Here we are again. Another Gary Taubes book. After reading it, I have pretty much the same feelings about this book as I did his previous books. To the lay reader it probably has the veneer of a thoroughly researched book by an author who sees through all the BS that’s out there and presents a no-nonsense recitation of the facts. But the reality is quite the opposite: Taubes seems to ignore a lot of evidence that is contrary to his ideas and the evidence he presents is usually taken out of it’s original context and placed into a new context that is created to really change the original meaning. I would say that this is Taubes’s biggest failing in writing the book, but I’m fairly certain this is not simply incidental human error.
Another flaw of the book (in my opinion) is a heavy reliance on a kind of anti-intellectual rhetoric mixed with a weird version of classism. What I mean by this is that nutritional experts and nutrition researchers are treated with contempt. It should be noted that he only treats the researchers that publish findings contrary to Taubes’s theories with contempt. If they happen to align with his theories they are treated with reverence. The narrative is very much infused with an elite ruling class of oppressive nutritional authorities and an innocent proletariat that just want to lose weight and go about their lives. You can believe all that if you want. I can’t stop you. Conspiracy theories are certainly in vogue nowadays.
Anyway, I am writing this introdution in between trying to sooth my finicky 4 month old son, so my thoughts my not be totaly coherent, but I think you are picking up what I’m laying down. But you didn’t come here for the introduction. You came here to witness me pick apart a book.
Not the Introduction
The first paragraph of TCFK is how we should have listened to a guy name Edwin Astwood:
On June 22, 1962, a Tufts University Medical School professor named Edwin Astwood tried and failed to correct how we think about the cause of obesity. We have been living with that failure ever since.
Taubes spends the next two pages building Astwood up by stating what a brilliant guy he is and listing his credentials, but he does not mention any of Astwood’s dietary arguments or what he believed and why. The thing Taubes does mention is the first sentence of a 1962 speech that Astwood gave in Chicago where Astwood says that obesity is similar to a sexually transmitted infection, in that the patient is often blamed.
So what are some of Astwood’s theories on obesity? Dr. Astwood argues that obesity is actually a heritable condition caused by a “defective enzyme” and dieting won’t help.
I wish to propose that obesity is an inherited disorder and due to a genetically determined defect in an enzyme; in other words, that people who are fat are born fat, and nothing much can be done about it. (1)
Big, if true. That would render the whole point of Taubes’s book moot, because why follow a ketogenic diet? It won’t matter if you’re fat or thin. Astwood goes on to argue that that there’s nothing wrong with being fat; in fact, it can be quite desirable in women if the fat is deposited in the right places. Seriously, he spends several paragraphs on this point. In doing so he gives us a phrase that I haven’t been able to forget: “I would not want to wager about how many enzymes determine the shape of voluminous pulchritude.” Quite a turn of phrase!
On page 23 Taubes invokes a narrative that he’s used before. To wit, German scientists developed the correct idea that obesity was caused by poor hormone regulation, but after Germany lost WW2 the science that had come from Germany fell out of favor. What replaced it was the incorrect notion that a calorie surplus caused obesity. The good German research was all but forgotten. Or that’s how Taubes tells it, at least.
Does he provide the slightest bit of evidence for this? Not at all, and in fact there is evidence to the contrary. German scientists were highly valued in the United States and elsewhere both during and after WW2. In fact, the US (and other countries like England) made a great effort to poach German scientists as a kind of “brain drain” operation. But nevertheless it is an interesting story for why Taubes’s pet theory of obesity has not been widely accepted for nearly a century.
On page 27-28 Taubes dismisses the idea that issues of psychology could play a role in obesity, and seems to denigrate psychiatrists as something akin to grifters.
[O]besity treatment had become the purview primarily of psychiatrists and psychologists. These were the medical professionals charged with teaching fat people to get thin and supposedly elucidating our understanding of the disorder. They saw the obese and overweight, not surprisingly, from their own unique perspective and context, as clearly suffering from mental, emotional, and behavioral disorders. They found it easy to ignore a revolution in endocrinology, because that wasn’t their area of study.
A couple paragraphs later Taubes goes back to Germanophobic theory of obesity and writes the following:
Astwood’s proposition and his theory, and the thinking of the prewar German and Austrian authorities, effectively disappeared. In 1973, after forty years of research had worked out the science of fat metabolism and storage in great detail, Hilde Bruch, the leading U.S. authority on childhood obesity, remarked on its absence. It was “amazing how little of this increasing awareness,” she wrote, “is reflected in the clinical literature on obesity.”
Hilde Bruch was a German-born psychiatrist that emigrated to the US in the 1930s. And that quote is taken from a text where she is absolutely not referring to a dearth of German research in the literature or even a lack of discussion on hormonal regulation. Rather, she was referring to the lack of behavioral science and family systems theory in obesity research. In other words, Bruch does not refer to what Taubes states and instead the “leading U.S. authority on childhood obesity” says precisely the opposite of what Taubes claimed a couple paragraphs earlier.
Taubes likes to cite Bruch in his other works, too, but fails to really put her works into context. Because if he did it would hurt his case for keto. One example is from the text Taubes cites here. As she explains in the text, there are really only two obesity treatments in her view: “manipulate the energy balance so that an obese person expends more than he takes in and thus loses weight.” The other is to “effect a change in the person himself so that he no longer abuses the eating function in futile efforts to solve other problems of living, and to help him gain sufficient inner strength so that he can face the task of reducing without undue mental strain.” (2)
She also discusses the impact of family dysfunction to obesity in her earlier work:
In such an environment which does not offer adequate emotional security, food gains an inordinate importance. Food is offered and received not alone for the appeasement of a bodily need but it is highly charged with emotional value. To many mothers the offering of food represents the only way of expressing their affection and devotion. The child increases his demands as his need for gratification and security in other respects remains unsatisfied. On the other hand, enjoyment of physical activities and social relation is greatly restricted. The atmosphere of fearful apprehension confers upon them the meaning of danger, threat, and insecurity. The development of obesity in such surroundings becomes comprehensible. Overeating and inactivity bring about the increasing storage of fat. But these symptoms do not befall a child suddenly; they are closely connected with his whole development. (3)
On page 29 Taubes is incredulous that medical textbooks don’t present alternative hypotheses that “compete” with the calorie model of obesity, stating “The absence of a competing theory is remarkable, especially given the stakes and the profound implications.”
One wonders if Taubes is equally incredulous that alchemy isn’t taught as a competing theory in chemistry textbooks, or that intelligent design is not included in (most) biology textbooks as a “competing” theory to evolution.
