Category Archives: Weight Loss
Scribner wanted the new edition to show people how to lose weight. We were happy to do that. I’d been planning to devote 2012 to weight loss and obesity blog posts, and then to write an obesity and weight loss book in 2013. We just moved the schedule up and squeezed the ideas into Perfect Health Diet.
Our book offers a unique take on obesity and weight loss. Some of the science is original to us – the ideas do not appear in Pubmed – and the conclusions are unusual for diet books:
The best diet for weight loss is delicious and does not generate cravings or more than mild hunger. You can – and should! – lose weight with minimal suffering.
The popular diets that generate the quickest short-term weight loss are not optimal for long-term sustainable weight loss; they are prone to yo-yo weight regain.
Unlike those diets, the Perfect Health Diet offers a path to lasting weight less and permanent restoration of normal weight and normal body composition.
If we’re right about the science and these conclusions, then our book could be a game-changer for weight loss.
Filling in Some Missing Context
The major defect of squeezing our obesity & weight loss material into Perfect Health Diet, instead of distributing it over two books, is that we didn’t have space to provide a lot of context to the obesity material. Our stage-setting chapters were devoted to the general question of “what’s a healthy diet” and were framed with a discussion of Michael Pollan’s food rules, not with discussion of issues specific to obesity and weight loss.
So let me add some context here.
The Recipe for a Popular Weight Loss Book
The recipe for a popular weight loss book seems to be:
- Declare that doltish mainstream authorities are stuck in some absurdly mistaken view, and their loyalty to this paradigm has led them to overlook the key to weight loss.
- The key to weight loss is simple: give up a single villainous food.
This formula has been followed to good effect by Dr. William Davis (Wheat Belly) who vilifies wheat, Gary Taubes (Good Calories, Bad Calories and Why We Get Fat) who vilifies carbs in general or sugar specifically, and Dr. Robert Lustig (Fat Chance) who vilifies sugar.
The view that authors attribute to mainstream authorities is, often, a straw man. Here is Gary Taubes in his Reddit “Ask Me Anything” describing the absurdly mistaken view that he calls “calories in, calories out”:
Imagine we have a pair of identical twins. Say 18-year-old boys. Every day we measure their energy expenditure and every day we feed them exactly how many calories they expend. So we match calories in to calories out. They get both the same diet with one exception: one gets 300 calories of sugar or HFCS where the other gets 300 calories of a different carbohydrate or of fat. Then we continue this feeding experiment for the next 20 years or so….
If you believe obesity is about calorie-in-calories-out and that’s the only thing that matters, then both twins are going to end up exactly the same weight with exactly same amount of fat on their body and they’re both going to end up expending the same amount of energy.
The view he is describing is that dietary quality doesn’t matter a whit, only quantity of calories matters: the only thing that affects body weight, fat mass, and energy expenditure is how many calories were consumed, and how many calories are consumed isn’t affected by dietary quality.
In other words, a diet of nothing but cotton candy, Twinkies, and Coca-Cola would generate after 20 years exactly the same body composition and health as a diet of fish, rice, and vegetables.
Is there a single person in the world who holds this view?
Here is a review of Dr. Lustig’s Fat Chance:
The book repeats and expands on the main point of contention in the sugar wars: whether our bodies treat all calories the same. The old guard says yes: A calorie is a calorie; steak or soda, doesn’t matter. Eat more calories than you burn, you’ll gain weight. Lustig believes that our bodies react to some types of calories differently than others. [PAJ: emphasis added]
The “old guard” does not always take kindly to the assertion that it never occurred to them that the body might react differently to different foods. The article notes:
[A] leading endocrinologist, who asked to go unnamed, called Lustig an “idiot.”
These are times when I wish our diet approved of popcorn!
Now, let me be clear: these authors are giving good advice. Indeed, we give the same advice. With Drs. Davis and Lustig, we recommend eliminating wheat and added sugar; with Taubes, we believe the average American should cut carb intake roughly in half. Taking these steps will help people lose weight.
But these books have significant flaws:
- The advice is incomplete. There are many factors which promote obesity. Removal of a single factor will rarely normalize weight.
