Saturday, June 29, 2013

Peter Attia: Is the obesity crisis hiding a bigger problem?

Peter Attia has dedicated his medical career to investigating the relationship between nutrition, obesity and diabetes. A surgeon who developed metabolic syndrome himself despite the fact that he ate well and exercised often, Attia realized that our understanding of these important health issues may not actually be correct. He devoted himself to using vigorous scientific inquiry to test both our assumptions and new hypotheses through the Nutrition Science Initiative, the nonprofit he co-founded in 2012. Attia also writes the blog Eating Academy, which charts his own adventures in nutrition and examines scientific evidence surrounding food, weight loss and disease risk. Overall, he hopes to convince others that sharp increases in the rates of obesity and diabetes -- despite the fact that we are more culturally aware of these problems than ever -- might be a result of people being given the wrong information.

Attia came to this calling through an unusual path. While he was studying mechanical engineering as an undergrad, a personal experience led him to discover his passion for medicine. He enrolled at Stanford Medical School, and went on to a residency in general surgery at Johns Hopkins Hospital and a post-doctoral fellowship at the National Cancer Institute. After his residency, he joined the consulting firm McKinsey & Company, where he worked on healthcare and financial system problems. The most valuable skill he learned along the way: to ask bold questions about medical assumptions. 

"Gary Taubes and Peter Attia, co-founders of the Nutrition Science Initiative (NUSI), did a historical analysis of weight-loss studies and determined the science was anything but clear. Now, they’re on a quest to facilitate and fund studies that will definitively answer the question 'What makes us fat?'"

I'll never forget that day back in the spring of 2006. I was a surgical resident at The Johns Hopkins Hospital, taking emergency call. I got paged by the E.R. around 2 in the morning to come and see a woman with a diabetic ulcer on her foot. I can still remember sort of that smell of rotting flesh as I pulled the curtain back to see her. And everybody there agreed this woman was very sick and she needed to be in the hospital. That wasn't being asked. The question that was being asked of me was a different one, which was, did she also need an amputation?

Now, looking back on that night, I'd love so desperately to believe that I treated that woman on that night with the same empathy and compassion I'd shown the 27-year-old newlywed who came to the E.R. three nights earlier with lower back pain that turned out to be advanced pancreatic cancer. In her case, I knew there was nothing I could do that was actually going to save her life. The cancer was too advanced. But I was committed to making sure that I could do anything possible to make her stay more comfortable. I brought her a warm blanket and a cup of a coffee. I brought some for her parents. But more importantly, see, I passed no judgment on her, because obviously she had done nothing to bring this on herself. So why was it that, just a few nights later, as I stood in that same E.R. and determined that my diabetic patient did indeed need an amputation, why did I hold her in such bitter contempt?

You see, unlike the woman the night before, this woman had type 2 diabetes. She was fat. And we all know that's from eating too much and not exercising enough, right? I mean, how hard can it be? As I looked down at her in the bed, I thought to myself, if you just tried caring even a little bit, you wouldn't be in this situation at this moment with some doctor you've never met about to amputate your foot.

Why did I feel justified in judging her? I'd like to say I don't know. But I actually do. You see, in the hubris of my youth, I thought I had her all figured out. She ate too much. She got unlucky. She got diabetes. Case closed.

Ironically, at that time in my life, I was also doing cancer research, immune-based therapies for melanoma, to be specific, and in that world I was actually taught to question everything, to challenge all assumptions and hold them to the highest possible scientific standards. Yet when it came to a disease like diabetes that kills Americans eight times more frequently than melanoma, I never once questioned the conventional wisdom. I actually just assmed the pathologic sequence of events was settled science.

Three years later, I found out how wrong I was. But this time, I was the patient. Despite exercising three or four hours every single day, and following the food pyramid to the letter, I'd gained a lot of weight and developed something called metabolic syndrome. Some of you may have heard of this. I had become insulin-resistant.

You can think of insulin as this master hormone that controls what our body does with the foods we eat, whether we burn it or store it. This is called fuel partitioning in the lingo. Now failure to produce enough insulin is incompatible with life. And insulin resistance, as its name suggests, is when your cells get increasingly resistant to the effect of insulin trying to do its job. Once you're insulin-resistant, you're on your way to getting diabetes, which is what happens when your pancreas can't keep up with the resistance and make enough insulin. Now your blood sugar levels start to rise, and an entire cascade of pathologic events sort of spirals out of control that can lead to heart disease, cancer, even Alzheimer's disease, and amputations, just like that woman a few years earlier.

