As a public school teacher, I am very concerned about the high carb load of foods we serve as a result of providing "free" meals for students. In addition, the foods served are so nutrient deficient. I would like see a study about the increase in child obesity and/or Type 2 diabetes in relation to schools that provide government funded meals.
Agree; this is why Nina Teicholz's group places such emphasis on the US government's official dietary guidelines. I have high hopes for RFK jr. really making a difference here.
After reading Good Calories Bad Calories 13 years ago I changed my medical practice. I encouraged my patients to eliminate sugar/starch from their diet. Blood pressure and blood sugar came down predictably. If I needed to prescribe medication I used only medications that did not raise insulin levels. At the time Victoza was the commonly used GLP1. I also used SGLT2 inhibitors. (SGLT2 inhibitors raise LDL and the cardiologists prescribe them).
I still use the GLP1s even though I think that they are a threat to finding success in dealing with chronic disease. The threat is that they will keep people from being on a highly nutritious diet, focusing too much on weight loss per se. Eating less food on a low quality processed food diet will likely lead to more problems with malnutrition in a few years. For example, sarcopenia.
Thanks. I do think the drugs can be extraordinarily valuable, and for some people perhaps necessary. I have the same issues you do, of course, and I worry that the relentless unbalanced media attention will exacerbate the tendency to opt for the easy solution of drugs.
I love your books and pretty much anything I can get my hands on you've written. I'm inclined to agree with you on the pernicious risks of depending on drugs when some other change could accomplish the same results.
But when drug interventions are phrased as "the easy solution" I worry that there's not some semblance of the same moralism that's plagued obesity treatment as experts questioned the self-discipline of patients who couldn't just do the right thing and eat less or take up jogging and then the eventual criticism of their character when they failed to do it.
I did a very low carb diet for about two years, lost 20 pounds, and while it wasn't "hard" in the sense that I struggled with hunger or couldn't eat the salty, fat proteins I loved, it was burdensome in terms of swimming against the current of general American food availability, living with family members who aren't pursuing the diet, going to restaurants (its eye-opening how much a $25 entree is comprised of carbs) and so forth. It also becomes a bit monotonous, and while some of this is maybe due to a lack of creative flair in my cooking, I only have so much time for creative flair in my cooking and restaurant meals themselves were sometimes challenging if I didn't pick the restaurant. It would have been financially burdensome too if I made less money, proteins are expensive.
To me it's just entirely obvious that GLP1s are considered more desirable than a diet which has a lot of deviations from the norm (don't get me wrong, the norm isn't good). Life is burdensome and time constrained.
In my opinion excess carbohydrate reduction needs to be a food supply question rather than as much of a question of individual choice. Figure out how to excise tax sugar and fellow travelers like corn syrup to make their inclusion (or inclusion in large quantities) economically burdensome for food producers. If you can cut excess carbs from the food supply, I think it will go a long way.
That's a good point, about less poor quality food not being the answer. I used Victoza myself a few years back until it vanished from the UK without trace! I liked it because I had a good quality diet, mostly organic ingredients or high quality if not organic. We spend a lot of our income on food quality and don't bother with holidays. For me Victoza cut out the food thoughts and helped me eat less. It helped me get a grip on portion sizes, which was my big issue. So I was eating less good food and not snacking.
Since losing Victoza I have been through a very stressful and medically unhappy time. And I'm a carer for my mother and trying to cope with a failing business thanks to Brexit. My mind is stressed and stretched. I could no more follow a ketogenic diet right now than I could fly to the moon.
But I do hope I can get onto one of the new injectables soon because without the food chatter I'm so much healthier. I believe that if I had not been going through such a difficult time when I lost access to Victoza I would have maintained the lost weight. I know how to eat. I just need help getting started again and shifting some of the bulk.
12 years ago I lost a lot of weight with low carbs. But it was hard and took a lot of work. Now, menopausal, hypothyroid (and not well medicated for it) and suffering some sort of spinal issue that's stopping me walking, bending and exercising I stand no chance of doing it the hard way.
Hi William - I hope you’re interested in other perspectives, as this is one of the major message boards for individuals and clinicians like myself who have observed the exact opposite: ketogenic diets have the advantage of being one of the easiest plans to follow over the long term.
If one can make it through the early phase of transitioning away from a high carb, insulinemic diet (which in my clinical experience can take up to 6 months), the physiological characteristics of fat adaptation (normalized appetite, lack of cravings, successful reversal of metabolic diseases, chronic pain and obesity) makes on-going compliance exceptionally easy. I have used the word “inertia” to describe the way ketosis amplifies and perpetuates the choices that maintain ketosis.
Most of my patients who successfully cross this threshold proclaim that they are ready to maintain their ketogenic diet for life, because of how great they feel and how manageable they find the lifestyle. They also know that they can “flirt” with carbs on birthdays and special occasions and get right back into ketosis.
Maybe low-carb/keto eating plans are hard for you, but not for me or for many, many other people. I've had lasting non-scale benefits. One example is that I've cut my ALT and AST numbers in half. Both have been at the top of the range (or slightly above) for years, but after going carnivore in August 2021 and cutting out all ultra-processed foods (along with fruit, veggies, fiber, grains, sugar, etc.), within about 6 months, both test results were in the 20s rather than the high 40s.
I found the idea of taking a drug to reduce weight, without changing the diet and lifestyle that caused weight gain, amazingly simple-minded.
If weight gain is caused by diet, surely the diet should be changed. It may be deficient in high-quality protein, vitamins, and minerals; it may lack high-quality animal fats; it may include dangerous seed oils (and grains, if they really are toxic).
Taking a drug may reduce weight, but if diet remains lacking in essential nutrients (and perhaps includes toxins), surely damage will continue.
I shall follow the story with interest - but not holding my breath - while continuing to eat my keto-ish diet and walk daily.
I agree with you completely, but.... the conventional wisdom is that we get fat because we eat too much and weight-loss diets work when they get us to eat less. So the conventional wisdom also agrees with you (and me), it just disagrees on how the diet should be changed.
This is one reason why I keep coming back to the cause-of-obesity issue. Whatever dietary factor triggers it has to be changed in a diet that prevents and treats it. I'll return to this (again and again) in future posts.
Excerpts from a June 13, 2024 article entitled 'Glucagon-Like Peptide-1 Agonists': "Glucagon-like peptide-1 (GLP-1) -agonists have gained popularity over the last decade for treating millions of Americans with type 2 diabetes (T2DM) and obesity. They are attractive primarily because of their beneficial effects on glucose regulation as well as the cardiovascular system. New indications, beyond those that are FDA approved, are actively being investigated, and with increased utilization, more emergency department visits for drug-GLP-1 agonist-related complications are occurring...The American Gastroenterological Association currently recommends semaglutide, 2.4 mg injected weekly, as the preferred treatment for obesity in conjunction with lifestyle modifications. Unfortunately, about 2/3 of patients regain weight if treatment is stopped." https://www.acep.org/toxicology/newsroom/may-2024/glucagon-like-peptide-1-agonists
It's not surprising that physicians are taking these GLP-1 drugs despite not knowing the long-term side effects. They did the same thing with the Covid jabs.
To me, many of those who've lost so much weight from these drugs look emaciated and a bit frail. I get it, it feels good to lose weight. And I also looked that way when I went on low-carb for a couple years. But looking at my old photos from back then, and being older too, I looked too thin. I've accepted gaining about 10 pounds from that point and carefully eating some carbs now; in fact, it's my understanding that having a little more weight is better for older women than being way too thin. I do weigh myself every day and am able to predict, pinpoint and adjust for any weight gain associated with the carbs I ate the day before.
Seeing these physicians pile in on a required lifelong drug that has unknown long-term side effects, gives me a reason to distrust any of their recommendations and especially their prescriptions. Except for those physicians who are micro-dosing the GLP-1 drugs so have a reasonable and not overly thin result, perhaps seeing their emaciated faces and bodies gives me a new and visibly easy way to weed out which physicians to avoid.
my sister has been on ozempic for three years--she is so thin she looks ill. she's like a sapling tree. she's also depressed now. She had to up her dosage because it was no longer keeping her blood sugar low enough. she eats whatever, but not much because if she eats too much she gets intense stomach pain. When I'm with her she snacks on candy. so....i have questions about the long term safety of this drug.
