Unless you’ve been living under a rock, you’re aware that science journalist Gary Taubes has a new book out: The Case Against Sugar.
I have not read the book myself, but have read a number of reviews of it. Including this one by Stephan Guyenet: Bad sugar or bad journalism? An expert review of “The Case Against Sugar”. Gary Taubes has penned a response to Stephan in a separate thread here: The Case against Sugar Isn’t So Easily Dismissed.
In his review, Stephan did have some elements of agreement and praise for Gary’s work. It’s by no means a slasher piece, at least not how I read it (three times). My purpose in this post is really not to either support or condemn low-carb diets, or sugar, for that matter. Rather, it’s to highlight differing perspectives and rather than me do it, I think Dr. Michael Eades does it best, via a lengthy email he sent me yesterday which I found fascinating and enlightening. He’s given me permission to post the email.
What kind of struck me when I read it is how much experience forms one’s views. You could call it “experience bias,” I suppose. One thing Mike and I always honesty emphasize with each other in our various correspondence (mostly focussed on current political events, not dietary intervention) is that bias is literally everywhere.
So here’s a rough template to illustrate this “experience bias,” for or against low-carb/sugar:
- Personal anecdote (for or against)
- Collectors, synthesizers, cherry-pickers of anecdotes, medical literature, books and articles (like a layman blogger—for or against)
- Professional researchers who review and contribute to the literature (like Stephan, Kevin Hall, etc.)
- Authors and journalists (like Gary, Alan Aragon, etc.)
- Actual clinicians (like Mike; Dean Ornish, Doug McDougall, etc.)
One could probably come up with more, but the point is to really dig in and understand how vastly different is the experience in each category, and as well, it goes both ways. In other words: everything works, and everything doesn’t work. It depends, and also, what works and what doesn’t work is experience that forms your “experience bias,” such that you may focus on what works (low-carb, calorie counting, plant based, etc.), or perhaps you’re a critic and your focus is on what doesn’t work (low-carb, calorie counting, plant based, etc.).
As for me, I’m part of both (1) and (2), above. Low-carb both worked and then didn’t, for me. As a blogger at it a long time, I have thousands of anecdotes in comments as to how it works, and how it doesn’t work. I don’t particularly think about carbs, or even sugar. I just eschew crappy, empty calorie stuff, both at the supermarket and eating out. But I also focus on meal frequency, and portion size—without calorie counting. It maintains my weight in the 180s effortlessly, about 10-20 pounds from what would be considered lean, but I feel better than when in the 170s. In terms of carbs intake, I’d guesstimate it averages to about 150g per day. But some days are super low and some days, moderately high. I try to go at least 12 hours per day with zero caloric intake, so a 12-/12+ eating/not-eating window, and try to extend to one 24-30-hr stint per week. In terms of empty-calorie sugar, some weeks I’ll have a sugar-soda or two, or three, some weeks none. In terms of empty-calorie fat, I use good fats, and I take it very easy on added fats. I tend toward leaner cuts and I trim the fat. So that’s me. My experience.
Here’s the experience from Dr. Mike Eades, who’s parts of (1), (2), (3), (4), and (5).
One of my favorite quotes is from Bertrand Russell.
“The stupid are cocksure while the intelligent are full of doubt.”
I like it because we all are like atomic particles: we change states constantly. In some aspects of our lives and on some subjects we are intelligent while in others we are stupid. And, consequently, we are either cocksure or full of doubt, depending upon our state.
The older I get, the more I understand how potent the confirmation bias is. And how it is almost impossible to overcome. I’m suffused with it, as are you, and Taubes and Guyenet and just about anyone else either of us can point to. As a result, I never know—for absolute certain—whether I am on the right side of any argument or not. Whether I’m cocksure or full of doubt.
