The first two parts of the macronutrient trend series, which explores the association between changes in carbohydrates and fat in the diet and the obesity epidemic in America, are here (Part 1) and here (Part 2).

In the first post of this series, I reposted a response of mine, involving a wealth of data from the USDA food balance dataset, to Dr. Ludwig’s claim that the low-fat diet caused the obesity epidemic. In the second post, I have reposted Dr. Ludwig’s response. This third post in the series is the final reply to Dr. Ludwig. Still deeper analyses will follow these first three posts.

Without further ado.

(Originally posted January 14, 2018 on Medium: https://medium.com/@kevinnbass/thank-you-for-the-thoughtful-response-dr-ludwig-b0db3314d658. Copied in full, with added figures in the text.)

Thank you for the thoughtful response Dr. Ludwig.

I agree that food availability data are problematic, for some of the reasons that I discussed and you pointed out as well. So I also included self-reported intake data, which I think told a similar story. Still, I agree this data, too, is flawed. My hope was that by using both data-sets, despite their limitations, at the least we can say what the data say. Obviously, reality could be different from the data. And if it is, we all want to know that and understand why that should be.

This means that the picture I have tried to draw could be qualified or even refuted if there was another data-set or interpretation and a compelling justification for why that data-set or interpretation is better. However, I am not persuaded that the data-set that has been offered as an alternative is better.

Reasons:

  1. Stephen and Wald use self-reported data and thus, as self-reported data, this data-set in principle has the same flaws as the NHANES data. Why should we use it over NHANES?
  2. Stephen and Wald’s set extends from 1920–1984, covering only 4 years after Guidelines were published.
  3. S&W’s data-set includes studies using heterogeneous assessment methods. This could be a weakness if each method had particular biases yet different methods were used more or less frequently over time.
  4. More importantly, I am not sure that the S&W data-set support the “low-fat” argument. First, the decline in fat intake seemed to have begun before the dietary guidelines were released. And second, fat intake was projected at around 31% in 1920, yet the 1920 obesity rate was dramatically lower than in 2000, when the fat intake was higher, around 33%. See: https://pbs.twimg.com/media/DTjWBwkV4AEle_T.jpg

5. The CDC data *are* the NHANES data. They show that % fat fell from ~37% to ~33% from 1980 to 2000. As we both must agree: this is around a 4% change. Again, as we also both agree, this decrease in % corresponded to ZERO change in intake. The % decrease happened because carb intake increased, but the driver here was more carbs. Total grams fat intake stayed constant from 1980 to 2000 according to the NHANES data. [Editorial: this point will be addressed in much greater depth in part 4. – KB]

6. Finally, I do not think that using USDA survey data for first data point in 1960 and combining it with the NHANES data for 2000 represents best statistical practice. I think comparisons between years should be made within data-sets, using the same methodology. If this is done, I believe that best estimate, barring a new analysis from a different data-set that covers the years in question (1980 to 2010), is that fat intake changed about 4%. Again, this is consistent between USDA and NHANES, using within-data-set comparisons.

Moving on, we agree that in, e.g. the 1980 DGA, the brochure recommended increasing carbs. But ONLY if one limited fats. Moreover, it advised eating complex carbohydrates, not refined, and advised against sugars. See screencap: https://pbs.twimg.com/media/DTjaOtCV4AAD0w1.jpg

And original source: https://health.gov/dietaryguidelines/1980thin.pdf

A diet rich in complex, unrefined carbohydrates is compatible with good health, as e.g. some of the macrobiotic diet trials for T2DM have recently shown (see my recent Twitter feed). But Americans took the message “carbohydrates,” and ignored the “complex” part.

The question should also be asked: Is it possible that Americans ate more refined carbohydrates for reasons quite apart from their (mis)understanding of the guidelines? I cannot answer this question, but I think it is a legitimate one.

Last, there is no disagreement that, in the context of the standard American diet, overconsuming refined carbohydrates is harmful to health, and that this is what Americans are doing.

We also agree that present low-fat recommendations should continue to be a subject of debate. Clearly we need to debate every aspect of the dietary guidelines. Again, my claim is only an historical one: that it is difficult to interpret the dietary trend data as one of decreasing fat, and thus, that it is difficult to blame the guidelines’ previous low fat recommendations for the obesity epidemic.

I remain open (and eager) to revise my positions. If we want to get policy right, clearly the facts need to be right too. I believe that doing this and making a positive impact on others’ lives is what both of us are primarily interested in achieving.

I thank you for the opportunity to have discussed this issue with a researcher of such a high level of scientific achievement and important cultural legacy. It is an honor.

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As an MD/PhD student, my passion is for communicating the cutting edge of medical science and fighting misinformation. If this post is of use to you, please consider donating to my Patreon account. Your contribution will make a significant positive impact, and I will be greatly personally appreciative.

You can sign up as a patron at my page, here.

You can also find me on Twitter at @kevinnbass.

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Other parts in this series:

Part 1

Part 2

In response to my first post, Dr. Ludwig responded with his own. I have recopied it here in full, with his permission. Additionally, for illustration, I have added figures from several of the papers that he references in the appropriate places in the text.

(Originally posted January 10, 2018 on Medium: https://medium.com/@davidludwigmd/hi-kevin-appreciate-the-scholarly-debate-58a6b7df1bff. Copied in full, with added figures in the text.)

Dr. Ludwig:

Hi Kevin, appreciate the scholarly debate. Just a few brief comments. First, to be clear, I said your statistics were misleading, not that you’re wrong.

Ok, so what’s misleading? First, food availability data (see the bottom left caption in most of your figures) do not accurately reflect what is actually consumed. Nor do added oils, the focus of your comments elsewhere, reflect total fat intake. We know that the food supply contains about 3,900 kcal per person. Though actual calorie intake has gone way up, it’s nowhere near that level. Also, we need to be careful of self-report data, which has much selective bias.

Admittedly, data on dietary intakes can be problematic, but the long term trends are clear. Stephen and Wald summarize data in the US during the 20th century, estimating that in 1960 the proportion of calories as fat was about 40%.

The CDC has good data that proportion of dietary fat decreased to about 33% by 2000 (ie, near the government recommended level). The 2 figures in that report tell the story at a glance.

Yes, fat consumption in gram amount has remained about the same, but that’s just the point. We’re eating more of everything — arguably in part due to being hungrier from all the highly processed carbohydrates. As you say: “according to NHANES data, carbohydrates went up dramatically” from 1980 to 2000, consistent with the government advice to eat a high-carbohydrate, grain-based diet (those 6 to 11 servings a day!).

Of note, the “American Paradox” of decreasing proportion of fat as obesity rates rose was described by Heini and Weinsier 20 years ago — though it’s really no paradox at all considering the metabolic effects of processed carbohydrates.

Indeed, multiple recent meta-analyses show that high carbohydrate diets as actually consumed are demonstrably inferior to all higher fat diets for weight loss. Unfortunately, this high carbohydrate intake is also strongly linked to mortality among US cohorts. [Click here for the most relevant table from this paper. — KB]

So let’s certainly continue exploring this, but I don’t think that concerns about the low-fat diet recommendations are based on myths that need killing.

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Enjoy this article? Proceed to Part 3 of the macronutrient series, here [to be added].

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As an MD/PhD student, my passion is for communicating the cutting edge of medical science and fighting misinformation. If this post is of use to you, please consider donating to my Patreon account. Your contribution will make a significant positive impact, and I will be greatly personally appreciative.

You can sign up as a patron at my page, here.

You can also find me on Twitter at @kevinnbass.

There is a narrative online that Americans have become obese because they have too closely followed the Dietary Guidelines. I looked at this suggestion in depth in my post here and found it to be lacking. This post will have a narrower focus and look specifically at refined grains and sugar.

