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 in absolute grams (see below) 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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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.

===

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…

===

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.

===

In latest news, Jason Fung presents a sobering graph on increasing death from cancer, blaming doctors and “Cancer Incorporated” for the rise.

That is, until the last 20 years are included.

Source: Center for Disease Control (CDC)

Age-adjusted death from cancer rapidly declining?! Oops!

The United States is actually currently experiencing among the lowest rates in age-adjusted death from cancer in the past 100 years.

How come? Well, let us look at the cancer mortality breakdown among males.

What was responsible for the swift rise and then swift drop? Yep! Cigarettes. Who was responsible for reducing cigarette smoking? Yep! The medical and public health establishments. And their damned treatments and health recommendations that Jason Fung wants to discredit.

What about females?

Same dealio. Only difference is females adopted smoking later and peaked later. But when you look at the other cancers? They’re either stable or falling. For both sexes

Let’s look at more detail, broken down by age, shall we?

Source:

The rate of death from cancer has declined dramatically from 1950-2015 in all age groups except those older than 85. This is due to a dramatic improvement in cancer treatments at younger ages and a drop in lung cancer at older ages.

But we wouldn’t know that from Jason Fung’s narrative, based, as it is on a research article that is more than 20 years old:

Yep, Jason Fung is basing his conclusions on data that are 25 years old.

What about cancer treatments? We have already seen that among younger people, there has been a dramatic decline in cancer deaths, indicating massive success in modern cancer treatment. But let’s look at a breakdown in 5-year survival by cancer type (right-hand column):

Source: Summary of Long Term Changes in Cancer Mortality and 5-Year Relative Survival – sect_01_table.04.pdf

A far cry from the claims of Jason and his publisher Andreas Eenfeldt (owner of the popular low-carbohydrate diet website www.dietdoctor.com).

To finish, it is worth understanding the sleight of hand at play with Fung’s final presented graph:

How does this graph square with what we have seen earlier? Let’s recall:

This image has an empty alt attribute; its file name is Screen-Shot-2019-03-10-at-6.39.50-PM.png

So why is cancer mortality going up in Fung’s graph while age-adjusted mortality is going down? Here’s why:

Source: https://www.census.gov/newsroom/releases/archives/2010_census/cb11-cn192.html

And because cancer mortality is greater among older people…

Source: SEER*Explorer

Because the population is aging, and older people die of cancer at higher rates than younger people, presenting the statistics in a non-age-adjusted form and calling that “an increase in cancer” is seriously misleading. Jason Fung knows this, but presenting the data as they really are would destroy his narrative.

It gets worse. Let’s look at three charts. The last one is a whopper. But take a brief look at the next two first.

Let’s look at those aged 65 and younger.

Source: SEER*Explorer

Declining for the past 40 years.

What about those aged 65 and older?

Source: SEER*Explorer

Even among those whose risk of death from cancer goes up exponentially with age, death from cancer for the past 20 years has been declining.

Now let’s look at the cancer mortality for those aged 50 and younger.

Source: SEER*Explorer

A halving of the rate of death from cancer in the past 40 years in people aged 50 and younger.

If these three graphs do not demonstrate resounding success in the war against cancer, I don’t know what does.

So what’s up with Jason Fung’s article? What is his… goal? The same as everything else he writes. He hopes to instill fear and stir up and then capitalize on resentment and anger. He wants to paint the medical establishment and government as having failed the American people.

And then? And then… he wants you to take him as the authority. He wants to replace them… with him and his friends. And then he wants to sell his shitty books that also peddle an endless stream of deceit using exactly the same tricks that I have detailed here. And he wants to sell you bullshit supplements and fake science conferences.

Don’t let him.

The true story is that the drop in cancer deaths is directly attributable the very institutions that Jason Fung tries to discredit. Jason Fung is a fraud and his goal is nothing other than social corrosion for his own profit.

Don’t fall for his crap.

===

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.

===

Contrary to claims, Virta has not “reversed diabetes”.

