Mashed Sous Veades Low Carb Logic (Shai Update)

Well, the pudgy mirdled one, diet book author and former diet doctor Mike Eades has taken a break from changing the world** with his Sous Vide* to compose his ninth blog post of the year!  Last we heard from him here at The Asylum, he and his wife had resolved to -- yet again! -- diet in 2012.  You'll see why all of those links are relevant as we get into discussing his latest:  Are carbohydrates fattening?

His post refers to the 6 year follow-up (4 years after the initial 2 year study) from the famous diet comparison study from Shai et.al.  I discussed this study back in my more gregarious days (grin) in Gary Taube$, Shai-ster?   This study was done in a workplace setting in Israel, where through the cafeteria, they were able to assist participants in complying with the diet by offering choices labeled as appropriate for their assigned diet plan.  

In this 2-year trial, we randomly assigned 322 moderately obese subjects (mean age, 52 years; mean body-mass index..., 31; male sex, 86%) to one of three diets: low-fat, restricted-calorie; Mediterranean, restricted-calorie; or low-carbohydrate, non–restricted-calorie.

Lest there be any confusion as to how the diets were prescribed, here is that section from the original paper:

Low-Fat Diet

The low-fat, restricted-calorie diet was based on American Heart Association20 guidelines. We aimed at an energy intake of 1500 kcal per day for women and 1800 kcal per day for men, with 30% of calories from fat, 10% of calories from saturated fat, and an intake of 300 mg of cholesterol per day. The participants were counseled to consume low-fat grains, vegetables, fruits, and legumes and to limit their consumption of additional fats, sweets, and high-fat snacks.

Mediterranean Diet

The moderate-fat, restricted-calorie, Mediterranean diet was rich in vegetables and low in red meat, with poultry and fish replacing beef and lamb. We restricted energy intake to 1500 kcal per day for women and 1800 kcal per day for men, with a goal of no more than 35% of calories from fat; the main sources of added fat were 30 to 45 g of olive oil and a handful of nuts (five to seven nuts, < 20 g) per day. The diet is based on the recommendations of Willett and Skerrett.21

Low-Carbohydrate Diet

The low-carbohydrate, non–restricted-calorie diet aimed to provide 20 g of carbohydrates per day for the 2-month induction phase and immediately after religious holidays, with a gradual increase to a maximum of 120 g per day to maintain the weight loss. The intakes of total calories, protein, and fat were not limited. However, the participants were counseled to choose vegetarian sources of fat and protein and to avoid trans fat. The diet was based on the Atkins diet (see Supplementary Appendix 2).22

I've left the links intact so you can see the plans each were based on. OK, so by now most in this audience are well familiar with the results in the graphic at right (click to enlarge). Despite the fact that at the 1 year mark, the MDTN group had lost statistically equal amounts of weight as the LC group, low carb gurus like Eades were still touting this as a triumph for the late great Robert Atkins!  Now so you don't have to go link hopping, here's the self-reported dietary intake (self-reported, see article for details, some 24 hour recall X2)

Please note that these are changes from baseline not amounts consumed.  That direct information is unfortunately not provided.  I also want to make it crystal clear to anyone reading this, as I've repeated quite often since my first discussion of this study, that these self-reports in a free living study are meaningless.  M.e.a.n.i.n.g.l.e.s.s.  Except that Taubes and Eades and others have mentioned this study numerous times, and keep mentioning it.  It's central to Taubes' "oh shit I can't use the alpha glycerol phosphate stuff I got wrong in GCBC so I need to make up some other spiel low carbers will buy" newer theories on why we get fat:  Calories, fat or carbohydrates? Why diets work (when they do).   So successful with the indoctrinated was this argument (though not with the general public as WWGF barely made it onto the NYT Bestseller list and lasted all of a week there), that Eades reprised it in his AHS11 talk.***  He basically regurgitated Taubes in that segment of the talk.

Both offer up an analysis comparing just the LC and LF groups in the study, ignoring the MDTN group.  If you are going to believe the intake data, the MDTN group counters the argument, because they reportedly restricted  carbohydrates the least of the three groups yet lost the same amount of weight as the low carbers. To be fair, and this is just one reason this data is so useless, the MDTN group would counter a CICO argument because they also restricted calories less than either LF or LC and lost more weight than the LFers and the same weight as the LCers.  