So did the Dietary Guidelines cause Americans to eat more refined grains and sugar? Let’s look at the facts.

Americans currently eat about a quarter of the whole grains recommended by the current Dietary Guidelines for Americans, and about double the recommended refined grains.

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

If Americans eat too many refined grains, can it be the Guidelines’ fault?

Indeed, a 2010 study showed that only 1% of Americans eat the quantity of grains recommended by the dietary guidelines. One percent! Meanwhile, as we can see above, the average American far exceeds recommended intake of refined grains.

Here is a screenshot of the 2015-2020 Dietary Guidelines for Americans showing that it recommends at least half of grains consumed to be unrefined:

Reference: https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf

Some claim that only current Guidelines included the recommendation to consume unrefined grains, and that the early Guidelines didn’t. This is false. The Dietary Guidelines for Americans from 1980 repeatedly emphasized eating unrefined carbohydrates:

Reference: https://health.gov/dietaryguidelines/1980thin.pdf
Reference: https://health.gov/dietaryguidelines/1980thin.pdf

Indeed, the entire 4th guideline was dedicated to recommending unrefined carbohydrate foods. Since there were only 7 guidelines, that means 14% of the 1980 DGA were dedicated to telling consumers to eat unrefined carbohydrates.

Here is the second and final page of the 4th guideline again:

Reference: https://health.gov/dietaryguidelines/1980thin.pdf

Its summary statement says: “Select foods which are good sources of fiber and starch, such as whole grain breads and cereals, fruits and vegetables, beans, peas, and nuts.”

Does it say to eat refined grains and sugar? Does it say to eat donuts and pizza? Does it say to eat ice cream and cupcakes? No. It says to eat foods that Americans still don’t eat very much of. Many people do not eat any.

On the topic of sugars, do the Dietary Guidelines tell people to eat a bunch of sugar to “replace fat”–as is often claimed? No. The Guidelines tell people to limit sugar. In fact, #5 of the 7 guidelines is dedicated to this! Here is its summary statement:

Reference:https://health.gov/dietaryguidelines/1980thin.pdf

According to USDA food availability data, Americans today eat more refined grains AND sugar than they did in 1970. Americans have not followed the dietary guidelines. Americans have largely ignored them.

Reference: https://www.ers.usda.gov/amber-waves/2017/july/us-diets-still-out-of-balance-with-dietary-recommendations/
Reference: https://www.ers.usda.gov/amber-waves/2017/july/us-diets-still-out-of-balance-with-dietary-recommendations/

There is a large and thriving low-carbohydrate diet industry worth hundreds of millions of dollars. One of its major figureheads is @DietDoctor1, who spreads this kind of misinformation on his website, in a way strikingly similar to many anti-vax websites:

This is not a small website! It claims to have over half a million subscribers and runs a lucrative membership-only part of the website.

On this website, many of the above myths are propagated widely. For example, here is @bigfatsurprise‘s presentation on the topic:

https://www.dietdoctor.com/introduction-dietary-guidelines-start-obesity-epidemic

In this video, @bigfatsurprise propagates many of the myths that I have debunked in this thread, in large part by slickly presenting data that superficially supports her point of view and excluding data that does not. Because there is so much data, it is very easy to do this.

Spreading these myths is highly lucrative to these authors and doctors. The video I posted is only a preview. The full version is only available to those who have purchased memberships.

I am not sure what to do about this, but I am working on it with others. It is important to be vocal and assertive. These people are exploiting and generating confusion about nutrition to make millions. People deserve better than this.

(For more information about the carbohydrate and fat trends and their relationship to the dietary guidelines, please refer to the first half of my post The data overwhelmingly indicate that Americans do not follow the Dietary Guidelines.)

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As an MD/PhD student, my passion is for communicating the cutting edge of medical science and fighting misinformation. If this post is of use to you, please consider donating to my Patreon account. Your contribution will make a significant positive impact, and I will be greatly personally appreciative.

You can sign up as a patron at my page, here.

Stephen Phinney and Jeff Volek are among the most important minds of the low-carb movement. With three advanced degrees between them (Volek is a PhD and Phinney has both an MD and PhD) and hundreds of scientific publications on low-carbohydrate diets going back decades, after almost 10 years of low-carbohydrate dieting under my own belt, last year I was excited to sit down and read their book The Art and Science of Low-Carbohydrate Living, their popular primer on low-carbohydrate diets and, after having read almost everything published on low-carbohydrate diets in other popular books, really deepen my understanding.

Looking for a scientific treatment of the strengths, weaknesses, and gaps in the research record on low-carbohydrate diets, as I read I was first a little disappointed by the book. Then I was appalled. The first two chapters called into question everything that followed. This was a turning point for me in understanding low-carbohydrate diets and the people who advocate for them.

Phinney and Volek engage in rampant conspiracy mongering. I wanted to like the book. But I couldn’t. The content of this book and its worldview, in my opinion, so poisons the well of scientific discussion that it makes any serious adherent to the book immune to rational argument.

It is said that a great piece of literature raises more questions than answers. I believe the same could also be said of a great piece of science. It is also said that a work is not literature if it only provides answers–it is propaganda. By this definition, Phinney and Volek’s book is propaganda. It needn’t be, because I know that there remain many questions about low-carbohydrate diets.

Here is my thesis:

I believe this is a poisonous book. By believing that the other side is responsible for a conspiracy, one is justified in one’s own selective and misleading use of scientific research. I will now try to demonstrate what I mean by this.

These first two chapters are about indigenous groups that consume low-carbohydrate diets. Here is the key introductory paragraph to these paragraphs:

Before commenting, I should introduce my background. I have two bachelor’s degrees. One was my bachelor’s of sciences degree in biology, but I also have a bachelor’s of arts degree in anthropology. I decided to major in anthropology in part because after high school, I read Loren Cordain’s book The Paleo Diet, and this changed my life. I was Paleo. I was also an angry kid, and I thought that I wanted to learn about hunter-gatherers, because modern society was a bum deal.

So, as an anthropology major, imagine my perpetual surprise when I hear that hunter-gatherers were adapted to consuming low-carbohydrate diets. Just as with Phinney and Volek’s (hereafter, PV) claim that this was the case, this is never referenced. The reason it is never referenced is because it isn’t true. Every dataset that looks at hunter-gatherer diets–and there are several mainstays of anthropologists over the past century, employing varying methodologies–shows a range of carbohydrate intakes.

PV indicate that these three groups are “examples” of low-carbohydrate hunter-gatherer groups, while in fact they exceptions. Of the hundreds of hunter-gatherer groups observed, these are the only groups that might provide evidence for PV’s thesis.

Also the notion that Homo sapiens lived in barren or temperate regions until very recently–including during the Ice Ages–also is not supported by any evidence that I am aware of. When the Ice Ages occurred in Europe, Homo sapiens retreated to the Mediterranean:

They only recolonized Central and Northern Europe relatively recently. Indeed, Scandinavia was only colonized by humans at around 12,000 BCE–an eyeblink in human evolutionary history. Indeed, the lifeways of Scandinavia are only as old as agriculture itself.

The famous Inuit? Same deal. According to the book “A Paleohistory of the North: Human Settlement of the Higher Latitudes”, Alaska too was only colonized around 12,000 BCE, with the Inuit themselves arising on the scene only 2,000 years ago:

The Inuit arrived in Alaska after the fall of Attica at the hands of the Peloponnesians, after the deaths of Socrates, Plato, Aristotle, Alexander the Great, and Julius Caesar and during the reign, approximately, of Augustus in Rome. There was a reason indeed that the great civilizations began in Southern Europe: everyone else was just getting started. The existence of humans in the Northern climates is, to be clear, neolithic and in some cases almost modern in its novelty.

