ITIS -- It's the Insulin, Stupid (pt 7/8)

Seven down, one to go!

 

As of this writing, the first post in this series has 5316 views, and part 6 has just 739. Quite a decline in readership there, so my sincerest thanks and appreciation to anyone out there who’s still with me. (If I am extremely verbose in written media, you’d be amazed how quiet I am in person.)

Last time, in part 6, I introduced my interpretation of the chain of causality regarding metabolic/endocrine dysregulation and the accumulation of body fat. Conventional medicine and nutrition hold that people get fat accumulate excess adipose tissue because they are lazy, greedy, gluttonous, and too sedentary. They eat too much and move too little. These shortcomings in willpower, discipline, and good morals lead to overweight & obesity, and overweight & obesity subsequently lead to diabetes, hypertension, infertility, heart disease, and more.

But you’ll recall that I believe differently. I believe it works like this:

Blood glucose & insulin dysregulation (hormonal/endocrine issues) ---> preferential use of glucose for energy + storage of excess energy (from carbohydrates and fat) in adipose tissue + inhibition of 
lipolysis ---> accumulation of adipose tissue.

In my theory, metabolic and hormonal abnormalities come first, and the accumulation of body fat is the result. I like that much, much better than the chain of causality that looks like this:

Laziness, greed, gluttony, sloth, character flaws ---> accumulation of body fat ---> "diabeetus"

In my causation chain, people might even be going out of their way not to be weak-willed gluttons. See, what they really want for breakfast is a couple of fatty sausages with a fried egg or two, some greens sautéed in butter, and a cup of coffee with heavy cream. But, being very disciplined and wanting to do “the right thing” (at least, according to just about every medical and nutrition authority they’ve ever heard from), they ignore that primal instinct, call upon their willpower, and opt instead for a fat-free bran muffin with a small schmear of low-fat cream cheese and strawberry jam, and a glass of orange juice. If they’re feeling really indulgent, instead maybe they’ll have some nonfat liquid egg substitute cooked in a nonstick pan, which they will still coat with fat-free nonstick spray, just in case. (They will top the non-fat egg substitute with salsa [fat-free] and low-fat cheese.) The LCHF, Paleo, Primal, and Perfect Health Diet worlds are full of anecdotes personal accounts of people who were not greedy, not lazy, not gluttonous, and not sedentary, yet either failed to lose weight, or more likely gained weight, in conjunction with a dutifully followed low-fat, low-calorie diet, plenty of exercise, and morally superior, holier-than-thou avoidance of succulent, fatty animal flesh. (I know. I was one of them.)

CICO, SICKO, PSYCHO?

In the 8^th and final installment of this series, we’ll look at some of the things that might cause blood glucose & insulin dysregulation, because if glucose & insulin issues are what ultimately start the entire ball rolling, then we need to identify what triggers them. For now, though, let’s take a magical jaunt through fantasy land on the back of our majestic flying unicorn and talk about the phrase we all love to hate, “Calories in, calories out.” (This is usually abbreviated to CICO, and some folks in the LCHF crowd refer to its ardent adherents as CICOpaths or CICOphants. I’m not saying I do this; I’m just trying to lighten things up, since most of these insulin posts have fallen short in the humor department.) Another acronym that emphasizes the fundamental importance of reducing calories when weight loss is a goal is CRAP: calorie restriction as primary. Love it, love it, LOVE IT! (Hat tip to Dr. Jason Fung for that. I don’t know if he’s the one who coined it, but his blog is the first place I ever saw it.)

There’s a lot to say here. It’s hard to know where to start. I guess a good place would be a quote from Jonathan Bailor, author of The Calorie Myth:

“Calories count, but that doesn’t mean you have to count calories.”

The CICO model of weight regulation boils down to this: In order to lose weight, you must take in fewer calories than you expend.

That’s it. It says nothing about what happens to those calories once they’re ingested, or whether or not we even can “count calories” at all. It also fails to explain why people can take in the exact same number of calories and perform the exact same exercise, but their weight and body composition might not change in exactly the same ways.

There are approximately eight-hundred-zillion things wrong with the CICO model of weight fat loss.

We can pretend about a lot of things.
That doesn’t make them real.

BUT:

Let’s pretend, just for now, that this is only about calories in and calories out, and nothing else. Let’s forget about all the complicated biochemical processes happening that we have little to no control over. (We’ll get to them in a bit, but for now, let’s pretend they have no bearing on anything [even though they totally do].) We can probably all agree that the only way to get “calories in” is by eating and drinking. Okay, fine. Let’s also pretend, just for argument’s sake, that the only way to get “calories out” is through physical exertion, such as running, swimming, walking, biking, hockey, weightlifting, gymnastics, and sex. (And gymnastic sex!)

