Chris Gardner strikes again!

Weight loss on low-fat vs. low-carbohydrate diets by insulin resistance status among overweight and obese adults: a randomized pilot trial (Gardner et al., 2015)

 

diet compositions

 

Low carb diet: participants went from 230 grams/d to less than 50 for the first 3 months, then creeped up to ~80 over the next 3 months.

Will the critics say “the carbz weren’t low enough!”?  REALLY?

 

 

Background reading:
Carbs: Low vs. Lower
Insulin Resistance (includes a great video by Gardner)
Personalized Nutrition by Prediction of Glycemic Response

In brief, the one-size-fits-all diet theory is #fail.

Don’t be tied down to one approach; different #contexts require different approaches, and both can change over time.

On to the new study:

At baseline, patients were divided into insulin sensitive & resistant groups based on insulin levels (AUC) during an oral glucose tolerance test.  Then those groups were assigned to either a low fat or low carb diet.  There were four groups, three time points (baseline, 3 months, and 6 months).

 

To make a long story short, insulin sensitive patients randomized to the low fat diet lost about 20% more weight than those randomized to low carb.  Read that sentence again (just the part in bold).

 

weight loss by diet and insulin status

 

Insulin sensitive dieters lost more weight on a high carb diet than a low carb diet (10.4 vs 8.6 kg).  Insulin resistant dieters lost more weight on low carb (9.6 vs 7.4 kg).  Notably, of all four groups, the most weight was lost on a high carb diet (10.4 kg) despite low carbers consistently getting more protein.

Don’t be a science denier!

Body comp assessment would’ve been nice, but whatevs…

 

weight loss plot

 

Was there a lot of overlap? yes (EVERYONE lost weight)

Was there statistical significance? no, except  metabolic parameters improved more so in people assigned to the insulin-appropriate diet (ie, LC for IR, LF for IS).

Are these data meaningful? YES

 

I say this because the differences are very close to the magnitude we’d expect in these populations.  Insulin sensitive dieters lost 20% more weight if they were assigned to a low fat diet, but they still lost weight on low carb…  we wouldn’t expect insulin sensitive dieters to gain weight on a low carb diet, just lose a little less because it’s not optimal in this #context.

 

Diet chart

 

Are there a million other factors involved here?  YES.  Insulin sensitivity  is only one of ’em, but a pretty good starting point.

Theoretical scenario: a sedentary, obese insulin resistant patient starts off on LC and is initially successful.  They start exercising and focusing on sleep quality, insulin sensitivity improves (ie, new #context)... but weight loss stalls in many of these people.  Maybe at this point they would benefit more by switching the focus from strict LC to monitoring other things, like calorie or fat intake (ie, to match the new #context) –> progress resumes.
Maybe.

 

Don’t be tied down to one approach; different #contexts require different approaches, and both can change over time.

 

That’s all, for now.

 

 

calories proper

 

 

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  • Nutty_da_Squirrel

    “…but weight loss stalls in many of these people. Maybe at this
    point they would benefit more by switching the focus from strict LC to
    monitoring other things, like calorie or fat intake (ie, to match the
    new #context) –> progress resumes.

    Maybe.”

    Or maybe they could go on a ZERO-CARB diet.
    Maybe.

  • Ben G

    Your theoretical scenario is my current experience. Lost 105 lbs in a year on a low carb diet that evolved into a keto diet. Was obviously insulin resistant, high sugar intake for years including lots of sweet tea and soda. That was 2 years ago, over the last year slowly gained back 20 pounds (even though most of the time in keto via breath ketones) and was beyond frustrated. I was exercising like crazy, HIIT, cardio, weights, etc. I feared carbs and was starting to fear protein. I finally woke up to the lunacy.

    Last month I started adding back fruits such as blueberries, strawberries, blackberries and the occasional apple. Other carbs such as mashed potatoes (hat tip to Richard Nikoley), pinto beans, black beans…maybe even a piece of German Chocolate cake on a special occasion. I’ve dialed back the fat and probably hit around 50% fat, 30% carb, 20% Protein. Since I’ve added back carbs I’ve already lost 5 pounds and feel great.

    I feel like there is a ton of LC/Keto info out there for the noob IR folks…but then what? Once you lose the weight and are no longer IR, there just isn’t a lot of info out there on where to go next. All that to say, great and timely post Bill. Much appreciated.

    • thanks!

      wrt beans/legumes: I get a lot of positive anecdotal feedback about these foods — they seem to improve blood glucose control in a lot of people

  • Martin

    OK, people lose weight on HCLF. What’s next? Should they continue eating close to 60% carbs? What’s the long-term plan here?

    If you read Richard’s posts he points very strongly to one effect of his potato approach: overcoming hunger/cravings. I believe this is the key to weight loss and it might well be that switching from LCHF to HCLF fixes it for some folks. At least for a while. But what’s going to happen later after 1, 2, 3 year(s) of 60% carbs?

    • Phil Thompson

      1 IS person on HCLF regained Metabolic Syndrome from month 3 to 6. We don’t seem to have the 3 month weight data but that’s not a good sign.

    • Ben G

      If one feels they are going back towards IR, I would assume another period of LC or Keto would regain insulin sensitivity.

  • Danny J Albers

    I actually lost my first 75 or so lbs on the low fat, calorie counting, exercise approach, my only complaint was constantly hungry which honestly after about 6 months constant hunger is no longer a trivial thing! But its certainly a lot easier I find getting food variety in a low fat diet then a low carb even though my labs come out much better on low carb which really was the final arbiter.

  • TechnoTriticale

    The net carbs seem low enough, almost keto, really.

    The diets, however, were pretty radical for both groups (compared to SAD):
    “The fourth strategy was to promote high nutrient density (Quality). Other Quality concepts included “real food,” “minimally processed,” “seasonal,” “organic,” “grass-fed,” “whole grain,” and “pasture-raised,” depending on diet assignment. Both diet groups received similar instructions to drink water, maximize vegetable intake, and to minimize added sugars, refined white flour products, and sources of trans fats.”

    Added sugar intake dropped substantially for both groups. Is what we looking at actually captured by this:
    “Notably, there were no calorie restriction targets in the intervention. … Reported energy intake suggested an average ~600 kcal/day decrease at 3 and 6 months relative to baseline (~30% energy).”

    Spontaneous caloric intake reduction: Hawthorne effect, or the effect of removal of all that sugar and white flour in both groups?

    Lacking postprandial BGs, it would have been nice if they had measured HbA1c. I find it somewhat troubling that they didn’t. I would also like to have seen some other markers, like hsCRP.

    Using TG as a proxy for glycation, all were elevated going in, and if I read that confusing Risk Factor table correctly, it appears the LC group dropped faster. Additional useful/raw data is not in the supplementary material.

    I’m disappointed that they relied on LDL-C as a marker for anything. If LDL matters, actually measure it (LDL-P) via NMR, VAP or electrophoresis. The primitive Friedewald equation was an approximation to begin with, and was based on an assumed diet. This LC diet is not that assumed diet, and the LF diet may not be either.

    “…there was modest recidivism in the LC group whereas macronutrient ratios were more stable for LF during this phase.”

    That might be those “whole grains” talking.