In point of fact, modern genetic studies show that modern Inuit (a population from northern Alaska) spread through the Arctic less than 700 years ago, genetically and culturally replacing the Paleo-Eskimos, residents of the Arctic for about 4000 years. What this means in turn is that the Inuit were just getting settled in when the Renaissance was underway in Europe. Yet PV want to propose that the Inuit are an ancestral population!!!

When PV were imagining our ancestors chasing around woolly mammoths, they were probably actually eating pasta with Francesco somewhere in the South. OK, minus the pasta. But you get the point. What PV have done in this passage is to pretend that low-carbohydrate living in these harsh climates was the normal human lifeway. The Ice Age was a recent event, and humans had a very ambivalent relationship to it, with permanent settlements largely only existing in the South.

What this means is that the Inuit, Masai, and Bison People were not necessarily representative of our human ancestors. In fact, they were chosen by PV precisely because they stand out as exceptions, even as PV propose they represent the rule. And they aren’t even exactly what they seem either. We have only seen this in the case of the Inuit, but we shall soon see it with the Masai as well.

Yet, through a bit of hand-waving, they try to make this work:

Again, no reference is provided to support that most of the world’s cultures survived on low-carbohydrate diets–in fact, this is at odds with the available evidence, which shows copious dependence of our ancestors on a wide variety of foods, including fruit, tubers, legumes, and grains.

PV’s discussion of Ireland is unreferenced and just wrong: archaeologists believe that cereals, including wheat and barley, arrived in Ireland almost 7,000 years ago and were extensively cultivated.

The discussion on Scandinavia and Russia is equally unreferenced. It is difficult to know what to take seriously. Even if true, the amount of gene flow because of repeated migrations, especially in Scandinavia from mainland Europe during the course of the neolithic (except perhaps for Finland) would substantially undermine the argument.

Yet behind these attempts at justification lingers a rather curious value judgment: “low carbohydrate cultures were suppressed by the agricultural imperative.” A whiff of Jared Diamond and Marshall Sahlins and an insinuation of romanticization of hunter-gatherers so often latent among Paleo diet writers makes itself felt here. There is much more of this in the book, but we shall have to pass it by for our purposes at this time.

PV, perhaps sensing that their evidence is paper thin, now appeal to a supposed gap in evidence:

In other words, because writing didn’t exist, we don’t know that just because the evidence is so thin, these supposed low-carbohydrate cultures didn’t exist. Here PV make an incredible claim: >99% of ethnographic observers misreported their findings. The ones who told the truth are the ones that PV is reporting on. What a convenient and ridiculous remark.

PV give no evidence that this happened, content instead to accuse most observers of faking data. Still, if only an empirically unfounded claim, we might chalk it up to (serious) disagreements about interpretation. But it isn’t. It also simply doesn’t make any sense.

Here’s why. Ethnocentricity is a commonplace pitfall that most ethnographic observers are aware of. This is why it is so controversial when they report on infanticide, or on cannibalism: the observers might be biased, and trying to paint HGs are “primitives” or “savages.” Indeed, there is a (dominant) school of thought within anthropology that asserts that there is no such thing as an objective cross-cultural observer, precisely because such observers will always distort their analysis with their own biases. Even perception is biased.

But report they do. Outside the West, we know from cross-cultural observers that infanticide is a cultural universal. And we know that in diverse cultures, Bob is frequently offered as a blood sacrifice, or even taken as the main course on festive occasions. (Sorry Bob.) And this kind of reporting goes back to Herodotus, perhaps the most ethnocentric and biased cross-cultural observer in the Western canon. Indeed, most scholars now believe that Herodotus way over-reported differences.

Why? In part because they’re interesting. That’s why cross-cultural observers are interested in other cultures. They want to find differences. Through these differences, in turn, it is frequently argued that cross-cultural observers want to understand themselves.

That is why I studied anthropology: because I wanted to know the range of possibilities of human existence. Because I wanted to learn about something different. That is one of if not the major motivation of cross-cultural observation.

“Primitives” through Western history always been a foreign Other, an Other that contrasts with modern civilization; “primitives” tell us by their negative example who we are. Thus, the tendency in anthropology has been to exaggerate differences too much.

We need to ask, therefore, why it has been consistently OK to talk about eating Bob but not about restricting carbohydrates? About bizarre sexual rituals but not about eating only meat? About pagan idol worship, but not about foregoing grain?

Before proceeding, let us take a brief look at the paragraph that comes after PV accuse 99% of cross-cultural observers of fabricating data, because finding other human societies who don’t eat wheat would be too much existentially to bear.

Here PV, thinking they are supporting what they are saying, provide a perfect counterargument to their own argument. According to PV, when observers encounter HGs that do not live in houses, they report this accurately, and call them derogatory things like “uncivilized” or “unsettled”. Yet when they encounter HGs that do not eat carbs, they fabricate data.

This simply doesn’t make sense. It is like PV are trying to refute themselves.

At this point I started to become incredulous. Is it really possible that PV are truly the excellent minds that many claim them to be? Or is this a case of “hugely overrated”?

PV’s attempt to make the argument that cross-cultural observers couldn’t stomach low carbohydrate HGs demonstrates a lack of familiarity with the ethnographic literature, and the anthropological tradition. And just plain bad reasoning skills. What is most striking however is the lack of self-consciousness about this terrible way of arguing, yet the confidence of PV’s prose.

It’s questionable moreover whether PV’s examples serve their own argument. Inuit are widely understood to have rare genetic mutations that prevent them from entering ketosis, the very state that PV claim is ideal and evolutionarily normal. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4225582/

Also, as Evelyn Carbsane has pointed out, Masai women demonstrably do not eat low carbohydrate diets. Image below.

Original ref: https://books.google.com/books?id=T7aaAAAAIAAJ&pg=PA11#v=onepage&q&f=false
Evelyn’s post: http://carbsanity.blogspot.com/2015/03/masai-women-ate-low-fat-diet.html

What are the implications? Hyuge. This means that if we want to make the argument that Masai are low carb adapted, it’s only the men, but not the women. Yet… that’s not how genetics work.

Probably knowing that just discarding the evidence wouldn’t be sufficient, they accuse observers of not living with the people that they report on. Excerpt:

This is false. There are sections of libraries filled with books on HG populations by people who lived with them. Yet again we see PV accusing their opponents not just of dishonesty but now of laziness. Worst of all, in order to do this, they have to make things up.

In order to dismiss archaeological evidence as well, PV conclude that plant foods were probably not eaten or fed to dogs:

10/10 intellectual gymnastics. And no, there is not “some” data that dispute “these proportions”. Rather, virtually all available data do.

Let’s unpack this. First, they say “not all that is written of hunters and nomadic shepherds is incorrect.” No, they only mean to impugn everything that is in conflict with their theory. Which brings us to the next point.

What do PV mean when they say “when assessed against a modern understanding of metabolism”? Just what it sounds like. They cherry-pick the evidence that is consistent with their theory (although not really).

As for a “sparse but useful truth”—whether simple or complex, I prefer my truth unqualified, and not requiring in order to function, a vast intellectual conspiracy over hundreds of years to hide data by thousands of investigators.

If this post seems to drip venom, that’s because reading these chapters really did piss me off. And it makes me wonder, if the evidence from archaeology is so readily dismissed when it conflicts with their ideas, what would keep PV from doing the same when evidence from the own fields conflicts with their assumptions?

This is why I do not trust or value the work of PV. That is not to say that it cannot be valuable. It can be. But I question whether they are objective interpreters of their own science, and I now pay particular scrutiny when evaluating work on which either of them are an author.

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As an MD/PhD student, my passion is for communicating the cutting edge of medical science and fighting misinformation. If this post is of use to you, please consider donating to my Patreon account. Your contribution will make a significant positive impact, and I will be greatly personally appreciative.

You can sign up as a patron at my page, here.

