5 - June - 2014

Alan Aragons Research Review June 2014 [Back to Contents] Page 1

Copyright June 1st, 2014 by Alan Aragon

Home: www.alanaragon.com/researchreview

Correspondence: [email protected]

2 Internal vs. external cues: science, theory, &

practical application.

By Jordan Syatt

7 The effects of a ketogenic diet on exercise metabolism and physical performance in off-road cyclists.

Zajac A, Poprzecki S, Maszczyk A, Czuba M, Michalczyk M, Zydek G. Nutrients. 2014 Jun 27;6(7):2493-508.

[PubMed]

8 Prostate cancer and the influence of dietary

factors and supplements: a systematic review.

Mandair D, Rossi RE, Pericleous M, Whyand T, Caplin

ME. Nutr Metab (Lond). 2014 Jun 16;11:30. [PubMed]

9 The effects of water and non-nutritive sweetened

beverages on weight loss during a 12-week weight loss treatment program.

Peters JC, Wyatt HR, Foster GD, Pan Z, Wojtanowski AC,

Vander Veur SS, Herring SJ, Brill C, Hill JO. Obesity.

2014 May;22(6):1415-21. [Wiley Online]

11 Why you never seem to reach your weight loss

goals (and what to do about it). By Armi Legge

13 Whats causing the constant feuding between the

CICO and anti-CICO camps? By Alan Aragon


Internal vs. external cues: science, theory, & practical application.

By Jordan Syatt

____________________________________________________

An Introduction to Coaching Cues

An overwhelming amount of attention has recently been directed

towards the science & application of coaching cues and,

specifically, their impact on markers of performance.

Seemingly arbitrary nuances in word choice, research both experimental and anecdotal is consistently finding reason to believe some cues are more effective than others.

Specifically, external cues have consistently proven to be more

effective than internal cues at improving performance through a

variety of mechanisms such as decreased antagonistic muscular

co-contraction, improved full-body coordination, and enhanced

reflexive movement efficiency.1-10

As a result, it is now common among strength coaches to tout an

external focus as the end-all-be-all of coaching cues while

ostracizing an internal focus by deeming it a useless waste of

time.

But where is the context? Is one type of cue inherently better

than the other or does it actually depend on the individual and

their specific needs and goals? Once again, here we find fitness

dogmatism at its finest.

Considering this topic is still in its infancy, Im sure many coaches will vehemently disagree with my conclusions and

recommendations. That being said, the readers of AARR tend to

be the most un-biased, open-minded individuals within the

fitness realm, so Im excited to present my findings here first.

Drawing upon the scientific literature as well as my personal

experiences, by the end of this piece you will fully understand

the differences between internal and external focus cues, as well

as how to use them to achieve the best results with yourself and

your clients.

Defining Internal & External Cueing

When verbally instructing an individual to perform a given

movement you can either use an internal focus cue, external

focus cue, or a combination of the two.11

Allow me to define

each of these terms, below:

Internal Focus Cues direct the athlete to think about how their

body moves in relation to itself.

For example, during the squat, commonly used internal cues are:

Chest Up! Knees Out! Arch!

As you can see, each of these cues cause the athlete to think

about how theyre creating movement in relation to their body.

Conversely

External Focus Cues direct the athlete to think about how their

body moves in relation to the environment. For example, during

the squat, commonly used external cues are:

Show me the logo on your shirt! (in place of the chest up cue)

Spread the floor apart! Drive the floor away!

Whats the Difference? The fundamental difference between internal and external focus cues lies in where the athlete focuses

their attention. With internal cues, the athlete directs their

attention towards their own body in an attempt to complete the

movement. With external cues, however, the athlete directs their

attention towards their environment and the subsequent

movement effect.

Reviewing the Literature

When the goal is to improve performance in a given movement,

external focus cues are unquestionably better than those with an

internal focus. Period. End of story.

Whether the movement is a maximal effort squat, long jump,

basketball free throw, golf swing, or even throwing

dartsexternal cues are the superior coaching tool. 1, 7, 12, 13, 14

Why are external cues inherently better than internal cues at

improving motor control and movement performance? The

answer lies in what is known as the constrained action

hypothesis. As explained in a study by Wu and colleagues,7

...consciously focusing on the movements of a motor action disrupts automatic motor control processes that regulate coordinated movements. When athletes actively focus and consciously control their movements, they interrupt automatic nonconscious motor behavior processes that normally control movements in an efficient manner. In contrast, directing attention externally to the movement effects allows the motor control system to naturally regulate and organize motor actions. As a result, movements are unconscious, fast, and reflexive.7

In laymans terms, using an internal focus causes the athlete to move in a less efficient and fluid manner due to various

disruptions in what should be natural and unconscious processes.

Conversely, external cues tend to improve movement efficiency

as they reduce conscious thought processes and facilitate natural,

reflexive movement patterns. Plain and simple, external cues are

the absolute best tool to use when the goal is improved

movement performance. This includes all athletic and/or skill-

related competitions such as powerlifting, golf, sprinting,

jumping, ping pong, free throw shooting and countless other

events of the sort.

What if the goal is NOT to improve movement performance?

That is to say, what if the goal revolves around something else

like increasing muscle hypertrophy or improving muscle


activation in a rehabilitation setting? Are external cues

unquestionably better for achieving all training-related goals or

could internal cues play an important role after all? Lets investigate.

Rehabilitation

Call me crazy, but Id venture to guess not everyone cares about increasing their max squat, vertical jump, free throw, or other

performance-based movements.

Take, for example, those in a rehabilitation setting. Whether

theyre in pain, recovering from an injury, or a combination of the twotheir priorities tend to revolve around optimizing muscle recruitment patterns including frequency, intensity, and

duration of contraction.

Taking the above into consideration, we need to ask ourselves if

external cues are more effective than internal cues in a

rehabilitation setting. The answer: probably not. While research

has consistently found external cues to be optimal for improving

movement performance, internal cues have proven to be

extremely effective at increasing and/or decreasing muscular

activity in specified muscles.15-18

To name a few

Lewis and Sahrmanns 2009 study found internal cues to be more effective than external cues at increasing gluteal

EMG and decreasing hamstring EMG during prone hip

extension.

Karsts 2004 study found participants were more effective at recruiting the specified rectus or oblique

abdominis when provided internal cues.

In 2009, Snyder et al found trainees were better able to increase latissimus dorsi activation when given internal

cues.

Why is this important? Learning to use the right muscles at the right time is a major component of nearly all rehabilitation-focused programs. Through using internal cues we can actually

increase activation of specified muscles which, needless to say,

is of the utmost importance in a rehabilitation setting.

But Wasnt This Research Conducted Using EMG?

Naysayers of the aforementioned research will say EMG is

riddled with flaws and cant be used to make definitive statements. Theyre absolutely right.

EMG, like all research, has its own set of methodological faults

rendering it subject to the possibility of error. For example,

surface EMG is influenced by a variety of factors outside of

simple muscular activation such as cross talk (nearby musculature), blood flow, fiber type, and fatigue.

19 Clearly, it

isnt perfect.

That being said, there is no such thing as perfect research. There

will always be flaws no matter what methodology we use. As

such, its important to understand both the pros and cons in order to make the most intelligent decision based on a variety of

experimental and observational research.

Despite the flaws, EMG has proven to be extraordinarily useful

in that it can give us insight into patterns of muscle activation,

duration of muscle activation, and even a somewhat reliable

approximation of the amount (or intensity) of muscle activation.

Through using this knowledge (while bearing in mind the

possibility of error) we can grasp a better understanding of

which muscles were using at which times and with what intensity.

