Book Review: Why We Get Fat

Gary Taubes’s new book, Why We Get Fat: And What To Do About It, comes on the market later this month.  I give it five stars per Amazon.com’s ranking system (I love it).

♦   ♦   ♦

At the start of my medical career over two decades ago, many of my overweight patients were convinced they had a hormone problem causing it.  I carefully explained that’s rarely the case.  As it turns out, I may have been wrong.  And the hormone is insulin.

Mr. Taubes wrote this long-awaited book for two reasons: 1) to make the ideas in his 2007 masterpiece (Good Calories, Bad Calories) more accessible to the public, and 2) to speed up the process of changing conventional wisdom on overweight.  GCBC was the equivalent of a college-level course on nutrition, genetics, history, politics, science, physiology, and biochemistry. Many nutrition science geeks loved it while recognizing it was too difficult for the average person to digest.

Paradigm Shift

The author hopes to convince us that “We don’t get fat because we overeat; we overeat because we’re getting fat.”  We need to think of obesity as a disorder of excess fat accumulation, then ask why the fat tissue isn’t regulated properly.  A limited number of hormones and enzymes regulate fat storage; what’s the problem with them?

Mr. Taubes makes a great effort convince you the old “energy balance equation” doesn’t apply to fat storage.  You remember the equation: eat too many calories and you get fat, or fail to burn up enough calories with metabolism and exercise, and you get fat.  To lose fat, eat less and exercise more.  He prefers to call it the “calories-in/calories-out” theory.  He admits it has at least a little validity.  Problem is, the theory seems to have an awfully high failure rate when applied to weight management over the long run.  We’ve operated under that theory for the last half century, but keep getting fatter and fatter.  So the theory must be wrong on the face of it, right?  Is there a better one?

So, Why DO We Get Fat?

Here is Taubes’s explanation.  The hormone in charge of fat strorage is insulin; it works to make us fatter, building fat tissue.  If you’ve got too much fat, you must have too much insulin action.  And what drives insulin secretion from your pancreas?  Dietary carbohydrates, especially refined carbs such as sugars, flour, cereal grains, starchy vegetables (e.g., corn, beans, rice, potatoes), liquid carbs.  These are the “fattening carbs.”  Dozens of enzymes and hormones are at play either depositing fat into tissue, or mobilizing the fat to be used as energy.  It’s an active process going on continously.  Any regulatory derangement that favors fat accumulation will CAUSE gluttony (overeating) or sloth (inactivity).  So it’s not your fault. 

What To Do About It

Cut back on carb consumption to lower your fat-producing insulin levels, and you turn fat accumulation into fat mobilization.

Before you write off Taubes as a fly-by-night crackpot, be aware that he’s received three Science-in-Society Journalism Awards from the National Association of Science Writers.  He’s a respected, professional science writer.  Having read two of his books, it’s clear to me he’s very intelligent.  If he’s got a hidden agenda, it’s well hidden.

One example  illustrates how hormones control growth of tissues, including fat tissue.  Consider the transformation of a skinny 11-year-old girl into a voluptuous woman of 18. Various hormones make her grow and accumulate fat in the places we now see curves.  The hormones make her eat more, and they control the final product.  The girl has no choice.  Same with our adult fat tissue, but with different hormones. If some derangement is making us grow fatter, it’s going to make us more sedentary (so more energy can be diverted to fat tissue) or make us overeat, or both.  We can’t fight it.  At not least very well, as you can readily appreciate if look at the people around you at any American shopping mall.

This’N’That

Taubes’s writing is clear and persuasive.  He doesn’t beat you over the head with his conclusions. He lays out a logical series of facts and potential connections and explanations, helping you eventually see things his way.  If insulin controls fat storage by building and maintaining fat tissue, and if carboydrates drive insulin secretion, then the way to reduce overweight and obesity is carbohydrate-restricted eating, especially avoiding the fattening carbohydrates.  I’m sure that’s true for many folks, perhaps even a majority.

If you’re overweight and skeptical about this approach, you could try out a very-low-carb diet for a couple weeks or a month at little expense and risk (but not zero risk).  If Mr. Taubes and I are right, there’s a good chance you’ll lose weight.  At the back of the book is a university-affiliated low-carb eating plan.