- The scientific background is misleading. It often seems that the goal is not so much to provide insight, as to set up a compelling and entertaining narrative. The story reads like the script of a Hollywood action movie: a frightening and mysterious problem appears which befuddles everyone – a solution is proposed – a hero implements the solution.
Perhaps it is not possible to write books more popular than these, but I think it is possible to write books that provide more insight and have a better chance of delivering lasting weight loss to readers who are willing to invest effort.
Obesity is a complex disorder, and many factors contribute to it. I think we did a fairly good job of addressing many of those factors – enough to enable nearly all readers to lose weight effectively, but also to gain a deeper understanding of obesity and its causes.
The Puzzle of Fatty Acid Ratios
The focus on wheat, sugar, and carbs in the popular diet books ignores what may be the primary cause of the obesity epidemic. In my Q&A with Latest in Paleo readers, I gave six reasons why omega-6 fats promote obesity. Some of these are discussed in detail in the book.
Any explanation for the obesity epidemic should account for the accumulation of omega-6 fatty acids in the body that has coincided with the obesity epidemic:
This is a plot found on p 115 of the book; the data was compiled by Stephan Guyenet of Whole Health Source, the circles are the omega-6 fraction in adipose tissue, and the crosses are the obesity rate among 18-29 year olds. It is hard to make sense of this pattern if omega-6 fats are not causing the obesity epidemic. No carb-centric explanation for obesity will tend to make omega-6 fats accumulate this way. Unlike some of the other weight loss books, we make a good faith effort to explain data like this.
Why Do Low-Carb Diets Work?
The omega-6 accumulation is only one of a number of puzzles that a good theory of weight loss and weight gain should explain. Another is the efficacy of low-carb diets.
If carbs don’t cause obesity, why do low-carb diets promote weight loss?
This issue is explored in chapter 17, where we show reasons why reducing carbs to 30% of energy or less will be beneficial for weight loss, but also why there’s generally little long-term benefit from further reductions in carb intake. Low-carb is good, but very low-carb isn’t better for long-term weight loss.
The Problem of Yo-Yo Weight Loss
Another important puzzle: Why is yo-yo weight loss and regain so common?
Here is Jay Wright’s weight loss history, mentioned in the book at page 184:
Although he had successful short-term weight loss on a number of diets, including very low-carb Paleo, they always made him hungry and sooner or later the weight was regained.
On our diet, Jay reached his normal weight in October 2011. He emailed me a happy new year wish, and remains at his normal weight 15 months later – the first time since college he’s been able to maintain that weight.
Why did our diet normalize his weight permanently without hunger, when other weight loss diets led to hunger and weight regain? That is the primary subject of our chapter 17, and is one of our original contributions to the theory of obesity.
Malnutrition and Weight Gain
We argue that malnutrition is a potent cause of increased appetite and weight gain.
A theme of Weston A. Price’s Nutrition and Physical Degeneration is that pregnancy depletes nutrients in the mother, frequently leading (especially in closely spaced pregnancies) to malnutrition in both mother and child.
If we’re right, then this could be why pregnancies, especially closely spaced pregnancies, tend to produce maternal weight gain.
I got a New Year’s update from Jennifer Fulwiler, another source of a reader report in the book (on p 11). She’s now pregnant with her sixth child, and left a comment noting her much improved health this pregnancy:
I have been following the PHD for this pregnancy. The results have been amazing. In fact, with all five of my previous pregnancies I had debilitating, severe morning sickness. On the PHD, I had almost none!
In an email she gave further details:
My husband and I have a reality show that recently started airing [insert joke here about what we may have done to be deemed "reality show material"], and when the episodes air I’ve been engaging with fans on social media. One of the most common responses I get is that people are shocked that I look so healthy, since I’m pregnant with my sixth child in eight years. A lot of people just assume that women who have many and/or closely spaced pregnancies simply have to be overweight.
I used to assume that too. In fact, that had been my personal experience: I seemed to add a few pounds with each pregnancy, and after I had my fifth child I found myself tired, achy, and 35 pounds overweight. Thanks to the PHD I lost all the weight, and when the show was filmed, in my first trimester of pregnancy with my sixth child, I weighed the same as I did the day I got married, and felt better than I ever had in my life. A lot of people who watched the show asked me what my secret was, and of course I directed them to the PHD!
