What Caused the Obesity Epidemic
In February this year Cape Town was fortunate to host the Old Mutual Health Summit in the Cape Town Convention Centre. Organized by Karen Thomson it was a monumental success, perhaps one of the best such conferences on the low carbohydrate diet ever staged. Each moment of the Summit, addressed by 12 acknowledged world-leaders in the field, has been carefully captured by Jonno Proudfoot and his team from The Real Meal Revolution. Recently all the lectures we released onto the internet and can be accessed at this http://go.lchfconvention.com/tim-noakeshttp://go.lchfconvention.com/tim-noakes If you access it via this particular link you will get a discount.
Access to the lectures requires a payment to offset the not inconsiderable costs of preparing the lectures for this form of presentation that includes the lectures in both visual form and in text.
One of the stand-out speakers at the Summit was Dr Jason Fung, a renal physician from Toronto, Canada. Dr Fung’s secondary expertise is in the management of obesity and type 2 diabetes with dietary interventions that promote low carbohydrate eating and intermittent fasting. Dr Fung has since completed a book entitled The Obesity Code that is to be released in January 2016. The book is one of the very best in describing exactly what causes obesity and how it can be reversed and more importantly, prevented.
I was honoured to be invited to write the foreword for the book. Predictably I wrote more than the editors could include. So here is my complete tribute to Dr Fung and his book.
I have tried to explain why I think the book is so important in advancing our understanding of what causes obesity and by extension also type 2 diabetes mellitus.
In my opinion we are approaching a tipping point in the global realization that the diet we have promoted for the past 50 years is deeply flawed and is the root cause of much modern ill-health, especially that group of diseases linked to obesity.
We need Dr Fung’s book to feature prominently on the New York Times Best-sellers list in 2016 so that, like the books of Gary Taubes (Good Calories Bad Calories) and Nina Teicholz (The Big Fat Surprise. Why Butter, Meat and Cheese Belong in a Healthy Diet), his book can help speed up the dietary change that we all now know will happen.
The only question is: When?
Foreword for Jason Fung’s book – The Obesity Code.
Dr Jason Fung is a physician specializing in the care of patients with kidney diseases. He practises his speciality in Toronto where his key responsibility is to oversee the complex management of patients with end stage kidney disease requiring renal (kidney) dialysis.
Which does not obviously explain why he should author a book titled The Obesity Code or why he blogs on Intensive Dietary Management (IDM) (of obesity and Type 2 diabetes mellitus (T2DM)). To understand this apparent anomaly, we need first to appreciate who is this man and what makes him so unusual. And so special.
In treating patients with end stage kidney disease, Dr Fung learned two key lessons. First that T2DM is the single commonest cause of kidney failure. Second that renal dialysis is, however sophisticated and even life-prolonging, in truth just treating the final symptoms of an underlying disease that has been present for 20, 30, 40 or perhaps even 50 years. Gradually it dawned on Dr Fung that he was practising medicine exactly as he had been taught – treating reactively the symptoms of apparently complex diseases without first trying to understand or correct their root cause(s).
He realized that to make a difference to his patients, he would have to start by acknowledging a bitter truth: That our venerated profession is no longer interested in addressing the cause(s) of disease. Instead it wastes much of its time and many of its resources attempting to treat the symptoms of disease. His analogy is treating infection by focusing on the fever, whilst ignoring the infection causing the fever.
So he resolved that he was not about to waste his medical life treating symptoms. Instead, if he were to make a real difference to his patients (and his profession), he would need to understand the true causes of those conditions, for the treatment of which patients saught his (presumed) expertise.
Before December 2014 I was unaware of the mortal existence of Dr Jason Fung. Then one day I chanced upon his two lectures – “The Two Big Lies of Type 2 Diabetes” and “How to reverse type 2 diabetes naturally” – on YouTube. As someone with a special interest in T2DM, not least because I have the condition myself, I was naturally intrigued. Who, I thought, is this bright young man? What gives him the certainty that T2DM can be reversed “naturally”? And how can he be brave enough to accuse his noble profession of lying? He will need to present a good argument, I thought.
It took only a few minutes to realize that Dr Fung is not only legitimate but is also more than able to look after himself in any medical scrap. The argument he presented was one that had been bouncing around, unresolved, in my own mind for at least 3 years. But I had never been able to see it with the same clarity or to explain it with the same emphatic simplicity as has Dr Fung. By the end of his two lectures, I knew that I had observed a young master at work. Finally, I understood what I had missed.