If cutting carb consumption is so critical for long-term weight control, why is it that so many different diets—with no focus on carb restriction—seem to work, if only for the short run?  Taubes suggests it’s because nearly all diets reduce carb consumption to some degree, including the fattening carbs.  If you reduce your total daily calories by 500, for example, many of those calories will be from carbs.  Simply deciding to “eat healthy” works for some people: stopping soda pop, candy bars, cookies, desserts, beer, etc.  That cuts a lot of fattening carbs right there.

Losing excess weight or controlling weight by avoiding carbohydrates was the conventional wisdom prior to 1960, as documented by Mr. Taubes.  Low-carb diets for obesity date back almost 200 years.  The author attributes many of his ideas to German internist Gustav von Bergmann (1908).   

Taubes discusses the Paleolithic diet, mentioning that the average paleo diet derived about a third of total calories from carbohdyrates (compared to the standard American diet’s 55% of calories from carb).  My prior literature review  found 40-45% of paleo diet calories from carbohydrate.  I’m not sure who’s right.

Minor Bone of Contention RE: Coronary Heart Disease

Mr. Taubes provides numerous scientific references to back his assertions.  I checked out one in particular because it didn’t sound right.  Some background first. 

Reducing our total fat and saturated fat consumption over the last 40 years was supposed to lower our LDL cholesterol, thereby reducing the burden of coronary heart disease, which causes heart attacks.  Instead, we’ve experienced the obesity epidemic as those fats were replaced by carbohydrates.  Taubes mentions a 2009 medical journal article by Kuklina et al, in which Taubes says Kuklina points out the number of heart attacks has not decreased as we’ve made these diet changes.  Kuklina et al don’t say that.  In fact, age-standardized heart attack rates have decreased in the U.S. during the last decade. 

Furthermore, autopsy data document a reduced prevalence of anatomic coronary heart disease in people aged 20-59 from 1979 to 1994, but no change in prevalence for those over 60. The incidence of coronary heart disease decreased in the U.S. from 1971 to 1998 (the latest reliable data).  Death rates from heart disease and stroke have been decreasing steadily over the last 40 years in the U.S.; coronary heart disease death rates are down by 50%.  I do agree with Taubes that we shouldn’t credit those improvements to reduced total and saturated fat consumption.  [Reduced trans fat consumption may play a role, but that’s off-topic.] 

I think Mr. Taubes would like to believe that coronary artery disease is either more severe or unchanged in the last few decades because of low-fat, high-carb eating.  That would fit nicely with some of his theories, but it’s not the case.  Coronary artery disease is better now thanks to a variety of factors, but probably not diet (setting aside the trans-fat issue).

Going Forward

Low-carb dieting was vilified over the last half century partly out of concern that the accompanying high fat consumption would cause premature heart attacks, strokes, and death.  We know now that total dietary fat and saturated fat have little to do with coronary heart disease and atherosclerosis (hardening of the arteries), which sets the stage for a resurgence of low-carb eating.  

I advocate Mediterranean-style eating as the healthiest, in general.  It’s linked with prolonged life and lower risk of heart disease, stroke, dementia, diabetes, and cancer.  On the other hand, obesity is a strong risk factor for premature death and development of heart disease, stroke, diabetes, and cancer.  If consistent low-carb eating cures the obesity, is it healthier than the Mediterranean diet?  Maybe so.  Would a combination of low-carb and Mediterranean be better?  Maybe so.  I’m certain Mr. Taubes would welcome a decades-long interventional study comparing low-carb with the Mediterranean diet.  But that’s probably not going to happen in our lifetimes. 

Gary Taubes rejects the calories-in/calories-out theory of overweight that hasn’t done a very good job for us over the last 40 years.  Taubes’s alternative ideas deserve serious consideration.

Steve Parker, M.D.

Update December 18, 2010: I found Mr. Taubes’s reference for stating that Paleolithic diets provide about a third of calories from carbohydrate (22-40%), based on modern hunter-gatherer societies).  See References below.   

References:
Coronary heart disease autopsy data:  American Journal of Medicine, 110 (2001): 267-273.
Reduced heart attacks:  Circulation, 12 (2010): 1,322-1,328.
Reduced incidence of coronary heart disease:  www.UpToDate.com, topic: “Epidemiology of Coronary Heart Disease,” accessed December 11, 2010.
Death rates for coronary heart disease:  Journal of the American Medical Association, 294 (2005): 1,255-1,259.

Cordain, L., et al.  Plant-animal subsistance ratios and macronutrient energy estimations in worldwide hunter-gatherer dietsAmerican Journal of Clinical Nutrition, 71 (2000): 682-692.

