Diet Wars

The Diet Wars – to see whose cuisine reigns supreme – has been going on for some time. The incumbent, and increasingly looking-really-old-fashioned Low Fat diet has been recommended for many decades by most health professionals. It made its first appearance in the late 1970’s based on its supposed benefit for reducing heart disease. Dietary fat will clog your arteries! was the battle cry. Health professionals like doctors rallied behind the great Empire of Low Fat. But in a galaxy far, far away, a small Low Carb rebel band was forming to challenge this dietary orthodoxy, and embraced natural fats believing instead the culprit was sugar and refined grains.

The Empire put its prodigious resources into a massive ‘Death Star’ study that would prove the Low Fat paradigm for once and for all. Once this was completed, they believed, it could blast any rebel strongholds at will. The resulting Women’s Health Initiative (WHI), recruited close to 50,000 women into a ginormous randomized controlled trail lasting over 8 years. Women were randomly assigned to their usual diet group or a low fat diet. After 8.1 years, researchers would find, lo and behold, that these Low-Fat women would have less heart disease, less obesity, and less cancer. Ummm. Right. That’s exactly what DIDN’T happen.

Published in 2006, the WHI showed that following the low fat diet for 8 years, compared to eating the usual diet, did NOT reduce heart disease. It  did NOT reduce colo-rectal cancer. It did NOT reduce breast cancer. Despite reducing calories, it did NOT reduce weight either. That massive ‘Death Star’ study? Yeah, it just got blown to pieces. While the Low Fat dogma took a beating, but the Low Fat Empire, with its calorie restriction still limped on, trying to become the First Order.

Many of the formerly ‘crazy’ beliefs of the Low Carb Rebel band have been accepted into dietary orthodoxy. For example, few people believe that eating white bread, pasta, or sugar is all that slimming. Yet the original Food Pyramid exhorted Americans to eat 6-7 servings of bread daily. Where high fat foods like olive oil, avocados, fatty fish and nuts were shunned a mere 10 years ago, there is growing acceptance of these ‘healthy fat’ foods. Ten years ago, the term ‘healthy fat’ did not exist, because it was ‘well known’ that all dietary fats would kill you.

The latest battleground in The Diet Wars is the most recent study that just got published in the Journal of the American Medical Association comparing the Low Fat diet to the Low Carb diet. The details are well covered in this article, since the study itself is pay-walled (you need to buy it). As background information, I’ve written in many posts here that calories are not the major cause of obesity. Instead, it is a hormonal imbalance, predominantly of insulin, but also cortisol.

If this theory is correct, then giving insulin or cortisol will cause obesity. And guess what? It does. This is the Hormonal Obesity Theory, as opposed to the Caloric Theory, which holds that excess calories is the cause of obesity. If the calorie theory is correct, then reducing calories will cause weight loss. This has been tried millions of times over the last 50 years to absolutely stunning failure. No diet fails quite so spectacularly as the caloric restriction diet.

There is, of course, an overlap between the insulin stimulating effect of food and the caloric value. All normal foods increase insulin to some degree, unless you eat pure fat. Since most people don’t drink a cup of olive oil for dinner, we can safely assume that most people eat meals that have some combination of carbohydrates, proteins and fat. Thus all foods increase insulin to some degree, but some will raise it more than others. That simply implies that some foods are more fattening than others, even if exactly the same number of calories. This is just pure common sense and exactly what your grandmother would have told you, after chastising you for having no brains. Except for academic obesity specialists and researchers, who is foolish enough to think that 100 calories of brownies is equally fattening as 100 calories of kale salad? The calorie hypothesis – it’s a trap!

Insulin is one of the main drivers of obesity, leading to the Carbohydrate Insulin Hypothesis (CIH). This holds that dietary carbohydrates are the main or only cause of increased insulin, and thus reducing carbohydrate intake is necessary to lose weight. However, the CIH is incomplete, because there are many, many different influences upon insulin levels other than carbohydrates, including meal timing (eating late at night releases more insulin, incretins, vinegar, fibre all reduce insulin, insulin resistance and fructose directly increase insulin etc). This leads to a far more complete theory of obesity that takes all these factors into account instead of merely the carbohydrate or calorie content of foods.