I agree with your observation that many glp-1 consumers look too thin and frail. A friend of mine used to work in Hollywood, and they would refer to extremely thin people as X-rays, because you could practically see all their bones. That's how a lot of glp-1 consumers look to me. The skin looks saggy, especially in older folks. Many are not doing any kind of resistance training to keep their muscle tone (in fact, part of their weight loss is muscle tissue, according to studies I've read). And, they're not eating the right macros to develop and maintain the muscle. People think thin=healthy, but this is not accurate.
A worrying amount of the weight loss is muscle loss. I haven't seen reliable figures but I expect you are right that very few are doing resistance exercise.
I've seen estimates of around 40% lean mass loss for the typical consumer of glp-1. If I could remember where I saw that number, I'd link to it. Clarification: Of the weight that a typical consumer of glp-1 loses, 40% of that is lean muscle mass, from what I understand.
Congrats on the weight loss. Regarding loss of muscle, sarcopenia is a serious problem as people age. Maybe a dexa scan is the best way to know what, if any, is an acceptable amount of muscle loss.
Initially there was desperation and fumbling at hospitals as doctors struggled to find out what worked best, or what just worked - some dummies even tried Ivermectin. Didn't work for them. Yes, the bodies piled up. It was a HORRIBLE time. That says zero [0] about vaccination's effectiveness at the population level. Yes, I hear a dog whistle with "jab." Which is why, ya know, I said it.
I’m sorry but this is a really ignorant comment. Doctors were given protocols from hospital administrators who were receiving gobs of money from the federal government if they managed Covid cases a specific way. This meant denying any type of early treatment and putting them on ventilators and/or remdesivir which both had extremely high fatality rates.
When the vaccines arrived it was obvious early on they did not prevent infection/transmission and were causing serious side effects. They were neither safe nor or effective, yet morons at all levels of the government wanted them mandated. A very ugly and dark time for this country that still has not been rectified.
Have you looked at dictionaries from back in those days and pondered whether or not the jabs are vaccines-as-then-understood? Or just taking on faith someone's statement and reasoning that they are not?
Taking what one reads on faith for a while is necessary for scientific understanding. Or one falls into the common modern trap of using unexamined prejudices to form a premature and often incorrect criticism of new ideas.
But there is a time then for "critical thinking", skepticism. Here, looking at some old dictionaries and seeing whether or not "jabs" satisfy some common & old definitions for vaccine or not.
I understand the desire to lose weight. I don't understand the use of virtually unknown drugs (in terms of longer-term adverse effects) to get there. Scares the hell out of me.
I have fought (and I'm sick of fighting) binge eating and weight since I was 5 years old. A whole slew of psychology, trauma, blah blah blah. I'm 67 this year and I WANT IT TO STOP. The drug route is so tempting and I've looked at it inside and out. But those I know who went on it lost weight because they were MISERABLE. They were nauseous, bloated, constipated, and felt awful - so awful they never felt like eating. And still dont. That's why they lose weight so fast and look gaunt - the muscle goes too. What's going to happen to their digestive systems after years on these drugs? So tempting....but I can't take a route that will make me feel like shit every day of my life.
I'm not a medical doctor, so I can't give any advice, but I can say what i suggest in The Case for Keto, which is that all these dietary approaches and drug therapies can be viewed as self-experiments. If you try the drugs and you feel miserable, nauseous, bloated, constipated, etc, then you stop trying the drugs. You can do the same with a ketogenic diet. See if it helps. I get WANTING IT TO STOP, but we can try different approaches to see if it does. As Suzie Lee says in her comment, food noise goes away on ketogenic diets, too. Infact the first time I ever heard the phrase food noise was from Steve Phinney, one of the pioneers in ketogenic diet research (and a co-founder of Virta Health). That was back around 2010 when I was doing the research for my book Why We Get Fat, and Steve told me that people on KDs say food noise vanishes, they stop thinking about it.
I do think the diet is a healthier choice than the drugs and I personally like having the control over my health that I feel I have with the way I eat and don't have when I'm on drug therapy. But it can all be tried as an experiment. See if it works and how you feel.
The one KEY issue with no starch/no sugar (Keto) for me is the unfavorable change in my lipid profile. I don't know what to make of it and what to do about it. Any ideas anyone ?
I can relate to this Jennifer. I read “Magic Pill” (Johann Hari) last year and was fascinated by the description of how the constant “food noise” disappears within hours of a GLP1 injection.
As a functional medicine practitioner, I had also read books about ketogenic diets (Gary’s The Case for Keto being one of them, of course) and suspected that the physiology of ketosis should also reduce food noise — not as quickly or dramatically, but substantially enough to be noticeable and effective. I’ve been keto for almost a year and am amazed at how much agency and calm I have developed around food. Carb cravings and binge eating have completely disappeared.
The transition was quick for me (about two weeks) but it took another 3-6 months to really solidify the new physiological patterns. Now I can do the miraculous… I can eat 3-4 French fries off my husband’s plate and feel completely satisfied. We’ve had a quart of ice cream in the freezer for 4 months that I haven’t even once considered eating. I CAN EAT JUST ONE DATE. Miraculous.
I can’t tell from your comment whether you’ve tried the keto route, but I can’t recommend it highly enough!
It is possible to lose weight and keep it off without experiencing discomfort if one knows how to make one's endocannabinoid system work properly. I'm 78. About 9 years ago and before I was struggling with about 25 pounds of weight gain every winter. Fortunately, in 2016 I read a British Medical Journal article that said, "We now know that major changes have taken place in the food supply over the last 100 years, when food technology and modern agriculture led to enormous production of vegetable oils high in ω-6 fatty acids, and changed animal feeds from grass to grains, thus increasing the amount of ω-6 fatty acids at the level of linoleic acid (LA) (from oils) and arachidonic acid (AA) (from meat, eggs, dairy).” https://pmc.ncbi.nlm.nih.gov/articles/PMC5093368/
I found it useful to reduce my meat intake, particularly pork and poultry. The flesh and fat of monogastrics fed up on oilseeds is typically overly-rich in omega-6 arachidonic acid and omega-6 linoleic acid. Excerpt: “Poultry meats, in particular chicken, have high rates of consumption globally. Poultry is the most consumed type of meat in the United States (US), with chicken being the most common type of poultry consumed. The amounts of chicken and total poultry consumed in the US have more than tripled over the last six decades… Limited evidence from randomized controlled trials indicates the consumption of lean unprocessed chicken as a primary dietary protein source has either beneficial or neutral effects on body weight and body composition and risk factors for CVD and T2DM. Apparently, zero randomized controlled feeding trials have specifically assessed the effects of consuming processed chicken/poultry on these health outcomes.” https://pmc.ncbi.nlm.nih.gov/articles/PMC10459134/
Researchers in Ethiopia attempted to explain where the problem lies. "The increased n-6/n-3 ratio in today’s westernized diets has shown a rapid increase in the primary risk factors (predictor) for cardiovascular diseases such as obesity. On the contrary, maintaining the low ratio of n-6/n-3 has been concluded as a good strategy in the prevention and management of obesity." https://onlinelibrary.wiley.com/doi/10.1155/2021/8848161
Written by researchers with English as a second language, the narrative is a little hard to follow. Never-the-less, there are a numerous valuable references that one can peruse.
Excellent as always, Gary. I just want to say that carbohydrate restriction and GLP-1 drugs don't have to be mutually exclusive. In an ideal world, anyone who learns about keto and wants to try it (for whatever reason - improving health, weight loss, managing an otherwise intractable condition) would find a reputable source, implement the plan, stick to it diligently, and reap the benefits. Unfortunately, while for many people, keto "sticks" immediately - they ditch the carbs effortlessly and never look back - for many others, staying on plan is a struggle. They know what to do, and maybe they even have a supportive partner/family and the support & guidance of a doctor or keto-friendly nutritionist or dietitian. And yet, it's *still* difficult. Keto would work ... if they could implement it consistently over the long term. I wish it were effortless for everyone to stick to keto who wants to do that. For some people, keto alone quiets the "food noise" the GLP-1 drugs are becoming so famous for silencing. Keto completely regulates hunger, appetite and cravings, and life is grand. But for others, staying away from certain foods or stopping binge eating isn't as simple as, "Why don't you 'just' do keto." Many have tried - over and over and over.
