Constitutional Obesity Resistance Vs. Constitutional Obesity Propensity

Although activity on my Facebook and Twitter accounts might suggest otherwise, I’m not a big fan of social media. I participate in it because I feel like I “have to,” not because I particularly enjoy it. Then again, as I am extremely introverted, it’s a great way to interact with people without having to really interact with them. I can unplug and disengage the second I start feeling uninterested, overwhelmed, or exhausted. That being said, one of the great things about Twitter is that I get to interact with some quite brilliant people whom I would never otherwise have “met,” and I am regularly presented with ideas that blow my mind. (That’s how I came across the stuff about Dr. Kraft’s insulin assays, which inspired the insulin series.) Often, these are ideas and concepts that should be pretty obvious to me, and the only reason they aren’t is that I’ve just never stopped to think about them. And not only are they pretty obvious, but they’re often put out there or tweeted about casually, as if the writer is saying something relatively simple. A one-off post or a couple of lines about something that seems like no big deal and is a total no-brainer to them, but which, upon reflection, turns out to be a huge deal to me.

For example: the registered nurse who goes by the online nickname “Woo” frequently drops knowledge bombs that send me into a hurricane of thoughts. She holds no punches and does not suffer fools. Her writing style takes some getting used to, but she is truly one of the most intelligent and insightful people currently writing about metabolism, endocrinology, calories, ketosis, fat adaptation, body weight regulation, PCOS, and lots of other things many of us are interested in. Time and time again, something she posts makes me see things in a new light. So much light, in fact, that she should buy stock in General Electric, Phillips, or some other company that manufactures lightbulbs, because that is how many of those things go on over my head when I read her work.

Case in point: a few days ago, Woo made the correct observation that, in many cases, children who are put on a ketogenic diet (KD) for epilepsy can actually stop the diet after a couple of years and remain seizure free for life. Something about staying on a KD for some period of time during one’s formative years seems to actually permanently correct the underlying problem, such that the diet can be abandoned later on and the seizures do not return.

Coupling this fact with some observations about people on low-carb and Paleo diets, she came to some rather fascinating conclusions, and proposed an observational study. First, I’ll tell you about the study, and then we’ll work through the rationale for it, via exploring some intriguing things about body weight, and why some of us are so incredibly prone to accumulating excess adipose tissue, while others are not.

The observational study would be intended to test the following hypothesis:

• Children on a strict ketogenic diet for epilepsy (or some other condition) who are eventually able to return to a more “normal” diet and remain seizure free, are protected from developing obesity later in life. (I would venture to say we would likely observe the same outcome even among kids who follow a modified Atkins diet [a.k.a. “MAD”], and who were not strictly ketogenic.)

The study could be carried out in two ways:

1. A retrospective cohort. Find as many teenagers and adults as possible who were on ketogenic diets as children, but who no longer follow a KD. Assess anthropometric parameters. (Body weight, body fat percentage, etc.) The older the people we can find, and the longer they've been off the diet. the better.
2. A prospective cohort. Enroll as many children as possible who are currently using a strict KD or MAD to manage some sort of medical condition, and follow them for as long as possible after they abandon the special diet. Assess anthropometric parameters. Again, the longer we can follow them through their lives, the better.

To reiterate, the hypothesis is that these kids will remain lean into and throughout adulthood, even after returning to a more typical, Western-style, obesity-inducing diet. They will be what Woo (fabulously) calls “constitutionally obesity resistant.” (I love this phrase. Being “constitutionally lean” is one thing, but “constitutionally obesity resistant” really hammers home the point that it’s basically impossible for these people to become fat, even upon exposure to the same things that make the rest of us so.) I can’t speculate on whether they would remain free of the myriad other effects of the metabolic syndrome-inducing crap American diet, but it makes sense to me that, at the very least, they wouldn’t become obese.

Here’s the logic:

As we all know, there are people who can eat ungodly amounts of sugar and refined carb-laden junk food without gaining an ounce, while there are others who need to buy larger pants after merely looking at a cupcake. What gives? Could something in childhood or adolescence be “programming” us for these fates later on? How much does the dietary—and, therefore, hormonal—landscape of early life influence body weight regulation throughout the rest of one’s life?

