Blog - The Eating Academy | Peter Attia, M.D.

Why Weight Watchers is actually a low carb diet

Why Weight Watchers is actually a low carb diet
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Invariably I get asked the question, “If carbohydrates are so bad, why did [so-and-so] lose weight on the [such-and-such] diet?”, where “such-and-such” diet is not a “low-carb” diet. Obviously, this is an important question and a pretty complex one.

There are several layers to this and, frankly, there are some things we can’t fully explain – I’ll always acknowledge this. That said, many of the successes (at least weight-wise, though hopefully by now you realize there is much more to health than just body composition) of popular diets can be explained by a few simple observations. Above is a list of this year’s most “popular” diets, according to Consumer Reports. Popularity, of course, was determined by a number of factors, including compliance with current government recommendations (sorry Atkins), number of people who have tried the diet, and reported success on the diets. So it’s actually quite misleading when the report says it’s reporting on the “most effective diets.”

Keep in mind the average American (i.e., at baseline) consumes about 2,500 to 2,700 calories per day (different sources, from NHANES to USDA will give slightly different numbers for this, but this range is about correct), of which about 450 grams (about 1,750 calories worth or about 65% of total caloric intake) comes from carbohydrates. You can argue that those who are overweight probably consume an even greater amount of carbohydrates. But for the purpose of simplicity, let’s assume even the folks who go on these diets are consuming the national average of approximately 450 grams of carbohydrate per day (in compliance with governmental recommendations, as a percent of overall intake).

Take a look again at the figure below, which shows you how many calories folks are consuming on each diet and, more importantly, where those calories come from. [It’s not actually clear to me how Consumer Reports was able to figure out exactly how much folks eat, beyond self-reporting or diet-book recommendation, mind you. In other words, these numbers could actually be wrong, but it’s what we’ve got for now.]

Why diets work

You’ll note that people on these diets, including the strictest low-fat high-carb diets, significantly reduce their total amount of carbohydrates (therefore reducing the amount of insulin they secrete). Even the Ornish diet, which is the most restrictive diet with respect to fat and most liberal with respect to carbohydrates, still reduces carbohydrate intake by about 40% from what people were likely eating pre-diet.

The reason, I believe, most of these diets have some efficacy – at least in the short-term – is that they all reduce sugar and highly refined carbohydrate intake, either explicitly or implicitly. No one on the Ornish Diet or Jenny Craig Diet is eating candy bars and potato chips, at least not if they are adhering to it. Hence, these diet plans do “clean up” the eating habits of most folks.

Someone made a great point in response to my post on why fruits and vegetables are not actually necessary for good health. The point was, essentially, that telling people to eat 5-6 servings per day of fruits and vegetables can hopefully drive a beneficial substitution effect. If you tell someone who eats Twinkies, potato chips, and candy bars all day to eat more fruit (and they do), you’ve almost guaranteed an improvement in their health if they eat bananas and apples instead of the aforementioned junk food. That doesn’t mean bananas and apples are “good for you” – it just means they are less “bad for you.” Here’s the kicker, though. We’re led to believe that the reason such folks get leaner and more healthy is because they are eating more fruits or more vegetables or more grains or more [fill-in-the-blank], rather than because they eliminated the most egregious offenders from their diet.

I can’t really overstate this point. I have no intention of engaging in a battle with proponents of plant-based eating or no-saturated-fat diets. I’m reasonably confident that the proponents of these diets are good people who really want to help others and have nothing but the best intentions. But that doesn’t mean we can or should overlook the errors being made in drawing their conclusions. Many people do very well on plant-based (e.g., vegan) diets, for sure. But why are they doing well? That is the single most important question we should be asking ourselves. Why did the people in the China Study who ate more plants do better than those who ate more animals (assuming they did)? Parenthetically, if you actually want the answer to this question, beyond my peripheral address, below, please read Denise Minger’s categorically brilliant analysis of the study.

I know a lot of people who eat this way and, I’ve got to say, these folks do not eat a lot of sugar or a lot of highly refined carbohydrates. In fact, many are so conscientious of their health that they actually have far better carb-habits than most (e.g., which breads they choose, which fruits and vegetables they eat).

While I do plan to write an entire post on this topic of what one can and cannot conclude from an experiment, I do want to at least make the point here: The biggest single problem with nutrition “science” is that cause and effect are rarely linked correctly. Stated another way, it’s one thing to observe an outcome, but it’s quite another to conclude the actual cause of that outcome.

Let me digress for a moment to provide an important example of this phenomenon. One of the most prominent figures in the diet/nutrition space is Dr. Dean Ornish. I don’t know Dr. Ornish personally, and I can only assume that he is a profoundly caring physician who has dedicated his life to helping people live better lives. He is nationally, and internationally, regarded for his efforts.

One of the reasons for his prominence, I believe, is the work he did in the early 1990’s on lifestyle modification and the impact it can have on reversing coronary artery (i.e., heart) disease. In particular, Dr. Ornish was the principle investigator on a trial published in the journal The Lancet in 1990. An abstract of the paper can be found here. But as always, I STRONGLY encourage folks with access (or folks who are willing to purchase it) to read the paper in its entirety. For people who don’t want to read the study completely, or who may not have much experience reading clinical papers, I want to devote some time to digging into this paper. Why? Well, for starters, reading abstracts, hearing CNN headlines, or reading about studies in the NY Times doesn’t actually give you enough information to really understand if the results are applicable to you. Beyond this reason, and let me be uncharacteristically blunt, just because a study is published in a medical journal it does not imply that is worth the paper it is printed on. My mentor at the NIH, Dr. Steve Rosenberg, once told me that a great number of published studies are never again cited (I forget the exact number, but it was staggering, over 50%). Translation: whatever they published was of such little value that no one ever made reference to it again.

I am, to be clear, not implying this is the case for this trial, but I want you to understand why it’s important to read papers fully.

This trial, The Lifestyle Heart Trial, prospectively randomized a group of not-so-healthy patients into two treatment groups: the control group and the experimental group (or what we’d call the “treatment” or “intervention” group).

The experimental group (22 patients) was asked to adhere to the following changes for one year:

  1. Change their diet to a low-fat vegetarian diet (10% fat, though obviously no animal fat; 15-20% protein; 70-75% complex carbohydrates) with several other restrictions (e.g., no sugar, flour, or refined carbohydrates; limited alcohol; no caffeine; limited salt; limited cholesterol intake; no egg yolks)
  2. Smoking cessation
  3. Exercise regimen (minimum of 3 hours per week, at minimum of 30 minutes per session)
  4. Stress management (e.g., meditation, progressive relaxation, breathing modification)
  5. Join social support groups for help with adherence (twice weekly)

The control group (19 patients), obviously, remained under “usual-care” (i.e., no change in lifestyle).

One aspect of this trial that made the results particularly interesting was the use of angiography to actually measure and document the coronary artery lesions (i.e., blockages in the coronary arteries) in the patients before and after the lifestyle interventions. The study was not powered to measure “hard” outcomes (e.g., heart attacks, strokes, cancer, death), so the use of blood markers, physical parameters, and angiography were the best proxies for a reduction in disease risk. In other words, there were not enough subjects in the study to determine a difference in these “hard” outcomes, so we can’t make a conclusion about such events, only the changes in “soft” outcomes. I’m not discounting soft outcomes, only pointing out the distinction for folks not familiar with them.

So what happened after a year of intervention versus no intervention?

First off, and perhaps most importantly from the standpoint of drawing conclusions, compliance was reported to be excellent and the differences between the groups were statistically significant on every metric, except total average caloric intake. In other words, for every intended difference between the groups a difference existed, except that on average they ate the same number of calories (though obviously from very different sources), which was not intended to be different as both groups were permitted to eat ad libitum – meaning as much as they wanted.

Who was “healthier” at the end of a year? The table below shows the changes in both groups. If you want a quick primer on p-values, this is as good a time as any to get one. These tables (i.e., results tables) are a bit cumbersome if you’re not used to looking at them, so let me walk you through one row in detail. Let’s look at HDL cholesterol concentration. In the experimental group, HDL-C fell slightly from 1.00 +/- 0.26 mM (39 +/- 10 mg/dl for Yankees like me) to 0.97 +/- 0.40 mM (38 +/- 15 mg/dl), while it slightly fell from 1.35 +/- 0.52 mM (52 +/- 20 mg/dl) to 1.31 +/- 0.38 mM (51 +/- 15 mg/dl) for the control (i.e., no-intervention) group. It’s hard to tell if this change was statistically significant by inspection, so you glance at the p-value which tells you it was not. (To be exact, the p-value of 0.8316 tells you there is an 83% chance that this difference was random – as a general rule we don’t consider a difference to be statistically significant — meaning we’re going to assume it wasn’t just a chance fluctuation, the roll of the dice — until the p-value is below 0.05, and ideally below 0.01).

Take a moment to look over the rest of the table (or just skip reading it since I’m going to keep talking about it anyway).

Ornish Lancet paper

What else was not significantly changed?

  • Triglyceride level
  • Apoprotein A-1 (not surprising, I guess, since HDL particles carry the bulk of apo A1)
  • Blood pressure, both systolic (“top number”) and diastolic (“bottom number”)

What was significantly changed?

  • Total cholesterol concentration (down in both groups, but significantly more in the experimental group
  • LDL cholesterol concentration (same as above)
  • Apoprotein B (again, to be expected given that LDL particles carry apo B)
  • Body weight (this was, as you can see from both visual inspection and the p-value, the most significant change between the two groups)
  • Though not shown in this table, the experimental group also reported less chest pain severity (though chest pain frequency and duration were not statistically different).

What about the angiographic differences? That is, how did the actual measured lesions in the subjects’ coronary arteries change? 

Seven patients were excluded from this analysis: 1 patient in the control group (patient underwent an emergency angiogram in another hospital, but lesion sizes were not measured); and 6 patients in the experimental group (1 died while exercising in an “unsupervised gym,” 1 could not be tested at follow-up due to a large unpaid hospital bill, 1 patient dropped out, 1 patient’s pre-intervention angiogram was lost, and 2 patients did not have adequate overlay of pre- and post-images).   To justify the findings of this trial we need to believe that the exclusion of these seven patients did not alter the conclusions, but we’ll never know.  This disproportionate exclusion of 6 patients from the treatment group and only 1 patient in the control group, for (perhaps) the most interesting outcome, is (perhaps) the most significant methodological flaw of this trial.

Excluding these seven patients, the experimental group experienced an overall reduction in coronary artery stenosis (blockage) from a mean of 40% to 37.8%, while the control group experienced a progression in coronary artery stenosis from a mean of 42.7% to 46.1%, which was statistically significant.  This trend also held for larger lesions (i.e., those starting out over 50%).  Most importantly, in my mind, within the experimental group there was a strong correlation between adherence score and lesion regression.  Translation: The more rigorously a patient was compliant with the lifestyle changes, the greater was the regression of their coronary artery lesions.  This correlation is quite suggestive that the lifestyle change was responsible for the regression of coronary lesions.