In these cases, it doesn't have to be a choice between keto *or* a GLP-1 medication. It can be both. I know a few people in this situation and they are thriving. The medication is giving them a little pharmaceutical leg up that helps them do what they were unable to (but firmly wanted to) do on their own. And they are using the GLP-1s in conjunction with a keto/low-carb diet with an emphasis on protein and strength training. The risks for long-term complications are still there, but at least they're pulling all the levers rather than just the pharmaceutical one while ignoring what they're actually eating and not taking deliberate action to build or preserve muscle mass. We have some mutual physician friends who prescribe GLP-1 meds in conjunction with supervising them on keto because the drug makes it easier for them to get some momentum with keto, and maybe doing it that way will help to reduce the risk of weight regain if the meds need to be stopped at some point. The same might not be true about the potential long-term complications, though. Will keto prevent those? That remains to be seen, although I suspect we may still be in the early days of even identifying all the possible complications now that so many more millions of people are taking these. (/Fin to the longest comment ever! 😆)
Thanks for the very thoughtful comment and I agree with you. I didn't mean to imply that the drugs didn't have their use, including helping with a transition to a healthy weight and a way of eating that doesn't promote weight regain. I'll post about that shortly.
Cardiologist here. Have been on Mounjaro for about a year now and am down from 230-240 to 195-200. Labs all look good. Alcohol down to once or twice a week. Tried Keto/Atkins years ago but couldn't stick with it. It would have worked in a controlled environment but as a "free range rat" there are just too many ways to fall off the wagon. Side effects of the GLP-1 agonists are real, especially GI side effects. My wife is on Mounjaro too and I worry about sarcopenia. Both of us have taken to spreading out doses for weeks. Funny, not any literature on effectiveness of spreading out the doses, no economic incentive to do it.
Realistically, these drugs are only going to become more prevalent as the cost comes down. They are likely to change the entire focus of medicine in the coming decades. Aside from the occasional pandemic, what aspect of "modern medicine" doesn't concern itself with the complications of the disorders of our modern diet and lifestyle?
Thanks, Kel. Your last comment resonated: "what aspect of `modern medicine' doesn't concern itself with the complications of the disorders of our modern diet and lifestyle?"
As I said in the post, it was my experience researching the insulin story that made me a bit anxious about a different question, which is, what are the chances that modern medicine in the future will be concerning itself, all too often, with the complications of the disorders of these drugs.
Insulin, too, was a wonder drug. Very quickly after it appeared, virtually all patients with diabetes were getting it. Only 10 to 15 years later, after an acute disorder (type 1) was transformed into a chronic disorder and insulin therapy for type 2 has become the norm, did physicians realize that they were dealing with a tsunami of chronic complications. Patients were going from apparently healthy to dead within a year or two, suffering from the neuropathies, retinopathies, accelerated atherosclerosis, etc, that we now know associates with diabetes.
The point, though, is that the diabetologists had no idea then and perhaps even still how much of a role the insulin therapy was playing in these complications. They assumed the problem was poorly controlled blood sugar and so they advocated for more intensive insulin therapy, even for patients with type 2 who already had hyperinsulinemia.
So, yes, these drugs are going to be ever more prevalent, and if complications start appearing, we'll have yet newer drugs that can be tried. (I have friends who had issues with benzodiazepines for insomnia after a few years of use and their prescribing MDs responded by suggesting they change drugs, or up doses, not get off the drugs and use behavioral therapies to help with sleep.) It makes me nervous. I hope unnecessarily so.
'But physicians “are a good litmus test for drugs that are highly effective.”'
Yeah. That's why Sir Richard Doll used doctors as his population for studying the effects of smoking. Practically all doctors smoked before 1950 - and recommended cigarettes to their patients as "a tonic".
I wonder how many doctors today have been eschewing cholesterol and eatin lots of "healthy whole grains" and seed oils.
I thought about this comment, too. Gina Kolata, the author, doesn't say they're a litmus test for drugs that are known to be safe in the longterm, because they don't know that. They only know they work in the short term and they have a front row seat for that. Ultimately, though, they're no better guides than anyone else to the longterm risks and benefits.
What about people like me who have eaten very low-carb for 20+ years (since the late 1990s) and still have not achieved a healthy weight? I'm 70 years old, 5'6", I weigh 182, and can't seem to get lower than that; I should probably lose another 30 pounds (or more), but how? I went from low carb, to very low carb, to keto, to now carnivore. My blood sugar averages around 82. I'm not perfect, but will say I'm close to pure carnivore. I avoid starches, grains, fiber, sugars, and processed foods. I have experienced many non-scale victories, but what I have NOT experienced is losing body fat to achieve a healthy weight. So what do I do? I'm already following a whole-foods diet, avoiding carbs (zero on most days), and yet I've been stuck at the same weight for a couple years now. I'll go up a couple pounds, and come back down to the set weight, but can't seem to get any lower. I'm seriously thinking that a GLP might be my only answer. I'd love to hear your thoughts on people like me who seem to be totally resistant to fat loss.
I’m 73 and went from 199 to 167 and am holding steady there for 3 years. No drugs just low carb. Beef butter bacon and eggs. Dropping another 15 pounds would be perfect but hard to get to. Fasting 3-4 days periodically and a daily eating window of 2 hours is what I need to do to break through the weight plateau. Fasting from day 2 on gets pretty easy. First day is the worst. I eat a half teaspoon of Redmonds Real Salt every day I fast.
Your arachidonic acid intake may still be excessive. Try cutting your meat intake in half.
Fasting and exercise can be helpful. "During fasting/refeeding cycles and increased levels of exercise, tissue PUFA concentrations have been shown to deplete rapidly in both humans and rats. These studies show that most PUFAs, including α-linolenic acid (ALA) and linoleic acid (LA), are preferentially oxidized in periods of exercise or fasting. During refeeding, SFAs and monounsaturated fatty acids (MUFAs), such as palmitic acid and oleic acid, are also more rapidly replaced than any of the PUFAs. Similarly, the concentrations of most plasma PUFAs and MUFAs have been shown to be significantly lower in rats fed a high fat ketogenic diet than in controls. https://pmc.ncbi.nlm.nih.gov/articles/PMC5167222/
You can be on a zero carb diet and still be totally carb dependent, and not "burning" fats, which you need to do to lose body fat. What might be happening is your liver is "stuck" converting protein and fats into glucose. An indicator of this would be high triglycerides--above 150 mg/dL. It might be a good idea to have your liver function checked. One possible solution might be to go on a fast for two or three days to give your liver a rest and time to heal itself. Ask your doctor if you are healthy enough to do that. Or, do intermittent fasting, confining eating to a 6-8 hour period giving your liver and the rest of your body a longer daily rest and healing period.
Gary, thank you for this info. It's an interesting concept. When last tested this past May, my triglycerides were at 87. I do intermittent fasting almost every day.
What level of exercise have you been doing over that 20 year period? If you have been doing everything right but still not getting the results you want, it is surely reasonable to try a drug. Just be sure that you have really been doing it right consistently!
A point I make in The Case for Keto is that the link between what we eat and excess weight goes primarily through insulin and so minimizing carb consumption will (ok, should) minimize the dietary influence on your weight, but there are plenty of others. 182 may be a healthy weight for you, much as you'd like to be leanner (as many of us would). If I'm right, than you were more or less programmed in the womb (the technical term, literally, is fetal programming) to weight more than you'd prefer. Then a lifetime of carb-rich, sugar-rich foods probably exacerbated this. Maybe had you been on keto or carnivore for life, you'd never have weighed more than 140 or 150. But having eaten that way for decades, it gets harder to undo your bodys' shift to storing excess fat. So I think the lowest weight you can achieve and maintain by diet is going to be whatever you weigh on keto or carnivore, and that's probably a healthy weight for you. You might get lower with the drugs, but, as others have commented, that could also be from lean tissue loss. Clearly many people on the drugs also plateau at a weight higher than they're prefer. (Although with the drugs, there's always a new one coming along that might make them leaner yet.)
It's a tricky business and I wish there were easier answers. Some of us, though, are just programmed to be heavier than others. We can fix it to some extent by diet, but it's not only diet that's influencing our weight.
Well, that's the single most depressing thing I've read in a long time. Thank you, though, for your honesty. I do remember reading in one of your books that you can lose weight on keto (or any other plan, for that matter), but not necessarily all the weight you WANT to lose.
You are one in a small group of experts in this field that I truly respect and look up to. Keep up the good fight.