Average Weight Changes, kg/lbs

    2yrs loss all           LF:  2.9/6.4    MDTN:  4.4/9.7     LC:  4.7/10.3

    2yrs loss comp.    LF:  3.3/7.3    MDTN:  4.6/10.1   LC:  5.5/12.1

    6yrs loss:                LF:  0.6/1.3    MDTN:  3.1/6.8     LC:  1.7/3.7

    4yr regain

       calc:                      LF:  2.7/5.9    MDTN:  1.5/3.3     LC:  3.8/8.4

       reported:             LF:  2.7/5.9    MDTN:  1.4/3.1     LC:  4.1/9.0

We'll get back to the initial Shai study in a bit.  But let's FF to current times and what Eades gleaned from the update from Shai.  Here's how the groups fared weight-wise, I've reported the weights in both kg and lbs in the caption, and included the 2-to-6 year regain for each group.   From this graph, the 2 year data is for the completers of the dietary intervention (2nd line of caption), but the weight gains reported in the followup don't match exactly when calculated from the 6 year losses (3rd line - 2nd line),  likely do to slight differences in the group that was followed up on.   I included both, as the differences are rather inconsequential.

It would appear to me that Eades sees the greater regain by the low carbers as evidence that carbs make you fat.  Man oh man they are truly desperate in LLVLClue-land these days if they are willing to risk discussing this anecdotal phenomenon -- of greater regains post-LC than other diets -- to promote the intellectually bereft  notion that carbohydrates make you fat.  

First, however, I'm going to call Eades out once again for ignoring the Mediterranean dieters.  This group regained the least for the largest net loss all the while reporting the smallest changes in both carbohydrate and caloric restriction.  Hardly impressive, but them's the facts folks, and we only have a low carbohydrate cheerleader, diet book author, guru to thank for pointing out this information!  The Mediterranean diet target was 35% fat, with the extra fat vs. LF to be MUFA.  It was still lower in fat than LC.  Try as they might, none of these ridiculous theories make any sense using Shai for reference unless you ignore the Mediterranean dieters.  

Let's look a bit at what Eades is now writing -- remember, this guy still thinks the solution to all of your weight problems is to go low carb!

Many years ago, I was taking questions after giving a presentation to a large group of both doctors and laymen. A lady stood up and told me she always lost weight whenever she went on a low-carbohydrate diet, but she also always gained it back more quickly after going off such a diet than she did when she regained weight she had lost on a low-fat diet. As I listened to her question, my brain was busily formatting a smart-assed answer along the lines of, Well, that’s God’s way of telling you not to go off of your low-carb diet. But, looking out over the audience, I noticed a lot of heads nodding in agreement. I realized I needed a reasonable answer.

Aside from the fact that this guy comes off as a jerk admitting how he planned a smart-ass response to the woman were it not for the fact that a lot of heads were nodding in agreement, this is an admission by Eades that he's aware of this, at least anecdotally, and has been so for many years.  Since he and his co-author, wife and otherwise partner in crime both continue to struggle with their weights and staying on a low carb diet, it seems all the more unethical for these two to continue to promote a diet that potentially sets one up for greater regains than other approaches.  Is there really anything to boast about in terms of greater weight losses if greater regains are in store?

Before going on, I must mention my personal experience here and why this is so important to me.  This is one of my own issues with LC, and yes it's just an anecdote, but it is what it is.  After developing my eating disorder in my late teens, I struggled with my weight for many years thereafter always seemingly "topping out" at roughly the same weight and size before embarking on an effort to drop the weight.  After my first bout with Atkins, I very quickly regained the 40 lbs or so lost, and blew right on through my former "weight ceiling" to the tune of another 60 or so lbs!  I see this in quite a few in the community, including one blogger who *still* advocates for the diet??!!!    One cannot advocate for a diet based on short term "superiority" in good conscience when evidence is all around you that it can be counterproductive in the long term.   

So when Eades goes on to say:

My bias was/is that carbohydrates are vastly more fattening than the same number of fat or protein calories, so let’s assume that at the start.

A low-carb diet restricts carbohydrates, and so restricts the most fattening of the three macronutrients. If my assumption is true, then people on low-carb diets should lose more weight faster, which the majority of studies shows to be the case.

A low-fat diet restricts fat and secondarily protein, because most forms of high-quality protein contain fat. Both fat and protein are less fattening per kcal than carbohydrate. If this assumption is true, then people on low-fat diets that restrict fat and/or protein should lose less weight and lose it more slowly, which a majority of studies shows to be the case.