With that background, I suggested in The Obesity Code that the main steps to reducing obesity are:

  1. Reduce your consumption of added sugars.
  2. Reduced your consumption of refined grains.
  3. Moderate your protein intake.
  4. Increase your consumption of natural fats.
  5. Increase your consumption of fiber and vinegar.

But above all else my main advice is to  eat unprocessed real food. Processed grains are not good, but neither is processed fats such as seed oils or processed red meats.

OK. Good. Now onto the study where they compared two groups – Healthy Low Fat (HLF) and Healthy Low Carb (HLC). The ‘Healthy’ part applied to both groups included instructions to:

  1. Maximize vegetable intake
  2. Minimize intake of added sugars, refined flours and trans fats
  3. Focus on whole foods

Other than the part about eating natural fats, it’s virtually identical to the advice we give in our Intensive Dietary Management program. Patients attended instructional sessions for the diet over the period of 1 year. In addition to the above advice, the Low Fat group restricted dietary fat to 20g/day and the Low Carb group restricted carbs to 20g/day. Participants then gradually added back fat or carbs to the lowest level they believed they could sustain. Yes, this part is not very rigorous, but it’s what happens in real life. Deal with.

As you can see, the dietary instructions worked pretty much as planned. There was no instructions given for caloric intake, tacitly acknowledging the complete futility of calorie counting as a useful dietary tool. Patients should eat until hunger is sated, no matter how much they ate. Nevertheless, both groups reduced their calorie intake from roughly 2200 cal/day to 1700 cal/day with no difference between groups.

This underscores that it is likely the intervention applied to BOTH groups that caused this caloric reduction. When you eat real food, you activate natural satiety mechanisms – cholecystokinin, peptide YY, stretch receptors in the stomach, incretins etc. that signal us to stop eating. But this applies to both low fat and low carbohydrate foods. When you eat processed grains (donuts) you don’t get full. When you eat unprocessed carbs (beans) you do. Thus you stop eating because you are not hungry at a level that is far below the previous caloric intake (roughly 500 calories/day). But it did not require calorie counting to achieve this. It requires cutting out all processed foods.

Was there any difference between the Low Fat and Low Carb groups in terms of weight lost? Yes and no. The HLF group lost 5.3 kg and the HLC lost 6.0 kg, not a statistically significant difference, but in Body Mass Index the HLF group lost 1.75 and HLC 2.07, which is statistically significant. There were no other important differences. Metabolic rate was similar in both groups. 

There was also some huge differences between people in the same diet. In both groups, some people lost 25 kg (over 50 pounds) and some gained 10 pounds. ON THE SAME DIET! This shows the significance of one of the other importance of one of the IDMP’s main ‘rules’. Do what works for you.

We are not dogmatic about what diet to follow. If you follow a low fat diet and lose weight, great. The only logical thing is to keep doing it. BUT. If it does not work, then change it and see if it works better. The general rules are all the same – avoid processed foods, avoid added sugar, avoid refined grains, but you can tweak endlessly around the edges. The only thing that really matters to us is that you get results. Look, we are all individuals. I am good at medical physiology and suck at basketball. LeBron James is good at basketball and probably sucks at medical physiology. I make a living doing what I do, and he makes a living doing what he does. So why force one dietary approach to fit all?

So, call this a tie, although you could argue it’s a win for the Low Carb rebel band based on the BMI. So, why do I usually recommend a Low Carb diet? For several reasons. First, most carbs in Western society are refined grains. So Low Carb is a useful short hand for reducing sugar and refined grains. Secondly, Dr. Eenfeldt at www.DietDoctor.com smartly points out that if you consider all the Low Fat vs Low Carb studies (58 in total), Low Carb comes out on top 29 times and tied 29 times.  The Low Fat diet came out on top a grand total of 0 (zero) times. Yes. Zero times. This clearly favour the Low Carb rebel band. Anyways, would you bet on a team that wins 29 and loses 0, or the one that wins 0 and loses 29?