Not tolerating carbohydrate is a pathology. If diabetes has been reversed, glucose tolerance should be restored. If glucose tolerance has not been restored, then LCHF is no different paradigmatically than symptom management with pharmacotherapy.

That disease reversal requires a test with carbohydrate does not imply that a high carbohydrate diet should be resumed for more than a few days, if a low-carbohydrate diet is the preferred means to achieve disease reversal.

That disease reversal requires a test with carbohydrate only implies that a brief demonstration of carbohydrate tolerance is necessary to demonstrate disease reversal.

A few days of carbohydrate at reasonable calorie intake will not compromise glucose tolerance if disease reversal has been achieved. If it does, then disease reversal has probably not been achieved.

Since Virta has not verified disease reversal in the manner explained above, it cannot be said that the Virta study has achieved reversal of diabetes. This is well-understood by the Virta scientists, and it is still unknown why their study has not incorporated this evaluation.

(Originally posted January 10, 2018 on Medium: https://medium.com/@kevinnbass/the-data-do-not-support-the-idea-that-the-low-fat-dietary-guidelines-caused-the-obesity-epidemic-687e382894ed. Copied in full to Patreon September 21, 2018, with sporadic additional commentary as noted in the text.)

According to Dr. David Ludwig and many others endorsing the Low Fat Dietary Guidelines Caused Obesity Story (including Dr. Robert Lustig, journalists Gary Taubes and Nina Teicholz, and others), the Dietary Guidelines for Americans (1980) caused Americans to reduce fat consumption, increase carbohydrate to compensate for the reduction in fat, and become obese.

This occurred because, according to the story, carbohydrate is uniquely obesogenic: carbohydrate consumption is said to stimulate appetite and food intake. And, because carbohydrate consumption increased as a result of the dietary guidelines, the dietary guidelines can therefore be said to have caused the obesity epidemic. The conclusion: if we change the dietary guidelines Americans will eat fewer carbohydrates, and the obesity epidemic will be solved; in short, to regain our health, we must to return to the Lost Lower Carbohydrate Dietary Guidelines Golden Age.

I believe that a substantial range of data demonstrate that this story is incorrect and not even plausible from the point of view of a well-informed human behavioral ecology. However, for the time being, I will focus simply on refuting a core claim, namely that in response to the Dietary Guidelines for Americans, fat consumption was drastically reduced. I will demonstrate here that this claim is directly contradicted by the available evidence, namely that released by the Centers for Disease Control and Prevention (CDC) and United States Department of Agriculture (USDA). I know of no available evidence that supports this core claim of the story.

Although I have characterized the position that I will be providing evidence against, before proceeding let us focus on precisely the words used by the proponents of the story in question. I will focus on the claims of Dr. David Ludwig, in part because of his influence, in part because his statements are representative of the widely held narrative. But mostly, I will admit, because he told me I am wrong.

But unless I have made some fundamental error in my dozens of hours spent in front of Excel spreadsheets, poring through, organizing and re-organizing, and thinking about the data, then I am not wrong. I do not rule out the possibility that I have made such an error. Much stranger things have happened in science, to more gifted individuals.

Therefore I’ve no ego in this. But, I will argue against what I interpret as a popular myth, based upon a long and careful assessment of the data. I hope if someone has a different interpretation that they feel equally certain about, they will do the same in turn against me.

Onward.

That’s a misleading statistic, Kevin. If we’re to look at trends, then total fat vs total carbs is more relevant — and that point is clear (it’s been the processed carbs). For a more complete review, see my pieces JAMA or CNN, linked here: https://t.co/GMriOyh8U7https://t.co/104Ap8D74H

 — @davidludwigmd

In providing these quotations, I will reference the above article, as well as the CNN and JAMA articles that Dr. Ludwig has provided as support for his claims in that original article.

Quotation from the original article that started this discussion:

Source: https://medium.com/@davidludwigmd/genetic-study-supports-carbohydrate-insulin-model-of-obesity-327d84be6d2b

(It is worth noting that Stephan Guyenet [Twitter: @whsource] has written an interesting rebuttal to this post of Dr. Ludwig’s, here: http://www.stephanguyenet.com/interesting-new-genetic-study-on-insulin-secretion-and-body-mass/. – KB 09/21/2018.)

