Fat and Always Hungry? No, cutting the carbs won't cure your weight struggle.

It’s 10 AM Sunday and quite frankly, I’d much prefer to be leisurely finishing my coffee after my blueberry pancakes-topped with a dollop of vanilla yogurt and heated real maple syrup. But Ludwig and Friedman’s Always Hungry? Here’s Why piece in the NY Times  today compelled me away from my plate.

To start, let’s get a title change, please, let’s say Here’s What We Think based on virtually no research at all. This is an opinion piece stating two doctors’ theories about why we get fat and what we should do about it. Period. But with the sensational image and title you, like most people, will be drawn into more myths about weight management.

Here’s where we agree—and disagree

Do you just eat bread for your meal?

Agree: There are factors outside of your control that may contribute to your size. Genetics and the presence of fat cells exert their influence. Once you have gained to a higher weight with an increase in fat cells, you will be fighting an uphill battle to lose that weight and keep it off—without disordered behaviors.  And it’s not your fault. For more on this see Professor Lowe’s work on weight suppression and bulimia. 

Agree: Metabolic rate slows down with food restriction—that’s indisputable from the research. Obese individuals who have undergone extreme low calorie diets will have a lower metabolic rate as a result of the decrease in muscle mass that results, compared to same weight controls who had not dieted. Less aggressive approaches to dietary activity change tend to spare the muscle loss and help maintain metabolic rate.

Before dieting...

But the authors state that metabolic rate also decreases with weight increase:  “…factors in the environment have triggered fat cells in our bodies to take in and store excessive amounts of glucose and other calorie-rich compounds. Since fewer calories are available to fuel metabolism, the brain tells the body to increase calorie intake (we feel hungry) and save energy (our metabolism slows down).” Yet there appears to be few examples of this cited in the scientific literature, with the exception of a possible rare genetic mutation, not likely the cause of obesity in the greater population.

And the temporary slowed metabolic rate seen with weight loss has been demonstrated to be reversed with weight restoration in the obese (albeit a small sample size studied) and more dramatically in those who are underweight with anorexia, summarized well by Carrie Arnold in ED Bites.  In practice we see dramatic increases in metabolic rate—calories burned and required each day—with weight gain in anorexic individuals at least until they have restored to their healthy state.

Agree: Insulin increases nutrient uptake and in excess causes weight gain. And carbohydrate results in an increase in insulin secretion.

Disagree: Ludwig and Friedman’s leap that foods that increase insulin secretion should therefore be reduced or avoided for weight management is faulty reasoning—unless there is a documented underlying metabolic abnormality. A relatively small percentage of the total population has PCOS or hyperinsulinemia—a faulty regulation of insulin. For these individuals, addressing carbohydrate amount or glycemic load (impact of a food on raising blood sugar) has a positive impact. But there’s no evidence that a low carbohydrate diet is any better at long-term weight management than any other dietary intervention. 

In addition, while individual foods and their glycemic index—the amount they raise blood sugar (and therefore subsequent insulin levels) may seem valuable, practically speaking they have less impact.  You see, we generally don’t eat single nutrients like carbohydrate. Rather, we eat mixed meals, containing protein, fat and carbohydrate. And in this combination, the impact on insulin levels that even the white potato might have if eaten solo is minimized with that piece of chicken and the added olive oil or nuts in the salad.

This banana chocolate pastry has plenty of fat to lower its glycemic load!
(From Tartine Bakery, San Francisco)

And did you know that many of the villainized desserts have a minimal impact on insulin levels? Peanut M&Ms aren’t much different than lentils (see glycemic load—the best measure of blood sugar impact which considers portion) and cheesecake made in it’s full fat recipe will no doubt come in quite low as well.

I don’t share this to promote a diet full of low nutrient, processed foods. Rather, to make a point. Viewing foods as good and bad will do nothing to help you manage your weight—nor your mental health. In fact, there’s plenty of evidence that feeling deprived by denying yourself foods you enjoy leads to rebound overeating.

The authors also state “what if it’s not overeating that causes us to get fat but the process of getting fatter that causes us to overeat? Unfortunately, I think they have oversimplified their hypothesis.

Sure, having more fat cells may contribute to our struggle if attempting to lose weight. But it’s not simply a macronutrient issue. Being larger presents more challenges for being active; larger individuals report being subjected to fat shaming while exercising—presenting its own challenges.

Rebound binge eating following starvation—think dieting—has been well documented as well. All or nothing thinking—what I call the “what the heck effect” results in overeating when you believe you’ve already blown it.

After...

Our over-scheduled lives with multiple competing needs don’t help us either. Multitasking while eating makes us less aware of what we are consuming and contributes to overeating. And the larger the containers or plates we are eating from, the more we will over-consume (see Prof.Wansink's extensive work on this).

Time and money constraints add flames to the fire—we take little time to plan, shop and eat mindfully. In fact, our cognitive ability is compromised by these stressors and worsened when we diet. Perceiving that we won’t have enough food to meet our wants or needs, referred to as scarcity creates a range of secondary effects. Poor decision making, impaired ability to organize and follow through and hyper-focusing on the immediate benefits without considering the long term consequences of food choices are well researched and described in the fascinating new book, Scarcity.

Unrealistic goals set by national organizations  and by ourselves adds to the problem. If 150 minutes per week plus 2 days of muscle strengthening/wk is unattainable, why bother?