These thoughts came to Woo because of very keen observations she’s made about some prominent figures in the low-carb and Paleo worlds. Some people can do just fine on a diet of 100-200g of carbs a day, while others—at least for the sole purpose of achieving and maintaining a significant fat loss—need to stay under 50g (or less!) forever. (Remember, in this post, I am referring only to weight issues. I am not talking about cognitive function, neurological health, diabetes, or some other condition that might benefit from a very low-carb or ketogenic diet for reasons that have nothing to do with body weight or fat mass. Those are separate issues, to which this logic might not apply.) To the hardcore low-carbers and keto dieters out there, 150g of carbs per day might sound like a lot, but compared to the standard American diet, it’s actually relatively low. (It’s 600 calories, which would be just 30% of a 2000 calorie per day diet. Compared to a diet of 50-65% carbs, 30% is low.) If you’re in the habit of reading the success stories & testimonials on Mark’s Daily Apple, or Robb Wolf’s site, then you’re familiar with the idea that some people can eat sweet potatoes, white rice, beans, gluten-free bread and pizza, and maybe even have a weekly or monthly “cheat meal” or splurge, without regaining any of the fat they lost by going Paleo or Primal. Who are these ninjas who get to have their cake and eat it, too have their cake and their steak, and eat them both?

Well, more often than not, these success stories—the ones where people have far more carb leeway than the rest of us—seem to be written by people whose extra weight/excess body fat was a temporary situation. Maybe it was the freshman fifteen, or post-baby weight, or some extra pounds that had come on due to very stressful life events: a divorce, a death in the family, loss of a job. These are people who were, for the most part, for most of their lives, lean. Being overweight was a blip on the radar, caused by something fairly easy to identify: lots of late-night study sessions over takeout and beer; a few months of drowning one’s fears and worries in a pint of ice cream and a family-size bag of chips (crisps, for my UK readers). Being heavier was not these people’s default state. So, when they cleaned up their diet—even just 80% of the time—their bodies easily returned to their naturally leaner state. Since being heavy was not the norm, getting back to a smaller size was easy, because it’s what the body wanted. (Maybe even what the body was programmed for.) In order to get back to a lower weight and body fat percentage, all they had to do was remove the stimuli that were moving things away from the norm, and it’s almost like the body automatically went back.

Never in my life have I been this ridiculously 
happy about an apple.

Woo observed that many of the Paleo success stories like this involve individuals who were vegetarian or vegan for some portion of their youth. Some also come from people with backgrounds of long-term disordered eating, mostly in the form of severe caloric restriction and/or exercise addiction. Now, vegetarian & vegan diets are not necessarily low­ insulin diets. If someone’s living off of bread, pasta, potatoes, and rice, then sure, they might end up with insulin and blood sugar issues. But plenty of vegetarians and vegans are not starch-a-tarians and grain-a-tarians. For the ones who eat mostly non-starchy vegetables, fruit, nuts, and maybe even beans, this is actually a very low insulin diet. (Even more so if it’s a raw vegan diet, because grains and dense starches must be cooked in order to be edible. Except for raw honey, there are almost no foods on a raw vegan diet that would spike insulin to any significant degree.) The effects on fuel partitioning are even more profound when we account for this also typically being an extremely low-fat and relatively low calorie diet. (Which is possible even on an omnivorous diet, so this isn’t limited to vegetarians and vegans. We could be talking about anyone who followed an extremely low-fat/low-calorie diet.) See, even if someone does have a big insulin spike, if there’s not a whole lot of food energy coming in to begin with, then there isn’t a whole lot for insulin to influence the storage of, regardless of the macronutrient composition of the diet. (To make this simple: If you were to eat a diet of 100% leafy greens, that’s almost 100% carbohydrate, but you will not get fat. Even if you were to eat a few potatoes or some rice along with that, you wouldn’t get fat. The total energy density of the diet is just too low. You can’t store anything when there isn’t enough coming in to be stored. BUT, keep in mind, I’m talking here about insulin-sensitive people. I am not talking about the constitutionally insulin resistant, which I’ll get to in a minute.)

