Calories? Again? Already?

Are we not sick of this subject already?

There have been some excellent articles and lots of “food for thought” on this topic recently.

Robb Dunn did a guest post at Scientific American about “The Hidden Truths About Calories,” which—to summarize in a way that does no justice to the article at all—basically boils down to the fact that most of the hidden truths about calories are so hidden we simply don’t know much about them at all. (I second this: Why Calories Count Fo’ Shizzle.)

Go Kaleo has a great post on this topic called “Putting the (Calorie) Pieces Together.” 

And Regina Wilshire has a puzzle for us at Weight of the Evidence called “Working Through A Stall.” 

Sooooooo – do calories in general matter, or is only the “kinds” of calories (i.e. the “good” kind vs the “bad” kind) that matter?

I think Go Kaleo said it very well: “All that black and white thinking has got people believing a false dilemma: It’s EITHER ‘calories in vs. calories out’ OR ‘the kind of calories you eat’ that matters!” She’s right in saying that it is a false dichotomy.

Neither approach comes close to acknowledging the complex interplay of factors that is human metabolism. I’m down on the calories in/calories out paradigm because it is so limited in scope, but I am equally down on any paradigm that says they don’t matter at all.

There are far too many unknowns about how the energy content of the food we eat interacts with the energy needs of our bodies to insist upon a singular health-maintenance paradigm based on “calories in, calories out.” At the same time, there are far too many unknowns about insulin metabolism (we currently don’t even have agreed-upon ways to measure and discuss insulin dysregulation) to create a new singular health-maintenance paradigm based on “fat in, carbohydrates out.”

One thing that complicates the picture is that we equate the metabolic situation that causes fat gain with the metabolic situation that will induce fat loss. My understanding of the biochemistry is that there are two necessary aspects to weight gain: excess calories to store (although we seldom know how to measure or even estimate what we mean by “excess”) and the insulin signal that provides the mechanism for storage to take place. Remove one of these factors—again with the caveat that we have a limited understanding of what “excess calories” means—and you won’t have weight gain.

Weight loss may be a different matter entirely. For weight loss to take place, we have to figure out NOT ONLY how to not create a metabolic situation where these two factors are at play, we also have to figure out how to convince our body to reverse the fat-storage process. This may involve processes which go beyond just one eliminating insulin-stimulating carbohydrate foods because—unless someone has Type 1 diabetes—some basal levels of insulin (and we may or may not know what they are or if they are “normal” or how that matters) are always present. This may also involve processes which go beyond just eliminating “excess” calories because, as I hope I’ve made clear, we don’t really even know what that means.

Some people can reduce overall calorie intake and lose weight (this usually also involves a lowering of carbohydrate foods that stimulate insulin release) ; some people can just reduce their carbohydrate food intake  and lose weight (this usually also involves lowering calories available for storage); some people have to do both–deliberately and carefully—in order to lose weight. The trick is how to do this without

  1. inducing willpower-withering hunger pangs
  2. depriving the body of essential nutrition
  3. creating other metabolically-unfortunate side effects/consequences.

The answer will not be the same for everyone. Reducing the number of nutritionally-empty carbohydrates gets at both the calorie and the carbohydrate issue–so that’s sort of a no-brainer, but carbs and calories are not all that matter.

Like what?

Metabolism matters. Nourishment matters. Information signaling—provided by your body’s encounters with the environment, including food encounters–matters.

Do calories affect these things? YES!!! Do carbs affect these things? YES!!! Are there about a bazillion other things that affect these things? YES!!!

When the clinic doors at the Duke Lifestyle Medicine Clinic open, the first two patients through those doors were both very much alike and radically different.

Both were “obese” adult white males, but that’s about where the resemblance ended. One gentleman, who was almost as big around as he was tall, was actually pretty healthy. Most, if not all, of what we think of as meaningful or predictive health biomarkers (blood pressure, cholesterol, glucose, etc) were normal. His problems were primarily orthopedic; i.e. his weight was impacting his hip and knee joints.

The other gentleman was far less obese, but his weight (as you may guess) was concentrated in his abdomen, his predictive health biomarkers were in the toilet, and he had a bag of prescriptions meant to normalize those biomarkers to prove it.

I (now) think of the first gentleman as having “simple” obesity and the second gentleman as having “metabolic” obesity. Such fat patterning has also been referred to as gynoid obesity (“pear”) and android (“apple”) obesity, and the different health consequences of each have been recognized, but even these differences are over-simplified concepts.

Android obesity (Gentleman #2) has been associated with excess insulin and with more metabolic derangement than gynoid obesity. It has been fairly well explained at this point that, aside from its role as a fat storage mechanism, excess insulin causes other metabolic problems.*

Is gynoid obesity (Gentleman #1) primarily associated with “excess” calories or “excess” storage of calories, rather than insulin dysregulation? We don’t know. Can “excess” calories cause other problems besides those leading to fat storage? We don’t know that either. One of the problems with asking these questions is—again—how we define “excess.”