This was me (I've never gone carnivore, but I've been low carb for many many years). There's other issues with my body (digestive/esophageal disorder that needed to be surgically corrected), but I went on a GLP and I have finally gotten down below 'overweight.' I exercise, I keep low-carb. I am so grateful for this tool.
I don't know what your exercise level is, but when I was on a ketogenic diet and measuring my blood ketones, the only thing that would really get them up was exercise.
Gary is a friend of mine, so I don't think he'll mind me dropping a link here. Kathy, I'm a keto/low-carb nutritionist who works a lot with Dr. Eric Westman - whom Gary knows well and has mentioned in several of his books. Please watch this video when you have a chance -- it is NOT enough to be told your thyroid is "normal" - even if everything falls within the reference ranges. I see this in clients *all the time* -- normal does not mean optimal. I cannot emphasize this enough. In fact, I'm writing a book about thyroid now because it's such a critical issue. (If you think nutrition science is backward and in the dark ages, that's nothing compared to how many people are suffering because of undiagnosed or improperly treated low thyroid - including many people whose labs are "normal."
Please do give it a watch when you have time and contact me if you have any questions or need help finding the right practitioner who really understands the nuances of all this: https://youtu.be/ZE6-FHf-0oY
Amy, I do know about you and almost think we spoke on the phone once. I'll definitely look into the info you provided. Thank you so much for reaching out. It can be VERY confusing to wade through all the information that is out there. We all want to do the right thing, but when one expert you trust says one thing and another expert you trust says the opposite, it's hard to know what to do.
I've had the entire thyroid panel tested repeatedly. Granted, it was a few years ago. I was put on Armour thyroid for a while, but it didn't seem to help with anything.
Yes, obesity and especially morbid obesity are symptoms of an eating disorder but the eating disorder is merely the wrong solution to the real problem which is the self image of the obese individual. As general practice dieting doesn’t work over time and I doubt that long term use of drugs will keep the formerly obese from restoring their eating disorders any more than gastric surgery which has dubious long term success. The better alternative is to join Overeaters Anonymous which works as well as Alcoholics Anonymous. I am a member of a 100 pounder + group which includes many members that have sustained weight losses of 100 pounds or more. I am sustaining a weight loss of 140 pounds for three years and have enjoyed continuous sobriety for more than 38 years. I am at a loss to understand why news articles overlook OA as an option.
I'm glad to hear you've been maintaining your weight loss. I disagree with you on obesity being a symptom of an eating disorder. (Although I can imagine eating disorders being symptoms of obesity.) I also have issues with the idea that overeating of all foods is the problem. I'll discuss all this in future posts.
I have high hopes, too. I'm not so sure the problems with the foods, though, are that they're nutrient deficient. The kinds of studies that would help get tricky, but they can be done. My fingers are crossed that the new administration will want to do them.
1. I think this is a typo: “They have convinced themselves that their patients won’t stay on diets long-term and that their patients would prefer diets to drugs.” Should be they think their patients prefer drugs to diets. 2. I quit sugar and flour when I read GCBC 20 years ago and have been very happy with the results though I eat lots of other carbs. 3. Deborah Gordon was my girlfriend 50 years ago. 4. 5 year Virta and Roy Taylor results are not impressive, though a small percentage of diabetics do great (10% in Taylor’s study.
We all too easily relegate “diet and lifestyle” approaches as a personal struggle. We refuse to act on the forced “lifestyle” of carbohydrate inducements that are packed into every square foot of a supermarket, every restaurant menu, substantial areas of pharmacies, vending machines, and at every store checkout. I wonder when these repurposed pharmaceuticals will similarly become as ubiquitous as the products that they seek to mask?
When I was getting my MS in nutrition 13 years ago, the weight loss therapy approach was the infamous energy deficit - eat less and exercise more, which seemed ridiculously inefficient even back then.
After reading Good Calories, Bad Calories, I was so excited. Finally, this made sense! I started coaching my clients to reduce carbs vs calories, and the results were impressive. Both blood sugar and weight improved significantly with one caveat: people had to follow the diet.
I don't even go to the extremes of the Keto diet; ketosis is usually not necessary to reap the benefits. But carbs, like baked goods, potatoes, rice, corn, etc., are what most people eat. Carbs are the cheapest part of a meal, and ready-to-eat foods are full of them.
Getting people back into their kitchens to cook food vs. eating packaged or takeouts - that's where the struggle is. The low-carb eating style works beautifully, but taking the pill is so much easier. As a nutritionist, it's exhausting to always go against the current. First, against conventional medical advice, and second, against the convenience of the food industry's generous offerings.
I agree with you Max, perhaps because I am a journalist.
Although one way the Pharma money definitely influences the news coverage is it often pays for these studies. And even academic researchers study drugs and look for drug targets--much of the genomics research being done--because of all the biases I discuss in the post, and.... that's where the money is. So the entire research agenda gets warped by the gravitational pull of big Pharma.
Brilliant as usual Gary. Thank you. Your article reminds me that most physicians don't even clearly understand what health is. Why don't they? Because we (as a society) have never agreed upon a clear and widely-accepted (and science-based) definition for the term "health". Unless all of public/private healthcare/biotech establishes and concurs on a science-based working definition for 'health', we are forever lost! Lewis Carroll said "If you don't know where your going, any road will get you there" Kissinger famously said: "If you don't know where you are going, every road will get you nowhere"! The Oxford English Dictionary (login required), the definitive dictionary for the English-speaking world, defines health as: "that condition (of the body) in which its functions are duly and efficiently discharged... the general condition of the body with respect to the efficient or inefficient discharge of functions." I believe this is a pretty good definition. In my own practice we define health as: "... the presence of proper function from the cellular (micro) level to the social (macro) level." Health is truly all about proper/correct FUNCTION (from the cellular to the social level). Most of healthcare is focused on altering (not improving) cellular function (via meds) in order to create favorable 'downstream' effects systemically or socially. The focus is never on improving or correcting function at the cellular level. These new expensive meds are (once again) simply ALTERING cellular function (inhibiting one or or more normal cellular functions) but there is an attractive (short term) downstream result: weight loss, felling better, improvement in social function and also improvement in some 'surrogate indicators' of health. But we have NO idea what lays ahead for these folks in the long term and most don't seem to care. Anyone with a serious understanding of human physiology should be concerned, IMHO.
I completely agree (and thanks for the quotes, which I hadn't seen). When I was writing this, it got me thinking about the fact that we discuss putting diabetes into remission, but never obesity. Of course, the criteria for diabetes into remission is getting the patient to a health A1C without drug therapy. If we used a similar definition for obesity, with the bar being a healthy weight, then by definition it could only be achieved by diet. That then gets into all kinds of issues about what effective and safe dietary therapy and the swamp we've been wading through since the Atkins days. My definition is very different than the medical communities and even different from a few folks commenting on my posts. How do we solve that?
Thanks for your response Gary. I believe it would be appropriate for the NIH to create its own definition for the term "health". They currently do NOT have a working definition for "health". I repeat: The NIH has no official definition for "health". The NIH occasionally (when necessary or convenient) defers to the WHO's definition for health, which , IMHO is a terrible definition (primarily because of its subjectivity). Perhaps RFK, Jr can officially publish (in MMW?) a more rational and "official" definition wherein health is equated to "proper function", similar to the Oxford English dictionary definition. My harping on this might sound trivial but I believe this issue is key to changing the direction of healthcare and focusing more people and resources in the same direction (toward proper function in the cells/organs/systems/human!)
As a public school teacher, I am very concerned about the high carb load of foods we serve as a result of providing "free" meals for students. In addition, the foods served are so nutrient deficient. I would like see a study about the increase in child obesity and/or Type 2 diabetes in relation to schools that provide government funded meals.
Agree; this is why Nina Teicholz's group places such emphasis on the US government's official dietary guidelines. I have high hopes for RFK jr. really making a difference here.
After reading Good Calories Bad Calories 13 years ago I changed my medical practice. I encouraged my patients to eliminate sugar/starch from their diet. Blood pressure and blood sugar came down predictably. If I needed to prescribe medication I used only medications that did not raise insulin levels. At the time Victoza was the commonly used GLP1. I also used SGLT2 inhibitors. (SGLT2 inhibitors raise LDL and the cardiologists prescribe them).