When I was in my middle thirties, I started gaining weight like crazy. Before I knew it, I was 35-40 pounds overweight. Like most doctors, I didn’t know shit about nutrition, so I went on the current fad diet at the time, which was in a book by a physician named Stuart Berger (who later died young and morbidly obese). It was low-fat, and I did okay, but hated it. I lost a bit, then regained. I then went on Pritikin, which I really hated. I think I tried one other diet, also low-fat (those were the only ones in vogue at that time), and it didn’t do me a lot of good. Optifast, a hospital-based fasting program was all the rage then, and I discovered there was a similar program (Medifast) set up to be administered through physicians’ offices, so I sent off for the info with the idea of using it as a means to increase revenue in our clinic. When I got the instructional materials, I read it through them and realized that it sounded suspiciously like a shake version of Atkins, whose book I had read years before and discounted, because the medical profession had badmouthed it. (At that time, I was as mainstream as mainstream can be.) The packet contained a few scientific papers, so I read them. The data they presented seemed convincing, so I decided to do the program myself before putting patients on it. I lost effortlessly, wasn’t particularly hungry, and had no decrease in energy levels as I had experienced with the low-fat, low-cal diets I had tried. Which was interesting, because the shakes themselves were low-fat and low-calorie. So the difference had to have been the carb restriction.
The problem I saw with the program was that the shakes worked great to effect weight loss, but when all the excess fat was lost, the company promoting the program had a low-fat, high-carb diet for maintenance. That seemed strange to me because all the papers that came in the physician starter kit argued for the effectiveness of the program as being a consequence of the carb restriction. If the papers were correct, I couldn’t figure out why the Medifast people thought adding a ton of carbs in for maintenance would do anything but bring about weight gain. So, I redid the maintenance program and designed it low-carb.
My patients, many of whom were overweight, had observed my weight loss and asked me about it. I decided that I would start running my own version of the fasting program and maintenance diet in the clinic. It became a hugely successful operation. I finally decided that if the fasting program worked so well, why wouldn’t a low-carb food program work just as well. So, I tried it. But since that diet contained a lot more fat, especially saturated fat (which was verboten in those days), I was worried about using it on anyone of heart attack age. MD sent me a patient from her clinic and I had a few others that disabused me of that notion.
After my experience with these early patients, I overcame my fear of saturated fat and for the rest of the time I was in practice, I used low-carb diets that I fiddled with and refined to treat an enormous number of patients. Most of those patients had tremendous success with it. MD and I hired on to be one center of a major drug study for the drug that ultimately became Xenical. It was a maintenance study, so we had to recruit patients and put them on a standardized, 6-month lead in weight loss diet which was the state-of-the-art low-fat, high-carb diet, designed by the drug company, to get them to lose enough to be accepted into the maintenance part of the program, during which they were to get the drug. All they had to lose over the six months was four percent of their body weight to qualify for maintenance. A 200 pound woman would have to lose eight pounds over six months to qualify. And I can’t tell you how many of them didn’t qualify. We got paid a fortune to do this study, but the payment schedule was skewed toward the end because the drug company (Hoffman LaRoche) obviously wanted patients to get to the maintenance phase to test their drug, so we did everything in our power short of horse whipping the patients to get them to stay on the program and lose.
One of the problems was that the drug-study patients came and waited in the same waiting room as our regular patients, all of whom were on low-carb diets. They would talk among themselves, and when the low-fat, high-carb, drug-study patients heard how much the low-carb patients were losing (sometimes almost as much in a week as the drug study patients were losing over months), the former became discouraged and wanted to be regular clinic patients instead of drug-study patients. It was a major pain in the ass. But it was extremely informative to me, because I saw first hand the difference in outcome of patients who had extensive nutritional counseling, dietary guidance, a dietitian on call, and weekly office visits (the drug study patients) versus our regular clinic patients on low-carb diets who had a short session on what to eat and came into the clinic once every couple of weeks to weigh in. There was no comparison. The low-carb diet vastly outperformed the low-fat diet, hands down. Better weight loss, better lab values, better sense of well being. Virtually any parameter you want to measure, the low-carbers did better. (The FDA requires study centers to keep all the data for something like 12 years, and I still have it all. I keep thinking someday that I can use it as the low-fat arm of a study or something. It is extensive.)
The point of this long story is that I have many years of experience dealing with low-carb diets, so I have a difficult time believing it when people tell me that low-carb diets are just the same as any other diet. My years of experience, both personally and professionally, tell me otherwise, irrespective of the findings of a few episodes of n=1 bro science here and there. My confirmation bias is damn near set in stone.