You can also find me on Twitter at @kevinnbass.


There is a narrative, circulating for the past decade or longer, that Americans have gotten fat because of the dietary guidelines. This narrative has been circulated above all by Gary Taubes, author of Good Calories Bad Calories and other best-selling works. Gary is a masterful storyteller.

This image has an empty alt attribute; its file name is Screen-Shot-2019-05-04-at-3.53.09-PM.png
Reference: Good Calories, Bad Calories by Gary Taubes

And the story he has told has echoed throughout the online nutrition world like wildfire. It is repeated by the likes of Tim Noakes, Nina Teicholz, Jason Fung, and the rest of the who’s who of low-carbohydrate dieting. Nina Teicholz, in particular, has taken Gary’s claims to an special extreme, giving many talks around the world on how the Dietary Guidelines caused the obesity pandemic. Her book, which was centered around this idea, was highly praised by both the Wall Street Journal and the Economist.

Here is a link to a popular presentation by Nina Teicholz on just this subject: https://www.dietdoctor.com/introduction-dietary-guidelines-start-obesity-epidemic

The problem? The story that Gary and Nina tell isn’t true.

Let’s dissect through the main points of this story, piece by piece.

For one, Americans never really consumed a low-fat diet, and they never followed the Dietary Guidelines to try to consume one. Here are food availability data from both the Food and Agricultural Organization and the United States Department of Agriculture.

Below is the above data, but with a breakdown for each nutrient class.

Now let’s look at percentage of fat in the diet, with cutoffs prescribed by USDA:

Indeed, if we look at total fat (the first two graphs in this article), it seems not to have decreased at all after the dietary guidelines. If we look at % fat, it decreased from 41% to 37% (in 1997), only 4% and nowhere near the value prescribed by the guidelines of 30%. Moreover, even at its lowest level of 37% in 1997, it was still higher than in 1980 when the guidelines were released. And after 1997, the absolute dietary fat intake increased to its highest ever.

That’s not all. While some claim that the food availability data presented above are flawed, the survey data present their own problems. Here are the survey data:

Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4598942/figure/F1/

So far, so good. Until one plots macronutrient trends not as a percent, but as absolute grams/day:

Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4598942/figure/F1/

Strange, because all we see here are an increase in intake of carbohydrate, not a reduction in fat. What could have caused this? In a recent paper, Edward Archer notes that this apparent increase might have been caused by artifact. Indeed, the methodology of the survey changed between the second and third surveys:

Reference: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0076632

In addition, obesity trends also seem to contradict the claim that dietary guidelines caused the obesity epidemic. As we can see below, obesity has been steadily increasing since at least the 1880s–a century before the Dietary Guidelines.

Reference: http://www.nber.org/papers/w16252.pdf

Not unimportantly, USDA does have a food availability dataset that goes back almost this far, using a different methodology to document years prior to 1970. The parallels between the increase in obesity and this dataset are striking. (Look at the two graphs side-by-side.)

What’s more, the above graph is roughly consistent with the food availability data. If we look closer (below), we see that calories also inflect at roughly 1960–20 years before the Dietary Guidelines.

It is likely that many factors account for the recent explosion in obesity, but whatever they are, the above evidence suggests that the seeds were planted in the 1950s or 60s or even the 1870s or 80s–not the 1980s.

If you would like to read more about macronutrient trends, please see my upcoming macronutrient trend series.

But let’s get back to the question at hand.

What exactly are Americans eating today? How close are they to the Dietary Guidelines for Americans?

For instance, what percentage of Americans fail to consume the foods recommended by the Dietary Guidelines?

These values were reported in a 2010 study:

80% fail to get the recommended total fruits
75% whole fruits
89% total vegetables
96% green leafy vegetables
98% orange vegetables
96% legumes
61% starchy vegetables
58% other vegetables
85% milk
99% whole grains
48% meat and beans
80% oils

The percent of Americans consuming more than their maximum discretionary energy allowance from solid fats and added sugars?

Solid fats 95%
Added sugars 77%

Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2937576/

How far are Americans from meeting the recommendations laid out in the actual Dietary Guidelines, on average? Data are available on this as well.

They are eating about half as many total vegetables, half fruits, adequate grains (we’ll return to this in a moment), half dairy, and generally adequate protein as recommended by the dietary guidelines:

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

Americans are eating a quarter of recommended dark green vegetables, a third of red and orange, a third of recommended legumes, half of starchy vegetables, and inadequate “other vegetables”:

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

They are overconsuming refined grains almost two-fold and consuming only about 25% of recommended unrefined grains.

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

Men are eating too much meat, and women have an adequate intake. Seafood is under consumed. Nut consumption is generally adequate.

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

Solid fats are overconsumed, while oils are underconsumed:

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

Added sugars are overconsumed–by between 20-80%, depending on the age group:

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

The average American intake of saturated fats exceeds the maximum recommended intake:

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

The sodium intake is double the recommended intake in many age groups:

Reference: https://health.gov/dietaryguidelines/2015/guidelines/chapter-2/a-closer-look-at-current-intakes-and-recommended-shifts/

That was from survey data. But how do the food balance data look?

Not great.

Americans still consume less than half of recommended fruit, less than 70% of recommended vegetables, and half of recommended dairy:

Reference: https://www.ers.usda.gov/amber-waves/2017/july/us-diets-still-out-of-balance-with-dietary-recommendations/

They overconsume total grains, with most of the recent increase from corn. (Remember that they vastly underconsume whole grains, which means that these grains that they are overconsuming are refined grains.) They also over consume protein foods relative to recommendations.

Reference: https://www.ers.usda.gov/amber-waves/2017/july/us-diets-still-out-of-balance-with-dietary-recommendations/

Americans massively overconsume sugar, consuming almost double that recommended by the dietary guidelines:

Reference: https://www.ers.usda.gov/amber-waves/2017/july/us-diets-still-out-of-balance-with-dietary-recommendations/

What kinds of foods do Americans eat? According to a recent study, nearly two-thirds are ultra-processed.

Reference: https://blog.aicr.org/2017/06/13/processed-foods-calories-and-nutrients-americans-alarming-diet/

What are the major sources of calories in the American diet? A 2012 study cleanly summed this up in a single table:

Reference: https://www.mdpi.com/2072-6643/4/12/2097

It is worth noting that critics often point to the large quantity of grains in the American diet as indicating that Americans are somehow following the dietary guidelines. Yet it is worth looking (again) at what kinds of carbohydrates (and grains) Americans actually eat:

Reference: https://www.mdpi.com/2072-6643/4/12/2097

Scarcely a whole grain to be found, consistent with the above 2010 paper showing that only 1% of the American population, yes 1%, consumed the recommended whole grains.

And then, it is worth looking at the guidelines themselves:

Reference: https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf

Americans are not consuming anything remotely close to what the Dietary Guidelines for Americans recommends. Suggesting otherwise—as such people as Nina Teicholz, Jason Fung, Tim Noakes, Zoe Harcombe, and many more do—is dishonest. But it’s all part of the same old game.

The purpose of making such a claim is sensationalist. It turns the diet wars into a battle of David against Goliath. Of truth-telling rebels against corrupt bureaucrats. This is the kind of story that sells. And when you need to sell a story to make a livelihood in the Internet age, it can be a very tempting story to tell indeed.

The real truth is that the self-styled truth-tellers are in fact fabulists exploiting an obesity pandemic to make money and get attention. They do not have a side of the story. They do not have an opinion informed by evidence. Theirs is not an unpopular point of view. They have simply made a career of fooling others–and some of them have even fooled their own selves.