With that scare, I got busy changing my diet radically, adding and subtracting things most of you would find almost assuredly shocking. I did this and lost 40 pounds, weirdly while exercising less. I, as you can see, I guess I'm not overweight anymore. More importantly, I don't have insulin resistance.

But most important, I was left with these three burning questions that wouldn't go away: How did this happen to me if I was supposedly doing everything right? If the conventional wisdom about nutrition had failed me, was it possible it was failing someone else? And underlying these questions, I became almost maniacally obsessed in trying to understand the real relationship between obesity and insulin resistance.

Now, most researchers believe obesity is the cause of insulin resistance. Logically, then, if you want to treat insulin resistance, you get people to lose weight, right? You treat the obesity. But what if we have it backwards? What if obesity isn't the cause of insulin resistance at all? In fact, what if it's a symptom of a much deeper problem, the tip of a proverbial iceberg? I know it sounds crazy because we're obviously in the midst of an obesity epidemic, but hear me out. What if obesity is a coping mechanism for a far more sinister problem going on underneath the cell? I'm not suggesting that obesity is benign, but what I am suggesting is it may be the lesser of two metabolic evils.

You can think of insulin resistance as the reduced capacity of ourselves to partition fuel, as I alluded to a moment ago, taking those calories that we take in and burning some appropriately and storing some appropriately. When we become insulin-resistant, the homeostasis in that balance deviates from this state. So now, when insulin says to a cell, I want you to burn more energy than the cell considers safe, the cell, in effect, says, "No thanks, I'd actually rather store this energy." And because fat cells are actually missing most of the complex cellular machinery found in other cells, it's probably the safest place to store it. So for many of us, about 75 million Americans, the appropriate response to insulin resistance may actually be to store it as fat, not the reverse, getting insulin resistance in response to getting fat.

This is a really subtle distinction, but the implication could be profound. Consider the following analogy: Think of the bruise you get on your shin when you inadvertently bang your leg into the coffee table. Sure, the bruise hurts like hell, and you almost certainly don't like the discolored look, but we all know the bruise per se is not the problem. In fact, it's the opposite. It's a healthy response to the trauma, all of those immune cells rushing to the site of the injury to salvage cellular debris and prevent the spread of infection to elsewhere in the body. Now, imagine we thought bruises were the problem, and we evolved a giant medical establishment and a culture around treating bruises: masking creams, painkillers, you name it, all the while ignoring the fact that people are still banging their shins into coffee tables. How much better would we be if we treated the cause -- telling people to pay attention when they walk through the living room -- rather than the effect? Getting the cause and the effect right makes all the difference in the world. Getting it wrong, and the pharmaceutical industry can still do very well for its shareholders but nothing improves for the people with bruised shins. Cause and effect.

So what I'm suggesting is maybe we have the cause and effect wrong on obesity and insulin resistance. Maybe we should be asking ourselves, is it possible that insulin resistance causes weight gain and the diseases associated with obesity, at least in most people? What if being obese is just a metabolic response to something much more threatening, an underlying epidemic, the one we ought to be worried about?

Let's look at some suggestive facts. We know that 30 million obese Americans in the United States don't have insulin resistance. And by the way, they don't appear to be at any greater risk of disease than lean people. Conversely, we know that six million lean people in the United States are insulin-resistant, and by the way, they appear to be at even greater risk for those metabolic disease I mentioned a moment ago than their obese counterparts. Now I don't know why, but it might be because, in their case, their cells haven't actually figured out the right thing to do with that excess energy. So if you can be obese and not have insulin resistance, and you can be lean and have it, this suggests that obesity may just be a proxy for what's going on.

So what if we're fighting the wrong war, fighting obesity rather than insulin resistance? Even worse, what if blaming the obese means we're blaming the victims? What if some of our fundamental ideas about obesity are just wrong?

