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I’ve avoided the show The Biggest Loser on purpose, but Dr. Doug McGruff happened upon it in the break room between patients in the emergency ward:

I have never watched this show, as I assumed it would be ridiculous. I was shocked how much I had underestimated. I could not believe the amount and types of exercise these poor people were being put through. They even showed one contestant collapsing on a treadmill and being spit off the back of the machine by the spinning tread. Then there were multiple scenes of the contestants being screamed at by that Gillian lady in the tank-top/midriff shirt (talk about narcissistic) and some sadistic guy with tattoos all over his arms. The instructors’ contempt for the obese was obvious as they spewed insults (and saliva) in the faces of the contestants. I don’t care how fat or desperate I was, if someone did this to me I would punch them in the face and storm off the set. I checked in on the show between patients. The diet and exercise shown were prescriptive for ravenous hunger and ultimate failure. As I continued to work, I kept thinking about the importance of biologic signaling, and why it does not have to be this hard.

Dr. McGruff graduated from the University of Texas Medical School at San Antonio in 1989 and studied Emergency Medicine at the University of Arkansas in Little Rock, where he served as Chief Resident. He is one of the “smart guys” I like; not a researcher in some academic office running computer queries to do some fancy meta analysis, but a practicing physician who sees real people with real problems every week.

Every person who has struggled with a “diet and exercise” program to lose weight knows the problem Dr. McGruff identifies:

Overtraining (especially in the obese) triggers cortisol and other stress hormones. A low fat, high carbohydrate diet signals insulin release. These signals defend a high level of stored fat and drive huger…a true prescription for misery and failure.

Theories abound in what passes for dietary science. The ones based on science rather than just observation appeal to me the most. Dr. McGruff explains why a short high intensity workout is better than the Biggest Loser’s cardio-based workouts:

The key to turning around these sorts of metabolic disasters is to send the correct biologic and hormonal signals. If the correct signals are given, there is a disproportionate improvement in the metabolic state and body composition. This disproportionate response is courtesy of a second messenger system. Most hormones do not act directly on their target organ or tissue.

The cell wall protects the cell; most hormones cannot pass through the cell wall easily. Instead, the hormone’s fat soluble receptors bind the hormone on the outside of the cell wall and transmit the signal to a messenger inside the cell itself. I always think of the way an amplifier can take the puny signal from an iPod, process it, and play it through big, power hungry speakers. And in this case, amplification does indeed happen. The second messenger, on the inside of the cell, amplifies the signal:

The unique thing is that the second messenger then activates a chemical cascade that multiplies the signal at the target. This way a single molecule of primary messenger can produce thousands of second messenger signals at the target.

In other words, your cellular stereo amplifier is set on “10″ (or “11″ if you are a This is Spinal Tap fan).

This is why a proper signal is so important…the beneficial effect is hugely magnified. A brief, but intense workout that fatigues the musculature activates growth hormone, testosterone and adrenaline which all signal to empty glycogen and fat, both short and long-term. A hunter-gatherer diet creates a low insulin signal which triggers the body to defend a lower body fat set point.

The fact is, you don’t need a skinny person who has never fought a weight battle yelling at you to lose weight or become healthier. And chances are, even after that ordeal, your weight problems will return:

On camera, Zwierstra seemed giddy and brash, interrupting host Caroline Rhea, hollering at her friends in the audience, tipsy on her 3-inch heels. Secretly, she was woozy, having dehydrated herself by avoiding liquids, baking in a sauna and fasting for days to skim off those last few pounds.

The studio audience went wild as the cameras panned in. Zwierstra stepped on the scale. Rhea hollered, “Your current weight is …”

The scale heightened the tension: Beep. Beep. Beep.

144 pounds!

She’d lost 45 percent of her body weight.

But it wasn’t enough.

In the end Erik Chopin, a New York deli owner, took home the big check, losing more than 200 pounds from a starting weight that topped 400.

In January he appeared on Oprah to describe how he’d gained half of it back.

The top two contestants of The Biggest Loser’s third season have not solved their problems. The impossible standard set by the program’s extreme exercise program won’t work for them, or for many people. At its heart, The Biggest Loser uses the “calories in / calories out” principle, comparing the human body to a gas engine rather than to a metabolic organism. It is rooted in the 19th century science that measures food content in how much heat it gives off when burned in a furnace, rather than using modern science to understand how the human body actually works.

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In the UK, the government sponsors the “National Child Measurement Programme”, an attempt to combat childhood obesity by assessing the height and weight of children. The program does the measurements in the schools, and then sends letters home to parents.

