • Peter Attia  July 2, 2014

      Well, yes, we definitely have our work cut out for us. I try not to reflect on that often, otherwise I’d stop tomorrow and do something different.

    • K.Duncan  July 3, 2014

      It certainly wasn’t my intention to discourage. Let me add a little perspective to my frustration. I’ve been dieting by the conventional wisdom for over 30 years. Not only was I unsuccessful, but I was worse for it in ways that go well and far beyond a number on a scale. I won’t take up space and time with personal specifics. Suffice to say that I completely related to your personal journey (x 100!)

      The majority of the focus tends to be on physical wellbeing, but as someone who has lived over half my life as an obese woman I feel there is a significant need factor in emotional and socioeconomic wellbeing, too. Perhaps I took things too personally, but all I could think listening to this discussion was how people will take what they are saying as hard fact and use it to justify judging, shaming, humiliating, underestimating, undervaluing and underpaying a rather sizeable group of individuals.

      However, what I was really trying to accomplish in my post was to get the folks who value your efforts as much as I do to donate to NuSI. Perhaps I was too subtle. I can’t imagine the effort it takes to prepare for these types of discussions and to maintain this blog (heavy on real information with very clear explanations of complex ideas) and you’re not even trying to sell me supplements, powders, or books. There are no advertisements. There’s not even a donation button. Top that with heading a non profit and I have to wonder when you sleep! But here’s what got me. All this effort has the potential to benefit me far more than it will you, yet you are making most of the sacrifice (I’m sure you aren’t making the salary you would as a Surgeon!). It is truly the least I can do to forgo a few lattes!

  56. CW  July 2, 2014

    Well, how about starting with a citizen and health professional lobbying effort to have a government funded review of current medical research that determines once and for all what a healthy diet is comprised of? Different nonprofit and public interest groups could work together to fund the lobbying effort.

    Once a healthy diet is determined, pressure the appropriate government agencies to change public policy to support the research. THEN the bumper stickers kick in! (the parallels with the tobacco industry are pretty amazing.)

    The “carb lobby” is going to fight it all tooth and nail b/c profits are involved! But we did manage to drastically reduce tobacco use in this country.

    It’s always interesting to me to walk through the grocery stores and see the aisles of carbs. Whole aisles devoted to energy bars, cereal, crackers, etc., many purported to be healthy! It’s going to take an effort to alter public perception, but it can be done.

    (reply)
    • John U  July 2, 2014

      I am also thinking along the lines of CW. We all need to start writing to our ELECTED government reps stating our case to the best of our ability. I believe that elected reps pay attention to such things when there is a significant volume of letters, whether email or otherwise.

      I just finished reading “The Big FAT Surprise” by Nina Teicholz which I enjoyed immensely. Even though most of us were aware of the general picture about Keys and his cronies, Nina included a lot of information about other players and research of which I was unaware. Significantly, I was surprised that, according to NT, elected officials, who started to receive mail from their constituents about the nonsense that was going on, reacted and started to panic. This is what we need to make happen again. I can’t believe that the leaders in the diet-heart hypothesis and their many associates (including elected officials) are not aware of the ground swell of rebellion regarding the poor nutritional advice which became and still is public policy. I bet they are still counting on the fact that we are a small group of unorganized sh*t disturbers and they will prevail, at least for another 10 years. In this age of internet, speed of light, communications, I think they will lose. We need to help make this happen as fast as possible by bombarding our reps and the media with letters, facebook posts, tweets, whatever, protesting the stupidity that is being ignored by the establishment and the waste of money which is being spent on dead-end research. Where is the science in all of this? There isn’t any.

  57. Ron  July 3, 2014

    One possible tactic for getting the word out

    The way in which news stories propagate across the most watched platforms (web, TV, radio, print) often times depend on an originating source with sufficient credibility for news editors in smaller newsrooms to be comfortable repeating the story with minimal incremental investment in time or resources. That is the nature of the news industry with constant demand for stories yet limited budgets for original content creation.

    For those intent on having their message heard given a viral news propagation environment such as we have, it is necessary to have each new message published or posted by a news outlet with sufficient credibility within the news-editor community such that the virus begins to multiply within and across news platforms (ie. go-viral).

    There are a few national outlets that could be targeted (AP, Time, CNN) and the tactics may be varied depending on the openness of a news outlet to counter or non-mainstream ideas (regular columnist, panel member, feature article, or editorial influence).

    Once Peter were to become a regular contributor to any of these credible source news organizations, there is created an instant viral multiplier effect which can be counted on to reach millions of people as multiple news outlets reproduce the storyline on thier platform. This would be a much more powerful for message propagation than the blogging model which tends to attract like-minded people with a strong interest in a topic.

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  58. Brian G.  July 4, 2014

    I just saw something online that I have never read about in detail in any of my voracious reading of low-carb books, blogs, etc. I would be grateful if you would address it briefly here.

    Maybe this isn’t totally relevant to your post, but since the topic is success vs. failure, I suppose any comment could be technically be responsive, provided it has to do with whether various theories re weight loss have any merit. 🙂

    Here is the issue. Most everything I’ve read from you, Taubes, Eades, etc., have focused on reducing carbs as the primary way of lowering insulin levels to control obesity. And it all made sense to me. But I just watched a YouTube video by a Dr. Jason Fung. He spoke about how various foods score on the insulinogenic index — and the levels do NOT always correlate with the glycemic index or carb load. Apparently some proteins cause a far greater insulin response on this index than do some carbs. I did some research online and found this to be true. (E.g., Per the always reliable Wikipedia, All Bran has a 40 percent lower score than beef!)

    Question: why shouldn’t we be focusing more on this index as opposed to carb grams if we want to lose weight, avoid metabolic syndrome, etc.?

    Thanks!

    (reply)
    • Peter Attia  July 4, 2014

      Not sure. It’s more than just unit insulin response, it’s also the substrate being provided. Protein will primarily be used for muscle anabolism before GNG, but starch will first be used to replace glycogen, then DNL.

  59. Brian  July 5, 2014

    Thanks much for your answer re the insulinogenic index. The fact that I can write to you and get a response within a few days says much about my thoughts on the question you posed here.

    I know your question is how to get the word out, and it is an important one, but just a few thoughts on the unstated assumption that it isn’t happening.

    The Internet is allowing it to occur organically in ways that were never possible before. Gary Taubes wrote GCBC in 2007 (just under 7 years ago) and WWGF fewer than 4 years ago. I’m not a doctor (unless you count being a Juris doctor ;-)) but it seems from my the ideas he wrote about are now largely considered (at worst) somewhat controversial and untested scientific theories, and (at best) obvious scientific truths that need more study.

    But when he first wrote “What if it’s all a big fat lie” in the NY Times magazine (12 years ago this month), the reception he received was that of a total lunatic. It was essentially the same as the one Atkins received 30 years before. I was struck by this a few weeks ago when I reread the article and then some reviews of it in the popular press.

    Thing has come so far, so quickly. And I have every hope that NuSI is going to continue this progress exponentially in the same manner that things have already been happening.

    You are a perfect example of this phenomenon. You are now posed to become one of the world’s most respected authorities on obesity and nutrient metabolism. But just five years ago, you were just some overweight (but fit) physician who never could have predicted where your life would quickly turn after your wife’s gentle comments on your physique got you thinking. If she had made those comments in 1985, you may still have been spinning your wheels trying to follow Pritikin or something else. The low-carb resources you found online have been seen by millions of others.

    For every Peter Attia, there are docs who are learning about these ideas and lay people who are too. They may not end up leading a 501(c)(3) that may change the world, but they are opinion leaders who are creating a critical mass of thought. I think of an acquaintance who trains people with Cross-Fit. He (and his colleagues) would never consider urging their clients to eat low fat muffins in the morning to stay fit.

    Before the Internet, these “new” ideas couldn’t be shared at 1/100th of the efficiency they can be now. Not only does the Internet give people the means to learn about and share ideas more quickly, but it also gives a voice to smart people (non-MD researchers) who can spread the word without fear of funding being cut off. Had the Internet been around from 1950 onward, I believe Yudkin would have won the debate against Keys. Keys could not have held a lofty, largely untouchable place from which he would spread untested theory as gospel. Nor could he have easily acted as a scientific bully to mock those who disagree with him without fear of being challenged by the masses (eg., opinion leaders who read about this stuff – docs and others – and then share their thoughts online).

    I think it is beyond reasonable debate that the progress that has been made in the past 5 years will be a fraction of what takes place between now and 2019. That is just the way things work when people learn about ideas. One person tells two, who each tell two, etc. Before long, people who read the “Big Fat Lie” article would view it as a mundane statement of the obvious and not the scientific equivalent of an argument that the world is flat.