Why is it that some of us want to run, swim, walk, bike, and lift, and others don’t? (As for sex, if you don’t want to do that, there’s probably something deeper going on than insulin dysregulation, and you’ll have to find another blogger who specializes in that!) Why do some people feel driven to athletic endeavors, while others can barely muster the energy to call out for pizza before they collapse onto the couch after work? Granted, some people simply don’t enjoy athletic pursuits, and that’s fine. To each their own. But what about those who do enjoy them, or even those who don’t enjoy them, but who, knowing all the supposed benefits of exercise, would still manage to get themselves to participate in physical activity either more intensely or more frequently, but who lack the energy to do so? Why do some people feel motivated to do intense exercise, and others don’t?

Why are some people bursting with energy to the point where they almost have to get up and move, while to others, it’s a chore just to get up off the sofa and cook dinner, or do laundry, let alone do an uphill sprint session, or a kettlebell workout? What is the role of insulin in either facilitating or blocking the “oomph” that makes people want to move more?

Calories in & calories out are not

independent variables

To some extent, the type of calories in has a huge influence on calories out. This is not an absolute, all-or-nothing scenario (human physiology almost never is), but the overall message is this: to some extent, calories in help determine calories out. We know that in people who are insulin resistant—we might also call them “carbohydrate intolerant”—eating a ton of carbohydrates raises insulin, and insulin levels tend to remain high for longer than in someone who is more sensitive to the hormone. And, as we covered in parts 4 and 5 of this series, prolonged elevated insulin inhibits the breakdown of fats. But, as I explained way back in my series on fuel partitioning (long before anyone was reading this blog), fat is the body’s most efficient fuel, and it’s also the fuel we store the most of. So, when insulin levels are chronically elevated, access to our body’s best and most abundant fuel is blocked. (Like I said on the podcast I recorded with Robb Wolf, it’s as if we’ve got 10 gallons of fuel sitting in plastic jugs on the backseat of a car. The fuel is technically “inside” the vehicle, but it’s not in the gas tank, where the engine can access it.) Good luck wanting to hit the gym--or even just go for a walk--when you are unable to access your body’s best fuel.

Bottom line: if you eat a ton of carbs, and high insulin for a prolonged amount of time squirrels most of that fuel away inside your adipose tissue, you will not have much energy. In fact, one of the most commonly reported side effects of a low-carb diet is an increase in energy levels. People in the real food world seem to have a love/hate relationship with Gary Taubes these days, but put me squarely in the camp that loves him. (Well, maybe not him. I’ve never met him, so I can’t say, but I do certainly love his work.) His writing is where I first came upon this idea of reversed causality when it comes to the (presumed) relationship between exercise and weight fat loss.

Just put stuff in and take it out.

Pay no mind to what happens to it inside the box.

The CICO and CRAP crowds claim it works like this: Expend more energy than you take in, and your body weight will decrease. (Never mind that they don’t necessarily say your fat mass will decrease. Only your weight.) They believe the human body—the complex, frustrating, beautiful, aggravating, wondrous body—is no more complicated than a dime-store calculator, or a first-grade subtraction problem. The body is like a cardboard box: put in less “stuff” than you take out, and there will be less stuff remaining. Again, this says nothing about how to get someone to take more stuff out, or why some people’s bodies are so much better at letting go of “stuff” than others’. It also says nothing about the fact that the human body is not a cardboard box. That is, it is not simply a holding vessel for calories, and it is absolutely not a static entity. The properties of the body (box) change, depending on what we put into it. The biochemical reactions that take place in the body are influenced by the type of calories in, and we can make a decent argument that the type of calories has an even greater influence on these reactions than the total amount of them. (Even within a single macronutrient category, the source of calories has far more influence than the number. Think about 500 calories of cookies versus 500 calories of broccoli. They're both carbohydrate, but that's where the similarities end.)

Among the myriad effects of a low-carb diet is a lowering of insulin levels. Things vary from person to person, and for sure, many things affect insulin besides just carb intake. (More on this next time.) But in general, if one has a goal of reducing their overall insulin load, a low-carb diet is a pretty damn good place to start. By lowering insulin levels, we take the gasoline that’s been sitting on the backseat and we pour it into the tank. When insulin and its anti-lipolytic effects are no longer an obstacle, all of sudden, we have access to the good stuff—the best stuff—fat. And when we have access to our body’s best fuel, lo and behold, all of a sudden, we have energy. And when we have energy, we want to move. We can move. This is what Gary Taubes elucidated so well: People don’t burn fat because they’re moving more; they’re driven to move more because they’re burning fat.

