How Kevin Hall tried to kill the insulin hypothesis with pure spin

July 21 2016 by in Dr. Jason Fung, Gary Taubes, Ketosis, Low carb & high fat, New study, NuSI, Weight loss

Kevin Hall, the senior NIH researcher recently published a paper in AJCN that has received a lot of media attention. He claims this study refutes the insulin hypothesis so completely that it is now ‘dead.’ That’s interesting, I thought, as I sat down to read the article.

It was therefore a little surprising to read this paper and realize that Hall’s conclusions were entirely his own opinion. He suffers so badly from confirmation bias that he may as well have written “My mind is already made up regarding the insulin hypothesis. Please do not confuse me with facts”.

Confirmation bias is a well-known psychological phenomenon whereby facts that agree with your pre-formed opinion are accepted as true and those that are not are ignored. All facts become filtered through this bias to confirm your previously held opinion. It’s also known as a closed mind.

So, let’s take a closer look at this paper and its claims. The paper is titled “Energy expenditure and body composition changes after an isocaloric ketogenic diet in overweight and obese men“. Let me give you some background. The award-winning science journalist Gary Taubes believes that obesity is essentially a disease of too much insulin – hyperinsulinemia. As refined carbohydrates stimulate insulin more than fat or protein, reducing carbs will result in greater fat loss.

Gary Taubes set up the non-profit organization NuSI to raise money to fund research and this paper is the first one published. 17 overweight men were admitted to a metabolic ward where all the food they ate was carefully measured. There was a 4-week run-in phase to establish a baseline where men would eat a high carbohydrate, high-sugar diet and then switch to a carefully designed low carbohydrate, low-sugar diet. Various measurements were then taken, including energy expenditure (EE – how many calories the body is burning), over the next 4 weeks.

Does a ketogenic diet cause fat loss?

Here’s the result. Over the 4-week KD, yes there was fat loss. There was an initial period of greater weight loss which all agree may be some diuresis. We can also agree that insulin levels were brought down by the KD. Secondly, using measures of EE there was an increase in calories burnt.

Those are all facts, not opinions, derived straight from the study. Isn’t that a good result?

Well, if you’re Kevin Hall, no. You need to find a way to spin this in a negative way. Then you can tell all your friends in the media so you can declare ‘I was right.’ Let’s see how this was done.

When patients embarked on their run-in phase, they were switched to a 2700 calorie/day high-sugar high-carb diet, meant to replicate the Standard American Diet (SAD) that caused the obesity epidemic. Nobody actually believes that this is a healthy diet, and nobody believes it should cause fat loss. But it did. Why?

Anybody who has done research knows why. It’s the effect of going into a study and knowing that people are testing you. It’s a universal effect. That’s the precise reason why we have run-in phases. To establish a baseline.

So, people lost weight on this SAD diet. But instead of using this new baseline, Hall decides that the downward trend is the new baseline. The unspoken premise or assumption is that if these people had taken another 4 weeks of the SAD, they would continue to lose weight at the same rate indefinitely. WHAT? Are you out of your mind? That’s completely illogical.

Let’s take an analogous situation. Suppose we are teaching math. We teach one semester with no tests, no exams, no checking of homework and no projects. Students are just supposed to spend 1 hour in class and 1 hour of homework a day. They all say they do it. Then, unbeknownst to them, we test them on a standardized test. They do really bad and score 65%.

Next semester, they have daily tests, a final exam, and daily checking of homework. They still spend 1 hour in class and 1 hour of homework. Scores should be theoretically unchanged, because they were doing the same amount of work. Of course, in reality this is completely false. Because they know we are regularly checking them, they do a better job. Now they score 80%.

This is the same effect we see when people enter a study. No matter what we are measuring, things improve simply by entering a study. It happens with blood pressure, blood sugars, cholesterol, diets, depression – everything. But the results do not get better indefinitely. It’s a one time benefit.

Students’ scores might improve from 65 to 80 in one semester. This does not mean that another semester of testing will raise their scores to 95. Instead they will likely stay at 80. But this is exactly what Hall does – he assumes that this one-time benefit will persist indefinitely.