    • erdoke

      Reduced weight, reduced insulin, reduced triglycerides. No chance that inflammation was not reduced. Most likely losing weight = losing inflammation.

  • NY

    “Insulin sensitive dieters lost more weight on a high carb diet than a low carb diet (10.4 vs 7.4 kg). Insulin resistant dieters lost more weight on low carb (9.6 vs 8.6 kg). Notably, of all four groups, the most weight was lost on a high carb diet (10.4 kg) despite low carbers consistently getting more protein.”

    Looking at the table, should it not be: IS on LF vs LC ( 10.4 vs 8.6KG) and IR on LF vs LC (7.4 vs 9.6 KG)?

    Also looking at total values: total weight lost on LF: 17.8KG, total weight lost on LC: 18.2KG.

    Terms IS and IR are highly vague. People who gain weight easily have highly insulin sensitive fat cells.

    The question about high carnbers is for how long would they stay “IS” in the long run?

  • billslo

    “Body comp assessment would’ve been nice, but whatevs…”

    If you’re only talking about short term weight loss, maybe. But if
    you are talking about long term health, isn’t the preponderance
    of evidence that LCHF is superior to LFHC in improving
    health markers?

    • “metabolic parameters improved more so in people assigned to the insulin-appropriate diet (ie, LC for IR, LF for IS)”

      • billslo

        “Body comp…” Not answered.

        Wouldn’t someone’s “metabolic parameters” “improve” if someone is packing more fat into their fat cells during the interval until their fat cells don’t have any more capacity?

        You haven’t answered other posts regarding what do you think happens to the people on the 60% carb diet for decades.

        Gardner’s stuff always seems disingenuous to me.

        • “what do you think happens to the people on the 60% carb diet for decades?”

          Nothing.

          • billslo

            It’s your blog…

          • plenty of people have been observed to thrive on a wide variety of diets, common theme seems to be a focus on high food quality

          • Guido Vogel

            Interested to see what “high food quality” means. I never ate much sugar/McDonald’s/packaged food. Always interested in good food, 30+ years homecook. But overweight.

            Failed for 30 yrs to lose weight on low-fat/cal. restricted. Succeeded with LCHF. Weight stable for 3,5 yrs now. Seems there is much truth in the insulin model of obesity.

            But as Chantelle nicely describes, there might be other ways to lose weight/stay lean with lots of good carbs.

            My question: what is/are the main mechanism(s) for getting obese other than via the insulin pathway?

          • CICO. Plenty of people have gained fat mass even while in strict nutritional ketosis.

            Less common? perhaps

            Easier to do w/ processed junk food? definitely

          • billslo

            CICO is not a mechanism, it’s a tautology.

          • Chantelle

            Great article – Seems like ketosis is likely a protective mechanism designed by our bodies to enable us to meet our energy needs during times of scarcity. In that case, it doesn’t sound like something that should be used 100% of the time. Maybe as a short term hack for those who need to lose weight. thoughts?

          • Chantelle, thank you for all of these great and thoughtful comments! Very much appreciated.

            As to your question, ketosis isn’t necessary for fat loss (a short term hack, as you said, perhaps… but not *necessary*). Strict ketosis is important in certain clinical situations like drug-resistant epilepsy and even some cases of bipolar disorder… but not fat loss per se.

            Here are two other articles I’ve written about this with links to relevant studies:

            http://caloriesproper.com/carbs-low-vs-lower/

            http://caloriesproper.com/dietary-protein-ketosis-and-appetite-control/

            And even in the study in this blog post (Gardner et al.), low fat [non-ketogenic] dieters still lost a lot of weight.

          • Chantelle

            Great articles … lots of amazing insights around low carb and ketosis. I would have thought otherwise. Thanks for that … and great being part of this community!

            BTW … came across this article from Denise Minger … which discusses the benefits of ultra low fat (pretty aggressive at 10% fat). Denise seems to think that the Holy Grail lies in the extremes – either very LCHF or very HCLF. http://rawfoodsos.com/2015/10/06/in-defense-of-low-fat-a-call-for-some-evolution-of-thought-part-1/

          • Thanks!

            If you’re interested, Michael Greger over at http://nutritionfacts.org/ did some videos on those VLF studies a few years ago. Interesting stuff, imo.

          • rs711

            Hi Chantelle,

            you might find Peter’s *speculative* alternative explanation to Denise Minger’s “carbosis” (ultra low-fat) blog post interesting – if very technical. http://high-fat-nutrition.blogspot.fr/2015/10/protons-and-ultra-low-fat-once-more.html

            Fyi, if you take the conclusions found in Denise Minger’s references at face value, then yes, her blog posts makes sense. If however you dive into the references she cites, you will discover that the quality of evidence is extremely poor (sample size, surrogate measures, no replication etc. etc.).

            I would suggest being skeptical of the conclusions had in those “carbosis” references.

            Cheers ! 🙂

          • Chantelle

            Thanks for that … appreciate your input. As a person who is unbiased either way – am not a ketoisis or a carboholic advocate … I find that all research can be picked apart by the opposition. So I’m open to all information, then I make the right decisions for myself and my health – without falling into a trap on thinking one way is the only way. I love interesting research (it’s the way we find out more about our bodies) … but I hate dogma 🙂

          • rs711

            any time! 🙂

            unfortunately i think you are (somewhat) biased. How could you not? i think everyone is (more or less) biased given how every human must eat & is necessarily making decisions about what/how to eat (aka not die lol) every day. so i have no problem admitting my bias, although I am adamant about minimizing it. this is why i read so widely about the topic of nutrition and health generally.

            do you read the anthropological literature? i find it fundamental to understanding human health & behavior. If you’re interested, i can share many cool studies (& books) with you on the matter. 😉

          • Chantelle

            Ha Ha … you got me … I’m probably a “little” biased towards the way that has worked for me all these years. Personal experience ranks higher to me than any studies. But I’m like you … I’m curious – for myself – because nutrition and wellness are my passion. And because so many people are getting it wrong – so I really want to understand how our bodies work.

            Why Bill’s article resonated with me is because I truly believe there is no one size fits all. If you look at the Blue Zones across the world, the all do different things and are all healthy, vital and live pretty long. That makes me believe, there are a range of scenarios under which the body can perform optimally.

            That being said, I’m always open to learning more … so please share your cool studies. Would love that 🙂

          • rs711

            cool, you can email me at raphi.inter[at]gmail.com for the studies.

            “Personal experience ranks higher to me than any studies” ==> ah, that’s where we differ in an important way; i place science & empiricism above personal experience. By science, i mean as practiced by Richard Feynman, Carl Sagan, Paul Davies & Petro Dobromylskyj for example. Personal experimentation is something I love but it NEVER surpasses hard data.

            Chantelle, no one with half a brain would disagree with “I truly believe there is no one size fits all” 🙂
            But that’s a general truism that doesn’t get us very far in helping people get healthy. We must know how, why & what to do with individuals. So if I may be so bold in suggesting that you read the Gardner study yourself and seek out its limitations – we can agree with a general point/concept yet disagree with individual studies/pieces of evidence that purport to support it…

            For example, there are plenty of supposed reasons why LCHF is good for weight loss or health that i totally disagree with, yet i clearly think a well-formulated LCHF diet *can* be good for weight loss or health.