Personally, I can't afford the luxury of arrogance anymore, let alone the luxury of certainty. I have my own ideas about what could be at the heart of this, but I'm wide open to others. Now, my hypothesis, because everybody always asks me, is this. If you ask yourself, what's a cell trying to protect itself from when it becomes insulin resistant, the answer probably isn't too much food. It's more likely too much glucose: blood sugar. Now, we know that refined grains and starches elevate your blood sugar in the short run, and there's even reason to believe that sugar may lead to insulin resistance directly. So if you put these physiological processes to work, I'd hypothesize that it might be our increased intake of refined grains, sugars and starches that's driving this epidemic of obesity and diabetes, but through insulin resistance, you see, and not necessarily through just overeating and under-exercising.

When I lost my 40 pounds a few years ago, I did it simply by restricting those things, which admittedly suggests I have a bias based on my personal experience. But that doesn't mean my bias is wrong, and most important, all of this can be tested scientifically. But step one is accepting the possibility that our current beliefs about obesity, diabetes and insulin resistance could be wrong and therefore must be tested. I'm betting my career on this. Today, I devote all of my time to working on this problem, and I'll go wherever the science takes me. I've decided that what I can't and won't do anymore is pretend I have the answers when I don't. I've been humbled enough by all I don't know.

For the past year, I've been fortunate enough to work on this problem with the most amazing team of diabetes and obesity researchers in the country, and the best part is, just like Abraham Lincoln surrounded himself with a team of rivals, we've done the same thing. We've recruited a team of scientific rivals, the best and brightest who all have different hypotheses for what's at the heart of this epidemic. Some think it's too many calories consumed. Others think it's too much dietary fat. Others think it's too many refined grains and starches. But this team of multi-disciplinary, highly skeptical and exceedingly talented researchers do agree on two things. First, this problem is just simply too important to continue ignoring because we think we know the answer. And two, if we're willing to be wrong, if we're willing to challenge the conventional wisdom with the best experiments science can offer, we can solve this problem.

I know it's tempting to want an answer right now, some form of action or policy, some dietary prescription -- eat this, not that — but if we want to get it right, we're going to have to do much more rigorous science before we can write that prescription.

Briefly, to address this, our research program is focused around three meta-themes, or questions. First, how do the various foods we consume impact our metabolism, hormones and enzymes, and through what nuanced molecular mechanisms? Second, based on these insights, can people make the necessary changes in their diets in a way that's safe and practical to implement? And finally, once we identify what safe and practical changes people can make to their diet, how can we move their behavior in that direction so that it becomes more the default rather than the exception? Just because you know what to do doesn't mean you're always going to do it. Sometimes we have to put cues around people to make it easier, and believe it or not, that can be studied scientifically.

I don't know how this journey is going to end, but this much seems clear to me, at least: We can't keep blaming our overweight and diabetic patients like I did. Most of them actually want to do the right thing, but they have to know what that is, and it's got to work. I dream of a day when our patients can shed their excess pounds and cure themselves of insulin resistance, because as medical professionals, we've shed our excess mental baggage and cured ourselves of new idea resistance sufficiently to go back to our original ideals: open minds, the courage to throw out yesterday's ideas when they don't appear to be working, and the understanding that scientific truth isn't final, but constantly evolving. Staying true to that path will be better for our patients and better for science. If obesity is nothing more than a proxy for metabolic illness, what good does it do us to punish those with the proxy?

Sometimes I think back to that night in the E.R. seven years ago. I wish I could speak with that woman again. I'd like to tell her how sorry I am. I'd say, as a doctor, I delivered the best clinical care I could, but as a human being, I let you down. You didn't need my judgment and my contempt. You needed my empathy and compassion, and above all else, you needed a doctor who was willing to consider maybe you didn't let the system down. Maybe the system, of which I was a part, was letting you down. If you're watching this now, I hope you can forgive me.



  1. I am an obese male. And I would LOVE to be skinny. I went to the doctor for a check-up. This man was not in the best of shape physically or emotionally . In truth, his was unkempt and a bit greasy looking and rotund as well. My problems were virtually ignored as I was not given much room to speak and was told "consider this number" I said okay? The doctor had said "26,000" I said for what? He said "For gastric bypass" I was livid but what could I do? This man refused to listen to me, or offer me alternatives. Later on, as my family history was asked I had stated while my parents are a little heavier they are not supersized like me. Later when the doctor left the door was cracked and I overheard the nurse asking the doctor my "diagnosis" he replied "supersized."