By making this assumption that the SAD diet will continue to cause fat loss (which logic tells us is false) you can make a positive result negative. So, yes, KD does cause fat loss, but does not INCREASE fat loss and then you can make this your conclusion. Since most of Hall’s journalist friends never read the paper and only the abstract, it’s easy to convince them.

According to Hall’s assumption, you should therefore simply continue eating the SAD with 25% sugar and expect to lose weight indefinitely. Go ahead. See what happens. I already know. So do you. You’ll get fat, you’ll get type 2 diabetes, and then eventually, I’ll put you on dialysis and chop off your feet when they go gangrenous. But at least Hall can say that he was right.

What about energy expenditure on a ketogenic diet?

The second major issue concerns EE. When you switch from the baseline diet to the KD, the number of calories stays the same. If it causes continued weight loss, then you might expect to see an increase in EE in order for the body to lose weight. This is called a metabolic advantage. Surprise, surprise – that’s exactly what happened. So how can you spin this one? With language.

Look at how Hall describes the absolutely critical increase in EE. Here’s what he writes:

the KD coincided with increased EEchamber (57 ± 13 kcal/d, P = 0.0004) and SEE (89 ± 14 kcal/d, P < 0.0001) [emphasis mine]

Hall is telling you that this was merely a coincidence that patients are all burning an extra 57 calories per day. WTF??? There is nothing coincidental about it. You switched them to a KD. EE increased. The P value of 0.0004 means that there is a 99.96% chance that this is NOT A COINCIDENCE. Hall knows this as well as I do. This is basic statistics 101. Hall, a mathematician is surely aware of this.

Hall is saying “Oh, we switched their diet to test if EE would increase. It really was just a huge coincidence that all 17 men simultaneously increased their EE altogether at exactly the moment we thought it would. Ignore this, guys. Just write your newspaper article about how this proves it didn’t happen.”

So EE increased and yes, the effect waned over time. What did he expect? That things would continue indefinitely in a straight line? Life doesn’t work that way. Hall had assumed this would happen for fat loss during the SAD, but then correctly points out that EE does not. It doesn’t in either case, dude. Get a clue.

The key to lasting weight loss

The reason why EE is so critically important is that this is the key to lasting weight loss. Hall had just been profiled in the New York Times cover page measuring the EE of Biggest Loser Contestants. The reason they all regained their weight was that their EE slowed to such a degree that caloric reduction could not keep up.

So, an intervention like a ketogenic diet that increases EE is HUGE, GREAT NEWS. Except, of course if you’re Kevin Hall, because it means you were wrong. And you care more about your reputation than people’s health and well-being.

Dr. David Ludwig, a researcher from a little place called Harvard had shown exactly this same thing in his study from 2012. This study also tested for difference in energy expenditure following different dietary strategies. Once again, as Hall had shown, the EE is best with a very low-carbohydrate diet. So Halls study merely confirmed what had already been known.

Some people have also noted that this study controlled calories so it negates one of the KD’s biggest advantages, which is that it makes you feel full. Well, sorry, guys, that’s not the question it is designed to answer. Same goes for the fact that there are only 17 people in it. Again, that’s the study design, so it is what it is, and there’s no use complaining about it.

The problem is not the data but the ‘spin’

In the end, the main problem is not the study data. The data are excellent. The problem is the ‘spin’. Here’s the conclusion Hall writes in the abstracts conclusion (which is the single most important few sentences of the paper, the one that everybody reads).

The isocaloric KD ~~was not accompanied by increased body fat loss but was associated with relatively small~~ increases in EE ~~that were near the limits of detection with the use of state-of-the-art technology.~~

I’ve highlighted what is fact. I’ve crossed out what is pure spin. Did the KD cause body fat loss? Yes it did. And that’s really, really important. Hall spins it this positive into a negative by moving the goalposts – “Oh but it didn’t do better than before”.

Then he says the increase in EE is “relatively small’. So what? Did it increase or not? In fact, your own study from the Biggest Loser suggests that weight loss will DECREASE EE, so even the stabilization (let alone the increase) of EE is critically important. That’s the gold medal, buddy! You just threw it in the garbage.