          • please send me the studies, too! (or just post them)

          • rs711

            o_0 mine was a general invitation for whatever would interest Chantelle…i doubt that this would interest you Bill.

            However, if you are, then sure 🙂

          • Nutty_da_Squirrel

            Here’s what he, and others, think of being in ketosis:

            http://eatingacademy.com/nutrition/is-ketosis-dangerous

          • “Ketosis in an evolutionary context”

            http://caloriesproper.com/ketosis-in-an-evolutionary-context/

          • Nutty_da_Squirrel

            In that blog you said, “Most of the time, I advocate a plant-based low-carb Paleo-like diet
            for health; keto if obese insulin resistant. High[ish] protein for all
            (ymmv).”

            If that’s the case, then I don’t know what we’re debating and disagreeing about. Unless you’ve changed your mind, and hence your eating habits, since.

            If you’re into eating plant-based carbs, then I don’t see how you can’t be in ketosis at least some/most of the time unless you’re eating a ton of pure protein (protein shakes?) and/or starchy veggies.

            Ingesting HP usually goes along with eating HF, unless you’re consuming protein shakes as I mentioned. And cellular carbs contain a lot of fiber and water, but very little in the way of carbs (starchy ones being the exception).

            Sooo…???

          • “If that’s the case, then I don’t know what we’re debating and disagreeing about.”

            what did you disagree with?

          • Chantelle

            Interesting article … Ultimately there are factors that affect calories in/calories out – such as Sleep, Stress, Genetics, Hormonal Imbalance to name a few … but at the end of the day – when you factor in those things and the relative impact that they have on the equation … it still eventually comes down to CICO. If you are taking in more than you expend (for whatever the reasons listed above), it is almost impossible to lose weight.

          • weilasmith

            If you take in more than you expend, it’s almost impossible to lose weight. That is true, but the key point is why do people take in more than they expend? What leads to those cravings? In metabolically healthy people taking in good quality Whole Foods, cravings or appetite should be in balance to energy expended. So let’s stop looking at low carb vs. Low-fat, and look at what’s causing appetite to be out of sync with energy expended.
            I know someone in Taiwan who only eats good quality Whole Foods. He eats a lot of vegetables rice and fish in a traditional Taiwanese diet. But he has an office job where he is sitting for much of the day, and he never does any kind of real exercise. He is 51 years old and he has a nice big belly eating traditional Taiwanese food. He just eats too much of it for the energy he expends.

          • Chantelle

            Good point … I think people take in more than they expend for a variety of reasons – such as the ones listed above.

            Sleep – not getting enough can slow metabolism AND also increase appetite. Same for stress. Same if your hormones are imbalanced for example

            BUT – those are the reasons related to our physiology. What about external reasons – such as the fact that we are inundated with highly palatable and rewarding foods … it is EASY to overeat – even if it’s healthy food. And some foods affect the reward center in the brain so much so that we continue to eat, even though we are full. If people stopped eating when they were full – then no one would ever eat dessert. Think about it – we don’t eat dessert because we are hungry – we eat it because we WANT it … there is a psychological reward for eating it.

            And we don’t even want to get into the other psychological reasons – like for emotional fulfillment. If our lives aren’t where we want them to be – then we use different mechanisms to feel better – for some it’s shopping, for others it’s those 2 glasses of wine a night – for most … it’s food.

            Another reason is our approach to food growing up. If we were always told to “finish everything on your plate” … that translates into similar adult behavior, where conditioning bypasses our physical needs. There is a famous study with a never – ending bowl … where people kept eating as long as food was in the bowl. Way beyond their hunger needs.

            Our relationship to food is very complex … and in metabolically healthy people – we often look at the physical reasons why appetite and cravings aren’t in balance. But the psychological plays just as much if not more of a role.

          • weilasmith

            Chantelle, you are living in the modern world with all the temptations, but you aren’t tempted as evidenced by your good health. why is that? maybe you had a better foundation than most- your mom ate healthily and had no pregnancy complications- so you developed well in-utero, you don’t have the diabetes genes like TCF7L2 risk alleles, you had a childhood full of love, you learned to deal with stress in a healthy way, etc. so for all of us who have/had the opposite of that…. we can’t trust our appetite mechanism to the extent maybe you can. do you get cravings you have to fight?

          • so maybe your best diet will be different… doesn’t mean that other diets won’t work better for other people

            #context

          • weilasmith

            who said i was arguing about diet? i was just curious if she got cravings.

          • Chantelle

            Ciao Weila,

            I’ll admit … I did have a loving childhood and my Mom ate very healthily and breastfed all of us. But my life is just as crazy as anyone elses … I’m a Mom of 2 (3 if you count my hubby), who runs a business and a household. I don’t believe I have a diabetes gene, but the disease is prevalent on my Dad’s side of the family, so it is something that I’m aware of. All that to say, I have the same modern day stresses as most of us – including cravings…. and I wasn’t born with the insights on how to escape them.

            Over the years, I’ve developed my own approach for dealing. I’m passionate about mind-body healthy living – for me it’s become a lifestyle. On the physical side, I eat well… mainly whole foods, I exercise daily (strength training), I set an alarm to GO to bed because I believe sleep is very important. I believe stress can be one of biggest detractors of health. So I make every effort to manage my stress – no matter what. For example – I walked away from a very successful, but HIGHLY stressful Wall St career because I knew the rate I was going – I would end up with a chronic illness one day. Similarly at the same time, I moved from NYC to a suburb in Miami – close to the Ocean with lots of greenery. Why? Because it makes me feel peaceful and content inside :-). I meditate … and take at least one walk a day in nature … and if anything doesn’t serve my happiness – I remove it from my life. I do something I love for a living, and I surround myself with people I care about and who care about me. I truly believe this holistic mind/body approach to wellness has served me very well.

            As for cravings … you bet I get them! I have a wicked sweet tooth and I’m a sucker for ice cream and chocolate covered nuts. But I’m not a fan of long term deprivation. That to me can be a breeding ground for cravings – will power will only last so long. Rather I give myself permission to enjoy treats within reason. For instance, I generally have a small handful of chocolate covered nuts after dinner. That is enough to satisfy my craving … lest I find myself with an empty tub of ice-cream wondering what happened :-). Similarly, I reserve Sundays as my days for a delightful brunch – pancakes, waffles, fruit salad, crepes and the likes. I enjoy without guilt and then go into balance mode. All that means is when I overeat, then I’m pretty conservative in my calories the next day.

            Also, I’m very mindful about eating. Whenever I reach for something and I know i’m not hungry – I take a moment just to see why I want to eat it. Sometimes it’s just boredom – so I address it. Sometimes I might just want something sweet – so I’ll have a fruit instead. But being conscious about your food can be very helpful.

            ALL of this to say – over the years I’ve honed in on the behaviors that support my desire for a great bod, great health and happiness … then I’ve just committed myself to doing them :-).

            Hope that helps.

          • weilasmith

            it doesn’t help me because i can’t even eat much fruit with my diabetes genes, but it was interesting.

