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Challenging Eating Behaviors
So-called “emotional eating” might be “depressive eating” or just seeking out foods that make you feel better (sugar). If carbs and “low-quality” food are in the house, and the person is in an unpleasant emotional state, it’s going to be hard to stop emotional eating. The first lesson for a smoker trying to quit is to throw out all the cigarettes and ashtrays.
“Mindless eating” is due to boredom (and mild hunger, probably). Avoiding that too depends on the food not being available, and the low-carb food being easily available. I think mindless eating is treatable, through grocery shopping for healthy food and throwing out most food in the pantry that isn’t an ingredient.
“Craving eating” parallels craving in addiction. Typically one craves a type of food (sugar/fat). This is the kind of eating that will respond to naltrexone/buproprion, but it is probably not that common. In conjunction with craving eating is binge eating or uncontrollable eating, which is similar to OCD. It’s hard to stop once it starts.
Uncontrolled hunger is when the drive to eat simply cannot be satisfied (without eating). Typical restriction efforts fail, since food is everywhere and people are crafty. It’s an experience that every single person has experienced hundreds of times when they get themselves into a situation (e.g., plane trip) when there is no food (or no palatable food) available.
It seems unfair to folks that are losing all the weight that they can’t see it. If someone runs faster, they have a tally of the miles run and can see the speed increase. Perhaps folks could build up a pile representing the weight lost as they lose weight. Perhaps go out and buy an equivalent number of bricks (5 lbs each) for the weight loss. With every 5 lb weight loss, buy another and add it to the pile. In the end, you can put them in the garden as a reminder of how much you have accomplished. But, don’t pick up all the bricks at once. You will hurt your back! ?
Exercise/muscle building is great and wonderful and inspiring, but it isn’t a way to lose weight. That requires eating/drinking better food and less of it. Though, exercise/muscle building is essential to keeping the weight from coming back. Starting an exercise and muscle building plan early is essential (and good for people’s heart).
Ketogenic Diets and Protein
One must also keep up the protein. You want to keep muscle mass, especially heart muscle. A PSMF (protein sparing modified fast) diet is basically the same as someone who got weight-loss surgery. 65 g of protein is an absolute minimum to preserve muscle mass, but perhaps 100 g for folks who are active; especially heart muscle. Some claim that high protein can kick one out of ketosis, but I can’t find data to back that up, and I don’t see that claim attached to a mechanism. Too much protein yields a not very subtle ammonium smell in urine, since the body has no choice but to dump the extra protein. There is nowhere to store it. The body can burn it (yielding ammonium – NH3), but fat is easier.
The key is to have an amino acid available every time the body needs one, otherwise, it won’t be able to build up (or repair or rework) muscle. There are many amino acids, so the body needs the specific amino acid in the system that the body needs at that moment. Being high in one amino acid might mean one is low in another. That’s another reason to be on the higher side.
One value of insulin is it tells the kidneys to preserve ions. Thus, without insulin (because of no carbs), the kidneys will be “wasting” ions and need to make sure the body has enough. Leg cramps, especially at night, are the easiest way to know one is low. Assuming one has normal blood pressure, salt is no problem, and weight loss is the best treatment of high blood pressure for most people. Cramps can be addressed with 50/50 K/Na salt and other electrolytes. Zinc is also helpful, or a Ca, Mg and Zinc combo.
Once a person is ketogenic, they are no longer getting their energy from glucose and glycogen (stored glucose), but instead from fat stores. Essentially, for the next 4 months or so, that person (assuming they have fat stores) has an unlimited supply of energy. As long as they are getting protein, essential fatty acids, Ca, K, Na, Zinc, and Mg, they are good to go. They could run a marathon and never run out of energy. Some folks have run 100 miles just burning fat stores. It’s what the whole system is designed to do. How else would we have survived through winters and long periods of drought thousands of years ago? But, that energy comes slowly. It isn’t going to work for kickboxing or other high-intensity prolonged activity.
