Always Hungry?

It’s not often that faculty members of major academic institutions do anything but sneer at low-carbohydrate diets. But that all changes now. Today brings the publication of a new book by a professor at Harvard Medical School, Dr. David Ludwig, on the virtues of low-carb dieting. As you can probably discern from the title, Always Hungry? Conquer Cravings, Retrain Your Fat Cells & Lose Weight Permanently, this book isn’t an academic treatise about some arcane aspect of carb restriction. It is, doubtless, the most comprehensive book on all facets of low-carb dieting published to date.Always Hungry?_Ludwig

Dr. Ludwig starts his book with a brief description of the dietary struggles of Willam Taft, the 27th President of the United States. It is a story all too common for many of us.

In 1905, during his first term as secretary of war, William Taft weighed 314 pounds. On his doctor’s advice, Taft began a low-calorie/low-fat diet and exercise program, bearing striking similarity to standard weight loss treatment today. Soon, he reported feeling “continuously hungry.” At his presidential inauguration three years later, Taft weighed 354 pounds.

If you read the paper written about Taft’s efforts, you will see that from December 2 through December 24, 1905 he kept a meticulous handwritten tally of his daily weight. He ended up losing about 12 pounds over the 22 day period, while adhering to a draconian low-fat diet prescribed by his physician, showing that such a diet really can work for weight loss over the short term. But, as Taft’s ultimate result shows, the long term outlook is grim.

In an editorial published in the New York Times a year and a half ago, Dr. Ludwig details brilliantly why in the long run counting calories is doomed to failure.

Why is it so difficult to maintain a reduced calorie diet for any length of time? Because reducing calories, especially by reducing fat, leads to hunger, and hunger is hard to resist. Dr. Ludwig learned this both in his own life and in his experience with his many overweight patients.

Early in his career, Dr. Ludwig helped develop his hospital’s weight-loss clinic.

Like virtually all specialists at the time (and many to this day), our team … focused at first on calorie balance, instructing patients to “eat less and move more.” We prescribed a low-calorie/low-fat diet, regular physical activity, and behavioral methods to help people ignore hunger, resist cravings, and stick with the program. When they returned to the clinic, my patients usually claimed to have followed recommendations. But with few exceptions, they kept gaining weight — a depressing experience for all.

At the same time Dr. Ludwig was working with patients in the clinic, he was also involved in research. He found that his own research, along with that of many others, “demonstrated a fundamental principle of the body’s weight-control systems:”

Impose a change in behavior (for example, by restricting food), and biology fights back (with increased hunger). Change biology, however, and behavior adapts naturally — suggesting a more effective approach to long-term weight management.[italics in the original]

He “began to realize just how little evidence there was to support the standard obesity treatment.”

As he writes,

Soon my entire perspective shifted. I began to see food as so much more than a delivery system for calories and nutrients. Although a bottle of cola and a handful of nuts may have the same calories, they certainly don’t have the same effects on metabolism. After every meal, hormones, chemical reactions, and even the activity of genes throughout the body change in radically different ways, all according to what we eat. These biological effects of food, quite apart from calorie content, could make all the difference between feeling persistently hungry or satisfied, between having low or robust energy, between weight gain or loss, and between a lifetime of chronic disease or one of good health. Instead of calorie counting, I began to think of diet in an entirely different way — according to how food affects our bodies and, ultimately, our fat cells. [italics in the original]

Let’s digress a little to discuss the difference between academic physicians/researchers and clinicians in private practice.

Academic researchers vs clinicians in private practice.

When I stumbled onto the low-carb diet as the most successful way to help my patients lose weight, I was in private practice. Just about every diet book author falls into that same category. We’ve all seen what works by working with our own patients.

When I was on all of the many book tours I’ve been on, doubtless the most common question I’ve been asked is: If your diet is so good, why don’t you do a study? Most people have no clue what is entailed in doing a study, so, from their perspective at least, the question is a reasonable one.

But studies aren’t that easy to do. First, they require a lot of money. Second, there is a lot of bureaucracy involved, i.e., submitting to institutional review boards and various other procedural issues. Third, there is no guarantee of your results ever seeing the light of day. Frankly, most private practice clinicians don’t have a clue about how to get a study published.

Academic physicians, such as Dr. Ludwig, are set up not only to take care of patients, but to do studies as well. In fact, it’s pretty much demanded of them. The university systems within which they work provide the framework and some of the funding for these studies.

So, unlike their private practice counterparts, academic physicians can do the studies to prove (or disprove) the effectiveness of different therapies and diets.

During his 20 years of experience teaching, researching, and treating patients at Harvard Medical School, Dr. Ludwig has “overseen dozens of diet studies, authored more than 100 peer-reviewed scientific articles, and cared for thousands of patients struggling with their weight.”

The result of this effort has led him to a couple of conclusions regarding what drives obesity.

Overeating hasn’t made our fat cells grow; our fat cells have been programmed to grow, and that has made us overeat.

What is the driver of fat cell overgrowth?

Insulin’s effects on calorie storage are so potent that we can consider it the ultimate fat cell fertilizer.[italics in the original]

Dr. Ludwig’s studies on diet and insulin

One of the terrific features of Always Hungry? is the number of studies showing the superiority of the low-carb diet that Dr. Ludwig discusses in detail. Most of these studies he and his colleagues have themselves performed, so you’re getting the direct information. Another feature of the book is the 22 pages of citations, which is catnip for me and other medial literature hounds. Pretty much anything published on low-carb dieting is listed.

I want to take just a few moments to hit the highpoints of a few of Dr. Ludwig’s studies.

One of my favorites is one published in JAMA in 2012 showing that the body doesn’t treat all calories consumed equally.