For what Dr Fung achieved in those 2 lectures was utterly to destroy the currently popular model for the medical management of T2DM – the model mandated by all the different diabetes associations around the world. Worse, he explained why this erroneous model of treatment must inevitably harm the health of all T2DM patients unfortunate enough to receive it.
As I watched I began to wonder: How does one man realize that what he was taught and that which 99.9% of his colleagues believe to be absolutely true, is the exact opposite – blatantly wrong? I came to realize that Dr Fung has discovered the truth hiding in broad daylight. Then in a final act of courageous defiance, he has made his dissension public.
According to Dr Fung, the first big lie in the management of T2DM is the claim that it is a chronically progressive disease that simply gets worse with time even in those who comply with the best treatments modern medicine can offer. But Dr Fung argues that this is simply not true. For anyone with even a partially open mind has to know that some patients do “reverse” their T2DM; in fact we see it all the time. The condition of gestational diabetes reverses the moment the baby is born whilst both bariatric surgery (which neither I nor Dr Fung advise) and fasting can reverse T2DM. Fifty percent of the patients on Dr Fung’s IDM program that combines dietary carbohydrate restriction and fasting, are able to stop using insulin after a few months.
So why are we unable to acknowledge this? Dr Fung’s answer is simple: We doctors lie to ourselves. Because if T2DM is a curable disease but all our patients are getting worse on the treatments we prescribe, then we must be bad doctors. And since we did not study for so long at such great cost to become bad doctors, this failure cannot be our fault. Instead we must believe we are doing the best for our patients who must unfortunately be suffering from a chronically progressive and incurable disease. It is not a deliberate lie, Dr Fung concludes, but one of Cognitive Dissonance. Which is the inability to accept a blatant truth because accepting the truth would simply be too emotionally devastating.
So to reverse T2DM the medical profession must first rid itself of this Cognitive Dissonance.
The second lie according to Dr Fung is our belief that T2DM is a disease of abnormal blood glucose levels for which the only correct treatment is progressively increasing insulin dosages. But Dr Fung argues that this explanation simply makes no sense.
Instead he argues that T2DM is a disease of insulin resistance with excessive insulin secretion. Whereas in contrast, type 1 diabetes is a condition of true insulin lack. To treat both conditions the same way – injecting insulin – makes no sense. What is the logic of treating a condition of insulin excess with yet more insulin, he asks? That is the equivalent of prescribing alcohol for the treatment of alcoholism.
Dr Fung’s novel contribution is his insight that treatment in T2DM focuses on the symptom of the disease – an elevated blood glucose concentration – rather than its root cause, insulin resistance. And the initial treatment for insulin resistance is to limit the carbohydrate intake. So understanding this simple biology explains why this disease may be reversible in some. And conversely why the modern treatment of T2DM, which does not limit the carbohydrate intake, worsens the outcome.
So how did Dr Fung arrive at all these outrageous conclusions? And how did they lead to his authorship of this book?
First was his realization that the renal failure of the patients he was treating with dialysis did not suddenly arise as if miraculously, overnight. Instead its origins were to be found in decades of incorrectly treated T2DM. Why his primary focus on treating the symptoms of the disease with renal dialysis was illogical. And why the only long term logical solution was to prevent the disease by removing the causative factors that act over many decades.
Then almost by chance, in the early 2000s he became aware of a growing literature of the beneficial effects of low carbohydrate diets in those with obesity and other conditions of insulin resistance. Taught to believe that a carbohydrate-restricted high-fat diet kills, he was shocked to discover the opposite. That this dietary choice produces a range of highly beneficial metabolic outcomes especially in those with the worst insulin resistance. These studies designed, as he writes, “to bury the (high fat) Atkins diet” had instead “crowned it” as the best dietary option, especially for those with insulin resistance.
And finally the cherry on the top – a legion of hidden studies showing that for the reduction of body weight in those with obesity (and insulin resistance), this high-fat diet is at least as effective, and usually much more so, than other more conventional diets.
Eventually he could bear it no longer. If everyone knows (but won’t admit) that the low-fat calorie-restricted diet is utterly ineffective in controlling body weight or in treating obesity, surely it is time to tell the truth – that the best hope for treating and preventing obesity, a disease of insulin resistance and excessive insulin production, must surely be the same low-carbohydrate, high-fat diet used for the management of the ultimate disease of insulin resistance, T2DM. And so this book was born.