On page 30 Taubes mentions Dr. Reginald Passmore whom Taubes says was the author of “definitive” nutrition information for a generation of British medical professionals.
Passmore coauthored an article in the British Journal of Nutrition that began with the declaration: “Every woman knows that carbohydrate is fattening: this is a piece of common knowledge, which few nutritionists would dispute.” This observation resonated almost perfectly with what laboratory researchers were learning at the time about the hormonal orchestration of fat storage and fat metabolism.
That article certainly began with that declaration but ended quite differently. The article was about a study where people were fed excessive amounts of carbohydrate, with the expectation that the extra carbs would be converted to fat. But what Passmore found didn’t support that conclusion:
In each of the three series of experiments described above, it was found to be difficult to raise the RQs of the subjects significantly above 1.00. Thus, despite the large intakes of carbohydrate, there was no evidence of the net conversion of carbohydrate into fat in substantial amounts within 24 h. (4)
Emphasis mine. Taubes has a nasty habit of taking the words of researchers out of context and making them fit his own narrative. When writing an article, authors like to inject the mildest bit of drama into what would otherwise be a dry recitation of findings, so they craft their findings as if their results were surprising in some way. In this case the story was: Everyone knows carbohydrates are fattening, but we put this common wisdom to the test and our results might surprise you. Here’s what we did and how it challenges the conventional wisdom.
So it’s funny that when Taubes writes “this observation resonated almost perfectly with what laboratory researchers were learning at the time” it certainly wasn’t what that author was learning at the time. Or it would be funny if you think lying to a gullible audience is funny.
Throughout the text Taubes takes a very anti-establishment stance. He has taken similar stances in his other books, but I think TCFK is the most explicit and most pointed when it comes to attacks on “nutritional authorities.” Here’s a representative example on page 37:
[T]he nutritional and academic authorities have failed us, and they and we should acknowledge that. Had they not failed us, we would, almost by definition, never have reached this point of epidemic obesity. That’s the context of this discussion and all that follows. I believe it should be the context of every public discussion on obesity and weight control. If the conventional thinking and advice worked, if eating less and exercising more were a meaningful solution to the problem of obesity and excess weight, we wouldn’t be here. If the true explanation for why we get fat were that we take in more calories than we expend and the excess is stored as fat, we wouldn’t be here. So many more of us would be lean and healthy, and books like this one would not be necessary.
Emphasis in the original. It should be noted that, although Taubes frequently attacks the experts, when he finds one to quote that advances his pro-ketogenic argument, he goes out of his way to list his/her educational credentials, make sure you know they held professorships, mention how many years they did research, etc. You can see this very clearly in the first few pages of the book where Taubes lauds Dr. Astwood for pages, even describing an award he had won and comparing it to the Nobel Prize (“He won the Lasker Award, considered one step below the Nobel Prize, for the thyroid work”). So when it comes to attacking authorities versus embracing authorities, Taubes definitely wants to have his cake and eat it, too.
But I would like to address the maligning of the experts here. As I write this, the United States is mired in the depths of the COVID-19 pandemic. We have by far the most cases of the disease, and we are tied with the European Union for the most deaths.
Other countries have managed to get this pandemic under control. Where the US has over 200,000 new confirmed cases per day, South Korea has 745 cases/day, China has 100 cases/day, Taiwan has 5 cases/day, and New Zealand has 2 cases/day.
Why is that? Are those countries getting better health advice that the US? No, their public health officials were saying the same thing ours were: mask up, social distance, stay home if possible, wash your hands, etc. But there was clearly a difference in the application and execution of this advice.
Many factors led to the US being the hardest hit country: the White House’s efforts to “play down” the importance of the virus, inability to mobilize the resources of the federal government to acquire and effectively distribute supplies like ventilators and masks, our inability to perform widespread testing and contact tracing, nearly an entire political party that pretended the virus wasn’t real and openly participated in super spreader events… we could go on. But the advice of the epidemiologists and public health experts like Dr. Tony Fauci, Dr. Vin Gupta, and Dr. Peter Hotez is not to blame. These experts have been communicating every day exactly what we need to do to mitigate the spread of the virus for nearly a year now, but as a society we have been unable to universally coalesce around these messages and engage in effective mitigation and prevention.
This is similar to the obesity “epidemic.” The US also has the most overweight and obese people per capita. Again, why are other countries leaner and healthier in this respect? Other countries have nutrition experts and authorities that say basically the same thing our experts say. The problem in the US is that we are unable or unwilling to really apply those recommendations. It also does not help when people like Taubes write nutrition books full of deliberate misinformation.
One of the key elements in Taubes’s argument is that some people are simply “born” thin, while others are less fortunate and are born with a metabolic deficiency which causes them to become fat. This argument is distilled on page 45-46:
Those who fatten easily are profoundly different from those who don’t and may have been from the womb onward. Their physiology is different; their hormonal and metabolic responses to foods are different.
If these differences are so pronounced, you would think that there would have been ways to identify and differentiate these individuals long ago. Much like how you can identify people with diabetes with a simple OGTT. But I know of no such test and Taubes doesn’t present evidence of any type of test or even hypothetical investigative tool that would do so. One would imagine that (if Taubes is correct) such a tool would be very valuable for identifying those people at very high risk of developing obesity and therefore a likely milieu of other chronic diseases such as heart disease, cancer, diabetes, hypertension, etc.
In fact, the topic has been widely studied and no enterprising researcher has been clever enough to cash in on creating such an important diagnostic tool. Taubes tries to conceal that from you, though. Take, for example, a passage from this very same page as the above. Taubes discusses the hearings before the Select Committee on Nutrition and Human Needs of the United States Senate in 1977:
I want to be sure we don’t oversimplify,” Bellmon said. “We make it sound like there is no problem for those of us who are overweight except to push back from the table sooner. But I watched Senator [Robert] Dole in the Senate dining room, a double dip of ice cream, a piece of blueberry pie, meat and potatoes, yet he stays as lean as a west Kansas coyote. Some of the rest of us who live on lettuce, cottage cheese and RyKrisp don’t do nearly as well. Is there a difference in individuals as to how they utilize fuel?”
The doctor in the hearing replies “We constantly hear anecdotes of this type, but, to date, people doing research in this field have been unable to find clear evidence that people remain thin because of some special metabolic characteristic.” But Taubes would have you believe that a slavish devotion to an ancient religion led the good doctor to this belief and not a lack of clear and compelling evidence.