    So just keep it up, Dr. Attia. You are changing the world more quickly than you can possibly imagine.

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    • Brian  July 5, 2014

      And PS – it appears the increased knowledge is already paying health dividends. Last I looked, childhood obesity rates are already starting to inch down. And I’m sure the reason is an emphasis on decreasing sugar from the diet.

    • Peter Attia  July 7, 2014

      Not sure that’s anything more than a statistical artifact, unfortunately.

    • Brian G.  July 7, 2014

      Thank you, Norm. That is a great article discussing the notion that “insulin isn’t that important after all.”

  60. Ravi  July 6, 2014

    Peter,
    Love your work and have benefited greatly from it (lost over 40lbs being on a low carb diet and in being in ketosis). Also like your data driven approach. Speaking of being data driven, have you been able to measure your level of “insulin resistance/sensitivity” of muscles (while controlling for exercise and associated muscle glycogen depletion). In other words, are your muscles able to take up glucose more efficiently with smaller levels of insulin after your experiments with ketosis? Is there a test that can do this?

    Also, given the importance of insulin levels for fat storage and obesity (from your previous posts), wouldn’t a point-of-care blood insulin meter be of great interest (along the lines of a glucose and BHB meter?). I ask because I have seen some publications on technology that can accomplish this (from universities).

    (reply)
    • Peter Attia  July 7, 2014

      It would be great, Ravi, and I’ve wasted, err… spent, many hours discussing it with POC experts. The problem, unfortunately, is that POC devices don’t work for complicated assays, of which measuring insulin is. It’s a RIA and requires an ELISA or similar test to detect, so hand-held and quick options don’t work (yet).

  61. Anthony G Beck  July 6, 2014

    Peter,
    You are indeed a gentleman & a scholar! A literal breath of fresh air amongst an atmosphere heavy of intellectual smog. Thank you for your strength and fortitude. Hopefully I can buy you a shot of MCT one day 😉 Pursuing Bliss for the win!

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    • Peter Attia  July 7, 2014

      Thanks for the kind words, Anthony.

  62. Francis  July 8, 2014

    I read as much as I could trying to find your message about what to eat and what not to eat. Correct me if I’m wrong, are you basically endorsing the Atkin’s diet?

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    • Yossi Mandel  July 8, 2014

      The answer is probably no, as I haven’t seen an endorsement of any particular diet on the site, but Atkin’s is based on similar science as what is described here. My personal reaction to this site and Atkins was that this site allows me to tweak problems in weight loss on my own because I understand some of the underlying biochemistry, while in Atkins if you run into any problems you were/are expected to see a clinician for them to try solving it. Dr. Atkin’s was a clinician, and if you read the section in his book on when people run into trouble with weight loss, you’ll see that he was not successful with a certain percentage of people. Possibly a combination of his not having time to read all the relevant research and that we now have much more research results available than he did.

    • Vicente  July 10, 2014

      Peter Attia: “If you’ve been reading this blog at all you’ve hopefully figured out that I’m not writing it to get rich. What I’m trying to do is help people understand how to think about what they eat and why. I have my own ideas, shared by some, of what is “good” and what is “bad,” and you’ve probably noticed that I don’t eat like most people.

      However, that’s not the real point I want to make. I want to help you all become thinkers not followers. And that includes not being mindless followers of me or my ideas! Being a critical thinker doesn’t mean you reject everything out there for the sake of being contrarian”

      http://eatingacademy.com/nutrition/is-red-meat-killing-us

    • Peter Attia  July 10, 2014

      Thanks for reminding folks, Vicente.
      I noticed on Twitter someone was giving me grief for “having a blog called the eating academy, yet not wanting to spend much time talking about what I eat.”
      Isn’t that like saying you want to take a course on are appreciation (or wine tasting) and you want the teacher to just tell you their favorite art (or wine), rather than teach you how to appreciate art (or develop your palate for wine)?
      Obviously, what I do isn’t for most people.

    • Francis  July 13, 2014

      Forgive me for being new here. I found my way here via Tim Ferriss. I enjoy his approach with disseminating information and wanted to get deeper into what he eats to lose or gain weight. Obviously I am not going to follow everything he does nor will I do it here either. There’s a lot of info to digest here and from what I gather, correct me if I am wrong, this is similar(not exact) to the Atkins way. Nothing wrong with this. I just want to know where this blog stands.

      I don’t know your conversation on twitter, but I am not here for art/wine/food/health appreciation. I am looking to eat for optimal health. It’s akin to me taking a course by Tiger Woods on how to drive a golf ball. Yes, the info on the physics, mechanics, and drills are important. But I want to also see Tiger in action. I want to analyze his swing. I may never swing like him. But I can certainly learn a lot by seeing him put it all together. To a certain degree we learn and succeed by copying what other successful people are doing. And I hope to continue to learn from your wealth of knowledge.

    • Peter Attia  July 14, 2014

      Watching Tiger swing is likely to be much less helpful for improving your swing than having an expert golf pro actually teach you how.

  63. Dean  July 9, 2014

    Is there any work or reading material on something I find to be helpful to me.

    I read alot about the digestive system having its own “brain” in that it decides what saliva to combine with what food and how to digest and the many decisions that we do not make in our brain consciously.

    Then I read that the colon produces a lot of seratonin which produces a happy feeling.

    Could it be that without meaning to, we have shown our ‘gut’ how to eat certain foods to make us happy and the ‘gut is very smart and will do that for us to make us happy but it does not possess the awareness of our brain in our head. So people are very happy getting fatter and fatter. Is this something that has been studied?

    I think this is what has been going on with me because as I reduce stress and begin to eat well, I can experience a moment of stress that causes me to feel bad and my digestive system says to eat a fast food meal. Sorry for going on so long.

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  64. Jason Clements  July 11, 2014

    Dr. Attia,

    I want to extend my gratitude for everything that you share on your website. Using your information about Ketosis, I was able to lose 22 lbs of fat, gain 7 lbs of muscle and go from climbing V2 to V6. (Rock climbers will understand. V-scale is the climbing scale for difficulty.) The rock climbing improvements were the only data that I was interested in. The body composition data was a side benefit. Well, less fat on my belly was an excellent side benefit.

    Keep up the excellent work!

    Jason

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    • Peter Attia  July 12, 2014

      Thanks Jason. I’m pretty sure I’m a V0 if such a category exists.

  65. kelly  July 14, 2014

    Hi peter, I am very thankful to have found your blog. I am in my 4th week of no sugar, no starch and trying very hard to get into ketosis for weight loss. I have lost no weight despite being strict. I bought a glucometre that also reads ketones and my fasting results today was bsl 5.5mmols and ketones 0.3 .
    I also only eat very small amounts due to previous gastric sleeve. My gp doesnt know much about ketogenics and dont know what I sm doing wrong. I have eaten nuts but chose macadamia nuts and about 10 per day…and I have been having half cup of full cream milk in my twa. That is all I can think of. Would appreciate any advice.

    (reply)
    • Ellen Urciola  July 15, 2014

      Hi Kelly,

      For me, I had to restrict the amount of dairy I use ( heavy cream, 2tbl. In my one coffee a day). I love nuts and chesse (probably to obsession ) but found I needed to limit those to 2-4oz. A week. Remember, this is a lifestyle change, a process that will have to be adjusted several times. Also, the sugar cravings will be a constant source of contention for about a month (or more, depending on your body). Even now that occasional homemade cookie gives me cravings for days after I indulge. BUT, it will get easier. Read, experiment, and above all, Don’t give up. You need to find what works for you. I am just sharing what helped me lose the weight and become healthy. Hope this helps.

    • K. Duncan  July 19, 2014

      Hi,
      In addition to reducing the nuts and dairy, I found that counting calories and being really mindful of my ratio of fat to protein helped me quite a bit as well. For example, if a given meal has 25 grams of protein, I make sure that I’m getting at least 50 grams of fat as well…hopefully that makes sense.
      I know that many low carb high fat advocates say it isn’t necessary to count calories, but I’d like to point out that VERY few of them have ever been truly obese. I count calories because I’ve been so out of touch with my body for so long that I am just now, after over 2 months of LCHF, beginning to recognize when I am sincerely hungry, and not just eating out of habit.
      Of course, we are all different and it’s important to experiment to find out what works for you.

  66. Jonathan Christie  July 15, 2014

    Peter, the Energy Balance Consortium Study / Pilot study completion date was 6/30/2014 – any idea when the results will be released? This is really really exciting …

    (reply)
    • Peter Attia  July 15, 2014

      The pilot study will be completed this summer and data should be analyzed to design the 2nd phase by EOY.