Needless to say, this is pretty damn important. In fact, prominent

researcher and physical therapist, Mike Reinold, utilizes EMG-

based research in the development of his own pre/rehabilitation-

based programs. Specifically, Reinold has conducted a number

of studies examining the rotator cuff and surrounding shoulder

musculature and subsequently helped to identify which drills are

most effective at improving shoulder health and function.20, 21

Considering Reinold works predominantly with elite athletes,

one might even argue that, in this instance, internal cues could

be better than external cues at improving performance.

What about Muscle Hypertrophy?

Enough of the boring rehabilitation stuff. Whats better for increasing muscle hypertrophy: internal or external focus cues?

Lets find out.

The Mechanisms of Muscle Hypertrophy

Thanks to extensive research done by AARR regular, Dr. Brad

Schoenfeld, we know there are three primary factors responsible

for inducing muscle hypertrophy from resistance training. 22

Mechanical Tension Muscle Damage Metabolic Stress

Without going into excruciating detail (you can learn about these

3 factors in Brads famous research article HERE), suffice to say each of these factors are of the utmost importance and balancing

all three, rather than focusing on only one or two, will allow you

to achieve the best results.

Internal vs. External Cues for Hypertrophy

A number of prominent strength coaches have been quick to

jump on the external cues are ALWAYS better bandwagon and

have even gone so far as to make unsubstantiated claims

regarding the superiority of external cues in hypertrophy-focused

programs. The reality, however, is that we have no clue.

The research pertaining to coaching cues and muscle

hypertrophy is currently scant and it would be misleading to

make definitive statements for or against either type of cue. That

being saidwe can dig a little deeper.

The Mind-Muscle Connection

For years, some of the worlds most successful bodybuilders have continually referred to the importance of the mind-muscle

connection. Even Arnold, arguably the most respected and

successful bodybuilder of all-time, is one of the foremost

proponents of the mind-muscle connection and has been quoted

as saying you need to put your mind in the muscle to build bigger muscles.


Essentially, training using the mind-muscle connection entails

visualizing the muscle being trained and feeling it work through

a full range of motion. As you may have guessed, this is a form

of internal cueing as it causes the lifter to think about how their

body moves in relation to itself. Training in this fashion has been

said to increase muscle recruitment, potentially leading to

greater muscle hypertrophy.

In accordance with this train of thought, Bret Contreras has

performed his own EMG-based research and found comparable

results. Specifically, through using the mind-muscle connection

Contreras drastically manipulated gluteal activation when

performing a standard back extension. Without concentrating on

the glutes, gluteal activation reached just 6% of maximum

voluntary isometric contraction (MVIC). However, when

actively focusing on using the glutes to complete the same

movement, EMG activation rose to 38% MVIC.23

Snyder et al (mentioned earlier) noticed a similar phenomenon

regarding increased latissimus dorsi activation when instructing

participants to feel their lats while performing a pull down. The

authors noted concentrating on the target musculature resulted in greater activation of this muscle.

Does Increased EMG Lead to Greater Muscle Hypertrophy?

EMG skeptics are quick to point out that increased muscular

activity does not necessarily lead to greater muscle hypertrophy.

Theyre absolutely right. Increased muscular activity does not automatically result in greater muscle hypertrophy. If that were

the case, wed all be getting jacked from E-Stim treatments at our local PTs office and rushing to get those vibration belts that allegedly melt fat off our abs.

God, I hate fitness marketing...I digress.

Increased muscular activity alone does not lead to greater muscle

hypertrophy. We know this from Dr. Schoenfelds extensive researchas well as common sense. However, as Dr. Schoenfeld has previously mentioned, establishing a strong

mind-muscle connection (as utilized in posing by seasoned

bodybuilders) can improve neuromuscular control and improve

your ability to maximally contract your muscles thereby allowing you to generate more force during your lifts.24

Considering mechanical tension (a key factor in the hypertrophy

equation) is largely influenced by force production, it stands to

reason that using a mind-muscle connection to learn how to

maximally contract your muscles could potentially lead to

greater hypertrophic gains.

SoInternal or External Cues for Hypertrophy?

Based on the current available research its impossible to say with absolute certainty which is better or worse. However,

considering the information outlined previously, as well as the

experiences of some of the most successful bodybuilders of all

time, my gut instinct leads me to believe that internal cueing is

more effective than external cueing for improving muscle

hypertrophy.

As the body of research grows Im more than willing to change my opinion but, as of right now, I whole-heartedly believe in the

importance of using internal cues to maximally contract

specified muscular in order to optimize muscle hypertrophy.

My Personal Experience

Im a science guy. I understand and appreciate the importance of research as well as the implications it holds in real-world

performance.

Having said that, Im also an experience guy. Theres something to be said for those who spend years upon years working in the

trenches, coaching athletes, and actually lifting weights. In my

opinion, real-world experience is equally as important as

experimental research. One without the other is decentbut put both of them together and youve got a recipe for serious #gainz. Unless Im mistaken, Im the first person ever to use a hashtag in AARR. #Winning. [Editors note wow, lol]

Back to the topic at hand, Im a coach and a strength athlete. Ive worked with hundreds of individuals and helped numerous

lifters achieve extraordinary levels of strength. Ive worked with and trained under coaches such as Louie Simmons and Eric

Cressey, and I hold several IPA Powerlifting world records

including a raw 485lb deadlift at a bodyweight of 132lbs.

I say this, not to brag, but to let you know from where the

following information is coming. Im not some random desk jockey sitting in my dark and creepy basement trolling on

Reddit. I lift. I coach people to lift. And I do this every single

day. Thus, Im excited to share with you my personal observations from experimenting with internal and external

focus cues.

There is a major difference between performance and practice.

If theres one thing you take from this article, let it be this: performance and practice are two entirely separate entities and

should be treated as such. Allow me to explain.

Lets say youre competing in a powerlifitng meet and youre about to take your 3

rd and final squat attempt. This is a

performance. You will use the strength and skills acquired

during recent months of training in an attempt to perform your

best. This is NOT the time to change your technique.

Conversely, during the months leading up to the meet you are

practicing. You are practicing the movement, making

alterations, and tweaking things to find what works best for you.

See the difference?

The main goal of practice is to engrain the optimal movement

pattern so when it comes time to perform the movement you

dont think you just do.

Which Cues are Best for Practice and Performance?

Performance (i.e. competition) is the ideal time to utilize

external cues. The well-established benefits of external cues are

most valuable at this time as they facilitate the best execution of

a pre-learned movement.

Practice (i.e. training), however, is the ideal time to utilize both

internal and external cues. During this period of time the main


goal is to engrain the optimal movement pattern in preparation

for the performance. As such, its wise to experiment with both types of cues to see which ones resonate with each individual.

Start with Internal, Progress to External

I like to keep things simple. Likereally simple. Too often coaches assess a clients movement pattern like the squat, for example and throw 17 different cues at them in a matter of 12-seconds. This benefits no one. Its confusing, frustrating, and neither the coach nor athlete gets any better.

To keep things as simple and effective as possible, I use one cue

at a time and generally start with internal cues before

progressing to external. For example, if a clients chest caves during the squat the first thing Ill say is, get your chest up nice and high! Shocking, right? Very scientific. Usually this cue is sufficient and we can move on to correcting other aspects of the

movement.

In cases where this cue doesnt work, however, I will progress to an external cue such as, I want to be able to read the letters on your shirt throughout the entire movement! or show your nipples to the ceiling the entire time!

By this point the client almost always understands what I want

them to do and, more importantly, how to replicate the

movement time and time again.

Once the movement has been engrained, it then becomes

exceedingly easy to cue the lifter using only one or two words at

a time. For example, if the athlete gets lazy and allows their

chest to cave all I need to say is chest up! or nipples! and theyll fix the movement immediately.