Lucy, a five year old, was measured and the letter warned she “may have an increased risk of heart disease, diabetes, high blood pressure and cancer as her body mass index (BMI) was outside recommended guidelines”.

The Daily Mail Onlline recounts the reaction of the parents. As the mother said:

I couldn’t believe what I was reading, Lucy is five-years-old and not fat in the slightest. She shouldn’t even be thinking about her weight at her age.

‘I want her to be running around playing and having fun, not worrying about what she looks like.

It would be easy to say mum is a bit sensitive about her daughter’s weight, and in denial about how she is setting her daughter up for medical problems by her poor parenting.

The problem with formulas to determine optimum weight for an individual is that they are often just plain wrong. A number doesn’t make you healthy. And in Lucy’s case, the number is obviously wrong, as anyone with any sense can see. But perhaps that’s more than we can ask from a government program. Here’s a picture of Lucy:

She looks like the picture of health, to me. Sounds like the bloated, overweight, tub-of-lard actor in this issue is not the kids in Britain, but the fat-ass government.

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Dana Carpendar at Hold the Toast blog recaps the results of an interesting study in the Archives of Internal Medicine:

47% of the low carb group had their blood pressure medication discontinued in the course of the study, as compared to 21% of the low fat group. Dr. William Yancy, who ran the study, said the difference in the two groups might have been even greater had subjects remained on their blood pressure medication, but they instead took people off medications as their readings normalized.

The study started the low carb group at the true low carb level promulgated by the Atkins diet, 20 grams per day. Far too often, studies comparing low carb diets to low fat diets use 100 or more grams per day of carbohydrate. The study lasted nearly a year, long enough for true differences in the diets to be seen. For the low fat diet group, the study added a common diet drug, orlistat, a drug that sequesters fat so it can be eliminated before being absorbed by the body.

Weight loss for the two groups is statistically insignificant, even though some low carbers have pointed to the results proudly. The small sample size and small difference in the number of pounds lost between the two groups just doesn’t lend itself to proclaiming any victory for the low carb diet. But the study does show the low carb diet is the equal of a low fat diet in nearly every respect. The study’s Abstract points this out.

No matter what you read, the main benefit of a low carb diet in this study was that it matched the low fat diet in nearly all areas, and was superior in controlling high blood pressure:

Conclusion: In a sample of medical outpatients, an LCKD [low carb ketogenic diet] led to similar improvements as O + LFD [orlistat plus low fat diet] for weight, serum lipid, and glycemic parameters and was more effective for lowering blood pressure.

It would be interesting to see how the participants felt about their low carb or low fat diet. My experience has been that the low carb diet is much easier to maintain, as I rarely struggle with hunger even while losing weight.

And, I love bacon.

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Gary Taubes, the nationally acclaimed science writer, explains why exercise and weight loss are not physiologically linked:

The one thing that might be said about exercise with certainty is that it tends to makes us hungry. Maybe not immediately, but eventually. Burn more calories and the odds are very good that we’ll consume more as well. And this simple fact alone might explain both the scientific evidence and a nation’s worth of sorely disappointing anecdotal experience.

The New York magazine article is a good read, and includes Taubes’ signature style of including historical perspective to frame the issue. And he gets to the underlying philosophy behind the “calories in / calories out” theory of weight loss: the idea that the body is a thermodynamic black box that has to respond to the balance of calories taken in and calories expended.

But we are not gasoline engines. Taubes explains that the thermodynamic black box theory (TBBT) fails to take into account the role of fat tissue in our metabolism. Studies showed fat people maintaining or gaining weight while eating less than thin counterparts. But the thin people were more active. The correlation seemed to support the TBBT theory. But studies of overweight people who increased activity substantially, including a controlled study where Finnish researchers trained overweight men and women to run a marathon, showed that they maintained their weight.

Overweight people who have tried the “diet and exercise” remedy can commiserate with their Finnish brothers and sisters.

Taubes relates that our bodies have been shown to try and maintain certain levels of blood sugar, hormones, etc. We have evolved to try and counteract the entropy of our environment and gradual breakdown of our bodies. Our survival depends on it:

The key is that among the many things regulated in this homeostatic system—along with blood pressure and blood sugar, body temperature, respiration, etc.—is the amount of fat we carry. From this biological or homeostatic perspective, lean people are not those who have the willpower to exercise more and eat less. They are people whose bodies are programmed to send the calories they consume to the muscles to be burned rather than to the fat tissue to be stored—the Lance Armstrongs of the world. The rest of us tend to go the other way, shunting off calories to fat tissue, where they accumulate to excess. This shunting of calories toward fat cells to be stored or toward the muscles to be burned is a phenomenon known as fuel partitioning.