  67. kelly  July 15, 2014

    Oh and I add about a tablespoon of coconut oil to my tea at least once, twice a day and cook in more generous amts of butter, olive oil. I have noticed since regularly checking my ketones that in the late evening I am 0.9 and in the morning I am 0.4 and by lunch I am 0.5….
    When I quit sugar I gained 2kg and a couple of days after that I quit all starches too and my weight has not done anything…. I seem to have lost weight eating sugar and carbs and now I am healthy my body is rebelling!

    (reply)
  68. Angela, RD  July 15, 2014

    Very enjoyable and logical discussion! It’s interesting that there is currently a bit of a backlash against universal low carb recommendations within the ancestral health and low carb communities, which I think your points speak to beautifully. With obesity, we don’t have all the answers and can’t provide a universal prescription without completely understanding the various forms of the “disease.” I think that the issue is even more complicated in women, and hormonal health (especially thyroid) can have a significant impact in determining the “best” diet prescription. I’m so thankful that people are still out there thinking, exploring, and researching that are willing to admit we don’t have all the answers but are doing their best to find them. Bravo!

    (reply)
  69. Kelly  July 15, 2014

    Great job, Peter.

    The government fella, toward the end, was basically saying, “Just give me money so we can DO SOMETHING! We’ve got to DO SOMETHING!”

    That’s kinda how we ended up with these recommendations sending us down the path of diabesity, is it not? McGovern and his staff just wanted to “do something!”

    anyway, great job planting the seed.. maybe we don’t know what we think we knew.. maybe our premise is wrong…

    (reply)
  70. Jose  July 17, 2014

    Is it just me or is that Milken guy creepy looking?

    Anyway, since I’m originally from NYC the “Cynic’s Clinic” I speculated on the purpose of this event and the Milken Institute’s role/angle in it. It comes subtlety, like Ben Hur’s chariot” around min 39 when Mr. CDC explain’s the monumental profits to be had collectively and privately through public policy influence or otherwise. Who could benefit from a leg-up on that hey?

    I think “not thin” Peter did a good job not splashing a not small glass of water on Mrs “I solved obesity” Berkeley, and for avoiding a debate with undebatables, but I’ll argue, at risk of alienating my caring co-bloggers that there is no shortage of “confusion crimes” on either side of the nutritional debate isle; Belief puncturing aphorism’s “fructose is good/bad”, “saturated fat is good/bad” “Carbs are good/bad” I suspect are the hobgoblins of……….

    However, maybe all the Tempeh and tofu chicken I ate as a child, which falsely convinced me domestic livestock was much lighter and softer than it actually is, have instilled a desire for hard debate and generated fantasies of a Bruce Lee “Enter the Dragon” style shootout, where our nutritional icons and Iconoclasts (Fuhrman Mcdougall, Taubes, Attia, Ornish, Esselstyn, Bernard, Davis, Westman, Bernstein….) fling papers, journals, studies, chemistry, 19 syllable words and god forbid “epidemiological studies” at each other, one on one, until one gets the “deer in the headlights” look. (rear naked choke in the nutritional debate rule book). The last man standing owns the nutritional pyramid for a year.

    I need to work on the paring though….Barnard-Bernstein, Mcdougall-Taubes….hmmm, Pete who will you take first?

    (reply)
    • Peter Attia  July 17, 2014

      Ha ha ha! As long I’m not playing the character of Kareem Abdul Jabbar…

  71. Mark in Coronado  July 17, 2014

    The ultimate answer to the tobacco problem was simply people not smoking as much. They did this in a voluntary fashion, with some nudges. Part of the “nudge” was a legal one when the tobacco companies were found to be engaging in criminal behavior and this became widely known. Another part was the expense of smoking. Another part was the stigmatization of smoking.

    The parallels with obesity are imprecise. We will likely never have the near unanimity of agreement about the main root cause of obesity as we did with smoking; further, obesity is already maximally stigmatized. And, there’s no clear target for taxation, increasing the cost of the behavior causing the disease. This is a much more difficult problem than the one involving tobacco.

    The best chance for solution of the problem is mass education which requires solid data about what is really causing the problem. I believe sufficient data is already out there, but NuSi’s efforts will yield more. Solid data in the setting of a free market is the only thing which will solve the problem.

    Peter, you were the most important member of the panel because you and Gary are doing the only thing that can be done at this point — providing education and gathering more data. Pretty much everyone else up there on the panel was either useless, more or less, or an outright fraud.

    (reply)
    • Peter Attia  July 17, 2014

      At a minimum, we’re “in the arena.”

  72. Niki  July 17, 2014

    Hello Dr Peter Attia,
    I am intrigued with the paradigm and the data. My own weight struggles parallel the changes, but started in 1997 in Canada. Things got worst when I had my gallbladder out two years ago I was put on an extremely low fat carb diet, to lose 50 pounds and so called be better for my digestive system. Amongst other problems, I had no satiety. I controlled my calorie intake and for a time I (two years) was eating between 1200 and 1600 a day. And I was thinking about food all the time–it was horrible. During the two years, I gained 30 pounds. I thought I must be some kind of mutant at 5’10”. JM said I should be eating 2900 calories per day which I did not comply — she is nuts. I have dumped the low fat regime and I have reduced carb to 25-30 grams per day, added nuts and grass -fed or wild protein. BTW I am training for a half marathon, so moderate exercise. I am satiated. More to follow… . Niki

    (reply)
    • Elizabeth  July 18, 2014

      So many of you commenting on the blog are physically fit and avid exercisers. I am 61, overweight with high blood pressure. I just don’t know what to believe. I wasn’t tolerating blood pressure medication, so for the last 2 weeks I went on the DASH diet. My blood pressure lowered on all the vegetables and fruit, but my weight won’t budge. I’ve been logging on MYFITNESSPAL.com, faithfully sticking to 1200 calories. I’m hungry, and my weight won’t budge. I walk on my treadmill each day for 30 minutes. I started to read this blog when I started to search for answers. I am so confused. I would like to try your way of eating, but I’m scared to! I don’t want to lose my blood pressure lowering benefits, but I’m not satisfied with this low calorie way of eating. I eat a big apple and I’m hungrier than ever an hour later. I remember as a slender teenager I would eat rump roast with the crispy fat and it was so satisfying, and I stayed full, and I never gained weight. When I was 18 and got married and moved out of state, we lived with my inlaws for a while. I ate what they ate, bread with meals, and jello after dinner. I started to put weight on. All I know is the doctor told me I was insulin resistant, and so I got online to read about it. I feel like I have to figure out a rubic’s cube to go in the right direction. I wish I could trust something.

  73. Dan Walker  July 18, 2014

    This may not be the best spot for this, but I was curious to know if you had any plans, through NuSI or your personal work, at looking into the possibility of using intermittent Rapamycin as a possible treatment option, or aid, in treating NIDDM? Or possibly any work treating NIDDM involving mTOR deactivation through CR, with or without NK? Seems as though this would be an area ripe for further study. Especially in further characterization of “benign” IR due to low mTOR activity versus “malignant” IR (blocking) due to overactive mTOR.

    (reply)
    • Peter Attia  July 20, 2014

      I’m personally interested in this idea, but it’s not on NuSI’s radar.

  74. James  July 19, 2014

    TII. following Dr Bernstein since 2010, generally ok.
    But on April last year had a coronary;
    they saved me with angioplasty and placed a stent.

    Hi Dr A., what can i do about arteriosclerosis. I’m on LC already.
    Afraid that stent may not hold, another coronary and so on…
    many thnx in advance for your reply.

    44 Y/ old/ father of 2.

    United Kingdom

    (reply)
    • Peter Attia  July 19, 2014

      You should have advanced lipid testing to determine your true risk and be sure it’s being treated appropriately, even with pharma, as necessary. Many problems can’t be “fixed” or treated with diet alone.

    • james  July 19, 2014

      thank you doctor. They let me go in 2 days, no advice not follow ups. [usually i feel ok, it feels like almost it did not happen] I got ramipril & bisoprol for B.Pressure [now BP is fine] and 75 mg of aspirin. [for life they said] Also was give me 2 types of statins [which to tell you the truth i do not take] but i i have increased Aspirin to 150 mg, on my own initiative. Te problem i have is that this incident has caused quite some trouble in the family, they watch me everywhere and…are more concerned than me [I feel nothing, physically am ok] and I still don’t know what to do about arteriosclerosis. Will ask my GP very soon for a full lipid test/ bloods etc and post main parameters in here…so you can take a look- if at all possible.

