Wendy Myers is a functional diagnostic nutritionist, certified holistic health coach, and founder of Live to 110, a website and podcast series dedicated to providing readers and listeners with the tools for living a long, happy life. Wendy recently talked health and nutrition with Dr. David Ludwig, endocrinologist and author of the New York Times #1 bestseller Always Hungry? They discussed the misunderstood relationship between body weight and willpower, and detailed the surprising steps anyone who’s looking to lose weight should actually take.
Wendy: How did you become interested in nutrition?
David: I went to medical school and like so many medical students, I got very little training in nutrition. We tend to focus on drugs and surgery, although, ironically, diet causes most cases of chronic disease. We don’t have obesity, heart disease or diabetes because we have a genetic requirement for drugs that have yet to be discovered.
So I got interested. And since I had very little training in nutrition, I didn’t start thinking about diet in the conventional way. I started thinking about it as an endocrinologist, which is my area of research—how food affects hormones. That leads to some very surprising and alternative ways of thinking about weight control.
Wendy: I love that you’re a physician thinking out of the box about nutrition. I complain a lot that physicians aren’t tending to nutrition and supplementation, the main underlying root causes of disease. So I applaud you for that. What is the basic message that you’re trying to get out to the masses?
David: The premise is simple, but provocative—it’s based on a century of solid research and research we’ve done in my group for the last 20 years. The premise is that overeating doesn’t make you fat, at least not over the long term. The process of getting fat makes you overeat.
Something has triggered our fat cells to hoard too many calories. So they feast, but the rest of the body actually starves. We think of obesity as a state of excess, overabundance, but if fat cells are growing too fast and hoarding too many calories, to the body, it’s a state of starvation.
So then the brain does what it’s supposed to do. It doesn’t see the extra calories in the fat cells. It sees that the bloodstream doesn’t have a steady supply, so it makes us hungry. Another part of the brain makes us crave. It’s very difficult to not eat when those two things are happening. It makes it even harder by slowing down metabolism, which is a very sensible thing to do if you’re really starving. But in the case of fat cells on calorie storage overdrive, they continue to take the lion’s share of what we eat and it leads to progressive weight gain. It doesn’t solve the problem.
Now, if you just cut back calories like we’re told to do, eat less, you can slow weight gain down or even lose weight temporarily, but your body is going to fight back even harder because it just makes that basic problem worse—not enough calories in the bloodstream.
Let me give you an example, the analogy to the condition edema. That’s where fluid leaks out of the blood vessels and collects in body tissues. The legs might swell greatly. Someone with edema has too much fluid in the body, maybe 20 pounds extra. But they’re unquenchably thirsty. The brain doesn’t see that there’s too much water in the body. It sees that it’s not staying in the bloodstream, where it’s needed. If you tell people, “Just don’t drink,” that’s hard to follow and it doesn’t solve the problem. In the same way telling people with obesity, “Just don’t eat as much,” is very difficult and is not addressing the problem.
If you treat edema so that the blood vessels aren’t so leaky and the fluid stays in the bloodstream, then the body sucks up the extra water and your thirst is controlled. That’s the same with obesity. You treat the fat cells on calorie storage overdrive. They stop hoarding so much, calm down, open up, and release those calories back into the body. You feel a flood of energy, cravings vanish, metabolism speeds up, and you start to lose weight with your body’s cooperation, not with your body kicking and screaming.
Wendy: There are some people that can override their biology’s messages and have a very strict caloric diet, but most of us are not able to do that. Why doesn’t willpower work?
“Body weight is much more about biology than willpower over the long term.”
David: Body weight is much more about biology than willpower over the long term. Let’s take some classic studies—for example, force-feeding studies have been done for decades. You have people consume hundreds or thousands of calories too much per day, and they gain weight.
But what happens? They lose all interest in food. Their metabolism speeds up in an attempt to get rid of those extra calories and they feel miserable. They’re as unhappy as participants in starvation studies are. Once the force-feeding protocol ends, weight comes right back down to where it started.
There seems to be biological control systems that determine what your body weight should be. If you’re lean, it tends to stay lean. If you’re heavy, it tends to stay heavy, although something is causing that set point to keep creeping up year after year throughout the population. It’s not just genes. Something is going on in the environment. We argue that it’s mainly aspects of our diet that raise insulin levels too much. Insulin is the ultimate fat cell fertilizer.
