The MultiFactorial Nature of Obesity – How to Lose Weight II

The multifactorial nature of obesity is the crucial missing link. There is no one single cause of obesity. Do calories cause obesity? Yes, partially. Do carbohydrates cause obesity? Yes, partially. Does fiber protect us from obesity? Yes, partially. Does insulin resistance cause obesity?   Yes, partially. Does sugar cause obesity? Yes, partially. All these factors converge on several hormonal pathways that lead to weight gain. Insulin is the most important of these hormonal pathways. Low carbohydrate diets reduce insulin. Low calorie diets restrict all foods and therefore reduce insulin. Paleo diets (low in refined and processed foods) reduce insulin. Cabbage soup diets reduce insulin. Reduced food reward diets reduce insulin.

Virtually all diseases of the human body are multifactorial. Consider cardiovascular disease. Family history, age, gender, smoking, diabetes, high blood pressure, and lack of physical activity all influence, perhaps not equally, the development of heart disease. Cancer, stroke, Alzheimer’s disease and chronic renal failure are all multifactorial diseases. That smoking contributes to heart disease does not mean that high blood pressure does not. Both are correctly identified as important factors. Just because one is correct does not mean that the other is incorrect. It would thus be idiotic to compare a treatment strategy of stopping smoking against treating high blood pressure.

We should not expect obesity to be any different. Obesity is also a multi-factorial disease. What is required is a framework, a structure, a coherent theory to understand how all these factors fit together. Too often, our current model of obesity assumes that there is only one single true cause, and that all others are pretenders to the throne. There are endless debates about the true king. Too many calories cause obesity. No, too many carbohydrates. No, too much saturated fat. No, too much red meat. No, too much processed foods. No, too much high fat dairy. No, too much wheat. No, too much sugar. No, too much highly palatable foods. No, eating out. It goes on and on. They are all partially correct.

So the Low Calorie believers disparage the Low Carbohydrate people. The Low Carbohydrate movement ridicules the Vegans. The Vegans mock the Paleo supporters. The Paleo followers deride the Low Fat devotees. All diets work, because they all address a different aspect of the disease. But none of them work for very long, because none of them address the totality of the disease. Can’t we all just get along? Without this critical understanding of the multifactorial nature of obesity, we are doomed to this endless cycle of blame.

Similarly, most dietary trials are fatally flawed by this tunnel vision. The various trials comparing low carbohydrate to the low calorie diets have all asked the wrong question. These two diets are not mutually exclusive. What if both are true? Then there will be similar weight loss on both sides. Low carb diets lower insulin. Lowering insulin levels reduces obesity. However, all foods raise insulin to some degree. Since refined carbohydrates often make up 50% or more of the Standard American Diet, low calorie diets generally reduce carbohydrates as well. So low calorie diets, by restricting the total amount of foods, still work to lower insulin levels. Both will work.

That is exactly what Harvard professor Dr. Sacks confirmed in his randomized study of four different diets. Despite differences in carbohydrate, fat and protein content, weight loss was the same.  Maximum weight loss occurred at six months, with gradual regain thereafter. A 2014 meta-analysis of dietary trials reached much the same conclusion. “Weight loss differences between individual diets were minimal”. Sure, sometimes one diet comes off as slightly better than another. The difference is often less than one kg and often fades by a year. Let’s face it. We’ve done Low Calories Low Fat. It didn’t work. We’ve done Atkins. It was not the effortless weight loss that was promised. While important lessons were learned, it was not the right answer. Carbohydrates are only a single factor in a multi-factorial disease.  We’ve done high protein diets.  We’ve done cabbage soup diets.  We’ve done cookie diets.  All these diets address only a single factor in a multi-factorial disease.  Further, they completely ignore the question of “When to Eat” as well as the time dependent factors of obesity.

Sometimes these results are interpreted as the belief that everything can be eaten in moderation. This does not even begin to address the complexity of weight gain in the human subject. It is essentially a cop-out answer. It is a deliberate attempt to evade the hard work of searching for dietary truths. For example, should we eat broccoli in the same moderation as ice cream? Obviously not. Should we drink milk in the same moderation as sugar sweetened beverages? Obviously not. The long-recognized truth is that certain foods must be severely restricted. This would include sugar sweetened beverages and candy, for instance. Other foods do not need to be reduced in any way – kale or broccoli, for instance.  Other foods, may be best taken in moderation – animal meat.

