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….

Just Watched: Low-Carb High Fat Diet in Type 1 Diabetes

The origin of this post is that I sent a tweet earlier this week regarding the current crisis in insulin pricing referring to the Banting Diet, which is the precursor of the low-carb high fat diet (or LCHF diet). I sometimes do this (sending unclear messages) assuming that people will figure them out, and usually, that’s not the outcome 🙂 . At least it starts conversation (maybe I do this subconsciously, I don’t know).

In any event, I have been interested in nutrition for a long time and more interested recently (see:Just Read: Why Eating Fat May Not Make You Fat (The Big Fat Surprise) ), as more data is being produced about where our dietary guidelines came from. In the case of diabetes, I have been curious about the ways the medical and other professions counsel patients on diets in ways that may actually increase their risk of diabetes and increase their insulin requirement.

My question, therefore, has been whether the need for insulin could be eliminated in some people and reduced in others, which would blunt the impact of pricing and make living with diabetes more affordable. The other question I have is about the whether reducing the use of specialized insulins for some population would have an added effect, making the pricing power, less powerful.

I’ve read a few papers about this. I don’t feel comfortable doing a literature review myself because these days it’s really hard to interpret papers if hidden biases aren’t known. That and I may be a physician, but I do not know what it is like to live with diabetes. I do know what it is like to live as a former fat person so there is some relevance here for me.

Through the magic of YouTube, Dr. Troy Stapleton (@drtroystapleton) explains his own journey as a person with type 1 diabetes and the LCHF diet. He’s going to to have much more credibility than I and this is a good science-based + authentic overview from a patient perspective. Watch:

A person who produces insulin on this diet is going to have an insulin production curve closer to a person with type 1 diabetes (flat) compared to a person without diabetes (insulin spikes), with the idea that insulin and specifically too much insulin is a requirement for obesity.

#ILN innovating in nutrition, too. #LCHF in Chicago. #ketogenic #ketogenicdiet #lessinsulin

A post shared by Ted Eytan (tedeytan) on

I’m planning to do some more study this summer. At the same time, there are far more experienced researchers, journalists, physicians and scientists engaged in this work, so I’m more interested in dialogue than leadership (they are doing just fine). I always say if there’s a better way to do something, I want to know about it.

This is life in the family medicine revolution (#FMrevolution), where unlimited curiosity reigns in the interest of a person, family, community’s long healthy life. Feel fee to let me know your thoughts in the comments.

Just Read: The Case Against Sugar

One of my earliest memories was the rush to the grocery store by my family to stock up on saccharin sweetened beverages when it was feared they would be pulled off the market, in 1977. The shelves were bare (it was as much an emergency as any I remember in the household)…

This was the headline (behind paywal, if you have library access):

By, Tom Shales. 1977. “Tears & Fears: Threat to Saccharin Spurs New Hoarding! Diet-Rite Dementia, Tab Teetotaling in the Offing?” The Washington Post (1974-Current File), Mar 15, 2..

I looked this piece of history up online after I read Gary Taubes’ The Case Against Sugar, and amazingly, in this piece from March, 1977, they seemed to express some of the wisdom that’s now being discussed 40 years later (almost to the day):

From Pending FDA Saccharin Ban A Bitter Dose for Many in U.S. – The Washington Post, April 4, 1977

There are various problems with the high current levels of consomption, according to food experts. Measured in calories, sugar and other sweeteners – the main other sweetener is corn syrup – now provide about a fifth of the average American’s daily diet. But sweeteners contain none of the protein, vitamins and minerals the average person needs. These things must come from the other four-fifths of the diet: in this sense, the sugar fifth is wasted.

A second problem is the more familiar and simpler one, that sweetened foods are fattening. A third, related problem is the pervasiveness of sweeteners. A high percentage of our food today is processed, as opposed to fresh, and a high percentage of processed food is sweetened.

More than two-thirds of our daily sugar and other sweeteners comes to us in processed foods, including soft drinks and other processed beverages.

The wisdom they may have not had, at least in popular thought, was that sugar is more than wasted calories. There’s evidence that it is a metabolically active distinct subtance that changes the chemistry of our bodies in ways other forms of calories do not.

And actually, many scientists already knew that, however that science wasn’t promoted or supported by various interests….

Exonerating Fat, Arguing Against Sugar

This book continues a series of works by Taubes and others calling into question a 40 year experiment (see: Just Read: Why Eating Fat May Not Make You Fat (The Big Fat Surprise) in changing American (and global) eating habits to banish fat, which by definition means promoting carbohydrates (you have to eat something).