Disclosure:  I don’t know Gary Taubes.  I requested from the publisher and received a free advance review copy of the book.  Otherwise I received nothing of value for this review.

Disclaimer:   All matters regarding your health require supervision by a personal physician or other appropriate health professional familiar with your current health status.  Always consult your personal physician before making any dietary or exercise changes.

Update April 22, 2013

As mentioned above, WWGF was based on Taubes’ 2007 book, Good Calories, Bad Calories. You may be interested in a highly critical review of GCBC by Seth at The Science of Nutrition.

18 Comments

Filed under Book Reviews, coronary heart disease, Fat in Diet, Mediterranean Diet

18 responses to “Book Review: Why We Get Fat

  1. I think Taubes has a big part of the story. I’d agree with the notion that carbs are a huge part of the problem. Fat was stupidly maligned. I would wager, though, that there’s still more to the story. I’m curious to see if anything is borne out by Stanford’s studies trying to tailor diet with the individual. My hunch is there is something there from my own personal experience. When we tried the low carb, my wife did great. Lost weight and no untoward effects. I, on the other hand, became dumb as a brick. Everyone said it’d pass but after over a week on the low carb, I got progressively dumber. My body just did not adjust well to the lack of carbs. That’s not to say there’s not room for tinkering and fine tuning. I just suspect that there are people who need to stay below 20 grams of carbs a day while others may need 100-150 to be healthy and still function.

  2. Emily Deans

    I’m jealous – should have thought to ask for an advance copy myself! Taubes is thoughtful and an excellent writer.

  3. Isaac, I’ve no doubt you are right.
    Emily, I especially like how Taubes can put together a stepwise logical argument that the general public can understand.

  4. If Taubes was willing to fib a bit on the heart disease topic, do wonder or worry that he did the same in other sections of the book?

  5. Brenna, I’m not at all worried about that. Regarding heart disease, I think he just didn’t have a full grasp of the issue; not a fib. Even for me, a physician with special interest in heart disease, I had to spend an hour finding accurate data on incidence and prevalence of coronary heart disease over the years.

    Good to hear from you.

    -Steve

  6. kate

    The reason why cutting carbs works is because you end up cutting calories. This obvious fact is consistently overlooked – and Mr. Taubes doesn’t mention it himself, although it is the strength of the low-carb diet. This is a feature, not a bug! (an advantage, not a disadvantage)

    The calories that get cut on a low-carb diet are just calories. They are not carb calories, not protein calories, not fat calories – they are just any calories. Taubes doesn’t count on anyone actually reading the studies that are out there. They DO show that low-carb diets work, in comparison studies with other diets. Because they are studies, not blogs, they actually have to post the data. The data consistently shows that the low-carb dieters consume fewer calories.

    If you ever try a low-carb diet (in particular, do the Atkins induction), you will be hard-pressed to stick with it and wish you never had to look at another piece of meat on a plate. It’s not so awful. It’s a hell of a way to eat for the rest of your life, though. You end up craving carbs. Any carbs. All the low-carb diet books will tell you is that you ‘can have’ (yep, just the same kind of permission you have to get on other diets to eat something perfectly natural and healthy) certain carbs but you have to be very careful to RESTRICT yourself. Duh, is this a diet or what? Is this any different from counting calories – and denying yourself all the time, resisting temptation all the time, drawing lines in the sand all the time… no.

    What a crock.

    • Kate, good to hear from you.

      In Taubes’s chapter called “Following Through,” he starts one paragraph thusly: “It’s true that peole who restrict carbohydrates often eat less than they otherwies might.” I have also seen at least two studies that seem to document that very-low-carb dieters take in fewer calories compared to their baseline, pre-diet comsumption. And that’s despite the fact that proteins and fats are mostly unlimited (except for the admonition to “eat until you’re satisfied, not stuffed.” The perception is that proteins and fats are more satiating than carbohydrates.

      -Steve

    • The absolute calorie reduction does not explain the ketogenic diet’s effects on cholesterol, triglycerides, insulin, etc. when compared to other diets.

  7. Kate

    You’ve seen two studies that show that low-carb diets are actually lower calorie diets? Try a lot more than that.

    The study that gets the most attention is the A to Z study that compared Atkins, Ornish, LEARN and the Zone. The study lasted a year. The participants had tremendous support – were even paid money and given counseling, education, phone calls, the books, etc. They were all fat and wanted to lose weight and volunteered.