When a child with type 1 diabetes first comes in, before they have been diagnosed, they’ve invariably lost weight. There’s not enough insulin. They could be eating 5,000 to 10,000 calories a day and they’re still losing weight. Give them enough insulin and their weight returns to where it’s supposed to be. Give them too much insulin, and they invariably gain weight.
You can’t store calories without insulin. Now, for those of us who don’t have diabetes, your insulin levels don’t change based on injections. They change based on what you eat. The foods that make the most insulin are processed carbs—white bread, white rice, potato products, fat-free cookies, candy, cereals and sugary drinks.
We have to get at that source of the problem. Otherwise, just cutting back on calories creates this battle between mind and metabolism that most of us will lose. Even if you can force yourself not to eat, you’re not necessarily getting into the best biological state.
For example, when you give animals too much insulin, they get hungry, overeat, gain weight, get too fat. Keep giving them insulin, and put them on a diet, and you can prevent them from gaining weight. They start cannibalizing their lean tissue. So they develop too much fat at the expense of lean tissue, even if you keep them from gaining too much weight. Unfortunately, there are a lot of people in this state. It’s the state of “lean outside, fat inside.”
Wendy: A skinny fat person?
David: Yeah, that means that we’ve got metabolic problems which may or may not reveal themselves in our body weight, but that still increase risk for chronic disease and cause us to feel not great.
Wendy: The catch-22 is that many people that are overweight eventually develop diabetes, have to inject insulin, and end up gaining weight as a result of it worsening their condition. I saw this happen with my father, aunts, and uncles. They keep gaining more weight.
David: You’re talking about type 2 diabetes, which is different than type 1 juvenile. In type 2, the basic problem is that the body starts getting resistant to insulin. The cells that make insulin in the pancreas can’t keep up with that increased demand.
We try to deal with the situation by giving even more insulin. Typically, insulin levels are already very high. So that is sometimes necessary if blood sugar is very high, and that can be critical.
I’m not asking people to give up their insulin. But over the long term, it’s not a good strategy. It’s adding fuel to the fire. The fire is that we have already high insulin levels. Our fat cells are hoarding too many calories. We’re developing chronic inflammation, a condition closely linked to insulin resistance. We increase insulin levels to try to deal with that, but yes, you can bring blood sugar down at the expense of further weight gain. A much better approach is measures that reverse this physiology.
Bariatric surgery can cause total remission in type 2 diabetes, if it hasn’t been around for a very long time. And there’s no reason that diet can’t do the same thing. There’s a lot of promise with lower carbohydrate diets. What I recommend in my book is not a very low carbohydrate diet. We start by getting rid of processed carbs and increasing fat. It’s very lush, delicious.
Fat is very tasty. We used to really love eating it. The French love eating fat. They eat a lot of it and have lower heart disease rates than we do. So nuts, butters, full fat dairy, avocado, real dark chocolate, savory proteins and natural carbohydrates, fruits, vegetables and legumes.
In phase one, which is two weeks of the program, we get rid of all grains, potatoes and added sugar. That helps jumpstart a metabolic change. Phase two, your weight comes down to this new set point and you get to add back in whole kernel grains, steel cut oats, quinoa, buckwheat, wheat berries. Then, in phase three, you can add some processed carbohydrates based on your body’s ability to handle it. You eat until satisfied, snack when hungry, and forget calorie content.
Wendy: Can you talk about the research that helped you to develop this program?
David: My research partner, Dr. Cara Ebbeling, and I have been doing this work together for years. We have been looking at how food, independent of its calorie content, alters our hormones, metabolism, and the expression of our genes.
I can tell you about a couple of studies. In one case, we gave young men who were overweight two different milkshakes. The milkshakes have the same protein, fat, carbohydrate, and were designed to have the same sweetness.
One had fast-acting carbohydrate, that’s going to digest very quickly. The other had slow digesting carbohydrate. It doesn’t raise blood sugar and insulin much. We did this in a double blind fashion—rare in nutrition research.
When we analyzed the data, we found that, as expected, after the fast acting milkshake, blood sugar initially surged and insulin went way up. But four hours later, blood sugar crashed. At that time, people reported feeling hungrier even though they got the same calories.
Then we did imaging of the brain with a technique called Functional Magnetic Resonance Imaging, FMRI. We saw that one area lit up like a laser after the fast-acting milkshake. In fact, it happened in every single subject. We’ve rarely seen such a strong, consistent effect in research.
“If you’re hungry a lot, that’s bad enough. If your addiction centers light up, it’s game over.”