This is not without precedent. Echo chambers and cult-like behavior are the norm in human society throughout history. Think of the entire civilizations that have fallen victim to group-think and then self-destructed. In fact, think of the first major Western such civilization: ancient Athens. Now imagine such group-think taking place among an even smaller group of people. This is exactly what has happened among this group of low-carbohydrate diet advocates. They are Athens before waging war on Syracuse. They are clueless and hopeless–yet endlessly optimistic. They can stir up great crowds. But time and again, when one takes a moment to actually scrutinize most of their claims, it is clear that they are waging wars on the flimsiest of hopes and building castles on foundations of sand.

I do not mean by this that nothing from the low-carbohydrate diet proponents is useful. Some is useful, and I wholeheartedly support that. Fortunately, what is useful has been stripped from the useless, and responsible people, some of whom I consider my teachers, are in charge of developing these ideas further to help rather than mislead patients.

It is worth noting that the major website responsible for propagating the above false claims about the dietary guidelines and many videos associated with these claims over the past 5 years–dietdoctor.com–is in fact a storefront that uses criticism and inflammatory rhetoric directed at the medical establishment as a launching point for a business worth tens of millions of dollars. Among its targets are the United States government, individual scientists, cancer research, and life-saving statin drugs. Of the latter, the website promotes individuals who claim that these drugs harm patients, while statin scientists believe that these drugs have saved the lives of hundreds of thousands or millions of people. It is hard to not notice that this overall inflammatory approach and business model eerily follows the precedent trail-blazed by anti-vaccination groups.

This does not mean that the Dietary Guidelines are without flaws. They are not. They are poorly communicated. They are technocratic and difficult to understand. They are couched in politispeak and clearly the result of a painstaking consensus process–good procedurally, but terrible science communication. They need to explicitly recommend reducing consumption of ultraprocessed foods. The USDA, whose mandate is also to promote agriculture, probably should not be in charge of formulating them.

But make no mistake about it, what is abundantly clear is this: Americans do not follow the Dietary Guidelines. Given that, it is hard to believe, as claimed by Gary Taubes and Nina Teicholz, that they caused the obesity pandemic. Diets in the wealthy world are in many ways worse than ever–by almost every metric.

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As an MD/PhD student, my passion is for communicating the cutting edge of medical science and fighting misinformation. If this post is of use to you, please consider donating to my Patreon account. Your contribution will make a significant positive impact, and I will be greatly personally appreciative.

You can sign up as a patron at my page, here.

Lipoprotein(a) is a lipoprotein particle. Like the LDL particle, it increases the risk of cardiovascular disease. Before diving into details about just what Lipoprotein(a) is, let’s get a handle on just how much of an impact high Lipoprotein(a) levels can have.Lp(a) blood level show a dose-response relationship to cardiovascular disease risk in multiple studies, and Lp(a) is now widely considered a reliable marker for CVD risk.

Here is a graph showing ~4-fold increased risk at >95th-percentile Lp(a) level:

[Above is adjusted for age (left) and multifactorially (right). The multifactorial adjustment is for age, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, apoB, BMI, hypertension, DM, smoking, lipid-lowering therapy, and, for women, menopause and HRT.]

Here are the same data represented with a Kaplan-Meier curve.

As we can see, the unadjusted, >95th percentile Lp(a) associates with >2x lifetime incidence of myocardial infarct (heart attack).

At 80-years-old, 15% at the 22nd percentile or below but 30% at 95th percentile or above will have had a myocardial infarction.

30% of people at below the 22nd percentile but 40% at above the 95th will have cardiovascular disease (CVD).

In other words, Lp(a) = more frequent, more severe cardiovascular disease.

Why did investigators adjust for those variables in the first graph? Because risk factors go together: smoking goes with bad diet, lack of exercise, low income, etc. So if you do a study and conclude smoking causes X, it could actually be all those other things causing X.

So what investigators do is use statistical methods to estimate what the data would look like with all variables of non-interest equal, and just the variable of interest changing.

This multifactorial adjustment usually causes the risk attributed to the variable of interest to decrease relative to the unadjusted risk. Yet in this study, the risk doubled after adjustment. This is unusual, and investigators noted this but couldn’t explain it.

Could it be that somehow Lp(a) protected participants from diabetes, stopped them from smoking, reduced cholesterol, caused lower blood pressure? We may look at this more later in the thread.

Here is one more study (2016) showing the same epidemiological trend, using two different assays for Lp(a), analyzing data from the UK, showing the same results.

Again, we see a 2- to 4-fold increase in risk in CVD. Most people have ~1/3 chance of dying from CVD. CVD probably increases Alzheimer’s risk as well. This means that at the upper quintile for Lp(a) blood levels, we expect a large increase in absolute risk of both CVD and other diseases. It’s a really big deal.

That concludes our introduction to the importance of Lipoprotein(a). We will revisit all of this and more as we unpack our discussion about this marvelous and terrible lipoprotein.

Willpower is substantially genetically determined

The willpower versus genetics dichotomy in discussions of behavior is bizarre. Personality traits like willpower are substantially genetically determined. To the degree they are not, why do we assume that they are not determined by something else out of the person’s control?

Some people are blessed with a lot of inborn willpower. Some people need more prodding. Some people are in poor health for reasons they do not understand, and this saps and undermines their willpower. Some people were educated poorly and given bad examples of behavior.

All of these things, at least in the short-term, are not in people’s immediate control. They can all determine a person’s willpower.

The question is: can a person use willpower to increase their willpower?  Possibly, but why would they use willpower to increase willpower? What motivates the original use of willpower in the first place?

It’s clear, to me anyway, that something besides willpower, some external event or some epiphany must cause this. Such things just happen; they are out of a person’s control.

To the extent that free will does not exist, personal responsibility is necessary

This does not imply that I think people are not responsible for their behavior. They are. They are responsible for their behavior because by making people responsible for their behavior, we encourage good behavior.

Imagine a situation where we made nobody responsible for their behavior, because everything is ultimately caused by a mix of environmental and genetic determinants. What would happen? Well, people who are inclined to do bad things would do them.

And since they were immediately forgiven because it is not their fault, and because they were not educated not to do bad things because nobody really chooses to do bad things anyway, people’s bad tendencies would be allowed to run riot, and more bad things would happen.

Deterrents like the law, moral conditioning such as an early education appropriate to civilized society, and “softer” enforcement of social norms as occurs among communities of adults (who gets invited to parties, who wins company accolades, etc.) are all external incentives that shape behavior. It is in fact because in many ways were so externally determined that social norms, rewards and penalties for moral and immoral behavior, a legal system, etc. are so important.

It is exactly because we are not fully internally in control of our behavior that we must hold each other morally and social responsible for our respective good and bad behaviors.

If each of us operated entirely according to an internally decided willpower, that would be when we would not hold each other responsible for anything.

Because in that case, why should we? Our holding each other responsible could have no impact on each other’s behavior.

If internal willpower de novo determined everything, then moral responsibility would in fact have precisely no meaning or utility.

It is precisely because human beings are so determined by things outside their control that holding each other morally responsible is important and useful.

Moral characteristics are unequally distributed

Each of us are born with a different set of character traits with moral valence. Some of us will be intensely motivated. Others quite unmotivated. Some of us will be more predisposed to eating a lot. Others less. Some of us will be intelligent, others dim.

Some of us will be imbued with a sexual drive that can, if not controlled, cause us difficulties. Others the opposite. Some of us will have a drive, a craving for physical activity, up to dozens of hours per week. Others will want to be couch potatoes.

Some of us are relaxed. Others anal retentive to an extreme. For some of us, being on time is a real challenge, as we become consumed with other activities and lose track of the time. Others of us will not comprehend how such people could do this.

Many of these inborn characteristics will incline us to behave in ways that will be at odds with our own interests.

Realizing this is also to a degree dependent on inborn characteristics (such as intelligence). Reshaping behavior is to a degree depending on inborn characteristics (such as motivation). And things are likely far, far more complicated than even this.