I know what you’re thinking…Is there a point embedded somewhere in here?  Yes.

Here is my point: This was a well-done trial from the standpoint of testing what it set out to test.  It set out to test if a comprehensive lifestyle change could reduce markers of coronary artery (heart) disease, which it did. But that’s it.  It did not tell us if a comprehensive lifestyle change reduced actual heart attacks, which it very well might have if there were hundreds of patients in the study.  It is equally important to understand what we cannot conclude from this study.  We cannot conclude which element of the lifestyle intervention led to the reduction in markers of heart disease.  We know that in aggregate the lifestyle changes made a positive difference, but which ones actually caused the change and which were bystanders remains unknown.

Let’s take a leap of faith and hypothesize that the dietary intervention (rather than, say, the social support) had the greatest impact on the measured parameters in the subjects.  It’s certainly the most likely factor in my mind.  But what, exactly, can I conclude? Can I conclude that a low-fat vegetarian diet is the “best” diet for reducing the risk of heart disease?  Nope.  I can only conclude that a low-fat vegetarian diet is better than the average American diet consumed by the control group (if you are willing to stipulate that the dietary intervention was the most significant driver of outcome).  Why?  Because that’s what was tested.  Unfortunately, this study (and hundreds like it) can shed no light on which specific aspect of the diet in the experimental group provided the advantage.  Was it the reduction in fat intake?  The reduction in animal protein?  The reduction in sugar?  The reduction in simple, highly refined carbohydrates? Unfortunately, we do not know.

SLIGHT DIGRESSION: Tragically, all of U.S. nutritional guidance and follow-from-it policies, recommendations, and food-based infrastructure were derived from this type of science. Maybe their conclusions are correct.  Is fat bad for us?  Are complex carbs the best thing we can eat?  Though theoretically possible, there is no scientific evidence telling us this.  In fact, there is ample evidence actually suggesting the opposite is true.  Hence, this is why – exactly why – we are founding the Nutrition Science Initiative (NuSI) with a group of scientists who all agree that we need to actually test these hypotheses in the most rigorous manner possible, and only then make dietary recommendations.

How bad is it that nutritional recommendations are based on weak science?

Consider the following hyperbolic example: Imagine a clinical trial of patients with colon cancer.  One group gets randomized to no treatment (we’ll call them the “control group”). The other group gets randomized to a cocktail of 14 different chemotherapy drugs, plus radiation, plus surgery, plus hypnosis treatments, plus daily massages, plus daily ice cream sandwiches, plus daily visits from kittens (we’ll call them the “treatment group”).  A year later the treatment group has outlived the control group.  Great news, to be sure.  The treatment worked!  Here’s the problem…we “conclude” it was the 7th and 9th drugs in the group of 14 drugs, plus the kittens that caused the treatment effect and we enact recommendations based on that.  Are we right?  Sure, it’s possible, but actually it’s quite unlikely.  The only way to know for certain if a treatment works is to isolate it from all other variables and test it (in a randomized prospective fashion, of course).   Do the kind of science we were taught to do in 8th grade.

So what do I think happened in Dr. Ornish’s study?  I think the reduction in sugar and simple carbohydrates played the largest single role in the improvements experienced by the experimental group, but I can’t prove it from this study any more than one can prove a low-fat vegetarian diet is the “best” diet.  We can only conclude that it’s better than eating Twinkies and potato chips which, admittedly, is a good thing to know.

Ok, back to the Consumer Reports “best diet” list I started this discussion around.  Another point you’ll note in this table (up at the very top) is the overall amount of caloric restriction in each diet – an average of about 1,500 calories per day.  The caveat here is that these numbers are self-reported, so everything needs to be taken with more than the proverbial grain of salt.  I know what you’re thinking, “Hey, but you said calories don’t matter – why should it matter how many calories these folks are eating?”  Remember, you can always “force” weight loss by creating energy imbalance.  What I mean by that is you can force an energy imbalance if folks are willing to suffer (e.g., work really hard and/or starve).  The reality TV show, The Biggest Loser, is a great example of this.  Participants on the show are basically starved (under 1,000 calories per day) relative to their expenditure (6 hours per day of exercise at a cost of possibly as much as 4,000 calories per day).  The question is, or at least should be, does this form of “dieting” result in long-term, sustainable weight loss?  The overwhelming evidence is that calorie restriction (i.e., reducing calories significantly below active or deliberate caloric expenditure) results in transient weight loss, not sustained weight loss.  Why?  There are a few reasons, but I think the biggest two are:

  1. People don’t like to be hungry, and if they are reducing their caloric intake by reducing fat intake, they seldom find themselves satiated.
  2. Semi-starvation reduces basal metabolic rate, so your body actually adjusts to the “new” norm and slows down its rate of mobilizing internal fat stores.

Furthermore, most people can’t do six hours of heavy exercise a day (not to mention the world is full of people who do six hours of physical labor a day and are obese; I was fat doing 4 hours of exercise per day).  The real tragedy of this is that when folks restrict calories and then resume, when they can’t tolerate the discomfort of relative starvation anymore, they usually end up gaining back all, if not more, of the weight they lost in the first place.

Not to beat a dead horse, but I’d be remiss if I didn’t make this point one more time: When someone reduces caloric intake to 1,500 calories per day – even on a “balanced” diet – they are considerably reducing carbohydrate intake in aggregate and almost always disproportionately with respect to the worst offending carbs (e.g., sugars, simple refined carbs). 

Ultimately, the question we’re driving at is, why do these diets work? I argue that each of these diets does some good, especially with respect to eliminating the worst offending agents along the insulin-fat-metabolic derangement axes.   The problem, unfortunately, is that the scientific community is completely confused as to why they work.  Most people think the primary reason these diets work is that they reduce fat intake and total calories.

I argue that reduction of fat intake has nothing to do with it and that the reduction of total calories has a transient effect. And, the majority of the benefit folks receive comes from the reduction of sugars and highly refined carbohydrates. But now I’m repeating myself, aren’t I?

 

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About the Author:

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

Discussion

  1. Robb  February 22, 2012

    I’m glad you wrote this because this is something I’m having to accept is that all research I look at needs to be viewed with a much more critical eye than I previously used. Otherwise I’m just deferring to someone because of their standing. One thing that has bothered me about a lot of dietary studies of the “American diet” is they appear to be controlling for something way too broad. They never factor in that the chicken was breaded or that when someone ate steak or fish they had a large amount of bread of potatoes along with it. Plus maybe the person was drinking a big glass of Coke or Sweet tea with every meal. The end conclusion is the whole thing must be bad and therefore needs to be reduced or outright expunged from the diet. That is one big difference I’ve noticed between studies cited by writers who want to condemn the entire diet consumed by Americans vs those who look at it with a more in depth eye and realize that certain components are the problem not the whole diet across the board.

    (reply)
    • Peter Attia  February 22, 2012

      It’s *really* tough to study this stuff properly, especially compared to studying things blood pressure lowering pills, which are complex in their own right, but MUCH easier to control in a study. Here’s the good new: this CAN be done and we will get it done.

  2. Dr Valli gambina  February 22, 2012

    Comment
    Consumer reports publishes that which they are paid to publish. Case in point…they recently reported that olive oil is not good for you because it does not contain omega 6. And…sunflower and soybean oil are better. Pulp fiction!!!

    (reply)
    • Peter Attia  February 22, 2012

      I wish you were making this up…but I’m worried you’re not. That is tragic.

    • Jill  February 22, 2012

      A nutrition department of a university accepts funds from a company that makes confectionery.

    • Peter Attia  February 22, 2012

      Interesting, isn’t it?

    • Kevin Hughes  February 23, 2012

      In fact, The American Diabetes Assn. receives funding from Cadbury.

    • Bob Kaplan  February 24, 2012

      The current sponsors for the former ADA, now the Academy of Nutrition and Dietetics: Coca-Cola, Pepsi, Hershey’s, Aramark, Mars, General Mills and Kellogg’s.

      The American Diabetes Association’s biggest supporters include: Eli Lilly, Merck, Novo Nordisk, and Sanofi as the ‘elite’ sponsors.

      Do you think the Academy’s supporters want to hear that if you eliminate their products you will no longer need to rely on the products provided by the biggest supporters of the Diabetic Association?

    • Joe  February 25, 2012

      The point has clearly been made, but I can not resist adding to this. In my field, the American Academy of Pediatric Dentistry Foundation accepted a $1 million dollar grant from Coca Cola!

    • Michael  March 19, 2012

      Dr. Gambina, Dr. Attia: no, Consumer Reports accepts *no* corporate money whatsoever; that didn’t play into it.

      The main criticism I’d have for this analysis, Dr. Attila, is that while WW does indeed cut carbs, it does so in the context of also cutting fat and Calories (which of course you note): you’re not accounting for the fact that other, lower-carb diets (in both absolute and relative terms) were ranked more poorly, which is (surely) the issue.

      Marilyn, a commenter on p. 3, has a good point about some plans (including WW) having the advantage of group support, which I think is a very major confounder.

      Stylistically, Dr. Attia, I’d suggest that you have here and in several places bitten off too much at once: you analyze many different kinds of problems at once, which tends to make the post as a whole a bit rambling; I’d suggest finding one issue at a time and breaking it down. Eg, the criticism of the Ornish Lifestyle Heart Trial is excellent (and I LOVED the kitten-stroking quip), and really could and should have stood alone. Any time you feel compelled to say ,”Ok, back to the Consumer Reports “best diet” list I started this discussion around”, you probably have too much digression ;) .

    • Peter Attia  March 19, 2012

      Michael, I agree with you…sometimes I just get carried away and write too much. This post was really two posts in one. But, hey, consider it bonus material! To you point about ranking, the main reason a diet like Atkins does poorly on this is because of the component of the ranking that depends on adherence to dietary recommendations, which obviously run counter to Atkins.

  3. John P.  February 22, 2012

    Peter, I have a coworker who has recently lost 80lbs over the course of a year on weight watchers. It is wonderful to watch these people glow once they have found some sort of solution to their weight problem. After short diologue with her on the particulars of her daily intake I quickly realized her consumption of carbohydrate was significantly reduced and eliminated almost all fructose. Not that I wish any harm to her but my question is to what happens post weight loss goals? Do they rapidly regain the stored adipose? I recall hearing Gary talking about his discussion with a participant from the Biggest loser on Larry King and the rapant weight gain after the show. I admit, I get fired up watching Gary trying to make points to Jilian Michaels. Anything that helps these people I agree with you is well intentioned, yet lacks educating the persons what might have taken place inside their bodies instead of for example counting “points.” Do they even know? Keep up the great work!