Here’s the first episode of Jennifer’s reality show:
She does indeed look healthy, energetic, and more than a match for a Texas scorpion!
I mentioned the other day that we got a 4* review at Amazon:
This diet has controlled my cravings. After almost 40 years of interest in and great benefits from proper nutrition, I believe this is as close to perfect eating as we can get…. I didn’t give it 5 stars for two reasons: 1. no recipes…but can get those online and 2. very technical, leaving more explanation or clarification.
That about covers the pros and cons of our book as a weight loss guide. Our story isn’t quite as simple as the other diet books. Perfect Health Diet doesn’t resemble a Hollywood action movie.
But if you want to understand the science and find a successful program for long-term weight loss, we’re the best choice on the market. Perfect Health Diet will eliminate cravings and hunger, get you close to perfect eating, and help you normalize weight for the rest of your life.
The study randomly assigned 5,145 overweight or obese people with Type 2 diabetes to either a rigorous diet and exercise regimen or to sessions in which they got general health information. The diet involved 1,200 to 1,500 calories a day for those weighing less than 250 pounds and 1,500 to 1,800 calories a day for those weighing more. The exercise program was at least 175 minutes a week of moderate exercise.
But 11 years after the study began, researchers concluded it was futile to continue — the two groups had nearly identical rates of heart attacks, strokes and cardiovascular deaths.
It’s clearly a negative result for “eat less, move more” as a health strategy for obese diabetics.
Was “Eat Less Move More” Harmful?
A few Paleo bloggers are not surprised; indeed, Peter Dobromylskyj speculates that all-cause mortality – which Ms. Kolata and the NIH press release do not report – may have been higher in the “eat less, move more” intervention group:
It seems very likely to me that more people died in the intervention group than in the usual care group, but p was > 0.05.
Call me a cynic, but I think they stopped the trial because they could see where that p number was heading.
Peter may be a cynic but cynics are sometimes right, and I will bet that he’s right about this. In general, calorie restriction and exercise are better attested against cardiovascular disease than against other health conditions, so if death rates from CVD were identical in the two arms after 11 years, it’s quite likely death rates from other causes were higher in the intervention arm.
We discuss in our new Scribner edition two reasons why “eat less, move more” can backfire:
- On a malnourishing diet, “eat less” means even greater malnourishment. Less of a bad diet is a worse diet.
- Excessive exercise may over-stress the body and harm health. In diseased people, the volume at which exercise becomes excessive may not be that high.
On the other hand, ultimately some form of “eat less, move more” is needed if optimal health is to be attained:
- An energy deficit – eating less than the body expends – is necessary to lose fat mass, and obesity is probably incompatible with optimal health.
- About 20 to 30 minutes of exercise per day at the intensity of running or jogging is needed for optimal health, probably due to the role of daytime activity in entraining circadian rhythms (see “Physical Activity: Whence Its Healthfulness?”, October 11, 2012). Most people would need to “move more” to achieve this.
So the challenge in weight loss is two-fold: It’s necessary to adopt a healthy diet in which malnourishment doesn’t occur despite calorie restriction, and to find a healthy level of exercise that improves health without overstressing the body.
Look AHEAD: Bad Dietary Advice
The Look AHEAD Study Protocol tells us what the intervention group was told to do.
From page 29, here is the diet advice:
The recommended diet is based on guidelines of the ADA and National Cholesterol Education program [96,97] and includes a maximum of 30% of total calories from total fat, a maximum of 10% of total calories from saturated fat, and a minimum of 15% of total calories from protein.
This gives 55% carbs and probably 10% omega-6 fat. The omega-6 intake is far too high – for weight loss and good health, omega-6 intake should be less than 4% – and so is the carb intake – for diabetics, reducing carbs to 30% or less is highly desirable.
From page 30, here is the exercise advice:
The physical activity program of Look AHEAD relies heavily on unsupervised exercise, with gradual progression toward a goal of 175 minutes of moderate intensity physical activity per week by the end of the first six months. Exercise bouts of ten minutes and longer are counted toward this goal. Exercise is recommended to occur five days per week.