And promote they did, according to the record –

et tu, Consumer reports? American Heart Association?

In our lifetimes…

The magazine Consumer Reports may have captured this logic perfectly (of creating sugar sweetened cereals) in 1986 when it claimed, “Eating any of the cereals would certainly provide better nutrition than eating no breakfast at all.”

(By the mid-1990s, even the American Heart Association was recommending we have sugar candies for snacks, rather than foods that contained saturated fat.)

Bringing Occam’s Razor

The book adopts a philosophy that is used in medicine widely – Among competing hypotheses, the one with the fewest assumptions should be selected. Otherwise quoted as “if it swims like a duck, sounds like a horse, etc etc.”

In doing so, the possible causes of what are known as “Western Diseases” (read location 3729 on kindle to see the list) are reviewed through a lens that involves insulin metabolism, and specifically insulin resistance, which is known to be central to diabetes and probably a requirement for obesity. The counter-discussion is that obesity is a cause of insulin resistance, this is what we were taught in medical school, and this is extensively reviewed in the book.

In any event, everything from gout to hypertension is recast in an Occam’s mindset, in that the things we’ve been taught about what causes these diseases (purines for gout, salt for hypertension) may actually link back to insulin resistance as causing the causes we were taught about.

Which happens to track the increase in consumption of sugar in society.

In fact, a review of my own postings from social media in 2012 reveals that I was unsure about the causes of hypertension, based on my own medical training and extensive review of the literature. That says something: (7) Ted Eytan’s answer to Does weight loss cause blood pressure to go down, or are both the result of something else (like more physical activity)? – Quora

The People and the Science

As with Nina Teicholz’ book, there’s a discussion of the people and personalities involved in the science and sociology of our diet, and like most humans, they are fallible, imperfect beings. It is true now that when I read a paper involving nutrition, I now have to study who the authors are and which institution they are from so that I can track back to the potential conflicts they may have. We always have done that with medical literature (review the science and relate it to the person doing the science), this book just gives a roadmap (along with Teicholz’) to the nutritional science community.

Where we came from

I have always believed that we have to know where we came from to know where we’re going, and there’s a ton of history in here. It’s a marvel to think about what was going on in Washington, DC, and even my home state of Arizona, when I was growing up, that would shape our country’s health destiny.

(side story: while I was an undergrad in Tucson, Arizona, I did some data entry on a nutritional study to get research experience, and I remember that the software that we were using didn’t have entries for the new “fat free” foods being marketed. My faculty sponsor told me, “Fat free salad dressing is really just sugar and water, so code it like that”)

The question of whether artificial sweeteners are healthy or not is not fully addressed in the book, because it’s not fully addressed in the science. What they (sweeteners) did, though, was raise the cry for a healthier life and a freedom from obesity and diabetes. Just read the quotes from the above Washington Post article:

“Please . . .” a woman from Dallas implores. “I don’t know what we would do for grandma if saccharin is banned.”

“I am . . . a former fat person!” another woman, from Huntington Beach, Calif., exclaim. “I use saccharin every day in cooking.”

“As the mother of a 12-year-old diabetic child, I appeal to you . . .” writes a third petitioner, from Dunwoody, Ga.

And this commercial from 1979, when a calorie was a calorie, and people were so…thin*.

*As a former fat person, the intent of sharing this bit of history is not to fat shame, it’s to explore the history of obesity and causes that might be reversible or preventable in the interest of health, with the recognition that health is multi-dimensional and factorial 🙂

Just Read: What should people with diabetics eat? Study of a low-calorie ketogenic diet

Just catching up on my blogging and continuing a closer look at nutrition and health.

This paper discusses a different and emerging approach about diet in people with diabetes, beginning with the declaration that we really don’t know what the optimal diet for people with diabetic is:

The optimal degree of caloric restriction and macronutrient distribution of medical nutritional therapy in T2DM is not well defined.

Traditionally, a low-fat diet has been prescribed, which really is a high-carbohydrate diet that brings with it questions about why feeding carbohydrates to people who are intolerant of them makes sense.

In this intervention, subjects were divided and some were feed a ketogenic (higher fat, lower carbohydrate) diet. In medical school, we’re taught that ketones are a bad thing because of their association with a life-threatening condition known as keto-acidosis. However, in people who have some insulin left, ketones become an alternate fuel from the breakdown of fat.

The diet used here appears to be a little “engineered” compared to what I have read is also done, which is little to no calorie restriction.

And…the results show significant weight loss, glucose control, and as seen in other studies, a significant drop in triglycerides, that other under-emphasized lipid in our training (I’ll post on that later).