    (reply)
    • Peter Attia  February 22, 2012

      John, I point this out at the bottom of my post (not that I can blame you for not reading the whole thing…it’s a bit long). Sadly, virtually all folks (I’ve read stats anywhere from 80-95%) on these diets gain all the weight back once they leave the program and try to re-integrate into their normal eating pattens. Why? Probably because these diets don’t actually help people understand WHY they worked, so the helpless person is now trying to eliminate fat (or whatever else they think got them fat in the first place).

    • Kayla  February 25, 2012

      Exactly, it’s the WHY that is missing. I’ve done WW more times than I care to admit, and I’d always lose 20lbs, look better, feel lighter, but be miserable and starving. Why? Because my body couldn’t handle the “low-points” carbs I was feeding it. Now, I must point out that WW has changed it’s points system to be harder on carbs and easier on fat and protein, but they also made fruit a “free” item. Not a great idea. The one great thing that came out of my last WW adventure was that they did change the points system, and all my low points carbs, like bran cereal and small tortillas went up dramatically, so I eliminated them, and after a few days without any wheat realized that I felt terrific! No more wheat for me, it’s been over a year now. The thing is, it is possible to eliminate wheat and still eat way too many carbs (can we say ice cream?). So after actually losing another 5 lbs after quitting WW, just by cutting out wheat, I started to carb drift upwards, and gained 15lbs in just a few months. So after watching FatHead a couple of times I made the decision to try Atkins instead of WW this time – BEST decision I’ve ever made (well, other than marrying my husband!). I’m now happily in ketosis, and the best part is, I know the WHY of weight loss now, how totally liberating and hope giving. After 40 years of being fat, I have hope that the next 40 years will be quite different.

    • Peter Attia  February 25, 2012

      Kayla, awesome story! Thanks so much for sharing with us.

  4. Kypros  February 22, 2012

    Hi Peter,

    Great post!

    A question on fatty acids, as this is relevant to the diets described here: In Belgium, where I live the reference values for omega 3/omega 6 ratio is 0,28 – 0,45 while LA/DGLA is <7 and DGLA/AA is 0.10. What is your take on this?

    Finally any thoughts on Krill oil vs Fish oil vs Cod liver oil (fermented?).

    Looking forward to your next post, and of course people's comments for the current one!

    (reply)
    • Peter Attia  February 22, 2012

      I will discuss all of this in great detail, hopefully in the coming month, when I do a post on PUFA (polyunsaturated fatty acids).

  5. Kypros  February 22, 2012

    Correction: Reference value for DGLA/AA is > 0.10

    (reply)
  6. Anthony DiSante  February 22, 2012

    It’s sad how often you see a study stating a conclusion that isn’t actually supported by the data in the study. And given the fat-phobia brainwashing that we’ve received for the past several decades, maybe it’s not surprising that the actual data in the studies is almost irrelevent, since we already KNOW that the “correct” conclusion is that anything bad in the study was caused by saturated fat, and anything good was caused by whole grains.

    Sometimes I think/hope that the tide is turning, and the truth will start to gain some mainstream traction. But realistically, I think we’re going to have to wait for a lot of the current crop of “experts” to get old and die before the saturated-fat-is-bad lie will be exposed by the mainstream media in any significant amount.

    Anyway, it’s nice to discover someone who takes the Taubes viewpoint on things, and also takes the time to actually post online about it with some frequency, so thanks!

    (reply)
    • Peter Attia  February 22, 2012

      Anthony, I’m a bit more optimistic that we don’t need to wait that long. Also, don’t underestimate the importance of “normal” people like us who are fed up with fed bad science. Not confusing the hypothesis that people like me and Gary have about carbs/fat, the REAL issue is getting rid of amateur-hour science and joining the 21st century like all other scientific disciplines. Thanks for your support!

  7. Scott  February 22, 2012

    Great post! One of my favorite things to say to people who are scared of saturated fat is that even on an entirely plant based diet, (ala Ornish Diet), if they are restricting their caloric intake, their bodies will be running on the saturated (animal) fat that they have stored on themselves. A bit trite perhaps, but I think the point is an important one. Nobody debates that weight loss is good, but nobody seems to talk about the fact that if we are losing weight, our bodies are almost invariably going to be running on saturated fat.

    (reply)
    • jake3_14  February 22, 2012

      This assertion doesn’t make sense to me. The human body doesn’t store saturated fat. It takes saturated fat you eat and disassembles it with enzymes into it’s component fats. So, even when you’re metabolizing body fat, you’re not running on saturated fat unless you’re actually eating it.

      Did I take you too literally?

    • Scott  February 22, 2012

      Sorry if I was unclear. Human body fat is saturated fat. Otherwise our fat cells would be liquid, and we would be very sloshy. So when our bodies release FFAs from our fat cells, those FFAs are saturated, and our body is essentially running on saturated fat.

    • Peter Attia  February 23, 2012

      It’s actually a bit more complicated than that. For example the degree of unsaturated fatty acids in our membrane bilayer probably plays a role in our insulin sensitivity, just as one example. This is highly variable from cell to cell and person to person. As an anecdote, when making pemmican out of beef, the solidity of the meal at room temperature is highly dependent on where you’ve harvested the fat from the animal. The more peripheral the fat source, the more polyunsaturated, the less solid; the more central the fat source, the more saturated, the more solid.

    • Scott  February 23, 2012

      Oh absolutely, I was mostly referring to the fact that most of the excess carbs we eat are converted to palmitic acid, which is a SFA. I found the thought of a sloshy person funny, though, so I thought I’d throw it in. I like to imagine that if we stored all PUFAs we’d be like waterbeds.

    • Lisa Fisher  May 17, 2012

      There are times when I feel pretty sloshy. haha!

  8. Bob Kaplan  February 22, 2012

    Great post, Peter. The literature is virtually endless with bad ‘science’ when it comes to diet studies. The recent study by Bray in the AJCN is another great example. The conclusion was essentially that “when it comes to weight loss, how much you eat matters more than the proportion of fat, carbohydrate, and protein in your foods,” according to Marion Nestle. This coming from the author of “Why Calories Count,” so take it with a grain of [hypertenstion-inducing-heart-disease-causing] salt.

    The study looked at four different diets…except that it didn’t.

    There was an (1) average protein, low fat group (65% CHO), (2) High protein, low fat group , (3) Average protein, high fat, and (4) high protein, high fat (35% CHO).

    All data was self-reported which brings about another host of limitations.

    When you look at the self-reported data, the difference between the supposed ‘low fat’ group and ‘high fat’ group was a tablespoon of olive oil.

    In other words, the proportions of fat, carbohydrate, and protein were not much different between subjects and the results in terms of weight loss were not much different, either

    Many times when looking at the efficacy of an “Atkins” diet, the long-term (2 years) results will lead the investigators to conclude that the diet doesn’t work in the long term. But what you find is the subjects progressively increase their consumption of carbohydrates; and if you are testing the carbohydrate hypothesis (and not steeped in the calories-in/calories-out paradigm), you would expect this to happen and you wouldn’t conclude the diet doesn’t work.

    And the investigators will defend their views by saying they were looking at what happens when you ‘prescribe’ a diet, not the diet itself, and then that gets into intention-to-treat analysis, which is another can of worms.

    The ‘science’ really is questionable, to put it diplomatically.

    Again, illuminating post, Peter. Invariably, when anyone goes on a ‘diet,’ they switch from regular soda to diet soda, they ditch the twinkies, and so on…

    (reply)
    • Peter Attia  February 22, 2012

      Thanks very much, Bob, both for the kind comments and for sharing the other data with folks. We can solve this problem! We just need to be disciplined and patient enough to start doing good science.

    • jake3_14  February 22, 2012

      “Many times when looking at the efficacy of an “Atkins” diet, the long-term (2 years) results will lead the investigators to conclude that the diet doesn’t work in the long term. But what you find is the subjects progressively increase their consumption of carbohydrates; and if you are testing the carbohydrate hypothesis (and not steeped in the calories-in/calories-out paradigm), you would expect this to happen and you wouldn’t conclude the diet doesn’t work.”

      I don’t understand this comment. What long-term result from an “Atkins” diet would lead researchers to conclude that the diet doesn’t work:
      . weight loss?
      . improved compliance rate?
      . reduction in blood triglycerides?
      . increase in HDL?
      . reduction in amount of small, dense LDL particles?
      . decrease in fasting blood glucose?
      . decrease in HbA1C?
      . decrease in CRP?

      Do you mean the decrease in carbohydrates eaten? That’s not a result — that’s an input. Besides, all you’d have to do is define “Atkins” as carbs constituting 20% or less of a diet, with no grains, no processed sugar, and less than “x” g of fructose/day.

      Also, what does “…saying they were looking at what happens when you ‘prescribe’ a diet, not the diet itself, and then that gets into intention-to-treat analysis, which is another can of worms.” mean?

    • Bob Kaplan  February 24, 2012

      Hi Jake,

      Sorry for the confusion as I was not very articulate. The researchers will confuse adherence to a diet and the diet itself. This also brings up the point that an Atkins diet is not a good clinical intervention because the instructions including allowing carbohydrates to be added progressively through the trial. There should be more well-defined guidelines, say, 20gm/day, or 0.5gm/kg/day.

      Weight loss is certainly one outcome that researchers will conclude that Atkins doesn’t work any better than another diet. Here is one of those studies:

      http://www.annals.org/content/153/3/147.abstract

      Definition is obviously key in a study, and most diet studies are poorly defined.

      As far as intention to treat, I will point you in the direction of a couple of links that will illuminate the issue for you:

      http://www.proteinpower.com/drmike/bogus-studies/the-fraud-of-intention-to-treat-analysis/

      http://www.nutritionandmetabolism.com/content/6/1/1

    • Louisa Jones  February 25, 2012

      @Bob@Jake – I’m one of those former Atkins adherents from the 90s. I had a wonderful outcome, with trouble maintaining a few years out because I reverted to my old habits. I would just like to clarify a couple points for those who may not be as familiar with the details of Dr. Atkins’ plan. First, it is truly low carb whatever your ratios, the initial phase is 25g with increases of 5g daily in weekly increments. Second, adherents are supposed to cap at levels that prevent weight gain, for me that would be 50g (at least back then). So even in the lifetime maintenance phase, you are still low carb, some would say very low carb. The problem with execution is that a person must maintain impeccable process for self monitoring. If this were something I had a natural talent for, I would not have a weight problem in the first place. Add to this a cultural environment that says your way of eating is not only indulgent, but unhealthy, and I think remaining within the parameters becomes nearly impossible.

      Today, my hope is that with works like Peter’s and Gary’s and soon NuSI, we can turn this thing around. In closing, I’d like to say that I am low carb again, and only 10 lbs over my Atkins low. Know that there are thousands, maybe tens of thousands, of people with similar histories to mine that will benefit immensely from your efforts in the near term.

      Best, L.