In a seven month feeding study, during which researchers provided all the food, 21 young adult subjects went through multiple dietary regimens. After the weight-loss (~25 pounds) and weight-stabilization phases, the subjects went on diets with the same number of calories, but different carb, protein and fat ratios. One month was a high-carb diet (60 percent carb), another was a moderate-carb diet (40 percent) and the other was a low-carb diet (10 percent). The goal was to see if there were any differences in the number of calories burned in each of these three phases. Since the ‘calories in’ were the same for all diets, the number of ‘calories burned’ should be the same. It didn’t turn out that way, though.

We found that the participants burned about 325 calories a day more on the low-carbohydrate compared to the high-carbohydrate diet. This difference is equivalent to about an hour of moderately vigorous activity, in effect without lifting a finger.

One of the reasons I like this study so much is that it confirms what I had speculated. I wrote a post a couple of years before this study and guessed (based on many years’ experience with a lot of patients) that the metabolic advantage of a low-carb diet would be in the range of 100-300 calories per day. It was nice to see that number validated.

A couple of the really exciting studies Dr. Ludwig performed had to do with the after effects of high-carb diets as compared to low-carb diets.

I’m going to quickly mention just a couple, but you can read about these in detail in Always Hungry?

Dr. Ludwig and team provided adolescent boys three different breakfasts, each with precisely the same number of calories. One breakfast was a highly processed carb breakfast, another was a minimally processed carb breakfast, and the last was an omelette and fruit.

Blood sugar levels initially tracked with both amount of carbohydrate and the degree of processing, which would be expected. More easily absorbed carbs would get into the blood more quickly. But four hours later, the blood sugar levels of the kids who ate the breakfast of highly processed carbs were lower than those who ate the intermediate carb meal and the omelette. So, quickly up and quickly down.

Are these results mere scientific curiosities? Changes in the emergency stress hormones suggest not. Adrenaline surged at four hours after the [highly processed carbs], but remained stable after the other meals, suggesting the brain had experienced a true metabolic crisis — signs of hypoglycemia — after the [highly processed carbs].

To me the most exciting aspect of this study was the next part.

The researchers gave the teens these same meals for lunch, then provided them with platters of tasty foods and allowed them to nosh on as much as they wanted for the rest of the afternoon. Of course, the research team carefully measured the number of calories consumed over the afternoon. What did they find? A huge caloric difference in intake depending upon what had been eaten previously. Those consuming the high-carb breakfast and lunch ate a whopping 650 calories more over the rest of the afternoon compared to those who had the omelettes and fruit.

Similar effects have been observed in more than a dozen studies by different research groups. If only a small fraction of this 650-calorie difference happened for the general public meal after meal, day after day, it could account for much of the increase in body weight since the 1970s, as consumption of highly processed carbohydrate soared.

The final study I want to touch on is one Dr. Ludwig’s group did showing what happens in the brain after consumption of corn syrup, a highly processed carbohydrate found in many, many processed foods.

Overweight males consumed two different milkshakes. One contained corn syrup and the other uncooked cornstarch, a carb, but a slow-acting one. Aside from those differences, the two milkshakes were exactly the same: they each contained an equal number of calories and had the same macronutrient composition. The sweetness of the shakes was kept the same by the addition of artificial sweetener. The study was double blind in that neither the staff nor the patients knew which shake was which.

As in the study mentioned above, blood sugar rose faster and higher after the corn-syrup laden shakes. And, in similar fashion, the blood sugar fell further, and those consuming these shakes reported greater hunger. What’s really interesting, though, is what happened when the researchers scanned the brains of these subjects.

We conducted brain imaging scans, using a technique called functional magnetic resonance imaging (fMRI). The scans detected one brain region, called the nucleus accumbens, that lit up like a laser after the fast-acting shake. The effect was so strong and consistent, it occurred in every one of our participants, providing strong statistical confidence in the results. The nucleus accumbens is considered ground zero for reward, craving and addiction — including alcohol, tobacco, and cocaine abuse. Activation of this brain region on a weight loss diet would erode will power, making that sticky bun exceedingly hard to resist.

Hunger is hard enough to fight under any circumstances, but once the nucleus accumbens joins in, it’s all over.

These are just brief examples of a few of the many fascinating studies Dr. Ludwig describes in his book.

He discusses the many studies showing the low-fat diet to be of limited value. He also writes about the many studies showing low-carb diets to be vastly more effective. He discusses at length the issue of chronic inflammation and how it affects the fat cells and, consequently, obesity.

Here is a short video in which Dr. Ludwig talks about why low-fat diets have been such failures.

I was delighted to see Dr. Ludwig delve into the idea that chronic inflammation adversely affects the hypothalamus, which is a current interest of mine. When scientists want to make a laboratory animal fat, they can easily do so by damaging its hypothalamus. I’ve thought for a long time that the hypothalamus might be the root of the problem of resistant obesity.

Most people, it seems, can chug along okay and eat pretty much anything they want until they become obese and develop insulin resistance and all the rest that goes along with it. I’ve always suspected the hypothalamus must somehow get damaged in this process, because after the damage is done, it is difficult to control obesity, especially without carb restriction.

Sleep, gut bugs, fructose, fetal programming and salt

Not only does Dr. Ludwig dive into the literature, much of which he wrote himself, on the dietary control of obesity, he also looks at the studies on how important sleep is in both preventing and treating obesity. And how the multitude of bugs in the gut play a role in our health. He also discusses how obesity and excess carb consumption can even affect infants in utero.

He talks about empty calories and how fructose fits into the obesity equation. You’ll probably be surprised at what he has to say.

Ditto for salt. He lays out all the latest research showing how salt intake relates to insulin resistance.

And this is just the scientific part of the book.

The solution to the obesity problem

In this section of his book, Dr. Ludwig lays out an encyclopedic plan to, as he says in the subtitle, conquer cravings, retrain your fat cells and help you lose weight permanently.