          • Chantelle

            Well that’s one way to look at it … or find the best approach for your situation. As to fresh fruit – buy a glucose meter and check to see how your body responds to fruit. You may be surprised.

          • “Ketosis in an evolutionary context”

            http://caloriesproper.com/ketosis-in-an-evolutionary-context/

          • Hamish Ferguson

            Lost 20kg over six months on limited exercise using a fitbit to estimate CICO, maintained protein intake to 1.2-1.6gr/kg, eat 35gr fibre, 50% carbs, 30% fat and 20% protein, no hunger unless I eat way less than I expended. I ate carbs and lived!!!

          • “I ate carbs and lived!!!”

            Hahahaha haa!

          • Chantelle

            love it :-).

          • Thomas Hemming Larsen

            That is exactly the point and everyone seems to miss it.

          • rs711

            “Plenty”, really? Send over the case-study references, I’d like to read them (really!).

            Ok, *of course* you can gain fat mass in ketosis (duh) – but how easy is it? do you need to introduce vegetable oil & (small amounts) of refined sugars? How much fat mass can be gained? When it happens, is it an experiment to see if it’s possible or is this seen in free-living populations trying to lead a normal life?

          • “Ok, *of course* you can gain fat mass in ketosis (duh) – but how easy is it?”

            of course, I agree with you here. I’ve written about this many times about this!

            No proper refs, but check out Eric Hislop’s case, he gained fat mass and was reporting ketone levels at the time, iirc.

            Also, strongly suspect we selectively hear from keto successes, and people who don’t lose weight (or gain fat) simply don’t talk about it :/

          • billslo

            The theme of this study seems to be “short term.”

  • Guido Vogel

    “Opportunity to detect differential response may have been limited by the focus on high diet quality for both diet groups and sample size.” states the conclusion in the abstract.

    Interesting finding is the quantity of carbs apparently did not matter that much. Can you inform us about the “high diet quality” as I think full atricle is behind paywall

  • Nutty_da_Squirrel

    Well, it’s no secret that Dr. Gardner is a self-admitted die-in-the-wool vegetarian. And he became a vegetarian he said for ethical reasons and because it reflected his values and not because he was convinced at that time it was the healthiest way to live.

    Sounds to me like a lot of confirmation bias going on here! In any event… he appears to me to be a lone wolf intent on separating himself from the pack.

    • He’s not exactly Durianrider or McDougall.

    • “Sounds to me like a lot of confirmation bias going on here! In any event… he appears to me to be a lone wolf intent on separating himself from the pack.”

      I don’t think so! Check out this video — he seems like a well-spoken, humble guy: http://caloriesproper.com/insulin-resistance/

      • jasmine johend

        Gardner is delightful, see him here with Taubes https://www.youtube.com/watch?v=UMQKtvj1htU and whilst I’m never going to turn vegan anytime soon I’ve incorporated some complex carbs into my diet and I have far less hunger on a calorie comparison to HF.

        • awesome 🙂

        • Wab Mester

          Great debate. I always wondered why Taubes ignored the multi-factorial arguments. Occam’s razor.

        • weilasmith

          Jasmine, I know that you put more complex carbs into your diet. How is your blood sugar reacting to that increase, did it go up?

          • jasmine johend

            I will let you know in a few days as I ran out of strips ($54 for a box at pharmacy but found some on ebay for $25) which I am waiting to arrive any day. However I have lost weight and now maintaining at goal because hunger is down. I’m also sleeping better and dreaming every night, with more energy. Maybe my diet just needed a shake-up.

          • weilasmith

            i would wait to see how your blood sugar pans out before up voting.

          • jasmine johend

            In the past I always had excellent BS after testing with beans, and then there is the so called “lentil effect” or the “second meal” effect. Everyone is in agreement that shitty processed carbs are bad, but I believe the good carbs have been unfairly lumped in with them. My next addition will be buckwheat which was a staple of my ancestors (along with beans and potatoes). It’s not even a grain, it’s a seed. I’m moving more towards a high fibre lower fat diet and am feeling better for it. If my A1c is through the roof in a few months time then I will have to reassess.

          • jasmine johend

            @weilasmith HA1c down from 5.6 (LC) to 5.0 (HC). PP’s lower after big bowl potatoes (120 – 30 mins after and 110 – 2 hours). In the past my highest PP’s were normally 150-160’s on LC (I prob ate too much meat though, I was never really super HF). Morning fasting sugars up slightly around 110 compared to below 100’s previously. Anyway Dr happy with my numbers, all good, will stick to this protocol for now. I am LF though with this eating more carbs, I figure it’s got to be LCHF or HCLF and wouldn’t experiment otherwise.

          • rs711

            did you measure your insulin response?

          • except in the case of T1DM, safe to assume insulin is elevated if glucose is high

          • rs711

            [leaving T1D aside]

            No, in fact blood sugars can be controlled for years as long as the insulin response is…responsive! It’s usually in the non-initial/later stages that insulin starts waning & thus blood sugars start going high.

            Hence Kraft’s pre-diabetic (or diabetes in situ) distinction from the ADA’s classical criteria.

            Your assumption is the same unsafe one made by the ADA. You should update it.

          • you should re-read what I wrote and update your comment

          • rs711

            My bad, i should have started with “yes,”
            and not said you were making the same assumption as the ADA – at least you’re not from that particular comment.

            If i’m not mistaken however, in the past you have placed too much importance (imo) on fasting glucose as a predictor of glucose tolerance. I guess that’s what I was thinking of when i referred to you having an ADA-like assumption.

          • “If i’m not mistaken however…”

            you are mistaken, and now seemingly just making stuff up about me. Great.

            Fasting glucose can be completely normal in someone with impaired glucose tolerance (this is known as “isolated IGT”).

            OGTT is a better assessment of glucose tolerance, and insulin AUC for insulin sensitivity (this is what Gardner used).

          • rs711

            Ok Bill 🙂

            im glad you’re saying that now.

          • honestly not glad you’re still making stuff up about me, but whatevs, it’s the internet and all that jazz

          • rs711

            oh come on, thicker skin man, don’t ascribe ill intent when there is none.

            it’s simple ==> (http://caloriesproper.com/ketosis-is-a-hack-heres-why/) it comes down to how you use Cornier, Pittas & Ebbling to talk about the non-IR obese. I already voiced my disagreement to you about how they use inappropriate macros to draw a conclusion, which i don’t necessarily disagree with (!) – but not according to THEIR data. I disagree with how you classify some as IS-obese, given the former reason and the much more stringent Kraft criteria.

            I’m not “making stuff up” and am genuinely sorry if you feel that way. I argue specifics in an attempt to advance the conversation, not to nitpick. One might think this could be appreciated … :/

  • Nutty_da_Squirrel

    Ramped up carbs to ~80gms? Paleo gurus, such as Mark Sisson, suggest that’s still in the sweet spot for fat loss and good health.

    http://www.marksdailyapple.com/press/the-primal-blueprint-diagrams/#axzz446zLiStp

    • For a grown man, yeah, only the most zealous low carbers scoff at 80 grams (it’s not surprising for this to be ketogenic in some fit athletic peeps).

      For women, that number might be a little lower.

