15
Making Adjustments
Abstaining from carbohydrates does not imply eating less; it implies eating fat and fat-rich foods.
What does it mean for a weight-control diet to be meaningfully sustainable? Health journalists and nutritional authorities will now insist that the best diet—the one that they say “works”—is the diet that we can sustain, to which we can stick for life. But what does that mean? Sustaining a diet that doesn’t help us reach and maintain a healthy weight is of little benefit and clearly isn’t one that’s working. And to sustain a way of eating for life, almost by definition, we have to be able to eat to satiety. That implies we’re not walking away from our meals hungry. It implies we’re not counting our calories; we’re just eating, as lean people do. Anything that requires a lifetime of hunger (in a world in which food is abundant) is a promise of failure.
This is why outside the world of academic research, in the fad diet world and that of the physicians with hands-on experience, LCHF/ketogenic eating prescriptions come without the advice to count calories or eat less. The technical term is ad libitum: Eat as much as you like. Eat when hungry, and eat until satiation. Physicians who advocate this way of eating to their patients, particularly those with the most clinical experience, tend to be adamant that their patients eat whenever they’re hungry. The expectation is that if we don’t, we will eventually give up on the diet, or we will binge-eat in response to the deprivation, losing the health benefits.
To make this work in practice, to abstain from carbohydrate-rich foods while eating to satiety, we have to eat significant amounts of fat. Carbohydrates typically constitute half of the calories we consume. So if we’re abstaining from carbohydrate-rich foods and the energy they supply, then we’re going to have to replace some large proportion of those calories by eating more protein or more fat, and real food sources of protein invariably come with significant fat attached.
While nutritionally adequate eating requires a minimum amount of protein for lean tissue repair and growth, the protein itself is composed of amino acids, and these can be converted to glucose in the liver and then stimulate insulin secretion. This is a slower process than eating refined grains or drinking sugary liquids, but the result is still likely to be at least some insulin secretion. If your fat cells are exquisitely sensitive to insulin, even this amount might be too much. An eating pattern that minimizes insulin is not high-protein. This would have been less of a problem in the 1960s, when the typical meat sold in supermarkets and by butchers was 70 percent fat by calories and people ate their poultry with the skin attached. But as the anti-fat message was broadcast widely and we turned to leaner cuts of meat (like the skinless chicken breast) and lean fish, eating to avoid carbohydrate-rich foods can all too easily mean eating too much protein.
Say you eat for lunch or dinner a skinless chicken breast and green vegetables or a green salad. This kind of meal seems like an eminently reasonable compromise between nutritional paradigms. It has no starchy vegetables, grains, or sugars and so is low-carb and can seem suitable for ketogenic eating. The skinless chicken breast keeps it low in fat as well. It’s easy to understand, in the midst of this endless nutrition controversy, why we might want to hedge our bets this way. Maybe people like me are right in arguing that the major problems with modern diets are the refined grains and sugars, but it’s also hard to believe that the anti-fat authorities got it all wrong. Thus what seems like a happy compromise: restricting your fat consumption, while getting your carbohydrates from sources we all agree are benign—specifically, nonstarchy vegetables. The skinless chicken breast has plenty of protein and not that much fat. The carbohydrates in the meal are “good” carbohydrates, “slow” carbs. They’re bound up with fiber, and we’ll digest them slowly.
But the devil, as ever, is in the details. If the portions are small enough and if we eat slowly enough, the insulin secretion from the amino acids in the protein and from the carbohydrates in the green vegetables may indeed be insufficient to rise above the insulin threshold. We’ll still be burning more fat than we’re eating. It doesn’t flip the switch on that insulin threshold. But not so for large portions, obviously. If we’re consciously choosing small portions, we’ll likely be hungry afterward. If we’re hungry, we’re likely to cheat on our diet, or quit it entirely. We might be able to eat like this while we’re losing weight, because we’ll be burning our own fat, too, but what about once we plateau at a healthy weight? If we increase the portion size, though, the insulin response increases as well. Eat enough calories to be satiated, and it can reasonably be expected that we will store more fat and be hungry between meals, while still hungering for carbohydrates. It can be a recipe for eventual failure, reasonable as it may seem.