In my time, I have read a lot of diet books. In fact, I’ve written a lot of diet books. And I can tell you unequivocally that Always Hungry? is the most comprehensive one I’ve ever read. There is nothing I can find that Dr. Ludwig has left out. He has recipes, shopping lists, substitution tables, a guide for roasting nuts and seeds, a series of weekly prep worksheets, the list goes on and on. He even includes a section on how to stay on the program at an Italian restaurant, a Chinese restaurant, a Mexican restaurant, etc. etc. etc. as the King of Siam would say.

Lest you think I’m a PR guy paid to hype Dr. Ludwig’s book, I’ve got to confess that I do have a few minor quibbles with it. First, he is a little less embracing of saturated fat than I am. Whereas I welcome it with open arms, he is still a little stand offish. But he does lay out the studies on which he bases his opinion.

Second, he recommends a little less carb restriction than I typically do. But, as he admits, people can lose faster on a lower-carb diet. He just feels that although it takes a little longer with a slightly higher level of carbs, such a diet is much more user friendly. And a diet easier to stick to will probably help people hang in there better through the hard times.

Finally, Dr. Ludwig is much more taken with the idea of the glycemic index (GI) than I am. And the glycemic load (GL). I’ve always been of the opinion that the GI and GL are basically carb restriction tarted up so that it is more palatable to the academicians, most of whom can’t otherwise abide the thought of a low-carb diet. Given the studies Dr. Ludwig has done on the slower absorbing carbs, i.e., those that are low GI, I can see how those carbs would cause less of a problem.  But, still, old prejudices die hard.

These tiny quibbles aside, and they really are tiny, I can’t think of a better book to read if you’re planning on starting a diet or restarting your diet. Or if you have a friend or family member who is struggling with weight, this is the best book you could give them.

I can’t recommend it highly enough.

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86 thoughts on “Always Hungry?

  1. “the GI and GL are basically carb restriction tarted up so that it is more palatable to the academicians”

    When I was collating the research for Principia Ketogenica I came across one called “LoBAG* Diet” that had me scratching my head for a while, until reading through the paper and realised that’s exactly what they were doing – avoiding any possible way of saying “low carb” or “Atkins” for fear of being conflated *that* crowd.

    *Low Biologically Available Glucose

    • Yep. LoBAG. I think that was coined by Frank Nuttall and Mary Gannon, who have collaborated on some terrific papers. Same reason, though. Making low-carb easier to stomach by academics.

      • Originally funded by the American Diabetes Organisation! I think the funding went away because they kept coming up with the “wrong” result.

        • Ha ha ha! Isn’t that the truth. The still advise eating “moderate” carbs………as long as they are whole grain. As if they don’t create blood sugar.

          • Curiously while their “medical nutrition therapy” promised an improvement in A1c of 1 – 2%, people on their very own forum were routinely reporting 5 – 8% improvements and sometimes over 10%. Probably still the case . Anecdotally this is very common on most diabetes forums but never seems to occur in “studies”. Look at their sponsors to see why this might be so – and why they have been bleating for over a decade that “there are no long term studies of low carb diets” without financing one.

  2. I read your review of this book with interest. A friend of mine in the U.S. is a huge fan of your Protein Power book. I haven’t read it yet, but I didn’t have great success losing weight the times I tried Atkins. I think the problem is that while carb-restriction certainly reduces appetite, it doesn’t reduce it sufficiently (for me) to naturally reduce the calories I eat enough to actually lose weight.

    In 2012 I had a heart attack and one stent installed, and afterwards my doctor recommended an 1800 calorie/day diet and lots of exercise – that was the only advice. I decided to go further than that and went on the Ornish heart-disease reversal program. I stuck with it for about 700 days and did lose 40 kg. But then eating urges started coming back and I’ve since regained half of what I lost. On my vegan diet my HbA1c dropped to normal naturally over time (I think that is just affected by weight – not by the kinds of food I eat). But my cholesterol did not drop until I started taking one daily statin. It’s been normal since then – again regardless of what I eat – vegan, lots of eggs, it doesn’t seem to matter. My blood pressure has always been normal.

    I’m desperate to avoid a full rebound, and so on January 1st I again started a vegan + no oil + no nuts diet and am logging all calories and exercise and sticking to within 1800 calories/day. This first week so far I’ve lost 1.2 kg (2.6 lb). But… (1) I’m always hungry and (2) digestively I feel too bloated. So I worry about whether I can stick with this long term.

    I’m always toying with the idea of trying low carb again, but Atkins 20 carbs/day plan never really worked for me. I know it was just that I was eating too many calories. I’m suspicious of diets which claim calories don’t count (like Gary Taubes claims).

    Anyway, I found this review interesting. I’m thinking of buying the Protein Power book and reading it – but I notice the version at Amazon was written in 1997. So I wonder why it hasn’t been updated the last 18 years. Nevertheless, I’m curious and toying with the idea of trying low carb again.

    But calories do count, right?

    And if I go low carb, what to do with the air popcorn maker I just bought? 🙂

    Thanks for the interesting review.


    • Yes, calories do count. Even on a low-carb diet. But usually on a low-carb diet you don’t have to worry about counting calories because the calorie issue usually takes care of itself. And, as Dr. Ludwig discovered when he studied it, you burn more calories on a low-carb diet.

      Protein Power is still a good source of info, but it’s not as up to date as Dr. Ludwig’s book. We are working on a 20 year anniversary edition, but it won’t be out for a while. Given your previous problems with a more rigid low-carb diet, I would recommend Always Hungry since it is advocates a little higher carb content.

      • Hi Dr. Eades,

        Hope all is well.

        Energy is nothing more than a very abstract mathematical concept. Energy ,itself , is not anything. It is merely a concept, a property. It has no existence in physical reality. Energy is entirely a very abstract man made , human mathematical concept, nothing more.

        Calories are not anything, they are a concept. They are just a unit of energy and have no existence in reality. Fire is not energy, it is a collection of hot particles that habe energy. Photons are not energy, they have energy. Huge difference. Energy can only be conberted into other forms of energy. Calories do not matter, but CARBON does. There is no caloric energy EVER being turned into,matter in a human, and that is what bone, organ, muscle and fat tissue are -matter.