How does one cheat or go off a low-fat diet? By eating more fat and/or protein.

How does one cheat or go off a low-carb diet? By eating more carbohydrate.

Since – in my view – carbs are more fattening than fat and/or protein, it makes sense that adding the more fattening carbs to a low-carb diet would cause more weight gain than adding the less-fattening fat/protein to a low-fat diet.

Ergo, in going off of a low-carb diet one would pack on pounds more quickly as compared to going off a low-fat diet.

Seemed to make sense to me at the time, and it made sense to the audience.

OK ... it seems to make sense.  But it doesn't make sense to anyone who knows that you have to eat roughly 3500 extra calories to gain a pound of true fat.   Nevermind the nuances of that argument -- yes, I know that you don't gain just fat, and it never adds up exactly because of other reasons, but it's those other reasons, not the carbs, that I think are at play here.  What other reasons?  Well, (1) the nature of the tissue gained and (2) metabolic adaptation.  Sorry to skip around so much, but I'll discuss what I think is really going on in a follow-up post.  Right now I'd like to look a bit more about Shai and what it tells us and what Eades' analysis of it tells us.  

Firstly, Eades is making one erroneous assumption ... that in the 4 year follow-up we're looking at people who "went off the diet".  Did they?  It appears that the follow-up analysis is only for completers at the 2-year mark.  Whatever the impact, we're talking about groups that represented 90.4% for LF, 85.3% for MDTN and 78% for LC of the original participants.  Of these they were able to follow up an an impressive 259 of 272 2-yr completers.  This tells me that those that stuck it out for the two years were fairly motivated and likely "weeded out".  But did the low carbers who regained the most to prove Eades' point that carbs are fattening go "off the diet"?  Not according to the paper!!  (Did Eades read it?)  

At 6 years after study initiation, 67% of the participants had continued with their originally assigned diet, 11% had switched to another diet, and 22% were not dieting (P=0.36 for all comparisons).

That P=0.36 means that the breakdown of compliance was similar for each of the groups.  So, the low carb group gained back more weight than either of the low fat diet groups despite roughly two-thirds remaining on the diet!   If one goes back and uses the maximum weight loss at the 4-5 month mark of about 6.4 kg, this group regained roughly 4.7 kg.  Given the differentials between completers and all subjects at the 2 year mark, one can infer that this group likely averaged even more impressive losses at the nadir. But they regained about 75% of their losses.  Meanwhile, for the MDTN group we can pretty much ignore the little blip at the 10 month mark and using the slightly more impressive 4.6 kg loss for the 2-yr completers, the regain is roughly 30%.  We can massage this data any which way, but there's not a person out there who should be touting the typical LC weight loss trajectory as in any way superior or preferred to that seen for the MDTN group in this Shai study.  

So, what do we learn from Shai?  That on average, the Mediterranean diet is the most successful weight loss intervention among three rather unsuccessful approaches.  We are given scant information as to what it meant to still be "dieting" for the 67% who claimed they were still following their diets.  I tend to think that's rather inflated, but this brings me to another trap with LC -- the peril of the "tryers".    There is one low carber who I have apparently made famous for pointing out her dogged devotion to the diet despite the horrendous results.  Yes, I speak once again of Amy Dungan who is the poster-dieter for what happens to someone who tries to stay LC, and perhaps manages to do so about 80% of the time (I'm pretty sure I'm recalling her saying that was her degree of compliance during this now over a decade of "lowcarbing", sorry no link).  Starting out her journey at 177 lbs, she lost 45 lbs in 2001-2.  Then she regained and gained more (sound familiar?) so that in 2007 her "before" weight was 203 lbs.  Near as I can tell, the 159 "after" weight that year is the lowest she's been since, and likely she's weighed more than her initial 177 lbs for most if not all of the intervening years.  Is Amy Dungan the person Dr. Eades is using as an example of why carbohydrates make us fat??  Does he ever wonder why his friend struggles so?

How about the more die-hard?  You didn't really think I'd make it through this post without mentioning Jimmy Moore did you?  What does Eades think of his gaining 55 some-odd pounds over the course of about 6 months in 2011, all the while eating low carb?  I suppose Eades will blame the occasional paleo sweet potato for this phenomenon, but c'mon, you can't blame a poor potato when it's in the form of fries, or doused in butter, or mixed with a ton of almond butter.  I think phenomenal weight regains on low carb are far more the norm than we hear about.  Giving as his AHS11 presentation was really all about how paleos are "caving" on the carb thing, I tend to think Eades really does tune this inconvenient stuff all out.