  9. DominiqueA  February 22, 2012

    Thanks for this post! Great explanations. I have tried WW in the past-and did not have much success.
    Since going low-carb in September, I have been tempted to track my ‘points’ using the WW system (just for fun). My daily ‘points’ consumed would far outweigh my recommended ‘points,’ yet I am still losing weight. For example, if I had 30 ‘points’ to use per day, I am probably consuming about 50 points a day because of how they weigh fat/protein in the system.
    It is also interesting to note that although they allow ‘unlimited’ fruit with the new system, they note that if your weight stalls, you should reduce your fruit consumption.
    I’m not sure it will ever be in WW’s interest to concede it is the reduction in carbs that makes the difference.
    Although I wonder if there is enough of a shift in society’s thinking about carbs, will WW follow? Only if it benefits the bottom line I guess.

    (reply)
    • Peter Attia  February 22, 2012

      The only way “mainstream” nutrition will be able to change is when the medical establishment begins to use real science to study the impact of food composition on health. Until we do that, folks like me and many others who disagree with Current Dogma will be marginalized.

  10. Colby  February 22, 2012

    Once again, a terrific post. I thoroughly appreciate the work and attention to detail you put forth. Hate to sound like a tin foil hat-wearer, but this is just another reason I can’t believe most of what I read, hear, or even see. Keep up the good work! And yes, Denise’s breakdown of the china study is awesome.

    (reply)
    • Peter Attia  February 22, 2012

      Colby, thanks so much. Have you also read her analysis of “Forks Over Knives?” Equally brilliant.

  11. steve  February 22, 2012

    Hi Peter: Excellent post! If you look at healthy populations around the world, ie Japan and France that have different macro nutrient compositions you note several things: No eating of junk food, and the carb intake even with the rice eating Japanese is considerably less that what you see with the Standard American Diet. On top of which most to all eating is done at meal time; snacking like in the US is virtually absent.
    Esselstyn is an Ornish acolyte with no fat mantra and has shown plaque regression, but if you look closely at the book(which i browsed)all who experience regression, or almost all were on statins.
    For me a whole food diet is the way to go with emphasis on animal products some fruits veggies and starch in form of potatoes and some rice.
    Look forward to your review of Polys. As you know the med profession is on the bandwagon of the Mediteranean diet with emphasis on poly’s. Not sure what Medit diet is by the way.

    (reply)
    • Peter Attia  February 22, 2012

      You got it, Steve. I’ll get there as soon as possible.

  12. Helga  February 22, 2012

    Thanks for the great post. There are two points with the plant based diet that I can’t seem to get over. The first is that a whole foods plant based diet is not nutritionally complete for humans. Mainly because it lacks B12, but also is very low in other essential nutrients. So to be a healthy vegan you have to take a man-made vitamin.

    Also, how could whole grains and legumes be the perfect foods for humans when no one had much access to them until 10,000 years ago? Even after the invention of agriculture, many people didn’t, and still don’t have any access to these products. It doesn’t add up that we are perfectly suited to consume foods we never ate for over 100,000 years.

    (reply)
    • Peter Attia  February 22, 2012

      Helga, I do ask myself the same question. When I watch my cat tackle and devour mice and birds effortlessly, I can’t seem to understand why I would ever force him to eat a diet of zero animal products. Isn’t evolution supposed to be smarter than us?

    • jake3_14  February 22, 2012

      “So to be a healthy vegan you have to take a man-made vitamin.” To be a healthy low-carber/paleo eater, you have to take man-made vitamins, too. Grok the caveman didn’t, because his environment was relatively clean. Ours isn’t, so we have to compensate. Nor do we get out in the sun much. If you’re not taking with at least an omega-3 supplement, vitamin C, D, and K2, you’re not getting the amount of these nutrients you need to cope with the toxic environment in which we live.

    • Leoni  February 25, 2012

      I actually disagree with this, mainly because I find the whole RDI ‘science’ suspect.

      Vitamins and minerals as quantifiable RDI values are a rather modern concept. Their ‘discovery’ is what, 100 years old or so, and the science on which the RDI’s are based is NOT based on cultures eating carnivorous or ‘paleo’ diets. Recommended intakes are derived from deficiency levels ascertained within the context of a modern agricultural diet.

      We cannot conclude that these RDI numbers apply as some kind of ‘absolute’ objective human essential.

      For example, our supposed Vitamin C ‘requirements': Since Vit C competes with glucose (same receptors) for entry into cells, the modern RDI tells me nothing about how much I need if I don’t eat carbs. If I eat a SAD diet maybe I need the RDI’s 60mg to prevent deficiency.
      But if I don’t eat carbs, my requirement for Vit C may in fact be MUCH smaller and easily thus available in sufficient levels from animal sources.

      Considering also how grains and other agricultural foods contain all sorts of anti-nutrients like phytates, lectins, oxalates etc which bind to and prevent absorption of many minerals, it is not surprise that RDI levels based on modern diets are so high that it ‘seems’ like animal foods alone don’t have enough to provide the ‘correct’ levels every day.

      But without the modern foods the levels of these vitamins and minerals in animal products is just fine to prevent deficiencies.

  13. Debbie  February 22, 2012

    I only recently realized that when I initially lost my weight – 80 pounds about 23 years ago – I was on a low-carb diet. I went to WW, but modified it by leaving out the bread servings. I did this knowing, frankly, the diet was too many calories for me, and – this was before the big food pyramid change – that I needed my protein, and starch was fattening.

    (reply)
    • Peter Attia  February 22, 2012

      Good for you! Very exciting when folks figure thing out by experimenting on themselves. Thanks for sharing.

  14. Adam  February 22, 2012

    Peter, I’m sure you heard about Weight Watchers’ latest drama… they revised the diet last year so that one can eat unlimited fruit (i.e. fruit is now zero points). The only problem? People stopped losing weight and many started gaining! They are now back-tracking…

    http://well.blogs.nytimes.com/2012/02/06/in-new-diet-math-subtracting-is-hard/?ref=health

    (reply)
    • Peter Attia  February 22, 2012

      Adam, yes, this is sad for the poor people out there who are working so hard to lose weight, while being given woefully incorrect guidance not substantiated by any science.

  15. Matt Taylor  February 22, 2012

    Another nice post, Peter. I will reread it when I have more time. Purely-constructive criticism here… I think you may have tackled two subjects at once though – the reason other diets sometimes work, and the typical flaw in many diet studies. Each would warrant its own post and may be easier to digest on its own. Love the kittens analogy – very effective.

    (reply)
    • Peter Attia  February 22, 2012

      Very fair point, Matt. I definitely experienced some “scope creep” on this one. Don’t worry, I’ve got lots of planned writing on the “bad science” issue…This will be a full course!

  16. Alexandra  February 22, 2012

    Great post, excellent insights about what actually gets eliminated with most of these diets!

    When I first came upon your blog, I mentioned that I can’t “like” you on Facebook because I’ve got “hard science-y” friends (e.g. a planetary climatologist) who jump all over me whenever I post something about the poor science behind the saturated fat scare. Recently I posted a couple of excerpts from a Harvard School of Public Health article which quoted this result from a large review study:

    “There is insufficient evidence from prospective epidemiologic studies to conclude that dietary saturated fat is associated with an increased risk of CHD, stroke, or CVD.”

    They then go on to say that replacing saturated fat with refined carbohydrates is bad for your heart. Hurrah! Progress!

    Not so fast… A little further down you’ll find:

    “The net effect is as bad for the heart as eating too much saturated fat…

    But wait, I thought you said… Oh, nevermind.

    My pointing out on Facebook of this bizarre disconnect resulted in the usual accusations of “cherry picking” and not understanding science, etc. But I think I scored some points when I noted that the article also cites PIZZA as one of the main sources of saturated fat in the American diet, so there are plenty of confounding variables when trying to determine exactly what it is that is so unhealthy.

    I look forward to your post about PUFAs, especially since one of the main takeaways of the Harvard article is that we should now replace saturated fats with corn and soybean oils…

    http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/fats-full-story/

    (reply)
    • Peter Attia  February 22, 2012

      Alexandra, I think you already know more than enough to defend your positions to smart “hard science-y” friends. Fear not (and stay tuned for the PUFA piece…)

    • Alexandra  February 22, 2012

      BTW, what’s a healthy light-flavored oil to use for homemade mayonnaise? Extra-virgin olive oil has too strong a flavor when I’m making a base for something like sesame mayo to go with salmon teriyaki. Is peanut oil a good choice?

    • Peter Attia  February 23, 2012

      Peanut is certainly better than canola or safflower.

    • Rebecca  February 23, 2012

      Hi, try a mixture of Light Olive Oil, Almond or Macademia oil and Coconut oil. Play around with the ratios till you hit the jackpot.I haven’t perfected the ratios yet, but I am close.

    • Deb M  March 27, 2012

      I like to use Avocado oil as a nice light oil when olive oil is too strong. I also have a lighter version of olive oil that doesn’t have the strong flavor regular olive oil has.

  17. Leighan Meddick  February 22, 2012

    It’s like what Gary said that time isn’t it; the reason most diets work, even when low-fat, is because generally people ALWAYS get rid of things like soft-drinks and sweets first.

    (reply)
  18. Birgit  February 22, 2012

    Peter,
    This is a truly outstanding post. In addition to explaining why many diets seem to work it will hopefully help many people understand how research works (or doesn’t work)and why we sometimes need to have the courage to try something based on anecdotal evidence only. You have been a great role model for that. I believe it takes courage to change the world and it seems we don’t have too much time looking at the health crisis in the developed world and our overburdened health care system. You have the rare gift to analyze complicated issues to where the average American (with some college education) can understand them.
    Cheers,
    Birgit

    (reply)
    • Peter Attia  February 22, 2012

      Thanks so much for such kind comments. I’ve very optimistic that a change in afoot. If we (the “normal” people) start to demand real science, the truth will come out. Then we can begin to course correct (assuming the current path is incorrect, which I personally believe it is).

  19. Dorian  February 22, 2012

    Peter — on your graphic, the red numbers (e.g. “203 gm carboydrates”), are those supposed to be calories (i.e. “203 kcal from carbs”)?

    (reply)
    • Peter Attia  February 22, 2012

      No, grams of carbohydrate, so closer to 750-800 calories, in this case.

  20. Matt  February 22, 2012

    One thing I don’t see mentioned here – but I believe you mentioned it elsewhere – is the hormonal aftermath of low-calorie diets. You know, the new study finding that leptin levels remain at least one-third lower for an entire year after a dieter loses weight on a low-calorie diet? So this is part of the reason Weight Watchers people gain their weight back 95% of the time, right? After a successful low-calorie intervention, they go on to face lower leptin levels – and an attendant compulsion to overeat – until they return to their former caloric intake (and thus their former weight). Or so I gather.

    I have two questions:

    1) Do you think this study is legit? Was it methodologically rigorous enough to accept the claim that low-calorie diets have this chain of hormonal effects?

    2) Are there comparable studies showing that low-carb diets don’t have these effects? My own low-carb experience has been free of cravings, but I wonder if anyone has measured hormonal impact the way this study did.

    (reply)
    • Peter Attia  February 22, 2012

      When you say was this study legit, do you mean the Ornish/Lancet study of 1990?