But external feedback from society is also likely to play an important role, since it can bypass intelligence and motivate us in ways that we might not be intrinsically motivated.

Moral feedback and social norms can be harmful

External feedback from society can also be incredibly demoralizing and painful.

Imagine that you are a psychopath with sadistic tendencies and you had a tough upbringing. You might have the strong internal drive to become a serial killer, or you might want to kidnap and torture small children.

Society would tell you not to do this, and it would punish you severely if you did. Your life would likely not be a good one.

People like this exist, and other well-meaning people have decided to try to rehabilitate them. Jon Ronson talks about this in the Psychopath Test.

And Ronson notes that rehabilitation programs for such people have been an abysmal failure. They don’t work. These people are permanently bad apples.

What to do? Well, if such people are permanently bad apples, that is a very sad thing for everyone. The victims of such people and the people themselves.These people could simply be isolated, or they could be made an example of to encourage others who are less extreme cases not to behave in this way.But what is clear is that externally motivating such extreme cases not to misbehave won’t work. We should abandon such an approach, as it is likely to be fruitless and unnecessarily painful.

Even though moral feedback and social norms can be harmful, they should still be rationally enforced

When we can identify such hopeless cases, we should. The problem is that this is very hard to do for almost any person or any behavior. But when we can, we should.

Deciding when and how to act to motivate others morally, in other words, is an empirical question. We study what the odds are that x, y, or z course of action will change a, b, or c behavior, and we then implement that course of action when appropriate.

Sometimes we will miss the mark and exert pressure on someone whose behavior will not be alterable. Other times, it will require a great deal of discomfort for a person who is amenable to change to actually make that change. In still other cases, change will be easy to induce.

What we need are ways to understand where, when, and how to change others’ behavior in a way that produces net benefit rather than net harm.

Conclusions and a final question

A few things seem clear:

  1. Moral characteristics like willpower are to a degree inborn and may be largely determined by things outside our control, so the dichotomy between willpower and genetics is nonsensical;
  2. Even if we are entirely determined by genetics and environment, this says nothing about the usefulness of holding others morally responsible;
  3. Holding others responsible requires that they do not have complete free will, or else it would be useless to hold them responsible;
  4. Some people are going to be more or less amenable to change by being held responsible—the way that we hold them responsible and try to change their behavior is important;
  5. It is very challenging to identify which people will be amenable to behavior change before trying;
  6. Nonetheless, a rational and evidence-based way of holding others responsible and trying to elicit change would be useful to avoid unnecessary effort and pain and maximize benefit.

To all this might be added a question: How much pain justifies change, if it is achievable?

It all started with an argument.

Opening the refrigerator door. I say to my wife, scowling, “Why do we have so much cheese? We have talked about this.” Compared to milk, cheese is less nutrient dense and contains more calories. I find it very easy to overeat cheese, and this undermines my ability to stay lean while I put on muscle. I also don’t care for the dairy industry. And I want to instill good eating habits in my kids; I want them to treat foods like cheese as what I think they are: indulgence foods for special occasions. Not something for regular consumption in the house.

My wife, who is taking a nutrition class, responded: “Dairy has a lot of calcium.”

I shoot back, “There are better sources of calcium.”

She responds, levelly, “Yes, but they are not nearly as bioavailable or rich in calcium as dairy.”

My jaw dropped as I stared at her blankly. I sat down at my computer to begin wife-fact-checking. She might be right, or she might not be. But by the end of this, I would understand more about calcium.

How much calcium do humans need?

I started with a Google search and came upon this post by the National Academy of Sports Medicine, which provided the following two tables:

Gotcha wife. You’re wrong!

But was she? I looked closer at the numbers, especially in the far-right column.

It quickly became clear that while some vegetables provided a higher % of absorbable calcium of total available than milk, milk by far provided more total absorbable calcium PER SERVING. Just take another look:

This image has an empty alt attribute; its file name is D4CeJ06W0AQL_G4.png

So how many veggies do I need to get my calcium?

Then I started looking at the recommended calcium intakes. That’s when my eyes opened wide. If milk provides only 96.3 mg of calcium in a 240 g serving (about 240 mL), and the recommended intake for adults is around 1000 mg/day, then that would mean that more than 240 mL x 10 = 2.4 liters of milk per day are necessary to meet the recommendations.

And since milk way more calcium than everything else, that’s going to mean a lot of servings of everything else. We’re talking pounds and pounds of vegetables. 6.2 pounds of kale, 7.3 of broccoli, 14.2 of Brussels sprouts. No way!

Fortunately, that’s not quite right. It turns out that the Institute of Medicine takes this into account and provides a rough estimate of TOTAL calcium. This causes the numbers to settle down.

For milk at least.

For the rest?

9 pounds of Brussels sprouts
4.5 pounds of Broccoli
3.1 pounds of kale
0.8 liters of milk

Not looking so great for our cruciferous friends. It turns out that my wife had a point.

Manageable by the average vegan

OK, but if kale calcium for example is twice as absorbable as milk calcium, shouldn’t it get a handicap relative to milk?

For instance, what if because milk calcium was 32.1% absorbable, and broccoli was 61.3% absorbable, we multiply the broccoli calcium by 61.3/32.1, or 1.9? And do that for the remainder of the foods, as well?

In that case, we get:

Brussels sprouts 4.5 pounds
Broccoli 2.4 pounds
Kale 2.1 pounds

That’s still a LOT of food. It should be noted that a VERY LARGE salad is about 200 grams of leaves. 2.1 pounds is about 1 kilogram. So we are talking 5 very large salads each day to meet the calcium recommendation by the Institute of Medicine.

What about the other foods listed? Here’s what a final calculated table would look like:

8 pounds spinach
6 pounds cooked pinto beans
4.5 pounds Brussels sprouts
2.4 pounds broccoli
2.1 pounds kale
1.1 pounds almonds (2880 calories)
~1 pound collards*
0.8 liters milk

* It turns out that collard greens contain some of the highest amounts of calcium per serving in any food.

What would a typical diet with adequate calcium look like? Something like this:

100g almonds, 1-2 pounds of beans, and 3 large kale salads per day.

Or 4 pounds of beans, 1 kale salad, and some almonds.

Theoretically possible for sure, but manageable by the average person? Probably not.

Are the Institute of Medicine recommendations high? Recommendations from around the world

It might be suggested that the Institute of Medicine’s recommendations might be a little high. Yet the IOM’s recommendations are similar to other organizations around the world. Britain’s National Health Service recommends 700 mg per day. Nordic recommendations are between 800 mg and 900 mg per day. The European Food Safety Authority recommended 950 per day.

In fact, in 2003, the World Health Organization put the minimum (rather than recommended) calcium intake to prevent osteoporosis at 400-500 mg. That means that just half of the calcium intake as proposed above will pull a person into the range for potential osteoporosis.

Is fortification the answer?

There should be no doubt that it is theoretically possible to achieve adequate recommended calcium intake on a strictly vegan diet without fortified foods. However, the question is whether such a diet is likely to be reasonable for most people at the present moment. The answer to that question is emphatically no.

There is some question, moreover, about whether fortification itself is optimal. Recent evidence suggests a connection between calcium supplementation and cardiovascular disease–but no connection between dietary calcium and CVD–and the dominant explanation is that supplementary calcium might be too rapidly absorbed. Therefore, if fortification is pursued, it may be best to avoid foods that might be expected to be digested and absorbed particularly rapidly (e.g. soy or almond milk). That said, we just don’t know with certainty. These are just some of my best guesses.

Other alternatives

What we do know is that without eating dairy products–or if you’re Paleo-inclined, bones–it’s not particularly easy to meet the recommendations without eating a high-quality diet rich in leafy green vegetables, or without fortification.