        Carbon, matter, it is matter that builds our bodies. And it is the removal of ATOMS that make us lose matter. “Calories” (they are only an abstract concept) have nothing to do with it. All the atoms are still present. Unlocking the carbon is the first step. Atoms cannot be burned away or burned up. Without atom removal, no weight will ever be lost. Fat is matter. It is made of atoms. Fat is NOT turned into heat or energy or “pure energy”. Most doctors got this surbery wrong. Pure energy is no se se. Energy itwelf, is a is not stuff, not anything itself. Cellular respiration is extremely selective amd hereditary, genetics, age, disease states, etc, can affect it. Burning dood is irrelevant and an extremely poor analogue ofmwhat hapoens to matter, molecules in our body. Not even remotely the same. Fire is wild indscriminate oxidation.

        Complex biochemistry and partitioning of matter and resultant chemical interactions determines what it becomes. Some people lay down fat tissue way easier than others. But not a,single calorie EVER,turns into matter of any sort in a human or animal. Saying that it does actually violates conservation of energy . Because energy can only be conberted to other forms of energy. On the scale of themunibers3,it does not apply. Did you know on the cosmic scale energy is NOT conserved? We already live in a uniberse where energy is not,conserved. For example, the expanding universe etc. Conservation of energy is conditional. Locally it is, but not onthe cosmic scale. “Energy Is Not Golden Sacred Cow Urine” is a great article to read by an excellent physicist. Energy and matter are as different as worms and heaven, as physicist Matt Strassler notes. E=Mc2 is a UNIT conversion equztion that deals with MASS , which is much different than matter. Mass is NOT stuff either. Mass, like energy are Properties, concepts only. That equation is converting in the sense of 3 miles to 5 kilometers. Even Dr. Sharma I had to correct. In nuclear reactions the rest energy of urnaium atoms is converted into kimetic energy. No transmutation

        In science laws are not holy truths hamded down or somethi g imoosed upon the universe. We humans make MODELS and guesses, that is all laws are. .They can and are broken and we make new models. These laws are not at all something imposed upon the univerwe. Physics itself is what WE say about nature, NOT how nature really is as Bohr noted. The calorie idea is wrong. CARBON flow AMD EXTRETION of CARBON MATTER is behind the mechanisms.

        I support low carb because it ties in with possibly helping the biochemistty of what becomes fat tissue from our carbon ingestion.

        Energy is an extremeky difficultmcomcept as Feynman stressed. It gave him trouble. I eee this concept abused daily on the Blogosphere. Usually by the CICO paths. That is fitness industry nonsenseztalking about caoories as if theynare stuff or physical realuty. Particle physicsts laugh at that . I am dedicated to exposing the CICO people.

        I hope your readers will tell them what physicsts told me” Assigning reality to an abstract human matjematical co cept is oberdoing it “. There are NO BOOCKS as Feynman stressed.

        Best wishes,

    • Doug, if you drink coffee you could roast your own coffee beans in the air popcorn popper! In the U.S. a great source for green coffee beans, and how-to videos is Sweet Maria’s. Since Mike is a coffee lover I hope he won’t mind me mentioning Sweet Maria’s.

      I want to do low-carb but like you, Doug, I have some trepidation. I will be buying Ludwig’s book (I’ve read other low carb books including PP, and Volek & Phinney) to see if it can convince me. I too have had success losing weight (with equal success on blood work) with an Ornish/McDougall-type, high-carb (about 80%) whole foods, no oil, low-fat vegan diet. But, yes, I was “Always Hungry” and had to eat about every 2 hours. Also, it was hard to eat out. About 8 years ago I lost 30 pounds on it but over the last couple years gained 10 back. Like so many of us, no matter what the diet, I became lax in my following of it, thus the weight gain. I’ve been trying to restart it but I just can’t enjoy the extremely low fat food, all the time, anymore.

      Even though I’ve been eating fat, and animal meat for a while I’m nervous about eating it, especially in light of being a “High Risk” for heart problems partially due to my Beta-Sitosterol level. This I was told relates to cholesterol absorption. I hope there is some information on this in Ludwig’s book. Currently, my total cholesterol cholesterol is mid 200s but got down to 170 on McDougall diet. No high blood pressure, nor diabetes. No meds.

      I hope I can have my cake (lamb chops) and eat it (them) too. I think I’ll cry if I have to go back to sauteing garlic and onions in water (yuck) as I did following a Ornish/McDougall-type low fat program!

      Thank you, Mike for all your book reviews. Love them, especially the non-diet ones. Mike, btw, do you still like your Nespresso? I’ve thinking of getting one.

      • Elle,

        Yes, you and I sound like we are in very similar situations.

        I actually loathe coffee though. 🙂

        Usually I am fine drinking just water. That’s 99% of what I drink. But I might have plain green or black tea, with no sugar sometimes.

        One thing I prefer about low-carb / high-fat eating is that usually it feels “digestively” better. While on Ornish, even though I lost 40 kg and kept it off for almost two years, I was constantly feeling bloated and never really felt comfortable. That feeling goes away when doing low carb in just one day. But… on low carb I gain weight! At least so far. I haven’t been able to find the “perfect plan” yet.