It seems that these folks, the ones who lived for many years in a low-insulin state—particularly if this low insulin state was during the formative years, either early childhood or maybe into and throughout the teens—are almost “immune” to becoming obese. Their bodies simply won’t let them get there. Sure, they might gain a few pounds here and there after some period of time of especially debaucherous eating. Maybe they’ll gain, say, ten, twenty, or at the very most, thirty pounds. But their bodies simply will not allow them to accumulate 200, 300, 400+ pounds of excess adipose tissue. At their heaviest, these people will never be candidates for bariatric surgery. (Maybe they’re even protected against heart disease, Alzheimer’s, tinnitus, nephropathy, and some of the other conditions associated with caused [at least in part] by hyperinsulinemia, but again, I can’t speculate on that.)

Like the hypothesized long-term weight regulation effects of children on ketogenic diets, having spent at least some significant amount of time in a low insulin state may grant these people some degree of protection against amassing body fat as readily as other people do.

Okay. So what about those other people?

I am one of those other people. I am one of the ones who acquires an additional chin after just walking past a bakery. I am someone we might call “constitutionally overweight-prone,” or, “constitutionally resistant to remaining lean.” Right now, I’m not obese. I’m not obese, but I am a far cry from lean. (In fact, by the BMI chart, I am squarely in the overweight category. BMI is a terrible and unreliable metric, but still.) And it is my firm contention that the only reason I’m not obese is that I am keeping my biological propensity for the accumulation of inordinate amounts of adipose at bay via a low-carb diet. If I were to return to a diet of 50%+ carbohydrate, there is no doubt in my mind that I would be obese. Heck, I gain weight easily even just getting a little too casual with my diet now, and that’s not even coming close to a “normal” level of carb intake.

So the question is, why? What is it about me—and the other people who are constitutionally overweight or obesity-prone—that differs from the people who were heavy for only a short period of time, and whose accumulation of weight was easily reversed?

Well, I can’t speak for others, but here’s what happened with me. When I look at pictures of me from when I was a baby, and up until sometime in elementary school, I was thin. No sign of impending weight problems. But not long after that, my parents opened an ice cream store. They sold homemade ice cream, candy, cakes, novelties, etc. This store was a presence in my family for ten years. Every kid’s dream, right? Yes. ... If they want to fight their weight for the rest of their life, that is.

I take 100% responsibility for my dietary habits during that decade. Maybe my parents could have kept a better eye on me, but my father was working two jobs, and my mother was in the store seven days a week. Ultimately, the person who fed me all that junk food was me. Maybe, at nine years old, I didn’t understand that I was setting the stage for metabolic consequences I would face the rest of my life, but the ignorance of youth doesn’t absolve me of personal responsibility. So I blame no one but myself. Honestly, though, it doesn’t matter. It doesn’t matter how or why I’m in the metabolic pickle I’m in now. I’m in it, and there’s no way out of it. No permanent way, anyway. (More on this in a minute.)

Even after the store was a distant memory, my diet was high-carb. Not high-junk, but still high carb. I was a major starch-a-tarian in high school and college. Bread, cereal, pretzels, pasta, bagels, granola—hey, starchy foods are cheap, and they’re low in fat! It’s the double-score for a college girl! Because I spent so many of my formative years in a high insulin state, I am almost the opposite of the obesity-resistant. No, not “almost.” I am the opposite. I am obesity-prone. Unlike the people who gained a few pounds in college, or due to a stressful and unpleasant, but short-lived life situation, my body’s norm is not lean. My default state is chubby. While it’s (relatively) easy for the constitutionally lean to lose weight, it’s (extremely) easy for the constitutionally obesity-prone to gain weight. When a constitutionally lean person gains weight, the body wants to get rid of it. It wants to return to its “happy place” of a lower weight. When a constitutionally obesity-prone person loses weight, the body wants to regain it. It wants to return to its happy place of a higher weight.

I said above that there’s no permanent way to reverse my body’s proclivity toward accumulating fat. But there is, depending on how you look at it. I can manage my obesity-proneness via a permanent low-carb diet, relatively low stress, good sleep, and exercise. But I cannot reverse it. I can’t go back in time and erase having spent most of my adolescence and young adulthood awash in high insulin. Those effects are permanent, or, at least, they seem to be. This is why those of us who, for whatever reasons—be it mom & dad’s ice cream store, or lots of junk in the house, or the maternal diet/gestational diabetes exposing us to hyperinsulinemia in utero, or something else—now seem “programmed” to be heavier, and have to fight so hard to keep weight off and be so diligent about our diets. Yes, we can indulge here and there and not gain back fifty or a hundred pounds, but we can easily gain back at least a few. And the truth is, if we’re not careful, and those indulgences get out of hand for a long enough period of time, we will gain back fifty or a hundred pounds. 