Taubes does this throughout the book; framing a conclusion based on facts and evidence as if it is some sort of irrational, unscientific dogma. In reality, Taubes is guilty of the very thing that he accuses others of doing. Taubes himself has not meaningfully changed his beliefs on why people get fat in nearly 20 years despite all evidence to the contrary. He has called scientific studies that don’t fit his beliefs pseudoscience, and he has denounced the researchers and results he himself funded (through his organization NuSI) that he expected would prove his theories correct. He has even openly admitted that he would not alter his beliefs no matter what the evidence demonstrates.
Whenever I go back and read ones of Taubes’s references I very often find that Taubes took the original author out of context, and something immediately following (or immediately preceding or both) will undercut the point Taubes is trying to make. I imagine Taubes at home on his computer writing a draft of TCFK, pulling an old nutrition book off his bookshelf, flipping though it while his finger traces the words and thinking “Can’t use that… Nope… That’s no good… Hmmm, doesn’t really support what I’m saying… Definitely not that… Okay, I could probably use that sentence as long as I make sure to leave it ambiguous as to what he’s actually talking about… And that’s it. Can’t use anything else.”
One such example is Taubes’s mention of a 1936 textbook on metabolism as an example of why thinking that the body strictly regulates calorie intake and fat accumulation is ridiculous. Page 52:
[O]ther experts in the early decades of the twentieth century saw it as a reason to question the whole way of thinking. Eugene DuBois, for example, the leading authority on human metabolism in the United States in the 1920s and 1930s, suggested in his seminal textbook that this simple mathematics tossed the whole energy balance (gluttony and sloth) concept of body weight regulation into the realm of the absurd. Considering how exquisitely accurate the imbalance has to be to avoid obesity, how few calories actually have to be stored in excess as fat every day to become obese, to lead to tens of pounds of excess fat every decade, he said, “There is no stranger phenomen[on] than the maintenance of a constant body weight under marked variation in bodily activity and food consumption.” (Another phrase used by physicists to describe this kind of problem is “spherically senseless,” meaning it makes no sense no matter which way you look at it.)
DuBois then goes on to illustrate in pretty striking detail how exactly this phenomenon occurs. Like I mentioned earlier, many researchers like to present problem/conundrum/question upfront, then go on to answer the question they proposed with their work. Much like Darwin is taken out of context by creationists to make it seem like Darwin himself didn’t believe in natural selection, Taubes does the same with the authors he cites.
DuBois actually seems to endorse the gluttony and sloth concept of obesity that Taubes rails against:
[I]n some individuals, with apparently normal endocrine glands, the weight increases to the point where it exceeds the normal limits. These are the cases of so-called simple or exogenous obesity. The term exogenous indicates that there is no endocrine disturbance, but that the fault lies either in too much food or too much laziness. It is not strictly exogenous because greediness and laziness certainly rest within the body. (5)
DuBois also throws cold water on Taubes’s metabolic defect theory:
We must conclude that simple or constitutional obesity, which seems to be in many cases an hereditary disease, is accompanied by no abnormality of metabolism striking enough to be demonstrated by our present methods.
On page 45 Taubes attacks Jean Mayer for accepting the fact that it’s pretty difficult to gain weight if you exercise a lot or don’t eat anything.
Our current obsession with physical activity is largely rooted in Mayer’s proselytizing in the 1970s. But at the beginning of his career in the 1950s, he studied a strain of obese mice. “These mice,” he wrote, “will make fat out of their food under the most unlikely circumstances, even when half starved.” […] Mayer’s mice did not get fat by overeating. They got fat by eating. Half-starving them didn’t make them lean.
Emphasis mine. That quote comes from a book on overweight that Mayer wrote in 1968. Taubes doesn’t cite any page number for this quote, but it’s found on page 49 for those that are curious.
Taubes has to remove quite a bit of context here to make this passage fir his anti-exercise narrative. If you bother to read the couple paragraphs preceding the above quote you will find that
- The mice are inbred to create abnormalities like obesity to make it easier to study the condition. I’m not sure Taubes wants to equate obese people with inbred mice.
- One of the reasons the mice are obese is because they don’t exercise like normal mice. Mayer describes them as “extraordinarily inert” and basically don’t move. He states that you can get them to lose weight by putting them on a treadmill or by introducing genes that cause them to pace around their cages all day. Sounds like this could be evidence that physical activity can cause weight loss after all.
- Another thing that Mayer mentions is that if you put the obese mice on a reducing diet they will lose weight, but interestingly they lose much more muscle and less fat than you might expect. Mayer explains that this is because their particular abnormality makes it easier to burn lean muscle for fuel rather than fat. Kind of an interesting factoid, but I’m not sure that this aberration in inbred mice is terribly relevant to humans. (6)
If it’s not obvious to you, there are a lot of problems when you try to apply some logic to this bizarre thinking. Let’s take an example of ex-athletes. After an elite athlete retires from their sport, it’s not uncommon for these athletes to then gain some (or quite a bit) of weight. See Charles Barkley or Mike Tyson. For Taubes’s mice analogy to be true in humans you would have to believe that elite sportsmen like Tyson, Barkley, and others were actually just born obese. Their training and physical activity played little to no role in their lean periods while they were professional athletes, and the lack of intense training and playing at an elite level played no role in gaining weight after their retirement. Moreover, what appeared to be lean muscle on their bodies during their heyday was really just extra fat, since they can never be truly lean. Maybe what appeared to be muscle on Mike Tyson was just hardened fat, and much like the obese mice on low calorie diets didn’t actually have much lean muscle.
Or maybe all these obese athletes were on strict ketogenic diets while training and playing and just as they retired, they all went back on bread and pasta. I mean, this thought experiment really strains credulity.
There was a period of time around the 1940s to the 1960s where incoming freshman to Ivy League universities like Harvard would be asked to strip naked and be photographed from different angles as part of the new student orientation. The students were told this was for purposes of posture and if anyone’s posture was extremely bad they were sent to posture classes. However, that was not true and the students were not informed as to what the photos were really being used for, which was to lend an air of scientific respectability to a eugenicist.
What does that all mean? And what does it have to do with TCFK? Great questions I will soon answer. The eugenicist in question is a man named William H. Sheldon, and he had certain ideas about undesirable people and how to make a great society. To help humanity achieve this great society Sheldon believed we needed a way to identify undesirables, and so began Sheldon’s somatotyping project. Sheldon believed that one look at your body type revealed volumes about you: how intelligent you were, how ambitious you were, how sexually deviant, how lazy, how confident, and all other types of traits and behaviors. So he set out to prove this when he was at Harvard using these questionably-obtained photographs of college freshmen.