Your Takeaway: Keeping things simple will make training a far

more enjoyable (and effective) experience for both you and your

clients. Along these lines, I recommend beginning with internal

cues and progressing to external as you see fit.

Internal Cues Are Better for Coaching Activation

DrillsExcept When They Arent.

As previously discussed, research has repeatedly shown internal

cues lead to significant increases in specified muscular

activation.

For the most part, my experience has also found this to be true.

For example, when performing a side-lying clam many

individuals have trouble feeling the glute medius contract.

However, if I palpate the glute med and instruct the client to lift

with that part of their butt (internal cue) they almost always feel

it working.

Same goes for isolation movements like bicep curls and tricep

extensions. When I instruct an individual to focus on the muscle

being contracted (refer to mind-muscle connection), they almost

always feel the desired muscle working more than if I had

presented them with an external cue.

Having said that, there are similar situations in which Ive found external cueing to be superior. For example, when performing a

standard glute bridge, beginner trainees often have difficulty

feeling the glutes contract. Despite palpating the glutes and

telling them to squeeze, they often dont feel them working as they should. To expedite the process and get them using their

glutes more effectively, Ill tell my clients to imagine cracking a walnut in between their butt cheeks while hitting the ceiling with

their hips (external cue). More often than not, this solves the

problem immediately and drastically increases glute activation.

Your Takeaway: Dont feel locked into a single type of cue. Some cues work better than others in a variety of situations for

seemingly inexplicable reasons. When one doesnt work, try another and keep trying until you find the one that eventually

makes things click.

Never Underestimate the Value of Demonstration

Sometimes, no matter what cue you give, the client just wont understand what the hell youre talking about. This happens to every coach at one time or another and, more

often than not, has absolutely nothing to do with their coaching

competency or skill level; rather, it mostly has to do with the

client and their individual learning style.

To accommodate for differences in learning style, its important to understand verbal cues (those with an internal and/or external

focus) arent the only way to teach an exercise. In fact, sometimes were better off scrapping verbal cues and using a completely different approach altogether.

For example, if verbal cues just arent cutting it for a certain client, get in there and physically show them how its done! Of course, using a variety of verbal cues along the way will

likely be more beneficial than not, but often times simply

demonstrating the movement will help the client master the drill

in the shortest period of time.

Your Takeaway: Internal and external cues are obviously

phenomenal coaching tools given the right situation, but dont forget there are other ways to teach proper movement patterns

that are equally, if not more, effective.

Different People Respond to Different Cues

As a subscriber to AARR, you know and understand that

individualization is key. You fully appreciate the fact that each

and every person responds better or worse to various stimuli and,

as such, requires an individualized approach. Coaching cues are

no different. Some people respond better to internal cues

whereas others respond better to external cues. Per usual, there

is no absolute right or wrong way to coach all exercises. Rather, whatever constitutes the best cue is almost entirely dependent on the individual and their specific needs.

Wrapping Up

Similar to how people want to know which is the single best

supplement, food, or exercise to help them get shredded, many

coaches and athletes want to know which type of cue is

inherently best regardless of the situation.

Unfortunately, thats not how it works.


Per usual, the answer lies in a clear understanding of the fact that

there isnt an innately optimal coaching cue. To recap, external cues are unquestionably better at improving specific

movement performance. Whether youre competing in powerlifting, football, baseball, basketball, golf, darts, or any

other athletic and/or skill-related activity, external cues will help

you perform pre-learned movements in the most efficient

manner.

Internal cues, on the other hand, are better at improving

specified muscular activation which may be of greater benefit in

a variety of settings such as rehabilitation and hypertrophy-

focused programs.

Practically speaking, a combination of both internal and external

focus cues is likely more effective than either one alone.

Regardless of whether youre working with a large client population or simply coaching yourself, remember to

incorporate both internal and external cues to find what works

best for the individual in question.

Never Minimal. Never Maximal. Always Optimal.

-J

___________________________________________________

Jordan Syatt is a strength training & nutrition consultant and an IPA world record powerlifter. He is Precision Nutrition and Westside Barbell Certified, has a B.S. in Health & Behavioral Science, and is the owner of www.syattfitness.com. Fitness aside, Jordan is an avid traveler, self-proclaimed nerd, and unashamed of his obsession with the Harry Potter series.

____________________________________________________

References

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The effects of a ketogenic diet on exercise metabolism and physical performance in off-road cyclists.

Zajac A, Poprzecki S, Maszczyk A, Czuba M, Michalczyk M,

Zydek G. Nutrients. 2014 Jun 27;6(7):2493-508. [PubMed]

PURPOSE: The main objective of this research was to determine the effects of a long-term ketogenic diet, rich in polyunsaturated fatty acids, on aerobic performance and exercise metabolism in off-road cyclists. Additionally, the effects of this diet on body mass and body composition were evaluated, as well as those that occurred in the lipid and lipoprotein profiles due to the dietary intervention. METHODS: The research material included eight male subjects, aged 28.3 3.9 years, with at least five years of training experience that competed in off-road cycling. Each cyclist performed a continuous exercise protocol on a cycloergometer with varied intensity, after a mixed and ketogenic diet in a crossover design. RESULTS & CONCLUSIONS: The ketogenic diet stimulated favorable changes in body mass and body composition, as well as in the lipid and lipoprotein profiles. Important findings of the present study include a significant increase in the relative values of maximal oxygen uptake (VO2max) and oxygen uptake at lactate threshold (VO2 LT) after the ketogenic diet, which can be explained by reductions in body mass and fat mass and/or the greater oxygen uptake necessary to obtain the same energy yield as on a mixed diet, due to increased fat oxidation or by enhanced sympathetic activation. The max work load and the work load at lactate threshold were significantly higher after the mixed diet. The values of the respiratory exchange ratio (RER) were significantly lower at rest and during particular stages of the exercise protocol following the ketogenic diet. The heart rate (HR) and oxygen uptake were significantly higher at rest and during the first three stages of exercise after the ketogenic diet, while the reverse was true during the last stage of the exercise protocol conducted with maximal intensity. Creatine kinase (CK) and lactate dehydrogenase (LDH) activity were significantly lower at rest and during particular stages of the 105-min exercise protocol following the low carbohydrate ketogenic diet. The alterations in insulin and cortisol concentrations due to the dietary intervention confirm the concept that the glucostatic mechanism controls the hormonal and metabolic responses to exercise. SPONSORSHIP: None listed.

Study strengths

This study is innovative since its the first to ever examine the long-term effects of ketogenic diet on training adaptations and

exercise performance in trained endurance athletes (in this case,

competitive off-road cyclists with a minimum of 5 years training

experience and a minimum VO2max of 55 ml/kg.min). Diets in

both conditions were designed by a dietitian, and the nutritional

specifics of each (targeted) diet were reported in detail, including

fatty acid types.

Study limitations

No indication was made that dietary journaling or compliance

was enforced. No mention was made of dietary accountability or

assessment aside from the assignment to the respective

conditions at the outset of each trial. This study involved a cross-

over design, yet no specifics were mentioned of a wash-out

period between trials. Its possible that in the absence of a washout period that is, if the subjects immediately proceeded from one diet to the next for each of the successive months there could have been an order effect or carry-over effect

confounding the results. As acknowledged by the authors, the

sample size was small (8 subjects) and the body composition

assessment method (bioelectrical impedance) was crude. They

also mentioned that the ketogenic condition lacked a 2-3-day

carbohydrate loading phase prior to testing.

Comment/application

The ketogenic diet (15% C, 15% P, 70% F) outperformed the

mixed diet (50% C, 20% P, 30% F) in several parameters.