That area has the technical name of the nucleus accumbens. It is the center of the dopamine pleasure and reward system, considered ground zero for the classic addictions of cocaine, heroin, alcohol, which raises a provocative idea—yes, we need food to live, but these highly processed carbohydrates are hijacking the brain’s reward systems. And that is making it very difficult for people to control their cravings. If you’re hungry a lot, that’s bad enough. If your addiction centers light up, it’s game over.
We did another study to look at energy expenditure. We gave 21 young adults with high body weight first the low calorie diet to bring the weight down. Of course, calorie restriction works in the short term. We bring the weight down by 12%.
Then we put them on one of three diets: low, medium, and high fat. Low fat is 20%. Medium was 40%, a typical Mediterranean diet. Or high fat, like Atkins, 60% fat. We put them on these diets for a month in random order.
We found that on the low fat diet, metabolic rate plummeted 400 calories a day. In the low carb diet, there was no fall-off in calorie burn at all from before they lost weight, so they lost 12% of their body weight, but their brain didn’t even feel like it had lost weight. It wasn’t trying to go into starvation mode. The Mediterranean diet, 40% fat, was in the middle.
So there’s difference between the low and high fat diets in their calorie burn. It was like an hour of moderately vigorous physical activity without lifting a finger. That difference is pretty much the whole obesity epidemic.
Wendy: Do you think there are some people that don’t do well on a high fat diet? Say they have genetic reasons or other metabolic issues.
David: Yes. The Always Hungry Solution is not an Atkins-type, very low carbohydrate diet. I don’t think that for most people, we need to go to that extreme. It allows for a much more flexible approach to eating.
But I do believe that people differ. So we start everybody on a 50% fat diet that has 25% carbohydrate. That’s pretty high, but you’re still eating fruits and vegetables. And it’s just two weeks to jump start metabolism. Then we start lowering the fat toward 40%. Most people will wind up 40% fat, 40% carb, 20% protein. That’s a very balanced diet. It’s how we ate before the low-fat craze started 40 years ago.
There are some people, the high insulin secretors, who are going to do best with keeping processed carbs low and staying on the high fat side. Other people, who are low insulin secretors, have more flexibility and may do fine with more carbohydrate.
But again, one size isn’t going to fit all. By paying attention to your body, you can find your own tipping point. You reach it and then pull back a little, realizing that the rewards of feeling in control over your cravings and not having to fight your body are so much greater than the fleeting pleasure of highly processed carbohydrates.
Wendy: Yeah, I love that. People need to pay attention to their bodies and find what works for them because everyone is so different. Ultimately, people have to play around with their percentage of their macronutrients to find out what works.
David: We believe that if you create the right internal conditions, your body determines what rate of weight loss is right for you. We did a national pilot, 250 people from around the country. Some people lost weight at a rate of 2 lbs a week or more. Others were losing weight at maybe a half pound. But without hunger and feeling great, the results are progressive and sustainable.
Wendy: What is your opinion of intermittent fasting? It’s very popular today—there are books that say, “Do 500 calories once or twice a week” or “Don’t eat for half a day.”
David: There are some interesting potential benefits from fasting. The argument is that humans evolved during food unpredictability, although frankly many societies and even hunter-gatherers had plenty of food most of the time.
But yes, there were times without food, and we would have gone into a fasting physiology, and that could be very good for the brain and body. The fundamental problem right now is that we are in a starvation state. The body doesn’t have enough calories in the right places in the bloodstream, and that’s why we’re hungry. So then you tell people, “Well, just stop eating.” That’s tough.
Now, if you change the quality of what you’re eating, then it becomes much easier to fast. But I think that’s advanced. We’ve got to start out by putting an end to the starvation. And the best way to do that is, we tell people, “Don’t starve yourself.” Eat as much as you want. Listen to your body. Once people feel they have mastered that, and diet quality is high, then you can play with intermittent fasting. But when you start off with intermittent fasting, you may make a bad situation worse.
Wendy: I absolutely agree. You can’t go from the standard carb-rich American diet to fasting because people get the blood sugar drop and then overcompensate by eating everything in sight. They can lose willpower. So you have to start eating a healthier, higher fat diet and then maybe play around with that. I don’t think it works for everyone.
“We’re bingeing not because we have poor willpower, and we’re not doing it because the food is so tasty. We’re doing it because our body is driving us to do it. To try to control that with willpower is a losing proposition. Control it biologically.”