    • Hi Doug,
      Just an observation. Many people do not realize that a low-carb diet is actually a high fat diet. This is understandable as eating fats has been considered a no-no for weight loss. But the truth is that eating fat does not make us fat. The level of insulin is what initially determines how much fat we store. And I high insulin level can prevent us burning fat (hypoglycemia). Once we have reached a metabolic syndrome in our bodies because of all the sugar we’ve been ingestion for years and years, all bets are off. But in order to drop weight you need to keep your insulin levels as low as you can through diet alone. That means keeping your carbs (ie: glucose) down as much as you can.
      Well, ok, but don’t we need carbs for energy? The answer is “no”. Fat is also an energy source and archaeology teaches us that it was probably the energy source we evolved to utilized most efficiently while carbs we a once in a while treat.
      The bottom line is if you get rid of carbs you must replace them with fats. Then the struggle to stay on the low carb diet evaporates. I’m talking 5%Carbs, 20-30%Proteins, 65-75%Fats daily intake.
      Also, upping your fat intake will not impact your bad cholesterol level as that is ironically actually driven by carbohydrate consumption.
      So a great book to read is The Art and Science of Low Carbohydrate Living.
      One Last Note, not all fats are created equal, some need to be avoided so do your research:

      • Hi Diana,

        I can buy that eating fat doesn’t make us fat. By itself. But as Dr. Eades said above, calories do count. So eating too much fat (eating too much of anything) can cause us to gain weight.

        I wonder if the fact that I probably have reached metabolic syndrome is what is preventing the low-carb diet from helping me lose weight.

    • Doug,
      I’ve read many times recently that the main reason that the Atkins Diet does not work for some people is that they are eating too much protein! Protein does stimulate insulin to some degree and I don’t think Dr. Atkins wrote about that. It’s been many years since I’ve read the book but I believe the new updated version covers that fact. Eating more fat and reducing protien to a minimum has worked for me as well as many individuals I’ve read about. Perhaps you’re extreamly insulin resistant like me. At one point many years before my Ketogenic diet, my tryglisarides were 1200. When I start getting real hungry I can tell I’ve been eating too much protien and if I eat just a little pure fat, the hunger goes away and stays under control.

      • Steve,

        I may very well have become extremely insulin resistant. But doesn’t Dr. Eades recommend a lot of protein?

        What kinds of pure fat do you eat that is low in protein? Except for butter and oil I can’t think of any high fat low protein foods.

    • Get a full thyroid workup. Don’t let ’em put you off with just a TSH test, either. You’re describing low T3 syndrome: heart attack, increased blood cholesterol, insulin disturbance, unmanageable weight. (I’d guess your BP has gone up as well, even if it’s not yet called hypertension.)

      80% of people over age 50 have some loss of T4 to T3 conversion capability, so their T3 is low, but their TSH and T4 levels will still test in the “normal” range. 50% of cardiac incident patients have low T3. When T3 is low, some of what you eat will always be stored as fat no matter how restricted your calorie intake, and borderline hypothyroidism can also make you feel hungry ALL the time. I could go on and on about this, but those are the basics.

      • Hi Reziac,

        No, it’s not my thyroid. And my BP is usually fine – like 116/67. As a matter of fact it only jumped up to 132/70 while trying Protein Power for 12 days. Or maybe it was just the weather turning cold. At any rate, my blood pressure has always been normal, which amazes my doctors, considering my weight.

        My blood cholesterol has also been under control for at least 4 years now – smack in the middle of the normal range.

        My blood sugar has been rising as I have gained weight though. If I lose weight I find my blood sugar goes down naturally, no matter what I eat.

        So the trick, I think, is finding a way to lose more weight!

    • Have been reading lots of LC, and/or HF diet etc.. Have tried LCHF and do agree that this diet helps level up your blood sugar (but increase HDL and LDL at the same time) . I still cannot get over the fact that the Asian who eating HC for centuries are all very slim. We can see that the Chinese started to get all sort of disease now – when they are getting wealthier -> eating lots of food (not just carbs).
      I am still in doubt that it is only the carbs that caused all the problem…

      • Penny,

        That’s what I don’t understand either – and would love to see an explanation of it. I live in Japan and am surrounded by rail slim people who mostly eat refined grains (e.g. white rice, udon, ramen, etc.) and very little protein or fat.

        The obesity rate here is one-tenth that of the U.S. and we have about the longest lifespans in the world.

        I can’t wrap my head around the contradiction, and haven’t seen an explanation of that in the Protein Power book, or by Gary Taubes, or at the Atkins site, etc.

        And it’s not just added sugar either. Everything here has sugar in it!

        I would love to figure that out.

  3. Great!! 20 years ago I learned most of this by following you and Mary,,
    I am always under 110 pounds and your life style was complete,, I recomended
    it still,,, Nice to know research proves what you have always taught,, Thank you, Cj

  4. I work in a skilled nursing facility, and the diet plans for diabetics have always been horrendous, (pie, fruit juice, sugar laden processed foods, then cover it with insulin) but at least the dietitians are paying lip service to carb restriction, at least on paper. But what comes out of the kitchen shows they really still don’t get it. I think the patients are going to have to take the initiative and empower themselves.

    • That’s why a book like this from a professor at the most mainstream of mainstream institutions will make an impact. I’m hoping it will change a lot of the kind of thinking you discussed.

    • I have a disabled sister who lives in a group home in Michigan. She’s “pre-diabetic” and is supposed to be on a low-sugar diet, per her doctor. So, no cookies or candy, but she can have all the orange juice, bread, starches, etc. that she wants. I had them give me a list of food for a typical day. It added up to more than 300 grams of carbs!!! I tried to explain that a low-sugar diet means low carbohydates in all shapes and forms, too. It fell on deaf ears.

  5. Ooh, I wonder what Uncle Walt (Willett) will have to say about this book!

    The breakfast experiment demonstrates exactly what used to happen to me (and thousands if not millions of others) dutifully eating our high carb breakfasts. The insulin turns up late, then fails to shut off properly, leading to a blood glucose drop too extreme for glucagon alone to handle, so it calls in its big brothers epinephrine, norepinephrine and cortisol. The result is BG rollercoastering for hours.

    This used to be called “reactive hypoglycemia” but I understand this must no longer be diagnosed and is replaced by “idiopathic postprandial symptom” thus carefully insulating doctors from the mechanism or how to defeat it, namely eating low enough carbs to avoid the glucose spike and the ensuing insulin spike.

    I might buy this one, not just to read but to leave to my doctor in my will, along with Protein Power, Taubes, Sissons, Bernstein and Gretchen Becker.