So I am happy to hear Eades address this disturbing phenomenon associated with low carb diets.  It goes well past those first 5-10 lbs of glycogen and associated water in either direction.  More than a smart-ass response or a steeped-in-bias response is required from the diet doc, though I doubt highly we'll ever get one.   I have some ideas to share with you soon.  Maybe it might help the doc himself get off the DIET rollercoaster.  Perhaps rather than repeating and repeating the same mantra, he might be interested in the possible real reasons why this might be.  Then, maybe, he'll ring in 2013 without the need to resolve to diet (low carb of course) once again, and without the low fat bashing amidst the reality that it seems harder and harder to lose the weight each time one tries.  This too seems to be especially true for low carbers.  Right now Jimmy is "succeeding" by adopting an incredibly extreme diet.  It's the only thing left in LC to try unless Volek & Phinney can come up with The Art and Science of Negative Carbohydrate Living once the nutty ketosis brings diminishing results.

This is what LC advocacy has been reduced to.  Go low carb!  Buy my books, buy my products, buy whatever, support me and my community, etc.etc.etc.  And what do we have to show you?  A still obese man who has lost the same 50-some-odd pounds for the umpteenth time since he lost them the first time in 2004, only has to eat essentially zero carb to do so?  A more obese woman who can't seem to turn her dogmatic devotion to determined adherence and suffers because of it?  A diet doctor who keeps needing to diet and likely wears Spanx for men and clothing to camouflage them for public appearances?  A website (carbsmart.com) run by an obese man who never lost much weight a while back. and surely has regained most or all of it, carrying articles by said obese man, with aforementioned obese woman as webmaster, soon to be publishing a book by another low carb yo yoer who has now resorted to alternate day fat fasting to keep things in check?  What IS the low carb world coming to?  

Ultimately I find this all very sad.  Because I think LC can be a lifesaving and powerful *intervention* for the metabolically compromised -- especially the extremely obese and/or sedentary.  What I've come to believe, however, is that unlike other interventions, long term compliance is likely not the best course of action.  That is, in maintenance LC fairs rather poorly (and no, that Ebbeling/JAMA study recently does not say otherwise, that was a short term, very high protein (around 250g/day) diet following weight loss with a 25% protein, LFHC approach.  If you go in eyes-wide-open, it's great, but the promoters of this diet don't want you to do that.  

But at least now you know this much:  When you go off of a LC diet, you tend to gain weight back faster than going off any other diet.  Dr. Eades tells us so!

---

Quotes from the ever humble Dr. Eades:

*The Sous Vide Supreme is the first new category of kitchen appliance since the microwave, so we’re incredibly excited about our role in what we think is a world-changing event. At least world changing in the same way the microwave was world changing.

**First off, I’ve got to apologize for the lack of attention to this blog lately. As I mentioned in an earlier post, I hadn’t realized that changing the world would be such a time-consuming endeavor, but it really is.

*** Some comments on the Eades' AHS11 talk:

It had been a good long while since I watched that talk, and I had intended to comment about this at the time.   I hope that AHS13's call for abstracts does indeed prove to be a step in the right direction for that organization, the symposium and the community as a whole.  In Eades' 2011 presentation, he actually included bashing someone for an exchange he had with her in comments on his blog.  Really?  And his was supposed to be a "sciencey" presentation by a medical professional.  It wasn't just an off hand comment, he made up a slide so it was planned!    Eades' was just one of many presentations of opinion/dogma and not fact.  It is likely impossible for the organizers to fact check presentations, but hopefully the screening process will be serious enough to look at the intended content of some of the proposals.  I don't know how much of the AHS11 content was fluid almost right up until the event, but AHS12's content sure was -- from complete changes in presentation titles/content, to last minute "substitutions", to full hours devoted to panels with completely undefined content of broad topics.  Eades' inclusion of the comment exchange in his presentation was totally unwarranted.  It added nothing to the presentation, no opportunity for learning by the audience.  What I learned was that Eades is a "diet book and other stuff" shill first, doctor and learned individual a distant second if that ... and "scientist"?  Not.