Compared to the mixed diet, the ketogenic diet resulted in lower

body fat & body weight, greater increase in oxygen uptake

(VO2max) at the lactate threshold, which was speculated to be

due to increased sympathetic activation or increased fat

oxidation. Furthermore, there was a reduction in triglycerides

and greater increase in HDL-C at rest and during exercise. LDL-

C was higher at all points in the ketogenic diet, but not to a

statistically significant degree (with the exception of 45 minutes

during exercise, where the LDL-C of the ketogenic diet did

reach statistical significance). Its notable that the ketogenic diet in this study was specifically designed to contain a high

proportion of unsaturated fatty acids, including a significant

proportion of omega-3 fatty acids, and its this characteristic to which the authors attribute the favorable changes in lipids and

lipoproteins during the ketogenic diet.

On to the unfavorable effects of the ketogenic diet. Although

cortisol levels were lower at rest, they were higher at all time

points during exercise. Resting and during-exercise testosterone

levels were lower as well. Perhaps the most critically adverse

aspect of the ketogenic diet was its ergolytic effect on high-

intensity exercise performance. Specifically, the mixed diet

resulted in higher maximal work load as well as a higher lactate

threshold work load; in other words, the ketogenic diet resulted

in compromised high-intensity work output. This forced the

authors to concede that, Low carbohydrate ketogenic diets decrease the ability to perform high intensity work, due to

decreased glycogen muscle stores and the lower activity of

glycolytic enzymes, which is evidenced by a lower LA

concentration and a maximal work load during the last 15 min

of the high intensity stage of the exercise protocol.

This endurance performance-enhancing capability a low-

carb/high-fat diet has been equivocal, and thus controversial,1

especially for high-intensity bouts. The most recent example

aside from the present study is Lima-Silva et als finding that compared to a 70% CHO diet for 48 hours, a 25% CHO diet

lowered performance and total aerobic energy provision during

supramaximal exercise.2 Prior to that, Havemann et al found that

a 6-day high-fat diet (68% of total energy) followed by 1 day of

carb-loading (8-10 g/kg) lowered sprint power output compared

to a high-carb diet (68% of total energy).3 Prior to that, a review

by Phinney4 reported a similar phenomenon, stating that the

sprinting capability of his subjects on a ketogenic diet in an

earlier study5 remained constrained during the period of

carbohydrate restriction. This consistency of research showing detrimental effects of low-carbohydrate dieting on high-intensity

work casts a strong shadow of caution against the presumption

that this diet would maximize endurance race performance, and

certainly performance in sports involving more even mix of

moderate and high intensities.


Prostate cancer and the influence of dietary factors and supplements: a systematic review.

Mandair D, Rossi RE, Pericleous M, Whyand T, Caplin ME.

Nutr Metab (Lond). 2014 Jun 16;11:30. [PubMed]

BACKGROUND: Prostate cancer is the second most common

cause of cancer worldwide after lung cancer. There is increasing

evidence that diet and lifestyle plays a crucial role in prostate cancer

biology and tumourigenesis. Prostate cancer itself represents a good

model of cancer in which to look for chemopreventive agents due to

the high disease prevalence, slowly progressive nature, and long

latency period. Dietary agents have gained considerable attention,

often receiving much publicity in the media. AIM: To review the

key evidence available for potential chemopreventive nutrients.

METHODS: The methodology for this review involved a PubMed

search from 1990 to 2013 using the key-words "diet and prostate

cancer", "nutrition and prostate cancer", "dietary factors and

prostate cancer", "prostate cancer epidemiology", "prostate cancer

progression". RESULTS: Red meat, dietary fat and milk intake

should be minimised as they appear to increase the risk of prostate

cancer. Fruit and vegetables and polyphenols may be preventive in

prostate cancer, but further studies are needed to draw more solid

conclusions and to clarify their role in patients with an established

diagnosis of prostate cancer. Selenium and vitamin supplements

cannot be advocated for the prevention of prostate cancer and

indeed higher doses may be associated with a worse prognosis.

There is no specific evidence regarding benefits of probiotics or

prebiotics in prostate cancer. CONCLUSION: From the wealth of

evidence available, many recommendations can be made although

more randomised control trials are required. These need to be

carefully designed due to the many confounding factors and

heterogeneity of the population. SPONSORSHIP: None listed.

My commentary

As a systematic review, this paper doesnt lend itself well to the typical breakdown of design strengths & limitations seen with

controlled interventions. What I find interesting about this paper

right off the bat is that its published in a journal produced by the Nutrition & Metabolism Society, an organization dedicated to

promoting low-carbohydrate dieting and adjacently, high-fat

dieting with an emphasis on saturated fat. The irony about the

publication of the present paper in N&Ms journal is that much of its findings and conclusions are at odds with the values and

objectives of the N&M Society. Ultimately, its refreshing to see journals publish opposing outcomes and perspectives instead of

maintaining a single-track bias.

The present systematic review is important since according to

the American Cancer Society, prostate cancer is the second

leading cause of cancer death in men in the world (lung cancer is

in the lead), and its estimated that 1 in 7 men will be diagnosed with prostate cancer in his lifetime.

6 The authors assert that

prostate cancer is an ideal form of cancer for investigating

therapeutic interventions since it has a high prevalence, slow

progression, and long latency period. As such, its reasonable to speculate that diet may play a significant role in the etiology of

this disease. The present review included observational and

experimental studies from 1990-2013. In an effort to limit

inclusion to high-quality evidence, Scottish Intercollegiate

Guidelines Network (SIGN) clinical guidelines were employed.7

Here is their summary of the current evidence on the relationship

between dietary factors and supplements and risk of prostate

cancer:

1. Well-done meat is associated with increased risk of prostate cancer; consumption of red meat should be limited to


The effects of water and non-nutritive sweetened beverages on weight loss during a 12-week weight loss treatment program.

Peters JC, Wyatt HR, Foster GD, Pan Z, Wojtanowski AC, Vander Veur SS, Herring SJ, Brill C, Hill JO. Obesity. 2014 May;22(6):1415-21. [Wiley Online]

OBJECTIVE: To compare the efficacy of non-nutritive sweetened beverages (NNS) or water for weight loss during a 12-week behavioral weight loss treatment program. METHODS: An equivalence trial design with water or NNS beverages as the main factor in a prospective randomized trial among 303 men and women was employed. All participants participated in a behavioral weight loss treatment program. The results of the weight loss phase (12 weeks) of an ongoing trial (1 year) that is also evaluating the effects of these two treatments on weight loss maintenance were reported. RESULTS: The two treatments were not equivalent with the NNS beverage treatment group losing significantly more weight compared to the water group (5.95 kg versus 4.09 kg; P < 0.0001) after 12 weeks. Participants in the NNS beverage group reported significantly greater reductions in subjective feelings of hunger than those in the water group during 12 weeks. CONCLUSION: These results show that water is not superior to NNS beverages for weight loss during a comprehensive behavioral weight loss program. SPONSORSHIP: The study was fully funded by The American Beverage Association. Study strengths

There is a scarcity of controlled interventions directly comparing the weight loss effects of diet beverages versus water, so this study is a welcome addition to the skeletal body of literature. One of the strengths is study the relatively large sample size (279 subjects completed the trial). Another strength was that the diets were designed to achieve a realistic weight loss target of 1-2 lbs per week. Physical activity increases were targeted weekly and tracked via subjects journaling as well as electronic means (Body Media arm band). Adherence to the non-nutritive sweetener (NNS) and water treatments was assessed via journal records. Subjects attended weekly group weigh-in meetings led by registered dietitians or clinical psychologists, and meeting topics included self-monitoring, portion sizes, food label-reading, and physical activity. Study limitations

Unfortunately, no reporting of dietary intake (in terms of total energy and macronutrition) was made in the text. This makes it impossible to assess how the treatments may have impacted surrounding dietary intake (this would have been useful and interesting data). The authors acknowledge that based on this studys limited assessments, its impossible to elucidate a mechanistic explanation for the results. I would add that although waist circumference is a fair proxy for body fat change, it would have strengthened this design to assess body composition through a more sophisticated means such as DXA. Comment/application

The main finding was that the diet beverage group lost 1.85 kg more weight than the water group, and this difference was

statistically significant. Furthermore, decreases in total and LDL-C were significantly greater in the diet beverage group. No significant between-group differences were detected in waist girth reduction, glucose, blood pressure, triglycerides, and urine osmolality (indicating hydration status).