There’s a reason this is so damn hard!

We are what Woo calls “weight-reduced obese” (or overweight) people. We are fat people who happen to be, right now, at this moment in time, slimmer than our bodies’ biological norms. That fat is waiting in the wings to come back as soon as we give it the opportunity. This is why it is so much more difficult to maintain a significant weight loss than it is to lose the weight initially.

Those of us who were overweight or obese for a long period of time—especially if this time includes childhood—are capable of becoming lean. We can become lean, but we will never be as lean, nor maintain that leanness as effortlessly, as someone who was never obese at all. I think being awash in insulin during youth is especially problematic, and probably makes people especially prone toward overweight. But even if you were thin during your formative years, if you were obese in adulthood for a long period of time--decades, perhaps—then you will probably struggle just as mightily as those who were heavy in adolescence. This is especially troubling for the youth of today, who are, as Dr. Ted Naiman says, “marinating in insulin in the womb.” These kids are in trouble from minute one. Literally before they are even born, their bodies are being conditioned by a hyperinsulinemic environment. If you think the “diabesity” epidemic is bad now, just you wait. (Not to mention cancer, Alzheimer’s, and more.)

WHY is this all so difficult? WHY is it possible to “manage,” but not completely reverse the biological propensity toward accumulating excess adipose tissue?

Again, Woo, with her brilliant insights. (I would link to or embed her relevant tweets here, but her account is protected, so I can’t do that. She is extremely protective of her real life identity. My paraphrasing her and giving you the gist will have to suffice.) She posted this picture:

This is a photograph of a normal-sized man standing next to a man who had a growth hormone (GH)-secreting tumor earlier in life. A tumor that secretes inordinate amounts of GH prior to the closing/fusing of the epiphyseal plates will cause the bones (especially the long bones—femur, humerus, tibia, ulna, etc.) to be much longer and larger than normal. (The epiphyseal plates are the tissues between the long bones that remain soft and pliant during growth, but which eventually—sometime in the late teens or very early twenties, fuse and solidify, stopping further growth. Once your epiphyseal plates have closed, you can stop expecting your growth spurt. You’re as tall as you’re ever going to be without lifts in your shoes. [I have to admit, though, I’m 37, but at just 5’2”, I am confident my growth spurt is coming any day now!])

The point of this picture is to demonstrate that some of the endocrine influences early in life are irreversible. Their effects are permanent. Take the guy with the GH tumor: after doctors remove the tumor, it’s not like this guy is going to shrink back to a normal size. He is huge and will always be huge. You can take away the excess growth hormone, but he will still be 8 feet tall. He will still have enormous hands and a very deep voice. You can’t make those things go away. You remove the tumor, and the pathology is arrested (meaning, he's not going to get even taller), but the effects of that pathology are not reversible. This guy cannot be “cured” of his excessive tallness simply because we have removed the stimulus that made him tall. In the same regard, we can remove chronic hyperinsulinemia, but that does not automatically make us insulin-sensitive. It doesn't magically "undo" all those years of elevated insulin. The constitutionally obesity-prone cannot be cured of this propensity. We can only eat and live in such a way that we don’t trigger the effects. (And if you’re planning to have children, or you have young children already, you can do your best to prevent them from having this propensity in the first place. That’s probably the best place to start.)

I’ll paraphrase some of Woo’s tweets, since I can’t share them with you directly: 