It is worth noting here that Dr. Ludwig considers the “low-fat diet craze” a central point of contention, and indeed, as we shall soon see, the causal factor of the “flood” of processed carbohydrates that he believes is responsible for the obesity epidemic.

Now, let us take a look at the relevant quotation from the CNN article that Dr. Ludwig references in his tweet:

Source: https://www.cnn.com/2016/10/05/opinions/debate-low-fat-diet-ludwig/index.html

Here Ludwig cites unreferenced figures (>40% to ~30%) that I shall soon show are at odds with known facts. Perhaps more important, however, Ludwig causally links the replacement of fats with carbohydrates to “surging rates of obesity and diabetes”. Once again, we see how pivotal the notion of “low-fat” is to Dr. Ludwig’s explanatory schema — and how dramatic he considers the shift from the traditional American diet to the post-1980 low-fat diet to be. As we shall see, however, low-fat was neither causal in the increase in calories, nor was fat indeed reduced; fat increased after the guidelines were released.

Let us finally look at the relevant quotation from the Journal of the American Medical Association (JAMA) opinion piece that Ludwig referenced in his tweet:

Source: https://jamanetwork.com/journals/jama/article-abstract/2564564

Again, we find an unreferenced “30%” figure, as well as the claim that this 30% figure was caused by the dietary guidelines. The 30% figure is demonstrably untrue; the claim of causation by the guidelines is both unestablished and unreferenced, and I believe does not hold up to scrutiny when compared to the behavioral scholarship that is presently available to researchers.

What do the data say? We will begin by using USDA ERS data. USDA ERS data are obtained by USDA. USDA surveys food producers and compiles these records to estimate the total production in a country, county, city, etc. There are dozens of survey types, covering many types of food producers. USDA tries to capture data from all major food producers. USDA ERS supply data is considered a good proxy for consumption, though it cannot easily take into account waste. Because of this, calorie estimates per capita are often higher than what is actually the case. This is an important limitation of USDA data. However, USDA data are generally regarded as representative of food consumption trends, even as the number of absolute calories may be substantially lower.

With these caveats, let’s take a look at USDA supply data on fats and total calories.

As we can see, supplied calories from fat has consistently increased since 1910; they have not been decreasing relative to America’s traditional diet; they have been increasing; arguably, fat calories supplied increased at a faster rate post-1980 than before. This is not consistent with Ludwig’s claim that fat was reduced after the release of the Dietary Guidelines, nor with the claim that fat was higher before the guidelines.

Indeed, immediately after the guidelines were released, we actually see a small spike in fat calories supplied, the opposite of what we would expect if Ludwig’s hypothesis were true.

To remind ourselves of Ludwig’s claim that fat decreased, let us revisit his quotation from JAMA:

Note that Ludwig is correct that total calories have increased. Indeed, this increase, according to USDA and as we shall see, has largely been driven by an increase in fat calories — not carbohydrates.

Let us now take a look at the percent fat of total calories changes:

Although there is indeed a decline in fat calories as a total % of total calories, note how modest this decrease is, from 41% to 37%, or a 4% decline. Yet, this 4% decline in fat calories is claimed to account for the obesity epidemic.

Is this a plausible theory?

(Note, as a percentage of total calories, the increase in fat calories from 1980 to about 2000 (seen in the previous graphs) does not translate into an increase in fat %. This is because carbohydrate calories during the 1980–2000 period are increasing at an even faster rate than fat calories.)

Note, moreover, that by the year 2010, fat calories % was actually higher than in 1980. If Ludwig’s theory were true, we might therefore expect for carbohydrate intake to have decreased to levels below that of 1980. However, we can see that this is not the case:

Here we can see that carbohydrate intake in 2010 was still much higher than in 1980, and had only decreased modestly from its height in 2000 — despite a record high in fat intake (and, correspondingly, obesity).

Finally, let’s take a look at food categories and see what these have been doing over the past 40 years.