S & M Er, I mean D & W

This brings up a good question: Isn’t this all just a matter of discipline and willpower?

Proceeding in our romp through the Land of Make-Believe, where fat loss boils down to nothing but CICO, wouldn’t everyone—everyone—lose weight if they just had enough willpower to eat fewer calories, even when they’re very hungry, and had enough discipline to exercise, even when they’re tired? Doesn’t this still come down to fatsos overweight folks being lazy, greedy, and morally inferior to those who are slim? Sorry; I call bullsh*t. No, actually, I call f*cking bullsh*t. (Also, we need to stop for a sec, because the Pegasus we’re riding needs a carb refeed, so let me just haul out this giant bucket of oats…)

Listen, people. Yes, there are roles for discipline and willpower (D&W) in fat loss and improving health. At some point, you do have to pass up some of the foods you love if they’re going to hinder your progress. And once in a while, you do have to force yourself to get off your fanny when you’d rather conk out. BUT: D&W are finite resources. You can only deny your animal instincts for so long, and you can’t white knuckle your way through every meal and every workout.

Besides, what are willpower and discipline, anyway? When it’s the dead of winter and you put on a coat to go outside, does that mean you’re weak-willed? Could you tolerate the cold better if you just had more willpower? Don’t be ridiculous. (Tibetan monks who melt ice blocks with their body heat notwithstanding.) When it’s freezing out and you put on a coat, you’re not weak-willed. You’re following your instincts. It’s cold out, so, as an intelligent freaking human being, you bundle up! When you’re exhausted after a long day at work and a few meals of crappy food, and you come home and fall onto the couch, could you go for a sprint session or drop and do some pushups if you just had more discipline? Yeah, maybe, but come on. If you’re tired, it’s not “undisciplined” to lay on the couch. When you have no energy, as an intelligent freaking human being, you wouldn’t do something that requires a lot of energy!

Like I said, sure, sometimes you do have to override these instincts. (Doing things you don’t like is called being a grownup, and yes, it sucks.) But you can’t live like this every day, for your entire life. Let me repeat: willpower & discipline are finite resources; you can only white knuckle things for so long.

So even if fat loss comes down to nothing but CICO, as it does in Fairy Tale Land, you can see why a low-carb diet is still a pretty good way to go. If you absolutely must “move more” in order to expend energy and get more “calories out,” then you’re going to need as much energy as you can get. And it seems one of the best ways to get that energy is to keep insulin low, as that will facilitate constant access to fat, which is, again, the body’s best and most abundant fuel source. If you’re new to this and don’t understand why fat is such a better fuel source than carbohydrates, I encourage you to read the following three posts I wrote a while back. If you’re pressed for time, skip the first one, as I’ll be covering the basics in the rest of this post: 

• Calories, Schmalories
• Human Body as Hybrid Car
• The Hybrid Car’s Gas Tank 

The human body is not a cardboard box, where things get put in and taken out, and nothing happens in between

And now, it’s time to return to the real world, where CICO and CRAP are worthless when it comes to helping human beings—with their incredibly complex biochemistry & physiology, and who are not bomb calorimeters—lose body fat.

I could probably write another 10,000 words on this subject alone, but since part 7 of what I said will be just 8 posts is already too long, I’ll sum up the basics and then give you some of my favorite resources for exploring things further:

We know for sure that not all foods are 100% digested and assimilated into the body. That is, we do not absorb 100% of their “calories.” If you’ve ever had a bowel movement and noticed whole, intact kernels of corn, sesame seeds, or bits of leafy green things in your stool, then that is your proof right there. In the case of that corn kernel, it’s pretty obvious whatever calories are there weren’t absorbed; it passed through completely unchanged, for cryin’ out loud! I’m not suggesting that a couple of corn kernels and sesame seeds here and there would account for someone gaining or losing twenty pounds. I’m simply making the point that “calories in” sometimes do wacky things—or nothing at all—before they become “calories out.”