    • Alexandra  February 22, 2012

      “the new study finding that leptin levels remain at least one-third lower for an entire year after a dieter loses weight on a low-calorie diet”

      Do you have a link for that?

      I watched Dr. Lustig’s presentation to the Ancestral Health Symposium and it was fascinating to see how people reached a weight-loss plateau after losing a certain amount of weight (whether by toughing it out through hunger or taking an appetite suppressant)due to leptin deficiency. When leptin was restored, weight loss resumed.

      I get pretty annoyed when I think about how much further ahead we could have been with this research if we hadn’t taken a thirty year detour through sloth-and-gluttony land!

    • Matt  February 23, 2012

      NO, I meant this one:

      Sumithran, P., Prendergast, L.A., Delbridge, E., Purcell, K., Shulkes, A., Kriketos, A., Proietto, J. (2011). Long-term persistence of hormonal adaptations to weight loss. New England Journal of Medicine, 365, 1597-1604.

  21. Lee  February 22, 2012

    Great read, Peter. Kind of like GT’s Why Diets Work, When They Do article.
    Keep it up.

    (reply)
  22. Jill  February 22, 2012

    Excellent article. After eating a low carb diet for two years I went to the optomotrist. I was wondering if she would say my blood vessels are clogged with fat. No. I am thrilled to say they are very healthy. Thanks again.

    (reply)
  23. Gary  February 22, 2012

    Peter –
    When I first looked at Atkins and South Beach, I came to the conclusion that they work because they were just another way of restricting calories. Old Calories in, Calories out theory.

    From the Consumer’s report data listed above, both diets are 1500 calorie-ish. Is there any data where the low-carb/non-calorie reduced diet has been compared?

    Or are we needing to just wait for the new studies?

    Great Blog . . .keep it up.

    (reply)
    • Peter Attia  February 23, 2012

      Gary, most studies comparing macronutrient swaps are low to normal calorie and/or free-living. What has not yet been done is the “definitive” study on this topic.

    • jake3_14  February 23, 2012

      The methodology CR used is really screwy. Peter highlighted some of the nonsense used to define “popular” for the study, and the caloric intake is another piece of hogwash. Atkins is completely silent on the matter of how many calories one should eat, mostly because it’s so individualistic. I for example, vary my calories between 1700 and 2300/day, with no guide but my appetite and exercise plans.

  24. Barbara Hvilivitzky  February 22, 2012

    Great Peter! And Wow! The traffic is really getting heavy eh? Good for you!!

    (reply)
  25. Erica  February 23, 2012

    Any “study” that ranks Slimfast, which relies on two shakes a day if I recall from the commercials, among its top picks is completely inane in my view. Talk about not sustainable long-term! I completely agree with all your points, but even paying attention to this article enough to pick it apart gives it more weight (so to speak) than it deserves!

    (reply)
    • Peter Attia  February 23, 2012

      Perhaps, but keep in mind how many people are “influenced” by this sort of information? I think I just want to help people understand how to evaluate information, given that we are bombarded with it (and most of it is lousy).

  26. Henry Miller  February 23, 2012

    The ornish study included elimination of smoking as an intervention, and they think they can draw any form of conclusions about diet?

    I don’t have access to the study, and your summary/the abstract are not enough to draw conclusions. Still, I would guess that most – if not all – of their great results can be explained solely by the smoking factor.

    (reply)
    • Peter Attia  February 23, 2012

      Henry, the first time I read this study (about a year ago), I assumed the same thing before I dug in. The paper says only one patient in the treatment group was a smoker (and she quit). To my reading I could NOT see how many patients in the control group were (and remained) smokers. Because of this, I do believe diet was probably the biggest driver, but again, we just can’t know from this study.

  27. Dan Hackam  February 23, 2012

    Peter, fantastic blog posts – very informative. I’ve had a couple patients on the Ornish diet now who decline any dietary alteration because of the ‘science’ in that Lancet paper (and the subsequent follow-up paper in JAMA).

    In a nutshell, what is your opinion on the Mediteranean diet and the Lyon Heart Study done by de Lorgeril? Is this a high carb diet? (My understanding is that the Indo-Mediterranean diet studies in the Lancet turned out to be fraud, so in a sense these confirmatory studies haven’t confirmed anything).

    Thanks for sharing your wisdom with the wider community.

    (reply)
    • Peter Attia  February 23, 2012

      Dan, I agree with a previous comment the the semantics of “low carbs” are so vague, that we should probably refrain from throwing it around. There are many issues to discuss with these studies, which I can’t reflect on now. What did the study actually test? How did it test? Can the results be applied more broadly? What *actually* caused the effect? You get the idea…

    • DHackam  February 23, 2012

      Well….if I could boil it all down to one simple fact and mechanism based on my N=1 experience…..restriction of carbohydrate induces weight loss. I have phased nothing else out of my diet and do not exercise; yet I have lost 32 pounds in the space of 10 weeks. There is also considerable epidemiology that (intentional) weight loss is associated with favorable prognosis and outcomes. Any diet that does not restrict carbohydrate intake – the primary driver of weight gain – is destined to fail.

  28. Marilyn  February 23, 2012

    1. You have a cat. :-) :-) =^..^=

    2. Having seen all the revisions Weight Watchers has gone through since their beginning, I’d have a hard time believing they got it right *this* time, either.

    3. I wonder if the people doing the self reporting of these various diets (assuming that’s the case) were also calculating their own calories/fat/carbs/protein. And if they did, if the people conducting the studies provided a single resource for all to use. And if they did, if each of the studies used the same resource. As anyone who’s ever tried to track these values knows, the numbers for allegedly the same portion of the same food can vary widely from one database/government publication/diet book to another.

    Very good post, and yet another good reminder that things might not always be as they seem/are reported.

    (reply)
  29. Anthony  February 24, 2012

    Hi Dr Peter.
    If I stick to your blog I will know more about nutrition than….. well most people and so call experts. There was a TV show (American) that tracked one obese man’s transformation due to a diet I believe was soley based on juice (juicing fresh fruit and veg). Unsure what juice but my question is more the point of what you blog article was. Is this more about what was EXCLUDED than was INCLUDED? We also get these infomertials (Amercian again) with some old fitness legend promoting his fantatsic juicing machine and the benefits of juicing.
    It is just another angle on weight loss.
    Biggest Loser programs (I can now not watch anymore because I disagree fundamentally with the whole approach. It’s like a moral thing with me now) and other diets are not sustainable so therefore cannot be a long term solution. Diet in its traditional meaning is something like – Way of Life. Unsustainable is no way of life?
    It feels good to be educated again.
    Anthony – Brisbane, Australia

    (reply)
    • Peter Attia  February 24, 2012

      Anthony, thank you. I’m so glad you’re able to find value in this. Hope to keep it interesting and informative.

  30. Matt Taylor  February 24, 2012

    This blog is outstanding, but I gotta say… the comments and the follow-up are arguably even more effective. There is definitely something very positive going on here. It’s no wonder traffic is spiking.

    (reply)
  31. Mike Hurley  February 24, 2012

    Excellent, well written post. You do a great job of showing how confounding factors make it impossible to draw certain conclusions from studies. If 10 variables are changed with respect to a control group and achieve a statistically significant result, we have no way of knowing which variable or combinations of variables were actually what caused the different result. Maybe some of those variables prevented what could have been greater change. Your example with kittens and ice cream sandwiches made me laugh, very good example.

    One other thing regarding the diets that is often neglected, and it drives me crazy, is that the Atkins diet is an all you can eat diet. Weight Watchers certainly isn’t, everyone I know that’s done it is constantly starving and complaining about hunger. It’s probably the social support you get with Weight Watchers that accounts for a lot of the benefit.

    (reply)
    • Peter Attia  February 24, 2012

      Mike, that’s an EXCELLENT point I had not considered in this post. How people treat you DOES matter. Any by the way, how you FEEL does matter, too.

  32. Marilyn  February 24, 2012

    Correct me if I’m wrong here. In some respects, this Consumer Reports analysis is comparing apples to oranges. Some of the programs, such as Atkins or South Beach, are do-it-yourself programs, originally based on books. Subsequently, online communities and some commercial products have developed. But the programs are not first and foremost commercial.

    Weight Watchers, Jenny Craig, Slimfast, on the other hand, are basically commercial. A quick internet search got me the following: Weight Watchers was owned by Heinz from 1978 to 1999, when it was bought out by Artel Luxembourg. It is now public, with Artel owning 50% of the stock. Jenny Craig is owned by Nestle, and Slimfast is owned by Unilever.

    I don’t know what kind of organizations Jenny Craig or Slimfast have, if any. But WW is something to which one *belongs* as a member. Like many other organizations, there are regularly scheduled meetings and dues requirements. There are even life memberships. If a person moves from one community to another, one can continue to go to meetings in the new community if there is a “chapter” there.

    I don’t know if one would call the WW system “support” or “pressure,” but if more people lose weight on the program, it isn’t necessarily because the diet itself is superior.

    (reply)
    • Anthony  February 26, 2012

      Wow. Nestle owns Jenny Craig? First they take your money, make you fat, then they take your money and try and make you thin. Brilliant business plan to make money on both sides.

  33. Trisha Eldridge Gilkerson  February 24, 2012

    Another great post. I tried weight watchers (at the urging of a couple of friends who had lost well on it) a few years back. I had been doing Atkins and had lost some weight but was amidst a several month stall where I couldn’t get my weight to budge. I never thought of WW as low carb because it gave me so many more carbs than what I had been eating. I switched to weight watchers and put on over 10 pounds in just a couple of months! I was horrified and decided that was enough of a trial for me. Needless to say I went back to a very LC diet!

    (reply)
  34. Anu  February 24, 2012

    A suggestion for your website: I, like probably many others, am getting a lot of value out of the questions/comments/answers at the bottom of your blogposts. Would you consider getting a little tracker that would go on the side of each page that lists the latest comments over the entire site? Comments are listed chronologically but often new comments are posted on pretty old posts that people may never see. Just an idea, but I could understand if you thought it would be too cluttered or something.

    (reply)
    • Peter Attia  February 24, 2012

      Anu, let me look into a way to make the Q&A better. I agree with much of the feedback – it’s a good forum and there is good info there. Just need to figure out how to make it more accessible.

    • Leoni  February 25, 2012

      Oh that would be so great! It would make it possible to keep up with all the new comments.

      Anu, I’ve been wondering that too, as I am also finding the comments very informative but stuggling to find the ‘new’ ones because they are scattered all over the posts.

      Thank you Peter for all the time and effort you devote to everyone!!

  35. Brad  February 25, 2012

    It seems like this would be an easy thing to test: give a group of people a diet that keeps their carb intake exactly what it was pre-diet (both in terms of absolute quantity of carbs and the type of carbs, i.e., the same ratio of complex carbs to simple carbs), but bring down total calories by reducing fat and protein, and see if they lose weight. That would be an interesting study; there’s still more than one variable at play but at least you could test the hypothesis that diets that reduce total caloric intake are successful because they reduce total carbohydrate intake. If you kept total carb intake the same but varied the other inputs, you could see if that idea holds water.