      • 100g net carbs are what i aim for and still remain in Ketosis .3-.8mmol/l Am to Pm. Also do a Carb Refeed every 3 weeks. Carbs help me retain water and electrolytes else i look flat and have wrinkly skin at age 62 at 10/12% body fat. The few health issues i had were fixed by just eliminating processed carbs, sugars and wheat grain products, in the process my BF dropped from 15% to 10%. I only eat whole food Carbs, Protein and Fats now because of the nutrient density and eat at a sight cal surplus for LBM gain. This style of eating i find sustainable long term, very low carb not so, too restrictive. Good Carbs are tasty and rewarding, nutrient dense and easy to eat plenty of, but i understand metabolically damaged people cannot eat this way, but if can reverse that damage, heal, adding back carbs up to your tolerance is a great reward.

  • Pedro Luis Schütz

    And the hunger?
    LF miserably starving in caloric restriction….

    • “And the hunger?”

      similar spontaneous declines in food intake in all the groups… may have in part been due to strong focus on food quality

      • Guido Vogel

        I was always hungry on LF/cal. restricted diet (and lost weight). Willpower can do that for 6 months, not a lifetime.

        So unclear what longer term results are and of course research is not real life (e.g. Hawthorne effect).

        LCHF fairly easy to maintain.

        • Pedro Luis Schütz

          Exactly.

          LCHF much easier to maintain.

          • in this study, however, both diets were equally acceptable and easy to maintain

        • Hamish Ferguson

          I lost 20kg and have maintained that loss for six months on 50% C 30%F and 20% P. Only moments of hunger were when the estimated (via Fitbit) cals out were way higher than recorded, measured and weighed calories in.

  • Chantelle

    Just reading through these posts … and I have to ask – what’s wrong with eating 50-60% carbs? Most cultures (including the Blue Zones) around the world do it. They don’t obsess over every macronutrient the way we do, but rather eat what is fresh, in season and available. This will vary depending on your geographical location, but in most cases, it will likely lean heavily toward plant food – AKA carbs.

    For me (I grew up in Jamaica) – it meant tons of fruits (yes mangos, bananas, pineapples too), lots of green veggies, root veggies (we love our yams), tons of beans …. lots of fresh fish and chicken, meat and fresh baked breads and rice. And 6 pack abs were quite common on the local youth … and no we didn’t have any gyms. Growing up I hardly knew any overweight persons – I cannot remember any. AND most of the elders in my community lived to 90+ without disease. So yes … that can happen on a high carb – high quality food diet.

    We only started seeing disease in my country, once we imported the American way of eating …

    I myself (insulin sensitive and a size 4) do exceptionally well on a naturally low fat diet (meaning that fat that is naturally in my food and similar to the style of eating mentioned above) – and I’m not hungry all the time … actually have to remind myself to eat! So no … everyone isn’t starving on a LF diet. And I do NOT do well on LC at all. I feel awful and generally do not lose much weight for the effort.

    So find the diet that works best for you, eat real food … and go with it! There really is no one size fits all.

    • pretty sure I agree with everything you said 🙂

      • mike

        You may agree, but it’s clearly nonsense. The claim that “most of the elders in my community lived to 90+ without disease” is patently absurd. As for the rarity of overweight, from GCBC:

        By 1973, according to Rolf Richards of the University of the West Indies, Kingston, 10 percent of all Jamaican men and nearly two-thirds of the women were obese in a society in which “malnutrition in infancy and early childhood remains one of the most important disorders contributing to infant and childhood mortality.”
        […]
        Rolf Richards wrote about Jamaica in the 1970s. “Malnutrition and subnutrition are common disorders in the first two years of life in these areas, and account for almost 25 per cent of all admissions to pediatric wards in Jamaica. Subnutrition continues in early childhood to the early teens. Obesity begins to manifest itself in the female population from the 25th year of life and reaches enormous proportions from 30 onwards.”

        • Chantelle

          Hello Mike,

          Thanks for your response. My post was hardly nonsense … this was my experience growing up … and our lifestyle was just as I explained. After reading your post, I really thought about it … and I stand by my post – I hardly knew any overweight people growing up. And as for people living until 90 without disease – that was also the case. My grandma (last of her generation) died just under a year ago in Jamaica. She was 106 years old – No disease, No hospitalizations for any chronic illness ever, of sound mind and body, very lean in stature, was taking No medications – everything worked as it should. She died of old age … peacefully in her sleep. Yes, this is anecdotal, but this was what was common in my community growing up.

          As for your excerpt from GCBC, I cannot tell you the lifestyle of the people they mentioned. I believe that excerpt was part of a larger discussion around obesity and malnutrition within impoverished communities in industrialized countries. That would represent just a segment of the population. Yes, there was a tremendous amount of poverty in Jamaica, but that can hardly be extrapolated to the rest of the country. What I know for sure is that was not the case in my community – we were not impoverished but rather upper middle class. We lived by the ocean where vegetation was lush. We had PLENTY of food.

          The other thing I would question is the validity of the numbers mentioned. 2/3s of women were obese? That would be 67% of women! That is not even the case today, where the island is overrun with Burger Kings, McDonalds and big giant supermarkets with lots of processed foods. So I have to doubt that was the case then. So the source of that info is questionable.

          But in any event … I fully stand by my experience. My point was … and still is …

          I eat just as I mentioned above -all whole foods – tons of fruits and veggies, root veggies, beans, eggs, fish, some meat/chicken with “treats” a couple of times a week. I definitely fall more in HCLF – with mainly naturally occurring fats. It works for me. I maintain for the most part a Size 2 to 4 and my health markers are EXCELLENT. In my last 3-hr glucose test – my resting was 72, and even after consuming 100 gms of sugar, my blood glucose never went above 93. I take that to mean my body is very insulin sensitive.

          LCHF doesn’t work for me … I’ve tried it and did not lose much weight and it was hard for me to maintain. I take it to mean that my body needs some level of carbohydrates.

          Different things work for different people (as we can see in the referenced article above). Try what works for you and go with it.

          I post my experience here, not to negate anyone else’s experience, but rather to show a different perspective. Please take it for what it is worth.

          Peace!

          • mike

            Well, perhaps GT did quote Rolf Richards out of context. But then again, you state that you “would question is the validity of the numbers mentioned. 2/3s of women were obese? That would be 67% of women! That is not even the case today”.

            http://www.jamaicaobserver.com/editorial/The-obesity-danger-Beware-our-love-for-fat-women_7963424

            “The Pan-American Health Organisation reports that in Jamaica 52 per cent of persons 15-74 years old are obese by accepted medical standards. Obesity is most prevalent among Jamaican women, indeed 65 per cent of them are obese. Put bluntly, that is two out of three.”
            That was 2010 however, so perhaps things are looking better today.

          • Chantelle

            Sigh… If it’s 2/3 in 2010… After being on the rise for years… Then it was very likely not 2/3 in 1973… Which is what the GC article states. Especially since the drivers of obesity – fast and processed foods- were present to a much less degree in 1973. Additionally, per the recent article you just referenced… They again talk about this obesity being dominant in poor communities.

            All that to say… I think you are missing the point of my original post… And I don’t want to go back and forth. So let’s just agree to disagree. I have my truth… And you have yours. A beautiful evening to you.