Long story short he writes some really racist things (like “Negro intelligence” comes to a “standstill at about the 10th year”), gets accused multiple times by his assistants of doctoring data, is not taken seriously by his fellow academics, leaves Harvard and has to rely on financial support from other rich eugenicists that liked his views, and fades into relative obscurity leaving behind a set of controversial racist, chauvinistic, and extreme eugenicist texts. (7,8)
Gary Taubes, however, seems to find value in his work and thinks it’s great to cite Sheldon on page 48 to support Taubes’s theories on obese people being born that way:
Cut back enough on the calories a fat person is allowed to eat, and the result is a less fat person. But as the Harvard psychologist William Sheldon observed in the late 1940s, starving a fat man (an endomorph, in his terminology) doesn’t actually turn him into a lean man (an ectomorph) or a muscular, athletic one (a mesomorph) any more than starving a mastiff turns it into a collie or a greyhound.
To reiterate, Sheldon was a deeply unscientific person and no one really takes his somatotyping work seriously. But even if we were to do so, Sheldon doesn’t even make the point that Taubes wants him to make in the book that he cites, because Sheldon mentions that endomorphs are generally lazy, not too bright, and eat a lot. I’m not going to copy-paste everything Sheldon wrote about endomorphs, but it’s deeply unflattering stuff that is written in some flowering language. I’ll mention a few here, just because I find them to be quite funny:
- “There is an essential dislike of bodily exercise. The arms often show a limp relaxation like that of a seal’s flipper, and the hands are likely to be soft and flaccid.”
- “The individual has a primary desire to be comfortable, and to bask in his comfort. He shows relatively great interest in being comfortable, and if he has any ingenuity, a considerable proportion of it is devoted to making himself comfortable.”
- “All responses are conspicuously slow. Movement is slow and deliberate. Both verbal and motor reactions are slow, as revealed by the common reaction time experiments of the psychological laboratory. Eye movements are slow, including those involved in reading. The eye wink is observed to be slow, like that of a sleepy child.”
- “There is a deep joy in eating, and a considerable fuss and ceremony are made overeating. Usually there is a history of having overeaten and of having desired more food than was needed to maintain normal weight or growth. In a true motivational sense the individual lives, partially at least, to eat.”
- “The greatest of social satisfaction is to be derived from the festive board, and from lingering over a fine, well-served meal.” [I mean, who can argue?]
- “Digestion is excellent and is a primary pleasure. To sit with a full belly and do nothing but digest, is to experience the fullness of life. Elimination too is pleasant and free from unpleasant psychological complications. It is especially pleasant to sit on the stool with the Sunday paper. If the individual is free from social inhibition, a fine belch is an excellent thing, and often flatus is most agreeable.” (9) [Who among us hasn’t enjoyed this from time to time?]
So if these are the primary traits of an endomorph, I’m not sure that it helps Taubes sell the idea that fat people aren’t fat because they eat too much and exercise too little.
On page 52 Taubes does his classic move of taking the introductory question of a paper out of context and ignoring the rest of the text:
Russell Wilder, the leading pre–World War II authority on obesity and diabetes at the Mayo Clinic, did ask precisely this question in 1930: “Why then do we not all grow fat?” After all, he wrote, “we continue to be protected against obesity, most of us, even though we hoodwink our appetite by various tricks, such as cocktails and wines with our meals. The whole artistry of cookery, in fact, is developed with the prime object of inducing us to eat more than we ought.” (That was almost ninety years ago when Wilder said “most of us” are protected against obesity. Today he might have to say “some of us,” but his point is still a good one.)
Wilder then goes on to answer his question with statements that are directly opposed to what Taubes is trying to argue. Wilder says that there is no difference in metabolism between the thin and the obese (contrary to Taubes’s earlier statements) but the difference lies in the brain, as obese/overweight people defend a higher setpoint than thin people. (Although he doesn’t explicitly say setpoint, as I don’t think that term was coined in 1930.)
Wilder also says the management of obesity is to control “calorie intake and output so that the latter will exceed the former” and “we can accomplish this reduction by either by limiting the food or increasing the outlets, that is, the expenditures of energy.” He also says that “I hope to have made it clear that there can be no gain of weight if the calories in the intake fail to meet those in the output.” (10) Wilder seems to have made it clear to anyone who does not want to deliberately misrepresent him.
Starting on page 67, Taubes brings up Hilde Bruch again, “a psychiatrist and psychoanalyst, known foremost for her work on eating disorders and obesity” as Wikipedia puts it.
“Researchers— physiologists, notably, and so not physicians or nutritionists and certainly not psychiatrists or psychologists— had discovered that the storage of fat in fat cells and the liberation of that fat from storage and its use for fuel (oxidation, in the lingo) wasn’t in any way the simplistic process that was implied then and is implied still by the nutritional authorities. Columbia University’s Hilde Bruch, who was the leading midtwentieth-century authority on childhood obesity, understood this and waxed indignant about it in a book she wrote in 1957 called The Importance of Overweight, which should still be required reading for anyone interested in understanding obesity.”
He devotes a few pages to Bruch and selectively quoting her. He brings up quotes from her on fat metabolism and fat regulation and how overeating is not a cause of obesity, but rather a symptom of some other issue. Taubes is again doing what I am going to now call the “Taubes Shuffle,” where you take quotes out of their original context and place them in a new context that makes it seem to a trusting reader like the author is supporting Taubes’s crackpottery, when that’s obviously not the case when you read the original text. In this instance, the Taubes shuffle makes it appear that Bruch’s book The Importance of Overweight is about the storage and metabolism of fat, but it’s really not. It’s really about environmental factors that lead children to overeat. Bruch focuses on family dynamics and domestic issues that influence how much children eat: overbearing parents, childhood trauma, chaos at home, overindulgent parents… All of these things, argues Bruch, can lead people to develop an unhealthy relationship to food, where food is a form of comfort, security, and self-soothing. Or weight is gained as a kind of armor against the cruel world. Many of the cases that are included in the book are heartbreaking. Bruch also argues that diets may work in the short term, but unless these psychological issues are addressed the weight will be regained later.
But of course Taubes’s book is not about how you need to get over your daddy issues to lose weight, it’s about how following a certain diet can make you lose weight—pretty much the exact opposite of what Bruch is stating in her book. In fact, if you look back at the passage in TCFK, immediately before Taubes introduces Bruch, he poohpoohs the idea that psychiatrists and psychologists would have any knowledge of the matter.
Another Taubes shuffle on page 69:
Researchers studying fat accumulation in animals would note how fat cells and the animals themselves could accumulate fat or mobilize it and burn it for fuel “without regard to the nutritional state of the animal,” as though how much or how frequently the animal ate was irrelevant to whether it was using up its fat stores or building them up.