    I’m agnostic on all this myself; my personal suspicion is that genetics and the body’s current fat content are likely to emerge as key players in how we respond to carbs; clearly there must be genetic differences at play because some populations are able to eat incredibly high-carb diets and remain skinny, and many of us know individuals who eat a diet high in refined carbs but don’t gain weight. My 23-year-old stepdaughter is sedentary, eats a diet consisting mainly of Wonder bread, white rice, pasta, mashed potatoes, cookies, cake, and very little protein or vegetables, and she has trouble getting her weight above 85 pounds. She has a naturally fast metabolism, as do her mother and father. But I’m not making any conclusions, I’m just looking forward to seeing some answers emerge over the next 30 years; I wouldn’t be surprised if it’ll take at least that long to get a conclusive understanding of the many factors that likely contribute to obesity.

    (reply)
    • Peter Attia  February 25, 2012

      Brad, you’re absolutely correct. This *IS* entirely testable, just like we test hundreds of other hypotheses in “real” science. This is exactly what the Nutrition Science Initiative (NuSI) will be doing. As to your point about genetics — undoubtedly this is the case, but don’t lose sight of the difference between what you can control and what you can’t. Someone who is born to be (i.e., genetically) 5’8″ may never play in the NBA, but if the practice basketball properly every day, they can still be an incredible basketball player, and far better than someone who is more genetically gifted (e.g., someone who is 6’6″) but never practices.

    • GP  February 26, 2012

      Genetics are one thing, but we also need to have a temporal approach to this problem of carbohydrate consumption. More simply, let’s check in with the 23 year old stepdaughter in 20 years and see how that unmitigated carb consumption is going for her. I suspect if she does not change her diet, her vitals will be less than ideal, and more likely than not she may now be overweight. I believe Lustig and Taubes have touched on the idea of metabolic syndrome, or syndrome X in their work, and I find this fascinating. From what I understand (in my oversimplified way), basically you stress your body at the cellular level through a constant barrage of insulin. This abuse is suspect in a variety of pathologies, from diabetes to the aging process itself.

      In a nutshell, many younger people can “get away” with a level of consumption of carbs and maintain a superficial level of health (e.g. skinny). But at some point insulin resistance and syndrome X demands that the same level of carbs (ignoring calories..not important) consumed now becomes a problem. Due to a variety of mechanisms related to insulin resistance, weight is put on as fat.

    • Peter Attia  February 27, 2012

      Absolutely. Could not agree with you more. When I was aged 14-18 I ate — no word of a lie — SEVEN sandwiches (yes, 14 pieces of bread) for lunch every day, plus 2 LITERS of apple juice. In ONE sitting! I was 5% bodyfat. Yes, I was training 6 hours per day, 6 days per week, but I was also (clearly) very insulin sensitive. By the time I was 30, if I looked at carbs I gained weight. So there is no doubt that both genes and father time play a very significant role.

    • Brad  February 27, 2012

      Agreed about the temporal element, but it’s also worth acknowledging that millions of American teenagers and those in their early 20s are obese and obviously can’t handle the same kind of diet that my stepdaughter lives on without gaining weight. Why is it that some kids eating junk food get fat while others remain skinny? That’s where I feel genetics is likely to be playing a role.

      Here’s another example: I won the pancake-eating contest in my house when I was a teenager (I ate 16 dinner-plate-sized pancakes), and I’ve always lived on a relatively high-carb diet. Yet at 53 I still fit comfortably into the suit I bought when I was 33; I’m 6’4″ and 180 pounds. But my oldest brother, who was a serious basketball player all through his teens and 20s, has struggled with obesity since his late 30s and his diet isn’t much different from mine.

      I don’t necessarily believe that our body weight is determined by genetics and there’s nothing we can do about it; my brother has successfully lost weight in the past but he’s a stress eater and gains it back periodically. But I do suspect that genetic factors may affect individual susceptibility to weight gain and how different people respond to carbs in the diet.

    • Shiv Kumar  February 27, 2012

      Peter, Brad, GP
      I believe age plays a role as well. But maybe it is epigenetics (rather than genetics).

      I was a national swimmer from 8-16 years. Was a bit on the chubby side during the whole period. Eat huge amounts of food. Just unbelievable amounts really. Every swimmer I knew did the same.

      From 16-26 or so I eat quantities equal to 3-4 adults for each meal and eat a large bowl of ice cream after lunch and dinner and 6 extremely sweet french toasts for breakfast. My teas and coffees were almost sugar syrup.
      I spent an hour a day at the gym, that’s it.

      The days I didn’t go to the gym I lost almost 4 lbs per day (probably because I didn’t eat as much). And usually it was because I wasn’t home so didn’t have my regular french toast etc.

      I had six pack abs. muscle bound and no fat. Couldn’t pinch my waist to get any kind of hold on the skin.

      After that, I stopped eating so much and stopped the ice creams and other deserts and french toasts etc. but started putting on weight gradually. Note that it’s not that I stopped eating all that stuff because I was putting on weight but rather, I stopped eating all that stuff and gradually (over the years) starting putting on weight. (so it must be age)

      15 years later, I was 65 lbs heavier. Didn’t go to the gym all those years (life came in the way) but still fairly active. Didn’t eat junk food, watched how much and what I eat for the most part. I have never been on medication of any kind and don’t any other pills.

      I also moved from India to the US 15 years ago. Got heart burn for the first time in the life literally on the first day (breakfast) and thought eggs were the cause. Years later I discovered it was gluten in bread (eats lots of wheat in India but never had an issue). Got my first headache a few years later. Didn’t know what it was until a friend of mine said, “it sounds like you have a headache”.

      So it could be a combination of things but primarily age rather than genetics or could it be epigenetics?
      NUTRITION AND THE EPIGENOME

      I believe Ornish showed that gene expression can be changed.

  36. Russell Holtslander  February 26, 2012

    I am on Atkins, and am always told it is dangerous, and they always have a website showing a study to prove their point. Meanwhile, I am getting more than the 5 serving of vegetables a day, haven’t added fruit back in,but more vegetables than I was eating. I am sticking to meat, mostly chicken , with one red meat meal a week. I have lost 113 lbs, and gotten off my diabetes meds. I still have to lower my triglycerides, and raise my HDL, which are both improving with each test, but have a 125 cholesterol, and a LDL of 51. I eat 4 XL eggs a day. I recently got gout, but I now believe it was while cheating, and drinking Pepsi. I noticed the flare-ups occured when I drank pop.. I suspect it is sugar, and have gone back on Induction to clean up my diet, and get losing again. Eating this way has reduced the flare-ups. I got off ALL diabetes meds, close to dropping my cholesterol meds, and my last BP check was 104/61. Yet if I say I am on low carb, people say it is dangerous. I can eat 10 servings a day of vegetables, but if my carbs get too low, it’s dangerous. I think sugar is dangerous, as well as elevated insulin levels, but no one says the diet that had me top out at 361 was dangerous, but the diet that is fixing them is. So, I am frustrated on a daily basis, and a friend showed me this site.

    It is a breath of fresh air to see someone who says what I am thinking. I have seen results, and they are contrary to popular beliefs. I am not going back, just to be ” normal”, and your articles make a lot of sense. Studies can be made to say anything, and I think a lot of them today, are set up to prove a point. They took away the objectiveness in the studies. They knew the answer before they ran them.

    Since I can’t trust whether the studies are unbiased, I am left with personal example. I will stick with no sugar, low carb, high vegetables,slightly elevated protein, and high fat diet that is working for me. I try to avoid saturated fats, drink plenty of water to stay hydrated, and work out 7 days a week. Nothing is going to change my plans, but it is nice to read this, and think maybe I am doing something correctly. It gets depressing when you are continuously told what you are doing is wrong, when you are seeing results.

    Thanks for the great point of view, and the in-depth explanations. Very interesting read!

    (reply)
    • Marilyn  February 27, 2012

      Good story, Russell! If you do some more reading on these various low-carb sites, you’ll probably find that both red meat and saturated fats are considered UN-dangerous. Many of us enjoy both in abundance.

  37. Michele  February 27, 2012

    Hi Peter,
    Without putting too much pressure on your already busy schedule, being able to see all new comments on your posts would be VERY APPRECIATED as the comments are also extremely valuable.

    Question – Russell’s post mentioned red meat is only eaten once a week. I eat a lot of red meat especially loaded with fat. My instincts are telling me this is OK but Russell’s post hast me thinking…

    (reply)
    • Peter Attia  February 27, 2012

      I have never seen a compelling argument for red meat being harmful. I’m working on the comments issue…

  38. Howard Nease  February 28, 2012

    Thanks so much for your work on this issue and in this website. I am a practicing general internist, and also have personally struggled with weight. I am currently down 40 pounds from my top weight and have lost gradually over the last 10 years using a variety of diets and exercise. However, I have been struck both personally, and even more, professionally, at how difficult long term weight loss is. I recently was asked to speak to a group of psychologists about weight loss, and I entitled my talk “Don’t Throw Your Big Pants Away”, to try to get across just how poor our long term success rate is with traditional weight loss advice.

    After reading Gary’s books, I have been moving toward low carb recommendations, and am following a low carb diet myself. Here’s my question. As a physician, I have seen most people that follow a low carb diet have the same problem that other dieters have with recidivism — they lose weight, but when I see them a year later, the weight is back (often plus a few more). In your reading/reviews have you seen much evidence that the low carb type diet can be effective for long term weight loss/weight maintenance?

    (reply)
    • Peter Attia  February 28, 2012

      Howard, like any treatment, it’s only as good as “compliance” for lack of a better word. The rate of recidivism is so high, I believe, because of poor information. Most people who lose weight on a low-carb diet don’t actually understand WHY they lost weight. Once the weight is off, they start gradually re-introducing carbs back on until they get back to their original weight. Carb reduction is not a “diet” — it’s a way of life, which sounds silly, I know, but if it is viewed as a transient change, then so too will be the health impacts. When you chose to restrict carbs it’s no different than choosing to give up something harmful (e.g., cigarettes). It comes back to information and understanding, which is really why I write this blog. I want people to know WHY.

    • Anu  February 28, 2012

      Another problem, I feel, is how little societal support there is for this type of eating. I know that if I did low-fat, or gluten-free, or even vegan, society at large goes out of its way to give me options. Yet a low-carb, or even worse ketogenic, diet is very difficult to stay on when the rest of the world runs on carbs, even when you physically feel great. I face this issue all the time — this weekend a friend has invited me to a crepe party, and I probably won’t go. This gets old fast, as sometimes it feels like a choice between having a social life and eating healthy. When you do slip up, as seems inevitable, the effects can be long-lasting, as getting back into ketosis takes a while.