Hall then downplays this relationship by calling it an ‘association’. As if the change in EE just happened to occur at the same time as the change in diet. What a load of crap. You changed the diet and measured the change in EE. Nobody doubts that. It’s causation, pure and simple. So why try to spin this as an ‘association’ which is a mere ‘coincidence’? Pure spin.

Hall then further tries to downplay the importance of stable EE by saying it’s ‘near the limits of detection with the use of state-of-the-art technology’. So what? Who cares? Did it stabilize or not? Isn’t that great news? Did you not just show that weight loss efforts fail because of decreased EE?

Unfortunately, spin-doctor Hall is now entering a logic free zone, and many journalists like Julia Belluz and other bloggers are happy to take what is shared at face value. “In this first Biggest Loser study, I demonstrate why stable EE is critical for weight loss. In this second study I’ll show how stable EE is absolutely worthless. Ta Da!”

Hall wants desperately to save his own reputation, even if he has to sacrifice your health to do so. Sad. So sad.

The facts alone, without any spin would be this. A ketogenic diet, independent of calories, causes fat loss and causes an increase (or at least the stabilization) in EE. That’s the facts. And I love it. Because I can use these facts to help heal patients and save lives.
—

Jason Fung

A Quick Guide to Ketogenic Diets

How to Lose Weight

Why the First Law of Thermodynamics Is Utterly Irrelevant

How to Fix Your Broken Metabolism by Doing the Exact Opposite

How NOT to Write a Diet Book

Videos about insulin

MEMBERS ONLY
Is obesity caused by too much insulin?
25:27
Is obesity mainly caused by the fat storing hormone insulin? Dr. Ted Naiman answers this question.
MEMBERS ONLY
Part 7 of Dr. Jason Fung's diabetes course
05:01
Dr. Fung gives us a comprehensive review of what causes fatty liver disease, how it affects insulin resistance and, what we can do to reduce fatty liver.

More >

More with Dr. Fung

Dr. Fung has his own blog at intensivedietarymanagement.com. He is also active on Twitter.

His book The Obesity Code is available on Amazon.

Name	Provider / Domain	Expiration	Description
ckdc-premium	.dietdoctor.com	1 month
app-banner	.dietdoctor.dev.dietdoctor.com	1 day	This cookie shows whether user closed the App Banner prompt
_gaexp	Google LLC dietdoctor.com	1 year	Used to determine a user's inclusion in an experiment and the expiry of experiments a user has been included in.
_gaexp	Google LLC .dietdoctor.com	1 year	Used to determine a user's inclusion in an experiment and the expiry of experiments a user has been included in.
_opt_awcid	.dietdoctor.com	3 days
_opt_awmid	.dietdoctor.com	3 days
_opt_awgid	.dietdoctor.com	3 days
_opt_awkid	.dietdoctor.com	3 days
_opt_utmc	.dietdoctor.com	3 days
_opt_expid	.dietdoctor.com	25 seconds
gtm_auth	.dietdoctor.com	3 days
gtm_debug	.dietdoctor.com	3 days
gtm_experiment	.dietdoctor.com	3 days
gtm_preview	.dietdoctor.com	3 days
_hjAbsoluteSessionInProgress	Hotjar Ltd .dietdoctor.com	30 minutes	The cookie is set so Hotjar can track the beginning of the user's journey for a total session count. It does not contain any identifiable information.
_ga	Google LLC .dietdoctor.com	2 years	This cookie name is associated with Google Universal Analytics - which is a significant update to Google's more commonly used analytics service. This cookie is used to distinguish unique users by assigning a randomly generated number as a client identifier. It is included in each page request in a site and used to calculate visitor, session and campaign data for the sites analytics reports.
_dc_gtm_UA-3268327-1	.dietdoctor.com	1 minute	This cookie is associated with sites using Google Tag Manager to load other scripts and code into a page. Where it is used it may be regarded as Strictly Necessary as without it, other scripts may not function correctly. The end of the name is a unique number which is also an identifier for an associated Google Analytics account.
_hjFirstSeen	Hotjar Ltd .dietdoctor.com	30 minutes	The cookie is set so Hotjar can track the beginning of the user's journey for a total session count. It does not contain any identifiable information.
_dc_gtm_UA-22012422-2	.dietdoctor.com	1 minute	This cookie is associated with sites using Google Tag Manager to load other scripts and code into a page. Where it is used it may be regarded as Strictly Necessary as without it, other scripts may not function correctly. The end of the name is a unique number which is also an identifier for an associated Google Analytics account.
AWSELBCORS	Amazon.com Inc. www.podbean.com	5 minutes	The cookies AWSELB and AWSELBCORS are functionally the same cookies. The latter has an explicit SameSite attribute set because of changes made from Chrome 80 and upwards.
_ga_YMCP8KW9S4	.dietdoctor.com	2 years
_hjIncludedInSessionSample	Hotjar Ltd www.dietdoctor.com	2 minutes	This cookie is set to let Hotjar know whether that visitor is included in the data sampling defined by your site's daily session limit
__cf_bm	Cloudflare Inc. .vimeo.com	30 minutes	This cookie is used to distinguish between humans and bots. This is beneficial for the website, in order to make valid reports on the use of their website.
_gid	Google LLC .dietdoctor.com	1 day	This cookie is set by Google Analytics. It stores and update a unique value for each page visited and is used to count and track pageviews.
CookieScriptConsent	CookieScript www.dietdoctor.com	1 year	This cookie is used by Cookie-Script.com service to remember visitor cookie consent preferences. It is necessary for Cookie-Script.com cookie banner to work properly.
__cf_bm	Cloudflare Inc. .podbean.com	30 minutes	This cookie is used to distinguish between humans and bots. This is beneficial for the website, in order to make valid reports on the use of their website.
_hjIncludedInPageviewSample	Hotjar Ltd www.dietdoctor.com	2 minutes	This cookie is set to let Hotjar know whether that visitor is included in the data sampling defined by your site's pageview limit.
_dc_gtm_UA-22012422-1	.dietdoctor.com	1 minute	This cookie is associated with sites using Google Tag Manager to load other scripts and code into a page. Where it is used it may be regarded as Strictly Necessary as without it, other scripts may not function correctly. The end of the name is a unique number which is also an identifier for an associated Google Analytics account.
_gaexp_rc	.dietdoctor.com	25 seconds