I still use the GLP1s even though I think that they are a threat to finding success in dealing with chronic disease. The threat is that they will keep people from being on a highly nutritious diet, focusing too much on weight loss per se. Eating less food on a low quality processed food diet will likely lead to more problems with malnutrition in a few years. For example, sarcopenia.
Hi John,
Thanks. I do think the drugs can be extraordinarily valuable, and for some people perhaps necessary. I have the same issues you do, of course, and I worry that the relentless unbalanced media attention will exacerbate the tendency to opt for the easy solution of drugs.
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I love your books and pretty much anything I can get my hands on you've written. I'm inclined to agree with you on the pernicious risks of depending on drugs when some other change could accomplish the same results.
But when drug interventions are phrased as "the easy solution" I worry that there's not some semblance of the same moralism that's plagued obesity treatment as experts questioned the self-discipline of patients who couldn't just do the right thing and eat less or take up jogging and then the eventual criticism of their character when they failed to do it.
I did a very low carb diet for about two years, lost 20 pounds, and while it wasn't "hard" in the sense that I struggled with hunger or couldn't eat the salty, fat proteins I loved, it was burdensome in terms of swimming against the current of general American food availability, living with family members who aren't pursuing the diet, going to restaurants (its eye-opening how much a $25 entree is comprised of carbs) and so forth. It also becomes a bit monotonous, and while some of this is maybe due to a lack of creative flair in my cooking, I only have so much time for creative flair in my cooking and restaurant meals themselves were sometimes challenging if I didn't pick the restaurant. It would have been financially burdensome too if I made less money, proteins are expensive.
To me it's just entirely obvious that GLP1s are considered more desirable than a diet which has a lot of deviations from the norm (don't get me wrong, the norm isn't good). Life is burdensome and time constrained.
In my opinion excess carbohydrate reduction needs to be a food supply question rather than as much of a question of individual choice. Figure out how to excise tax sugar and fellow travelers like corn syrup to make their inclusion (or inclusion in large quantities) economically burdensome for food producers. If you can cut excess carbs from the food supply, I think it will go a long way.
That's a good point, about less poor quality food not being the answer. I used Victoza myself a few years back until it vanished from the UK without trace! I liked it because I had a good quality diet, mostly organic ingredients or high quality if not organic. We spend a lot of our income on food quality and don't bother with holidays. For me Victoza cut out the food thoughts and helped me eat less. It helped me get a grip on portion sizes, which was my big issue. So I was eating less good food and not snacking.
Since losing Victoza I have been through a very stressful and medically unhappy time. And I'm a carer for my mother and trying to cope with a failing business thanks to Brexit. My mind is stressed and stretched. I could no more follow a ketogenic diet right now than I could fly to the moon.
But I do hope I can get onto one of the new injectables soon because without the food chatter I'm so much healthier. I believe that if I had not been going through such a difficult time when I lost access to Victoza I would have maintained the lost weight. I know how to eat. I just need help getting started again and shifting some of the bulk.
12 years ago I lost a lot of weight with low carbs. But it was hard and took a lot of work. Now, menopausal, hypothyroid (and not well medicated for it) and suffering some sort of spinal issue that's stopping me walking, bending and exercising I stand no chance of doing it the hard way.
Hi William - I hope you’re interested in other perspectives, as this is one of the major message boards for individuals and clinicians like myself who have observed the exact opposite: ketogenic diets have the advantage of being one of the easiest plans to follow over the long term.
If one can make it through the early phase of transitioning away from a high carb, insulinemic diet (which in my clinical experience can take up to 6 months), the physiological characteristics of fat adaptation (normalized appetite, lack of cravings, successful reversal of metabolic diseases, chronic pain and obesity) makes on-going compliance exceptionally easy. I have used the word “inertia” to describe the way ketosis amplifies and perpetuates the choices that maintain ketosis.
Most of my patients who successfully cross this threshold proclaim that they are ready to maintain their ketogenic diet for life, because of how great they feel and how manageable they find the lifestyle. They also know that they can “flirt” with carbs on birthdays and special occasions and get right back into ketosis.
Maybe low-carb/keto eating plans are hard for you, but not for me or for many, many other people. I've had lasting non-scale benefits. One example is that I've cut my ALT and AST numbers in half. Both have been at the top of the range (or slightly above) for years, but after going carnivore in August 2021 and cutting out all ultra-processed foods (along with fruit, veggies, fiber, grains, sugar, etc.), within about 6 months, both test results were in the 20s rather than the high 40s.
I found the idea of taking a drug to reduce weight, without changing the diet and lifestyle that caused weight gain, amazingly simple-minded.
If weight gain is caused by diet, surely the diet should be changed. It may be deficient in high-quality protein, vitamins, and minerals; it may lack high-quality animal fats; it may include dangerous seed oils (and grains, if they really are toxic).
Taking a drug may reduce weight, but if diet remains lacking in essential nutrients (and perhaps includes toxins), surely damage will continue.
I shall follow the story with interest - but not holding my breath - while continuing to eat my keto-ish diet and walk daily.
Hi Tom,
I agree with you completely, but.... the conventional wisdom is that we get fat because we eat too much and weight-loss diets work when they get us to eat less. So the conventional wisdom also agrees with you (and me), it just disagrees on how the diet should be changed.
This is one reason why I keep coming back to the cause-of-obesity issue. Whatever dietary factor triggers it has to be changed in a diet that prevents and treats it. I'll return to this (again and again) in future posts.
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Excerpts from a June 13, 2024 article entitled 'Glucagon-Like Peptide-1 Agonists': "Glucagon-like peptide-1 (GLP-1) -agonists have gained popularity over the last decade for treating millions of Americans with type 2 diabetes (T2DM) and obesity. They are attractive primarily because of their beneficial effects on glucose regulation as well as the cardiovascular system. New indications, beyond those that are FDA approved, are actively being investigated, and with increased utilization, more emergency department visits for drug-GLP-1 agonist-related complications are occurring...The American Gastroenterological Association currently recommends semaglutide, 2.4 mg injected weekly, as the preferred treatment for obesity in conjunction with lifestyle modifications. Unfortunately, about 2/3 of patients regain weight if treatment is stopped." https://www.acep.org/toxicology/newsroom/may-2024/glucagon-like-peptide-1-agonists
It's not surprising that physicians are taking these GLP-1 drugs despite not knowing the long-term side effects. They did the same thing with the Covid jabs.
To me, many of those who've lost so much weight from these drugs look emaciated and a bit frail. I get it, it feels good to lose weight. And I also looked that way when I went on low-carb for a couple years. But looking at my old photos from back then, and being older too, I looked too thin. I've accepted gaining about 10 pounds from that point and carefully eating some carbs now; in fact, it's my understanding that having a little more weight is better for older women than being way too thin. I do weigh myself every day and am able to predict, pinpoint and adjust for any weight gain associated with the carbs I ate the day before.
Seeing these physicians pile in on a required lifelong drug that has unknown long-term side effects, gives me a reason to distrust any of their recommendations and especially their prescriptions. Except for those physicians who are micro-dosing the GLP-1 drugs so have a reasonable and not overly thin result, perhaps seeing their emaciated faces and bodies gives me a new and visibly easy way to weed out which physicians to avoid.
my sister has been on ozempic for three years--she is so thin she looks ill. she's like a sapling tree. she's also depressed now. She had to up her dosage because it was no longer keeping her blood sugar low enough. she eats whatever, but not much because if she eats too much she gets intense stomach pain. When I'm with her she snacks on candy. so....i have questions about the long term safety of this drug.
Then just eat the healthy diet! No need for drugs with horrible side effects and no long term safety data.
I agree with your observation that many glp-1 consumers look too thin and frail. A friend of mine used to work in Hollywood, and they would refer to extremely thin people as X-rays, because you could practically see all their bones. That's how a lot of glp-1 consumers look to me. The skin looks saggy, especially in older folks. Many are not doing any kind of resistance training to keep their muscle tone (in fact, part of their weight loss is muscle tissue, according to studies I've read). And, they're not eating the right macros to develop and maintain the muscle. People think thin=healthy, but this is not accurate.
A worrying amount of the weight loss is muscle loss. I haven't seen reliable figures but I expect you are right that very few are doing resistance exercise.
I've seen estimates of around 40% lean mass loss for the typical consumer of glp-1. If I could remember where I saw that number, I'd link to it. Clarification: Of the weight that a typical consumer of glp-1 loses, 40% of that is lean muscle mass, from what I understand.