So, with that intro, telling you upfront where my bias is and why, let me get to the Guyenet article. Which I almost hesitate to do since I don’t think it really matters much. A year or so ago, I read a paragraph in Scott Adams’s book that changed my mind about engaging in these kinds of things. I think it pretty much sums up the way things are:
“If your view of the world is that people use reason for their important decisions, you are setting yourself up for a life of frustration and confusion. You’ll find yourself continually debating people and never winning except in your own mind. Few things are as destructive and limiting as a worldview that assumes people are mostly rational.”
So, with that said, here I go:
I’m sure you’re aware of the big brouhaha that took place at AHS11 when Taubes questioned Guyenet during the Q&A after Stephan’s talk. It was kind of chicken shit in that it wasn’t just a Q&A where Gary got in line to ask questions like everyone else. Gary was speaking right after Guyenet (and Gary was the big star of the show) and he took the opportunity as he approached the podium to zing Stephan.
Later that night, Gary, Rob Lustig, and I (maybe you were there by then) were in the lobby of the hotel having a drink when Guyenet walked up. The first words out of Gary’s mouth were, “Stephan, I’m sorry I was such an asshole today.” Stephan blew it off as if there was nothing to it, and we all sat there chewing the fat.
After the conference, the internet went wild with the spat (if that’s what you want to call it) with all these people posting their iPhone versions of it and many of them, maybe most, taking Guyenet’s side. I think it was only then that Stephan thought he had been ill used.
Whatever it was, Guyenet seems to have had it in for Gary since. And it’s a shame since they were friends before. I actually met Stephan though Gary. I happened to be in Seattle, and Gary invited me to a dinner he threw there for Philippe Hujoel who had invited him to speak at the University of Washington. Gary also invited Stephan and a couple of other people I can’t remember. Now it’s blown up and Stephan has aligned himself with that troll Evie along with James Krieger, Alan Aragon and all the other Taubes haters. So, it doesn’t surprise me that he wrote the review he did.
In my view, he took a lot of disingenuous shots at the book. I’m assuming you’ve never read the book, but I have. A couple of times, in fact. Once in manuscript and again in galleys. It’s like all of Gary’s books. Informative, well-written, and fun to read. Even if you don’t agree with all of it. But I don’t see how you can take a hostile reviewer’s side without reading the book in question to see if the reviewer is on the mark or not.
Gary was straight up at the outset of the book in saying that he was making the case against sugar. It’s even stated in the title: The Case Against Sugar. Not that he was being even handed. Not that he was being unbiased. But that he was gunning for sugar, much like a prosecutor in a trial. He made the point that Big Sugar has a promotional arm that spends hundreds of millions of dollars to make its case—he is simply making the case for the other side. And he basically ends the book by saying he hasn’t made the definitive case—all he has to go on are observational studies and poorly done, short RCTs. To really determine if sugar is causative would require years of randomized controlled trials, which would be prohibitively expensive, and impossible to monitor. The short term trials have been kind of bad for sugar, but that’s all they are: short term trials. Gary admits as much. Guyenet seems to be trying to make it out that Gary is definitively saying all the evidence is in and sugar is bad, when that’s really not the case. He’s simply presenting the anti-sugar case.
(If you read anything that Big Sugar has put out in the last few years, they are making their case – such as it is – by saying that sugar is simply calories, nothing more, nothing less. It’s a calorie just like an apple or a potato or a strip of bacon. In their view, a 2,000 kcal diet of meat, squash, and blueberries would be equivalent to a 2,000 kcal diet of pure cane sugar.)
Gary starts by presenting a history of sugar and the sugar industry. He discusses how the Dept of Agriculture was founded in large part to promote large ag industries, one of which was sugar beets. He also points out how in the early days there was a revolving door between the Dept of Agriculture and Big Sugar, just like there is now between the FDA and Big Pharma. And he describes many of the techniques Big Sugar used to increase the use of its product.