Name	Provider / Domain	Expiration	Description
IDE	Google LLC .doubleclick.net	1 year	This cookie is set by Doubleclick and carries out information about how the end user uses the website and any advertising that the end user may have seen before visiting the said website.
_uetvid	Microsoft Corporation .dietdoctor.com	1 year	This is a cookie utilised by Microsoft Bing Ads and is a tracking cookie. It allows us to engage with a user that has previously visited our website.
loc	Oracle Corporation .addthis.com	1 year 1 month	Stores the visitors geolocation to record location of sharer
test_cookie	Google LLC .doubleclick.net	15 minutes	This cookie is set by DoubleClick (which is owned by Google) to determine if the website visitor's browser supports cookies.
_gcl_au	Google LLC .dietdoctor.com	3 months	Used by Google AdSense for experimenting with advertisement efficiency across websites using their services
_uetsid	Microsoft Corporation .dietdoctor.com	1 day	This cookie is used by Bing to determine what ads should be shown that may be relevant to the end user perusing the site.
uvc	Oracle Corporation .addthis.com	1 year 1 month	Tracks how often a user interacts with AddThis
YSC	Google LLC .youtube.com	Session	This cookie is set by YouTube to track views of embedded videos.
MUID	Microsoft Corporation .bing.com	1 year	This cookie is widely used my Microsoft as a unique user identifier. It can be set by embedded microsoft scripts. Widely believed to sync across many different Microsoft domains, allowing user tracking.
_fbp	Meta Platform Inc. .dietdoctor.com	3 months	Used by Facebook to deliver a series of advertisement products such as real time bidding from third party advertisers
VISITOR_INFO1_LIVE	Google LLC .youtube.com	6 months	This cookie is set by Youtube to keep track of user preferences for Youtube videos embedded in sites;it can also determine whether the website visitor is using the new or old version of the Youtube interface.

Name	Provider / Domain	Expiration
_hjSession_1945121	.dietdoctor.com	30 minutes
_hjSessionUser_1945121	.dietdoctor.com	1 year
_ga_Y4DLH4EPXM	.dietdoctor.com	2 years