The only way to eat a satiating meal while minimizing insulin secretion is to add fat. It’s the one macronutrient that does not stimulate an insulin response. When Australian researchers led by Jennie Brand-Miller of the University of Sydney studied the effects of mixed meals on insulin secretion—the only ones to publish such a comprehensive study (2009), as I write this—the best predictor of insulin secretion was the fat content. The higher the fat content, the lower the insulin response. “Because protein stimulates insulin secretion, particularly when combined with carbohydrate,” they wrote, “the meals with the highest protein and carbohydrate content (and hence lowest fat content) produce the highest insulin responses.”
What about meals that are high in both fat and protein? I’ve heard from readers over the years who have taken the guidance from my books and others and applied it by eating three meals a day of fatty meat—rib eye steaks for breakfast, lunch, and dinner. In the growing world of people who describe themselves as carnivores or “zero carbers,” they don’t even eat green vegetables. Steve Phinney and Jeff Volek, who have done more research on ketogenic diets than anyone, believe that there’s an upper limit to the amount of protein we can eat and remain in ketosis—less than a gram of protein per pound of body weight.
Whether that much protein would inhibit mobilization of fat from the fat cells and ultimately shorten our lives is the kind of question that remains unanswered. The young man I mentioned earlier who weighed close to 400 pounds when he was eighteen preceded to lose over 120 pounds in four months of eating nothing but fatty meat that his father bought for him by the tens of pounds a week at Costco. His response to this kind of diet may be relatively rare if not freakish, but it could also be the norm. And even my friend’s response might change with time and age. Maybe this is the response of an eighteen-year-old male predisposed to obesity but not that of a forty-year-old or even an eighteen-year-old female. We have no way at present of telling.
The huge amount of individual variation in how our bodies process both protein and carbohydrates means you will have to experiment and find what works for you. No meaningful clinical trials have been done comparing LCHF/keto eating to what we might call LCHP—low-carbohydrate, high-protein. As discussed, consuming protein will also stimulate secretion of two hormones—glucagon and growth hormone—that work to get fat out of fat cells. These diet-induced hormonal responses are less well studied than that of insulin. What’s lost with protein because of the insulin secreted might be gained back by the glucagon and growth hormone response. Even if it is, though, and our meals are particularly rich in protein, replacing the carbohydrate calories we’re not eating will still require plenty of fat and fat-rich foods.
This is why the Indiana University physician Sarah Hallberg tells her patients that green vegetables are a conduit for fat and should never be consumed without it. Hallberg is the medical director of Virta Health and oversaw the start-up’s LCHF/ketogenic eating trial on patients with type 2 diabetes. The subjects with diabetes in the Virta Health trial got the same advice: When cooking vegetables, do so with copious butter or olive oil, then eat them with olive oil or melted butter. Lunch can be a salad so long as the salad dressing has plenty of fat and is low in carbs. Put olives or avocado on the salad or perhaps hemp seeds. A good salad dressing, says Hallberg, has plenty of oil and fewer than two grams of carbohydrates per serving. She recommends taking such a salad dressing, splitting it into two containers, adding more olive oil to each, and shaking them up to increase the fat content. By using vegetables as a conduit for fats, LCHF/ketogenic eating can be mostly plants if not all plant foods. It may be harder to do without the fatty animal products, but it’s certainly doable.
What is it like to eat to satiety on foods that are very low in carbohydrates but high in fat? Is this way of eating as radical as it’s often portrayed? I’m going to use pictures to answer these questions. In the process, I’m going to take the opportunity to demonstrate why weight control is less about how much we eat and far more about what we eat. That’s a primary reason it’s so helpful to stop thinking about how many calories you’re eating and how much you’re burning off in exercise. It confuses the matter; it doesn’t clarify, not if you want to achieve and maintain a healthy weight.