The chart above shows the differences in proportion of subjects from each group who achieved at least a 5% weight loss from baseline, with the diet beverage (NNS) group showing significantly better results. Whats interesting and ironic is how diet beverages have been speculated to contribute to weight gain via increasing appetite. To quote a recent review by Yang:

13

Sweetness decoupled from caloric content offers partial, but not complete, activation of the food reward pathways. Activation of the hedonic component may contribute to increased appetite. [...] Lack of complete satisfaction, likely because of the failure to activate the postingestive component, further fuels the food seeking behavior. Reduction in reward response may contribute to obesity.

The results of the present study fail to support Yangs speculations; in fact, they indicate the opposite. The diet beverage group not only lost more weight, but they also reported a slight decline in hunger while the water group reported a slight increase in hunger. This is the closest this study comes to suggesting a mechanism by which the diet beverage group lost more weight. Another interesting finding was the higher drop-out rate in the water group (10% versus 5.8% in the diet beverage group).

The present study extends recent findings of a 6-month trial by Piernas et al,

14 who found that compared to water, the diet

beverage group showed decreases in most caloric beverage groups and specifically reduced more desserts over the course of the trial. A unique strength of Piernas et als design was that the subjects were held unaware of the study purpose until afterward. This reduced the confounding potential of confirmation bias effecting the subjects adherence to their assigned treatment. On a final note the beverage industrys sponsorship of the present study has led many to dismiss its validity outright. This is a bias in and of itself. Ive often said that if youre going to be dismissive about industry-funded research, you cant be selective about your dismissals you have to dismiss all of it (which is a stupid thing since youd be willfully ignoring a huge proportion of the body of nutrition research).


1. Burke LM, Kiens B. "Fat adaptation" for athletic

performance: the nail in the coffin? J Appl Physiol (1985). 2006 Jan;100(1):7-8. [PubMed]

2. Lima-Silva AE, Pires FO, Bertuzzi R, Silva-Cavalcante MD, Oliveira RS, Kiss MA, Bishop D. Effects of a low- or a high-carbohydrate diet on performance, energy system contribution, and metabolic responses during supramaximal exercise. Appl Physiol Nutr Metab. 2013 Sep;38(9):928-34. [PubMed]

3. Havemann L1, West SJ, Goedecke JH, Macdonald IA, St Clair Gibson A, Noakes TD, Lambert EV. Fat adaptation followed by carbohydrate loading compromises high-intensity sprint performance. J Appl Physiol (1985). 2006 Jan;100(1):194-202. [PubMed]

4. Phinney SD. Ketogenic diets and physical performance. Nutr Metab (Lond). 2004 Aug 17;1(1):2. [PubMed]

5. Phinney SD, Bistrian BR, Evans WJ, Gervino E, Blackburn GL. The human metabolic response to chronic ketosis without caloric restriction: preservation of submaximal exercise capability with reduced carbohydrate oxidation. Metabolism. 1983 Aug;32(8):769-76. [PubMed]

6. American Cancer Society. What are the key statistics about prostate cancer? Last updated March 12, 2014. [ACS]

7. Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ. 2001 Aug 11;323(7308):334-6. [PubMed]

8. Alexander DD, Mink PJ, Cushing CA, Sceurman B. A review and meta-analysis of prospective studies of red and processed meat intake and prostate cancer. Nutr J. 2010 Nov 2;9:50. [PubMed]

9. Mao QQ, Dai Y, Lin YW, Qin J, Xie LP, Zheng XY. Milk consumption and bladder cancer risk: a meta-analysis of published epidemiological studies. Nutr Cancer. 2011 Nov;63(8):1263-71. [PubMed]

10. Ralston RA, Truby H, Palermo CE, Walker KZ. Colorectal cancer and nonfermented milk, solid cheese, and fermented milk consumption: a systematic review and meta-analysis of prospective studies. Crit Rev Food Sci Nutr. 2014;54(9):1167-79. [PubMed]

11. Forrest KY1, Stuhldreher WL. Prevalence and correlates of vitamin D deficiency in US adults. Nutr Res. 2011 Jan;31(1):48-54. [PubMed]

12. Ahn J, Peters U, Albanes D, Purdue MP, Abnet CC, Chatterjee N, Horst RL, Hollis BW, Huang WY, Shikany JM, Hayes RB; Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial Project Team. Serum vitamin D concentration and prostate cancer risk: a nested case-control study. J Natl Cancer Inst. 2008 Jun 4;100(11):796-804. [PubMed]

13. Yang Q. Gain weight by "going diet?" Artificial sweeteners and the neurobiology of sugar cravings: Neuroscience 2010. Yale J Biol Med. 2010 Jun;83(2):101-8. [PubMed]

14. Piernas C, Tate DF, Wang X, Popkin BM. Does diet-beverage intake affect dietary consumption patterns? Results from the Choose Healthy Options Consciously Everyday (CHOICE) randomized clinical trial. Am J Clin Nutr. 2013 Mar;97(3):604-11. [PubMed]


Why you never seem to reach your weight loss goals (and what to do about it).

By Armi Legge

____________________________________________________

You want to get leaner.

Youve been taught that if you want to achieve something, you need to set goals.

So you set a goal weight, and a deadline. You follow all of the

typical advice, using the S.M.A.R.T. criteria. You make your

goal

Specific.

Measurable.

Actionable.

Realistic.

Time-Bound.

You write your goal on a piece of paper and tape it to your

fridge.

You setup a workout and nutrition plan to reach your goal. You

visualize your new body, with veins, abs, and popping muscles.

You think of how good it will feel to take your shirt off at the

pool.

You follow your plan for a few weeks. You look forward to

every workout. You go to bed on time. You follow your diet

plan exactly.

But over time, your motivation wanes. You cut workouts short.

You stop following your meal plan. You stay up watching T.V.

and surfing Facebook.

Your progress slows, and you become even less motivated to

reach your goal.

Eventually, you stop losing weight. And then you give up.

Thats how most diets end1,2 even for educated, motivated people, like you.*

What happened?

You dont lack motivation, and you may be following a great plan. The real problem was your goal.

Why most weight loss goals dont work.

Studies have shown that people who set goals tend to lose more

weight and keep it off longer.3,4

Focusing on long-term goals can also increase peoples motivation to stick to the plan.

5

But setting goals can cause four unwanted side-effects.6

1. It can encourage you to focus on details, often overlooking the

big picture.

Example: Obsessing about the weight on your scale, rather

than worrying about developing healthy habits like

preparing your own meals and exercising.

2. If you set multiple goals, it can encourage you to focus on the

easier ones, even if theyre less important.

Example: Trying to get extremely lean and ignoring

relationship problems, financial issues, etc, despite being

healthy.

3. It encourages short-term thinking.

Example: Setting an aggressive weight loss goal, pushing

too hard to reach it, and then rebounding up to a higher

weight.

4. Goal-setting can encourage you to view yourself as

inadequate.