What is normal with diet? I lost 100# over a year (age 59). At least as estimated by impedance, 35# was muscle mass.
You don’t need as much to carry around 180# as for 280#.
"You don’t need as much to carry around 180# as for 280#."
Thank you for this comment ! True that.
Congrats on the weight loss. Regarding loss of muscle, sarcopenia is a serious problem as people age. Maybe a dexa scan is the best way to know what, if any, is an acceptable amount of muscle loss.
The Covid "jabs" (dog whistle for gonna say something negative about vaccination) saved hundreds of thousands of lives.
While the hospital treatment lost lots of lives.
I don't hear dog whistles but I imagine you do.
Initially there was desperation and fumbling at hospitals as doctors struggled to find out what worked best, or what just worked - some dummies even tried Ivermectin. Didn't work for them. Yes, the bodies piled up. It was a HORRIBLE time. That says zero [0] about vaccination's effectiveness at the population level. Yes, I hear a dog whistle with "jab." Which is why, ya know, I said it.
I’m sorry but this is a really ignorant comment. Doctors were given protocols from hospital administrators who were receiving gobs of money from the federal government if they managed Covid cases a specific way. This meant denying any type of early treatment and putting them on ventilators and/or remdesivir which both had extremely high fatality rates.
When the vaccines arrived it was obvious early on they did not prevent infection/transmission and were causing serious side effects. They were neither safe nor or effective, yet morons at all levels of the government wanted them mandated. A very ugly and dark time for this country that still has not been rectified.
Well it's not a "vaccine" how it used to be defined (in the days when "science" meant allowing for debate).
Have you looked at dictionaries from back in those days and pondered whether or not the jabs are vaccines-as-then-understood? Or just taking on faith someone's statement and reasoning that they are not?
Taking what one reads on faith for a while is necessary for scientific understanding. Or one falls into the common modern trap of using unexamined prejudices to form a premature and often incorrect criticism of new ideas.
But there is a time then for "critical thinking", skepticism. Here, looking at some old dictionaries and seeing whether or not "jabs" satisfy some common & old definitions for vaccine or not.
Prove it.
I understand the desire to lose weight. I don't understand the use of virtually unknown drugs (in terms of longer-term adverse effects) to get there. Scares the hell out of me.
I have fought (and I'm sick of fighting) binge eating and weight since I was 5 years old. A whole slew of psychology, trauma, blah blah blah. I'm 67 this year and I WANT IT TO STOP. The drug route is so tempting and I've looked at it inside and out. But those I know who went on it lost weight because they were MISERABLE. They were nauseous, bloated, constipated, and felt awful - so awful they never felt like eating. And still dont. That's why they lose weight so fast and look gaunt - the muscle goes too. What's going to happen to their digestive systems after years on these drugs? So tempting....but I can't take a route that will make me feel like shit every day of my life.
Hi Jennifer,
I'm not a medical doctor, so I can't give any advice, but I can say what i suggest in The Case for Keto, which is that all these dietary approaches and drug therapies can be viewed as self-experiments. If you try the drugs and you feel miserable, nauseous, bloated, constipated, etc, then you stop trying the drugs. You can do the same with a ketogenic diet. See if it helps. I get WANTING IT TO STOP, but we can try different approaches to see if it does. As Suzie Lee says in her comment, food noise goes away on ketogenic diets, too. Infact the first time I ever heard the phrase food noise was from Steve Phinney, one of the pioneers in ketogenic diet research (and a co-founder of Virta Health). That was back around 2010 when I was doing the research for my book Why We Get Fat, and Steve told me that people on KDs say food noise vanishes, they stop thinking about it.
I do think the diet is a healthier choice than the drugs and I personally like having the control over my health that I feel I have with the way I eat and don't have when I'm on drug therapy. But it can all be tried as an experiment. See if it works and how you feel.
I will keep fingers crossed.
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The one KEY issue with no starch/no sugar (Keto) for me is the unfavorable change in my lipid profile. I don't know what to make of it and what to do about it. Any ideas anyone ?
I can relate to this Jennifer. I read “Magic Pill” (Johann Hari) last year and was fascinated by the description of how the constant “food noise” disappears within hours of a GLP1 injection.
As a functional medicine practitioner, I had also read books about ketogenic diets (Gary’s The Case for Keto being one of them, of course) and suspected that the physiology of ketosis should also reduce food noise — not as quickly or dramatically, but substantially enough to be noticeable and effective. I’ve been keto for almost a year and am amazed at how much agency and calm I have developed around food. Carb cravings and binge eating have completely disappeared.
The transition was quick for me (about two weeks) but it took another 3-6 months to really solidify the new physiological patterns. Now I can do the miraculous… I can eat 3-4 French fries off my husband’s plate and feel completely satisfied. We’ve had a quart of ice cream in the freezer for 4 months that I haven’t even once considered eating. I CAN EAT JUST ONE DATE. Miraculous.
I can’t tell from your comment whether you’ve tried the keto route, but I can’t recommend it highly enough!
It is possible to lose weight and keep it off without experiencing discomfort if one knows how to make one's endocannabinoid system work properly. I'm 78. About 9 years ago and before I was struggling with about 25 pounds of weight gain every winter. Fortunately, in 2016 I read a British Medical Journal article that said, "We now know that major changes have taken place in the food supply over the last 100 years, when food technology and modern agriculture led to enormous production of vegetable oils high in ω-6 fatty acids, and changed animal feeds from grass to grains, thus increasing the amount of ω-6 fatty acids at the level of linoleic acid (LA) (from oils) and arachidonic acid (AA) (from meat, eggs, dairy).” https://pmc.ncbi.nlm.nih.gov/articles/PMC5093368/
I found it useful to reduce my meat intake, particularly pork and poultry. The flesh and fat of monogastrics fed up on oilseeds is typically overly-rich in omega-6 arachidonic acid and omega-6 linoleic acid. Excerpt: “Poultry meats, in particular chicken, have high rates of consumption globally. Poultry is the most consumed type of meat in the United States (US), with chicken being the most common type of poultry consumed. The amounts of chicken and total poultry consumed in the US have more than tripled over the last six decades… Limited evidence from randomized controlled trials indicates the consumption of lean unprocessed chicken as a primary dietary protein source has either beneficial or neutral effects on body weight and body composition and risk factors for CVD and T2DM. Apparently, zero randomized controlled feeding trials have specifically assessed the effects of consuming processed chicken/poultry on these health outcomes.” https://pmc.ncbi.nlm.nih.gov/articles/PMC10459134/
Researchers in Ethiopia attempted to explain where the problem lies. "The increased n-6/n-3 ratio in today’s westernized diets has shown a rapid increase in the primary risk factors (predictor) for cardiovascular diseases such as obesity. On the contrary, maintaining the low ratio of n-6/n-3 has been concluded as a good strategy in the prevention and management of obesity." https://onlinelibrary.wiley.com/doi/10.1155/2021/8848161
Written by researchers with English as a second language, the narrative is a little hard to follow. Never-the-less, there are a numerous valuable references that one can peruse.
Excellent as always, Gary. I just want to say that carbohydrate restriction and GLP-1 drugs don't have to be mutually exclusive. In an ideal world, anyone who learns about keto and wants to try it (for whatever reason - improving health, weight loss, managing an otherwise intractable condition) would find a reputable source, implement the plan, stick to it diligently, and reap the benefits. Unfortunately, while for many people, keto "sticks" immediately - they ditch the carbs effortlessly and never look back - for many others, staying on plan is a struggle. They know what to do, and maybe they even have a supportive partner/family and the support & guidance of a doctor or keto-friendly nutritionist or dietitian. And yet, it's *still* difficult. Keto would work ... if they could implement it consistently over the long term. I wish it were effortless for everyone to stick to keto who wants to do that. For some people, keto alone quiets the "food noise" the GLP-1 drugs are becoming so famous for silencing. Keto completely regulates hunger, appetite and cravings, and life is grand. But for others, staying away from certain foods or stopping binge eating isn't as simple as, "Why don't you 'just' do keto." Many have tried - over and over and over.