          • I want your blood glucose and insulin sensitivity!

            Give it to me now!

          • rs711

            Hi Chantelle,

            You said “I’ve tried it and did not lose much weight”…correct me if I’m wrong, but that implies you have weight to lose – were you eating the diet described above?

          • Chantelle

            NO I DONT… please see above. I’ve tried it when over the years when I’ve had weight to lose – like after the birth of my children or a summer spent eating my way across Europe. Outside of those instances, I’ve maintained a size 2/4 for pretty much all my life

          • rs711

            GOT IT :p hahaha

            good for you! and yes, croissants will definitely make most people pack on a few extra pounds.

            Look, it’s a FACT that people can eat a high-carbohydrate diet and remain healthy/lean ==> but there are important (to name just a few) caveats to that:

            1) this is getting rarer & rarer in modern environments
            2) to my knowledge, this doesn’t happen when evolutionarily inappropriate carbohydrate sources are a significant part of the diet (grains mainly)
            3) http://dx.doi.org/10.1016/j.nutres.2011.05.003 In the study “Diets of modern hunter-gatherers vary substantially in their carbohydrate content depending on ecoenvironments: Results from an ethnographic analysis”…the authors said “we calculated the carbohydrate intake (percentage of the total energy) in 229 hunter-gatherer diets throughout the world and determined how differences in ecological environments altered carbohydrate intake. We found a wide range of carbohydrate intake (?3%-50% of the total energy intake; median and mode, 16%-22% of the total energy). Hunter-gatherer diets were characterized by an identical carbohydrate intake (30%-35% of the total energy) over a wide range of latitude intervals (11°-40° north or south of the equator)”…this is to say that humans are *skewed* towards a lower/moderate carbohydrate intake & this is reflected in how your average person will cope with a HCLF or LCHF diet: on average, generally better on the latter.
            4) considering carbohydrates are non-essential, this means that when we eat them, we simply must displace other foods which are. Clearly we’ve got a considerable buffer to play around with, but the more ‘maladaptive’ our environment it, the more this becomes a liability

          • Chantelle

            I agree with everything you say – particularly with modern sources of carbs. It’s is essential that fruits and veggies make up the majority of our carbs. I’ve found that when I lower fat to about 20%, then I can go up in carbs with no problem. Hence why HCLF can work with healthy carb sources. Going to a 40% carb intake would give more room to increase fat to about the 40% – which is probably most ideal for a lot of people.

            BTW – check out Peter Attia’s recent podcast with Chris Kresser. What was most important was that he said the key to health and to longevity was glucose utilization – and some are able to metabolize glucose better than others. He finds that his sweet spot is about 20% carbs. But the % of carbs that one can eat depends on their personal biological makeup. Hence more evidence for Bill’s article above and for what you say here.

            He also said what had an even bigger impact on glucose utilization than nutrition – was Stress and Sleep. So even if you are eating all the right things, but are super stressed out and staying up all night – you are likely to be increasing the possibility for insulin resistance.

            I’m not sure if carbs are essential or not …what I do know is that I love them! Fruits, veggies and the occasional croissant …they make life delicious and fun :-).

            Thanks for the info 🙂

          • rs711

            Yeah i heard that podcast, Peter Attia is a great thinker.

            I agree with the point that, as long as you have a good insulin-glucose response & a good autoimmune/inflammatory reactions to carb/plant sources, then enjoy them – I’m a hedonist after all 😀

            What I disagree with is how Bill analyzed the study and the conclusions he took from it. The study doesn’t support the point he is making, in my opinion (despite the point about people being able to lose weight on higher-carb diets is true). It’s a methodological/technical disagreement, not one of principle. Apparently, that’s sufficient to be branded a “ketard” hahaha…

            Carbs are non-essential – this is as basic a nutrition fact as you’ll ever get (sorry, no debate here hehehe). See my break down of why [specifically point 4] https://raphaels7.wordpress.com/2015/09/19/rebuttal-of-14-claims-about-metabolism-genetics-paleoanthropology-stable-isotope-analyses-in-hardy-et-al-s-paper-2015-the-importance-of-dietary-carbohydrate-in-human-evolutio/

            Have a nice day/evening Chantelle

          • …that’s not why you’re branded a “ketard” 🙂

            Can a low fat diet ever be healthier than a low carb diet? (assuming they’re both comprised of good foods, no junk, etc.)

          • rs711

            HealthIER, ceteris paribus?

            I’d venture No – mostly because of the evolutionary skew towards a LCHF diet end of the spectrum & its protein ceiling.

          • “considering carbohydrates are non-essential, this means that when we eat them, we simply must displace other foods which are”

            the “essentials” can be met with about ~500 kcals

            the other ~2000 kcals are also “essential” (so you don’t starve) but aren’t displacing the essential ones…

          • rs711

            I don’t really get your point, it’s a statement of fact that if you substitute carbohydrates for a mix of fats (say nuts) containing some portion of EFAs, you are simply substituting some amount of essential stuff with non essential stuff (macros, say). We can talk about how much that matter (often I think it won’t, much), but you can’t tell me that that’s not what’s happening.

            Bill, i may be wrong, but you seem to be operating with a very narrow “RDA framework”:

            2 standard deviations above the Estimated Average Requirement based on the median need of 50% of a population to avoid developing lethal vitamin/mineral/EFAs/EAAs/caloric/ deficiencies.

            Let me bring up your favorite term again, #context: imo meeting the RDA within ~500kcals doesn’t suggest that one can fill-in the remaining caloric gap however one wants without consequence. We obviously have a lot of wiggle room with it, but that doesn’t mean we should take a relativist position that “oh once we’ve done the bare minimum, to hell with the rest, fill it with whatever”. Nope, still no free lunches in biology afaik.

    • billslo

      Why would you have tried LC if everything
      was fine on LF? You need to lose weight?
      Something doesn’t add up.

      • Chantelle

        I’ve tried LC in the past … if I’ve needed to lose some weight – after the Holidays, after a summer in Europe (lots of croissants :-), etc. But as women, we have all had times when we needed to lose a few pounds … and yes … the immediate response is to google and do what everyone else was doing. So I’ve experimented with different things in the past – including LC. But what has consistently worked well for me and keeps me at my target weight is to eat the way I mentioned above.

      • Eve

        LC isn’t only about weight loss, there are other benefits/fewer disadvantages, as well. The Hyperlipid blog is an amazing resource for those other reasons. I consider dental hygiene to be a compelling one.
        Note that the only time I have lost weight on low carb was when my protein levels were abysmally low. And yes, I weighed all food, tracked everything, and even had my thyroid checked.

    • This. “AND most of the elders in my community lived to 90+ without disease. So yes… that can happen on a high carb, high quality food diet.”

      • Chantelle

        I responded to Mike. Thanks!

      • Eve

        Yeah. My dad comes from a background where meat was a luxury, and rice a staple. People didn’t start getting metabolic issues/diabetes until sugar and vegetable oil became prevalent in the diet.

        • thanks, Eve. I think this says a lot wrt the obesity epidemic.