Recent internal documents from Big Sugar have come to light and were just published in the JAMA Internal Medicine (attached) showing that the sugar industry did indeed influence and promote the idea that saturated fat was bad in an effort to deflect attention from themselves. They spent a ton of money underwriting Frederick Stare, Hegsted, Keys and others to push the notion that saturated fat was the devil and deflect the attention from sugar. (The lead author on this study was one of Gary’s research assistants, whom he paid to travel to Boston to gather the documents. After leaving Gary’s employ, she wrote the paper and went through the peer-review process to get it published.)
I’m not going to go down Guyenet’s list one by one, though I could, but there are a couple of areas I will mention in which I think he is stretching it more than a little to make his point.
One is in saying that restricting calories will reduce insulin levels. Well, yes, sort of. But not by any stretch of the imagination to the extent reducing carbs will. A metabolic ward study published in 1996 shows pretty clearly this isn’t the case. Subjects in both arms went on 1,000 Kcal diets (low-calorie diets by anyone’s estimation) for 6 weeks. One arm went on low-carb, the other on 45 percent carb (which compared to the ~55% carb in the typical American diet isn’t that high-carb). Those on the calorie-restricted low-carb diet reduced insulin levels by about 50 percent, whereas the ones on the 45% carb diet slightly reduced insulin, but not to a statistically significant extent. (see attached)
As to the mentions of Kevin Hall, suffice it to say that that whole situation is mired in controversy, which won’t be resolved for a long time. Even I wrote on it. There is gotcha history there, and Gary probably shouldn’t have hired Hall in the first place. We can discuss the whole affair over a brew sometime.
And pointing the finger at the addictive qualities of sugar (should they exist – and Gary admits the jury is out on this) is not confirming the food reward theory. There is a real but subtle difference.
One of the questions Gary proposes is this: Is there an amount of sugar the consumption of which becomes deleterious for health? He reports on a number of researchers throughout the world who have asked this same question. If you look at sugar consumption per capita, people seem to be okay as long as the per capita consumption doesn’t exceed a certain level. I don’t have the book in front of me now, but, as I recall, these levels are in the 50-70 lbs/person/year, which is a helluva lot of sugar (I doubt that I consume five pounds per year, if that). When the people in a country start to exceed those levels of intake, though, diabetes starts to appear and increase at rapid rates. Gary didn’t make this up—he’s simply reporting the findings of other people.
One of the effects of the confirmation bias is that so many issues are never solved until the evidence on one side is so overwhelming that it has to be believed. It takes a long time for the evidence to stack up to that extent, though, so it takes forever for people to finally come together.
It can happen individually, as in the case of Tim Noakes, who is an internationally renowned sports doc. He wrote the early books on running and endurance exercise. Was a big believer in carb loading and wrote about it extensively. Until he developed diabetes. Then he tried low-carb, and changed his life.
It takes a lot longer for the profession in general, but it is coming around.
Anyway, many of Stephan’s criticisms would be on point if Gary hadn’t already admitted to them in the book, so they’re not really valid criticisms. It’s not like Gary is trying to pull the wool over anyone’s eyes.
In conclusion, it’s my view that the overall view of low-carbohydrate dieting is evolving, becoming more nuanced, actually. Perhaps kinder, gentler stances all around. I may be wrong and this may be wishful thinking. I do believe that people are gradually coming around—from all dietary perspectives—to view obesity and chronic disease as a multi-factoral problem. So, someone like me—biased towards modern industrial-engineered foodstuffs, ease and cost of acquisition—in being conciliatory toward LC, might say well, LC is generally the outer isle and that’s where most of the good food is. So, the chances are that a person doing LC will eat healthier, more nutritionally-dense food.
A calorie-counter, being conciliatory, might say that LC diets show promise because they can be generally more nutritionally dense (especially if weighted toward proteins and not fats), this curbs appetite, so people eat less.
The plant-based or vegetarian might say sure, you can absolutely do it LC style.
The Paleo might say sure, LC is one of the many available styles of Paleo.
And so on.
…Finally, I would ask that comments be value-add and respectful to my friend Mike, who graciously gave me permission to publicly post his private email because I thought it was an awful waste only for me, whether one agrees with its content or not. So, please be mensch.
Update: Mike has put this up in a post of his own, now, including an addendum.