The Case For Keto – Zoe H


This week’s note is about a book. It’s the latest book from Gary Taubes – due to be published on December 29th in the US and on January 7th in the UK. I am fortunate to have received an advance copy and so I’ll share some thoughts and extracts without giving too much away.

I need to declare bias up front. I am a huge fan of Gary. I love how he thinks, and I love how he writes. I’ve seen him present many times and almost every sentence could be tweeted as a stand-alone quotation. On the other hand, I’m not the biggest fan of keto. I think that it is a powerful tool when used in the right way by those who need it. I think it’s often misunderstood, and I think the high fat has been embraced more than the low carb by some people to the detriment of their health and weight goals. I think that many? most? people don’t need to go that far, and it then leaves nowhere left to go. Or rather, it leaves carnivore, which an increasing number of people who have tried keto are turning to.

With this in mind, let’s take a look at The Case For Keto. I’ve included page numbers in case you want to see more on a particular point if/when you get the book, which I obviously think everyone should 😉

Setting the scene

“This book is a work of journalism masquerading as a self-help book.” (p3)

The introduction is so compelling. It comes very much from a practitioner angle – recounting the advice that doctors had been giving their patients (low fat high carb) despite seeing so much evidence that it wasn’t working. It took a few doctors to realise this – and for many it was a personal revelation. When they realised that official diet advice didn’t work for them, they started to question why it would work for their patients. And so, the movement grew, and the introduction captured some really uplifting stories of success. I messaged Eric Westman after reading the introduction and said I’d just read a eulogy to him! Eric really does get the credit he deserves for being the forefather of this present era of low carb high fat (LCHF) (and Eric in turn credits Banting, Pennington, and Atkins – his forerunners).

If the intro was a eulogy to Eric, the first chapter is a eulogy to Edwin Astwood. Taubes describes Astwood as the Tufts University Medical professor who, in 1962, tried and failed to correct how we think about obesity (very much echoing the work of German/Austrian researchers pre WWII, which was lost post WWII). Astwood rejected the ‘gluttony’ theory of obesity. (The Harvard endocrinologist Jean Mayer had said a few years earlier “To attribute obesity to ‘overeating’ is as meaningful as to account for alcoholism by describing it as ‘over-drinking’.” (p23)). As an endocrinologist, Astwood presented obesity as a genetic/hormonal disorder, a fat-storage disorder – emphasising the role of insulin in the accumulation of fat. The established position at the time of Astwood’s challenge was that obesity was caused by an imbalance of energy – too much in and not enough out. That position prevails today – nearly half a century later.

The case against the calorie theory

The early chapters are the case against the calorie theory rather than the case for keto. The style is one of story telling with academic literature intermingled with anecdotes and insights. The book is the readable style of Why We Get Fat and The Case Against Sugar as opposed to the weighty tome of Good Calories Bad Calories.

Building on the Astwood/Austrian-German accumulation of fat model, Gary sets out a compelling alternative view on obesity:

“Fat people are not lean people who eat too much.” (p32)

“The counterargument, which I’m defending is, Astwood’s belief that those who fatten easily are fundamentally, physiologically and metabolically different from those who don’t.” (p44)

“So let’s redefine what we mean by obesity. People with obesity… [are] people whose bodies are trying to accumulate fat even when they’re half-starved. The drive to accumulate fat is the problem, and it’s the difference between the fat and the lean.” (p45)

He reiterates the position that he has held ever more strongly since the research for Good Calories Bad Calories:

“Whether they know it or not, every doctor, every dietitian and physical trainer and friendly neigbor and sibling, every figure of authority who has ever counseled that we eat less and exercise more to lose weight, that we count our calories and so try to consume fewer than we expend, is wedded to this idea that the lean and the eventually-to-become-obese are physiologically identical; only their behavior sets them apart.” (p43)

Gary reinforces the absurdity of this in the book in the same way he does in presentations: “If we’re getting richer, we’re making more money than we’re spending. But nobody would say we get rich because we overearn.” (p43) Similarly, saying that we get fat because we overeat is explaining nothing and it never was a helpful paradigm. (Indeed, in Why we Get Fat, Gary referred to this as the original sin!)

Gary does the bit he does in presentations about the 3,500 calorie theory. A couple of times I’ve been in the audience and he has joked “Zoë doesn’t agree with this bit!” And I don’t (the 3,500 number), but I know what he’s trying to do (Ref 1). If you believe the 3,500 calorie theory – that to gain one pound of fat you need to consume an excess of 3,500 calories and to lose one pound of fat you need to create a deficit of 3,500 calories – then the person who ‘overeats’ 19 calories a day will gain 40lb in 20 years. If you believe that being half a teaspoon of olive oil ‘out’ each day will make a lean person fat, the inevitable question then becomes – why is everyone not overweight? How does anyone get it ‘just right’ the whole time?