      I would like to know if there’s a drug/ medication out there who would help, and please do not hesitate to recommend it. I got plenty on Dr-s on both sides [mine/my wife’s] in my country of origin [not uk] but they all are terrified of LC, and being a “nutter” is not easy at best of times 🙂 let alone after what just-happened. They all were kind enough not to go in “we told you so” mood, but I don’t like “the looks” and tck-tck-tcks. So- drugs i can find, advice that fits (LC) me…not! For many years i been following Dr. Bernstein, also read quite few others, yours included and seen your videos regularly; still i can’t get my head around “how to treat lipids/ arteriosclerosis” Pls help me a little, if you can.

      Thnx!!!!!

  75. Dan Walker  July 20, 2014

    Have you seen this yet regarding rFGF1? Hopefully this stands up to further experimentation.

    http://www.nature.com/nature/journal/vaop/ncurrent/full/nature13540.html

    (reply)
    • Peter Attia  July 20, 2014

      I’ve become pretty obsessed with the FGF21 literature. This is just the tip of the iceberg. Probably worth a dedicated post at some time, as there is an interesting interaction with BHB.

  76. Dan Walker  July 20, 2014

    Hi James,

    Definitely take Peter’s advice to heart about the advanced lipid testing profiles that can be obtained. I would even go one step further and if possible find someone who is the equivalent of what we have here in the US which is a board certified lipidologist. They really do have advanced training in exactly what you need right now. Also think about more than just the underlying cause of the athero. I worked on the bench and then eventually used to help manage one the largest clinical reference molecular genetics and pharamcogenomics operations in the US (half a million+ DNA extractions alone per year) and I was surprised to learn that I actually carried a bad copy of a gene target known as Factor V Leiden which affects blood clotting in the reverse of Factor 8 Deficiency. Meaning I had a much larger chance of experiencing a complication from a blood clot than someone who didn’t have the gene. Someone that carries a bad copy from both parents has to be placed on anticoagulation pharma therapy immediately upon diagnosis. Little things like this can have a large impact on outcomes and if they aren’t known you can’t plan for them. Because of my discovery I began taking daily aspirin at a relatively early age and now I also supplement with Nattokinase. Do your best to learn all you can because ultimately you are the one most responsible for your health and to a certain degree we are all operating our own little health experiments even if we are allowing someone else to make all the decisions for us. Good luck to you and stay healthy!

    (reply)
    • james  July 21, 2014

      many thanks Dan, I certainly will. After the tests will post a lipid profile so you guys and the doctor can take a look. Any advice would be appreciated. For 1 yr they give you ticagrelor, then is discontinued. I know patients who have test for clots, “how thin their blood is” as they take blood thinners for ages; but obviously I’m not as bad as them – maybe they think of it this way. Truthfully speaking, I have no idea what’s going on with me/ them/ everything. 🙂

      I must enter into LC fully and ri-start to burn Ketones as I’m a T2 [like before/ but getting lil apprehensive/ i went more moderate] but is it good right now? Am also reading about Nattokinase, never having heard of it before; is it safe? is “Aspirin for life” safe also? ..and could 150 mg be too much? [i was recommended 75] Is there a “good statin” or any drug that can Fight Arteriosclerosis, so i get it asap and stat to take it… .

      From GP to anyone, the only advice I had was: stop LC [my cholesterol is lil high from few years] ” you eat too much fat” Wish i can jump to N.York and see Dr Bernstein but the guy charges a lot. So basically am stuck…:) thanks again, @ you an anyone who is reading us.

  77. Ellen Urciola  July 20, 2014

    Hi Elizabeth,

    I am not an avid exerciser nor a fitness expert. I am a 56yr. Old overweight female who also reduced my blood pressure medication on my own (perhaps unwisely, admittedly) from 10mg. To 5mg.. I would suggest you browse the posts and read the ones (comments included) you think are relevant. Somewhere among the lowcarb blogs I have visited I read it was possible to eat mostly low glycemic veggies and stay low carb. But perhaps you need to analyze what it was you stopped eating that contributed to your lowered pressure. Fat is not the culprit to your weight issues. Start reading, this blog offers plenty of advice from readers and experts alike, including books, and other websites (I posted one below). That said, if you decide to stay lowcarb you won’t be disappointed, but be patient, become informed, ask questions.

    http://livinlavidalowcarb.com/blog/does-insulin-deserve-a-bad-reputation-the-low-carb-experts-weigh-in/9458

    (reply)
  78. Dan Walker  July 21, 2014

    On a personal note since it’s coming up this week, I’ve wondered, does comic con drive you crazy or do you just rarely ever make it to the Gas Lamp? I have some close friends that live near Kensington and we all went in 2012 and 2013 and had a blast. Huge revenue generator for the city but I’m sure many people would rather see it go to Vegas or Anaheim. I hope it stays in SD forever though. I love visiting and am definitely going to make a few more cons before I’m finished.

    (reply)
  79. Caitlin  July 22, 2014

    Not to add anything further to your plate… but part of why I like keto so much is the effect it’s had on my mind. I feel superbly clear headed and able to focus for long periods of time. I find the relationship between insulin/leptin/dopamine incredibly interesting. I wonder, even if it’s not so much on your radar, if anyone is doing research on ketones and the brain. I have seen some studies being done with coconut oil and Alzheimer’s for instance. This article in the Economist this month got me thinking about how there could be so many more practical applications of ketosis… at least worth researching. http://www.economist.com/news/21608314-consortium-researchers-has-shone-powerful-light-schizophrenia-some-needles-haystack
    Is this even remotely on your radar?

    (reply)
    • Peter Attia  July 23, 2014

      Yes, very much on my radar.

    • Caitlin  July 24, 2014

      That’s encouraging! Except we kind of need a clone of you to keep up with all these applications (and maybe another to write the blog… ha!) Thanks again for all you do. I tried to explain ketosis to a friend once, and he laughed and said, “Fat is good for you? HA! Why don’t we ask my wife who’s in the medical profession?” (Which was, of course, rhetorical, and by the way she’s a physical therapist… sigh.) I stopped talking about it to people that aren’t my family because they think I’m crazy to question people with far more credentials and apparent “intelligence.” Classic logical fallacy, yet my friend is a successful lawyer. I try not to let it bother me though, it keeps the prices low on grass-fed beef. Yep, red meat can kill you… better go buy some Cheerios.

    • Peter Attia  July 24, 2014

      I’d welcome the clone, but I’m pretty sure the NuSI staff (and my wife) would not!

    • Mercurial  July 26, 2014

      Yes, I’m very much interested in this topic as well. I gained 25 kg in a short period (year or two) when I was given neuroleptic drugs for some “serious mental issues”. I lost that weight by restricting carbs, and also starting to exercise more. What’s more, I feel quite well, I don’t eat any psychiatric drugs anymore and so on. They’ve used low carb diet for treatment of epilepsy at least in children, and I guess it’s possible it can be helpful for some psychiatric diseases too. Of course it an in principle also be detrimental for some people, such as causing mania, etc. Some things maybe related to brain functioning and effects on mind of a low carb high fat diet: energy expedition and related issues (ketone bodies vs glucose, etc), GABA, inflammation.

    • Christopher Grove  November 7, 2014

      Caitlin, Regarding your friend’s rhetorical comment, “Why don’t we ask my wife who’s in the medical profession?” I get frustrated with this one too. I know someone who has a drastic case of progressive MS her mom is a doctor, (who is overweight and always trimming the fat off of her steak! hehe It is difficult to even hint at suggestions. Peter has commented about how little that diet and nutrition is covered in a doctor’s training… only a couple/few weeks worth. Doctor Terry Wahls, author of “The Wahls Protocol” has also commented about how little she was taught of diet and nutrition and has had to make a complete about face in now teaching how the Paleo Diet has made such a dramatic change to her own progressive MS.

      There is no quick comeback for these people (that isn’t just all-out insulting. hehe) but I would rehearse a few of these facts and learn some of the statistics. (verifiable) But then, as you yourself suggest, just be ready to walk away from a conversation. 🙁

      In order to make suggestions to people whose health is headed downhill fast, despite orthodox treatment, though, I try to keep a mental list of medically trained people, of whom Peter is one (thankfully) who actually know something, and point them in that direction.

      I also tell them that Peter’s Canadian and that gives him cred! *grin*

    • Christopher Grove  November 7, 2014

      Oh… btw… here is a link to a study (government website) of how many hours of nutrition, as a subject, that are included in medical training:
      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2430660/?report=classic

  80. Tim C  July 23, 2014

    I recently joined a low-carb online forum, and notice a lot of people saying things like “I did low carb a few years back, and lost a bunch of weight, but then [some life event] happened, and I gained a bunch of it back”.