    I am very glad this man in the article exists and he is doing the work that he is doing. I agree, at times, Doctors can fail their patients as human beings when they really need compassion and understanding rather than judgement. There really does have to be a change in attitude for society in general. I am thankful he is working as a catalyst in this way.

  2. A disappointing talk. 15 minutes of telling us he doesn't know the answer but they are investigating. The sort of pitch for money that all researches do.

    My suggestion would be to cut out refined sugar and carbohydrates and do something radical like using a Becks Zapper.

  3. Dr, Attia and Dr. William Davis (author:Wheatbelly) would form a powerful team in the cause for taking personal responsibility for living a health full life style. Please make that connection.
    Will I am

  4. As a Naturopathic Nutritionist, with over 30 years of experience I believe that people's insulin receptor sites are blocked from toxic residues of GMO's,excito-toxins,fluoride, aluminum, barium and the list goes on. The sites may even become genetically altered from the GMO's adding to a plethora of gastrointestinal problems. Look at the increase in inflammatory diseases, look at pigs stomachs after GMO ingestion. The food supply has been flooded with potentially gene altering substances and straight out toxic substances posing as food. Just as corporations masquerade as govt's eighty percent of processed food masquerades as nourishing food. High fructose corn syrup is not a natural sugar and contributes to the insulin resistance problem. I was writing a book that I believe was sabotaged by the FDA -computer crash after significant fax transmission and email. That was two years of work down into the computer abyss with no hard copy! I was encouraging people to clean and purify their indoor air, purify the water in their homes and consume organic food. There are many froms of detox but that is another dissertation.

  5. Thank you posting this report! Sense we are on the edge of so many health break throughs now and obesity is hugely significant on so many levels. I struggled with an eating disorder, being fat and obese, with the ashamed-stigma for all my younger adult life . . . hating my body and dressing in baggy dark clothing, trying every diet that never worked.

    And even though I finally slowly worked through what was the root cause for me . . . essentially emotional eating to cope living within the insanity of this human collective reality . . . and now manage to control my weight within more or less 10 pounds . . . I have found that the psychological damage still lingers because I only feel completely good about how I look when a size 4-6 . . . and my wardrobe is still schizophrenic. (by the time I was in my late 40's, it suddenly hit me that if the majority of women in the western world suddenly woke up at the same time, feeling 100% good about themselves from the inside, the stock market would crash in a heartbeat)

    Along the way, I also learned about the huge correlation between those of us who have been in high-anxiety since childhood (so it's "normal", as that is all we have ever known) . . . eating disorders and cancer . . . all designed to feed the drug companies. And even though it appears that women who get breast cancer fall largely into this group, am wondering if men that get cancer do too? I also now understand in the general sense, emotional eating and other addictions root cause can be by not feeling, one does not any choices in their their life. (why in my opinion, understanding what the IUV means is so critical now)

    Because of my own journey, I now have great empathy for those that struggle with obesity or just being "fat", therefore, I have a great interest in learning where Attia takes this new study. Ginger

  6. personally, after 50 years in the sick profit business-i have learned that health and healing is not even on the game board for this industry-it is all about profit-nothing more-unless the more is robbery, slavery and murder. Obesity is a healthy reaction to an unhealthy situation...and multidimensional in scope. I believe that most obesity starts with some sort of poisoning-and with our poisoned food, air, water, and soil in addition to ignorance of how the body works-and how INDIVIDUAL bodies cope with what they are dealt. ...and that is just on the physical level as there are astral (imagination), causal (emotions), mental(mind and intellect), and etheric (symbolic)"crap" to deal with as well. Most people know that shit rolls downhill--and anyone who thinks the higher dimensions are all peace love and light are delusional--but don't take my word for it--find out for yourself by expanding ones AWARENESS of what is going on in those levels and how they effect the physical and vice versa--that is what multidimensional existence is all about.

  7. Dr Tennant, a prolific researcher,speaks to the obesity problem. He says it is largely caused because cells of the body cannot get the nutrients they need because processed foods contain fats over heated to keep them from spoiling (transfats).The transfats (other factors are involved ) coat our cells like cellophane, which blocks absorption of fats.We keep oversupplying with more fat--which leads to other syndromes : obesity, hypothyroidism--which is hard to diagnose from lab test-and requires iodine, also in low supply in modern diet to repair damaged cells. His pdf‎
    and Tennant's book is must reading!.
    Keep up the good work AK!


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