Others have erroneously concluded that ‘it is all about the calories’. Actually, it is nothing of the sort. Calories are only a single factor in the multifactorial disease that is obesity. It seems to be a default answer, but it has already been shown to be disastrously incorrect. After all, caloric reduction has proved itself a dismal failure over the last 50 years. Low calories diets have been tried again and again. It failed every single time.

There are other answers that are not really answers. These include, ‘There is no best diet’ or ‘Choose the diet that suits you’ or ‘The best diet is one you can follow”. If supposed experts in nutrition and disease don’t know the right diet, how are you supposed to? This is intellectual laziness at its very worst, revealing a stunning lack of imagination about the problem of obesity. Does this mean that following the Standard American Diet is the best diet for me, because it is the one I can follow? Does this mean I can eat a diet of sugared cereals and pizza? Obviously not. ‘Experts’ who are too mentally sluggish in the quest for truth reach for the facile and incorrect answer that ‘All diets are equal’. This pure intellectual laziness is unacceptable. We don’t need another ‘expert’ give us the lame-duck answer “All diets work. Do whatever you want”.

In cardiovascular disease, for example, this answer would never be considered satisfactory. If the lifestyle factors of stopping smoking and increased physical activity both reduce heart disease, then we would strive to do both. We would NOT say, “The best lifestyle for heart disease is the one you can follow”. Unfortunately, many so-called ‘experts’ in obesity profess this exact sentiment.

Imagine three men who all study trees. One man looking at the trunk proclaims that trees are large, rounded and rough. Another man looking at the branches declares that trees are small, rounded and smooth. The third man, studying only the leaves, said that trees are small, flat and green. All three are at once correct and incorrect; just as each factor in a multi-factorial disease is at once right and wrong. In cardiovascular disease, we can see the tree. In obesity we cannot. Calories, carbohydrates, processed foods, sugar, fast foods, fibre, vinegar, fat, protein, and meat are all important parts of the obesity tree.

Most diets attack a single part of the problem at a time. But why is it necessary to address one facet at a time? In cancer treatment, for example, multiple types of chemotherapy and radiation are combined together. The probability of success is much higher with a simultaneous attack. In cardiovascular disease, multiple drug treatments work together. We use drugs to treat high blood pressure, high cholesterol, diabetes, and smoking cessation – all at the same time. Treating high blood pressure does not mean ignoring cholesterol. In challenging infections such as HIV, a cocktail of different anti-viral medicines are combined together for maximum efficacy.

The same approach is necessary to address the multidimensional problem of obesity. Rather than targeting a single point in the obesity cascade, we need multiple targets and treatments. But the Low Carbohydrate proponents don’t want to hear about calories, meat, or insulin resistance. For them, it is all about carbohydrate restriction. But all foods, even low carbohydrate ones contribute to rising insulin levels. The Low Calorie devotees don’t want to hear about carbohydrates, sugars, meats, or dairy. For them, it is all about caloric restriction. You can eat ice cream for dinner if it has the same number of calories as a large salad. We don’t need to choose sides. Rather than compare a dietary strategy of low calorie versus low carbohydrate, why can’t we do both? There is no reason.

Continue to Reduce Added Sugars – How To Lose Weight IV

Start here with Calories I – How Do We Gain Weight?

2018-11-26T12:53:33-04:0033 Comments

About the Author:

Dr. Fung is a Toronto based kidney specialist, having graduated from the University of Toronto and finishing his medical specialty at the University of California, Los Angeles in 2001. He is the author of the bestsellers ‘The Obesity Code’ and ‘The Complete Guide to Fasting’. He has pioneered the use of therapeutic fasting for weight loss and type 2 diabetes reversal in his IDM clinic.

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John
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John

So…it appears that our parents were correct. Eat three balanced meals per day…everything in moderation and at a reasonable calorie level. Combine that with proper exercise and adequate rest and you should lose fat. Am I somewhat correct?

kfacwpup
Member

Somewhat. It’s a little more complicated especially if you are trying to lose weight rather than just maintain proper weight. For that some foods, like sugar, sweetened drinks etc must be severely curtailed. Further, a 50% carbohydrate meal is not necessarily balanced.