    It’s got me thinking about one criticisms low carbers make: Calorie restriction doesn’t work for most people over the long term.

    If a person fails to abide by a diet, it doesn’t matter what the diet was…it still follows the prototype – start diet; moderate success; stop diet; gain it all back.

    Am I drawing a false equivalent here?

    It seems to me that one could counter the low carber’s argument with the argument that maybe no diet works for *most* people over the long term…and in that respect, the arguments would essentially cancel each other out, and neither side has the upper hand on that point.

    (reply)
    • Vicente  July 24, 2014

      Hi Tim,
      I don’t agree with that idea.

      When you follow a hypocaloric diet, you are always going to end the diet and you are doomed to gain the weight back. You can’t eat 1200 calories/day forever.

      When you eat low-carb you can follow the diet as long as you want. There is no deadline and there is no reason to gain the weight back because you don’t reduce your metabolism.

      May be you find this insteresting: http://novuelvoaengordar.com/2014/07/24/how-to-avoid-the-rebound-effect-of-the-diets/ (I just translated it from spanish to english)

    • Tim C  July 25, 2014

      Vicente – Thanks for the link!

      Don’t get me wrong, I completely agree with you; I just think that there’s a subtle distinction between “Low carb diets increase likelihood for long-term success” versus “People fail on hypocaloric diets over the long term; therefore, low-carb diets are better”.

      People can (and do) fail, regardless of dietary changes they make.

      I’m constantly on the lookout for logical fallacies, and I’ve certainly framed this one to beg the question…it could be that I see these arguments being made in the company of people who have already pre-supposed low-carb is the better lifestyle.

    • Caitlin  July 25, 2014

      Tim, I agree with you. Many people don’t stick with low carb long term and have difficulty adhering to any diet. I have been thinking about this a lot lately. I think that ketosis does help one lose weight and also purge other unhealthy organisms in the body, but perhaps it’s best implemented as a cycle. If we think about humans before the modern era, for most there were long periods of time (i.e. winter) where carbs were inaccessible, but during growing seasons carbs were accessible. Our bodies are certainly equipped to deal with carbs, so I’m not sure if I buy the argument that any carb reliance at any point in your life is unhealthy. There may be times when it was perfectly normal to fill up on fruits/vegetables and store some extra weight on your body. Perhaps it is also somewhat genetic, for instance, if you are a descendent of a less agricultural area of the world (Nordic, for example) you may be less able to handle carbs. So the issue, I believe, is more so that we find any weight gain unacceptable, when perhaps it is built into our survival system and a little bit is fine. The good thing about low carb is that it doesn’t mess with your metabolism in the same way as low fat and calorie restriction, so it makes excess weight easier to lose when you stop running on carbs. Just some food for thought… I’m sure it’s a bit more complicated depending on the individual and their health condition.

  81. Ann  July 24, 2014

    I am about to turn 70. Looking back at what I now see as metabolic syndrome (including infertility) and insulin resistance I am beginning to understand my individual experience. I was diagnosed with hypothyroidism 20 years ago and depression 3 years ago. I take meds for both and am now a very low carb eater (with 30lb weight loss) My question is any thoughts you have on metabolic/hormonal relationships among these things: inflammation, low thyroid, insulin resistance, function of fatty tissue and depression (fatigue), all of which I still cope with. I am frustrated because I feel it likely that research and “best practice” will not make it to my local M.D. before I am dead. Thank you for your brave work.

    (reply)
  82. Jeff johnson  July 26, 2014

    TEE – NOT

    Using TEE – total energy expended to explain your argument was probably a mistake –

    Everything besides REE – resting energy expended is exercise – ree + non-ree(or exercise) = tee

    The difference between the LF diet and HC diet using the REE CHART is (120-200) or 80 calories –

    You can’t use the TEE CHART unless exercise – either decreasing it or encreasing it (the only way TEE can change) – is part of your argument

    An 80 calorie decrease in DAILY REE is almost mute –

    Using the REE TABLE about a 1/3 of the group responded poorly to all the diets – (low fat – low glycemic index – low carb) or from almost 150 to 500 calorie drop)

    About 1/3 averaged abouut a 120 calorie drop –

    Another 1/3 went from a 60 calorie drop on the low fat diet too as much as a 200 calorie increase on the low carb diet

    So it seems to hold true that people can be devided into three general groups on how they respond to diet –

    About 1/3 doing poorly on all the diets – another 1/3 group more nuetral but still somewhat poor and 1/3 doing nuetral or just slightly poor on the low fat diet but doing very well on the high fat diet – for this 1/3 group your argument makes a slight amount of sense

    Still – personaly – I do not think any of these chages in calories are what causes rebound weight gain –

    When the majority of people go off planned eating and into the realm of mindless eating – the foods they eat and the amounts they eat change a great deal – they generally over-eat to obtain enough protein 1. – indulging in fats actually increases hunger to the point that they need 2000+ calories to get full 2. and the increase in carbs produces a hormonally created weight gain and whatever fat they do eat it tends to be stored permantently 3.

    That said – mindless eating cuases great problems for about a 1/3 of people – slight problems for 1/3 of people and no problems fo 1/3 of peple (weight wise)

    The question of why people gain weight – post planned eating – is obvious –

    The real question should be ? What keeps the people who need it on a planned eating program their entire life ?

    The connection between energy output and caloric balance: I difine these as two seperate things because they are – the point is these two seprate things need to communicate with one another –

    1.This communication is best done with low fat beans(soy beans are about 40% fat)

    2. A near or ketogenic diet provides a similarly result

    3. A very very low fat fruit/starch-vegetable high calorie diet also a similar result

    All these methods have an effect in the brain – and promote communication between energy output and caloric balance

    All three of these groups have a definite sort of mindset – they tend to stay on track and plan what they eat –

    which is better than mindless eating ?

    (reply)
  83. Jeff Johnson  July 27, 2014

    How To Eat An Egg

    Having nothing more dutious to do – I thoght I’d ramble and inflict upon you – how to eat an egg –

    Put the whole raw egg with shell in your mouth and chew – that’s how I do it –

    (reply)
  84. samalamadingdong  July 28, 2014

    Hey peter, I know you swim and ride bikes, but I was wondering if you run at all? I’ve never heard you mention doing triathlons or Iron Man’s. I don’t know what your style of humor is but this seems relevant http://www.youtube.com/watch?v=tzSEd7e6tdc.

    (reply)
    • Peter Attia  July 28, 2014

      I run when chased. Or late for a flight. Or playing with my girl. Otherwise, I gave it up in college. Used to run 60+ miles a week growing up, until about age 22.

  85. Randy  July 28, 2014

    Haha, that video is hilarious. I bet this is how the conversations at NuSI go down. “I’m a doctor too”. LOL!

    (reply)
  86. Kiran  July 30, 2014

    Hi Peter,

    I came across your website when I started my keto diet. You have a wealth of information that I have been slowly pouring over the past month.

    I fully understand that you cannot help me without knowing a lot more about my particular case. Here’s my history and my question will be at the end.

    1. I am a South Asian Indian, Male 32 years. I lead a mostly sedentary lifestyle. A couple of weeks back I was diagnosed with Uveitis and further research indicated that I had high inflammation and HLAB27 gene which predisposes me to a host of auto-immune and auto-inflammatory conditions.

    2. There is some research available that seems to suggest cutting out carbs and primarily starch reduces inflammation. I have been in Nutritional Ketosis (at least according to the ketone strips) for about 3 months now. I have been a lifelong vegetarian (by birth) and have occasionally eaten meat over the past 2-3 years. As part of my keto diet, I have started eating a lot more meat. Mainly beef burgers with cheese as I still am getting used to the taste of meat. Since my inflammation started, I added salmon burgers as well.

    Here are my questions
    1. As part of your n=1 experiment, were you tested for any inflammatory markers (EST, C-Reactive Protein, TNF-A etc). Did you notice any changes to any inflammatory markers prior to and after nutritional ketosis ?

    2. I am trying hard to find any link between ethnicity and processing of meat. Have you had any research or are you aware of any research done among different ethnicity that show how ketosis might affect them differently?

    For e.g. I can easily trace about 10 generations of my ancestors due to religious reasons would have been life long vegetarians. I understand that 10 generations is nothing in terms of evolution, but meanwhile could I have lost any enzymes or anything that could prevent me from processing meat. The reason for this is two-fold. It is hard to be on a ketogenic diet and be a vegetarian at the same time 🙂

    3. I am also willing to do a n=1 experiment on myself to try and see if any interventions might work. Is there any organization that you use that helps you with your tests or your doctor works with you to order these ? While I don’t have a lot of money, I believe I could try to improve my parameters.