What is the mechanism for storing calories as fat? Insulin, working in concert with an enzyme, lipoprotein lipase (LPL), determines if energy should be burned or stored as fat.

Low carb dieters know that one effect of eating a low carb diet is to even out the insulin response. Those of us with insulin resistance also know that as we even out the insulin response, our cells become less resistant to the insulin in the bloodstream, and more of the glucose in our blood is used for muscular energy rather than stored as fat.

A low carb diet is more than a weight loss diet; it is a lifestyle choice that leads to more stable weight for a lifetime. This is possible because, unlike exercise, eating lower carbohydrates in your daily diet aids in the feeling of being satisfied with the amount you have eaten. When you aren’t hungry, its easier to not reach for that snack.

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Stunning statistics from a study published in the December issue of Diabetes Care, as reported by Health Day News:

The number of people with diabetes in the United States is expected to double over the next 25 years, a new study predicts.

That would bring the total by 2034 to about 44.1 million people with the disease, up from 23.7 million today.

At the same time, the cost of treating people with diabetes will triple, the study also warns, rising from an estimated $113 billion in 2009 to $336 billion in 2034.

The increase is from adult onset, or type II diabetes. Health Day attributes the increase to obesity:

Factors driving the increase in diabetes cases include the aging population and continued high rates of obesity, both of which are risk factors for type 2 diabetes, in which the body does not produce enough insulin or the cells don’t use it correctly. In the study, the researchers assumed that the obesity rate would remain relatively stable, topping out at about 30 percent in the next decade and then declining slightly to about 27 percent in 2033.

The problem is that the official stance towards this problem has little hope of solving the underlying issue: our addiction to carbohydrates. While the general consensus is that people would not be diabetic if they lost weight, telling people to lose weight has proven to be a dismal failure. The reason is that very few people will starve themselves voluntarily.

The standard American diet is one rich in refined, processed foods (i.e., carbs). The “optimum” diet recommended by nutritionists is one that is low in dietary fat and eschews refined, processed foods in favor of “complex carbohydrates, such as whole grains, cereal, rice, pasta, potatoes, dry beans, carrots and corn”, with calorie reduction necessary to lose weight. It doesn’t work because you are always hungry on that diet.

Hungry people eat. And if they eat “complex carbs” that are “low in fat” they never feel sated, and will never stop eating.

Try this experiment … go to the sugar bowl and spoon out a scoop of sugar onto the counter. Then another. And another. Keep going, and when you have 22 spoonfuls of sugar on the counter, you have the average American’s intake of sugar. But what if you cut out all the added sugar found in soft drinks, cookies, candy and other snacks (even low fat ones)?

If you follow the various guidelines by the USDA, American Heart Association, et. al., you’ll limit fat to 20% of your dietary intake, and get adequate protein, making up the rest of your diet with those complex carbohydrates. Let’s take an example of a 2,000 calorie diet, and see how that works out in grams of each micro nutrient:

• Fat, 44g at 9 calories each = 20% of calories
• Protein, 100g at 4 calories each = 20% of calories
• Carbohydrates, 300g at 4 calories each = 60% of calories

Carbohydrates turn to sugar (glucose) in your gut in a very short time, within 2 to 4 hours. Even “complex carbs” turn to sugar.

Spoon out another 75 teaspoons of sugar onto your counter. That is the amount you are asking your body to metabolize when you eat 300g of carbohydrates per day.

Here’s a layman’s explanation of what is happening: The body needs sugar to run, but if it can’t use it in a very short time, it is stored as fat. Blood sugar spikes in 2 to 4 hours after eating carbs, and the body reacts by releasing insulin to drive the sugar into the cells so they can use it for energy. If the cells have enough, they refuse insulin’s prompting, and the sugar is stored as fat. As you abuse this system by overloading it with sugar, the cells become more and more resistant to insulin, and the body sends out more and more. When the sugar is pushed into fat cells, your blood sugar level drops, and hunger returns even though you ate only a few hours ago. So you eat again, and start the process all over again (if you eat a diet “rich in complex carbohydrates”). Sound familiar?

The emphasis on low fat, high carbohydrate diets has caused our expanding waistlines, and emphasizing that people should continue to eat this way but reduce calorie intake is counter intuitive. Survival depends on getting enough to eat, and your body will betray you if it thinks it is starving.