One option for vegans is calcium-fortified tofu. A single block per day (~500g) will provide for nearly the entire recommended daily calcium. If you’re thinking about going or staying 100% plant-based, that might be an important option to consider.

Another option is abandoning a strictly plant-based diet and consuming fish, especially sardines. A serving of just 3 ounces of sardines provides up to 1/3 of the recommended intake, and may provide health benefits beyond the calcium content, too.

Wrapping up

Regardless of the decision made, for bone and other aspects of long-term health, it is important to consider diet quality and what exactly one is willing to commit to when making the decision to consume a vegan or otherwise plant-based diet. Don’t take it lightly! If you decide to take that step, understand that consuming a plant-based diet while avoiding nutrient deficiency takes a lot more planning and care than when consuming an omnivorous diet. Take the time to do things right. Down the road, you will be happy that did.

If you have enjoyed this post or found it useful, please consider becoming a patron at https://www.patreon.com/kevinnbass for as little as $1/day. Your support allows me to keep writing articles like this.

The debate between Gary Taubes and Stephan Guyenet may be one of the most important scientific debates of the decade. Here’s why.

Gary Taubes is arguably the most influential nutrition writer of our generation, alongside Michael Pollan. He shifted the discussion about obesity by providing a seemingly unassailable framework for what was at the time called the Atkins diet.

Taubes—whose brother is an endowed chair of Mathematics at Harvard and who himself has degrees from Harvard, Stanford, and Columbia—is a science journalist who had previously written about pseudoscience in physics and wrote meticulous critiques of nutrition science for Science magazine.

And he changed the conversation about nutrition through what might be called a critical archaeology and reinterpretation of the history of obesity and health research, starting with pre-World War 2 German metabolic science and ending at the end of the 20th century.

The Atkins diet was then on the decline until Gary released his bombshell of a book Good Calories Bad Calories in 2008, which, despite being a 640-page book about science with more than 60 pages of references, topped bestseller lists and has never stopped selling.

Indeed, Gary’s book through its beautifully and masterfully crafted narrative, single-handedly spawned a whole industry of low-carbohydrate books, many of which repeat his book’s main points as if ancient wisdom passed down from some great sage. Echoes of Gary Taubes’s major narratives are everywhere in low-carb and almost everywhere in popular nutrition. (For an entertaining discussion of Gary’s… influence, see this article by Seth Yoder.)

Gary’s model of obesity goes something like this: carbohydrate intake causes an increase in insulin. This increase in insulin causes fat to be trapped inside fat cells and energy substrate to be unavailable for use by the body, resulting in internal starvation. To compensate, appetite increases, energy intake increases, and obesity results.

The obesity epidemic in turn was caused by Americans following the dietary guidelines, which mandated eating less fat. As a result, Americans decreased fat intake, which had to be replaced by carbohydrate. When carbohydrate replaced fat, this caused an increase in appetite according to the above mechanism and thus increased energy intake and thus caused the obesity epidemic.

The focus on energy balance by the establishment has been mostly the result of incompetence. The prejudice against fat in the diet has been mostly the result of ambition. Ancel Keys, one of the founders of nutritional epidemiology, set a precedent based on bad science that now cannot be broken.

Ancel Keys’s dominance in nutrition science is the result of World War 2. German scholars, especially German-Jewish scholars, understood that hormones caused obesity, but there was prejudice against these scientists in American society after WW2 ended. Their research was lost in the aftermath and replaced by that of scientific incompetents in America, an unsophisticated crowd who did not understand much about the scientific method and made everything out to be about calorie balance and just eating too much.

In telling this story, Gary’s demonstrates incredibly storytelling abilities, his command of facts awe-inspiring, and his logical penetration like that of a surgeon with a scalpel. There’s only one problem:

Most obesity researchers think he is dead wrong.

Meet Stephan Guyenet. Stephan came onto the scene in the late 00s and became known for his meticulous, science-minded, evidence-based articles. He eventually published his book on obesity The Hungry Brain in 2017, ten years after Taubes published Good Calories Bad Calories. Stephan, who did his undergraduate in biochemistry at the University of Virginia, his PhD at the University of Washington, and a postdoctoral fellowship under Michael Schwartz, a pathbreaking obesity scientist, presents a different theory of obesity than Taubes.

In fact, Stephan disputes Gary Taubes’s model in almost every detail; Stephan has been in what might be called low-grade conflict with Gary, a nutritional cold war punctuated by small-scale conflict since 2012, when Gary confronted Stephan’s understanding obesity during a fateful presentation at that year’s Ancestral Health Symposium, a yearly Paleo conference that took place at UCLA and which at that time was the epicenter of everything happening in the online nutrition community.

In it, Gary Taubes went after Stephan in a way that was and is rarely seen at the AHS or in discussions of nutrition science, period. Taubes singled Stephan out because Stephan’s theory of obesity was completely different from Taubes’s, and Taubes’s view is exclusive and singular.

When the exchange between Stephan and Gary finally reached a crescendo, Taubes ended by advising Stephan not to cherrypick the evidence, to which Stephan responded coolly, “Thanks for the advice.”

Wow.

This part of the debate can be found here: https://www.youtube.com/watch?v=4hzoFgwFeMQ

Stephan’s full presentation can be found here: https://youtu.be/2XhdP-9FQHE?t=2281

Since then, there has been more skirmishing, including Stephan’s highly critical review of Gary’s latest book on sugar here, along with an exchange between the two that occurred here.

To Stephan, obesity is caused by the omnipresence of calorie-rich, delicious foods high in both carbohydrates and fat. The brain, rather than the body, regulates body fat, and differences in body fatness between people in Western countries is largely due to differences in brains (with most obesity genetics discovered to this point being brain-related). Stephan’s understanding of obesity is the synthesis of the scientific community’s current understanding. This is in contrast to Gary Taubes’s understanding, which is often at odds with the scientific community’s. Stephan, along with a handful of other bloggers, has long battled with virtually every aspect of Gary Taubes’s and his followers’ ideas about obesity. Stephan and others contend that Taubes and his followers cherrypick their evidence and distort what the field has to offer.

What draw Gary often has in raw storytelling ability and an impressive reference list spanning over a hundred years, Stephan frequently matches in a dense and careful marshaling of evidence of his own. Correspondingly, Stephan and others have slowly converted many originally in the Taubes camp to what might be called the “scientific consensus view”. Stephan, like Taubes, now has a large following of his own, including many prominent figures in the scientific community.

Before moving on, it is important to clarify that Stephan is not defending so-called CICO, i.e. calories in-calories out. Stephan wrote about this here. Here is an excerpt:

That’s the Stephan versus Gary background.

So how did Rogan happen? And why?

2019. Keto is the hottest diet around, followed by everyone from liberal Silicon Valley CEOs, finance bros, and enterprising academics to diabetics, weight loss hopefuls, soccer moms and MAGA types. In other words, apparently everyone.

This is of course in stark contrast to the low-fat diets popular in the 1970s and 80s, which were supplanted by low-carb and keto in the 1990s, 2000s, and 2010s. Gary Taubes’s role in this revolution is second only to Atkins himself, and, in its own way, even more important.

Meanwhile, Joe Rogan, a huge keto proponent, runs the most widely listened-to podcast in the world, with almost 200 million downloads per month and likely more than ten billion total downloads. And Joe has interviewed virtually everyone who is important in the low-carb and keto space, some several times each.

This has resulted in a highly skewed representation of what the current science says about nutrition on the most popular podcast in the world. To quantify this, I analyzed this using sophisticated data-mining tools here.

Then, one fateful day… I challenged Rogan on this point. And that story was told here: https://www.youtube.com/watch?v=PzOpePYdWxc

To make the story short, Joe loves keto. Great. And keto and low-carb are really interesting and potentially important health strategies. But a lot of people that Joe has had on his show have, in my view and in the view of many other people, given a biased and distorted view of the role of carbohydrates in the diet. Given the enormity and importance of Joe’s show, things should and could be more balanced.