A 1948 study is cited for this and immediately after that quote the authors discuss how “lowering of the fat content of the tissue during hunger is the result of mobilization exceeding deposition.” (11) So if words still have meaning this would be the opposite of the phrase “how much or how frequently the animal ate was irrelevant to whether it was using up its fat stores or building them up.”
Back to another Taubes shuffle on page 79 when bringing up low-carbohydrate diets in the treatment of obesity:
These unbalanced diets restricted in sugars, grains, and starches, fat-rich instead, induced significant weight loss without hunger. This was the case in report after report, independent of how many calories the patients in these various institutions were fed, whether fewer than five hundred calories a day (as at the Mayo Clinic) or whether the patients were encouraged to eat as many calories as they could, as was often the prescription. “The absence of complaints of hunger has been remarkable,” the Mayo Clinic’s Russell Wilder wrote in 1933.
But if you read the study that Taubes takes the Wilder quote from, Wilder is clearly talking about a low-calorie diet he prescribed to patients. The diet in question is not fat-rich and not unlimited in calories. It’s a diet that is between 500-600 calories/day and includes 100 grams of lean steak, 500 grams of vegetables, and alternating days of 100 mL of whole milk or 100 mL of orange juice with 50 grams of brewer’s yeast.(12) All with plenty of salt and a precise amount of vitamins and minerals.
So just to spell it out, Taubes put a quote by Wilder claiming that a lack of hunger is remarkable immediately after talking about fat-rich diets where patients are encouraged to eat as much as they could, when the quote refers to something completely different. The Taubes Shuffle.
This next one is not exactly a Taubes Shuffle, but it’s definitely a deliberate omission. Here Taubes lists foods from an old textbook that are contraindicated for obesity:
Here’s the British endocrinologist Raymond Greene’s version from his seminal 1951 textbook The Practice of Endocrinology: Foods to be avoided:
Bread, and everything else made with flour
Cereals, including breakfast cereals and milk puddings
Potatoes and all other white root vegetables
Foods containing much sugar
Funny thing is there are eight items on that list, but Taubes only includes five. The other three being salt, fluids, and fats. I’m not sure why Taubes left fluids off (although drinking excessive amounts of water is popular in the keto diet community), but he has been a stout proponent of consuming more salt for years because that’s contrary to “conventional wisdom” and therefore he’s in favor of it. I think the reason he left fat off is obvious. A funny thing to read after reading Greene’s list is that Greene himself states that “this diet makes no claim to scientific accuracy […]” (13)
Since this is a text that is nearly 70 years old, there are some other interesting things about Greene’s recommendations, like that he also supports Turkish baths, amphetamines, diuretics, and dinitrophenol for weight loss.
This next passage is almost worthy of leaving out because it’s not terribly wrong, but I’ll mention it anyway. On page 81 Taubes mentions an Obesity conference in 1973:
Charlotte Young, a Cornell University professor, gave the only talk on dietary therapy, reviewing the hundred- year history of diets restricting sugar, starchy carbohydrates, and grains, and the results of the multiple clinical trials even back then, including Young’s own trials at Cornell. All these LCHF diets, Young said, “gave excellent clinical results as measured by freedom from hunger, allaying of excessive fatigue, satisfactory weight loss, suitability for long-term weight reduction and subsequent weight control.”
A couple things. 1) Young wasn’t exactly referring to all of the LCHF diets in the hundred-year history as Taubes says. She’s not even technically referring to a LCHF diet at all. She’s referring to a diet that she explicitly says is “moderate fat.” (14) Last I checked, moderate fat does not mean the same thing as high fat. 2) Young states that she tested 1800 calorie diets on obese men with varying degrees of carbohydrate: 30 grams, 60 grams, and 104 grams. She then says that the highest level of carbohydrate was the best. 3) Young wasn’t the only one with discussion of dietary therapy of obesity. She was the only one that had those words in the title of her talk, but many of the talks included discussions of how to treat obesity in different ways, from diet to exercise to fasting to pharmacological methods.
We have another Taubes Shuffle on page 87-88. He discusses insulin resistance and then basically states the thesis of his book: that any diet that works is not because it creates a calorie deficit, but rather that it creates in insulin deficit. Then he quotes Roxane Gay:
“I know the math,” Roxane Gay says in her memoir Hunger, as though that should be enough to solve her unruly body and reduce her excess fat. “In order to lose a pound of fat you burn 3,500 calories.” She then goes on to observe that this knowledge has clearly been useless to her.
I think the implication here is clear. When you link those two ideas you give the impression that Gay has attempted to lose weight by burning excess calories, but that’s useless because calorie deficits don’t work. Gay needs to reduce her insulin to lose weight, right?
Well, in fact if you read Hunger you’ll discover that chapter 46, where that quote is from, is all about how Gay doesn’t exercise. It’s about how much she hates it and considers it a waste of time. Gay says “I have a membership to Planet Fitness, though I have never visited the local facility. Basically, I donate $19.99 a month to their corporate existence and the idea that I can walk into a Planet Fitness, anywhere in the country, should I feel like working out.” (15) So to overly-explain what’s going on: it’s not that Gay is burning a ton of calories and not losing weight; it’s that she is not burning a ton of calories despite “knowing the math.” As a addendum, in chapter 65 she states that she tried low-carb diets. Those seemed to have been useless to her as well.
Nutritionists and dietitians of the conventional school of thinking have been instructed and will tell us that carbohydrates are the preferred fuel for our bodies and our brains, thus implying that they are indispensable. But these nutritionists and dietitians are thinking about it the wrong way. The observable fact is that when carbohydrates are available in our diet, we do use them for fuel and we use them first.
That’s what “preferred” means.
Most of those who had been mentored in science weren’t particularly good at it. They didn’t understand what it meant to be skeptical of their own ideas and so to check and triple- check their assumptions. (“The first principle” of science, as the Nobel laureate physicist Richard Feynman put it so aptly, “is that you must not fool yourself and you’re the easiest person to fool.”)
If that ain’t the pot calling the kettle black, I don’t know what is.
Taubes continues to discuss the merits of LCFH diets, because, well, that’s what the book is about. He mentions a pediatrician named James Sidbury on page 118:
Sidbury knew that carbohydrates stimulate insulin and insulin facilitates fat formation and traps fat in fat tissues. He also knew, as he noted in a 1975 book chapter on this work, that kids with obesity crave carbohydrate- rich foods— “crackers, potato chips, french fries, cookies, soft drinks, and the like.” Restrict the carbohydrates and feed these kids only fat and protein, he reasoned, and their insulin would come down, and their fat metabolism would work as it does in lean kids. These children would burn their stored fat and lose weight without obsessive hunger and without constantly grazing on carbohydrates. He instructed parents to feed their children with obesity only 300 to 700 calories a day, made up of virtually all protein and fat. The kids lost weight as if by magic.