And here’s the whopper: over the past 20 years, fats have been the only major food category to increase. Everything else has gone down. Calories up, obesity up.

Perhaps most worrying for Ludwig’s thesis is that USDA reports a slow decline in calories since 1909, then a sudden sloping upward starting in the 60s and 70s.

The sloping downward makes sense: people are engaging in less physical activity and consume fewer calories. But the sudden increase in calories starting in the 60s and 70s needs to be explained. And it can’t be by Ludwig’s theory.

Now, it might be argued that food supply data do not adequately show real consumption trends. Let us therefore look at data from the CDC, obtained through the National Health and Nutrition Examination Survey (NHANES). NHANES, like USDA ERS, estimates food consumption, but through a different method: consumer surveys. I prefer USDA data, and I am not alone. It is objective. NHANES data reflect aspirations and what people believe they should be doing, rather than what they are doing. Multiple studies have shown that consumers underestimate total calories consumed — and especially fat. Obese people underestimate more than lean people.

Nonetheless, we will look at the NHANES data, and as we shall see, it too tells a different story than Ludwig’s. Let us start with total fat calories reported:

As we can see here, consumers actually reported an increase in fat calories just after the Dietary Guidelines were published. This contradicts Ludwig’s (and others’) claim that a decrease in fat calories caused people to eat more carbohydrates, becoming obese.

Moreover, if fat grams are increasing, then according to Ludwig, carbohydrates should be decreasing. Yet, according to NHANES data, carbohydrates went up dramatically:

Why carbohydrates went up is anyone’s guess. But it wasn’t driven by fat going down.

Now, what makes less sense is that even as fat in the food supply went up over 200 calories per capita according to USDA, reported fat only increased slightly. While this goes against Ludwig’s thesis, I don’t have a explanation that I am confident about for why this should be.

One possible explanation is that all of this added fat is in the form of cooking oils in restaurants. Because the cooking oils are thrown out after they are used, presto, consumers eat the same amount of fat, but more fat in the food supply is recorded. This is supported by the USDA data, if we take soybean oil to be the principal form of added oil in cooking oil.

For this explanation to work, we would need to see at least *some* decline in other sources of fat in USDA data to compensate. This is because if people are increasing their fat intake through restaurant-fried foods (if only modestly, i.e. much less dramatically than USDA would indicate), they would need to decrease their other sources of fat intake.

We see something like this in the USDA data. People consume less margarine, less tallow, less red meat, more chicken. Balanced out, people would seem to be consuming an uncertain amount more vegetable oils, and an uncertain amount of fat from other sources.

Another explanation is that as people get fatter, they progressively underreport their fat intake. This is supported by the findings of several papers. One, published in the International Journal of Obesity, reports particularly striking results, with an increase in underreporting as the obesity epidemic increases, with obese individuals underreporting more often than non-obese individuals. A screencap of the abstract:

This article may incidentally also explain why carbohydrate and calorie consumption seem to be going down in NHANES, even though the obesity rate continues upward only slightly slower than in previous years.

Finally, let’s look at the NHANES data reported as a % of fat — not total quantity.

From 38% to 34%, despite an increase in total fat. A far cry from >40% to nearly 30%, which is Dr. Ludwig’s charge. This change literally consists of a few grams of fat per day, causing the obesity epidemic. Again, note that the total fat calories are identical in 2010 to those in 1980. Only the total calories have changed.

Wrapping up. As food for thought, let’s look at China, perhaps one of the most dramatic cases of an explosive and sudden obesity epidemic in the known record. What does China teach us?

(Macronutrient figure adapted from Wan, 2017. Diabetes data from Shen et al, 2014; overweight/obesity data from WHO.)

(And to answer the pre-empt the question: no, it’s not because of an increase in sugar. Sugar consumption in China has remained incredibly low and stable for the past half century.)

To nutrition afficionados in these days, such graphs may strike some as confusing, even bizarre. In part, this is because a lot of us have been taught that carbohydrates cause obesity. But again, epidemiologists have known for generations that the nutrition transition accompanying industrialization classically looks like China’s — with the attendant diseases.