    • Thanks for the great comment. If you do buy Dr. Ludwig’s book, please let me know what you think of it. Given your obvious familiarity with the issues, I would be curious to know your take.

      • Don’t hold your breath waiting! I’m currently reading/rereading a whole bunch of blogs. I dropped yours and William Davis temporarily, and Mark Sisson permanently, simply because of the volume, and Stephan Guyenet when he became a shill for the foodlike substance manufacturing industry. I still have some catching up to do!

        I dropped by to see how Protein Power 2.0 was coming along. People Who Know Stuff recommended the original PP as one of the best overviews, a sentiment with which I agree. The problem with books is that they are out of date even before they are published.

        How does Ludwig compare to Phinney & Volek? – another I haven’t gotten round to reading yet.

        • Dr. Ludwig’s book and the Volek & Phinney book are apples and oranges. Always Hungry? is a thorough and comprehensive guide for someone wanting to follow a low-carb diet. The Art & Science of Low-Carbohydrate Living is a bit more technical and is designed basically as a manual for physicians wanting to put patients on low-carb diets. Both books are excellent, but come at the issue from a different perspective.

  6. Thank you for this. I am grateful for you and your blog. You say all the things I want to but don’t have the words or education for. I share your blog posts frequently. I’m off to buy this book right now!

  7. What I found most interesting is that these studies would be news to Dr. Eades. It really shows how hard it is to nail down the death of low-fat when untwisted solid evidence is not well known. I guess media have their own agenda matching their low fat dogma.

    Sounds like this book should go along well with The Big Fat Surprise and Good Calories/Bad Calories.

    • No, I’ve been aware of these studies since they were published. It’s just nice to see them written in a diet book by the guy who did them. Had I been blogging as actively as I have at times in the past, I would have posted on each one. Especially the one showing the 325 calorie metabolic advantage.

      It is a nice companion to the other two books.

      • > Especially the one showing the 325 calorie metabolic advantage.

        Perhaps you should have made an exception here – if only for provoking that little moron down under, that – apart from having become completely irrelevant – still etches around on his website, continually dazing his (insulin resistant) followers with his guru-like praises of the mertis of carb loading and still slagging anyone who does not appreciate his sermons or even dares to question them…

  8. Thanks for this in-depth review. I’m going to send a copy to my daughter’s boyfriend, who’s in medical school. It amazes me that there is almost no discussion of diet in medical school—although at USC medical school, apparently, students do take a nutrition class (whatever that means). Maybe this book will give him a different framework. Does Always Hungry? address how people with Hashimoto’s should approach low-carb diets? How about athletes? Or is it more of a general discussion of the benefits of low-carb? Oh, and keep those monthly book recommendations coming—I love them!

    • This is the reason I think it’s so great that Dr. Ludwig is a professor at Harvard. Send a diet book to someone, and the first reaction is that it’s a fad diet by some know nothing. It’s a little more difficult to make that case when the author has great credentials.

      The book doesn’t really address specifically the issues you brought up. It is more of a general book on guiding someone through a low-carb diet.

  9. After reading your review, I went to Google Books to preview some of the book. In the parts I could preview, the author mentioned his website: He also mentioned a “Simplified Meal Plan” for single persons and persons who don’t cook a great deal. At the website I found a link for “Supplemental Materials.” There he has sample menus and full shopping lists, and in an Appendix 2 he has an outline of the Simplified Meal Plan, where he also gives a few of his simple recipes. Of course these free materials don’t supplant purchasing the book and may actually further inspire you to buy it, especially if you like simple.

  10. Banting all over again, isn’t it?

    I just want to stick my head on the Diet Purity chopping block and say counting calories is not only sometimes useful, for some of us it is mandatory. For me, it is the only way to keep my intake honest. My nag.

    I grew up bean pole skinny, 135# on a 6’3″ frame. Weight about perfect in my early forties, then kept going. Got to 280, down and up and down and up, etc. since then. Being someone that not only could eat as much as I wanted for the first 50 years of my life, in those earliest decades, I had to. So, my theory goes, I have a half century of eating habit that is really hard to reign in. Beyond the reward concept.

    Thanks for the review, it sounds great.

  11. Dr Eades,

    Thanks for a detailed review.

    I was wondering what percetage of carb calories is recommended by Dr Ludwig and also if any other issues, except adherence, with VLC have been highlighted?


    • Starts at 25 percent carbs in the early phases and moves to 40 percent carbs. All carbs are of the low-glycemic variety. I saw no other issues.

      • I think you have pointed it out before that no matter how low the GI, total amount of carbs DOES matter. I guess fat has to be quite low for 40% carbs to be effective?

        • No, Dr. Ludwig’s plan calls for about 50 percent fat. If the glycemic load is low, the carbs don’t exert the same effect and don’t matter as much. It’s just always been easier for me to think of cutting carbs than looking stuff up and multiplying the GI times the grams to get GL. But this book pretty much does that for you, so it’s not so burdensome.

          • I’m traveling right now, so I don’t have the book in front of me. I think the relative amounts of the macronutrients shift around a little differently on the final phase.

  12. re salt, not all salts are equal. According to what I’ve read Sel de Guerande is full of minerals and not bad for you. Also I think Weston Price’s research on fats is the one to follow and he is in favour of saturated fats, unlike modern medicine.

    • The amount of minerals in any consumer salt is negligible, sea or otherwise. While I’m just guessing, I’ll bet a gram of liver has more minerals that a daily dosing of sea salts on your food. To say nothing of all the good stuff!