We also can’t accurately account for the role of the gut flora, nor of small intestinal lining integrity. The microbes that inhabit our intestines extract some of the energy from the food that passes through. People with overt celiac disease can eat and eat and eat (lots of “calories in”), but if they spend half the day on the toilet, they are not absorbing much of the energy those foods provide. (Lots of “calories out.”) But come on, it’s not like they were doing a triathlon and earned an expenditure of calories; those “calories” are passing through because, due to a damaged intestinal lining, the body can’t absorb them. Untreated type 1 diabetics are another category of people who can eat seemingly endless amounts of food and still waste away. And no, it’s not because they’re eating endless amounts of food while simultaneously performing superhuman feats of athleticism. These folks’ hormonal milieu makes it such that they nearly can’t gain weight, no matter how much they eat. CICO, MY *SS. MY BIG, FAT, MARATHON-RUNNING, TWICE-A-DAY WORKOUTS *SS. (Sorry for the language in this one, folks. This is a very personal thing for me, and even with whatever professional knowledge I have about how this all works, I am still angry—and jealous!!—that there are people who eat far more than I do, and who exercise far less than I do, but who ARE THINNER THAN I AM. It really stings sometimes. Please, somebody, make it stop. I’ve been fighting this sh*t since I was twelve years old.)

Moreover, the human body does not “burn calories.” The body uses energy, in the form of ATP. The body does nothing, energetically speaking, with “calories.” It doesn’t even do anything, energetically speaking, with fats, proteins, and carbohydrates, nor even with fatty acids, ketones, amino acids, and glucose. The body knows only one type of energy currency, and that is ATP. The fuel that powers everything the body does is ATP, not calories.

The body uses ATP for everything. All the processes going on inside your body—whether you know about them or not, whether you can feel them or not, whether you control them or not—are using ATP. For example: the pumping of blood through your blood vessels, the expanding and contracting of your lungs, the lowering and raising of your eyelids, and the movement of food through your gastrointestinal tract. That’s right: your heart beating, your lungs breathing, your eyes blinking, and you digesting food all require ATP. We don’t typically think of any of these things when we think of “burning calories,” but that’s what they’re doing. They are using energy. (And no, I don’t think blinking your eyes more is a good fat loss plan.) So we’ve got to acknowledge that “calories out” is far more complex than the number of calories we can take deliberate measures to “burn.” This is why I get very angry when I hear the phrase "calories out" bandied about so casually, as if we can get tons and tons of calories out by running a few miles. Ain't happening, folks. Exercise doesn't burn anywhere near as many calories as we'd like to think it does.

Do this for health, if you like.
But don’t expect it to be your
silver bullet for fat loss.

“Calories out” certainly includes the overt use of energy, such as in running, walking, biking, and other physical activities we deliberately make time for in our lives. But it also encompasses the aforementioned physiological and biochemical processes, many of which we have no control over. In fact, the vast majority of energy used in the body—that is, the calories burned, or rather, the ATP consumed—happens via the biochemical reactions going on inside us 24/7, rather than the measly couple hundred calories—if that—burned during a workout. (Like Dr. Aseem Malhotra, Professor Tim Noakes, and Stephen Phinney, PhD, have explained ad nauseum, exercise is great for overall health and wellness, but it is a piss-poor way to lose body fat.)

What about a sluggish thyroid? We know, right off the bat, that this reduces the basal metabolic rate. If my thyroid is running slow, why should I have to spend three hours at the gym every day to “burn” the same amount of calories my friend burns sitting on her *ss in front of the TV? Let’s say we both eat the same foods—that is, equal “calories in.” Through nothing but the virtue of her body’s thermostat being set a couple degrees higher than mine, she has far more “calories out,” even if she does far LESS exercise than I do. Again, I’ve seen this time and time again: people who eat far more than I do, and exercise far less than I do, and THEY ARE THINNER THAN I AM. (No, this doesn’t mean they’re healthier, but when have you ever heard a guy pass a gal on the street and say, “Look at the low triglycerides on that one!” Or, “Wow, I bet she’s got great HDL.” When I am demoralized and crying in a shopping mall dressing room, my 5.0 A1c is of basically no comfort whatsoever.)

Guess what, everyone?

It’s still the insulin, stupid.

And as long as we’re on the CICO, fat/carbs, eat-less-move-more jag, allow me to broach another issue related to fat loss. Because, remember: most of us aren’t necessarily concerned with weight loss. What we are aiming for is fat loss. (Or, if you’re already at your goal weight, or you’re happy with wherever it is you are, then the aim is to maintain that fat loss and/or prevent fat gain, correct?) So what, pray tell me, is the purpose of eating carbs, burning carbs, and replenishing with carbs? When does fat ever enter into this equation?