John
Guest
John

When I was growing up, we would have oatmeal for breakfast with a dash of milk and perhaps peanut butter. Lunch was a sandwich (in the sixties) and supper was usually a portion of meat, some green vegetables and a ‘starch’. We did not eat after dinner. I do realize that the simple carbs need to be limited but was making the point that perhaps, if we ate more as our parents and grandparents did, we may not see the obesity and diabetes we see today. It would seem to me, that eating three, low insulin load(?) meals per day… Read more »

Kay
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Kay

John, I became a diabetic 5 years ago and lost a lot of weight until I started injecting insulin. I’ve gained around 50 pounds in a year! Is insulin the culprit? I do tend to eat carbohydrates now because I know I can cover it with insulin (I’m a grazer and must nibble all day).
I follow your blog. Fascinating insight.

Walter Bushell
Guest
Walter Bushell

Everybody knows insulin adds weight even the mainstream doctors.

If you go in with unexplained weight loss to a doctor, the first thing they will
think is diabetes and you will be tested stat.

Teen age girl with diabetes routinely cut their insulin to lose weight.

Storing fat (and protein) is what insulin *does*.

Guido Vogel
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Guido Vogel

I wonder what you will suggest as better option for diet than what Andreas Eenfeldt suggests, http://www.dietdoctor.com/lchf. The same is true for the suggested dietary approach for treating diabetes by Feinman et. al., http://www.nutritionjrnl.com/article/S0899-9007(14)00332-3/pdf.

erdoke
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erdoke

Well, if low insulin is the most desirable parameter then you just need to follow the graph presented in the article. I would only add that organic acids seem to lower the insulinogenic effect of other foods in general. That’s the very positive effect of fermented foods such as yoghurts and sauerkraut which effect was possible to replicate by just adding lactic or acetic acid on top of cooked white rice! To some extent high fat ratio of meals also mitigates the insulin response to meats and starchy side dishes. Then there is the well known (?) effect of improving… Read more »

kfacwpup
Member

Absolutely. There was a study with sushi rice as well. Rice vinegar is mixed into short grain rice and glycemic index was significantly lowered. Don’t forget about kimchi and vinegar for organic acids too. Vinegar taken with bread lowers the glycemic index, too.

John C
Guest
John C

Thanks for another insightful post. My own experience of low calorie and low fat diets confirms that, for me at least, they are effective in losing weight. I’ve done it several times and improved my glucose levels but still suffered spikes after eating certain foods. Eventually however, my self-discipline always relaxed and the weight went back on and the glucose control worsened until I summoned up the resolve for the next round. Then, last September, I decided to take a risk (it turned out not to be at all dangerous) and ignore my endocrinologist’s, nephrologist’s, dietician’s and family physician’s warnings… Read more »

Sam Feltham
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Fantastic article Jason, I’m in complete agreement! Hope all is well mate 🙂

MarieM
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MarieM

Excellent post–the conclusions are based on your extensive review of the available research and experience with your own patients. The advocates for a diet methodology that focuses on one aspect of nutrition (low cal, low fat, low carb, etc.) find it much simpler to “package” these types of plans for sale to a broad consumer base. Your approach in your Intensive Dietary Management program makes the most sense, especially for your obese patients by starting out with breaking the insulin resistance through fasting.

Kay
Guest
Kay

John C
Please tell me what you did? I’m insulin dependent.

John C
Guest
John C

Kay, I was type 2 so my experience may not be directly relevant to you but I have heard of type 1s getting some benefit too. I’m not a healthcare professional and nobody should follow my example without consulting their own doctors. I got my glucose levels down by weighing all my food, looking up the nutritional values online and calculating my daily calories, carbohydrate, fat, salt and protein. I lost weight steadily on under 1500 calories a day but glucose still surged after certain foods. I now have better control on low carb/ high fat and intermittent fasting as… Read more »

Dave
Guest
Dave

I have recently found that combining low carb with low calorie works well for controlling my T2D blood sugar. I eat low carb but restrict the total calories to about 1/2 of what I used to eat.

Kay
Guest
Kay

I’m a type 2. My doctor put me on insulin because my blood sugars were erratic on metformen

John C
Guest
John C

Metformin made me ill so I was on a variety of other meds until I lost weight. No meds for two years now except calcium/vitamin D supplement and statin, which I’m discussing with my doctor with a view to stopping. I had also been injecting EPO for anaemia until a couple of months ago but was told I could stop now that my Hb has improved. Remember we are all different and I am not offering medical advice, just reporting my own experience. You have to be guided by your own doctors.

erdoke
Guest
erdoke

Have your doctor watch this video: Rolf Luft Award 2014, Prize Lecture by Professor Roger Unger
http://youtu.be/VjQkqFSdDOc
I’d make it mandatory to all medical doctors dealing with any type of diabetes… I am sure Jason agrees.