Funny how Taubes attributes all this magic weight loss to lack of carbohydrates and not to the extremely low calories. (16) Abracadabra!
Another example of this thinking also dates to the 1970s and comes from George Blackburn and Bruce Bistrian at Harvard Medical School. Bistrian and Blackburn developed what they called a “protein-sparing modified fast” to treat patients with obesity: 650 to 800 calories a day of nothing but lean fish, meat, and fowl. It had effectively no carbohydrates, making it a ketogenic diet, albeit a very low-calorie version. Bistrian and Blackburn prescribed the diet to thousands of patients, as Bistrian told me when I interviewed him in January 2003, and half of them lost at least forty pounds.
It’s wild how these ketogenic diets are very effective as long as they are very low calorie. But calories don’t matter of course because Taubes tells us so.
I’ve accused Taubes before of having it both ways in the most promiscuous manner. It is true in his other books like it’s true in this one. In chapter 11 he states that exercise doesn’t work, but if it does work it’s only because exercising is like being on a ketogenic diet:
I haven’t discussed exercise in this book in part because precious little evidence exists to suggest that we can lose any meaningful amount of fat and keep it off merely by increasing the amount of energy we expend through exercise or physical activity. We all may know people, though, who swear they lost weight merely by upping their workouts or returning to them after a lengthy absence. If that’s true, then the physical activity had to increase the length of time their insulin levels stayed under the threshold for mobilizing fat.
It’s not just about exercise, though. He also says that if low calorie diets happen to work for some people, it’s only because they restrict carbohydrates. Fasting type diets? They’re ketogenic, too, of course.
He loves to have it both ways in his rhetoric. Throughout the text Taubes denigrates so-called experts and nutritional authorities. He treats them with such contempt. His rhetoric is very anti-establishment and treats any author or nutrition researcher as just another pezzonovante. Yet when he wants to quote someone that ostensibly supports his ideas, they are introduced reverently often as a “leading authority” with a list of their bona fides and pedigree. (But when looking at what this person actually wrote, it’s usually clear his/her work doesn’t totally support Taubes’s ideas.)
He cites studies that support his ideas, but also says that other studies are most likely wrong. (“The best reason to ignore the latest study results, the latest media reports suggesting we should eat this and not that, is that the interpretation of these latest studies is most likely wrong.”)
After my 2002 article suggesting that Atkins was right all along, I was accused of taking a contrarian perspective not because I really thought the evidence supported it, but because it was more newsworthy and would earn me a large book contract. Reporting that the conventional wisdom was indeed right would not. The editors of The New York Times Magazine might not have even published such a version because it wouldn’t have been news.
What’s interesting is that he doesn’t even argue against this notion. He just states it. And I would have to agree with him here. It’s much less likely that a longform article about how eating a plant based diet is usually pretty healthy and backed by evidence would have been published and led to a major seven-figure book deal.
Taubes wrote “What if it’s all been a Big Fat Lie?” Tell you what, I’ll pitch an article titled “What if You Already Know Pretty Much what a Healthy Diet Is?” to the New York Times and see if they bite.
A few years back I was working in a manufacturing plant. My boss was a smoker and one day when he was talking to me he excused himself to go outside and have a cigarette. And because I am was a smug prick I said “You know smoking takes years off your life, right?” He jokingly replied “Yeah, the worst years. It’s the ones at the end! It’s the wheelchair, kidney dialysis, adult diaper years. I don’t want that.” He was paraphrasing a Denis Leary bit.
Gary Taubes must have heard that bit, too, but instead of thinking it was a joke he must have thought it was a great argument for shortening your life because he makes that argument earnestly in chapter 12. He mentions that some “experts” claim that LCHF diets are bad for you and can shorten your life. His response is basically “So What? Do you really want to live a few more years in your nineties?” He even likens avoiding saturated fat to rearranging the deck chairs on the Titanic. We’re all gonna die anyway, so who cares? Live it up! (17)
Page 151-152 Taubes mentions the article he wrote in 2002, claiming he was right all along:
In my [NYT] article, I noted that five clinical trials had recently been completed (albeit not yet published) comparing the LCHF/ketogenic Atkins diet to the kind of low-fat, calorie-restricted (semistarvation) diet recommended then and still by the American Heart Association. The trial participants ranged from overweight adolescents in Long Island, who followed the diets for twelve weeks, to Philadelphia adults weight averaged 295 pounds and who followed these diets for six months. The results of those five studies were consistent. The participants eating the LCHF/ketogenic high-fat diet lost more weight, despite the advice to eat to satiety, than those who ate the AHA recommended low-fat, low-saturated-fat diet. Moreover, their heart disease risk factors showed greater improvement.
A few things:
- Taubes provides no evidence that the AHA recommends a low-fat, semistarvation diet, because there isn’t any. Read the org’s own nutrition recommendations yourself.
- The results of the trials Taubes cites were not consistent and they did not all show greater improvement in heart disease risk factors.
- For example, one study he cites by Foster et al., showed no significant differences in weight loss (low fat vs low carb) after one year. (18) That same study had mixed effects on risk factors. Comparatively, HDL was increased and triglycerides decreased in the low carb group (an improvement), but the LDL and total cholesterol were both increased (the opposite of greater improvement).
Figure 1 From the Foster Study
- Additionally, two of the authors Taubes cites here (Brehm and Yancy) author a meta-analysis of low carb vs low fat diets a couple years later, and their findings show that it’s not all roses for low carb diets. (19) They show that at 6 months weight loss is greater on low carb, but at one year weight loss in the same. Moreover, some heart disease risk factors (like total cholesterol and LDL) show greater improvement on low fat diets, while HDL and triglycerides show greater improvement on low carb. Also, weight loss favors low carb in the short term, but after a year there is no difference between the diets. Basically, the results from several trials mirror the results of the Foster trial described above.
The following piece is almost not worthy of inclusion, but I wanted to say a couple things about it anyway. On pages 152-153 Taubes discusses a study by Dr. Sarah Hallberg that got quite a bit of positive attention from the low-carb community a couple years ago. (20) Probably because Hallberg and two other authors, Steve Phinney and Jeff Volek, are part of the low-carb money-making ecosystem.