Example: You feel like once you get lean, everything else

will be easier. Youll get more done at work, have more success with the opposite sex, and have the confidence to

pursue your other goals. You feel like once you reach your

goal, then youll be happy, fulfilled, or accomplished but youre still not good enough yet.

The truth is that once you get lean, you just stop worrying about

getting lean it doesnt make the rest of your life easier. Sometimes getting lean makes life worse.

Im not saying weight loss goals are bad, but theyre overrated, incomplete, and sometimes counterproductive.

Focus on your daily actions instead of goals.

goals are good for planning your progress and systems are good for actually making progress. James Clear

Most people set goals and then figure out a system to achieve

them. Thats ass-backwards.

If you want to lose weight, focus on the system, then your goals.

In the past, youve always focused on your goal weight, and your new lifestyle as a necessary side-effect to reach it. Even

healthy, motivated people like bodybuilders fall into this trap.

Look at weight loss from the opposite perspective. Focus on

developing the right habits and lifestyle first, and look at fat loss

as a positive side effect.

The problem is that a lot of people set ambitious weight loss

goals before theyve mastered the basic habits they need to get lean.


Heres an example.

Sarah is about 20 pounds overweight, but she loves exercise. She

lifts weights four times per week, goes hiking on the weekends,

and rides her bike to and from work. She prepares almost all of

her meals at home, mostly from whole plants and animals. Sarah

wants to lose those 20 pounds, so she sets a goal weight of 110

pounds.

John has just finished college, and trains with his buddies

whenever its convenient. His schedule is flexible, so he works out a lot. He eats most of his meals at restaurants, the only dish

he knows how to make is scrambled eggs, and he changes his

sleep schedule constantly.

John wants to prepare for his first bodybuilding show in a year.

Hes tried to get lean in the past, but he always rebounded and binged. He still binges occasionally, but since hes bulking he doesnt worry about it.

As a young guy, John doesnt have to work that hard to stay at 12% body fat. But he desperately wants to get down to 5%.

He creates a set of calorie and macronutrient guidelines, weighs

all of his food, adds more cardio, and stops hanging out with his

friends so he can focus on his diet. He sets weight benchmarks to

make sure hes on track for his competition.

On paper, John is much closer to his goal body than Sarah. But

thats not what matters.

How much do you think Sarah will need to change her lifestyle

to lose weight? Almost none. If shes a little more diligent about her food intake, shell easily shed fat and probably keep it off forever.

John, on the other hand, will have to work harder.

He might reach his goal weight before Sarah, but what then? He

has no system for maintaining it, and hes probably going to rebound up to a higher weight after hes ripped. Thats assuming he can get his binge eating under control and get lean.

Sarah focused on her lifestyle first, and then set a weight loss

goal. John did the opposite.

The right way to achieve your goals.

Theres enough research to show that goal-setting is a good idea.

But research shows that people who visualize their goals as

already happening are less likely to achieve them.

In a series of studies, researchers found that people who

visualized themselves getting a good job ended up doing worse.

Two years after college, they had applied for fewer jobs, were

offered fewer jobs, and, if they got a job, were paid less. The

researchers found similar results for people who were trying to

pass an exam, find a romantic partner, or go through surgery.(7)

In another study, students who visualized themselves studying

did much better than those who visualized themselves getting a

good grade on the test.(7)

Its good to have a general idea of what you want to look like, but dont get too fixated on specific numbers.

Achieving your goals is a side effect of sticking to the right

habits, not the other way around.

If youre cutting, dont worry about hitting your goal weight at first. I want to lose weight, is a fine goal to start. Train and eat to lose the first 3 pounds, and then worry about the next 20.

This might feel uncomfortable at first. Youre used to deadlines and exact numbers.

So, in the next AARR, Ill give you instructions on how to create a system for achieving your goals that uses a habits-first approach for weight loss.

* If youre reading AARR, youre ahead of 99% of everyone else out there already. Pat yourself on the back.

__________________________________________________

My name is Armi Legge, and Im the editor of EvidenceMag.com, a website that helps obsessive people, like you, simplify their health and fitness. If youd like to see some of my best articles, click here.

___________________________________________________

References

1. Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr. 2005;82(1 Suppl):222S225S. [PubMed]

2. Wing RR, Hill JO. Successful weight loss maintenance. Annu Rev Nutr. 2001;21:323341. [PubMed]

3. Bandura A, Simon K. The role of proximal intentions in self-regulation of refractory behavior. Cogn Ther Res.

1977;1(3):177193. doi:10.1007/BF01186792. 4. Brown MJ, Sinclair M, Liddle D, Hill AJ, Madden E,

Stockdale J. A systematic review investigating healthy lifestyle

interventions incorporating goal setting strategies for

preventing excess gestational weight gain. PLoS One.

2012;7(7):e39503. doi:10.1371/journal.pone.0039503.s001.

[PLoS ONE]

5. Fujita K. Seeing the Forest Beyond the Trees: A Construal-Level Approach to Self-Control. Social and Personality

Psychology Compass. 2008;2(3):14751496. doi:10.1111/j.1751-9004.2008.00118.x. [Wiley Online]

6. Ordonez LD, et al. Goals Gone Wild: The Systematic Side Effects of Over-Prescribing Goal Setting. Hardvard Business

School. 2009. Available at: http://ssrn.com/abstract=1332071

7. Pham LB, Taylor SE. From Thought to Action: Effects of Process-Versus Outcome-Based Mental Simulations on

Performance. Pers Soc Psychol Bull. 1999;25(2):250260. [P&SPB]


Whats causing the constant feuding between the CICO and anti-CICO camps? By Alan Aragon

____________________________________________________

So it begins...again!

Those of you living in a cave might be unaware that computer

software programmer-turned diet guru Jonathan Bailor (whose

methods I critiqued in the Nov 2013 issue of AARR) struck up a

partnership with Quest Nutrition. They launched a high-

production video series called The Quest to End the Calorie

Myth, but terminated it as it barely got off the ground. Quest

pulled the series due to an immensely negative response on

social media as well as directly on Quests Youtube channel where the video was hosted. A major shortsight on Quests part was not realizing that a large segment of their online market are

fitness and bodybuilding-oriented proponents of tracking

macronutrition and being flexible about the food sources

comprising the diet. IIFYMers (the If It Fits Your Macros camp) were utterly enraged by Bailors video. This vicious reaction was justified, just feast your eyes on the following

ridiculous quotes from the video:

Quality of calories, not quantity of calories, is the key to healing your body and dropping fat.

Those sugar calories cause a hormonal clog that makes it difficult for your body to burn fat regardless of how little you eat or how much you exercise.

Eating sugar triggers a release of a hormone known as insulin that pulls that sugar out of your blood stream, and takes it and sores it in your fat for later use.

In the following discussion, Ill dig into what I feel are the main elements that keep the calories in/calories-out (CICO) and anti-

CICO camps at war.

Straw men & false dichotomies

The underlying message of the video was that calories dont matter as long as they arent carbohydrate calories. This is the typical war cry of folks who have bought into the dogma that

carbohydrate intake is the prime culprit in the modern obesity

epidemic. A common thread among low-carb diet proponents is

a passionate dismissal of the CICO model of weight loss. A calorie is NOT a calorie! they scream. What they mean is that the macronutrients, as well as the foods that contain them, do not

have identical metabolic effects. Heres the irony: no one in the CICO camp disputes that.