  13. I found this review really interesting. Not that I needed to be convinced.

    I have been doing Atkins (new version) for almost a month now . The ridiculous problem with it is that I am never hungry after the first meal of the day (I eat 16:8) so I am having trouble eating enough salad etc and so I am loosing really slowly but I do notice that fat rolls are melting way 🙂

  14. Thank you Dr. E, I value your opinion.

    I was wary about what Dr. Ludwig’s real message is, because reading about the “Optimal Weight for Life” program he heads at Boston Children’s the cover photo shows a staff member appearing to instruct a child on how much orange juice is OK to drink (see

    On their “healthy recipes” ( there are a lot of carbs in the form of bread, legumes, grains and fruit–even some agave syrup, but low fat is emphasized with low fat dairy products, reduced fat mayo, egg whites, chicken and turkey breast. No red meat is on the menu or shopping list, and cooking spray is recommended for cooking–no natural cooking fats. One recipe (zucchini muffins) has a little canola oil in it. I don’t know how low glycemic the recommendations are, but they really read as just another low fat, calorie restricted menu for obese kids. I think these kids would be “always hungry” on the recommended diet.

    • I haven’t looked in depth at the Optimal Weight for Life program, but I have read Dr. Ludwig’s book carefully, and I can assure you that, whatever the situation at OWL, the book is terrific. And it really is a low-carb book.

  15. I was KETO for two years, then graduated to ZC (zero carb) for over a year now. I am nine books deep, mostly all the best sellers of low carb, I’m ready to order this one. Question, wouldn’t it be great to be interviewed by Jimmy Moore?

    • Who? Dr. Ludwig or me? I think Jimmy is going to do an interview with Dr. Ludwig. I’ve had a dozen interviews with Jimmy. I’m trying to figure out how to do a Skype interview and have a chat with Dr. Ludwig myself. If I can figure out the technology and actually make it all work, I’ll post the interview.

  16. Nothing in the book about fasting, as I see it as a form of low carb since you are eating zero carbs and using fat as fuel?

    • True. I suppose fasting could be construed as a form of low-carb. I didn’t see it in the book in my reading. I think Dr. Ludwig’s strategy is to keep his patients eating filling foods that stave off hunger while allowing a steady but sure loss of fat take place.

      • I’ve never deliberately fasted but I find my body does it for me. On the HCLF diet I would need to eat every couple of hours, or I would sometimes literally fall over.

        I started by doing this

        which was devised by diabetics in 2002 if not earlier and based on Bernstein, then fine tuned the process of dietary change by following my lipid panels (doubled HDL, trigs 10% of what they were, not much change in LDL, nothing out of the ordinary!)

        Now I mostly eat a small low carb high protein moderate fat breakfast and usually go 5 – 8 hours and often over 10 hours without getting hungry or needing to eat. I have my main meal – low carb, moderate protein, high fat – any time between late afternoon and late evening, and usually a high fat snack at night.

        The way my body sees it is that my food is so rewarding (Ha!) that it keeps me satiated for long periods. The process only breaks when I spike my insulin.

        Ten years later and the only real problem is that I am ten years older . . .

  17. I’m curious as to whether Dr. Ludwig discussed the linoleic acid content of of our modernized food supply as it relates to obesity. Bill Roberts discussed the matter in this article. Joseph Hibbeln discussed the effects of high linoleic acid in this interview. Excerpts: Normally those high fat diets used for mice in studies are composed of high linoleic acid, found in soybean oil. When we deleted that one single molecule, the Omega 6 fatty acid, we were able to obliterate the ability of a 60% high fat diet to induce obesity in the mice… And we did it also in diets that were 35% of calories from fat, and also diets that were 12% of calories from fat. We were able to induce obesity in low fat diets, in the mice, by changing the bioactive properties of the fat, not just that it was high fat and more calories.”

    I find it peculiar that linoleic acid is routinely omitted from the picture. As Frances Sladek notes, The incidence of obesity in the U.S. has increased from 15% to 35% in the last 40 years and is expected to rise to 42% by 2030. Paralleling this increase in obesity are a number of dietary changes, most pronounced of which is a >1000 fold increase in consumption of soybean oil from 0.01 to11.6 kg/yr/capita from 1909-1999: soybean oil consists of 50-60% linoleic acid (LA), so the energy intake from LA has increased from 2% to >7%/day.

    Then, there’s this talk by Stephen Guyenet. I found it when I Googled David Ludwig linoleic acid.

    • He does not spend a lot of time discussing linoleic acid. Not because it’s not important, but because there is only so much info that can be realistically crammed between the covers of one book. If any author addressed every detail of nutritional medicine, it would take three large volumes like my set of The Encyclopedia of Nutrition.

  18. I just started low carb again, seriously this time, and your review of this book has really put the wind in my sails. Great to see academic support for a 325 cal metabolic advantage (how long before a certain Aussie comes out of the woodwork?)

    I get great pleasure from your lucid and witty writing style–a rarity these days! Keep blogging.

  19. Your review excellent, and I agree with it for the most part, esp. how much carb to include, though I’ve always felt fruit is fine for me. I’m happy to see Dr. Ludwig doesn’t go for artificial sweeteners, as they are the one thing about the low-carb diet that I can’t tolerate, no matter which I’ve tried. Not sure I’ll eat whole grains again, but you never know.

    I’m greatly interested in the advocacy angle of this program. I will try the shopping and so on, but this does not strike me as a diet for poor people, at least not in the community where I live, where good grocery shopping is very limited in poorer parts of town. And even if the stores were there, not sure the people could follow the diet without a lot of support and intervention to get them started–I’m having a bit of trouble not being overwhelmed by all the lists and things myself.

    On the whole, though, it’s a great book, really well written and edited, and the explanation about why insulin resistance is so important to understand is up there with the best–the kind of info I think will actual changes people’s minds and behavior.

    I remember in 7th grade learning about the Islets of Langerhans and thinking, “Well, if that’s the way it works, shouldn’t we not eat so much sugar and stuff?” I should have listened to my 12-year-old logic and saved myself a lifetime of difficulty!

    • I bought the book the day it came out based on advance reviews and for myself, I did decide to follow his menu for the first four weeks. As you say, I was surprised at how much the groceries were and that I had to go to multiple stores to find everything.