    • Nutty_da_Squirrel

      It stands to reason, Chantelle, that people with certain genotypes are more evolutionarily suited to a higher carb intake, and others are better suited to lower. This says nothing in support of either camp, only that optimizing body composition and health would probably require knowing more about the food environments where our individual ancestors lived.

      But, judging by your pic you appear to be in your early 20’s. Most folks don’t start experiencing the effects from years of eating a HC diet until they reach middle age.

      As for not feeling well on a VLC diet, most Keto experts will tell you that it takes 3-6 weeks to become Keto-adapted. And some folks make a lot of mistakes while trying to reach that stage.

      • Chantelle

        Ciao Nutty … I completely agree with you. BTW … I’m not in my 20s (although most people think I am) … rather I”ll be turning 47 this year … and my body and health markers are in excellent condition. So I think this way of life might agree with me :-).

        • Sky King

          47..?? Wow!! You sure do look great for your age! Whatever you’re doing… KEEP IT UP! 🙂

        • weilasmith

          Black don’t crack

  • JJ Bell

    Thanks Bill, great information and really interesting study.
    My only concern would be stressing the conclusions too much as I feel that most who typically struggle with weight are probably insulin resistant.

    • I hear this rebuttal a lot, but what’s the application?

      Tell obese patients there’s only one diet for them because we’re guessing they have insulin resistance?
      I disagree with this — and even if they have insulin resistance, this study showed you could still lose a respectable amount of weight on a low fat diet… so if it’s just plain easier for a particular individual to stick with LF, in this #context, then I’m all for it.

      • jasmine johend

        Bill…thank you for this post…the LC forums are full of mainly females not losing/gaining on HF and being advised to eat more fat, less protein. Not working? Well now they are told to fast longer. It’s just getting out of hand; it’s madness out there.

        • BOOM!

          • billslo

            …the internet is full of mainly females not losing/gaining on LF and being advised to eat less and move more. Not working? Well now they are told by the medical establishment and the federal gov’t to eat less fat and move more. It’s been getting out of hand for about 40 years; It’s madness out there.

            BOOM!

          • jasmine johend

            You’re missing Bill’s point; as someone said above “I ate carbs and I lived”. It’s not an argument about whether LC or LF is better. No-one here is arguing that except maybe you. It’s about people scared to eat 500 cals carrots/potato whilst drinking1000’s of calories butter/cream/pork skin. This is the madness I refer to. At some point in time, CICO or at least CI matters. If LC works for you fantastic, no-one is disputing this, Bill is just being the voice of common sense and reason here.

          • billslo

            Guido (not I) asked : “…what is/are the main mechanism(s) for getting obese other than via the insulin pathway?”

            Again, CICO is not a mechanism. It is the common wisdom which has been used to hector people for 40 years. That’s the madness I refer to. The insulin theory has not been in any way dispelled by this short term pilot study.

          • how do people gain fat mass if they’re on a ketogenic diet?

            –> the same way they gain fat mass if they’re on a high carb diet

          • billslo

            –>Too deep for me…

          • Emmie

            Not deep at all–EXCESS food–regardless of the nutrient involved–is stored as body fat. Eat too many calories, and you will gain fat mass.

          • Emmie, I agree with you in principle, but some of the protein-overfeeding studies are really pushing the envelop!

          • Flapjack Snafflington

            How so?

          • Martin

            Well, overload of calories from any macro-nutrient will raise insulin levels. Sure, it happens easiest with carbs and proteins but even if you overeat fat your insulin will go down and the ‘regular’ insulin-based mechanism triggers. Sure, for most/some folks overeating fats is not an easy task, but some of us can actually do it.

        • Chantelle

          sounds like madness to me! Get off the crazy train 🙂

      • Emmie

        Bill-
        After a lifetime of morbid obesity (from early childhood), I lost 180 lbs post menopausal eating very low carb and moderate fat–and closely monitoring calories. I’ve maintained that loss for the past 7 years with the same way of eating–very low carb and being careful with calories.

        All my labs are superb, and at age 75, the only Rx I take are my thyroid hormones. I’ve been eating this way for over a decade, so I think that for someone whose body thrives on low carb, it can be a long-term way of eating. As I’m sure you know, the ‘significantly reduced’ face challenges in managing their weight–and low carb is what works for me.

        I’m not advocating it for anyone else because I totally believe that their are different paths to effective weight management. The key IMO, is learning about YOURSELF.

        • congrats on your progress and current state of excellent health! 🙂

          • Emmie

            Thanks. I should add that in the 80s when Dean Ornish first published, I lost 40 lbs eating very low fat and wasn’t ‘hungry’ the way that LC folks are always claiming. The key (IMO) was that I focused on vegetables with lean meats and fish. My ‘carbs’ were a condiment–e.g., perhaps 1/2 cup of rice for a stir fry. So although I don’t eat that way now, I appreciate it as a healthy diet.

            I actually plan to try this again soon because I also believe in ‘changing up’ healthy ways of eating from time to time.

  • Thomas Hemming Larsen

    This post talks so much sense. I know I’ve praised you before for spreading this message but I still think it’s very important.

    Keep up the good work Bill!

  • Gearoidmuar

    My family is obviously IR. All my father’s family were fat, and this was a long time ago. His mother and one brother died of DM2. I cannot keep weight off except on a lowcarb diet. 50g in my case is my max. If I eat more, and I have tried, I put it on. If I cut it back, it falls off slowly. You have to experiment on yourself. Some people can eat no carb, some can eat tons. I think, however, that sugar is really bad especially when added, and refined flour is clearly bad if you read the history of the results of its introduction, everywhere it was introduced.
    I’m just back from Hong Kong where I spent five days. I’d read just before that they were the most longlived population in the world, both men and women AND they were the world’s biggest meat eaters and beef eaters.
    God, they are SERIOUSLY thin.

    • This is true for you & me – but I really don’t think it’s universal.

      I’ve lost a lot of weight and have tried to Bro it up and lift weights even to improve my insulin sensitivity. I still can’t eat high carb – I’m not sure how much leaner I can become.

      I’m healthier than before but still low carb & still following the GI index (low GI carbs like legumes are OK) but I see people eating tons of carbs and still lean and healthy.

      Its not fair, but that’s life.

      • word — I hear this a lot, too.

        and there’s those legumes again! probably the most positively-viewed carby among LCHFers. And many say they help manage blood glucose.

        • Eve

          I have a serious aversion to legumes, except edamame. They make me feel drained of energy. A

          • jasmine johend

            Same, I found some legumes too heavy for me but if you are OK with edamame, try black turtle beans which are now my favourite. They freeze well so you can cook up a big batch, eat and then freeze in ziplock bags and add to salads/soups/stir-fries. Fava beans are another good choice and I recall reading they increase dopamine? Like edamame they are bagged in frozen food section and take 5 mins to boil. Lastly iherb sell salted dried endamame which are very more-ish 🙂 Sorry if I’ve hijacked this into a bean comment but I have found them effective as BG flat-liners

          • Eve

            Thanks, I’ll look into it. Edamame pasta has been a lifesaver, but the dried, crunchy beans remind me of hay. 🙂

          • Eve

            Ok, black beans in brownie form are pretty awesome.