Interestingly, I ran across this medical practice based in San Francisco (@VirtaHealth) using this approach to achieve better outcomes in Diabetes. So, I suppose this is becoming a thing. With science attached to it, including its own published intervention trial.

Maybe we are set to really change the way we think about healthy eating….

Just Read: Why Eating Fat May Not Make You Fat (The Big Fat Surprise)

For some reason, I have always had a keen interest in my personal health – I took nutritional sciences courses in college before I went to medical school, something only a few of us pre-med students did.

The curiosity of my medical school pathology textbook warning about high carbohydrate diets and atherosclerosis

To this day, I still remember a curious statement in my Pathology textbook from medical school (and while writing this post, I confirmed that it was there, as of the 2005 Edition). It said:

Risk Factors for Atherosclerosis: Lesser, Uncertain, or Nonquantitated: High carbohydrate intake

I thought that was strange to see in my pathology textbook at the same time my professors were advocating, and all of America were/are being told to indulge in a high carbohydrate diet.

This book, by Nina Techolz (@BigFatSurprise), develops that theme in exquisite detail. On the topic of high carbohydrate diets of the 1990’s she includes this historical context:

Choose “snacks from other food groups such as . . . low-fat cookies, low-fat crackers, . . . unsalted pretzels, hard candy, gum drops, sugar, syrup, honey, jam, jelly, marmalade,” stated a 1995 AHA publication. In short, to avoid fat, people should eat sugar, the AHA advised.

Teicholz, Nina (2014-05-13). The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet (pp. 136-137). Simon & Schuster. Kindle Edition.

I followed up in my own grocery store where in 2016, there are still traces of this diet approach:

The AHA even rode the profit wave of refined carbohydrates from the 1990s onward by charging a hefty fee for the privilege of putting the AHA’s “Heart Healthy” check mark on products …. in 2012, the check mark still appeared on boxes of Honey Nut Cheerios and Quaker Life Cereal Maple and Brown Sugar, which might have healthier-sounding names but are both higher in sugar and carbohydrates than Kellogg’s Frosted Flakes.

Teicholz, Nina (2014-05-13). The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet (p. 137). Simon & Schuster. Kindle Edition.

2016.10.29 Heart Health and Diet 3311
2016 leftover from a bygone era, when high carbohydrate diets were king – 2016.10.29 Heart Health and Diet 3311 (View on Flickr.com)
2016.10.29 Heart Health and Diet 3312
What do you notice about the shape of the cereal bowl and does the evidence support it… 2016.10.29 Heart Health and Diet 3312 (View on Flickr.com)

Does eating fat make you fat?

The answer, according to the book, is probably no.

It’s a very in depth read of the history, personalities, and science behind the diet-heart hypothesis, about what has been thought to make people fat and cause heart disease, and whether the evidence supports it.

The book has been well reviewed and critiqued with lots of surrounding controversy, so I won’t re-cover what Teicholz covers about this, which in a nutshell is

  • many of the studies that we have counted on to tell us what’s right about our diets are flawed
  • there are numerous people involved with long careers dependent on a particular version of diet and health
  • things we take for granted, like the Mediterranean diet, didn’t really exist in the way we think they did
  • the impact of saturated fat, especially when substituted for carbohydrates in the diet, is probably not as dire as we were taught

The part about the people is really important. Teicholz goes in depth into the careers of the most famous food scientists across human history, alive and no longer alive. I now see their names in name-your-article and I have to go back to the book to understand from which perspective/history they are speaking. Otherwise, their conclusions to me are uninterpretable.

A 40 year experiment in low-fat diets, is it over?

I was especially taken by this quote:

No doubt a Cretan or Calabrian peasant might find it ironic that New York socialites and Hollywood movie stars— indeed, nearly all the wealthy peoples on the planet— are now trying to replicate the diet of an impoverished post-war population desperate to improve its lot.

Teicholz, Nina (2014-05-13). The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet (p. 223). Simon & Schuster. Kindle Edition.

..because following this era in Italian history, meat intake tripled, heart disease rates declined, average height increased by 3 inches.

There’s a lot more going on in this dialogue (and I know I’m several years into it) including the recent decision by the British Medical Journal not to retract Teicholz’ 2015 article, which you can read about here.