    They all lost weight. The Atkins and Ornish were allowed to eat all the calories they wanted (ad libitum) and they lost weight. The Zone and LEARN had to obey calorie limits. They ALL lost weight and here’s the kicker: the Atkins lost a little more weight but not much. All the groups lost a bit of weight, hardly what you would expect from a year of dieting!

    And the Atkins, by the time they reached month 12, were eating more carbs than ever and the Ornish, by month 12, were eating more fat than ever. So much for how ‘easy’ and great these diets are. Certainly not any easier or any better than the Zone and LEARN!

    Lesson learned: look at the calories. The Atkins ate fewer calories. They lost more weight – but not by much. So much for the metabolic advantage, the weight ‘just melting off’ and the sheer boredom of the Atkins ‘advantage.’

    That’s the study people like to crow about and point to and make videos about. It proved one thing – Atkins won’t kill you in a year. It will improve some biomarkers and yet it’s hard to tell if you could PAY the participants money to stay on it past the 12 month mark.

    Yeah, yeah. ‘I lost a ton of weight on Atkins and I’ve kept it off for 12 years and I don’t eat vegetables and I run triathalons, blah, blah, blah.’ People like to talk. Especially people on the Internet!

  8. Thanks for chiming in, Kate. I don’t recall looking carefully at the A to Z Study.
    I’ve counted calories and I’ve counted carbs to lose weight. It’s easier for me to count carbs. But that’s just me.
    -Steve

  9. I admit I did not read Good Calories, Bad Calories just because of the title. It sounded like a typical diet book and I was getting tired of reading all the low carb books that felt they needed some new kind of twist to be different from all the other low carbs “diets”. I even flinch when I see Primal Blueprint when the original Neanderthin was my guidebook and Primal is nothing new. I am pleased to hear a good review, but it still doesn’t pull me. I don’t need any convincing about low carb diets. I know they are a life saver.

    I disagree with Kate, I love being on a ketogenic level diet, and never tire of eating meat and veggies. I have been eating this way on and off since 1998 and solidly for the last 17 months with no desire to ever quit. And no, I have no cravings to eat carb rich foods. Sorry, Kate, your disdain doesn’t cut it. You aren’t convincing me that I am deluding myself about the calories vs carbs that lead to weight loss. As a lay person, I care less about the minute details of a study and more about how I feel eating this way and how my body returns to a healthier state. I am getting there and embrace it. I have lost 85 pounds on low carb and doing so without exercise and being middle aged to boot. Loving every single bite of this lifestyle!

  10. Hi, Martini!
    Paul Jaminet wrote elsewhere on this blog that “in 1975 a gastroenterologist named Walter L. Voegtlin published a book called The Stone Age Diet arguing for a low-carb Paleo diet. S. Boyd Eaton was second. Not much happened for a time, then it picked up in the late 1990s and early 2000s. Ray Audette with Neanderthin was first to market. Oh, and I forgot Jan Kwasniewski’s Optimal Diet, which was first published in Poland around 1970. Not exactly a Paleo diet, but close.”

    Neanderthin, from 2000, still sells respectably at Amazon.com.

  11. kate

    Martinimouse,

    Your being on a ‘ketogenic diet’ ‘off and on’ is a very telling, and predictably defensive comment from a low-carb dieter. I’d love to see actual data of what you ate (not what you claim you ate and the weight just DROPPED right off your body, although you stuffed yourself with calories – yeah, right…)

    In fact, eating meat and vegetables, you have cut lots of calories from your diet by NOT eating other things. And if you were on a metabolic ward, where your intake was strictly observed and measured, you’d be like any other participant in a diet study. Losing weight because you eat fewer calories.

    Duh, double duh. My disdain comes from seeing the ‘magical thinking’ that permeates the low-carb community. They are incensed when they realize they have been cutting calories. Say it isn’t so!

    And, so telling, that ‘off and on’ description of a diet. Like it’s not the description of any other diet. Diet… yeah, cutting calories on a diet. It’s also known as ‘rearranging the deck chairs on the Titanic.’

