Fat Chance, by Dr. Robert Lustig

Just came across “Fat Chance:  Beating the Odds Against Sugar, Processed Food, Obesity, and Disease,”  by Dr. Robert Lustig.

Dr. Lustig is a pediatric endocrinologist and the Director of the Weight Assessment for Teen and Child Health Program at the University of California San Francisco’s Benioff Children’s Hospital.  Dr. Lustig came to the issue of weight and obesity via a start caring for children who had survived brain tumors.  The therapy to get rid of the tumor often damaged the hypothalamus.  Some of the kids developed hypothalamic obesity, because the neurons in the hypothalamus that sense the leptin signal are all dead.  ”Even if these kids eat only 500 calories a day, they gain weight.” Why?  ”Leptin is a protein made and released by fat cells.  It circulates in the bloodstream, goes to the hypothalamus, and signals the hypothalamus that you’ve got enough energy stored up in your fat.”   If the hypothalamus can’t hear the signal, the person will continue to store, not burn, energy.

So Dr. Lustig knew years ago that weight was not only about “calories in, calories out.”  His book argues forcefully that obesity is not a “choice” or the result of bad individual decisions.  He recounts the stories of obese 6 month and 1 year olds, and the fact that some kinds of infant formula have roughly the same amount of sugar per serving as coca-cola.  Did the 6 month old or the 1 year old make “bad choices?”

He would like to see a public health attack on what he believes are the true sources of obesity:  sugar, especially fructose, and processed food of all kinds.  He notes that many individuals, children among them, have no practical control over what they eat either because of lack of access to real food–in urban “food deserts,” for example, or because of poverty.  Nutrition programs that support low income people, such as Women, Infants, and Children (WIC) are not first and foremost nutrition programs but rather ways of disposing of federally-subsidized agricultural surplus crops.

Perhaps the most interesting part of the book for me, however, as the parent of a teenager who has tried most everything (except a starvation diet) to bring her weight down to a healthy level, is his estimation that in his practice, 60% of kids can resolve their weight issues by eliminating unhealthy carbohydrates such as sugar, flour etc., but 40% CANNOT.  They need additional support in the form of supplements, or drugs that do things such as improve insulin sensitivity, and even bariatric surgery.

This is the FIRST place I have ever seen a 40% failure rate for a low carb eating plan.  In Life Without Bread, about which I’ve written before, Dr. Wolfgang Lutz, practicing in Germany from about 1960 on reported 100% success with a low carb eating plan for his pediatric patients within a year except in very extreme cases, which might take longer to resolve, or in cases where it was subsequently learned patients hadn’t actually followed the plan.  And failure is too strong a word–there is no question that a low carb eating plan has vastly improved Juliana’s quality of life–she weighs less; she has far more energy, and a more positive and more stable mood on a low carb eating plan.  But she’s not all the way to a healthy weight and remains at risk for metabolic syndrome and diabetes.

In fact, in Fat Chance there is a description of something called acanthosis nigricans.  In all my low carb reading, I’d never heard of it.  It is a darkening, or thickening, and ridging of the skin at the back of your neck, armpits, and knuckles.  People think it’s dirt, or on the neck “ring around the collar.”   In fact, it is excess insulin working on the skin.  It can’t be washed off.  Juliana has had this on her neck, even after months on a low carb eating plan, and after her fasting insulin level was tested at an excellent “3″.  Even though her fasting insulin level is fantastic, I suspect there is still something else going on with her non-fasting insulin response–her hormonal response to food.

I wonder whether the difference between Dr. Lutz’s clinical experience and Dr. Lustig’s clinical experience is literally the change in the world in the past 50 years.  When Dr. Lutz began his practice, endocrine disruptive chemicals were not everywhere.  Now they are.  It is practically impossible to avoid exposure.

Oh, and is it any surprise, that Dr. Lustig is a buddy of my hero Gary Taubes, whose work first led us to try a low carb eating plan?

How to do an elimination diet

In a previous post, I described how Juliana tested positive for various food intolerances, and that we had begun a test by eliminating every food to which she had a measured reaction.