• Even though the insulin reducing protocol acts exactly like tumor surgeries in other endocrine diseases (in that it arrests the pathology), CICO-phants are too dense to understand and acknowledge the efficacy of low-carb diets and other insulin-reducing measures. 
• When we see this phenomenon in obesity, ignoramuses think this is evidence that insulin must not cause obesity because low-carb diets are not a “cure.”
• Insulin does not simply alter fuel use acutely, and drive growth or shrinkage of the adipocyte (fat cell). Insulin is to fat tissue as growth hormone is to the rest of the body. (Meaning, some of the effects will be permanent, especially if the chronically elevated insulin was present for a long period of time, and even more so if it was present during the formative years.) Therefore, even if you perform the obesity equivalent of a GH tumor removal surgery by putting someone on a diet to lower insulin, it’s still not a “cure.”
• Depending on the nature of the problem—at what point in life did obesity develop, and for how long was it present—maybe an “ancestral” diet works. On the other hand, maybe not even a keto diet does. Meaning, for people who were only a little overweight, and maybe only for a few years, an “ancestral” diet works like magic. Beans, fruit, non-gluten grains, potatoes – it’s all good! No weight regain, no metabolic syndrome, no nothin’. But for others, who were very overweight for a longer period of time, maybe not even a low-carb diet works. Maybe not even a ketogenic diet works! (Not by itself, anyway.) Maybe those people need a ketogenic diet plus fasting, plus exercise, plus metformin, plus, plus, plus. And it is these people—the ones who struggle the most—who will be struggling their entire lives.

Then again, it depends on what we mean by “struggle,” right? Certainly, eating delicious pork chops, steaks, broccoli, Brussels sprouts, and cheese, isn’t exactly “struggling,” right? (“First World problems,” as they say.) And maybe being “forced” to get sufficient sleep, manage stress levels, and engage in physical activity more than the average person for the sole sake of preventing fat regain isn’t much of a struggle, either. But you know what I’m trying to say: the lifelong battle to prevent fat regain might not be a hero’s quest worthy of Greek mythology, but for the people who are constitutionally overweight- or obesity-prone, it is a lifelong battle. We will never be able to eat as casually or without thought to protein/fat/carbs as those who are constitutionally obesity-resistant.

Wow. So that was the [very] long way of offering at least one explanation for why some people do just fine on higher carbs, and others don’t. And also why, for many people, a low-carb diet, by itself, is not enough to lose weight and maintain that loss. (Also: just so we’re clear, when I talk about “higher carbs” and an “ancestral diet” as opposed to low-carb or ketogenic diets, I’m not talking about loads and loads of sugary breakfast cereals, toaster pastries, and other outright garbage. I’m talking about unprocessed, real foods, such as rice, potatoes, beets, and lentils, which are wholesome and nutritious foods that have nourished healthy and robust populations for centuries, but which just happen to be high-ish in carbohydrate. The people I referred to in the success stories on MDA and Robb Wolf’s site—the ones who thrive on 80/20—sure, sometimes, maybe they do a header into a tub of gelato, or hit up their favorite BBQ joint for some brown sugar-smothered ribs and a big, honkin’ piece of cornbread, but even they don’t do that every day. Now and then, yes. And they can get away with it, for reasons discussed here today. For the most part, though, their “higher carbs” still come from real foods.)

That’s all. Just a little more nuance to explain why people are so different with respect to weight gain, loss, and maintenance.

P.S. I am so tempted to name names – to say exactly who I mean when I referred to some of the well-known figures in the low-carb, Paleo, and ancestral nutrition worlds, and how some of them will never become effortlessly slim, while others will never become obese. Some of the heavier folks will get slimmER than they are naturally, but they will fight tooth and nail every day to stay that way. And some of the constitutionally lean may put on a few pounds once in a while, but those pounds will slide off easily with not much more effort than a couple sprinting sessions and dropping the coconut sugar-filled “Paleo treats.” Alas, I will not name names. Not my style. I avoid confrontation and controversy as much as possible. (Most of you know who I’m talking about anyway. :P) I do wish, however, that they were more careful not to extrapolate from their own personal experiences to everyone else. Guess what? If you were never overweight, or were only slightly overweight for a relatively short period of time, YOU DO NOT UNDERSTAND the metabolic challenges of someone who was overweight or morbidly obese for many years. And vice-versa: if you have battled weight for most of your life, you probably have a hard time understanding that there are, in fact, people who can eat beans, potatoes, bananas, and rice, and remain lean. All I know is, the closed-minded and angry rhetoric on both sides is getting uglier every day. I hope to remain true to the tagline at the top of my blog: “A source of sanity in the sea of nutritional madness.”

Remember: Amy Berger, MS, CNS, NTP, is not a physician and Tuit Nutrition, LLC, is not a medical practice. The information contained on this site is not intended to diagnose, treat, cure, or prevent any medical condition and is not to be used as a substitute for the care and guidance of a physician. Links in this post and all others may direct you to amazon.com, where I will receive a small amount of the purchase price of any items you buy through my affiliate links.