Moderate-intensity walking is encouraged as the primary type of physical activity.
I think this is reasonable advice. It translates to 35 minutes per day for 5 days. The intensity is quite low. This level of exercise is hardly likely to be excessive; indeed, it’s probably grossly insufficient for optimal health. It represents about a mile and a half of walking per day, five days per week. This may have been a homeopathic level of activity.
There is another reason the exercise may have produced no observable benefit. Since I believe the health benefits of exercise occur primarily through circadian rhythm entrainment, it’s likely that daytime exercise is much more beneficial than night-time exercise. Night-time exercise might be ineffective or even harmful to health if it disrupts circadian rhythms.
Unfortunately many people find it difficult to find time during the day for exercise. If the walking was performed at night, even the modest benefits of the activity may have been lost.
Weight and Health: What’s the Direction of Causation?
The one “success” of Look AHEAD was that it brought about some weight loss: the intervention group lost 5% of their original weight.
We know that obesity is associated with poor health. Since causation implies correlation, the existence of this correlation suggests that either (1) obesity causes poor health, (2) poor health causes obesity, or (3) some third factors cause both obesity and poor health.
The Look AHEAD study presumed (1) – that obesity causes poor health. The “eat less, move more” intervention was wholly directed at weight loss. If obesity is the cause of poor health, Look AHEAD should have improved health. It didn’t. This tells us that the direction of causality is either (2) or (3). Obesity doesn’t impair health; other factors that impair health cause obesity.
It’s easy to make faulty inferences about the direction of causation. The Look AHEAD scientists made the same mistake this woman did:
The basic flaw in the Look AHEAD study was that it was designed to bring about weight loss, and hoped that weight loss would improve health.
A better intervention would seek to improve health through a more PHD-like diet and through circadian rhythm therapies. Successful health improvement would, more than likely, lead to weight loss.
For the overweight and for diabetics, the focus should not be on weight, but on health. Improve health, and weight loss will follow. Focus on weight with a simple-minded “eat less, move more” intervention without tending to the quality of your diet and lifestyle, and you might be doing yourself more harm than good.
Alfredo asked us to offer ideas for how to fast during Lent:
What to eat during fasting (other than cranberries & coconut oil) is on my mind. Looking for some variation in the fasting menu.
It’s a great question. We did have a post on one possible fasting food – Neo-Agutak: “Eskimo Ice Cream” – but never discussed alternatives or the reasons for eating particular foods during a fast.
Fasts don’t have to be food-free
Some people think a fast should involve no food at all. On the Neo-Agutak post, Don Matesz commented:
I would not say that I was fasting if I consumed more than 625 calories during any period of that “fast.”
But that’s not the position of the Catholic Church. During Lent, Ash Wednesday and Good Friday are fast days. The US bishops allow one full meal and up to two snacks:
The law of fasting requires a Catholic from the 18th Birthday (Canon 97) to the 59th Birthday (i.e. the beginning of the 60th year, a year which will be completed on the 60th birthday) to reduce the amount of food eaten from normal. The Church defines this as one meal a day, and two smaller meals which if added together would not exceed the main meal in quantity. Such fasting is obligatory on Ash Wednesday and Good Friday. The fast is broken by eating between meals and by drinks which could be considered food (milk shakes, but not milk).
Children, the elderly, and those whose health might be threatened are exempt from the requirement to fast.
So let’s consider a fast to be any period of reduced calorie consumption – not zero food.
Basic fasting: Electrolyte and fluid replacement
It is certainly a mistake to consume nothing at all during a fast.
People deprived of fluids and electrolytes die quickly. In a famous case cited in Wikipedia (“Starvation”), Drusus Caesar, son of Agrippina the Elder, was starved to death in 33 AD by the emperor Tiberius, and managed to stay alive for nine days only by chewing the stuffing of his bed. When Saint Maximilian Kolbe and nine others were starved in Auschwitz, seven of the ten died within two weeks.
