All Medical Science is Wrong within a 95 % Confidence Interval
or: A Review of Taubes' "Good Calories, Bad Calories"
Recently I read a very impressive book by Gary Taubes, previously a reporter for the journal Science. The work in question is, "Good Calories, Bad Calories."' In the book, Taubes collects research to challenge the common knowledge of nutrition: that fat is bad for you, that we should eat polyunsaturated vegetable oils, that we should exercise for sixty minutes a day, etc.
The genesis of Taubes' book is an article he wrote for the NY Times in 2003. Five years later, Good Calories, Bad Calories was published. As background, there is a video of Taubes here where he overviews his thesis (1 hour 11 minutes, not safe for work since there are pictures of naked obese individuals) and adds a few pieces that were not in the book. Even if you have read the book, I recommend listening to the lecture. You can see from the video, Taubes is very solidly built.
In return for knocking down a bunch of accepted "common knowledge" hypotheses , Taubes presents ten new hypotheses (p.454) and I will add a few more than I extracted from reading the book:
1. Dietary fat, whether saturated or not, is not a cause of obesity, heart disease, or any other chronic disease of civilization.
2. The problem is the carbohydrates in the diet, their effect on insulin secretion, and thus the hormonal regulation of homeostasis—the entire harmonic ensemble of the human body. The more easily digestible and refined the carbohydrates, the greater the effect on our health, weight, and well-being.
3. Sugars—sucrose and high-fructose corn syrup specifically—are particularly harmful, probably because of the combination of fructose and glucose simultaneously elevates insulin levels while overloading the liver with carbohydrates.
4. Through their direct effect on insulin and blood sugar, refined carbohydrates, starches, and sugars are the dietary cause of coronary heart disease and diabetes. They are the most likely dietary causes of cancer, Alzheimer's diseases, and the other chronic diseases of civilization.
5. Obesity is a disorder of excess fat accumulation, not overeating, and not sedentary behavior.
6. Consuming excess calories does not cause us to grow fatter, any more than it causes a child of grow taller. Expending more energy than we consume does not lead to long-term weight loss; it leads to hunger.
7. Fattening and obesity are caused by an imbalance—a disequilibrium—in the hormonal regulation of adipose tissue and fat metabolism. Fat synthesis and storage exceed the mobilization of fat from the adipose tissue and its subsequent oxidation. We become leaner when the hormonal regulation of the fat tissue reverses the balance.
8. Insulin is the primary regulator of fat storage. When insulin levels are elevated—either chronically of after a meal—we accumulate fat in our fat tissue. When insulin levels fall, we release fat from our fat tissue and use it for fuel.
9. By stimulating insulin secretion, carbohydrates make us fat and ultimately cause obesity. The fewer carbohydrates we consume, the leaner we will be.
10. By driving fat accumulation, carbohydrates also increase hunger and decrease the amount of energy we expend in metabolism and physical activity.
11. RM: Man, being the premier predator on the planet, evolved to eat a diet high in fat (and in particular the saturated and mono-unsaturated fat found in animal tissue). In the absence of clinical data, we should endeavor to structure our diet to be similar to that we evolved eating, prior to the introduction of agriculture approximately 10,000 BCE.
12. RM: Advanced Glycation End-products (abbreviated AGEs) may be a cause or byproduct of the oxidative stress that causes aging and many of the maladies associated with it.
13. RM: A low-calorie, high-carbohydrate diet will make you lethargic as chronically high insulin levels will try to convert glucose to fat while not leaving sufficient calories for the remainder of your basal metabolism. In comparison, low-carbohydrate, moderate-calorie diet will leave you energetic and lean.
One cannot help but wonder how a number of the weak hypotheses that Taubes explores came to become common knowledge in the field of nutrition? Taubes paints a picture of a few egotistical researchers who were able to effect what was essentially scientific fraud, by fitting their bias to the data rather than examining it critically. In Taubes words (p. 451), "it is difficult to use the term "scientist" to describe those individuals who work in these disciples [ed: nutrition, chronic disease, and obesity], and, indeed, I have activity avoided doing so in this book."
More importantly, once they established the common wisdom, they were able to better direct government funding to only support their hypotheses. I came to a somewhat different conclusion to Taubes, in that I see the puritanical aspects of American culture in the formation of these bogus hypotheses. For example, Taubes' quotes Jean Mayer, one of the fieriest preacher that lack of exercise causes obesity, in a 1955 The Atlantic magazine article:
Obesity, it is flatly stated, comes from eating too much and that is all there is to it. Any attempt to search for causes deeper than self-indulgence can only giver support to patients already seeking every possible means to evade their own responsibility.
Like I said, puritanical. This line of thinking can be traced all the way back to people like Sylvester Graham in the 1800s. The idea that cardiac disease might be caused by inflammation and bacterial infection and not by living a sinful life has been remarkably slow to percolate through the American consciousnesses yet it is well understood to be the case now. Obesity is probably not dissimilar.