You said there are some people that don’t release insulin well, and others release it very readily. Can you account for the differences and why that’s the case? Do you account for toxicity levels that prevent insulin release, or mineral or nutrient deficiencies?
David: There are undoubtedly many. Micronutrient deficiencies can affect insulin dynamics, glucose control, in many ways. The beta cells that make insulin and the target cells that affect insulin resistance.
Some supplementation is prudent, but not as an alternative to a whole foods approach. That’s the foundation. If you’re in the Northern Latitude and not getting much sunlight, some vitamin D supplementation is helpful. If you’re not eating much fish, long chain omega-3 supplement is good. If you’re not eating fermented foods, take a probiotic. Those are the top three.
Others argue that the soils that we’re growing our foods in are depleted and aren’t containing as many. So there may be a role for additional supplements, but I think that’s secondary, and the primary focus is the foundation of good nutrition. A whole foods diet is going to provide so much more than can ever be distilled into a pill.
Wendy: Absolutely. So how many meals do you think people should eat per day? Evolutionarily, a lot of the population ate one or two meals per day.
David: Men and women ate so many different ways based on culture, location, food availability, season. If you were an Inuit in the far north, most of the year, you would have been eating just fat and protein—fish, caribou, maybe whale. Then the berries would come in, in August and September, and you would gorge on that.
I don’t know that we can come up with an optimal meal pattern considering our Paleolithic ancestors. Let your body decide. If you’re not hungry, you’ll just not be interested in so much food. Have a light meal. We want people not to skip meals for the first two weeks. After that, you can individualize.
Wendy: What are your top tips for kicking food cravings?
David: Just one—feed your fat cells well. Once we reprogram fat cells to calm down and release their calories back into the body, cravings vanish.
Think of a few different things that one could binge on. Highly processed carbohydrates, so bread, to get 400 calories, that would be five slices.
Another thing you could do is eat three big bowls of berries. That’s full-acting carbohydrate. A fat you could binge on would be butter. A lot of people think butter is very tasty.
But what’s going to happen if you try to binge on just butter? The first bite might taste okay. The second bite, “This is getting a little weird.” Third bite, you’re getting sick to your stomach. Why? You can’t binge unless you get processed carbs that raise your insulin levels.
You binge on the bread, you want more a few rounds later. We’re bingeing not because we have poor willpower, and we’re not doing it because the food is so tasty. We’re doing it because our body is driving us to do it. To try to control that with willpower is a losing proposition. Control it biologically.
Wendy: What do you think is the most pressing health issue in the world today?
David: In broad terms, it’s diet-related diseases in the developed world. The developing world still has a lot of undernutrition, starvation, infectious illness. But in the developed world, and increasingly in developing countries, obesity, diseases of so-called “overnutrition,” have surpassed smoking as the number one cause of preventable chronic disease.
We predicted in 2005 in the New England Journal of Medicine that life expectancy will begin to decline in this country in the next couple of decades. Unless we do something about obesity, beginning with children, then we’re already starting to see a stalling of life expectancy.
This is a matter of national security. If we’re spending more and more money trying to manage chronic diseases—medicines to lower blood sugar, blood pressure, cholesterol, to keep our blood from clotting excessively, to manage depression, impotence, all of these consequences of unhealthful diet—if all the money is going there, there’s no money left for the nice things in life, for investing in our social infrastructure, for education. That’s fueling political debate in Washington and it’s probably driving such fierce polarization of the parties.
If we could address diet-related disease, we’d have so much extra money. Democrats could have social spending and Republicans could have a balanced budget and we’d have a chance to detoxify the political environment in Washington.
Wendy: Yeah, I wonder if the amount of money we’re going to have to spend on medical care is going to hurt our position as leaders. We’re drowning in national debt because of our health crisis.
In the United States, two-thirds of the population is obese because of our diet. And we’re finding, in India and China, more and more of the upper and middle classes are eating fast food. They are having a huge problem with developing the same diseases that are so rampant in the United States.
David: All the peasants in China eat a lot of white rice. That’s a processed carbohydrate, and they didn’t get obesity or diabetes. But they were working 14 hours in the field, and that white rice wasn’t making them feel very good, but it was keeping them alive.
They move to the cities, bringing their highly processed carbohydrate diet, but leave behind all that physical activity, and rates of obesity and diabetes are skyrocketing. One recent estimate suggests that there may be close to a half a billion people in China with diabetes or pre-diabetes. How do you get your mind around that kind of an estimate? We have a true international crisis on diet-related diseases. We’re going to be eating ourselves to death.