Suffice it to say, I believe that my Pathology textbook was telling me to be as curious as possible in my medical career…

Addendum, forgot to add this (thanks for the heads up @SDThinkBig & focus on the deep fat and steak part only 🙂 )

Just Read: Listening to Physiology instead of a Wearable for Weight Loss

Comparison Wearable induced vs Physiologic  induced weight loss 161003
Comparison Wearable induced vs Physiologic induced weight loss 161003 (View on Flickr.com)

After reading the study about the impact of (a certain type of) wearable devices on weight loss (See: Just Read: Study – Wearables don’t improve weight loss – can you outrun a bad diet? ) – answer, not much – I also read this study at the same time that focused on exercise and diet in a very different way, and had much different outcomes.

In Mark S, Toit S Du, Noakes TD, et al. A successful lifestyle intervention model replicated in diverse clinical settings. South African Med. J. 2016;106(8):763. Available at: http://www.samj.org.za/index.php/samj/article/view/10136 [Accessed October 2, 2016], a few conventional and unconventional things were tried in a group of willing subjects interested in weight loss:

  1. Behavioral intervention – variable timeframe (conventional)
  2. Caloric restriction until the reaching of weight goal, including fat, sugar, refined cardohydrate restriction (conventional)
  3. NO moderate or vigorous exercise until weight goal achieved (UNconventional)
  4. HIGH fat diet after weight goal achieved (UNconventional>

Foods consumed on the maintenance diet included beef, poultry, fish, eggs, oils, moderate amounts of hard cheeses, and small amounts of nuts, nut butters, seeds and berries.

I can’t determine the actual time to follow-up for the groups, but it looks to be around 2 years, which is the same time as the group in the wearables study. Therefore, I charted the two groups (S1 and S2, for “site 1” and “site 2” in rural practices in British Columbia, Canada) along side the results of the subjects in the wearable study, above (click to enlarge).

Lots of caveats

  • The interventions were different, however both interventions involved manipulation of diet. For the wearables subjects, it was caloric restriction and low-fat (high carbohydrate). For the Canadian subjects it was caloric restriction initially, and then transition to high fat (low carbohydrate).
  • The populations are different, and the starting weights of the subjects makes it hard to compare % weight loss, although to my eyes, they started out pretty close in weight
  • Neither study controlled for diet, meaning there was no comparison group of people who didn’t have their diet manipulated

This is also the part where conflict of interest disclosures are important.

For the wearables article:

Conflict of Interest Disclosures: Dr Jakicic reported receiving an honorarium for serving on the Scientific Advisory Board for Weight Watchers International; serving as principal investigator on a grant to examine the validity of activity monitors awarded to the University of Pittsburgh by Jawbone Inc; and serving as a co-investigator on grants awarded to the University of Pittsburgh by HumanScale, Weight Watchers International, and Ethicon/Covidien. Dr Rogers reported serving as principal investigator on a grant awarded to the University of Pittsburgh by Weight Watchers International. Dr Marcus reported receiving an honorarium for serving on the Scientific Advisory Board for Weight Watchers International. No other disclosures were reported.

For the lifestyle intervention article:

Conflicts of interest. SDT, KN, DC, MM, SVDS and JF have no conflicts of interest to declare. SM is the founder of a sole proprietorship, Approach Analytics, providing analytical support to clinical and public health initiatives. JW is on the Scientic Advisory Board for Atkins Nutritionals Inc. and has accepted honoraria and travel expenses to attend meetings. TN is the author of the books Lore of Running and Waterlogged and co-author of e Real Meal Revolution, Raising Superheroes and Challenging Beliefs. All royalties from the sales of e Real Meal Revolution and Raising Superheroes and related activities are donated to the Noakes Foundation, of which he is the chairman and which funds research on insulin resistance, diabetes and nutrition as directed by its Board of Directors. Money from the sale of other books is donated to the Tim and Marilyn Noakes Sports Science Research Trust, which funds the salary of a senior researcher at the University of Cape Town, South Africa. The research focuses on the study of skeletal muscle in African mammals with some overlap to the study of type 2 diabetes in carnivorous mammals and of the e ects of (scavenged) sugar consumption on free- living (wild) baboons.

The unconventionality of the the intervention is mentioned in the article as something that was hard for others to accept:

Despite the rigour of our quality improvement process, our efforts to communicate the merits of this intervention to health system administrators met with a frustrating lack of uptake. This is not surprising, given that the research literature has many competing ‘solutions’ for the epidemics of obesity and diabetes,[15] many of which are difficult to falsify.[16]

From my understanding of the culture of medicine, something like this written in a scholarly article is usually a vast understatement.

The next several months/years are going to be exciting in this part of health, now that we have a better understanding of physiology and newer tools to (potentially) change our environment and our behavior (maybe).