There are several key takeaway messages. First it reinforces the uselessness of the counting calorie approach. Second, by adopting generally agreed upon ‘Healthy’ eating patterns gets you most of the way to target. Third, it’s arguable that the Low Carb approach was better, but with all the differences between individuals, you really need to be open minded. Eating whole unprocessed carbohydrates might work for you. But eating all meat may also work for you. I care more about people getting healthy than being right. At IDM, we don’t tell people what they ‘must’ eat. There is no such thing. We see what they eat, and see if they get the results they are looking for. If it works, great. If it doesn’t work, then we change.

2018-04-25T06:40:29+00:0033 Comments

About the Author:

Dr. Fung is a Toronto based kidney specialist, having graduated from the University of Toronto and finishing his medical specialty at the University of California, Los Angeles in 2001. He is the author of the bestsellers ‘The Obesity Code’ and ‘The Complete Guide to Fasting’. He has pioneered the use of therapeutic fasting for weight loss and type 2 diabetes reversal in his IDM clinic.

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BobM
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BobM

I basically follow Dr. Fung’s advice in #1 through #5 above, except I eat higher protein, lower fat. Sometimes really high protein, as in 120+ grams at a sitting. I bought a continuous glucose monitor (CGM) to test Ted Naiman’s theory that eating high(er) protein is good, so I would eat as much protein (in real food, such as beef, shrimp, mussels, fish) as I could in a single sitting. I did not find any increase in blood sugar, and I found that high protein even with low fat could be quite filling. On the other hand, I cannot test… Read more »

Pete Kaye
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Pete Kaye

We should remember Dr. Fung’s demographic is severely insulin resistant people. Their response to higher protein may be more pronounced than yours. Since you lift regularly, I assume you’re not in that group, and like the good Dr. Naiman, maybe you look good enough in form to be allergic to shirt too.

Brenda
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Brenda

You are awesome

BobM
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BobM

Well, I had two DEXA (dual energy x-ray absorptiometry) scans done. Both indicate I’m still well into the obese range. Was a former pseudo-bodybuilder though (one needs genetics and drugs to be a real bodybuilder), so maybe that helps. I am down over 50 pounds since my high weight, using IF and low carb. Unfortunately, there’s no real test for insulin resistance. I did a short glucose tolerance test with insulin, and my low-carb doctor said I had a good insulin response. At the same time, I had a higher fasting insulin level. Why? Due to higher protein? It’s not… Read more »

Pete Kaye
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Pete Kaye

So I’m roughly in the same boat as you. I have one kidney though (lost one to cancer 12 years ago) so I keep my protein under 100g a day so as not to load it with too much nitrogenous waste to filter. What I see is a reduction in the loose skin after I lost a shitload of weight. I do not know the real answer, but since protein means growth, at 66 I’ll err on the lower protein side!

Pete Kaye
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Pete Kaye

BTW, judging by my strength on gym machines, I’ll wage I gained a few ounces of muscle too, even with the lowered protein.

BobM
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BobM

You know, there’s no good answer to the protein debate:

http://roguehealthandfitness.com/higher-protein-greater-weight-loss/

https://blog.virtahealth.com/protein-ketogenic-diet/

I think higher protein is better, but then it’s difficult to know what “higher” protein even is. I hate to say this, but I might just start counting calories to see what my protein intake is (I only counted for specific meals, not over all). Ugh. I haven’t counted calories since I tried to keep my fat content below 10% by calories, back 20+ years ago.

thenitch
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thenitch

Search youtube for Dr. Ben Bikman, low carb breckenridge 2018. Real good info about protein consumption and insulin response.

Joanne
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Joanne

This was amazing, thank you.

Lee Chiew Yan
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Lee Chiew Yan

Dear BobM – i m interested to find out the brand of your CGM, as i find that the only available so far is the abbott which is a minimally non invasive, I am looking for a CGM which is totally non-invasive. Appreciate if you could recommend. thanks so much. CYLee

Grace
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Grace

Lifting weights will allow you to take in more protein and like Dr. Fung says, “Do what’s right for you”. I am insulin resistant, I don’t work out, just a bit of light walking. If I fast all day and eat a dinner of Salmon and Broccoli, my sugars are over 100. If I eat breakfast and lunch then fast till the next morning, sugars go down. And that’s eating 5% carbs, 20% protein and 75% Fats.