Prior to my introduction to the world of low-carbohydrate diet, I hadn't paid too much attention to nutritional science. I worked on biophysics, where I formed the opinion that medical science was mostly garbage. This isn't largely the fault of the scientists involved; there's little opportunity for adequate learning though experience of repeated experiments and the systems involved are extraordinarily complex. As a physicist, if I get an correlation coefficient, R2 < 0.9997 in an experiment, I would consider that a poor result. A nutritional researcher working with human patients cannot even dream of achieving the degree of control or characterization I can, and their data are overloaded with spurious noise.
Researchers in the soft sciences typically do not have sufficient math skills to understand the statistical methods that are they are using to evaluate their data. I've lost track of how many times I've seen evaluations of the mean and standard deviation for distributions that are clearly not normal (also known as Gaussian). Don't even get me started on p-values. More importantly, very few medical studies attempt to test a single hypothesis. Far too many studies will compare apples to bananas, rather than apples to no apples, or they'll compare apples, oranges, and bananas to no fruit. Making conclusions from such messily designed experiments is rife with the potential for misinterpretation. Drug studies are often an exception.
The Insulin Hypothesis
The central thesis of "Good Calories, Bad Calories" is that chronically elevated insulin levels is likely responsibly for the, "diseases of Civilization," such as diabetes, heart disease, cancer, etc. I put, "diseases of Civilization," in scare quotes because although these diseases are absent from primitive cultures, it is obnoxious to explain to individuals of non-Western ancestry that they do not suffer from these diseases because they are uncivilized (Burkitt and Trowell). Wikipedia calls these Lifestyle diseases, which seems a more apt terminology.
Let me be clear: nothing about Taubes' insulin hypotheses are actually owned by Taubes. The idea that carbohydrates are fattening has been known from well before the discovery insulin. The knowledge that diabetes could be cured by avoiding carbohydrates was also known before the discovery of insulin. Taubes is merely going over old research and bringing it together as a strong argument.
When viewed through the prism of evolutionary science, this makes a lot of sense. Fat stores would have been necessary to maintain the organism when hunting failed and there were insufficient edible plants. Carbohydrate stores, on the other hand, requires a huge amount of water to act as solvent. Each gram of glycogen that you store needs ~2.5 g of water solvent, so at 4 kcal/g carb, you have an effective storage capacity of 4 kcal/3.5 g = 1.15 kcal/g. Fat is 9 kcal/g and it doesn't require a solvent when stored in adipose tissue so that's a 7-fold increase in storage capacity. Fat is a vastly superior way to store energy.
So what was the source of carbohydrates for humans before we developed agriculture? Presumably wild fruit. Fruit matures, more or less, all at once as anyone who has owned an apple tree knows, and rots rather quickly after it has fallen off the tree. Thus, when fruit is available, it is perfectly logical to gorge oneself and use all that easily harvested sugar energy to synthesize fat storage for consumption in lean times. Thus the evolutionary reason for our sweet-tooth is easily explained.
Effectively, we evolved to preferentially burn-off the glycogen in our muscles and liver before we switched to fat. There's ~300 g of carbohydrates stored in the body, which corresponds to ~1500 kcal. Just you try and burn 1500 calories via a cardio-workout. Eating three square meals a day with carbs at every serving implies that you will never burn through your reserves and hence the body will never resort to burning fat.
So, briefly, how does one use these conclusions to achieve a healthy low body fat (and BTW, waist circumference is the #1 metric for heart disease)? Certainly not by the standard, low-calorie, high-carbohydrate diet (semi-starvation diet in Taubes' terms) which has been nothing but a dismal failure from a clinical and practical perspective. There are three basic strategies:
1. Very long and very slow exercise (4+ hrs), typically hiking or cycling in my case. This is a far cry from the type of anaerobic-limit cardio exercise one typically sees recommended, for example, by the American Heart Association. There is a yawning gulf between walking and jogging. I personally approve of anaerobic exercise, such as sprint intervals or plyometrics.
2. Consistently eat carbohydrates at a low enough level that the brain (which prefers glucose over ketones) consumes the entirety of carbohydrates that you eat, leaving the body to burn ketones. This is a slow process.
3. Periodically fast for an extended period of time so that your basal metabolism burns through your glycogen reserve and then begins to mobilize fat. This is not a calorie reduction method, rather you are simply not eating three times a day (on average), and as such having more extremely calories negative and calorie positive periods.
Eventually, everyone will plateau at a certain level of body fat. The number of fat cells in your body is more or less set by age twenty; dieting simply changes how full they are. Eventually, fat cells will revolt and through leptin demand a stronger appetite. So is there any need at all for carbohydrates in the diet?
Grains are the ultimate, "empty calories," in terms of micronutrients. Not only to grains have essentially no micronutrients (they are fortified for a reason), they also have a number of anti-nutrients that impede the uptake of nutrients from vegetables and animal tissue. From a health perspective, there's no need to eat grains or starchy vegetables such as potatoes.