    Listen to this Eric Westman podcast. He’s the spokesman for Atkins these days. He blatantly says, ‘It’s the calories, folks…. ‘ Replay the podcast to listen to the nuances you think should be there. You don’t WANT to eat more so you cut calories. It’s a nice feature when you actually don’t WANT to eat the food that is prescribed for you diet. It’s a diet.

    http://radio.theheart.org/bob-harrington-show/2010/12/10/31-atkins-diet-obesity-and-cardiovascular-disease-risk-with-dr-eric-westman?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed:+radiotheheartorg+(radio.theheart.org)

    • Kate, I don’t know Martinimouse personally, but I have no reason to think she’s prevaricating. I’ve seen many of my patients struggle to lose weight on reduced-calorie, low-fat diets, suffering with lots of hunger. Then they switch to very-low-carb eating and it seems relatively effortless, and it works. At least for a while, if not long-term. But long-term failure is a problem with all weight-loss systems, even bariatric surgery.

      The individual response to the two aforementioned diet styles may be genetic in origin.

      The successful low-carb dieters I know don’t seem too hung up on exactly how it works, nor upset if it happens they’re eating fewer calories. They’re just happy it’s working and that they don’t have the gnawing hunger they had when eating low-fat/calorie-controlled. Of course, there are exceptions.

    • Kate, it’s easy to be a heckler shooting from a dark corner of the room. Please start your own blog that others can comment on. Taubes is doing more than his share of addressing the obesity and diabetic epidemic with his articles, books and blog. Where is your book? Where is your blog? Write on…then join the discussion. Let’s have a debate. Come to my blog.

  12. Kate

    Here’s something for you to ponder, Andre:

    Dieting, for low-carbers, is like a religion. If you ever want to mimic the tone of religious zealots, get a bunch of low-carbers ranting about how ‘science’ has been proven WRONG, wrong, I tell you! I ate 82 calories a day and I never lost weight – EVER! Then I low-carbed, eating only red meat and a handful of salad greens and I was HEALED! And it was SO easy. And I ate 4,000 calories a day, I swear. And I only went off the diet twice a month!

    Not like that horrible diet where I looked at how many calories I was putting in my mouth and HAD to count them (instead of just having a really, really good idea of how many calories I eat, which is what I do on a low-carb diet!)

    Then ask yourself, Andre: if you have a strong opinion about the ideas professed – about food and doctors and science and BIG PHARMA (can’t forget them). coming from people who portray themselves as victims constantly (‘Eating low-fat beacause the MEDICAL ESTABLISHMENT told me to made me LOW- FAT! THEY made me FAT! My metabolism was broken, I got a rash, my ear hurts, my elbows were never the same!), why not just go right to something more meaningful? Like religion.

    People on diets – especially low-carb diets – are going to fall of of the wagon and climb back on and fall off again, and they’re going to be completely irrational about it. They’ll also swear that their patterns of falling off and then getting on the horse again are so special, they are different from any other diet’s ‘problem maintaining.’

    Now, if I were to blog, I’d cut straight to the chase and do religion. It may make just as little sense when it comes to differentiating but it is going to be a hell of a lot more meaningful in what people think about in how they live their lives.

    Only drawback to blogging about religion: you can’t sell shakes and specially-calibrated nutrition bars!

    • John

      Kate: Nothing personal here, but you are sounding like a zealot yourself. 14 exclamation points?

      Re less calories: of course I eat less calories, but why? Is it because I’m less hungry, because my high priest says I must, or because I’m not feeding my fat cells? I choose option number three. If you read the, book you might catch on to this cause and effect thing.

      RE sticking with it: you exemplify the resistance we meet. You argue unabashidly against it with virtually no evidence. You refuse to acknowledge the near 100% success rate I see with type 2 diabetics not only losing weight but reducing meds and improving lipds profiles. The fact that you cannot demonstrate how fat and cholesterol causes heart disease I hope is beyond this discussion. Hopefully you can see through that bad science: association is not proof!

      Try eating low carb for a week and please document all the forces against you. Your doctor will scream at you, your diabetes educator will refuse to talk with you, your dietitian will scream at you about high sodium, your family will think your on a fad diet, your friends will roll their eyes and try to tempt you, and good luck finding food in a restaurant or a mall food court. Nobody will believe that your 5.6 A1C, your lost 25 lbs, your increased activity (gym 4x a week), your improved sleep, your improved sex life, your improved mental state, and your competely stalled 17yr proliferative retinopathy has anything to do with it.

      Personally I’m very tired of the baseless arguments people like you throw around, simply because this can’t be true, because it seems so wrong.

      The science is sound and the results are real.

  13. Pingback: Diabetes a rapid personal re-study after a lifetime of incorrect facts « Just Another Journey