A better approach is to limit carbohydrates to about 1/3 of all calories if you are at your goal weight and otherwise healthy. For a 2,000 calorie diet, that’s about 167 grams of carbs. The rest of your calories can come from fat and protein. It is best to calculate your minimum protein requirement, usually calculated at about a half gram per pound of lean body weight. “Lean body weight” is your weight minus your fat (take your body fat percentage times your weight, and deduct that from your total weight to get your “lean body weight”). The book The Protein Power Lifeplan has this approach as a “maintenance diet”, and people can tolerate it for life … because you don’t get hungry.

And if you need to get to your goal weight, the first phase of the diet can help you do that without getting hungry. You can short-circuit the vicious cycle of carb intake, insulin response, fat storage and premature hunger by eating a diet that is tuned to your needs.

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Tom Naughton deconstructs the “obesity epidemic” at his blog Fat Head:

But what I found most interesting was the data on who’s “overweight” and by how much. Here are the numbers:

• More than 50 pounds overweight: 6%
• 21-50 pounds overweight: 17%
• 11-20 pounds overweight: 15%
• 1-10 pounds overweight: 24%
• At ideal weight: 18%
• 1-10 pounds underweight: 7%
• 11-20 pounds underweight: 3%
• More than 20 pounds underweight: 1%
• Undesignated: 9%

As we noted in our post Does Being Overweight Harm Your Health, all-cause mortality studies show that you have a 17% less chance of dying if you are in the “overweight” BMI (as compared to being “normal weight”). Even being “obese” was statistically even with being “normal weight” in these studies. The absolute worse thing you can do is be “underweight”, with a stunning 73% greater risk of dying than a “normal” weight person.

We have also noted our belief that individuals have to assess their own health needs and identify their individual risk factors, rather than focusing on a “society wide goal”. If your risk factors lean more towards developing diabetes II, then controlling blood sugar levels may be more important than being within 10 pounds of some goal weight. And as McNaughton notes, adult onset diabetes is at epidemic levels:

A different Gallup poll underscores another point I made in the film: there is a genuine epidemic out there, and it’s called diabetes. More than 11% percent of Americans adults have diabetes now, and more than 90% of those have type 2 diabetes, which is mostly preventable. The rate has more than doubled in the last decade alone. Among senior citizens, the numbers are even more harrowing: nearly one-quarter have diabetes. Just think of all the physical damage that’s causing. And even those numbers don’t count the pre-diabetics.

Nutritionists tend to focus on the weight end of the scale (so to speak), but they are missing the point. You can’t push a string. People are overweight because of their blood sugar levels (i.e., hyperinsulinemia, insulin resistance and related disorders leading to diabetes). They are not suffering from high blood sugar levels because of their weight. As Naughton sums it up:

The constant drumbeat about the obesity epidemic and the emphasis on losing weight is sending the wrong message. We need to tell people to get their blood sugar checked and keep it under control with the proper diet. If we do that, the 10 pounds will take care of itself. And if it doesn’t, well … so what? A bit of belly won’t kill you if it’s not the result of high blood sugar.

If your blood sugar is elevated, the way to get it under control is by adopting a low carb eating lifestyle. You will lose weight, but the most important thing is that you will live longer. And living longer is the goal.

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Ever wonder just how they determined what a dietary calorie is, and how they know how much energy you get from it? Like many things in dietary science, the answer is surprising.

They burn it and measure the calories (a unit of heat energy) the food gives off. Sort of. A scientist in the 1800’s figured this out, and we’ve been using his system ever since.

Except it doesn’t work. Your body does not “burn” food, it digests it. So there are problems with the method. But as New Scientist notes, there is resistance to changing the flawed system:

“There will be errors, but not very serious errors, and nobody can do their calories anyway so what difference does it make?” says Marion Nestle, a nutritionist at New York University.

Gotta’ love those nutritionists.

The article gives a real-world example that is worth noting. Two foods may have similar calorie counts but end up being utilized (DIGESTED!) by the body in different ways. A brownie, filled with refined starches and sugars, may have a calorie rating of 250 and a “healthy” snack bar with “complex carbs” a rating of 300, yet the body will extract more calories from the brownie. The dieter counting calories is fooled by the system. But, it doesn’t really matter to nutritionists; no one does it right anyway, right?