People deserve to know the truth. The truth goes deeper than anything presented by the low carbohydrate advocates. And it is much more complex than anything I have presented here. But only with the truth can we solve our present crisis of obesity and chronic disease.

The low-fat-caused-obesity story is a myth, and one that needs to die. Will Dr. Ludwig help us put this myth to rest? We can hope. The sooner we can come to an agreement, the sooner we can solve the present crisis — which is one of far greater significance than merely health, as Dr. Ludwig has written — and help the many people who struggle with their weight and their health.

In the meantime, for an in my opinion excellent overview of what many obesity researchers do think makes us fat, I recommend obesity researcher Kevin Hall’s recent article, “Did the Food Environment Cause the Obesity Epidemic?” http://onlinelibrary.wiley.com/doi/10.1002/oby.22073/full

I look forward to comments and criticisms.

===

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.

===

“Eat like your ancestors. Go Paleo like your caveman forebears. Eat in an evolutionary way. Cut gluten—our ancestors didn’t eat wheat—and gain your health back. Intermittent fasting—like hunters who haven’t yet caught their prey—maintains lean muscle mass but shreds fat: it’s how we were evolved! Whole30: 30 days of eating like evolution wants us to!”

We are told over and over that if we “just eat like our ancestors,” we will attain optimal health.

But what if this is a popular myth, an ideology that romanticizes the past, and what if the diets that propose that one eats in this way are based on mythical constructions of that past?

I disagree that we should “just eat like our ancestors.” Here’s why.

1. What did our ancestors actually eat? Knowing what our ancestors ate is possibly as difficult or more difficult than nutrition science itself. For instance, it was long thought that our ancestors never consumed grains. We now know that grains were regularly and almost universally consumed during the entire record of the Paleolithic to which we have access:

(From: “Plant foods and the dietary ecology of Neanderthals and early modern humans“)

2. Which ancestors to look at to eat like? What our ancestors have eaten has changed radically and rapidly over time. A brief look at the history of the European diet over the past one or two thousand years demonstrates this clearly. (For example, see: https://en.wikipedia.org/wiki/Medieval_cuisine.) The wide variety of documented dietary strategies in the anthropological and archaeological record does likewise.


(Credit: Jen Christiansen, Scientific American)

3. What timeframe is most important for evolutionary change? Recent evidence suggests that recent evolutionary change could be the most rapid. (For more, see: “Recent acceleration of human adaptive evolution“.)

4. What are our goals? Our ancestors were optimizing for fecundity not longevity, and within certain resource and/or time constraints. Many of us are optimizing for long-term health, and we have far fewer resource constraints. Our ancestors were looking to stay alive and maximize survival reproduction. They didn’t have their eyes on how they will maintain health into their 70s, 80s, 90s, or even 100s, because most of them did not expect to make it to those ages. Today, we face the real possibility of living that old—especially if we maximize health and minimize our rate of aging early in life.

It is true that industrialization and what might be called the post-industrialization of the food system has been a catastrophe for chronic disease risk. And starting with whole foods is likely to be the best starting point for creating a diet. But that’s the end of it.

After that, a better approach is to look at populations that have the characteristics we want—say, maintaining a healthy weight and being healthy for as long as possible—and try to determine what features of these populations explain these characteristics. Using animal models, well-designed observational studies and wherever possible randomized clinical trials in modern populations, we then test our ideas. If our ideas hold up to these tests, we incorporate our findings into recommendations. If they don’t, or if they have intolerable downsides, we try to explain why we got things wrong.

Logical, science-based. No romanticization of a past that we reconstruct in our imaginations involved. No conspiracy theories necessary. Modern health science incorporates all evidence in a critical way to come to conclusions. That is why modern science is better than the Paleo paradigm or so-called ancestral health.

We still must tailor the recommendations to our own life situations. Only we as individuals are can adapt the science to what feels best and healthiest for our own bodies. But we need to keep our minds open to what the cutting edge of hard, critical science can contribute to that quest for personal optimization. It isn’t always–or even often–what the Paleo gurus would have you believe.

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