Moving onto side effects, Gary uses the Ancel Keys Minnesota Starvation experiment as an illustration of the devastation that hunger, and calorie deprivation can cause. I’ve summarised Keys’ experiment previously – as it is the best study that we have to show the impact of eat less/do more (and not much more either) (Ref 2). That brings the case against the calorie theory chapters to a close.

An alternative view

We then move on to thinking differently. What if the authorities got it wrong? Yes, it would need to be virtually all of them, but what if? What if overeating isn’t driving fat accumulation? What if it’s the drive to accumulate fat, rather than using it for fuel, that leads to the hunger and any seemingly excessive eating that occurs?

Then the question becomes – what regulates the process of fat accumulation? Lean people burn fat for fuel. “Why do those of us who are fat keep so much of it stored away? Why do some of us fatten easily while others don’t?” (p67) If obesity is an issue of fat storage, then the even more positive question arises: “Can this fat-storage problem be fixed?” (p69)

The use of personal experiences throughout the book is engaging and powerful. Most are from physicians whom Gary has interviewed. This one is from Hafsa Khan, a West Virginia physician: “’In the last year I’ve been struggling like hell to lose seven or eight pounds,’ she told her friend, ‘when I have seventy to lose.’” (p72) The reader is left thinking there must be another way and, of course, this leads us into the proposal of “LCHF/Ketogenic eating” (Gary prefers ‘eating’ to ‘diets’) as a/the possible solution.

Gary sets out “we can’t escape the logic that a successful diet, a diet that works, must remove or at least minimise consumption of whatever is causing the ailments or making them worse” (p75) (GT’s emphasis). Gary summarised what ‘those who fatten easily’ would like “They’d like to be able to eat to satiety without being fat or getting fatter. Whether that is too much to ask is another critical question. It may not be possible. But if it is, they’d like to remain relatively lean for a lifetime, without having to consciously, day in, day out, live with hunger, count calories, measure out portions, go to bed hungry, wake up hungry… we can’t expect to endure hunger.” (p76)

This is where LCHF/keto eating comes in. If carbohydrates are the problem, then keto removes/minimises them. If hunger must be avoided, physicians have turned to the advice from Dr Pennington (1953) having found that “unbalanced diets”, restricted in sugars, grains, and starches, fat-rich instead, induced significant weight loss without hunger. Pages 79-81 reassuringly shared diet advice from the 1950s “Eat meat, fish, birds, eggs, cheese, all green vegetables, fruit if unsweetened (except bananas and grapes).”

The science of keto

The chapters then whiz by as we go through insulin, insulin resistance, diabetes, fat accumulation, metabolic flexibility and how we fuel. The underlying theme is captured by the following. The conventional wisdom, then and now, is that “All diets that result in weight loss do so on one basis and one basis only: they reduce total calorie intake.” The alternative wisdom is “All diets that result in weight loss do so on one basis and one basis only: they reduce circulating levels of insulin.” (p87)

Because I’ve also spent many, many years looking at this topic, I’m where Gary is, and I find it baffling that people can’t see that the alternative wisdom is the right one. The body doesn’t just burn body fat because we ate less or did more. The body has a multitude of other options and they are far more likely responses e.g. eat less -> do less. More importantly, the body can’t burn body fat in the presence of insulin and thus weight loss can only occur when insulin levels are reduced. Just as insulin facilitates fat storage, so its absence facilitates fat loss.

These chapters might be preaching to the converted, but one also hopes that they also convert some of the calorie preachers – especially the physicians who then go on to liberate so many other people following their own enlightenment.

The longest chapter is chapter 12, which addresses the question: is LCHF a safe/healthy way to eat? Having done my PhD in this field, this is not something that bothers me. The very notion that ancestral foods might be unhealthy, and modern foods might be healthier, is absurd. The chapter goes through the evidence for and against low and high fat eating, but the opening chapter quote nailed it for me. ‘Rachel’ on her Instagram account posted (with #eatbaconloseweight) “Someone asked me the other day how I was losing weight. I told them I eat less than 20g of carbs a day. They told me how dangerous it was. Told me that carbs were essential to human survival… Finally, I was like, dude, do you really believe I was healthier 90 pounds heavier than I am now?” (p132)

Later in the chapter, we get the joy of more Rachel wisdom. She noted that friends never criticized her diet when she weighed 380 pounds, but having switched to LCHF/keto eating and having lost (by then) 120 pounds, they would express concern about how much bacon she was eating! (p154)

The diet

Just before ‘what we eat’ is spelled out in chapter 14, chapter 13 sets the scene: “Carbohydrate-rich foods are fattening.” Or, because the individuality of carbohydrate tolerance is nicely emphasised throughout the book, “For those of us who fatten and particularly those who fatten easily, it’s the carbohydrates that we eat – the quantity and the quality – that are responsible.” (p171) It thus follows, if carbohydrate-rich foods make us fat, then we have to deprive ourselves of the pleasure of their eating (as Brillat-Saverin said, in The physiology of Taste, almost 200 years ago in 1825).