Mujahidul Islam
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Mujahidul Islam

You are telling you follow dr jason and you take lower fat.. Are you really following him????

Mathieu
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Mathieu

Calorie counting doesn’t matter (or is usually not necessary) if you eat unprocessed food, but in the end, energy balance matters…That’s “CICO”, and against what you have always been promoting.

BobM
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BobM

I don’t think that’s correct. I used to eat some whole grain cereal for breakfast, pasta for lunch, and whole grain rice/beans for dinner. The pasta I guess was “processed” (whatever this means), but nothing else was. I had horrible blood sugar swings, depression, etc. This whole reliance on the word “processed” is troubling. Unless you’re taking down your cow and eating it with your teeth, you’re eating “processed” meat. Same if you cook your meat. Moreover, for vegetables, they have too many anti-nutrients unless you process them by cooking. Same with any “whole” grains (though if you’re here, you’re… Read more »

Mathieu
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Mathieu

Processed when you buy them. This applies to pasta, but not to meat.
I put ” around CICO, because the main component is energy balance, which is not far. CICO is indeed too simple. But calories matter. And this notion is often refuted by low carb / keto advocates.

Richard
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Richard

Mathieu: How can you possibly say “calories matter,” as if it was profound, when Dr. Fung has just explained why calories don’t matter? Inherent in the the idea that “calories matter” is the idea that one counts calories as one eats, and stops eating AFTER eating x amount of calories, BECAUSE ALL CALORIES ARE EQUAL… The two issues that Dr. Fung fully addresses are that all calories are NOT equal and that the body does NOT count calories. The body systems react to the type of thing you have eaten: protein, fat, carb, etc. Not calories directly. Dr. Fung’s point… Read more »

BobM
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BobM

Another thing I don’t do is increase my fiber intake. I think fiber is bad for me. I tried resistant starch and other prebiotics and probiotics for months…and it seemed to cause more problems than it solved. I find eating less fiber and fewer vegetables and more meat to be the best for me. I haven’t gone “carnivore” (all meat) yet, but I’m close.

Sharon Lee
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Sharon Lee

I would really like to know Dr Fung’s take on Zero Carb/Carnivoir diet.

Jeremy
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Jeremy

WTF? For that new Low Fat vs Low Carb study, how can they even call that low carb? I would say its moderate carb at best. By the end of the study they were eating 132 grams per day, over 20g of which were added sugars. To me that is not low carb. On a really bad day I might push 100g, but that’s only going to happen a few times a month. Also, if they are going for sustainablity, rather than drop carbs way down to start and slowly add back in, a better approach would have been to… Read more »

myusrn
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myusrn

I 2nd that WTF. I think it is really irresponsible for any article to discuss matters relating to Fat and Carbs w/o qualifying the type. Fats from animal products have substantially different impacts than fats from whole food plant based [wfpb] sources. Similarly Carbs in the form of simple carbs coming from processed sources have substantially different impacts than complex carbs from wfpb sources. Every time I read articles or hear talks where they don’t qualify what type of fat and/or carb they are referring to I find it misleading and pointless.

Deborah McKee
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Deborah McKee

Just a quick question,does a high fat diet show comparable reversal of coronary disease as low fat? Dr Dean Ornish has shown a reversal of build up in artery’s with a low fat diet. Will the hflc do the same? I understand that the primary concern is the insulin but will reducing insulin do the same as the low fat? Or should those with heart disease follow low fat, low complex carbs,moderate protein? I have just started water fasting and moderate carb intake and my blood sugar is now starting below135 after a meal and 85-95 when waking up in… Read more »

Lucy
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Lucy

IMO the thing about Dean Ornish was he changed a lot of stuff at one time. So the people were exercising, losing weight, eating vegan, and meditating. There’s too many variables there. So IMO it’s impossible to tell if the regression of CAD was the low fat diet.