          • jasmine johend

            I’ve got some in pressure cooker right now. Half are going in a salad and the rest I’m making a dip with onion/cilantro/lime

        • Legumes work well – yellow dahl has a really low GI, high fiber and is filling for me.

          Potatoes, rice – I’m left starving though and it’s not necessarily the blood sugar response which is usually ok now.

    • perhaps you visited one of the “Westernized” regions of Japan, according to this study: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3798621/

  • Stipetic

    Hi Bill,

    If you are interested, I’d like to point out a couple (few) major issues that you might have missed that affect the interpretation of the study. Firstly, this was a pilot study, so it could not be powered to detect real differences, which is why the results are not statistically different. Meaning? There is not a 20% difference between LF and LC in IS, or any difference at all in any of the treatments. The data is suggestive that LF should be better for IS, and LC for IR, but the data is too weak to confirm this. The authors even claim this lack of difference in their conclusions—last paragraph of the article. Second, if you look at the IS group, the LF started with a significantly wider waist circumference (Table 1), so they had a weight-loss advantage (more fat to lose). Randomisation is a bitch sometimes…it can’t control for everything. Another important point, I think, is that they didn’t measure where the weight came off from–fat or muscle? Probably mostly fat for all groups, but still… Lastly, and most importantly, which ties in to this being a pilot study is the fact that the data in the IS group is driven by outliers–for both the LF and LC, but in opposite directions. Look at Table 3. Let’s start with the LC boxes on the right side. The mean, the line that cuts the box in two, is right down the middle of the boxes for both LC and LF. So in the LC arm for both IS and IR groups, the number of subjects above and below the mean are about the same. And the standard deviation is about the same above as it is below the mean. In essence, a good distribution. You don’t see this in the LF arm at all. In the IS side–the left side–you can see the extremely large standard deviation. And more importantly, if you look at the LC mean, it’s on the lower side of the box (with the large standard deviation above the mean), meaning that a “mild” outlier or two or three is driving the LC arm to show less weight loss than you’d expect if no outlier data was present (i.e. if the mean cut the box in half). You see the opposite with the LF arm. There, it’s clearer that the greater weight loss is driven almost entirely by a extreme outlier or two.The standard deviation is huge below the mean, and the mean is in the upper third! of the box. It would be interesting to see the results if the outliers were taken out (or just see the individual results). I bet the 2 kg advantage for the LF arm would vanish. You might even see a 2 kg advantage for LC with the IS as well. Just sayin’

    • Thanks for the comments, Marcel.

      The BW results didn’t reach P<0.05 because as you noted about Figure 3, wide variation…

      However, I'd ask: was the P-value <0.1? 0.2? Does it matter? Their findings are in agreement with previous ones, so the exact level of statistical significance doesn't matter that much to me; if their findings were going against a large body of literature, I'd agree with you.

      I still maintain the results were clinically significant because in Table 3, health markers improved more for IS on LF than LC and for IR on LC than LF (and some of these *did* reach statistical significance).

      Lastly, despite the overall effect size being small (20%, NS), it was enough to invest a lot more time and money on a massive follow-up…

      • Stipetic

        Thanks for responding Bill. Since I believe a study should be judged on its own merits, I’ll stick to this study. Regarding p values, I’m not a big fan. I prefer study designs that allow the use of confidence intervals, which are more telling, IMO. Personal preferences aside, the main takeaway message from this experiment is that Gardner failed to show a difference between treatments for whatever reason.

        Regarding health markers, I don’t see any real differences, and apparently neither did Gardner (page 84; first paragraph): “No significant 6-month change differences were detected among groups for any of the above risk factors.”

        The only differences that were statistically
        significant at 6 months were LDL and fasting insulin/AUC; LDL was due to a macronutrient difference effect (saturated fat difference), while IR recipients benefited more from insulin lowering because , well, you’d expect them to be more IR to begin with. Gardner addressed this too.

        Statistical significant is a much smaller hurdle to clear than clinical significance. If statistical significance was not reached, by default clinical significance was not reached. At least this is my experience. Gardner seems to be in agreement (page 85 of the discussion; first paragraph: “In absolute numbers, the average weight loss results in this study paralleled the findings from the other studies—the more IR group lost slightly more weight on LC, and the IS group lost slightly more weight on LF, but the differences were not statistically or clinically
        significant.”

        My initial point, in essence, was that this study by itself is not as noteworthy as you seemed to argue. It only took a glance at Table 3 to notice something odd (that’s what I do for a living; I’m a Table 3 glancer). As I said, the low carb boxes on the right side show what you’d expect in terms of distribution. The boxes for the low fat don’t have a normal distribution—the mean values of both IS and IR are not where you’d expect them to be. I mentioned in my previous post that the data for low fat being driven by outliers. I still believe this and believe this to be important. I don’t know what drove the outliers, though. Could be that an individual or few in the IS group decided to cut calories or exercise more while not reporting it. There are several reasons, but the point is the distribution is odd. That’s why, if I had to decide whether to recommend moving on to the pivotal study based on the primary objective and this model, I’d be hesitant and like to see the individual graphs. Short of that, instead of the mean values, I’d like to see the medians for all groups as this is an quick way of eliminating outliers. I would bet the mean and median values for the low carb side would be very similar (with similar difference). I wouldn’t be surprised if the “2 kg loss advantage” seen in the low fat arm for IS became a 2 kg advantage for LC. This based strictly on the data, not my LC bias (which I admit I have). Right now, though I agree in theory low fat could be better for IS folk than LC, I find the study results inconclusive on this aspect.

        It appears the actual grant for the pivotal study was approved prior to the completion of this pilot study. According to Gardner (second to last paragraph), “a primary objective of this pilot study was to test the approach undertaken to achieve greater differentiation of diets and treatment fidelity for the purpose of incorporating this approach in a future, larger, longer trial; that follow-up trial, with a sample size of 600 and duration of 1 year is currently underway.” Regardless of what I have to say, the pivotal study will clear any misunderstanding I may have. I hope.

  • The greatest trick Taubes ever pulled was convincing the world carbs make you hungry.

    • Martin

      Bill, what is your position then, in clear terms? What would you recommend to people who struggle with weight/fat loss? Simply high quality, eat less? Or perhaps low fat and 60% carbs?

      You seem to be picking up studies which are interesting, I admit, but somewhat biased in one direction. Ant then you’re not trying to be too critical about them either, are you? Take e.g. Stipetic’s brief critique below, have these things occurred to you? Or now that Stipetic mentioned them, any plan to address them?

      • Martin

        I also think the greatest trick Taubes ever pulled was creating NuSi that might one day finance studies that will prove Taubes wrong, and inviting his opponents to the board.

  • Alex McMahon

    Awesome post! I’d love to hear your thoughts on the idea that as someones health changes their diet should change too. What helps someone reverse insulin resistance may not be the best diet for them to follow once they have regained health. Just an idea that’s been bouncing around my head.

    • Hi Alex, thanks!

      that’s a really complicated question (I tried a guess with the “Theoretical scenario” in this blog post) — eg, is health truly restored? or are you just now fighting a different battle, eg, the difficulties associated with a weight-reduced state.
      I don’t know, but it’s definitely worth exploring imo.

      and #context 🙂

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