Just Read: Always Hungry, by David Ludwig, MD

I actually didn’t just read this book, I read it awhile ago, but haven’t posted on it, until now (thanks for the nudge @ePatientDave).

I recommend this book as a companion to the others I have reviewed here (Why We Get Fat, Big Fat Surprise, The Case Against Sugar) because it’s more practical, written for a non-clinician audience by an experienced physician expert in the field, David Ludwig, MD (@davidludwig).

(Editorial comment, unlike other heath-oriented movements I have interacted with, I am pleased to see so many in the nutrition movement to be using social media to communicate their ideas. This is not the case among other physician-involved health movements I have seen, and it’s a loss for them, because there’s nowhere to go to ask questions.)

The Science

David covers just enough of the science to be useful for someone to understand the why of this approach:

So, in the 1970s, prominent nutrition experts began recommending that everyone follow a low-fat diet, in the belief that eating less fat would automatically help lower calorie intake and prevent obesity. Thus began the biggest public health experiment in history. Over the next few decades, the U.S. government spent many millions of dollars in a campaign to convince Americans to cut back on fat, culminating in the creation of the original Food Guide Pyramid…

Ludwig, David. Always Hungry?: Conquer Cravings, Retrain Your Fat Cells, and Lose Weight Permanently (p. 18). Grand Central Publishing. Kindle Edition.

And one example of the answer to whether this approach worked (the Look Ahead Study):

The study, conducted in sixteen clinical centers in the United States, assigned about five thousand adults with type 2 diabetes to either a low-fat diet with intensive lifestyle modification or to usual care. The study, published in the New England Journal of Medicine in 2013,33 was terminated prematurely for “futility.” Analysis by independent statisticians found no reduction of heart disease among participants assigned to the intensive low-fat diet, and no prospect of ever seeing such a benefit emerge.

Ludwig, David. Always Hungry?: Conquer Cravings, Retrain Your Fat Cells, and Lose Weight Permanently (p. 59). Grand Central Publishing. Kindle Edition.

There’s tons of published information about these findings, though, this book is more directed at successful behaviors.

The Behavior

The book is really designed as a plan to change dietary habits to ones that are more consistent with maintaining a healthy weight. Ludwig appropriately diminishes the argument that being overweight is about lack of self-control or too-large portion sizes or calories-in vs calories-out.

Although the focus on calorie balance rarely produces weight loss, it regularly causes suffering. If all calories are alike, then there are no “bad foods,” and the onus is on us to exert self-control. This view blames people with excess weight (who are presumed to lack knowledge, discipline, or willpower)—absolving the food industry of responsibility for aggressively marketing junk food and the government for ineffective dietary guidance.

Ludwig, David. Always Hungry?: Conquer Cravings, Retrain Your Fat Cells, and Lose Weight Permanently. Grand Central Publishing. Kindle Edition.

As I have mentioned previously, I am a former-fat person, and even before I went to medical school, I felt the medicalization of obesity had serious shortcomings from my own personal experience – it appeared to me that the creators of this approach had never experienced being overweight, like so many other things in medicine that have been designed TO people and not WITH people.

One of the challenges of moving away from a low-fat diet, though, is that there are extreme versions of the opposite, such as ketogenic diets. These may be successful for some, however, they require a level of commitment and medical supervision that’s not feasible for everyone.

From my read, Ludwig takes a very reasonable patient-centered approach (since he’s a physician, after all :)), and steers away from extremes into a slow modification approach that a person could follow if they were thusly motivated (and that’s the caveat, see below). He does not permanently forbid foods and the book is obviously written with enough guardrails (he is a physician after all…) that it appears safe relative to other guides I have seen.

The Motivation

The book is great for those who are motivated and want to make a change. At the same time, it’s also very well known from studies that giving people information is not sufficient for them to change their behavior (see this review from the American Heart Association – the smartphone app graveyard continues to grow in size: Just Read: Current Science on Consumer Use of Mobile Health for Cardiovascular Disease Prevention).

I have recommended this book to some people, and my assessment of the uptake is “marginal,” not because of the book, because of where people are in their journey. Which is fine, that’s where information fits in, for the times that support is there and people are ready.

As Ludwig states, we’re in the middle (maybe the end?) of a 40-year failed experiment in changing the nutrition habits of the world. The data shows that people did in fact listen to the advice given and changed their habits (yet another perpetuated myth – “if people would just do as they were told”). It’s going to be an exciting next 40 years….

3 Replies to “Just Read: Always Hungry, by David Ludwig, MD”

  1. I can’t thank you enough for those books. While out on my runs & walks I’ve now ear-read (audio) Big Fat Surprise and Case Against Sugar, and they both make sense. I’ve modified my diet … I’m having so much fun having bacon & eggs whenever I want, etc. But as we know, it’s really hard these days to avoid added sugar! Hoping the FDA will finally mandate the revised nutrition label with added sugar as a separate line item.

    When I made the change I did experience a week of constipation, which (as Sugar says) is a claim the sugar people used aggressively against Atkins-style diets. It wasn’t painful constipation, just no “results.” I had informed my doctor of the change and the problem, and with his involvement, adding more water and more fiber (and a few doses of Miralax powder) cleared it up in a week.

    I’m currently ear-reading The Gene, another big (19 hour) book by the author of the Pulitzer-winning Emperor of All Maladies, and now I know what’ll be next up. 🙂

    Since I first met you, the distinctive thing your blogging has taught me is its power to share information directly to the grass roots – the people with a need. Thanks!!

    1. Hey Dave,

      Glad to hear about your progress and I am also glad to you know you’re involving your doctor in this journey, and that of all people you know how to leverage the medical profession for better health :).

      I’m actually going to a full-week conference on the topic of this diet in a few weeks as part of my continuing medical education, to satisfy even more of my curiosity. I’ll report back what I learn. Keep walking!

      1. Not just walking – I’m a runner now! (And walker.)

        I’ve ordered (by slow-boat, apparently) a print copy of Always Hungry, because the reviews on Audible.com said that although the book itself was fine, a separate infomercial-hustler voice read the various testimonial quotes that are sprinkled throughout. I can’t stand being annoyed 🙂 so I’m waiting for the print copy …. while working my way through that epic The Gene, which is a really remarkable scientific treasure hunt.

Leave a Reply