After the not-so-compelling browning/muslei bar example, the article actually talks about real food. What you quickly see is that trying to count calories becomes incredibly complex, and as our expanding waistlines have told us, does nothing to help reduce obesity.

For my money, counting what you can’t count accurately doesn’t make a lot of sense. Paying attention to what you eat, and not just how much, seems more consistent with human health.

Unless you think you really are a bonfire. Then burn, baby, burn.

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Periodically, the idea of a “soda tax” floats to the surface buoyed by the assertion that it will help curb obesity. But the arguments often fall apart when people start to compare different foods they think are more healthy than a 16 ounce bottle of Coca Cola.

The Wall Street Journal Health Blog contains this statement, pointing out a common fallacy:

But if you look at the prices with the hypothetical sugar taxes added ($2.02 for the two-liter bottle and $4.64 for a 12-pack using Sicher’s numbers) and compare them with the price of a half gallon (1.89 liters) of 100% orange juice, which the Health Blog is lucky to buy on sale for $3.50 at her local grocery store, it would still be far cheaper to buy soda.

From this statement, you would believe drinking 16 ounces of orange juice would be healthier than 16 ounces of Coca Cola. If you surveyed people, they would probably say overwhelmingly that orange juice is healthier than soda.

To be fair, the point of the statement is that even with an extra tax, soda would still be cheaper that what we consider to be healthier alternatives. While this tax masquerades as an attempt to improve American’s health like other “sin taxes”, it is simply a way to extract more money from the populace for whatever government program is being considered. Like all “sin taxes” those engaging in the “sin” oppose it while those who never indulge in that particular “sin” support it. But neither position is based on “health”.

“Unsweetened” orange juice has 3.75 grams of sugar per ounce, while Coca Cola has 3.25 grams. Orange juice, even given its paltry nutrients, is not a good substitute for Coca Cola. Orange juice provides even more sugar ounce for ounce. Sure, you get your daily value of vitamin C and small amounts of calcium and vitamin A, but you also get the bad effects of all that sugar.

Orange juice used to be served in small, 3 or 4 ounce glasses. These “juice glasses” have all but disappeared from the American cupboard, and the standard 12 or 16 ounce glass is the one most people reach for, and the drinks they put in it are most likely going to contain from 40 to 60 grams of sugar.

The portion of sugar our body retains either gets used immediately for energy or stored as fat. If you aren’t running a marathon, drinking 50 grams of sugar is going to add to your fat stores.

For perspective, imagine that instead of reaching for that glass full of orange juice you pull out a teaspoon and scoop up regular table sugar. And eat it. And then you dip the spoon in the sugar again, and eat another teaspoon. And then another. And another. After you have eaten 12 and a half teaspoons of table sugar you have almost the amount of sugar in the 16 ounces of orange juice.

Now, let’s talk about potatoes …

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Two studies alluded to in my post “Does Being Overweight Harm Your Health” have been linked on our Obesity research page.

The surprising results of these two studies, and others like them, is that being in the overweight category when measured by BMI is not harmful. You have the same statistical chance of living to the same age as normal weight people.

Making Sense of the Studies
What about studies that show cancer deaths are reduced for people in a certain weight class, or that deaths from diabetes are higher for people who are overweight? What the two studies linked show is that overall, in the general population, people’s lives average out longer if they are normal or overweight, but are much shorter if underweight or obese.

But you are not an average. So you have to look at your individual risk factors. In my case, I have high risk for diabetes because of my “syndrome X” or “metabolic syndrome” risk factors. My diet is designed to reduce those risk factors and so far, I’ve made good progress. If the end result is that I’m not diabetic but still a bit overweight, I’ll fret that my profile isn’t what it was when I was 17, but I’ll live as long as my thin brother. And I’ll enjoy life.

I could go beyond addressing my individual need, and work for a vanity outcome: thin as a Hollywood star. But I wouldn’t enjoy my life nearly as much. And I would die younger, according to the averages. Its small consolation that a bunch of overweight people will cry at my funeral.

Healthy has to be the goal, and healthy might mean different things to someone with different family histories or other risk factors. Weight alone is not the standard.

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The eternal question, and subject to much debate, is if low carb (LC) diets do better at promoting weight loss. Today I’ve added a Research Page to collect links to studies showing the effect of low carb diets on Obesity.

The first study was tweeted by Dr. Michael Eades, Effects of two energy-restricted diets differing in the carbohydrate/protein ratio on weight loss and oxidative changes of obese men. Remember that in Europe, where this study originates, the term “energy” in this context means the same thing as “calorie” does in the US.

Very interesting.