Hard to believe, but eventually, someone with lots of adipose will lose it all. And then the ketogenic low carb diet runs into a problem. How do you get enough calories for all that activity you need to do to keep from gaining weight? The carbs have to come back, but slowly and carefully. Be mindful of your diet, else you are back to the same unhealthy situation where you started.
A recent article gives another win for eating a whole food, plant-based, keto, low carb, or any reasonable restrictive diet.
- Hall Kevin D, Ayuketah Alexis, Brychta Robert, et al. Ultra-Processed Diets Cause Excess Calorie Intake and Weight Gain: An Inpatient Randomized Controlled Trial of Ad Libitum Food Intake. Cell Metabolism. May 16, 2019;0(0). doi:10.1016/j.cmet.2019.05.008.
Despite the ultra-processed and unprocessed diets being matched for daily presented calories, sugar, fat, fiber, and macronutrients, people consumed more calories when exposed to the ultra-processed diet as compared to the unprocessed diet. Furthermore, people gained weight on the ultra-processed diet and lost weight on the unprocessed diet. Limiting consumption of ultra-processed food may be an effective strategy for obesity prevention and treatment.
This is another reason for there being no hope in the obesity epidemic, since food, beverage, restaurant, grocery, (and many farming) industries make their money from the foods folks should avoid. It’s a battle between capitalism and obesity.
Reducing Carbohydrates and Increasing Fat Intake Increases Metabolism
Yes, carbs are bad. That doesn’t mean that fat is good, but instead that fat is key to satiety. So lowest fat = highest hunger.
- Ebbeling Cara B, Feldman Henry A, Klein Gloria L, et al. Effects of a low carbohydrate diet on energy expenditure during weight loss maintenance: randomized trial. BMJ. November 14, 2018;363:k4583. doi:10.1136/bmj.k4583.
They found that:
- “overweight adults who cut carbohydrates from their diets and replaced them with fat sharply increased their metabolisms.”
- “after five months on the diet, their bodies burned roughly 250 calories more per day than people who ate a high-carb, low-fat diet, suggesting that restricting carb intake could help people maintain their weight loss more easily.”
- “Those on the low-carb diet burned 209 to 278 more calories per day than those on the high-carb diet, a difference that would lead to an estimated 22-pound weight loss over three years if researchers weren’t intervening to maintain weight.”
- “the effect was even larger for those who produced high levels of insulin in response to carbohydrates478 more calories a day on the low-carb diet than they did on the high-carb diet.”
It is going to take concentrated behavior change to revert the tide of increasing obesity in the population. The question is, will that happen?
A recent study said that basically diet doesn’t matter for weight loss, be it low carb or low fat. Even if you look at markers, they don’t really vary.
There was no significant difference in 12-month weight loss between the HLF and HLC diets, and neither genotype pattern nor baseline insulin secretion was associated with the dietary effects on weight loss.
- Gardner Christopher D, Trepanowski John F, Del Gobbo Liana C, et al. Effect of Low-Fat vs Low-Carbohydrate Diet on 12-Month Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion. JAMA. February 20, 2018;319(7):667-679. doi:10.1001/jama.2018.0245.
This actually matches what the precision medicine folks came to admit; that diet-wise, precise nutrition is a waste of time and that we should just offer an across the board strategy that can be implemented widely and effectively across the population (lots of veggies, low sugar, no refined carbs, etc.)
The study is interesting because it is the opposite of the earlier studies in that it went with a more community-based treatment model in which all of the measurements in terms of dietary and physical activity are self-reported. Self-report is often incredibly inaccurate and usually on the unhealthy side (more calories, less exercise). So the report of how much food they ate and how much exercise they had, much less what kind of food they ate, is most likely erroneous. But that isn’t the only mistake of this study.
They say the study followed low carb (<20g carb/day). I truly doubt it. Almost no one can handle that low. And, strangely enough, they didn’t measure ketosis, so there is no evidence they actually changed their metabolism from carbohydrate/sugar to fat. This is the common, greater mistake in terms of low carb versus lower carb. They focused on “lower-carb”, but missed the fact that low carb is not JUST decreasing carbohydrates, but attempting to change the way the body generates fuel to burn. Specifically, to look for fat for fuel vs. carbs. That is a huge shift, but only if and when it happens. And it is miserable and complicated. In the week of conversion (or longer), the person is basically starved for energy and lethargic (think flu). The only time that low-carb really has a significant impact is when it is substantially decreased so that it alters body metabolism. Nobody in the low carb world argues that you just need to go a little way toward eliminating carbs.