The study in question compares a group of obese diabetics following a low-carb, ketogenic diet to another obese group following no prescribed diet. Turns out the group that followed a diet lost weight, and with that weight loss some other benefits were gained as well, like improved insulin sensitivity, blood pressure, and other risk factors. Taubes evidently finds these results “particularly compelling” and the study is reinforcement of Taubes’s thesis that ketogenic diets can cure diabetes.
But in my humble opinion, there is nothing noteworthy about the results. I say this because pretty much any diet that results in an obese person losing a significant amount of weight will lead to those outcomes. This trial didn’t compare low carb to another diet, but other studies have done this before. Weight loss from low-carb or low-fat diets produce the same improvement in insulin sensitivity. (21) In fact, it doesn’t seem to matter much how you lose the weight (diet, physical activity, weight loss drugs, bariatric surgery) because they all will improve insulin sensitivity, with greater weight loss producing greater glucose control. (22) In other words, there is nothing uniquely beneficial to following a keto diet in this respect.
Back in the salad days of Good Calories, Bad Calories, Taubes blatantly lies about the results of a Cochrane review:
In 2001, the Cochrane Collaboration published a review of “reduced or modified dietary fat for preventing cardiovascular disease.” The authors combed the literature for all possibly relevant studies and identified twenty seven that were performed with sufficient controls and rigor to be considered meaningful. These trials encompassed some ten thousand subjects followed for an average of three years each. The review concluded that the diets, whether low-fat or cholesterol-lowering, had no effect on longevity and not even a “significant effect on cardiovascular events.”
The lie was that the review he cited actually stated a significant risk reduction in cardiovascular events. (23) Here in TCFK he does much the same thing but is not quite as blatant about it. He cites a more recent version of essentially the same Cochrane analysis:
Now, thirty years later, the most recent unbiased review of this evidence—from the Cochrane Collaboration, an international organization founded to do such impartial reviews— concluded that clinical trials have failed to demonstrate any meaningful benefit from eating low-fat diets and so, implicitly, any harm from eating fat-rich foods.
Not at all what the review says, primarily because the review does not examine low fat diets. It does, however, examine replacing saturated fats with unsaturated fats and finds a significant benefit from doing so. (24)
Another pretty obvious lie that can be easily verified are the statements made that there has been no clinical trial evidence that fruits and vegetables and such are good for you. It’s just something we collectively decided to believe despite zero evidence. Page 157:
As for the idea that a healthy diet must be mostly plants, that it must include fruits, vegetables, whole grains, pulses, and legumes, we don’t have even the ambiguous 1960s- era studies to support it. We have no meaningful clinical trial evidence to support this idea, as Michael Pollan infers in In Defense of Food, the book that brought us the mantra “Eat food. Not too much. Mostly plants.”
Emphasis mine. This statement is pretty egregious. You can do what I just did and go to PubMed, type in “plant based diet” and filter results to only show randomized clinical trials. I got 521 results.
Moreover, these results are not demonstrating how plant-based diets promote ill health, quite the opposite. The first result is a trial that concludes those that followed a plant-based diet (ad libitum consumption of “whole grains, legumes, vegetables and fruits”) resulted in “significant improvements in BMI, cholesterol and other risk factors.” If you’d rather use the search terms vegetarian diet, you get 216 results.
The only thing that Taubes can use to defend his use of that claim is the adjective “meaningful,” but only if he wants to claim that literally all of the trails that were conducted were personally meaningless to him for some reason.
Taubes even tries to argue that salt does not lead to hypertension, it’s actually insulin because insulin must be the cause of all human’s chronic diseases, I guess. Page 164:
By the mid- 1990s diabetes textbooks, such as Joslin’s Diabetes Mellitus, described chronically elevated levels of insulin as likely to be “the major pathogenic defect initiating the hypertensive process” in patients with type 2 diabetes.
Not surprisingly, Taubes takes this quote waaaay out of context, such that he changes it’s intended meaning. Here’s the full quote:
Should hyperinsulinemia be the major pathogenetic defect in initiating the hypertensive process in patients with NIDDM, it is unlikely that it sustains the hypertension indefinitely. (25)
He also mixes up the words pathogenic and pathogenetic.
Some of this stuff I don’t even know how to respond to it. Sometimes he sounds like an alien. Page 167:
Eating abundant fruits and vegetables, as a recent New York Times article said, “can promote health,” as though these foods contain indispensable ingredients that work to make us healthy and keep us healthy. By this logic, the more fruits and vegetables in a diet, the better.
Ummm…. Yeah. Yep.
At the end of chapter 12 Taubes actually brings up the climate change problem, but only briefly. His position is basically the following: Does eating animals contribute to climate change? Probably. But can we really know for sure? No, we can’t. So just go ahead and eat the cows. He doesn’t do the least bit of effort to actually investigate or evaluate the science. I imagine that is because he has done so and the results are not favorable to his keto diet promotion, therefore he pretends like it’s unknowable.
Much of the remainder of the book is devoted to unsourced and unverified anecdotes, testimonials, and claims from low-carb proponents that it really works for me! Or It really works for my patients! One example is Sean Bourke, a physician who owned a chain of for-profit weight loss clinics:
Bourke, a Yale- educated emergency medicine physician, is the cofounder of the dozen JumpstartMD clinics in the San Francisco Bay Area. He told me that some fifty thousand patients had come to these clinics looking for advice on controlling their weight since he opened the first one in January 2007. This is, in effect, his clinical experience. (With his JumpstartMD colleagues and a collaborator at the Lawrence Berkeley National Laboratory, Bourke recently published a paper in the Journal of Obesity on the results from over 24,000 of these patients, for whom he had complete clinical data.
The paper is not cited, but I believe I have found it and want to note a couple things: there is not data from over 24,000 patients included, the diets are explicitly low-calorie (spoiler: that’s the real weight loss sauce, not the ratio of carbs to fat), and the attrition rate is pretty high. Half the patients drop out at 6 months and about 2/3rds are gone after one year. I thought that adherence to LCHF was supposed to be easier.
Based on the evidence presented here, I really can’t recommend this book. Maybe I’m just dumb, but I don’t understand why you couldn’t write a fact-based book that advocates for low carb diets. For instance, you could honestly make evidenced-based arguments like Low-carb diets have proven to be an effective strategy to reduce caloric intake for many people. If you couple that diet with some daily or semi-daily physical activity, that’s a successful way to lose wight. But instead we’re treated with all kinds of nonsense from this book like there’s a big conspiracy among the scientific elite to keep you fat and unhealthy, calories don’t matter, exercise is ineffective, insulin is the root of all evil, animal-based diets are healthy, and don’t worry about climate change.