In The Obesity Code Dr Fung has produced perhaps the most important popular book yet published on this topic of obesity.
Its strengths are that it is based on an irrefutable biology, the evidence for which is carefully presented; it is written with the ease and confidence of a master communicator, in an accessible and well-reason sequence. So its consecutive chapters systematically develop, layer by layer, an evidence-based biological model of obesity that makes complete sense in its logical simplicity. It includes just enough science to convince the sceptical scientist, but not too much to confuse those without a background in biology. This in itself is a stunning achievement that few science writers ever achieve.
By the end of the book, the careful reader will understand exactly what has caused the obesity epidemic; why our attempts to prevent the obesity and diabetes epidemics were bound to fail and what, more importantly, are the quite simple steps that those with a weight problem need do to reverse their obesity.
Perhaps what impresses me most about Dr Fung’s style of communication is his remarkable capacity to explain with such clarity that which we had previously missed. We are left to wonder: But why did I not see that when it is just so blatantly obvious.
So what caused the obesity epidemic? The answer according to Dr Fung is simple. When we blamed saturated fat for heart disease we had to replace the fat removed from our foods, with carbohydrate. But we have always known that carbohydrates make us fat. So we had to come up with a new theory.
Again there was a simple way out: “The solution was to suggest that carbohydrates were no longer fattening. Instead, calories were fattening”. So we forget the message of Dr Benjamin Spock in his 1946 classic Baby and Child Care: “The amount of plain starchy foods (cereals, breads, potatoes) taken is what determines…how much (weight) they gain or lose”.
Instead we were assured that: “Dietary fat, with its high caloric density, must therefore be bad for weight gain as well (as for heart disease). However there was never any data to support this assumption”.
And so we descended onto the disastrous “calories-in calories-out” (CICO) model of obesity forgetting that Dr Ancel Keys had shown that any calorie-restricted diet produces “semi-starvation neurosis” in which people eating starvation diets “dream about food. They obsess about food. All they can think about is food. Interest in all else diminishes. This behaviour is not some strange affliction of the obese. In fact, it’s entirely hormonally driven and normal. The body, through hunger and satiety signalling, is compelling us to get more food”.
So humans overeat not because it is a “personal choice” but because “it is a hormonally driven behaviour – a natural consequence of increased hunger hormones”.
Why is obesity a time-dependent condition that typically worsens with age? Because our insulin resistance typically deteriorates with age as a result of progressively worsening carbohydrate-driven, insulin-induced, insulin resistance. A key driver of our progressively worsening insulin resistance is that we are now always eating because we are encouraged to eat more: “Now it’s acceptable to eat anywhere. We can eat in the car. We can eat in the movie theatre. We can eat in front of the TV. We can eat in front of the computer. We can eat while walking. We can eat while talking. We can eat in a box. We can eat with a fox. We can eat in a house. We can eat with a mouse. You get the picture”.
“Millions of dollars are spent to give children snacks all day long. Then millions more are spent to combat childhood obesity. These same kids are berated for getting fat. Millions more are spent to fight obesity in adults”.
Is there any end to this lunacy?
And what is our solution: “The first choice in our arsenal was the beloved Eat Less, Move More (ELMM) approach, which sported a record unblemished with success”. Here we learn that 3 separate (and quickly forgotten) multi-million dollar studies of this ELMM intervention have failed spectacularly to prevent childhood obesity. In fact they were without effect. But yet we persist as if repeating the same tired slogans will miraculously produce a different outcome. And all we do is confirm our collective insanity.
But the solution needed is that which Dr Fung has now provided: “Obesity is also a multi-factorial disease. What we need is a framework, a structure, a coherent theory to understand how all its factor 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. Endless debates ensue…They are all partially correct”.
In providing one such coherent framework that can account for most of what we currently know about the real causes of obesity, Dr Fung has provided much, much more.
He has provided a blueprint for the reversal of the greatest medical epidemics facing modern man – epidemics which he shows, are entirely preventable and potentially reversible. But only if we truly understand their biological causes. And not just their symptoms.
The truth he expresses will one day be acknowledged as self-evident.
The sooner that day dawns, the better for us all.
Timothy Noakes OMS, MBChB, MD, DSc, PhD (hc), FACSM, (hon) FFSEM (UK),
University of Cape Town, Cape Town, South Africa