    I have a lot more questions. I don’t want to take up too much of your time, but any guidance you can give me towards my self-improvement would be invaluable. My email address in case you are interested is d (dot) kiran at yahoo com

    Thanks,
    Kiran

    (reply)
  87. Indy M.  July 30, 2014

    FYI , Dr. Attia: (unlikely chance that you did not already know this):

    Google’s “Baseline Study” aims to get clear picture of human health
    http://time.com/3045429/google-baseline-study-human-health/
    (I recently had my biome baseline done with the UCSF folks)

    Also Dr. Cynthia Kenyon has joined Google:
    http://www.sfgate.com/health/article/Geneticist-Cynthia-Kenyon-is-heading-to-Google-5415673.php

    Take care!

    (reply)
  88. Jim  July 31, 2014

    Peter, A few minutes ago, I finished watching your TED presentation and felt a connection. I’ve watched hundreds if not thousands of the presentations and there are exactly two of them that have hit me right in the guts. They all have value. But number one was a 50 year old man demonstrating a new method of tying shoes. Changed my life and summed up everything I’ve learned over the past 3 yearsy. Viewing things from a slightly different perspective changes everything. Number two is your presentation. In your talk, you mentioned melanoma, shocking dietary changes, reducing exercise resulting in improvements, etc.

    I could stop and simply say beautiful! But, I’ll continue to ramble for a bit. I’m not associated with the medical community at all. I work in the field of meteorology but health is my passion. Thought I knew everything until I hit 40(over 3 years ago). From the age of 20 until 40, I took an ACE inhibitor. Developed hypothyroidism and vitiligo at the age of 35. I’m 6 foot and weighed about 170 until the age of 30. Creeped up to 220 in my 30s. Was on a low salt diet from the age of 13(when first diagnosed with mild hypertension). Was tested extensively(by the VA), when I was 20 in order to determine the cause of my extreme hypertension. At the end of the day, it was considered essential. I’ve also been a chain smoker since the age of 23 and still am today.

    One day, when I was 40, I asked myself a question: just why is drinking 8 glasses of water a day so important? Couldn’t really find a good reason. At this point, I have not consumed one drop of plain water in 3 years. I drank the 8 glasses prior to the age of 40. Noticed positive changes quickly by simply reducing water consumption. If cutting out water has this effect, what else? Increased cigarette smoking, increased coffee intake, reduced exercise, Increased dietary fat, decreased carbs, went crazy with salt, and began consuming fermented foods. Started sunbathing, staring into the sun, and all kinds of other crazy things. Within one year, I had lost 70lbs, the vitiligo that covered most of my legs, feet, hands, and arms was nearly gone. My blood pressure began to drop dangerously low and I dropped both daily meds(thyroid and hypertension). No need for the meds today and my VERY skeptical doctor agreed(not with my actions but the no need for meds).

    At the age of 42, went in for blood tests(6 vials) and plotted time series back to the age of 20. Remarkable! Introduced some exercise earlier this year and participated in masters sprinting this past June. Like the blood tests, it(sprint time) was beneficial data to compare with past times of my youth. At this point, I don’t view the extreme exercise as healthy, but really don’t know? At the very least, it’s a slippery slope.

    Today, I feel as though I know nothing because I thought I knew much and everything was incorrect. This is the sense I got from your presentation. A helluva long winded way of saying you’re not alone!

    Don’t know the origin of this quote, but it feels right:
    True knowledge is knowing the extent of one’s own ignorance.

    (reply)
    • Peter Attia  August 2, 2014

      Amazing story, Jim. And brilliant quote, also. Thank you.

  89. Dominick  August 1, 2014

    After about 4 weeks of fine tuning my eating, I am finally in ketosis. I’ve lost 13 lbs. and my energy level is unbelievable. Just as you described in your experience, no more 3pm crashing. I work till 6-7pm and still leave with energy to spare. I have long way to go to get to my goal (45 lbs.). You have changed my life. Thank you!

    (reply)
  90. Lee  August 13, 2014

    Dr. Attia,,
    In your opinion do you believe that radiation from medical tests such as multiple CT scans can cause cancer? If so what can be done to combat this type of radiation ? Do you think lthat the belief of less than 100 Msv that the risk is minimal? A lot of patients are not told of the risks of radiation from cr scans . Thank you.

    (reply)
    • Peter Attia  August 13, 2014

      Certainly any radiation can lead to cancer in high enough doses. This is pretty well documented in the radiology literature.

  91. Lee  August 13, 2014

    Thank you. So two Ct scans a year could even if it is below the level of 100 msv? Is the 100# per year or during your lifetime?

    (reply)
  92. Joan Barber  August 16, 2014

    Dr. Attia,
    Regarding diabetes, once a person has it, wouldn’t a start for better control and more success in helping manage, and perhaps reverse some (perhaps many) cases, if test strips were non-prescription items and less expensive? In my years of dealing with diabetic patients, usually those who fall slightly above low income, a large problem with compliance and other related failures in personal care, testing and owning blood sugar levels is inhibited by not being able to afford test strips, and therefore not renewing prescriptions. What are your thoughts?

    (reply)
    • Peter Attia  August 18, 2014

      Yes, direct, frequent, and actionable feedback is the key to behavioral change.

  93. Jimena  August 17, 2014

    Thanks a lot for your great postings, I just found them yesterday and I haven’t stopped reading them. I just landed here by coincidence using the word ‘ketosis’ because I’m thinking about starting a diet called ‘pronokal’ coming from Spain where one only eats their powder proteins with high biological value. On top of that one receives all kind of supplements to take at different times of the day and one needs to eat one spoon of olive oil per day. Since I have never done a diet before, and have 12 pounds to loose I am just wondering if this is right for me… And after reading some of your posts looks that this ketosis stage is the right thing to do, even if I was pretty scared of it, but now, I feel this is what I should do…

    (reply)
  94. Jeff Johnson  August 19, 2014

    Pyramid Caloric Design

    When viewing a 2-dimensional pyramid face on – some things are apparent – it has one top point and two bottom points and is structualy stable in this position –

    Turned upside down with it’s one point on the ground it becomes unstable and will fall down at some point in time(sooner than later) –

    Thisleads into the 1/3 – 2/3 rule a rule that has some different applications —

    The top of are pyramid – the one point – represents maximum calories and the two bottom points resting on the ground – represent two macronutrients of minimum calories

    So– there are three macronutrients and three points of a pyramid – this sort off fits nicely together –

    The point of all this –

    The unstable pyramid (upside down) represents two macrobutrients(maximum calories) — any two – and is here considered to produce bad results –
    Examples

    1. High Carb and High Fat – (minimum protein)
    Unless calories are very carefully controlled in this setup – for a negative example – 1000 calories Fat – 1000
    calories carb – fat accumulation is fairly certain and since more fat equals more hunger – 2000 calories fat and 2000 xalories carbs is probabaly more likely tp occur – many morbidly obese peoiple eat just this way –

    This combination simply does not work –

    2. – High Fat and High Protein – this negative combination fails most often becuase it’s diffucult to limit intake from fat calories when past a certain amount is eaten – 2000 calories is what it takes to get full on fat – add an equal amount of protein or even less and you have a recipe for fat gain –

    3. – High Protein and High Carb – 250 grams protein is about 1400 calories – add 1400 calories carbs to this and excess glucose production from two different sources occurs – plus too many calories – period – it’s a negative combination –

    Okay – these are the bad combinations and there are only three possibility’s –

    Three Good Combinations

    Here only one macronutrient is maximised and the other two macronutrients are minimum as in a stable upright pyramid –

    1. – High Fat – (minimum carb and protein)- this is a standard Keto type diet that even at 2000 calories fat results in fat loss for many people –

    but fails to work for many people also – unless 25% body fat or higher is your idea of fun – there are simply too many calories here for many men and even more women to lose fat beyond a certain point –

    2. High Carb – (minimum fat and protein) – this combo works – examples being Dorian Rider and his Girl-Friend – I myself lost 60 pounds eating three heads lettuce and 1/2 cup peas for six straight months and nothing else – it’s easy to eat very low calorie on this combo –

    3. High Protein – (low fat and low carb) – this a resonable combo also – even extreme amounts of protein (1000 grams or more eaten evenly thru a 24 hour period) – results in zero weight gain and can have a rather dramatic effect on hormones – if you restrict calories following this extreme amount of injested protein (preferably whey protein) – weight loss can be quite certain – this doesn’t need to be done more than like once a month or at most once a week –

    This is a form of glucose – protein produced carb loading that can actually work – as opposed to other methods – which may and probabaly will not work –

    Iv’e eaten 1500 grams whey protein spaced evenly over a 24 hour peroid and nothing else and felt great the next day and lost fat follwong this –