In these cases, it doesn't have to be a choice between keto *or* a GLP-1 medication. It can be both. I know a few people in this situation and they are thriving. The medication is giving them a little pharmaceutical leg up that helps them do what they were unable to (but firmly wanted to) do on their own. And they are using the GLP-1s in conjunction with a keto/low-carb diet with an emphasis on protein and strength training. The risks for long-term complications are still there, but at least they're pulling all the levers rather than just the pharmaceutical one while ignoring what they're actually eating and not taking deliberate action to build or preserve muscle mass. We have some mutual physician friends who prescribe GLP-1 meds in conjunction with supervising them on keto because the drug makes it easier for them to get some momentum with keto, and maybe doing it that way will help to reduce the risk of weight regain if the meds need to be stopped at some point. The same might not be true about the potential long-term complications, though. Will keto prevent those? That remains to be seen, although I suspect we may still be in the early days of even identifying all the possible complications now that so many more millions of people are taking these. (/Fin to the longest comment ever! 😆)
Hi Amy,
Thanks for the very thoughtful comment and I agree with you. I didn't mean to imply that the drugs didn't have their use, including helping with a transition to a healthy weight and a way of eating that doesn't promote weight regain. I'll post about that shortly.
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Cardiologist here. Have been on Mounjaro for about a year now and am down from 230-240 to 195-200. Labs all look good. Alcohol down to once or twice a week. Tried Keto/Atkins years ago but couldn't stick with it. It would have worked in a controlled environment but as a "free range rat" there are just too many ways to fall off the wagon. Side effects of the GLP-1 agonists are real, especially GI side effects. My wife is on Mounjaro too and I worry about sarcopenia. Both of us have taken to spreading out doses for weeks. Funny, not any literature on effectiveness of spreading out the doses, no economic incentive to do it.
Realistically, these drugs are only going to become more prevalent as the cost comes down. They are likely to change the entire focus of medicine in the coming decades. Aside from the occasional pandemic, what aspect of "modern medicine" doesn't concern itself with the complications of the disorders of our modern diet and lifestyle?
Thanks, Kel. Your last comment resonated: "what aspect of `modern medicine' doesn't concern itself with the complications of the disorders of our modern diet and lifestyle?"
As I said in the post, it was my experience researching the insulin story that made me a bit anxious about a different question, which is, what are the chances that modern medicine in the future will be concerning itself, all too often, with the complications of the disorders of these drugs.
Insulin, too, was a wonder drug. Very quickly after it appeared, virtually all patients with diabetes were getting it. Only 10 to 15 years later, after an acute disorder (type 1) was transformed into a chronic disorder and insulin therapy for type 2 has become the norm, did physicians realize that they were dealing with a tsunami of chronic complications. Patients were going from apparently healthy to dead within a year or two, suffering from the neuropathies, retinopathies, accelerated atherosclerosis, etc, that we now know associates with diabetes.
The point, though, is that the diabetologists had no idea then and perhaps even still how much of a role the insulin therapy was playing in these complications. They assumed the problem was poorly controlled blood sugar and so they advocated for more intensive insulin therapy, even for patients with type 2 who already had hyperinsulinemia.
So, yes, these drugs are going to be ever more prevalent, and if complications start appearing, we'll have yet newer drugs that can be tried. (I have friends who had issues with benzodiazepines for insomnia after a few years of use and their prescribing MDs responded by suggesting they change drugs, or up doses, not get off the drugs and use behavioral therapies to help with sleep.) It makes me nervous. I hope unnecessarily so.
Are you doing regular resistance exercise?
'But physicians “are a good litmus test for drugs that are highly effective.”'
Yeah. That's why Sir Richard Doll used doctors as his population for studying the effects of smoking. Practically all doctors smoked before 1950 - and recommended cigarettes to their patients as "a tonic".
I wonder how many doctors today have been eschewing cholesterol and eatin lots of "healthy whole grains" and seed oils.
I thought about this comment, too. Gina Kolata, the author, doesn't say they're a litmus test for drugs that are known to be safe in the longterm, because they don't know that. They only know they work in the short term and they have a front row seat for that. Ultimately, though, they're no better guides than anyone else to the longterm risks and benefits.
What about people like me who have eaten very low-carb for 20+ years (since the late 1990s) and still have not achieved a healthy weight? I'm 70 years old, 5'6", I weigh 182, and can't seem to get lower than that; I should probably lose another 30 pounds (or more), but how? I went from low carb, to very low carb, to keto, to now carnivore. My blood sugar averages around 82. I'm not perfect, but will say I'm close to pure carnivore. I avoid starches, grains, fiber, sugars, and processed foods. I have experienced many non-scale victories, but what I have NOT experienced is losing body fat to achieve a healthy weight. So what do I do? I'm already following a whole-foods diet, avoiding carbs (zero on most days), and yet I've been stuck at the same weight for a couple years now. I'll go up a couple pounds, and come back down to the set weight, but can't seem to get any lower. I'm seriously thinking that a GLP might be my only answer. I'd love to hear your thoughts on people like me who seem to be totally resistant to fat loss.
I’m 73 and went from 199 to 167 and am holding steady there for 3 years. No drugs just low carb. Beef butter bacon and eggs. Dropping another 15 pounds would be perfect but hard to get to. Fasting 3-4 days periodically and a daily eating window of 2 hours is what I need to do to break through the weight plateau. Fasting from day 2 on gets pretty easy. First day is the worst. I eat a half teaspoon of Redmonds Real Salt every day I fast.
Your arachidonic acid intake may still be excessive. Try cutting your meat intake in half.
Fasting and exercise can be helpful. "During fasting/refeeding cycles and increased levels of exercise, tissue PUFA concentrations have been shown to deplete rapidly in both humans and rats. These studies show that most PUFAs, including α-linolenic acid (ALA) and linoleic acid (LA), are preferentially oxidized in periods of exercise or fasting. During refeeding, SFAs and monounsaturated fatty acids (MUFAs), such as palmitic acid and oleic acid, are also more rapidly replaced than any of the PUFAs. Similarly, the concentrations of most plasma PUFAs and MUFAs have been shown to be significantly lower in rats fed a high fat ketogenic diet than in controls. https://pmc.ncbi.nlm.nih.gov/articles/PMC5167222/
You can be on a zero carb diet and still be totally carb dependent, and not "burning" fats, which you need to do to lose body fat. What might be happening is your liver is "stuck" converting protein and fats into glucose. An indicator of this would be high triglycerides--above 150 mg/dL. It might be a good idea to have your liver function checked. One possible solution might be to go on a fast for two or three days to give your liver a rest and time to heal itself. Ask your doctor if you are healthy enough to do that. Or, do intermittent fasting, confining eating to a 6-8 hour period giving your liver and the rest of your body a longer daily rest and healing period.
Gary, thank you for this info. It's an interesting concept. When last tested this past May, my triglycerides were at 87. I do intermittent fasting almost every day.
What level of exercise have you been doing over that 20 year period? If you have been doing everything right but still not getting the results you want, it is surely reasonable to try a drug. Just be sure that you have really been doing it right consistently!
Hi, Max! I'll admit to not doing a whole lot of exercise. But, I hear you. I can certainly up my resistance exercises, and will.
Hi Kathy,
A point I make in The Case for Keto is that the link between what we eat and excess weight goes primarily through insulin and so minimizing carb consumption will (ok, should) minimize the dietary influence on your weight, but there are plenty of others. 182 may be a healthy weight for you, much as you'd like to be leanner (as many of us would). If I'm right, than you were more or less programmed in the womb (the technical term, literally, is fetal programming) to weight more than you'd prefer. Then a lifetime of carb-rich, sugar-rich foods probably exacerbated this. Maybe had you been on keto or carnivore for life, you'd never have weighed more than 140 or 150. But having eaten that way for decades, it gets harder to undo your bodys' shift to storing excess fat. So I think the lowest weight you can achieve and maintain by diet is going to be whatever you weigh on keto or carnivore, and that's probably a healthy weight for you. You might get lower with the drugs, but, as others have commented, that could also be from lean tissue loss. Clearly many people on the drugs also plateau at a weight higher than they're prefer. (Although with the drugs, there's always a new one coming along that might make them leaner yet.)
It's a tricky business and I wish there were easier answers. Some of us, though, are just programmed to be heavier than others. We can fix it to some extent by diet, but it's not only diet that's influencing our weight.
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Well, that's the single most depressing thing I've read in a long time. Thank you, though, for your honesty. I do remember reading in one of your books that you can lose weight on keto (or any other plan, for that matter), but not necessarily all the weight you WANT to lose.