      That said, I think you could easily and cheaply follow Dr. Ludwig’s approach if you read the menu and incorporated the principles without actually following the suggested menu. Although I didn’t “officially” start until today, I started incorporating the main principles the day I bought the book, and followed them last week while I was on a ski holiday with friends (cut the sugar and carbs/grains, up the fat) and not only wasn’t hungry but lost some weight even without following the exact menu.

  20. I was interested in the idea that damage to the hypothalamus could be the root of the obesity problem. My question is can the hypothalamus be healed?

    • That’s the big question. And I don’t know the answer to it. It’s kind of like type II diabetes. Can it be healed? Many people completely get rid of all the signs and symptoms of type II diabetes by following low-carb diets. Does that mean they’re healed or just in remission? If they go back to their old way of eating, the signs and symptoms of Type II diabetes return. I suspect the hypothalamic damage works the same way, but I don’t know for sure.

      • In 2014 I took a class in Switzerland with famed Russian neuroscientist V. Klucharev. Altho’ adult brains can grow (very slowly) new neurons in certain brain parts, including parts of the hypothalamus, it currently seems we don’t grow new cells in the portion that controls body weight. See:

        So right now the answer is NO – once your body weight regulation in the hypothalamus is broken, you’re done. Game over. You will always be broken and often, always obese. Forever. Or until we discover a stem cell brain treatment. Best wishes.

  21. I have been browsing Dr. Ludwig’s book this morning, looking at recipes etc.. I have a question, if he thinks calories and fat don’t matter that much, why does he recommend using egg whites in so many recipes? I like to cook, but I have limited time with two little kids. Separating eggs is just one more step…. I wonder why he thinks it’s worth it? Chooesteral? calories? fat? I couldn’t find my answer in the book.

    In general I find many of these books don’t really value time. Every minute matters, I need short-cuts! While I appreciate the shopping list and weekly meal planner and recipes on the supplemental materials on the Always Hungry website, they are not written with the time-crunched person in mind. Make your own ranchero sauce? Really? Wholefoods typically has some salsa in the front near the produce. Wouldn’t that do? Every 5 minutes of chopping cutting and cleaning matters when you have little ones around.

    • I think the time thing is a trade off. If you make it yourself, you know exactly what’s in it. But it does take time. So, basically, you’re trading time for information. Which is fine. I think Dr. Ludwig is putting the recipes in for those who want to do it themselves. If you’re a good label reader, you should be able to find something close and save the time required to make it yourself.

    • Perhaps it is because a serving of egg whites is more protein dense than a serving of whole eggs, as typically one substitutes 2 egg whites for one whole egg. Two whole eggs have 12 grams of protein, but 4 egg whites will have 24.

      Than again, I am just an art teacher 😉

  22. I recognize his name as a leader of one of the NuSI studies.

    I don’t recall you commenting on NuSI. Are you confident that their studies will be a game-chasing as I hope (and my hopes are high)?

    Any idea when we’ll hear anything about their first results?

    And any idea when Gary Taubes will be publishing his long-awaited sugar book?

    Sorry for assuming you’re your brothers’ keeper.

    • I think, though I don’t know for sure, that the sugar book is finished. But the wheels of publishing grind along slowly, so who knows when it will come out.

      Same with the NuSI studies. I’m not really sure of the status.

      • Dr. Mike, Peter Attia recently blew outta NuSI. It’s going into slow-mo. Unsure if it will die without him, as the funders, the Arnolds, were his friends, not Gary’s. NuSI may wind down without Attia.

    • I suggest you grab a copy of Dr. Ludwig’s book and/or Protein Power. From these, you should learn a lot and start getting things under control.

  23. Great conversation all! Michael, I wish I would have found your book earlier on. I had my thyroid removed last March. I recently purchased Always Hungry and I am on day 3. I felt great day 1! On day 2 I felt a bit off, but I think my body was adjusting. By the afternoon, I was back to normal. Today, great. My downfall has always been popcorn and nibbling in the evening. For the past 3 days, I have not wanted anything. Not hungry at all. I couldn’t even eat the listed desert after dinner. I appreciated all the information in the book and the great recipes. Thanks for your wonderful review of the book. I feel better reading what you had to say about it and your thoughts about it.

  24. Hi Dr. Eades,

    Regarding being always hungry etc : Gary Taunes made truly excellent points in regard to exercise, specifically aerobic, for increasing appetite. Working up an appetite is real. People training for the 5 k (and more ) often get RAVENOUS. I know several who gained fat tissue and you hear this alot on those,forums. Gary Taubes even interviewed a long time runner (aerobics) and how he is fatter today.

    Things like 200 meter sprints or lifting weights with tiny breaks tend to stiffle the appetite, at least for most of the day. I have noticed long steady slower aerobic runs increase it a lot, especially for myself and my friends and people I work with. Really high carb diets that lack protein and fat create a persistent hunger pang for food- carbon matter (atoms) , not non-existent entitiy called calories(a concept and cannot act on a body) 🙂

    I choose a lower carbohydrate style of eating because it blunts hunger and probably better for hormones and diabetes prevention. There are also many unknowns about how this style of eating very well could affect carbon matter partitioning and lay down muscle tissue instead of all or mostly fat tissue. Complex biochemistry could explain why obese people lay down fat tissue so easily from overeating carbon (food) a bit, while typical mesomorph lays down some muscle too. I choose Art DeVany style workouts too because I feel they are good for hormones. Biochemistry and genetics are HUGE parts of obesity. They are right up there with carbon flow.

    I am glad Dr. Ludwig write this book. What do “authorities” tell us, oots and lots ofmaerobic exercise and high carbohydrate diet. This is a DISASTER for always being hungry. Hopefully, the book will generate attention and i spire people to think formthemselves and reject “authority” and the extremely poor science of the fitness/nutritional fields. We obviously do not u nderstand onesity that well and it is high time medical doctors admitted it. When is the last time we saw failed small pox or polio treatments? They obviously worked.