Gary pulls no punches in terms of what need to be done (although he has an indescribable way of delivering tough news in a way that makes it feel not so bad): “For most of us who have struggled with our weight for years, or decades, rigid abstinence would be ideal.” Gary brings along reinforcements. “’The word on the street’ says Eric Westman ‘is that I’m too strict. But maybe you have to be strict.’” (p179) Then Dr Robert Cywes “To cut to the chase, we are a carbohydrate substance abuse program, not a weight-loss program.” (p181)

The reward for this abstinence? “It does not mean that anyone who is obese will become lean, only that they will very likely become leaner and healthier, and they will do so without hunger.” (p178)

Abstinence is then set out as what we can’t eat: any grains or products from grains whatsoever; any starchy vegetables – above ground vegetables only; no fruit (except avocados, olives, and tomatoes – berries might be OK for you); no beans or legumes; absolutely no sugar whatsoever; no milk or sweetened yoghurts.

What we can eat is then: meat (ideally fatty and pasture fed); fish and shellfish; eggs; butter (grass fed sourced again) and oils (from fruits rather than nuts/seeds i.e. olive oil, avocado oil and coconut oil); low carb/above ground vegetables; olives and avocados; full fat dairy (cheese, cream, natural yoghurt – not milk). Gary steers people away from nuts and nut butters and seeds and seed butters. I was pleased to see this, having been steering people away from nuts and seeds since my first book in 2004. (Westman supports avoiding these too) (Ref 3).

And that’s it folks. And in this summary, the result of interviewing approximately 120 of the physicians who have converted to LCHF/keto eating, Gary has addressed my big concerns about keto – that it’s misunderstood, that the high fat is embraced more than the low carb and also that I see people baking nut and seed bread, muffins, and cakes, with nut and seed butter and then wondering why they’re not losing weight. Keto is strict. If you lose weight and maintain weight loss without going that far – great. But if you’re enjoying fruit, dark chocolate, cappuccinos, and carrot soup, you’ll be eating more like I do, but you’re not doing keto.

Chapter 16 is a must for all people following LCHF/keto eating – especially anyone who may not be doing well. Gary has captured the top six lessons from LCHF/keto practitioners. They were all spot on, but I think Dr Ken Berry’s was my favourite “This is not something you are going to do. This is what you are going to become.” (p204) Chapter 17 is equally important – for the same reason – as it covers factors that might be hampering success. From net carbs to protein to alcohol – the views of the practitioner experts are all shared.

Closing thoughts

This book is terrific. I highly recommend getting a copy. Whether it’s for the one liner bits of brilliance, or the anecdotes, or little penny drop moments “Until recently humans rarely if ever had the opportunity to drink fat without at least some protein… now we do… bullet proof coffee.” (p240)

I was wondering what it was about the book that made it even more readable and powerful than those before it. By the end of Chapter 2 I realised. The chapter that started with the quotation “Fat people are not lean people who eat too much” ended with “We fatten easily; they don’t… We have to eat differently because we are different.” Gary is included in that “we.” Gary has had his own struggle with weight and discovered for himself that eat less/do more doesn’t work and wasn’t sustainable even if it did work.

He started in the field of nutrition with an award winning article on the problems with epidemiology. More awards followed with the articles in Science on salt and fat and then the NY Times classic “What if it’s all been a big fat lie?” (Ref 4). Along with the articles and books, Gary is a giant on the speaker circuit. And on that speaker circuit we (for I am part of that “we” too) meet hundreds of others just like us. People who tried to eat less/do more and ended up fatter than we started and then we tried again – with an extra portion of self-loathing on the side – and the same thing happened again. We all have our own stories to tell of how we only sorted ourselves out when we ditched official dietary guidelines.

I personally am real food/managed carb rather than keto. Eric is Keto. Shawn Baker is carnivore. When asked about his diet, Gary says “I don’t eat starches, grains or sugar because they make me fat”! It doesn’t matter much what we do – it matters that we’ve all rejected the calorie theory and official dietary advice and we’re angry that it was ever given to us and that it is still being given to others. To his credit, Gary never comes across as angry. He comes across as intellectually curious with perhaps just a glimmer of incredulity that most of the medical profession ‘don’t get it.’ But make no mistake. The reason the book’s words leap into your heart is – for the author and all the practitioners interviewed – this time, it’s personal.


Ref 1:
Ref 2:
Ref 3: I advise people to stay away from nuts and seeds as they are the unique natural foods, which contain fat and carbohydrate in good measure. Other natural foods tend to be carb proteins or fat proteins. Fake food tends to be fat/carb combos and nuts and seeds share this attribute. Gary notes that the carb content can encourage fat accumulation and Gary, Eric and I all think that they are easily overconsumed.
Ref 4:

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