When fluids are provided, however, survival can be much longer. Even in his 60s, Gandhi was able to go without food for 21 days. In the Irish hunger strikes of 1980-1981, no one who fasted less than 46 days died, and about half those who fasted between 46 and 73 days died.
So fluids and electrolytes extend the duration of a fast by about a factor of four. Since we want our fasts to be safe and health-improving, we should certainly take:
- Sodium and chlorine. During a fast protein is converted to glucose and ketones, releasing nitrogen waste in the form of urea. Sodium and chloride are excreted along with the urea. Salt loss can be fairly rapid during a fast, equivalent to as much as a teaspoon of salt a day. A large amount of water is lost along with it.
- Potassium. Potassium is the intracellular electrolyte, sodium the extracellular, and osmotic pressure must be balanced. So potassium will be lost along with water and sodium, and should be replenished with it.
- Calcium and magnesium. These also serve electrolytic functions and it is desirable to maintain their concentrations.
- Acids. These are beneficial for the digestive tract and metabolism, and also for solubilization of minerals. Citrate, for instance, helps prevent kidney and gallstones.
Vegetables are the best source of potassium; bone broth is a source of calcium and magnesium. The best acids are citrus juices, such as lemon juice, and vinegars, such as rice vinegar. Sea salt, or salty flavorings such as soy sauce or fish sauce, can provide sodium chloride. So the most basic food to take during a fast is a soup made of vegetables in bone broth, with salt and an acid added.
Here are some pictures. First, make up a bone broth by cooking bones in acidified water:
It’s best to use a ceramic or enameled pot to prevent leaching of metals from the pot.
When you’re ready to eat, put some scallions or celery and cilantro or basil in a bowl, and add hot broth:
Add salt, pepper, acid, and spices to taste.
Spinach and tomatoes are great vegetables for these broths, because they are rich in potassium. Here is a tomato soup:
Here’s a slightly fancier example. I think this had tomatoes, onions, peppers, carrots, and kohlrabi:
Served with parsley and scallions, rice vinegar, and sea salt:
Adding some food
So far we haven’t provided any calories to speak of. The next step in reducing the stress of the fast is to add some nutrition to the soup.
The stress of a fast is largely due to the absence of dietary carb and protein. The body has limited carb storage – glycogen is depleted early in a fast – and is loath to cannibalize lean tissue for protein. On the other hand, the body has abundant fat reserves. So
Two strategies may make sense in different circumstances:
- A protein-sparing modified fast. Protein, which is convertible to glucose, is eaten to relieve the carb+protein deficit.
- A ketogenic fast. Short-chain and medium-chain fatty acids, such as are found in coconut oil, are eaten to generate ketones. Ketones can partially substitute for glucose utilization.
What these have in common is that they reduce the carb+protein.
Probably 90% of people who fast should favor the protein-sparing approach. Those on ketogenic diets for neurological disorders should probably favor the ketogenic fasting approach.
An example of a food suitable for a ketogenic fast would be Neo-Agutak: “Eskimo Ice Cream” (Dec 5, 2010).
A suitable food on a protein-sparing modified fast would supply most calories as protein; carb and fat calories would be from nutrient-dense sources. Egg yolks, which are rich in phospholipids like choline, and potatoes are good examples of nutrient-dense fat and carb sources.
The easy way to implement this healthy fast: just add eggs, potatoes, and maybe some fish or shellfish (which tend to be protein-rich, and comply with the Catholic guidelines for Friday abstinence) to any of the soups shown above. Heat the soup in the microwave and there you have it: a healthy fast-day meal!
Those on weight loss diets will notice that by adding protein, carbs, and a few nourishing fats to our fast-day soup, we’re getting very close to our recommended diet for calorie-restricted weight loss diets: see Perfect Health Diet: Weight Loss Version (Feb 1, 2011).
There’s a good reason for that: both posts work from the same design principles. Both aim at the greatest possible nourishment on the fewest calories.
Would you like to lose weight? Consider making these nourishing soups a staple of your diet.
Even if you’re not fasting or trying to lose weight, consider making these soups a regular part of your daily meals. It’s very easy to make a broth on the weekend and warm it up and pour it over diced vegetables at mealtime. You might find them a very satisfying addition to your diet.