What follows is a day’s worth of meals in pictures, beginning with dinner and working backward to breakfast. The dinner plate at the top—a roast chicken breast, broccoli, and potatoes—is fattening to those of us who are predisposed because of the carbohydrates in the potatoes. The plate at the bottom—roast chicken thighs for the higher fat content of their meat, and broccoli with butter (or olive oil per Hallberg’s guidance)—is not. It’s part of a weight loss and maintenance way of eating. The two plates of food as pictured contain essentially identical calories—just over six hundred. One has potatoes and is fattening; the other one doesn’t, has a larger portion of chicken (by calories because of the greater fat content), more broccoli, and the butter on the broccoli. It’s not fattening. The larger portions of chicken and broccoli and the butter (or olive oil) make up the difference in calories. If you were ordering this in a restaurant, you would order the roast chicken and ask the waiter or waitress to replace the potatoes with more broccoli or a green salad. Simple enough.
Two versions of a dinner just over six hundred calories. The fattening meal (top): a roasted chicken breast, broccoli, and potatoes.
The non-fattening/weight-loss meal (bottom): two chicken thighs, more broccoli, no potatoes, butter.
David Unwin, a general practitioner in England who in 2016 won the National Health Service innovators award for advocating LCHF/ketogenic eating to his patients with diabetes, describes this as “turning everything that was white on your plate to green.” Even with equal or greater calories, the plate on the bottom is part of a weight-loss program (a fad diet, Atkins!); the plate on the top is likely what you’ve been eating all along and has contributed to making you fatter.
Eating dinners like the one on the bottom should be easy to sustain. All you’re doing differently is not eating a potato and eating your vegetable with butter or olive oil. As for heart health, virtually all authorities would consider the meal on the bottom to be as healthy as the one on the top, certainly if the added calories come from olive oil. So that would be the compromise. If you choose butter instead of the olive oil, you’re assuming that all I’ve told you in this book is correct.
Lunch could be identical to dinner, with the same implications about sustainability and health, but let’s give it a fast-food, standard-American-diet twist. The plate on top, unappetizing as it may appear, is a typical fast-food meal: a McDonald’s cheeseburger on a bun (along with pickles, onion, ketchup, and mustard), a small order of french fries, and a small Coca-Cola. It has about seven hundred calories (with the ketchup) and is fattening to those predisposed because of the bun, the fries, the sugar in the soda, and even the sugar and carbs in the ketchup. The plate at the bottom has a Double Quarter Pounder with cheese (along with lettuce, tomatoes, onions, and pickles), no bun, salad and ranch dressing, no fries, and water instead of soda. It has the same number of calories but without the grains (the bun), the starches (the fries), and the sugar in the soda and ketchup. It’s not fattening. The two meals have equivalent calories but different carbohydrate content, and they create different metabolic, hormonal responses—different effects on fat accumulation.
Two versions of a seven-hundred-calorie lunch. The fattening meal (top): A small cheeseburger, fries, ketchup, and a small Coca-Cola.
The non-fattening/weight-loss meal (bottom): a Double Quarter pounder with cheese (no bun), a green salad with ranch dressing, and ice water.
The fast-food meal at the top makes you fatter. The fast-food meal at the bottom makes you leaner. It fits into LCHF/ketogenic eating. It’s the rare health expert today who would suggest that a meal with two hamburger patties instead of one, plus a salad, is less healthy than a meal with the one burger plus fries and a sugary beverage. If you showed the health experts only the picture at the bottom, they might mutter about the red meat, but they’d probably accept that it’s healthy even by their predilections, so long as you weren’t eating “too much.” If you replaced the two hamburgers with a nice piece of salmon or salmon burgers (still no bun) or even an Impossible Burger (meat-free, no bun), we would mostly all be in agreement: a healthy meal.