Ronald
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Ronald

I want to reverse insulin resistance. I want insulin sensitivity in Liver and Muscles. How about
a vegetarian Plan based whole food diet? No oil or meat (saturated fat) Just Carbohydrates> some feel this will reverse the SOURCE of the problem Insulin Resistance. Also reduce cholesterol. Any thoughts?

Lucy
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Lucy

okay this is just an opinion, I tried that vegan stuff and my joints started falling apart. I think veganism is a bad idea. Plus eliminating saturated fats IMO and people replace the fat with carbohydrates. This is just my experience, but it seems I have met quite a few vegan diabetics for some unknown reason. Fat is neutral on blood sugar see above.

Ronald
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Ronald

Thank you for the reply about Insulin Redistance. I understand Insulin Resistance is FAT clogging Cells ( insulin receptors) eliminating saturated fat seems to me to not add to that fat but it will assist in removing it from cells. This Insulon sensitivity and reverse insulin resistance. A way to REVERSE a root problem with ty2 diabetes.what do you think?
I appreciate your feedback.
Ron

dolph
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dolph

A few points: -Carbohydrates are not altogether bad if taken with a meal and with fat and protein, it’s just a question of limiting them; the main thing is not to snack on carbohydrates. I’m sure you all know this. But that’s where the problem lies, because carbohydrates give instant energy, can be processed into various forms, and have a long shelf life. So they are great for the food industry, which can produce them in bulk and distribute them everywhere. -Your ability to affect this outcome is zero; I don’t mean you as an individual, as an individual you… Read more »

Richard
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Richard

Love your absolutes: “people,” “all,” People are hopeless,” “them,” “society,” and “nobody…” Etc. A word to the wise is sufficient: Dr. Fung can do little more than put the word(s) out there, into the public view, and go from there. He is not being paid for this task of public health intervention. Still, the word is getting to the public at large, even though messages like yours may undermine the effort. In any event, messages of food intervention are, in fact, quite successful on a historical basis: the messages have been corrupt and misguided, perhaps, but they have been effective.… Read more »

Joyce Ewing
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Joyce Ewing

Ha! Love the Star Wars analogy. The Empire, indeed!!!!

Benthamite
Guest

I think that the issue isn’t appetite controls in response to food that keeps the pounds off, but rather a complex weight regulatory system. This is effectively present in the books of Gary Taubes. He states that a 1% excess in calories in would result in obesity in 20 years. Thus it is not how many calories you eat each day, but rather a regulatory system that kicks in on the follow day to reduce appetite, and if a period of over-eating as during the Christmas season, that system when work causes eating left in the subsequent months until the… Read more »

Barbara Young
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Barbara Young

The thing that worries me is that the average weight loss after 12 month following either plan was approximately 6kg – that is 0.5kg/1.1lb a month. I personally would find it very disappointing to be making that much effort/deprivation and to only lose 0.5kg a month. And longer term studies show that the weight comes back in most people after 2-5 years.

Valentina
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Valentina

I have learned so much from Dr Fung’s posts and the commentators’ stories that I would like to ask/raise a question even though it’s not completely relevant to the topic of this blog post. Everything I have read about insulin resistance, blood sugar deals with management through diet, weight loss, and exercise. But what about thin people who eat by the book and still have high blood sugar, cholesterol, and hypertension? It’s frustrating to struggle to do everything right and still fail to change the outcome. I’m 56 years, 5’ 3″, 114 pounds, carry no fat around the waist (the… Read more »

myusrn
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myusrn

. . . this excerpt from document above is concerning “First, most carbs in Western society are refined grains. So Low Carb is a useful short hand for reducing sugar and refined grains.” mostly because many will never remember this subtlety and so you have a bunch of people running around declaring carbs are bad including complex carbs coming from whole food plant based [wfpb] nutrition. I can understand this excerpt from document above if idm goal is to primarily to lower weight and insulin resistance “At IDM, we don’t tell people what they ‘must’ eat. There is no such… Read more »

John Petter
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Hi
This is very much great and hope fully nice blog. Every body can easily get perfect information from here.
thank you so much!