    So to sum up – theirs three good combo’s and three bad combo’s –

    Only one macronutrient should be maximized and the other two mimimized for good results –

    (reply)
    • Jeff Johnson  November 5, 2014

      The Circle

      The circle sits below the pyramid – it’s top arc(the circle) just touching the bottom of the pyramid –

      Geometry and mathmatic’s avoid all shopistry – thank god –

      The circle is most interesting – for only a tiny portion of it’s top arc touches the bottom of the pyramid – the circle sit’s atop a square where only a tiny portion of it’s bottom arc touches the top of the square – what is says is this –

      calories should be limited from 0% to (25% or 30%) –

      In effect – calorie restriction is a Law it’s not something for debate or opinion – period

      Not eating is likely as important as eating –

      As long as calories are limited to between 0 to (25% – 30%) of RMR(resting metabolic rate) anywhere within these marks – should allow anyone to pratice fasting – trickle fasting – where 20 calories is eaten if needed to maintain sanity – once every four hours or so is the most comfortable way to fast(1/3 teaspoon dried coconut flakes – 1/2 teaspoon whey protein – a tiny bite of bakers chocolate) is what I prefer – if you try to fast at a 0 calorie rate you may fail – or not – but just be flexible if needed –

      Daily un-interupted full feeding is not human – never has been and never will be and no amount of ugly rhetoric will ever make it so –

      At ant rate – the geometric shapes and their relationship to one another tellsme all I need to know –

  95. jack  August 20, 2014

    Hi Peter,

    It seems as though the body works as a machine, it needs certain “fuel” to run properly. Some “fuel” is better then others (for different people), and it will run smoothly in the long run.

    Observational studies (nutrition speaking), seems to be incomplete and uninformative, at least what I have read (not all, but when it comes to making decisions for the masses, studies that do not hold a lot of ground are used).

    What would be the perfect (realistically speaking) study?

    Why isn’t there a study with 3,000 people (all volunteers), have a controlled environmental (nothing unethical) and try to find all the information possible rather then “guessing ” through observational studies.

    I found your blog 6 months ago and it has been an eye opener. I apologize if the questions sound “amateurish”.

    Thank you

    (reply)
    • Peter Attia  August 22, 2014

      I’ve certainly commented on my view of observational studies. If they find something strongly correlated, it’s worth investigating. When they don’t (which they usually don’t), we sure waste a lot of time on them.

  96. Ken  August 20, 2014

    There is a very fundamental problem (with diabetes, for instance) that almost always goes unmentioned. That is the economic problem of addressing these common and severe conditions by medical practice. At the whole societal level it is simply unaffordable, and so much so that it is doubtful that clever policies can solve the problem.

    Dr. Richard Bernstein has suggested the idea of group training for diabetics, recognizing that his own unique (and zealous) practice of intensive care is not economically viable for almost any conventional MD (nor for very many patients, IMO). But that interesting notion alone flies in the face of conventional practice, and it would probably not be enough to generate a viable business model by itself either.

    The economics of food itself is also a huge counterweight to healthy eating, of course. But a bottom-up growth of wisdom regarding healthful diet might take place over time in industrial societies.

    Top-down policies are virtually guaranteed to fail. The vested interests already built up will always be more powerful in influencing and corrupting such policy than those of any newcomers motivated merely by ideas of public welfare. It is these same top-down policies that have created the problem, but the days of Ancel Keys (i.e. outsized influence of a few individuals) are also arguably a thing of the past.

    For those of us who have lived most of our lives eating a SAD and have suffered damage to various tissues, I think we must each attempt to cope as best as possible on our own. I am one such.

    The young now have a big opportunity to employ a better diet given the amount of easily accessible info available. But this still takes effort and commitment on the part of each such individual. And it takes a certain independence of thought and behavior. And education and economic wherewithal of each individual.

    The old saw about how the old scientists (or doc’s or whomever) must die out before the new ideas and practices can take over is grossly optimistic. It doesn’t work that way. The old guys are installed in positions of power and influence, and many young guys (and gals) go to work for them and take advantage of associating with them. They inherit the same interests. Thus the torch is passed along, potentially indefinitely. It is much easier to make a living by going along to get along rather than being a zealot or maverick. At the institutional level it is a tough nut to crack.

    And by the way, although I have pored over the research literature on diabetes and think that a lot of good work has been done, we certainly don’t understand this complex and heterogenous condition very well. I wish it were not so. This lack of understanding makes it difficult for anyone to get a toehold in arguing for an ambitious public policy of any sort, and there will naturally be much disagreement about what should be done.

    (reply)
  97. JJ Bell  August 20, 2014

    Hi Peter

    I regularly revisit the articles (or ‘blogs’) you write and I hunt lie and low for material of a similar quality online (and in books). In summary, nothing compares, thank you again!

    Are there any resources you can recommend for someone obsessed with the type of questions you ask?

    Particularly anything that discusses energy expenditure and metabolic processes in enough detail to be meaningful without requiring years of study to understand.

    Many thanks

    JJ

    (reply)
    • Peter Attia  August 22, 2014

      I think there are lots of good blogs out there. David Allison has a weekly mailing list of studies that’s mostly full of lame studies, but always has a gem or two.

  98. Herb  August 22, 2014

    David Allison

    https://www.youtube.com/watch?v=RSLWt_g6JOs

    (reply)
  99. Judy D  September 12, 2014

    I think what I realize after reading your post is how the underlying paradigm of our current situation is one of distrust between patient and caretaker/advisor (doctor, nutritionist, policy maker, etc). I spent decades trying to make the low calorie, low fat, aerobic exercise formula work to my advantage. And for some stretches of time, I managed, albeit with a great deal of struggle.
    A few years back, I ended up in the hospital with a.fib, and as it turned out, low thyroid, pre-diabetes, sleep apnea, blood lipids going in the wrong direction, and more than 100 lbs overweight. I admit to a certain amount of despair/frustration with the diet/exercise situation after 10-12 years of perimenopause/menopause and my body’s seeming inability to lose weight. Yet, I still blamed myself.
    I left the hospital with a renewed commitment to addressing the problems at hand. I used the USDA Rate my Plate program to track my eating. I got my saturated fat levels to miniscule proportions. I also tightly controlled my other fats. I was the queen of nonfat eating. I ate nothing but whole grains. I had already eliminated artificial sweeteners. And, after about 4 months, removed all sweeteners. I ate very little meat, and mostly skinless chicken breasts, or fish. My weight barely budged, and the lipids continued their negative path.
    I had found Gary Taubes in my research, and read his “Why We Get Fat” book, and eventually Good Calories, Bad Calories”. I was pissed. I felt betrayed across the board. I decided to try Atkins, even though it scared me to death, for 30 days, and see how I felt. Within two weeks I knew there was no going back. The change in energy was dramatic. My bloodwork history did a dramatic change for the better. I was not hungry all the time. I thought about so much more than what I was going to eat, and when I could eat it. I now eat a diet that I would describe as ketogenic Paleo, with no eggs, dairy, nightshades, and next to no fruit. I feel much better. My inflammation levels are much lower.
    I still have a lot of weight to lose. And this is where life becomes problematic in my relationships with doctors. I find myself being coy about my dietary changes. I tell them I am eating low carb. I am even beginning to say high fat/low carb which causes raised eyebrows. I don’t fully trust that they are on my team. Likewise, I don’t believe they fully trusted me when I told them how fanatically I was following the low calorie/low fat recommendations.
    How do we fix the fix we are in, without addressing this basic underlying distrust of one another? And how comfortable are doctors with changing their recommendations? Are they afraid to open the door to low carb high fat and have to explain the 180-degree turnaround? This is a long post to get to my essential questions. Sorry for that!

    (reply)
    • Ellen Urciola  September 14, 2014

      Thank you Judy for your post. I find myself in exactly the same position. Your post echoed the very same sentiments I am struggling with. I would love to see your post as an article perhaps in Woman’s Day, Good Housekeeping, or even Oprah. Keep up the good work and know there are many more just like you who feel the same.

  100. mari  October 5, 2014

    Are you familiar with lipedema?

    http://rarediseases.info.nih.gov/gard/10542/lipedema/resources/1

    There’s a dovetail with your mission. With 11% of all women having this disease you could help a great number of people. – who need you. We need help and research.

    (reply)
  101. Marina  December 22, 2014

    Hi Peter,
    Thank you for another interesting and informative article.

    Just a quick question (unnrelated to your post I’m sorry):
    Would you have heard about “keto rash” or prurego Pigmentosa?
    Its a has a very specific “look” to it and starts off on the upper abdomen, back of neck, collarbone area and lower back.