But something was bothering me.  What if she was intolerant of something to which she hadn’t had a measured reaction?  In particular, to dairy?  Dairy is one of the “sensitive seven,” also including wheat, sugar, peanuts, soy, eggs and corn.  Furthermore, Jonny Bowden writes, you might want to expand the milk category to include cheese, and the wheat category to include all grains. Living Low Carb, p. 340.  And what if she was reactive to something else not on the sensitive seven list, like tomatoes, or citrus?

There are two distinct reasons why a substance might not have shown a reaction in the test.  First, she is reactive, but the test didn’t pick it up; and second, she is reactive but the testing was done incorrectly at the lab.  The opposite is also true:  she may not be reactive but a test could show that she is for either reason.  I was afraid that by only cutting out the foods to which the blood tests showed a reaction, we could still be missing something important. But I wasn’t sure how to proceed.

In a fascinating new book, with the terribly undescriptive title “Six Secrets of Successful Weight Loss,” Dr. John Mansfield, a physician from Britain, details the problems he encountered with various types of testing for food reactions in 30 years of clinical practice treating people for food intolerances.  He regards blood testing as next to useless.  His method, instead, puts people on a restricted eating plan that includes only about 40 foods for seven days.  Only foods with a very low likelihood of causing a reaction, in his clinical experience, are on the list.  After seven days, foods are tested, one by one, to see if they provoke a reaction.

There are two types of possible reactions.  One, a host of possible physical and mental symptoms:  migraine, stomachache, digestive issues, skin rashes, fatigue, low energy, depression, etc.  All the various symptoms that can be the result of food intolerances that are often thought to be psychosomatic because no clear causal pattern seems to exist to explain them.  Two, weight gain.  Sudden weight gain, such as 4 or 5 pounds over the course of a day or overnight.  Very interestingly, Dr. Mansfield treats weight gain itself as a food intolerance reaction.  He has found that the only symptom many people have of food intolerance is weight gain, and that when the offending food or foods are eliminated, normal weight is restored.

Since she eliminated grains and fruit, Juliana hasn’t had fatigue and low energy.  Her only remaining “symptom” was stalled weight loss.  Dr. Mansfield offers a protocol to investigate that symptom.  Interestingly, the approximately 40 foods that are allowed in stage 1 of the elimination diet include fruits like peaches, pears, and plums, and starchy items like sweet potatoes and turnips.  Juliana and I decided to try it.

She stuck it out for a week.  It wasn’t as hard for her as you might imagine, since she got to eat all sorts of things she has been avoiding for months, including fruit and starchy tubers.  Those were big treats.  At the end of a week, if you haven’t lost a significant amount of weight (5+ pounds), Dr. Mansfield would conclude that you don’t have food intolerance and you should  abandon the elimination diet.  So what happened?  Juliana gained 6 pounds.  (As an aside, there is no way that she ate an excess of 21,000 calories in one week.  Do we really need more evidence that weight is not a function of calories in, calories out?)

What does this tell us? Well, it certainly tells us, again, that she is very sensitive to carbohydrate.  The fruit and starchy tubers she ate sent her weight right back up. To get the most information, however, we cut out all the fruits and starchy carbs so she hopefully wouldn’t gain any more weight, and then we added back each food she had been avoiding, one by one, and watched for a reaction.

The first was broccoli, then lemon, pork, garlic, cauliflower, beef.  Juliana weighs herself on waking in the morning, and before eating dinner.  We test one new food or drink in the morning, and one in the evening.  A significant weight gain overnight or during the day–more than the normal variation we observed prior to starting the plan–is a reaction, and indicates an intolerance to the food.

Juliana hasn’t had a reaction to anything.  If she does have a reaction, we will have to wait for the reaction to die down before testing another food.

Dr. Mansfield offers an important lesson–that you can’t trust blood-test results.  His book goes on to recommend that if you don’t lose weight on the elimination diet, the next thing to do is to attack a systemic yeast (candida) infection, and the last thing to do is try a low-carb eating plan.  On the one hand, this is fascinating.  It’s the only place I’ve ever seen a detailed protocol for discovering whether food intolerances and yeast overgrowth, that are hinted at all over the low carb literature as possible problems, are actual problems.  But Dr. Mansfield, in my view, still doesn’t have it quite right.