If you eat 250 calories of carbohydrate, and you burn 300 calories of carbohydrate, there’s still no fat being burned. Yes, there’s a 50-calorie gap there, but it’s being filled by glucose, not fat. That fuel gap probably came from your muscle glycogen. And then you refuel with a granola bar, or a bagel, or a giant bowl of cereal. The cycle is nothing but carbohydrate. Carbohydrate in, carbohydrate out, and carbohydrate back in again.

Note: I am not unaware that certain athletic endeavors are more glycolytic than others, and that physical performance in some pursuits seems to be better when muscle glycogen is full. So yes, there is a rationale for carb repletion under the right circumstances. (I have written about this before.) According to the experts, “Fatty acids are the main source of energy in skeletal muscle during rest and mild-intensity exercise. As exercise intensity increases, glucose oxidation surpasses fatty acid oxidation.”

So yes, glucose usage is important for specific types of athletic performance. But how often do we typically engage in high-intensity athletics? For most of us, it’s less than an hour a day. (High-intensity means you couldn’t do it all day—not at peak intensity, anyway.) Even so, let’s play devil’s advocate and say, for some reason, you do intense athletics for a whopping four hours a day. In terms of improving body composition—that is, losing fat (and hopefully gaining some muscle)—which matters more: the calories you “burn” during those four hours, or how your body is partitioning and using fuel the other twenty hours of the day? If “fatty acids are the main source of energy in skeletal muscle during rest and mild-intensity exercise”—which are the main activities we’re all engaged in when we’re not working out intensely, then it’s still a good strategy to follow a low-insulin load diet. (With properly timed carb infusions for the purpose of driving athletic performance, not fat loss.)

If I rearrange the words from the quote above, we get this:

“As exercise intensity increases, glucose oxidation surpasses fatty acid oxidation. [But] Fatty acids are the main source of energy in skeletal muscle during rest and mild-intensity exercise.”

Even an insulin-resistant person’s body will still use some fat as fuel at rest and during low-intensity activity, but how much more fat would it use—and how much more easily would that person’s body access that fat—if the anti-lipolytic roadblock of insulin were removed? Remember: “calories out” is not accomplished solely through deliberate measures, such as running and swimming. We are putting “calories out”—that is, we are using energy (ATP) all the time, constantly, nonstop. The mere act of being alive uses ATP. You have no idea how many postural muscles are working to keep your head, neck, spine, and shoulders in line when you’re sitting in a chair, doing nothing. Why is it that some people’s bodies seem to want to use more fat for these hidden and underappreciated processes than others’?

I don’t know the answer to that. I suspect it has quite a lot to do with hormones, and insulin is merely one on a long list of hormones that affect fuel partitioning and the use of “calories.” But here’s what I do know: the extent to which any of us can deliberately induce a caloric deficit via eating a lot less and moving a lot more has far less impact on our body composition than the myriad biochemical processes we have virtually no control over. (In fact, if we go about that deficit the wrong way, we risk jettisoning our valuable muscle mass, which, over time, will decrease our resting metabolic rate, making the problem of fat gain even worse than when we started.)

*Continue to the 8th and final part of this series: http://www.tuitnutrition.com/2015/11/its-the-insulin-8.html

P.S. Now that I’ve written more than anyone ever cared to read about this, in case there are some masochists out there who’d like a bit more information on why this CICO bullsh*t is, well, bullsh*t (not 100%, but at least 94.6% [p<0.001]), I recommend listening to the podcast and reading the blog series linked to below: 

• Bill Lagakos, PhD, interviewed on the Sigma Nutrition podcast. GREAT STUFF on this calorie nonsense. Pay attention to when he talks about the biochemical effects of consuming salmon versus rice. (Many of you probably know Bill from his blog, Calories Proper. If you don’t, he is big-time awesome. Be warned, however: if my blog is the layman’s plain English explanation of biochem & physiology, then his is the one the experts go to.) 

• There is No Such Thing as a “Calorie” to Your Body:  This is an 8-part series by J. Stanton, and it’s absolutely brilliant. (He writes much more succinctly than I do, so these are 8 short-ish pieces.) Each part ends with a link to the next one, but just in case, here are all of them: 1, 2, 3, 4, 5, 6, 7, 8. If you don’t have time for them now, do go ahead and bookmark them. The series is great for a rainy or snowy day, when you’re looking for something to set your brain on fire. (In a good way.)

Remember: Amy Berger, M.S., 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.