The anti-CICO camp is under the false presumption that their

opponents believe that the macronutrient composition of the diet

has no impact on body weight or body composition. Of course

this is absurd, given the well-established differences between

macronutrients in terms of metabolic and hormonal (thus

behavioral & appetite-regulating) effects. The anti-CICO camp

is also assumes that CICO proponents ignore diet quality. On the

contrary, I have not met a single CICO proponent who thinks

that diet quality doesnt matter for long-term health. Making the leap toward thinking CICO folks completely dismiss the variable

effects of the macronutrients is likely due to the normal human

tendency to think in black-white terms. Speaking of which, its very common for low-carb diet proponents to issue a false

dichotomy. Specifically, they present their case as if there are

only two choices that can be made: an Atkins-type diet, or some

variant of the Standard American Diet (SAD), which is

characterized by a high intake of fast food and refined

carbohydrates, among other things that are actually shared by the

Atkins model (i.e., a high intake of saturated fat).1 So, in the

eyes of the zealots, its either low-carb or high-crap, with no other choices in-between. This type of false/binary thought is far

too common among preachers of the low-carb gospel.

Blatant denial of the evidence

Ill open this section with an excerpt from Wu et al in one of the most diligent review papers Ive read in recent years:2

Data from meta-analyses of dietary intervention trials suggest that some weight-loss diets, such as low-carbohydrate diets, low-GI/GL diets, and the Mediterranean diet, might be alternatives to conventional low-fat diets, especially for short-term weight loss, but have great variability of long-term effects. Moreover, the difference in weight loss among these diets is only 1-2 kg or less, which appears to be of little clinical significance. Thus, overweight and obese people can choose many different weight-loss diets on the basis of their personal preferences.

In other words, there is a wide range of diet types (in terms of

both macronutrition and food choices) that imparts similar

results. The weight loss differences in some cases reach a degree

of statistical significance, but in the long-term, these differences

are often too small to be meaningful in the real world.

Conveying the same message is an excerpt from conclusion of

the of a recent meta-analysis by Bueno et al:3

Undoubtedly, the present findings demonstrate that a VLCKD has favourable effects on body weight and some cardiovascular risk factors, as stated by Santos et al.(12); however, in the long term and when compared with conventional therapy, the differences appear to be of little clinical significance, although statistically significant.

Keep in mind, these conclusions were reached despite the

examination of diets that did not match protein (I really wanted

to add an exclamation point here). In comparison studies, low-

carbohydrate diets almost always exceed the protein content of

their low-fat comparators by a substantial margin; usually about

40%. This gives the low-carb treatments predictable advantages

in terms of LBM-preservation, satiety, and thermic effect. The

lack of a low-carb advantage for clinical outcomes (not just body

composition improvement) has been seen repeatedly in

controlled interventions that match adequate protein.4,5

Studies conducted in metabolic wards where all food and drink is provided and monitored have the highest level of control since the subjects have the least leeway for noncompliance. This type of research is the antithesis of observational research, and is a far cry from the confounding potential inherent with free-living


designs with self-reported intake. A friend and colleague of mine named Anthony Colpo has done the daunting diligence of compiling 26 metabolic ward studies comparing isocaloric diets with widely varying carbohydrate proportions and a minimum 3-week duration.

6 Of these 26 studies, only 3 showed a significant

weight loss advantage to the lower-carb diets. None of the studies showed a significant fat loss advantage.

Humorously, high-profile low-carb absolutists have dismissed the metabolic ward studies. Quoting NuSI (an organization headed by well-known low-carb/ketogenic diet advocates Gary Taubes and Peter Attia):

7

Metabolic ward studies typically used diets so hypocaloric that the control group was severely carbohydrate-restricted compared to a usual diet. [...] Under these circumstances, any differences might be too modest to detect.

The above quote is essentially dismissing all controlled, isocaloric studies comparing different carbohydrate content as long as the conditions are hypocaloric (since the higher-carb conditions will still not contain a high amount of carbs). This is an absurd dismissal since the issue at hand is the impact of carbohydrate within the context of when people are, um...dieting to lose weight.

Nevertheless, there indeed is metabolic ward research involving non-severe caloric restriction. A 4-week study by Stimson et al included a subgroup that compared 2000 kcal of a high-fat, low-carb diet (30% P, 4% C, 66% F) with a moderate-fat, moderate-carb diet (30% P, 35% C, 35% F).

8 This amounts to a

comparison of 80 g versus 175 g carbohydrate. No significant differences were seen in fat or weight loss between groups. Is it fair to use NuSIs logic and dismiss this because 175 g is too carb-restricted to be considered worthy of detecting differences compared to the 80 g treatment? That question was rhetorical.

Although not a metabolic ward study, Johnston et al carried out a controlled, isocaloric, adequate protein-matched comparison of a ketogenic (33 g carb) versus non-ketogenic diet (157 g carb) and found no weight or fat loss advantage of the ketogenic diet.

5

Once again, is it logical to dismiss these results because the non-ketogenic treatment wasnt high-carb enough? Thats just madness.

Collectively, the well-controlled evidence does not support the idea that carbohydrate is inherently obesogenic or inhibitory to fat loss at least compared to fat. This means that any proposed mechanism thereof (insulin flux or other) is irrelevant.

Over-reliance on anecdotes

Personal testimony or anecdote is a common way that low-carb

absolutists attempt to support their case. Anecdotes sit at the

bottom of the evidence hierarchy because they are subject to

multiple internal and external threats to validity. Anecdotes are

often merely case studies of the fulfillment of confirmation bias.

Nevertheless, low-carb zealots love to lean on their personal n=1

(single-subject) case studies, and kid themselves into thinking

they can be presented as objective evidence.

A popular example of n=1 dependence is personal fitness trainer

Sam Feltham, who self-reportedly ate over 5000 kcals per day of

a low-carb, high-fat diet for 21 days, and lost 3 cm of waist girth

while gaining 1.3 kg. While this is an interesting case study, it

cant be waved around as irrefutable evidence of the miraculous effects of this diet.

On the other end of the n=1 spectrum we have Chris Voigt, Executive Director of the Washington State Potato Commission Voigt ate nothing but potatoes the equivalent of 20 of them per day (amounting to roughly 2200 kcal) for 60 days. He lost 21 lbs, lowered his fasting glucose levels, cut his triglycerides nearly in half, and dramatically decreased his LDL-C while slightly increasing his HDL-C. Thats pretty impressive, and it brazenly violates every rule of low-carb dieting dogma, down to his low fat intake of roughly 2 tbsp/day from oil plus the trace amounts of fat inherent in potatoes. Once again, this is an interesting case study, but its far from definitive evidence of the universal superiority of a particular diet.

More on anecdotes and personal testimony: EAS, a sports nutrition supplement company, runs an ongoing transformation contest called the Body-for-LIFE Challenge, which began in 1997. Since then, theyve racked up a massive set of before-after pics of contestants. On their success stories page, you can view the pics of nearly 200 transformations. All of them are impressive in their own right, especially the transformations from the inaugural contest in 1997 (pics here). So, did these people follow an all-potato diet? What about a low-carb/high-fat diet thats widely preached as the savior of humanity? The answer is neither. The Body-for-LIFE plan is high-protein, moderate-carb, and low-fat similar to the dietary model that was popular among competitive bodybuilders in the 1980s and onward. Expectedly, 2 of the 6 meals per day are EAS meal replacement products.

To reiterate my point, anecdotes are a dime-a-dozen, and theyre inevitably subjective, so take these personal testimonies with a

grain of salt. None of the aforementioned case studies can

legitimately claim to be the one size that fits all.

Ignorance of what happens when calories disappear

When folks embark upon a journey to eat more than their predicted maintenance calories and either maintain or actually lose weight, they often conclude that CICO is BS. This is yet another failed line of thinking, since the energy-out side of the equations still counts in the CICO model, regardless of its difficulty to predict. An increase in energy expenditure occurs concurrently with an increase in training volume and/or intensity. This is a common occurrence alongside the attempt to eat more. Why? If you have more stored glycogen (the body can synthesize glucose and in turn glycogen from non-carbohydrate food sources

9) or incoming/postprandial calories, youll tend to

put more into your workouts, since youll have the spare energy (literally). This decreases the imposed surplus right off the bat.