    • Peter Attia  February 28, 2012

      This is a VERY good point. Just ask anyone who is overweight what it feels like to order bacon and eggs in a public place, or heavy cream for their coffee. We will fix this, in time.

    • Howard Nease  February 28, 2012

      I think in one of Gary’s books he says losing weight does require sacrifice, but at least let’s sacrifice the right things. I guess what I’m wondering is whether a low carb diet (“diet” as in what you routinely eat, as opposed to a transient weight loss “diet”) is easier to comply with long term than caloric restriction/increasing exercise. It seems like it would be, but anecdotally, I haven’t seen that; people tend to quit low carb eating and go back to their old ways. I think one interesting question would be why don’t more people stay with low carb eating– is it just hard for people to follow, do they get tired of it or do they not understand the concepts. I do think information is key, and I know one reason people quit low carb eating is that other people (including their doctors!) tell them that they are killing themselves eating this way. This is why I am so glad to see you and Gary and others out there providing high quality information.

    • Peter Attia  February 28, 2012

      Probably a combination of factors. Why do people use HIV infected needles when they can find clean needles at a shelter? Why do people go back to smoking when they have successfully quit for 6 months? Why do people sleep with prostitutes without condoms, even though you can buy condoms at any drug store? I don’t think there is one over-arching reason or explanation. Some of it is understanding of the problem. Some of it is social support and surroundings. Some of it is prioritization. Having done my residency in the heroin capital of the U.S. (Baltimore) I wanted countless lives ravaged by this drug, even after long periods of abstinence. Why? Probably because the pain it eases is greater than the pain it causes, at least in the short-term.

      Let’s keep asking these questions, though…otherwise we’ll never solve this problem.

    • Marilyn  February 28, 2012

      I recently reread the original Atkins book. Although I’ve read it several times before, I was struck this time with his advice on maintaining weight loss once a person is at a desired weight. The cost is eternal vigilance. Keep an eye on the scale, and before things get too far out of line, go back to square one and fix things.

      While all the low carb books have some information on maintenance, that’s usually the part of the book where things get less exciting. The adding more carbs part can be tricky — in some ways tricker than the induction/intervention phase. That’s where things start to get mushy in terms of what to do next, and with Atkins, a little too fiddley for my taste.

      Maybe what the low carb world needs is a Book II — “How Not to Lose Your Weight Loss.”

    • Brad  February 28, 2012

      Susan B. Roberts of Tufts has written an interesting book called The Instinct Diet, in which she focuses on providing people with the tools and understanding they need to maintain their weight loss for the rest of their lives. While one can (and will) quibble with her specific dietary recommendations, the five “food instincts” that she discusses are noncontroversial and are all backed by solid research; her descriptions of those instincts and how you can recognize them and work with them to keep your weight under control are, in my opinion anyway, worth the price of the book. I’m not sure I agree with her food recommendations, but she emphasizes that once you understand the food instincts and how to deal with them effectively, you can apply those lessons to any diet. Interestingly with regard to low-carb, she recommends it but not as the full focus of a sustainable diet, because one of the “food instincts” is that we like variety and a low-carb diet can get monotonous after a few years. She feels that low-carb has an important role to play, but for long-term weight control she favors mixing it up a bit so our “variety” instinct remains satisfied and we don’t slip into old patterns.

  39. Viktoria  February 28, 2012

    Like many who are reading this blog, I have experienced several lovely benefits from removing grains, sugars, etc from my diet, such as improved lipid profile, better sleep, etc.

    What I have not experienced is weight loss. I note the constant exultation of the instant effortless weight loss that many experience and it’s certainly not happening for me. I really resonated with something you (Peter) said in one of your posts (I can’t remember which) that you had a friend who told you that if she ate as you did, she would be subjected to constant ridicule. I feel like I am there now, firmly believing in the science, but my persistent lack of weight loss undermines everything I say to anyone.

    (reply)
    • Peter Attia  February 28, 2012

      I understand what you are saying Viktoria, and I’d give anything to have an answer and a solution for you. Just ask yourself this, do you feel better today (overall) than you did, say, a year ago? If so, then you’re on the right track.

    • Viktoria  February 28, 2012

      Certainly I feel better. So I can point to that as a success, and one that I’m not dismissing at all. In some ways it even seems more important for my overall health. I didn’t mean to sound upset in my last post. .

      My doctor is thrilled with my bloodwork. He is completely comfortable with reduced carb diets, thankfully. I’m lucky that he’s very supportive, and we have good discussions about the science.

      I am just unlucky from this particular genetic perspective, and have to adjust my diet more than some.

      As a scientist I understand the process of scientific discovery. Sometimes current understanding is overturned by a single critical experiment. Sometimes it’s whittled away bit by bit until it can no longer be denied.

      I do think that the current process of knowledge dissemination in science, publication in scientific journals, helps contribute to the problem. You can’t publish a paper unless you can point to a conclusion, and publishing is key to career success. The higher profile the journal, the more vigorously the conclusion has to be stated. So you get lots of data published and claims made that don’t necessarily have solid footing. Not to mention how the peer review process skews things.

      As a physicist, I’m more comfortable with systems that have controllable variables. Biology has always weirded me out a little. :-)

    • Peter Attia  February 28, 2012

      You and me both…I am optimistic that at some point we will get a better idea of what is actually happening.

  40. Dave  February 29, 2012

    So has the NuSI foundation been formed yet and/or have any kind of website for latest news? Also I was wondering if you know of any ground-breaking research that is taking place right now to cover more ground in making the case for the insulin hypothesis? Is Gary or anyone else up to anything that we should be looking out for? I’m tired of the naysayers and want to really see the calorie in/out hypothesis just go away.

    (reply)
    • Peter Attia  February 29, 2012

      Dave, we’re working nearly 24/7 to get NuSI up and running by summer. Lots of stuff planned scientifically, too. I will definitely be writing about this as we get closer to launch.

  41. Labhrain  March 4, 2012

    A little late here, but I just wanted to comment that I’ve lost weight on WW a few times. I lost 45 pounds on WW, but I was hungry and fighting the cravings all the time. Even more disheartening was that my high blood pressure, high triglycerides (over 200) and daily fight with GERD did not improve on WW.

    I went low carb a little over a year ago. I’ve lost 60 pounds, and am much more satisfied than on WW. The best news is that my dietary changes quickly led to normal blood pressure, low triglycerides (50) and no more GERD! While the weight loss is very important to me, the health marker are at least equally imprortant. And, they weren’t improving on a low fat, kcal controlled diet like WW. They did improve on a low carb, high fat diet.

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  42. lorraine  March 27, 2012

    This is such an excellent post as it relates to the need for folks to understand research methodology, which actually yields pretty well to common sense in the hands of someone who knows how to communicate it like yourself (and hopefully other workers in the field like me). Please continue to provide this important instruction in analyzing study methods. Ornish’s work came out just as I was leaving grad school into my first job doing clinical supervision of ketogenic diets in a hospital obesity clinic. His work was all the rage, but it didn’t jibe with what I was seeing, and I really felt the loss of those study participants, along with the “kittens” study design was severely problematic. But it was hard to argue with those CAT scans, they were dramatic and everybody drank the kool-aid. But there was a documentary film made sometime around then about the study participants, and the impression that remains in my memory about it was their fatigue and in some cases, depression.

    What surprised me about the diet comparisons is how much closer to The Zone in percent macronutrients WW has become over the years.

    Don’t even get me started about Biggest Loser…….

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  43. tim  April 14, 2012

    I apologize if this was asked but regarding the table at the beginning, how are you arriving at the carb count? For example, how are you getting the carb grams- ie ww 203?
    What do the other figures represent? Fat 24 Carbs 56, protein 20. Calculating fat at 9 Cal per gram and carbs, protein at 4, total Cal total 520?

    (reply)
    • Peter Attia  April 14, 2012

      The numbers in the table are % of calories. So for WW, 56% of 1450 calories is 812 calories, or approximately 203 gm of carbohydrate.

  44. Edward  August 8, 2012

    Currently Consumer Reports is putting a much more measured view of diets on their website. This page is available without a subscription. Although they are still reporting based on popularity, they are finally reporting some of the things we low carb types have known for years:

    http://www.consumerreports.org/health/healthy-living/diet-nutrition/diets-dieting/diet-reviews/overview/index.htm

    An extract:
    “It’s OK to go low-carb

    The 2010 edition of the U.S. Dietary Guidelines for Americans, which we’ve used as the basis for the diets’ nutrition Ratings (available to subscribers), still frowns on eating 10 percent or more of calories from saturated fat from meat and dairy products and more than 35 percent from fats overall. So the Atkins diet, which is 64 percent fat calories overall and 18 percent saturated fat, ends up with only a Fair nutrition score.

    But there’s more to the story. Evidence is accumulating that refined carbohydrates promote weight gain and type 2 diabetes through their effects on blood sugar and insulin. “If you have insulin resistance, your insulin may go up to 10 or 20 times normal in order to control your blood sugar after you eat sugar or carbs,” says Eric C. Westman, M.D., an associate professor of medicine at Duke University who co-wrote the newest version of the Atkins diet. “But the insulin also tells your body to make and store fat. When you restrict carbs, your insulin goes down and you can burn your body fat, so you eat fewer calories and aren’t as hungry.”

    Isn’t it dangerous to eat so much fat? That’s still a subject of vigorous scientific debate, but it’s clear that fat is not the all-round villain we’ve been taught it is. Several epidemiology studies have found that saturated fat doesn’t seem to increase people’s risk of cardiovascular disease or stroke. Other studies suggest that you might be even better off if you replace saturated fat with unsaturated fat instead of with certain carbs, the ones that turn to blood sugar quickly after you eat them, such as white bread and potatoes.

    A nutrition researcher, Frank B. Hu, M.D., of the Harvard School of Public Health, recently wrote that he believes “refined carbohydrates are likely to cause even greater metabolic damage than saturated fat in a predominantly sedentary and overweight population.”

    Moreover, clinical studies have found that an Atkins or Atkins-like diet not only doesn’t increase heart-disease risk factors but also actually reduces them as much as or more than low-fat, higher-carb diets that produce equivalent weight loss. ”

    It’s finally starting to penetrate! CR, for good or bad has a lot of credibility, mostly due to what was stated above, that they don’t EVER accept any money from corporations.

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  45. john  December 28, 2012

    I’ve been eating low carb for 4 1/2 months after a 40 year run on hi carb of mostly whole grains and very low saturated fats. My chloesterol has shot up from 160’s to 250 (Friedewald) but HDL rose to 71, Trig’s down to 27 and a VAP panel has my LDL in the lowest risk category for CVD. So my ratios are all excellent.

    My GP is horrified and thinks I’m a candidate for statins if I don’t bring my LDL’s down. With the elimination of grains and sugar, I have never felt better and returning to that diet is simply not an option for me.