Typically one might recommend 50-80 grams per day simply to supply the brain with glucose, but even this is not strictly necessary as the liver can convert fatty acids to glycogen. Of course, people who are obese are likely suffering from hyperinsulina (insulin resistance/metabolic syndrome) and as such may suffer discomfort upon undertaking an low-carbohydrate diet.
For the record, I dropped 22 lbs. (20 lbs. by August 2008) going from a BMI of 24.7 in May 2008 to 21.4 as of now. I've been as low as 143 lbs. in the past but I was never able to maintain that; typically I got to such a weight by bicycling 12+ hours a week at 30-40 km/h. I'm now sitting at 145 lbs. (edit: now 144 lbs.), in January (ed. February), in Edmonton, with no chronic cardio. This is a totally new scenario for me as I almost always put on 10 lbs. over winter.
When I put on weight it is prominently in the form of visceral and subcutaneous fat; I've never had significant interstitial muscular fat so I've always had relatively hard muscles. I try and aim for a distribution of 60 % fat, 25 % protein, and 15 % carbohydrate in my diet. Since my blood sugar/insulin isn't riding a roller coaster up and down throughout the day, I generally don't get hungry. I am much better at concentrating throughout the course of the day, irrelevant of when I last ate and I've found that my thinking process is much cleaner and crisper.
Unanswered Questions
Taubes criticizes a number of scientists in his book for over-simplifying the science of physiology in an effort to understand it. In that respect, reducing the argument of "Good Calories, Bad Calories" to carbohydrates-bad, fat-good is probably guilty of the same offense.
Taubes dose throw us a couple of bones, in the form of some of the more buzzword lines of research in nutrition today. One is Advanced Glycation End-products (AGEs); we know that AGEs are tightly correlated to age. From what I've read, thus far the early reports on AGEs are similar to those on cholesterol fifty years prior: lot's of smoke, but no fire. Efforts to link AGEs to ingestion of AGE materials (e.g. burned meat) has thus far failed, IMO.
Fat-soluble vitamins
One aspect of carbohydrate/fat balance that Taubes does not cover is the impact of the fat-soluble micro-nutrients. We, as humans, have given up our abilities to fabricate the majority of vitamins that we need in favour of having big brains. We are very poor at transforming one complex of a vitamin (typically the vegetable source) to the type we need to function.
As our consumption of fats has declined in favour of carbohydrate the quality of fats that we eat has also declined. As such, we are typically deficient in fat soluble vitamins, in particular D3 and K2. Not only we as a society getting far less vitamin D3 from sun exposure, but the animals we eat are also more often than not locked in a barn eating corn, so they also contain less fat soluble vitamin. When you consider that your skin can produce something like 10,000 IU of D3 in an hour compared to a multivitamin at 400 IU, it's not a giant stretch to believe that the majority of Western people are going through life deficient in it. K2 is similar; butter is a good source, but butter has been demonized by our corporate media.
Poly-unsaturated Fats
Palmitic acid is the fatty acid that your liver manufactures from sugars. In fact, the only fat humans evolved to burn for fuel directly is saturated fat. All other fats we trans-saturate first, and then burn. It would seem strange then given the complexity of the human body that we evolved to preferentially make saturated fats over polyunsaturates, unless we prefer saturated fat because it is more stable and hence less prone to oxidation.
The canard that saturated fats, "clog your arteries," is just that, bogus. The medical establishment has never believed this since they knew full well plaques form inside the arterial wall, not on the surface. Why this idea was allowed to percolate through the public, I do not know.
This begs the question, should we eat polyunsaturates at all? They are, after all, highly unstable and very easily oxidized. I ask a question: when was the last time you bought a nut oil, e.g. walnut or sesame, at the supermarket? Was is refrigerated on the shelf? Was is in a brown bottle to prevent light from damaging the polyunsaturated fat? I've seen flax oil sold in such a fashion but no other. Much of the fat we eat is oxidized by the time it reaches our mouths.
Fish oil (omega-3) is clearly doing people a lot of good, even if it sits in a cylinder for months. A lot of people do feel that we get far too much Linoleic acid, an Omega-6 essential pre-cursor, from soy, corn, safflower and other vegetable oils. It does, after all, have a significant hormonal effect.
This has led some to suggest that one should balance omega-3 and omega-6 consumption. I.e. if your omega-3 consumption is 3-4 one gram capsules of fish oil a day, then you shouldn't eat more than ~5-10 grams of vegetable oil. The American Heart Association apparently felt the need to push out an editorial recommending that the diet 5-10 % of calories should be in the form of omega-6 polyunsaturates to counter this meme. The fascinating thing about this editorial is that there are 81 references in 3 pages (which is beyond extreme), yet, there are no references — no studies, no research — that support the advised level of dietary intake. Take a look at the article (it's free access), it's quite amazing.
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