A lack of net gains in scale weight can also occur through a

simultaneous reduction of fat weight and gain in lean weight.

This is yet another common phenomenon, particularly in novice

and intermediate trainees undergoing novel and more demanding

training stimuli (especially alongside an increase from sub-

optimal to optimal protein intake).

The other ways calories disappear through routes that are not necessarily conscious or voluntary. As Ive discussed in recent


articles, non-exercise activity thermogenesis (NEAT) has been

seen by Levine et al to increase as much as nearly 700 kcal per

day as a result of overfeeding 1000 kcals beyond predicted

maintenance.10

Changes in occupation can also drastically alter

NEAT. In a subsequent review, Levine reported that changes in

leisure-time NEAT and occupational NEAT can increase energy

expenditure by as much as 1000-1200 kcal per day,

respectively.11

As recently seen in Antonio et al,12

an additional

800 kcal of protein seemingly disappeared into thin air.

However, the reality was likely a combination of a greater

thermic effect, an increase in NEAT, a certain margin of

reporting error, and greater excretory losses.

Excretion is a rarely discussed yet common route for the

disappearance of ingested calories. Excreted calories through urine or feces are essentially unused, hence the necessary

distinction between gross energy and metabolizable energy.

When folks increase fat intake and concurrently increase their

fiber intake, which in low-carb regimes is commonly done

through eating more non-starchy vegetables, nuts, seeds, and

low-sugar fruits like berries, an interesting thing happens: they

lose significantly more fat through feces. For example,

Kristensen et al recently observed that the supplementation of

15.6 g flaxseed fiber per day caused a 50% increase in fecal fat

output, and a corresponding 23% energy excretion compared to

the control condition.13

Combine this with the laxative effect of

beverages such as coffee, and its a great recipe for ramping up energy lossesstraight into the toilet.

Selective prejudice against the funding source

Low-carb zealots selectively embrace or dismiss research not

just according to whether the results fit their pre-existent beliefs,

but also according to whether or not they feel the sponsor is part

of a conspiracy. Its common to see this camp scroll down to the studys funding source while skipping all the details, and making a flash judgment of the studys validity. This is a bias in and of itself, and its perpetrated by both camps. Its just as foolish to automatically dismiss research funded by the sugar, grain, and

beverage industries as it is to dismiss research funded by the

beef, egg, fish, nut, etc. industries as well as everything funded

by the Atkins Foundation (and similar entities). Ill close with an excerpt from a recent editorial by Binks:

14

In summary, what are the best practices for ensuring a strong, unbiased body of obesity research? Certainly not refusing funding from those who wish to collaborate with scientists in becoming part of the solution; absolutely not by launching unsubstantiated attacks on reputable scientists with longstanding records of ethical conduct and meaningful scientific contribution; rather, it is first by giving funding source its proper position among many possible and equally important threats to objectivity and implementing safeguards to protect against such bias (and worse yet malfeasance). Second, we need to redouble our efforts to adhere to the basic principles of good science like reproducibility, replicability and other core evaluative procedures that ensure objective and reliable scientific reporting. Finally, we need to work toward open access to data regardless of its source. This will require the cooperation of those in the scientific community and among potential sources of funding. Ultimately, this type of

transparency regardless of funding source will deliver a more robust and complete body of evidence.

References

1. Hsu TM1, Kanoski SE2. Blood-brain barrier disruption: mechanistic links between Western diet consumption and

dementia. Front Aging Neurosci. 2014 May 9;6:88.

[PubMed]

2. Wu H, Wylie-Rosett J, Qi Q. Dietary Interventions for Weight Loss and Maintenance: Preference or Genetic

Personalization? Curr Nutr Rep. 2013 Dec;2(4):189-98.

[Springer Link]

3. Bueno NB, de Melo IS, de Oliveira SL, da Rocha Ataide T. Very-low-carbohydrate ketogenic diet v. low-fat diet for

long-term weight loss: a meta-analysis of randomised

controlled trials. Br J Nutr. 2013 Oct;110(7):1178-87.

[PubMed]

4. Soenen S, Bonomi AG, Lemmens SG, Scholte J, Thijssen MA, van Berkum F, Westerterp-Plantenga MS. Relatively

high-protein or 'low-carb' energy-restricted diets for body

weight loss and body weight maintenance? Physiol Behav.

2012 Oct 10;107(3):374-80. [PubMed]

5. Johnston CS, Tjonn SL, Swan PD, White A, Hutchins H, Sears B. Ketogenic low-carbohydrate diets have no metabolic

advantage over nonketogenic low-carbohydrate diets. Am J

Clin Nutr. 2006 May;83(5):1055-61. [PubMed]

6. Colpo A. Table 1, Chapter 1, in: The Fat Loss Bible. Self-published, 2012. [Amazon]

7. Nutrition Science Initiative. Review of the literature, 2012. [NuSI]

8. Stimson RH, Johnstone AM, Homer NZ, Wake DJ, Morton NM, Andrew R, Lobley GE, Walker BR. Dietary

macronutrient content alters cortisol metabolism

independently of body weight changes in obese men. J Clin

Endocrinol Metab. 2007 Nov;92(11):4480-4. [PubMed]

9. Berg JM, Tymoczko JL, Stryer L. Section 16.3Glucose Can Be Synthesized from Noncarbohydrate Precursors. In:

Biochemistry. 5th edition. New York: W H Freeman; 2002.

[NCBI Bookshelf]

10. Levine JA, Eberhardt NL, Jensen MD.. Role of nonexercise activity thermogenesis in resistance to fat gain in humans.

Science. 1999 Jan 8;283(5399):212-4. [PubMed]

11. Levine JA, Vander Weg MW, Hill JO, Klesges RC. Non-exercise activity thermogenesis: the crouching tiger hidden

dragon of societal weight gain. Arterioscler Thromb Vasc

Biol. 2006 Apr;26(4):729-36. [PubMed]

12. Antonio J, Peacock CA, Ellerbroek A, Fromhoff B, Silver T. The effects of consuming a high protein diet (4.4 g/kg/d) on

body composition in resistance-trained individuals. J Int Soc

Sports Nutr. 2014 May 12;11:19. [PubMed]

13. Kristensen M, Jensen MG, Aarestrup J, Petersen KE, Sndergaard L, Mikkelsen MS, Astrup A. Flaxseed dietary

fibers lower cholesterol and increase fecal fat excretion, but

magnitude of effect depend on food type. Nutr Metab (Lond).

2012 Feb 3;9:8. [PubMed]

14. Binks M. Judge the science, not the funding source. Int J Obes (Lond). 2014 May;38(5):625. [PubMed]


It is good to have an end to journey toward; but it is the journey that matters, in the end. Ernest Hemingway

If you have any questions, comments, suggestions, bones of

contention, cheers, jeers, guest articles youd like to submit, or any feedback at all, send it over to [email protected].

Table of ContentsEditor's Cut: Internal vs. external cues: science, theory, & practical application.Nutrition & Exercise: The effects of a ketogenic diet on exercise metabolism and physical performance in off-road cyclists. Supplementation: Prostate cancer and the influence of dietary factors and supplements: a systematic review.Less Recent Gem: The effects of water and non-nutritive sweetened beverages on weight loss during a 12-week weight loss treatment program.Study Comment ReferencesIn the Lay Press: Why you never seem to reach your weight loss goals (and what to do about it).Godd Question: Whats causing the constant feuding between the CICO and anti-CICO camps?

5 - June - 2014

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