    My question , Is there some science based upper limit of LDL, or TC, beyond which my heart will hit the wall? It seems that as long as my TC/HDL, Trig/HDL, LDL/HDL ratios are all excellent, blood lipids are not collecting on arterial walls or filling up my ventricles, and are just harmlessly going for a ride in my vascular system. My wife’s (same LC diet) TC is 309, with even better ratios than mine.

    Finding this site has been a godsend.

    Thanks,
    John

    (reply)
    • Peter Attia  December 28, 2012

      Hopefully I can address this adequately in Part X of the cholesterol series when I get to it. This may be a transient effect.

  46. lee  February 7, 2013

    I was once a weight watchers guy and lost around 20-25lbs but that was 15 years ago when I was in my twenties. I have more recently tried WW again and followed it to a T and found that it doesn’t work for me anymore and I’m wondering if its because of years of high carb diets making it harder to lose. I have since dec 2012 been following a paleo/primal diet with no grains or sugar (40-60g of carbs a day) and notice I am never hungry and even though I have not lost an ounce yet, I do see how the constant influx of carbs can really mess up your metabolic state. I’m sure it just takes time of healing on a low carb diet to fix years of the grain/sugar diet to start to see the affects. Love the Website Peter

    Lee

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  47. lee  February 8, 2013

    at 43yo and my waist being 41inches , there certainly has to be some improvements so this seems to be the way to go . WW obviously not. at least for me

    (reply)
  48. Holly K.  February 13, 2013

    Peter, have you heard of the Shangri-La Diet, by Seth Roberts? There’s a few variations of it, but the original idea is that you drink extra-light flavorless olive oil at least one hour away from eating or drinking anything else (except water) – this is to keep the olive oil “unassociated” with flavor calories. Other than doing the oil as directed, you can eat or drink anything. But you don’t feel like eating or drinking anything! Seriously, I had to remind myself to eat and then only wanted to eat healthy stuff. The first time I did the diet, 22 lbs melt off effortlessly and quickly – post pregnancy weight. This was after months and months of calorie counting and exercising. But the second time and third time I tried the diet, the appetite suppression part of it just did not work so I gave up. I feel like my brain figured out the tricks I was trying to play on it. I’d love to hear your thought about this diet, if you’ve ever looked at it. To me, it was Shangri-La, but only worked once. Now after reading this article and all the comments, I’m tempted to try again (since it’s low-carb w/ketosis but WITH massive appetite suppression). I think Seth Roberts is on to something big, but the explanation of why it works isn’t quite right. (sorry for the ramble!)

    (reply)
    • Peter Attia  February 13, 2013

      I have no idea. Are there any clinical trials?

  49. james oeming  February 14, 2013

    My anecdotal two cents:

    My 40 lb. weight loss has been maintained for 2.5 years.

    I lost my weight and have maintained the loss by first and foremost counting calories, strictly. I count what I burn in the gym, and count every morsel I eat, and keep meticulous records. I also factor in my baseline level of daily physical activity.

    I’ve noticed that it is easier to maintain my program if I eat big piles of low-calorie vegetables and lean meat.

    My working assumption is that when eating simple sugars and white stuff, like flour and sugar, it is quickly packed away into fat, like a miser quickly depositing money into a bank account, who then says, “OK, I socked that away in the bank account as fat for future use — so how about some some ‘spending money’ to get through the day?” (i.e., I become hungry for more food).

    Whether or not, and to what extent, these working assumptions are true scientifically, I cannot say for sure. All I know is that this “model” works for me. I

    By eating slow-burning stuff such as lean meat and veggies, my body seems to have more “spending money” longer, presumably from not “banking” the calories as fat.

    Placebo effect? Who knows?

    Regardless of what I eat however, as far as I am concerned, the “business end” of my diet is regulating net caloric intake. That is far and away the number one thing I monitor. Having done that, I can then choose which calories will make it harder or easier for me to stick to my diet. (As mentioned, lean meat and lo-cal veggies make it easier to stick to the diet.) However, I never presume that eating protein and veggies will somehow entitle me to eat more calories. For my money, never ever take your eye off the ball of calories.

    One more very important thing, in my view: Do not underestimate the significance of gentle physical activity all day long. In my job, there are days where I am on my feet all day, reaching up into cupboards, and doing gentle lifting of objects. I estimate this burns at least 75-100 calories an hour. In an 8-hour day, that’s 600-800 calories. That’s a lot! It doesn’t feel like I worked out, but I truly did work out — just slowly. On the other hand, there are days where I sit all day long, and I factor that into my net caloric intake calculation.

    I think many overrate the significance of eating lean protein and lo-cal veggies, thinking that calories are not that big of deal if that menu is followed. For my money, however, calories are always and forever the biggest deal, and should never be given a backseat when dieting. Calories are the ultimate coin of the realm. Some calories make it easier to diet, and some make it harder by making you more hungry, but the bottom line, always, is caloric intake.

    One last thing: I have noticed that some of the aerobic machines at the gym are too generous on their digital readouts of calories burned. I correct for this noting which machines are too lenient. I don’t do real vigorous aerobic workouts, so if a machine is saying I am burning more than 500-600 calories an hour, I discount that number. My favorite machine I discount by 25%. If it says I burned 400 calories, I assume I burned 300 calories.

    My anecdotal two cents, humbly submitted.

    Thank you for your great work, Dr. Blogmaster :0)

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  50. Janice  August 26, 2013

    One of the main problems with measuring “success” on any diet (I’m an ardent WW proponent) is the fact that unless someone starts tracking the post-diet lifestyle for at least 5 years, success must be deemed temporary. People who like to overeat and/or are insulin-sensitive, wheat-sensitive, etc etc, will resume their previous overeating lifestyle. The big trick of course is to stay ever-vigilant and of course, to pick up exercise somewhere along the way. Luckily I love to dance & do dance fitness & other exercise several times a week. However, the scale has to become my friend if I am going to work with it, for the rest of my life. I won’t tell you how many times I have tried unsuccessfully to learn this lesson. Luckily this time I am 4 years “sober” with a 30-lb. weight loss.

    At the beginning of any weight loss journey, the grossly obese don’t care exactly what is happening to their body. They are so thrilled with the LIFE changes happening all around them that all they care about is that it works.
    From my own many years of experience, WW is the easiest program to stay on long term. Yes, carbs are “counted for more points” now so they are discouraged. And yes, some amount of education takes place about generic healthy eating. And yes, fruits & vegetables are strongly encouraged. Like you said above, they are replacing at least some of the junk food. Isn’t that a good thing, at least at first?

    While I am not a WW leader or groupie I do believe that it would be difficult to get too scientific about what is happening in the average WW meeting. It would go over many heads & then they might not attend the meetings. Furthermore as you have so aptly pointed out the science of weight loss is so so complex and personal. I, myself for example, have hypothyroidism & high cholesterol, even with maintenance of a ‘normal’ weight & ongoing exercise for the 4 years. I’m sure there are several other categories of biochemical body types that would need to be studied on a long term basis (post-weight loss), including testing all the possible sensitivities you’ve mentioned.

    A friend recently told me that I need not ever eat anything that starts with a ‘w’ and ends with a ‘t’, again (because of my high cholesterol, 274). I’m at the first-step stage, admitting I am powerless over certain types of foods. I think analyzing some of the various sensitivities would be a good next step.

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  51. Mike  November 10, 2013

    Hi Peter:

    Well, I’m very impressed with all the statistical analyses you’ve done about what diets work, why people lose weight, why they don’t, what nutrients work best, who lost what type of weight in clinical trials, studies of how much weight was lost etc. etc. etc. But is all this really necessary? Seriously, I would have an easier time trying to figure Einstein’s Theory of Relativity than it was trying to follow your article. Please don’t get me wrong, I’m sure it was full of factual information and great advice, but again, is it really necessary?

    People today are getting fatter and fatter, can’t lose weight or yoyo diet because they can’t control their impulses when eating. This is in part fueled by the food industry using clever marketing tactics to entice people to constantly eat bad, unhealthy food and too much of it; and society has lost control of themselves as a result. The diet industry then comes along to take advantage of this and says “okay, such and such a diet is good for you because you need to cut out (pick one – fats, carbs, sugars, salts, saturated fats, hydrogenated fats, refined starches etc. etc. etc.). Then there’s all these studies done about the best way for the body to metabolized calories, but they all seem to ignore good old fashioned common sense. Why do we keep referring to “new science” or “old science” when all it takes is for people to eat sensibly, not consume as many calories and exercise? It’s worked in the past. The dieting advice from yesteryear with our parents & grandparents would be to “push the goddamn chair away from the table”. There was no Weight Watchers, Jenny Craig, Atkins, South Beach, Grapefruit diets and so on. People ate all types of foods but ate sensibly. This includes having a controlled portion of meat, chicken, fish etc. with a side starch and plenty of vegetables. Yes, you can have a daily sweet snack like ice cream, cookies, cake but don’t pig out. Also eat plenty of fruits & veggies as snacks in lieu of extra breads, cakes, cookies or anything else with high refined wheat content. Then get a good deal of exercise. It’s that simple.

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    • Russ Nelson  December 19, 2013

      I lost twenty pounds without exercising, just by dramatically reducing the carbs in my diet (except for binge day, when I overload, to keep the metabolism up.) Exercise is overweighted. Exercise just causes you to burn calories, make you hungry, and if you eat more calories that spike your blood sugar and invoke the insulin response, you’ll just get fatter.

  52. Russ Nelson  December 19, 2013

    I read the article, and didn’t read all the comments. Sorry if I’m repeating something someone already said. I want to point out one more confounding factor for the study discussed: the people who changed their lifestyle KNEW they were in the experimental group. If you take a group of people, split them in two, tell half that they are the control group, and the other half that they are the experimental group, it doesn’t matter what you are testing or how you then test it, the experimental group will do better at whatever you are testing for. Even if it’s autonomic. Even if you don’t tell them what you’re testing for. Even if you don’t tell them who is the control and who is the experimental group (because YOU know which is which — the Clever Hans effect — double blind studies FTW).

    You are definitely right — this kind of thing is *tough* to study, and I feel sorry for everyone who has tried and failed in predictable ways.

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  53. Manda  January 16, 2014

    I appreciate your clear presentation of the information. I have to say, as someone who has struggled with weight loss (-40 would be good for me) I have lived in the realm of shifting from one place of thinking to another. I’ve tried Weight Watchers, shifted to ‘green juices’ for 3 meals a day, shifted to a vegetarian diet, shifted to a carb-free diet, and then the cycle just continues. The bureaucratic LIES that continue to be FORCED upon the American public is just outrageous. I no longer believe almost ANYTHING I read about health, wellness, and weight loss – as I never know which company has paid to have their beliefs included in the report.

    I would love more information – or sites – that accurately report what nutrition is best for weight loss and your body in general…. For example – I’m still confused if it’s better to add a bit of sugar or splenda to my coffee???

    (reply)
    • Peter Attia  January 17, 2014

      See posts on sugar and, separately, artificial sweeteners.

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