Either way, the next step is to recognize that how we address different types of obesity may also need to be different. One type of obesity may be best addressed by a focus on reducing carbohydrate intake. The other type could be addressed by a focus on decreasing calories in and increasing calories out—however you want to do that. (As above, either approach involves some aspects of the other.)

But even differentiating dietary approaches based on fat-patterning must acknowledge that if there is a spectrum—with simple obesity on one end and metabolic obesity on the other—that any individual can be located anywhere along that spectrum and thus a combination of approaches would have to be used to address the needs of the individual, which may need to go beyond both carbs and calories.

It is crucial to remember that our bodies not really designed to either “gain”or “lose” weight, but to respond to our environment by small shifts in– up-regulating and down-regulating—the production of proteins, enzymes, and other biomolecules to meet the pressures of the environment. We are adapted to adapt. Food is one of the primary signals our bodies get about our environment. Food lets the body know what the conditions are like “out there” so that we can make appropriate adjustments “in here.” These adjustments, we know now, can be passed on from one generation to the next, so that our offspring are also prepared for what is “out there.”

What the body is looking for—all the time, without exception—is essential nourishment and adequate energy (and again our definition of “adequate” is as problematic as our definition of “excess”).  Note to paleo-thinking readers:  the origins of the paleo diet emphasize acquiring essential nutrition, rather than forbidding non-essential foods. This point may be the most important aspect of ancestral nutrition. (And thanks to Katherine Morrison for calling this to my attention.)

An eating pattern that conveys to our body that the environment is lacking in either of these things is going to result in metabolic adjustments to this information. What the adjustment looks like is going to depend on genetic factors (What food environment were your ancestors adapted to?), and epigenetic factors (Did you have an adequately-nourished mom?), and previous adaptive adjustments (Does your body regularly have to respond to caloric highs or lows? to regular bouts of intense energy expenditure? to reduced nutrition?), in addition to those other bazillion things we don’t know about yet.

So what are we going to do about it? I am so glad you asked. I’ve been trying to work my way to a blog post about n of 1, or individualized nutrition, for weeks now. I think I’m about there.

*See the work of Gerald Reaven and Wenhong Cao, for example.

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8 comments on “Calories? Again? Already?

  1. […] Calories? Again? Already? […]

  2. Ryan M says:

    Hello,
    I found this post via CarbSane, she mentioned this quote:
    “the origins of the paleo diet emphasize acquiring essential nutrition, rather than forbidding non-essential foods.”
    I totally agree. Given my interest in the subject, I couldn’t help but be charmed by yet another post about calories. I’m a student with no clinical experience, but I feel that I’ve summed up my opinions about the calorie issue with a series of blog posts, the most recent being perhaps the most comprehensive. I’d be happy to hear what you think.

    http://fitness-chronicles.posterous.com/insulin-and-fat-loss

    -Ryan

    • Adele Hite, RD MPH says:

      Thanks, I liked your posts, although I can’t agree that it’s all about calories any more than it is all about carbs. I’ve seen some young obese males–sedentary non-atheletes–lose weight and % body fat eating a ridiculous amount of low-carbohydrate calories. I have a young non-obese male in my house who is a sedentary non-athelete who eats a ridiculous amount of all kinds of calories (carbohydrate and otherwise) and does not gain weight–at least not yet. I will agree that “insulin” can’t solely responsible for the obesity crisis (insulin has been around even longer than MTV). At this point, I would say that it’s looking rather likely that poor policymaking is responsible for the obesity crisis, but even that is just a part of the causal puzzle–albeit a large & likely influential one. Did we increase our calorie intake in the last 30 years? Yes, but we don’t know why. Did most of that increase come from carbs? Yes, but we don’t know why. Are we more sedentary than we were 30 years ago? Maybe, maybe not–good long term data on this is simply not available. If we are more sedentary, we don’t have a good explanation why (no it’s not cars, TV, computers, etc.); if we’re less sedentary, that may help explain the calorie increase :)