Rob
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Rob

Nice articles. looking forward to the rest!

Natalie
Guest
Natalie

Hi Jason,

So when you talk about “when to eat”, are there any specifics aside from when you actually feel hungry?

Right now, I’m following a keto style diet, but I would like to up my carbohydrate intake gradually. Does it matter what time of day I eat carbs? Is it true that you should eat majority of your carbs in the morning, or does it matter if I have them at night?

Thanks!

kfacwpup
Member

We will cover exactly “What to Eat” but you can review the Hormonal Obesity series for a clue. Breakfast vs dinner likely makes only a little difference if any.

deirdra
Guest
deirdra

When you cover “what to eat” I’d be interested in hearing what you have to say about protein levels, since excess protein can increase BG levels, but too little can cause loss of muscle mass. Do you recommend aiming for a the same or different amounts of protein fasting vs. eating days?

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[…] my point is this.  Obesity is a multi-factorial disease, as I previously wrote about.  This means, that there must be multiple targets in the pathway to […]

sharal
Guest
sharal

Your view on obesity is very interesting and I have to agree with you. There are two biggest sides and communities, LOW-CAL (mostly goes hand in hand with low-fat) and LOW-CARB, which seems to be fighting all the time, proving that their methods are right and works the best. I managed to lose weight thanks to low-calorie diet many times, but always put it back later on. I was eating whatever I wanted, I only make sure that I was always getting enough protein and staying away from candies and fast food type meals. Besides that, it didnt matter that… Read more »

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[…] answer really lies in the multi-factorial nature of obesity. Let’s go back to our Hormonal Obesity Theory (HOT) […]

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[…] The MultiFactorial Nature of Obesity https://idmprogram.com/multifactorial-nature-obesity-lose-weight-ii/ […]

waleed
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waleed

I would like to suggest that ” weight loss ” should not be the main concern of dieters. Body fat becomes problematic when it is allowed to accumulate out of proportion. This can be easily proven mathematically; when going on LFHC diet, the dieter enters a fat storage mode, meaning that the body forces part of the eaten food to be stored and not be available for energy requirements, leading to eat in excess of daily requirements, and while this is an adequate temporary measure in times of food abundance, it is definitely the wrong thing to continue doing. On… Read more »

bachcole
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bachcole

“Can’t we all just get along?” Jason, you are one funny dude. LOL.

Nissa
Guest
Nissa

Dr Fung, How close to our BMR must the daily caloric intake be to avoid the complications of caloric reduction? I am LCHF and fast 23/1 six-seven days a week. My BMR should be around 1500 calories/day, but I’m full at 1200. I’m still getting cold and tired intermittently, which would indicate my body is experiencing that as caloric reduction. Should I be aiming to meet or exceed that calorie goal to avoid the symptoms of reduction? (Prior to doing LCHF, I was using reduced calories to lose weight, so my BMR may be unusually low). I’ve read TBO at… Read more »

jin
Guest
jin

Hello,

This is great information, thanks alot!

The link to the next blog post is broken though.

Sarah
Guest
Sarah

Hi, I got as far as “Continue to Avoid Miracle Cures – How To Lose Weight III and the page isn’t available and I can’t figure out how to get to the next section. Any ideas?

Doug
Guest
Doug

I’ve read from the beginning to here. Unfortunately the link to Avoid Miracle Cures – How To Lose Weight III doesn’t lead to anywhere. For the next installment I’m waiting with baited breath!

jf68
Guest
jf68

The right link to the next page seems to be this one: https://idmprogram.com/pro-tip-avoid-miracle-weight-loss-cures/ but don’t gives any further link at the end of the page. An advanced google search like this : lose-weight-III site:https://idmprogram.com ..don’t gives any file iii but show https://idmprogram.com/reduce-added-sugars-lose-weight-iv/ After the page V the site manager again forget to give a link. But now you have the key: make a key word search on the site idmprogram.com on google advanced search lose-weight-VI site:https://idmprogram.com To the site manager: please take care to the false, dead or missing links. Answer from a 72 years old frenchie trying to take… Read more »

Celee
Guest
Celee

I’m still a bit confused. I was thin all my life, and never had to worry about my weight. We ate ok, but we stuck to the low fat way of life. I have 4 children, but managed to keep my weight steady. Over the past few year I have been putting on weight steadily and I am now 10kg more than I would like to be. I’ve tried dieting, mainly cutting calories, but it hasn’t worked. I have started fasting since last week, but still unsure how much to eat. How do I reset my body set weight?