You are one in a small group of experts in this field that I truly respect and look up to. Keep up the good fight.
This was me (I've never gone carnivore, but I've been low carb for many many years). There's other issues with my body (digestive/esophageal disorder that needed to be surgically corrected), but I went on a GLP and I have finally gotten down below 'overweight.' I exercise, I keep low-carb. I am so grateful for this tool.
I don't know what your exercise level is, but when I was on a ketogenic diet and measuring my blood ketones, the only thing that would really get them up was exercise.
My sister exactly. One word: thyroid.
Just had all that checked (again). All normal.
Gary is a friend of mine, so I don't think he'll mind me dropping a link here. Kathy, I'm a keto/low-carb nutritionist who works a lot with Dr. Eric Westman - whom Gary knows well and has mentioned in several of his books. Please watch this video when you have a chance -- it is NOT enough to be told your thyroid is "normal" - even if everything falls within the reference ranges. I see this in clients *all the time* -- normal does not mean optimal. I cannot emphasize this enough. In fact, I'm writing a book about thyroid now because it's such a critical issue. (If you think nutrition science is backward and in the dark ages, that's nothing compared to how many people are suffering because of undiagnosed or improperly treated low thyroid - including many people whose labs are "normal."
Please do give it a watch when you have time and contact me if you have any questions or need help finding the right practitioner who really understands the nuances of all this: https://youtu.be/ZE6-FHf-0oY
Amy, I do know about you and almost think we spoke on the phone once. I'll definitely look into the info you provided. Thank you so much for reaching out. It can be VERY confusing to wade through all the information that is out there. We all want to do the right thing, but when one expert you trust says one thing and another expert you trust says the opposite, it's hard to know what to do.
When you say “all that,” I hope you don’t mean TSH. You’ll need a comprehensive thyroid panel including TPO and TGB antibodies to know for sure.
But the other thing I was going to add to this conversation was to ask if you have done Intermittent Fasting.
I've had the entire thyroid panel tested repeatedly. Granted, it was a few years ago. I was put on Armour thyroid for a while, but it didn't seem to help with anything.
Yes, obesity and especially morbid obesity are symptoms of an eating disorder but the eating disorder is merely the wrong solution to the real problem which is the self image of the obese individual. As general practice dieting doesn’t work over time and I doubt that long term use of drugs will keep the formerly obese from restoring their eating disorders any more than gastric surgery which has dubious long term success. The better alternative is to join Overeaters Anonymous which works as well as Alcoholics Anonymous. I am a member of a 100 pounder + group which includes many members that have sustained weight losses of 100 pounds or more. I am sustaining a weight loss of 140 pounds for three years and have enjoyed continuous sobriety for more than 38 years. I am at a loss to understand why news articles overlook OA as an option.
Hi George,
I'm glad to hear you've been maintaining your weight loss. I disagree with you on obesity being a symptom of an eating disorder. (Although I can imagine eating disorders being symptoms of obesity.) I also have issues with the idea that overeating of all foods is the problem. I'll discuss all this in future posts.
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I have high hopes, too. I'm not so sure the problems with the foods, though, are that they're nutrient deficient. The kinds of studies that would help get tricky, but they can be done. My fingers are crossed that the new administration will want to do them.
1. I think this is a typo: “They have convinced themselves that their patients won’t stay on diets long-term and that their patients would prefer diets to drugs.” Should be they think their patients prefer drugs to diets. 2. I quit sugar and flour when I read GCBC 20 years ago and have been very happy with the results though I eat lots of other carbs. 3. Deborah Gordon was my girlfriend 50 years ago. 4. 5 year Virta and Roy Taylor results are not impressive, though a small percentage of diabetics do great (10% in Taylor’s study.
Hi Peter,
You're right. Nice catch. I fixed it.
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We all too easily relegate “diet and lifestyle” approaches as a personal struggle. We refuse to act on the forced “lifestyle” of carbohydrate inducements that are packed into every square foot of a supermarket, every restaurant menu, substantial areas of pharmacies, vending machines, and at every store checkout. I wonder when these repurposed pharmaceuticals will similarly become as ubiquitous as the products that they seek to mask?
When I was getting my MS in nutrition 13 years ago, the weight loss therapy approach was the infamous energy deficit - eat less and exercise more, which seemed ridiculously inefficient even back then.
After reading Good Calories, Bad Calories, I was so excited. Finally, this made sense! I started coaching my clients to reduce carbs vs calories, and the results were impressive. Both blood sugar and weight improved significantly with one caveat: people had to follow the diet.
I don't even go to the extremes of the Keto diet; ketosis is usually not necessary to reap the benefits. But carbs, like baked goods, potatoes, rice, corn, etc., are what most people eat. Carbs are the cheapest part of a meal, and ready-to-eat foods are full of them.
Getting people back into their kitchens to cook food vs. eating packaged or takeouts - that's where the struggle is. The low-carb eating style works beautifully, but taking the pill is so much easier. As a nutritionist, it's exhausting to always go against the current. First, against conventional medical advice, and second, against the convenience of the food industry's generous offerings.
"Ultimately the drug bias in media coverage is a product of what health journalists consider news"
I beg to disagree. The bias is a product of the vast amount of money promoting Big Pharma.
Why do you think journalists are so biased by that? Do you think the pharma companies are paying them?
I agree with you Max, perhaps because I am a journalist.
Although one way the Pharma money definitely influences the news coverage is it often pays for these studies. And even academic researchers study drugs and look for drug targets--much of the genomics research being done--because of all the biases I discuss in the post, and.... that's where the money is. So the entire research agenda gets warped by the gravitational pull of big Pharma.
pharma buys advertising from media. a LOT of advertising.
Brilliant as usual Gary. Thank you. Your article reminds me that most physicians don't even clearly understand what health is. Why don't they? Because we (as a society) have never agreed upon a clear and widely-accepted (and science-based) definition for the term "health". Unless all of public/private healthcare/biotech establishes and concurs on a science-based working definition for 'health', we are forever lost! Lewis Carroll said "If you don't know where your going, any road will get you there" Kissinger famously said: "If you don't know where you are going, every road will get you nowhere"! The Oxford English Dictionary (login required), the definitive dictionary for the English-speaking world, defines health as: "that condition (of the body) in which its functions are duly and efficiently discharged... the general condition of the body with respect to the efficient or inefficient discharge of functions." I believe this is a pretty good definition. In my own practice we define health as: "... the presence of proper function from the cellular (micro) level to the social (macro) level." Health is truly all about proper/correct FUNCTION (from the cellular to the social level). Most of healthcare is focused on altering (not improving) cellular function (via meds) in order to create favorable 'downstream' effects systemically or socially. The focus is never on improving or correcting function at the cellular level. These new expensive meds are (once again) simply ALTERING cellular function (inhibiting one or or more normal cellular functions) but there is an attractive (short term) downstream result: weight loss, felling better, improvement in social function and also improvement in some 'surrogate indicators' of health. But we have NO idea what lays ahead for these folks in the long term and most don't seem to care. Anyone with a serious understanding of human physiology should be concerned, IMHO.
Hi John,
I completely agree (and thanks for the quotes, which I hadn't seen). When I was writing this, it got me thinking about the fact that we discuss putting diabetes into remission, but never obesity. Of course, the criteria for diabetes into remission is getting the patient to a health A1C without drug therapy. If we used a similar definition for obesity, with the bar being a healthy weight, then by definition it could only be achieved by diet. That then gets into all kinds of issues about what effective and safe dietary therapy and the swamp we've been wading through since the Atkins days. My definition is very different than the medical communities and even different from a few folks commenting on my posts. How do we solve that?
Best,
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Thanks for your response Gary. I believe it would be appropriate for the NIH to create its own definition for the term "health". They currently do NOT have a working definition for "health". I repeat: The NIH has no official definition for "health". The NIH occasionally (when necessary or convenient) defers to the WHO's definition for health, which , IMHO is a terrible definition (primarily because of its subjectivity). Perhaps RFK, Jr can officially publish (in MMW?) a more rational and "official" definition wherein health is equated to "proper function", similar to the Oxford English dictionary definition. My harping on this might sound trivial but I believe this issue is key to changing the direction of healthcare and focusing more people and resources in the same direction (toward proper function in the cells/organs/systems/human!)