Further, the food industry isn’t all bad. (And no, I am not a paid consultant to any food company!) They are the ones who bring us the convenience of precut and cleaned vegetables and canned, high fiber, low glycemic legumes. They allow us the convenience of reheating frozen brown rice and quick cook barley. And they have given us a range of milks in every fat percentage we could ask for, and yogurts of every style—Greek and higher protein, sweetened, full fat, real sugar, artificial sugar and no added sugar. But many of the choices remain ours.

So what’s the solution to our climbing weights beyond a healthy range?

• Move away from dieting and that sense of scarcity.
• Set realistic goals for change—be it frequency of a home-cooked meal or a visit to the gym.
• Begin to work on behaviors; separate eating from distractions, and delay seconds (see older posts on this blog for help)
• Include a range of foods and nutrients. Include high fiber, whole grains and legumes, fruits and vegetables, nuts and healthy oils; protein-rich foods such as poultry and fish, and less frequently red meat; low fat milk and yogurt and modest amounts of cheese.
• As part of a balanced meal, by all means enjoy your rice, breads and pasta, too. And you know my stand on baked goods! All or nothing approaches to dietary change will get you nowhere.

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Carbs Still Don't Make You Fat. But Taubes' Words May Make You Crazy

Don’t do it! Don’t dump your carb-rich foods because of yet another Gary Taubes’ article, which hand picks research to make for sensational headlines that successfully get propagated in the NY Times (albeit just in the Opinion section, not the Science one, thank God!) Yes, yet another news piece inappropriately attacks carbohydrate, failing to note the study’s limitations and the risks of jumping to irrational conclusions.  I’m no researcher but I’m a critical reader of research. And I find Taubes’ (and other such articles drawing false conclusions) simply appalling.

Serve with a Greek yogurt and include the nuts and the
glycemic load is lowered. Better than given this favorite up!

Taubes pulls from a recent study by Ludwig and colleagues at two well-respected Boston hospitals. The objective was to examine the effects of 3 diets with different composition of protein, fat, and carbohydrate and glycemic load, on metabolism. This was done on overweight and obese 18-40 year olds following a weight loss of 10-15%. Glycemic load refers to how much a food will raise blood sugar compared with a standard. It takes into account the amount of carbohydrate in a food, as well as the impact of that food on blood sugar.

Here are a few facts to consider. Taubes' carb-bashing article ignores some critical points, many highlighted by the study authors themselves:

• Total sample size of this ground-breaking study? 21—an embarrassingly small size to be drawing such global conclusions! Perhaps even more striking is that the study began with 32 participants--that's a 34% drop out, in spite of a $2500 financial reward for full participation. I am left wondering why such a high drop out rate? These were self-selected participants, in response to an ad. Were the results not as satisfactory in those that dropped out? We'll never know, but I could only guess that if they were satisfied with the weight loss and maintenance results they might have been inclined to stick with the study. If we had all 32 starting participants perhaps the results would be quite different.

Carb-rich wheatberry salad--a summer favorite!
One of 25 recipes at food-2-eat.com

• The study looked at the impact of three different diets after weight loss, which might be quite different than the impact on those whose weight has been stable. The body does act differently after being starved!

• 1 month per diet type only! That’s how long the study evaluated these various diets.

• Even if this were all valid, would the subjects actually gain weight? It is unclear, given these were not free-living conditions and resulting weight changes were apparently not explored. In fact, we have no evidence of how closely these diets were actually followed, given this was an outpatient setting. The study mentions likely predictors of future weight change (such as changes in metabolic rate), but no actual weight change data on each of the diets is described. Yet Taubes certain jumps to this conclusion.

• Even if they did gain more on a higher carbohydrate diet, there were 2 very negative effects of the lowest carb diet, that may result in long term serious consequences.  Both urinary cortisol levels (a hormonal measure of stress) and C-reactive protein (a marker for chronic inflammation) increased. And both of these are associated with increase risk of cardiovascular disease.

• With the most minimal effort on Pub Med, I found another study on the pediatric population exploring high and low glycemic load meals on energy intake, satiety and hunger. Guess what this study concluded? That there is no evidence for this population (of Hispanic youth) that changing the glycemic load effects short term hunger, fullness, satiety or energy intake. BTW, this one was also by Ludwig and colleagues. In fact, even in the study Taubes reports on, there is no advantage in terms of subjects sense of hunger on the three different diets.

• The authors of the study (not Taubes) state: 

Low carb? absolutely! But not without its risks.

"These findings suggest that a strategy to reduce glycemic load rather than dietary fat may be advantageous for weight-loss maintenance and cardiovascular disease prevention."  

Yes, reducing your intake of fat to very low levels is quite senseless. But no one is advocating for a diet rich in saturated fats, like those found in the meat above. Yes, fats are a welcome addition to diets, even for those watching their weight! And key words to note here are "glycemic load". In other words, think balance. Meals with a combination of protein, fat and carbohydrate will have only a moderate glycemic load, and that is what may be key--both for metabolic health, psychological well-being (think avoiding deprivation) and long term adherence. Yes, the study authors have the wisdom to add:

"Ultimately, successful weight-loss maintenance will require behavioral and environmental interventions to facilitate long-term dietary adherence." And they acknowledge that the study diets were not designed for long-term practicality, and that the very low carb plan would be difficult to follow long term.

Having worked with many thousands of individuals to manage their weight, I stand 100% behind including carbohydrate to do so. Carbohydrate-rich foods are a necessary, satisfying, and energizing part of a healthy diet. I urge caution to the public, which may be less experienced at reading such strong-stated opinions as Taubes' as if they were fact.