Breakfast seems to be the ultimate battleground, the meal that diverges most radically from conventional healthy thinking. This is the bacon-and-eggs problem. The authorities for the last fifty years did a very effective job in convincing us these were agents of death. We came to believe that the just-over-seven-hundred-calorie breakfast at the top of the following page—cereal, skim milk, banana slices, toast (buttered), and juice—is ideal, yet that breakfast is fattening to those predisposed because of the carbohydrates in all those (including the lactose in the milk). Because of its effect on blood sugar and insulin, it will leave those of us who are insulin resistant and predisposed to fatten likely to be hungry later. We’ll want a midmorning snack, likely a carbohydrate-rich one. The plate at the bottom—three eggs scrambled with cheese and sausage, two strips of bacon, avocado slices, and water instead of juice—has the same number of calories (approximately seven hundred) and is not fattening to us. And because insulin remains low, we won’t be hungry later; we’ll have no urge for a snack.
The three plates at the top constitute the standard American diet. With the exception of the fast-food lunch, the nutritional authorities would consider them part of a healthy lifestyle. But they are what most of us have been getting fat on, along with between-meal snacks of much the same macronutrient composition, and then the sugar-rich or carb-rich beverages, sodas, beers, and so on. The three plates at the bottom have the identical calories and are part of a weight-loss diet, an LCHF/ketogenic eating pattern—i.e., Atkins or keto—that will allow you to achieve and maintain a healthy weight.
Two versions of a breakfast of just over seven hundred calories. The fattening meal (top): cereal, half a banana, skim milk for the cereal (four ounces), buttered toast, and orange juice (eight ounces).
The non-fattening/weight-loss meal (bottom): three eggs scrambled with cheese and sausage, two strips of bacon, half an avocado (sliced), and ice water.
It’s not about the calories they contain. While some might look at the LCHF/ketogenic lunch plate at the bottom and say they can’t eat that much food for lunch (or at least not without a significant number of those calories coming as the sugar in the soda), others can imagine it effortlessly. They would very likely still lose weight or maintain a healthy weight eating it, because the fattening comes with the carbohydrates, not the calories.
These pictures also inform our understanding of sustainability, which is required for any dietary intervention to succeed. It’s true that the LCHF/ketogenic lunch requires a fork and maybe even a knife, and it certainly can’t be consumed while driving without creating a mess, which isn’t necessarily the case with the standard-American-diet version. But otherwise, what you’re primarily doing when you eat LCHF/ketogenic food is not eating certain foods, and so sustainability is about whether you can keep that up. When cigarette smokers quit smoking, the quitting is sustainable only so long as they don’t smoke cigarettes. The same logic holds for LCHF/ketogenic eaters and their abstinence from carbohydrate-rich foods.
Does eating more fat to compensate for the carbohydrate calories make it unhealthy? In the 1960s and ’70s, the British nutritionist John Yudkin pointed out that when we restrict carbohydrate-rich foods—specifically, grains, starches, and sugars—we are restricting the foods that bring the least to the diet in terms of vitamins and minerals. In the case of sugar, it brings nothing at all but energy (hence the term “empty calories”) and a metabolic burden to the liver that may very likely be the cause of insulin resistance.
The science of metabolic syndrome and its link to obesity, diabetes, and heart disease, as we discussed, implies that the carbohydrate-rich foods we have to avoid to attain a healthy weight are the same as those we have to avoid to attain and maintain good health. The evidence implicating natural dietary fats in heart disease has evaporated over the years. Because the LCHF/ketogenic meals eaten at the bottom in the photos will help us achieve and maintain a healthy weight, they are also correcting metabolic syndrome. We have significant evidence now that they will even reverse type 2 diabetes. These foods, including the fat, are integral parts of a healthy diet.
Another principle that we have to accept then is that these naturally occurring fats can both be good for us and constitute the great majority of the calories we consume. These are the fats from animal products—whether saturated or not, even lard and tallow and chicken fat—and the fats from vegetables that include oils we’ve been consuming for thousands of years, olive oil in particular, and oil from avocados. We’ve been eating these fats long enough as a species that we can consider them natural, as Geoffrey Rose might have defined it, and so believe with reasonable certainty (the best it gets) that these foods are benign. Will we shorten our lives by eating so much fat or red meat? The existing clinical trial research suggests that the answer is no, though there are no guarantees. The simple fact, though, is that in the short run, we get healthier.