    I’ve had this rash since my transition to keto (from very low carb) a week ago.
    It gets bigger each day and is so itchy, I am unfortunately thinking of quitting back to low carb eating as suggested by many people.

    Would you have any ideas on this rash?

    Thank you very much in advance for your time.

    (reply)
  102. Greg Dahlen  February 1, 2015

    Dear Pete: Thanks for what you do to help people with health issues and healthy eating. For a while now I’ve been pushing the masai diet. Are you familiar with the masai people of Kenya? They are famous for living only on products from their cattle: milk; beef; and blood that they extract from the cows without killing them. I can’t get blood here in the states, so I’ve taken the other two as the cornerstones of my diet. In theory I live only on fluid milk products and beef. But the Masai have an important saying: “if a man eats meat and drinks milk on the same day he is a glutton.” Hence every day I have to choose whether it will be a “milk day” or a “beef day.” Although I like beef, I prefer milk so for me for the last six years every day has been a “milk day,” living 95% on fluid milk products, mostly skim milk and a little cream. Many is the day when I have drunk two gallons (7.5 liters) of skim milk and eaten or drunk nothing else. It has been fantastic for my health. I am six foot one inch and this morning weighed 153 pounds. The blood tests from my annual physical support the diet, in 2013 I was in range on all 80 results, in 2014 the PCP said the results put me in the top 3% of people health-wise for people my age, 54. I believe this diet might help with many diseases and have been pushing various top medicals to test it. I have an ongoing correspondence with Ed Benz who heads the Dana Farber Cancer Institute at Harvard, and also with the director’s office at NIH. I think living on fluid milk products helps both because it makes it easy to lose weight; and because fluid milk products are exceptionally easy for the body to digest and use and hence don’t interfere with bodily processes as much as solid food. When I eat solid food various parts of my body start to hurt because although the body breaks up solid food, I don’t think it is as broken up as fluid milk products and hence clogs and irritates the cells; thus when I return to fluid milk products I feel better again; and I think other people’s bodies would respond about like mine. For these reasons I think the diet, particularly the fluid-milk-products part, might help with many diseases including biggies like cancer and AIDS. Some may think the diet is boring but I really enjoy it, milk tastes delicious to me. What do you think, is it a diet you’d try? Is it one you think you’d endorse? For whatever it’s worth, I have a bachelor’s from Stanford, English Lit.

    (reply)
    • Peter Attia  February 4, 2015

      Probably not a diet for me, just given the logistics of it. I travel >100 days a year, so whatever I do it needs to be “readily” available.

  103. Victor  April 24, 2015

    Peter,

    First of all – great Talk on Ted. Very inspiring, intutive and heart-felt. It seems that we are treating effect, not cause in many instances.

    About insulin resistance – you mentioned that you developed it, and you have reversed it. What modification did you do to acheive that? It will be very helpful for everyone to know that, I understand that it may or may not work for everyoe.

    Kind Regards
    -Victor

    (reply)
    • Peter Attia  April 27, 2015

      Dietary modification. I think I have post somewhere on this blog about it, but don’t recall where or what the title is.

  104. Tom Graham  June 8, 2015

    It seems obvious that the “calories-in/calories-out” hypothesis fails and your alternate hypothesis: hormones (insulin and likely others) regulated by the body response to macronutrients controls body fat accumulation is MUCH more promising. Can’t you test this hormone hypothesis more quickly by monitoring tell-tale hormones in the blood — over short term and long term periods and obtain definitive confirmation, falsification or refinement?

    (reply)
    • Peter Attia  June 8, 2015

      Unfortunately, just knowing the hormone levels is not sufficient to determine the role in fat balance. Ergo, the long, difficult, costly (!), experiments.

  105. Andrew  July 16, 2015

    Peter, maybe because the work you’re doing is so awesome, I keep finding myself pushed to share stuff that may help you along the way, plus thinking about themes around it. Below a bunch in no particular order of importance.

    1) Watching your TED Talk I realized something: you are one of the very few people I know who overcame attitude polarization (a type of confirmation bias) and got to the point of publically saying, in the middle of one’s successful profession, “you know, maybe I’m wrong about what I’m doing and my beliefs”. And instead of going to the opposite side, you paused and said “actually, we don’t really know what’s going on and we should stop and try to find out first”.

    Please accept my deep respect for your attitude.

    (reply)
  106. Andrew  July 16, 2015

    2) Recompress your blog jpgs or convert them to gif. Two advantages: you save bandwidth money right away, and you lower your bouncing rates (higher loading time drives more impatient people away). You can reduce size with no loss of quality at all. Many software for that depending on your operating system, also online tools.

    (reply)
  107. Andrew  July 16, 2015

    3) You said people normally get into nutritional ketosis in some weeks after they started for the first time, but you, on the other hand, seem to get back to it in a couple of days after a desert binge.

    Would you say NK works a bit like a muscle, in the sense that the more the body is used to getting into (or staying at) this metabolic route, the faster it is able to click back into it when starved from glucose?

    (reply)
  108. Andrew  July 16, 2015

    4) In some comments in some post, and maybe by you too, I saw criticism about studies in mice, as if implying that they are meaningless to extrapolate data to humans. My impulse wasn’t to join and laugh and agree. I’ve always thought that although you can’t directly extrapolate mice results to humans, they should be close enough.

    Two points from this: one, are mice results that bad, really? Is a clinical trial in rats worse than an observational study in humans?

    Two, and here I want to tease you with an idea:

    TED talk from “Barbara Natterson Horowitz: What veterinarians know that doctors don’t”. Long story short, she started noticing enormous parallel between animal and human diseases, and found that many of the “discoveries” we make to treat humans had been already discovered by vets years before.

    And she started looking into vet literature for hints of how to translate that to humans, and to put vets and human doctors in contact, which generated a lot of insights and new treatments.

    What is it that we already know about animal nutrition, obesity and IR in animals as well as their treatments that could translate immediately for humans and we are massively overlooking it because of our views of vets as “inferior” and because we (mistakenly) think of non-humans animals as being a world apart from humans?

    Contact her. I’m suggesting (as I think she would) that you talk to selected vets or go to a veterinarian convention, raise your hand, and say “Hi, folks. I’m looking deep into human nutritional and insulin resistance, and we need all the help we can find to solve this problem. What is it that you, vets, already know about this problem in animals, how they vary between species, and how do you treat it?”

    If you think about it, it’s not half as crazy as it first sounds, and may give you insights, good questions and good answers that you may not have had otherwise.

    All the best.

    (reply)
  109. Friendly Debater  July 19, 2015

    Peter,

    I find this article gold for the work you’re doing. Because making people listen and engage in the results of NuSI will be as important as the results themselves.

    “More and more, I find myself attempting to have difficult conversations with people who hold very different points of view. And I consider our general failure to have these conversations well—so as to produce an actual convergence of opinion and a general increase in goodwill between the participants—to be the most consequential problem that exists.” http://www.samharris.org/blog/item/final-thoughts-on-chomsky

    Looking only at the form the communications took, if you change the subject to nutrition, then in this exchange in http://www.samharris.org/blog/item/the-limits-of-discourse Harris is you and Chomsky would be, say, Ornish. The former trying to build a friendly joint inquiry and the latter indignated and bringing the pride of his decades-long experience. Cognitive dissonance.

    You could contact Sam Harris for a conversation about the issue of difficulty of having intelligent public conversations that are useful and non-competitional and how to improve it. You two seem to have a lot in common.

    Tim Ferriss is a common contact.

    (reply)
  110. Friendly Debater  July 19, 2015

    Peter,

    Scott Adams is your friend. Please give him a hug right now.

    “What is science’s biggest fail of all time? I nominate everything about diet and fitness.”
    http://blog.dilbert.com/post/109880240641/sciences-biggest-fail

    Here he exposes the bad logic of spurious correlations such as: exercise makes you lose weight, dog owners are healthier, married people and light drinkers live longer.
    http://blog.dilbert.com/post/121923199701/the-health-advice-i-dont-find-credible

    (reply)
  111. Kim  January 1, 2016

    I watched the video and got so frustrated at Lynn Goldman’s intentional misunderstanding of your plane crash analogy. Reason 1200 why I could never be on a panel.
    When she mentioned calorie count efforts in NYC, I was reminded of a study of how people actually react to calorie counts on menus- and that at best the results are net zero.
    Acedemics so prefer theory over real outcomes.
    Thank you for keeping it real 🙂

    (reply)
    • Peter Attia  January 5, 2016

      My half life for showing up on panels is approaching epsilon.

  112. Tim Rich  May 2, 2016

    Thanks for sharing with us…

    (reply)

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