      I really try to avoid PubMed duels with anyone. I will caution you about taking anyone’s description of a study–including mine and including Stephan Guyenet’s, who is a terrific fellow (he brought his mom to see him give a talk at Harvard Food Law TEDx–how precious is that?). He mentions an Astrup et al 2000 meta-analysis that looks at 19 ad lib low-fat diets, and is used to argue that low-fat (as well as low-carb) dieters spontaneously reduce caloric intake. How the authors squeeze the info that Stephan quotes out of that analysis is somewhat beyond me. Only 11 of the 19 studies report total energy intake, and the authors apparently use weight “change” (rather than loss, which are very different if the diet is not being studied for weight loss purposes, which was most of them) to arrive at their 3.2 kg difference between intervention and control groups. It looks suspiciously to me like Stephan only read the abstract, never a good idea, and it looks suspiciously like you read his quote of the abstract without thinking, hmmmm, how could this be, knowing what I know about biochemistry? The meta-analysis did not look at energy expenditure, lean vs. fat mass loss, and other things (hunger?) that might be worth knowing about before concluding that low-fat and low-carb diets work about the same way (I’m not saying they both don’t create weight loss, but how this weight loss looks when you examine the messy details may not be the same). Astrup is also the guy who famously explained that the reason for spontaneous calorie reduction during low-carb diets is the diet’s “monotony and simplicity.” Wouldn’t this also apply to low-fat diets? (Ahh, that’s why we have Snackwells!) It helps to know a little about Astrup’s history (lots of connections to food and pharma) and that his current stance is that “a calorie is NOT a calorie” because protein calories are more satiating. I am not saying he’s a bad scientist or that he creates bad science; I don’t know any bad scientists. I’m just saying that science is not created in a vacuum, and it helps sometimes to be aware of context. Which brings me back to Stephan: he’s a young guy in the field, seems really bright to me (and loves his mom, which means I personally am going to cut him all kinds of slack!). His name is not going to get made saying–oh yeah, I agree with what all them guys are saying. He’s going to get heard by disagreeing with some of the alpha males (Gary Taubes in particular). That’s good for him and good for Gary too. It’ll help keep them both honest, I hope. Just know that he has a case to make, just like Gary did, just like Ancel Keys did. Your job is to fact check them all.

  3. Kenny says:

    Hi Adele,

    I am curious about the education and training that RDs get about calories. Do they ever learn the true intricacies and history of nutrition science as it relates to calories?

    For instance, does any part of the RD curriculum ever touch upon the complexities outlined in great detail here,

    CHAPTER 3: CALCULATION OF THE ENERGY CONTENT OF FOODS – ENERGY CONVERSION FACTORS

    http://www.fao.org/docrep/006/Y5022E/y5022e04.htm

    FAO FOOD AND NUTRITION PAPER 77
    Food energy – methods of analysis and conversion factors
    Report of a Technical Workshop, Rome, 3-6 December 2002

    • Adele Hite, RD MPH says:

      No, RDs don’t learn much about the complexities of diet in general, unless we are talking about specialized clinical nutrition. Even in my PhD program, we do not explore the history of the field of nutrition, which is odd, because it is a fairly young science (i.e. we wouldn’t have to spend all that much time doing it, but right now we spend zero time) and there are controversies and issues that have been present from the start. We just never talk about them, at least not at UNC-Chapel Hill.

      • Kenny Gow says:

        Thanks for the answer, a somewhat disappointing reality but not exactly unexpected.

        Sick of reading about calories? Never! (at least not until we get the science right)

        I’ve become a bit of an amateur nutrition scientist in the last few years as I’ve researched the historical origins of calorie counting and the entire energy balance/weight loss paradigm.

        Mind you, I never wanted to learn so much about nutrition, but as a successful low-carber for the past 15 years, how else would I have learned the truth about nutrition? If I had listened to the “experts” early on, I’d have given up and become overweight and diabetic like so many others. Or all the (saturated) fat I ate/eat would have killed me by now for sure.

        I applaud your big thinking in changing the world of nutrition and health policy. I have my own grand ideas about how to get the Dietary Guidelines changed for the better. I often think about the “incalculable damage” that the Dietary Guidelines have done to us for the past 35 years as Gary Taubes wrote about in Why We Get Fat, and Tom Naughton brilliantly highlighted in his ORI speech.

        I found your blog last week and have read through all the posts and enjoyed them for their wide-scope and blue-sky, big-picture thinking combined with the small.

        I’ve got so much to say, I’m afraid it’ll never all fit here. And I haven’t found a Contact page where I can send you a direct message. It feels like I ought to get involved with your Healthy Nation Coalition.

      • Adele Hite, RD MPH says:

        Hi Kenny,

        I really appreciate your enthusiasm about this issue. I apologize for not having more easily-accessible contact info, but you have to understand that as a person who grew up in a time when computers still used punchcards, this whole blogging thing can still be a bit mystifying ;)
        You can email me at adele.hite@gmail.com, or check out our Healthy Nation Coalition website at http://www.forahealthynation.com (a website that could also use a good update). I’d love to hear more about your ideas.

  4. davebrown9 says:

    On aspect of metabolism that probably ought to get more press coverage is gut microbiota. http://www.docstoc.com/docs/30525645/Dieting-with-Microbes-Using-Probiotics-for-Weight-Loss—My-Experience

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