Further, the data firmly supports that low carb (as in “less carb”) is basically irrelevant if you allow folks to substitute calories. Now, this is not to say that limiting carbs is not necessary. But, in a world where you’re trying to maintain the same amount of calories, eliminating carbs and adding fat adds no value unless you eliminate almost all carbs (<20g/day and probably lower depending on success). The value of eliminating carbs (less-carb) for the general population is that one does NOT add other food, since the general population actually overeats. This also ties into hunger models since carbs drive hunger and fats/protein do not. So, asking a lower-carb person to eat as much is basically telling them to eat even if they are not hungry.
This, to me, is a fairly simple concept. Yet, I continue to see it confused in study after study. Of far more concern is the study was designed to allow people to “return to a more sustainable diet.”
Then individuals slowly added fats or carbohydrates back to their diets in increments of 5 to 15 g/d per week until they reached the lowest level of intake they believed could be maintained indefinitely.
This goes against the concept of how one should lose weight; through lifestyle change, not crash dieting. The implication that one can hopefully discard the diet is wrong. Then, one has no attachment to that strategy of eating and one looks forward to the day when they get to get rid of these miserable limitations on what they can eat. The main finding of Atkins was that once you’ve dumped the low carb diet, all the benefits went away leading to weight regain. Dumping your diet is always a bad idea, but for low carb it is deadly. The weight comes back with vengeance; potentially 3-5 pounds in a week. I’ll emphasize this. Low carb (real low carb) is a one-way ticket until ALL of the weight is gone and you change your life entirely to support an active lifestyle AND keep a very close eye on hunger. Otherwise, you will regain every pound you lost. Potentially within one month.
We don’t need more evidence that folks need to find a food intake strategy that they can live with for the rest of their life.
The genetic measures, on the other hand, are very interesting; as is their use of insulin sensitivity (but measuring insulin secretion after a glucose tolerance test sounds a bit too complicated for much of clinical care).
Qi et al reported that individuals with the IRS1 rs2943641 CC genotype were more successful with weight loss than those without this genotype when assigned to a low-fat and high- carbohydrate diet vs a low-carbohydrate and high-fat diet. Grau et al reported that individuals with the FTO rs9939609 TT genotype had greater decreases in the homeostatic assessment model of insulin resistance on low-fat vs low-carbohydrate diets; however, the diet-genotype interaction for weight loss was not statistically significant. Most prior studies examined single SNPs, with few replication attempts. The intent in the current study was to replicate the post hoc findings from the A TO Z (Atkins, Traditional, Ornish, Zone) Weight Loss Study.
The finding of no significant difference in weight loss in genotype-matched vs mismatched groups in the current study highlights the importance of conducting large, appropriately powered trials such as DIETFITS for validating early exploratory analyses.
These genetic tests should be a part of any standard weight-loss program, since I doubt they cost very much. It’s somewhat depressing that they didn’t find any impact on any of those measures, yet as I described above I think that’s based on a very poor study. If such measures were assessed at a huge population level like the Framingham study, I think we could start to see some differences in people and to identify where adherence is improved and impact is achieved. Again, I wouldn’t alter the diet, but I would look for differences in people and their attitudes to try and determine how we should approach the problem differently. To repeat, that doesn’t mean that we should change the diet, but we should identify the markers of barriers or strengths that help determine success and failure, mostly through adherence.
Bradley Tanner, MD, ME is a psychiatrist and Studio Head of HealthImpact.studio. In this role, he guides the development and evaluation of novel technological solutions to address health challenges including burnout, stress, and depression seen in medical students, residents, and practicing physicians in their early and later careers. You can reach Dr. Tanner at email@example.com. Personal health concerns and concerns related to suicidality should be addressed with your health professional.