In response to this criticism and after seriously seeing the analysis that I constructed, Joe decided to try to correct that.

Joe first offered to have me on to debate Gary Taubes.

For obvious reasons, I thought that Stephan Guyenet would be more appropriate. versus Gary Taubes was finalized.Phew.(For those who are interested, I am OK with going on Joe’s podcast if he wants to have me after I finish my PhD.)I think this is one of the most important health debates ever for the following reason:

Obesity is a serious problem worldwide, and contentions about the science are a source of policy paralysis. The reason that we cannot solve the obesity crisis is, in part, because we have a consensus crisis. We cannot agree about what causes obesity.

The low-carbohydrate diet is the most popular contenders for an explanatory framework of what causes obesity. My belief is that it is wrong, and that Stephan’s view is mostly or entirely right.

Having a public conversation about who is actually right is important in order to start moving to firm conclusions among the majority of the population about what has caused the obesity pandemic. This will in turn allow for policymakers to start making real decisions. So my belief is that public discussions like these are not just important scientifically but are the critical first steps to improving the health of, ultimately, billions of people, present and future.

Since this debate is with Gary Taubes himself and Stephan Guyenet, his most important critic—that is why I called this one of the most important scientific debates of the decade: they are both representatives of two of the major dominant strains of thought on obesity. This debate has the potential to be of historical importance.

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As an MD/PhD student, my passion is for communicating the cutting edge of medical science and fighting misinformation. If this post is of use to you, please consider donating to my Patreon account. Your contribution will make a significant positive impact, and I will be greatly personally appreciative.

You can sign up as a patron at my page, here.

You can also find me on Twitter at @kevinnbass.

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The following is a reposting of a thread (here)–with minor, introductory and concluding modifications to make it more appropriate for a blog–that I wrote on Twitter as part of an exchange with Joe Rogan on August 18-19, 2018. Before I wrote these things to Joe, I want to make clear that I had been a close follower of his for some time, and was very fond of his show, the aggressiveness of the exchange notwisthanding.

I also want to make clear that in response to that exchange, Joe had Dominic D’Agostino debate/discuss with Layne Norton and Chris Kresser debate/discuss with Joel Kahn. The final and most anticipated of these debates is that between Stephan Guyenet and Gary Taubes, which will take place on March 19th, 2019. The background information for this last debate can be found here.

Without further ado, it all started with a tweet…

To which Joe responded…

To which I responded…

Your show has positively impacted my life and scientific trajectory, @joerogan. However, contrary to tweets attached–JRE *does* present a unbalanced perspective on nutrition that overwhelmingly promotes a low-carb narrative. I will show this with data.

Here is a screenshot of my spreadsheet that I used to analyze these data. The two colored left-hand columns are an indication of the positions taken on the podcast re: carbohydrates. Green is positive, red is negative. Right column is Joe’s view; left is guest.

I will make the spreadsheet publicly available upon request (note: screenshot is not final), and in this thread, I will be communicating the methods after I have presented the data.

Graphical breakdown of overall findings, below. Of 1136 episodes analyzed, 99 (9%) discussed carbohydrates in a way that framed consuming them as “good” or “bad”. (Interestingly, of the last 157 episodes, 33 (21%) had discussions about carbs.)

There were 6 episodes where carbohydrates were discussed by scientists. 3 negatively (@gadsaad, @jordanbpeterson, @DominicDAgosti2 ), 1 neutral (@sleepdiplomat), and 2 positively (@DrAndyGalpin, @tattoosandbones). If we limit ourselves to nutrition scientists, there was one positive about carbohydrates (Dom) and one negative (Andy).

In contrast, there were 27 episodes with non-scientist gurus (popular communicators who are not scientists, such as healthcare workers, authors, etc.), of which 21 were negative, 4 were positive, and 2 were neutral. The positives were @richroll , @DBolelli, @CameronHanes. The two neutrals were @bengreenfield.

Of athletes, there were 24 episodes. 10 positive, 11 negative, and 3 neutral about carbs.

Of the 99 episodes, you (Joe Rogan) took a position 60 times. 53/60 were negative, and 7 were neutral. Some of these 7 might be considered positive depending on coding criteria. It should be noted that many of these 53 were overwhelmingly negative. “Bullshit” was not a rare word.

Next up. Here is a screenshot of the software that I used. As you can see, the audio “scrollbar” lights up with each mention of “carb”, according to the computer-generated transcript.

The most frequent occurrences of “carb” were Gary Taubes (@garytaubes), Nina Teicholz (@bigfatsurprise), and Robb Wolf (@robbwolf). These interviewees discussed carbohydrates the most (naturally). Here is a screenshot.

Note that all of the non-scientist gurus use scientific language and make scientific claims. Here is a shot of a real scientist, Dom D’Agostino (@DominicDAgosti2). He is also on the first page.

Now take a look at @AndyGalpin. 7 of 15 pages. Andy talks about carbs less than almost half of everyone else who talks about carbs. And Andy was as far as I am aware the only scientist to do something even close to a sustained critique on keto (9 minutes).

This means of approximately 100 episodes where scientific claims about carbohydrates are made (which are usually negative and lengthy), only 1 includes a scientist who can actually give an opposing expert opinion, and he barely talks about it.

You can do whatever you want @joerogan. Obviously.

But what else would you call not taking the many high-carb ppl who have wanted to be interviewed over the years–than refusal? Not sure if conscious or not. Does it matter?

Again, @joerogan you don’t have to have a balanced show. It’s obviously your choice. I commend you on your tweets yesterday where you promised more balance.

However, you did tell Chris Cage exactly this in Episode #939: “I am going to bring in people who are anti-ketogenic diet, as well, so that I can get a balanced perspective on it.” Episode #939 was two years ago.

Now you’re telling everyone you’re going to bring more balance to the show with an anti-keto guy AGAIN. When is it going to be @joerogan? A debate is NOT enough. We need someone who is capable of making an extended argument against @garytaubes and team.

You’ve one-on-oned dozens of people making an extended case against carbs. Interview one capable of making a scientific case a case for them. That’s balance.

Let’s talk methods.

(Then we’ll move onto the comment about kooks.)

I used the software FluidDATA (http://www.fluiddata.com ) to search through the computer-generated transcripts of 1136 JRE episodes available. This suggests 20 missing episodes, but this almost certainly will not affect the analysis.

Using the search terms “carb” (149 hits) and “carbohydrate” (128 hits), I found all instances in these episodes where these terms were discussed–at least according to the transcripts. I then characterized the discussions as positive, negative, or neutral.

Positive discussions were defenses of carbohydrates. Negative discussions were carbohydrate bashing. Neutral discussions were when views about carbohydrates were qualified, or when carbohydrates were spoken about in an ironic (i.e. ambiguous) manner.

In addition, I categorized the speakers involved in each discussion. I then categorized each speaker as of a) comic/author/media, b) guru, c) athlete, d) scientist, or e) @joerogan.

Looks like Twitter is ending my thread. Before I continue, I want to remind you why I responded this way. Attached.

My point is you always choose alt-health guests. Then you interview quacks like Shawn Baker (and others). But you won’t interview at any length a serious scientist that will criticize your beliefs. It’s either out of the mainstream or off the deep end.

Why not get a serious, establishment scientist? You know, to respond to the things you say about them. As for the Lancet paper, who is “legitimate” to you, @joerogan? This is all I have to say.

The rest is history…

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As an MD/PhD student, my passion is for communicating the cutting edge of medical science and fighting misinformation. If this post is of use to you, please consider donating to my Patreon account. Your contribution will make a significant positive impact, and I will be greatly personally appreciative.

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