If you really wanted to read these arguments for yourself then my advice would be just to borrow Good Calories, Bad Calories from your local library or buy a used copy. All the same arguments are made there and all the same studies are cited as well. There’s very little new that’s in TCFK. The main thing is that Taubes has historically bristled at being referred to as an author of diets books, but now he seems to have fully embraced it.
1. Astwood EB. The Heritage of Corpulence. Endocrinology [Internet]. 1962 Aug;71(2):337–41. Available from: https://academic.oup.com/endo/article-lookup/doi/10.1210/endo-71-2-337
2. Bruch H. Eating disorders; obesity, anorexia nervosa, and the person within. [Internet]. New York,; 1973 [cited 2020 Dec 9]. Available from: http://hdl.handle.net/2027/mdp.39015000282544
3. Bruch H, Touraine G. Obesity in Childhood: V. The Family Frame of Obese Children. Psychosom Med [Internet]. 1940 Apr;2(2):141–206. Available from: http://www.psychosomaticmedicine.org/content/2/2/141.abstract
4. Passmore R, Swindells YE. Observations on the respiratory quotients and weight gain of man after eating large quantities of carbohydrate. Br J Nutr [Internet]. 1963;17:331–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14045336
5. DuBois EF. Basal metabolism in health and disease [Internet]. Philadelphia: Lea & Febiger; 1936. p. 494 p. Available from: file://catalog.hathitrust.org/Record/002076603
6. Mayer J. Overweight: Causes, Cost, and Control [Internet]. Englewood Cliffs, New Jersey: Prentice-Hall; 1968 [cited 2020 Dec 28]. Available from: https://books.google.com/books/about/Overweight_causes_cost_and_control.html?id=4bRktQEACAAJ
7. Rosenbaum R. The great Ivy League nude posture photo scandal. New York Times [Internet]. Late Editi. 1995 Jan 15; Available from: https://www.proquest.com/newspapers/great-ivy-league-nude-posture-photo-scandal/docview/430004640/se-2?accountid=14784
8. Vertinsky P. Embodying Normalcy: Anthropometry and the Long Arm of William H. Sheldon’s Somatotyping Project. J Sport Hist [Internet]. 2002 [cited 2020 Dec 16];29(1):95–133. Available from: https://www-jstor-org.offcampus.lib.washington.edu/stable/43610055?sid=primo&seq=1#metadata_info_tab_contents
9. Sheldon WH. The varieties of temperament: A psychology of constitutional differences. [Internet]. New York and London: Harper and Brothers; 1942 [cited 2013 Jul 9]. Available from: http://archive.org/details/TheVarietiesOfTemperamentAPsychologyOfConstitutionalDifferences
10. Wilder RM. The Management of Obesity. J Am Diet Assoc. 1930;6(2):91–100.
11. Wertheimer E, Shapiro B. THE PHYSIOLOGY OF ADIPOSE TISSUE. Physiol Rev [Internet]. 1948 Oct 1;28(4):451–64. Available from: http://physrev.physiology.org/content/28/4/451.short
12. Wilder RM. The Treatment of Obesity. Int Clin [Internet]. 1933 [cited 2020 Dec 30];4(43):1–21. Available from: https://babel.hathitrust.org/cgi/pt?id=mdp.39015070332682&view=1up&seq=17&q1=remarkable
13. Greene R. The Practice of Endocrinology [Internet]. Philadelphia: Lippincott; 1951 [cited 2020 Dec 30]. Available from: https://catalog.hathitrust.org/Record/001580458
14. Bray G, editor. Obesity in Perspective. Vol 2 [Internet]. Washington: U.S. Govt. Print. Off; 1975. Available from: https://catalog.hathitrust.org/Record/000040052
15. Gay R. Hunger: A Memoir of (My) Body [Internet]. Harper Perennial; 2018 [cited 2021 Jan 1]. Available from: https://www.amazon.com/Hunger-Memoir-Body-Roxane-Gay/dp/0062420712
16. The diet is 300 daily calories up to age 8, 500 to puberty, and 700 after puberty. That’s really low. That’s less calories than my infant son drinks in formula every day. But weight is lost “as if by magic.” Truly this is sorcery.
17. He contentedly quotes another physician that prescribes LCHF diets who says her patients tell her “I don’t care if I die in ten years, I feel like crap today, I want to stop feeling like crap today.”
18. Foster GD, Wyatt HR, Hill JO, McGuckin BG, Brill C, Mohammed BS, et al. A Randomized Trial of a Low-Carbohydrate Diet for Obesity. N Engl J Med [Internet]. 2003 [cited 2013 Jun 9];348(21):2082–90. Available from: http://www.nejm.org/doi/full/10.1056/NEJMoa022207
19. Nordmann AJ, Nordmann A, Briel M, Keller U, Yancy Jr WS, Brehm BJ, et al. Effects of low-carbohydrate vs low-fat diets on weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials. Arch Intern Med [Internet]. 2006 [cited 2013 Mar 2];166(3):285. Available from: http://archinte.ama-assn.org/cgi/reprint/166/3/285.pdf
20. Hallberg SJ, McKenzie AL, Williams PT, Bhanpuri NH, Peters AL, Campbell WW, et al. Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study. Diabetes Ther [Internet]. 2018;9(2):583–612. Available from: https://doi.org/10.1007/s13300-018-0373-9
21. Bradley U, Spence M, Courtney CH, McKinley MC, Ennis CN, McCance DR, et al. Low-fat versus low-carbohydrate weight reduction diets – Effects on weight loss, insulin resistance, and cardiovascular risk: A randomized control trial. Diabetes. 2009;58(12):2741–8.
22. Grams J, Garvey WT. Weight Loss and the Prevention and Treatment of Type 2 Diabetes Using Lifestyle Therapy, Pharmacotherapy, and Bariatric Surgery: Mechanisms of Action. Curr Obes Rep. 2015;4(2):287–302.
23. Hooper L, Summerbell CD, Higgins JP, Thompson RL, Clements G, Capps N, et al. Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane Database Syst Rev [Internet]. 2001;(3):CD002137. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11687015
24. Hooper L, Martin N, Abdelhamid A, Davey Smith G. Reduction in saturated fat intake for cardiovascular disease. Cochrane database Syst Rev [Internet]. 2015 Jun 10;(6):CD011737. Available from: http://doi.wiley.com/10.1002/14651858.CD011737
25. Christlieb AR, Krolewski AS, Warram JH. Hypertension. In: Kahn CR, Weir GC, editors. Joslin’s Diabetes Mellitus. 13th ed. Philadelphia: Lippincott Williams & Wilkins; 1994. p. 817–35.