For individuals who know they are carb-sensitive, have gone low-carb, and are still having trouble losing weight, try Dr. Mansfield’s diet, but a low-carb version.  Granted this doesn’t leave you much to eat, but it’s only for a few days.



Advanced Low Carbing–Calories Do Count

Many low carb eating plans leave you with the impression that you can eat any amount of food, as long as you don’t exceed a certain number of carbs, and lose weight.  I suspect this is a conscious or unconscious counter-balance to the calories in/calories out model, where calories are ALL that matter.  The low carb plans want to make clear that what different foods DO in the body is more important than how many calories they contain.  Low carb plans in general suggest letting your appetite be your guide about how much to eat.  But the appetite of insulin-resistant children and teens may not automatically adjust on a low carb eating plan.

For children and teens who have suffered the gnawing hunger of insulin resistance combined with a high-carb, Standard American Diet, it’s worthwhile to pay attention to how much they eat as well as what they eat, even on a low carb eating plan.  Why?  Because they are afraid of being hungry.  They’ve been hungry a lot on the Standard American Diet, even if they were gaining weight all the while.

They can do fine, without hunger, on much less food if the carbohydrates are controlled.  The extra energy they need is made up, without hunger, by using up stored fat.  But they may not believe it at first.  They may think if they don’t eat a giant breakfast they’ll be starving, and stuck, in the middle of 2nd period math.  This is exactly what happened to Juliana on a low-calorie “balanced” eating plan.

So let’s compare a few approaches to limiting overall food intake.  How much is enough?  How much is too much?  If you are controlling your carbs, have tried all their other suggestions for getting weight loss going, and are still not losing weight, the Atkins eating plan suggests counting protein units.  The protein units come packaged with fat, without you having to count the fat.  For example, one egg is one unit.  It has approximately 7 grams of protein, and 5 grams of fat.  45 of 73 calories come from fat.  For a 5’4″ woman, the protein range for weight loss on the Atkins eating plan is 10 to 17 units.  That’s 3 to 4 units at 3 meals a day, and one or two 1 to 2 unit snacks.  Eat more if you are not satisfied at meals; less if you are satisfied. (And remember to wait 20 minutes to determine if you are or are not satisfied).

In Living Low Carb, Jonny Bowden offers a formula:  if you don’t have a really large amount of weight to lose, try multiplying your goal weight times ten to get the number of calories you can consume per day and lose appreciable weight.  For Juliana, for a goal weight of 120, that would be 1200 calories per day.

So how would a typical day’s Atkins plan of counting protein units compare to Bowden’s equation in terms of total calories?  Imagine these meals and snacks:

Breakfast:   2 eggs, 1 ounce cooked bacon, cauliflower roasted with oil

Snack:  1 ounce peanuts

Lunch:  3 ounce hamburger with 1/2 ounce melted cheese, broccoli, roasted with oil

Snack:  1 deviled egg

Dinner:  3 ounces roasted chicken, 1 cup green beans with 1 teaspoon butter

That’s 11.5 units on the Atkins eating plan, and about 1300 calories on the Bowden formula.  Pretty close to the 1200 calories Bowden suggests for Juliana’s goal weight.  By the way, 63% of the day’s total calories come from fat.

Fat is satiating, and the carbs that create rampant hunger are controlled.  But a day’s meals and snacks are a much lower VOLUME of food than Juliana was used to eating before she started eating low carb.  In her head, she has to get comfortable with the fact that she can eat so much less food AND NOT BE HUNGRY.

Kids and teens have less control over their lives than adults.  They may overeat when the food is available in case it’s not available later.  I can remember as a child eating as fast as possible so that my brothers wouldn’t gobble it up and leave nothing for me–the amount I ate didn’t always have a lot to do with appetite.   And up until now, you may have been encouraging your child to limit her intake even if she was hungry.  On a low carb plan, she shouldn’t be hungry.  But now she’ll have to learn to recognize true hunger, and trust that if she is hungry, she can always eat.