Comment on Guyenet vs. Taubes; or Why I Don't Give a Crap What the Kitavans Eat

This post started as a comment to Stephan Guyenet's excellent post on the carbohydrate hypothesis of obesity, got too long, and so I'm putting it here. Do read Stephan's post, and keep an open mind. It's got loads of interesting and cutting-edge science, and this sort of debate and information exchange is how science progresses. If you find yourself experiencing cognitive dissonance, remember that absolute belief is antithetical to science. We always must update our beliefs as new information emerges.

Short summary of Stephan's blog post: the hypothesis that carbohydrates in general are fattening is probably over-simplified and does not reflect the most recent scientific understanding of metabolic regulation. It also leads one into a variety of paradoxes, a la the "French Paradox" of the diet-heart hypothesis.

I think part of what we're seeing here is the rather poor taxonomy of nutrition. We discuss things in terms of macronutrients, but those macronutrients come with (or without) all kinds of other metabolically relevant substances. And even within a given macronutrient group there can be significant metabolic differences, e.g. for fatty acids of different chain lengths, or between glucose and fructose (though Dr. Feinman might have something to say about the latter).

I've posted here before on my favorite example of this, and it seems like a good time to revisit (working from memory and about 4 hours of sleep, so please correct me if necessary). The Aztecs had a corn-based diet. They did experience obesity, but despite documenting a wide variety of health issues in detail never described diabetes. The Egyptians ate a wheat-based diet, also experienced obesity (along with heart disease, cancer, and the whole host of other fun "diseases of civilization"), and did document diabetes. Two high-carb diets, both resulting in some level of obesity, but from what we can tell (thousands of years later), both having radically different metabolic endpoints.

Two take-home points here. First is that we likely need to consider a broader dietary context than that imposed by our artificial macronutrient classification scheme, i.e. wheat and corn both provide primarily carbohydrates as energy, but probably do not have the same metabolic effects, particularly when considering over the timescale of a human life. Second, obesity is a symptom. A given symptom may result from multiple underlying conditions. We need to focus the discussion on more specific pathologies than just "obesity".

In the US and many other Westernized countries, one can take a look around and do a "liver check". How many people do you see with a protruding pot belly as opposed to a general body-wide distribution of fat? Most people I see have the big belly, sometimes even being very lean elsewhere (particularly in the arms and legs); there are a few "Rubinesque" figures as well, but the pot bellies seem to be running away with the obesity stakes. The big belly is indicative of fatty liver. Considering how central the liver is in metabolic regulation, it should come as no surprise that an inflamed fatty liver could lead to a whole host of metabolic disturbances: obesity, abnormal lipid profile, elevated blood sugar, elevated insulin, etc. In other words, metabolic syndrome.

I would argue that the rapidly growing health problem is not simply obesity, but metabolic syndrome (remember obesity is only one symptom, and there are thin people with metabolic syndrome too). We want to understand both how we arrive at metabolic syndrome (so our children can avoid it), and also how to treat it for those who did not avoid it. It is clear "carbohydrates" across the board are not causal in the development of metabolic syndrome. Stephan provides several counter-examples; another is the Tarahumara, who like the old-school Pima subsist largely on corn, beans, and squash, but who have one of the lowest rates of Type 2 diabetes in the world.

But the cure is not necessarily the reverse of the cause when it comes to disease. Metabolic syndrome brings a whole host of issues, not the least of which is broken carbohydrate metabolism. So while carbs in general may not lead to metabolic syndrome, once you've arrived dumping carbohydrates on your broken carbohydrate metabolism is tantamount to doing jumping jacks on two broken legs. I believe the science (along with a massive stack of anecdotal evidence) is pretty clear here, in that the most successful treatment for metabolic syndrome is carbohydrate restriction.

So while yes, Virginia, the Kitavans eat a very high-carbohydrate diet and exhibit general metabolic health, for my personal dietary choices I don't really give a crap. The Kitavans have healthy carbohydrate metabolisms, but I don't (prior to going low carb I had a trophy beer gut, which in retrospect was my liver telling me "You're killing me slowly"). If you look down toward your feet and can see only your protruding liver, you might consider trading in the bagels for bacon (better yet, get yourself a blood glucose meter and check your post-bagel blood sugar - it might frighten you). It is important to remember that carbohydrate restriction is successful as a treatment for a disease, but it doesn't necessarily follow that all carbs are bad for everybody. We have several examples of cultures who thrive on diets of lean protein and whole food sources of carbohydrate, like starchy tubers and fruit. We also have examples of cultures thriving largely on protein and fat. Humans appear to have a remarkable ability to survive as omnivores eating whole foods, which in no small part explains why we are one of the most widely spread species on the planet. So if you have a healthy metabolism, you probably can choose from a wide variety of whole foods (and by "whole food" I mean something you could plausibly obtain from Nature without the aid of much more technology than fire and a sharp stick). Once your metabolism is broken, you will likely need to make some choices to avoid those things which, due to your disease state, have become effectively toxic. In other words, make your nutritional choices based on actual knowledge of metabolism and your own state of health rather than picking a buzz-phrase and applying it blindly.

And for God's sake, stop eating wheat ;-)