Seven Against Thebes

Energy Balance Versus Insulin and Carbs, Again

Genuinely, we admire the persistence of David Ludwig. Today in the Washington Post, he has an opinion piece about his opinion piece in the European Journal of Clinical Nutrition. Once again he wants to sell the world on his concept that carbs and insulin are more important for understanding obesity than simply thinking about energy balance. Obesity is about more than just calories in, calories out, and calories stored as fat.

On this we agree. Obesity is more complex than policy makers and popular culture typically suggest. We entirely embrace his conclusion in the Post:

“We must consider different ways of solving the intractable problem of obesity and open our minds to a radical-sounding notion: Overeating is a symptom, not a cause.”

Repetition to Sell an Idea

When selling an idea that cuts across the grain of typical thinking, repetition does indeed help. Our readers might have noticed, for example, that we mention the need for curiosity and objectivity about obesity whenever we can. It’s fundamental for getting out of the rut of health policy that’s stuck on finding ways to nudge people eat less and move more.

So Ludwig’s persistence in selling his model in every forum he can find might serve his purpose well. But, as Daniel Drucker points out, the repetition can become a bit tiresome:

A Plea for Funding?

The truth is that Ludwig is right. It’s not just an excess of calories that is causing the problem with obesity. But he seems stuck on replacing one simplistic idea (it’s all about calories) with another (it’s all about carbs). He wants more funding to study low-carb diets, as he explains in the Post:

“Meanwhile, despite investing in many major low-fat diet trials (virtually all failing to show any benefit for the main outcomes), the government’s National Institutes of Health has yet to fund a single long-term low-carb trial of similar scope. This hasn’t been a fair contest of ideas.”

Environmental Obesity DriversCan We Think More Broadly?

This is the part of Ludwig’s crusade that’s hard to buy. We will be shocked if another big, expensive study of low-carb diets (yes, there have been some) shows that such diets will provide the definitive answer for overcoming obesity.

As a matter of fact, obesity has more than one factor driving it. Just as calories alone can’t tell the whole story, neither can carbs and insulin. For that matter, food is not the the whole story, either. Stress, distress, drugs, chemicals, physical environment, and technology all play contributing roles. Just as a simple focus on calories can be misleading, so too can a singular focus on sugar, carbs, and insulin.

So we’ll say it again. Nobody has this thing figured out. Getting to better answers will indeed require more curiosity and objectivity about the subject – not just passionate advocacy for one’s favorite model.

Click here for Ludwig’s commentary in EJCN and here for his commentary about his commentary.

Seven Against Thebes, painting by Aleksandra Ekster / WikiArt

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July 29, 2022

6 Responses to “Energy Balance Versus Insulin and Carbs, Again”

  1. July 29, 2022 at 7:38 am, Allen Browne said:


    I agree with your persistence. Keep it up.


  2. July 29, 2022 at 9:17 am, David Ludwig said:

    Ted, your post reflects an unfortunate, but prevalence, double standard.

    • There are 20+ papers claiming to have “falsified” or otherwise disproven the carbohydrate-insulin model (see our EJCN review for a partial list).

    • There are 100s of papers – including from the government and the big professional societies – promoting some version of the energy balance model.

    • There have been exactly 3 detailed scholarly reviews in the last 4 years aiming to build the carbohydrate-insulin model.

    Yet somehow, this is a “repetition” (used 3 times in your post), a “crusade,” something we’re aiming to “sell” (used 4 times), and “tiresome.”

    Good scientific practice requires all hypotheses and assumptions be critically appraised (including comfortable, conventional ones). But when conventional approaches keep failing – and rates of obesity continue to climb – alternative views should be welcomed, not belittled.

    David Ludwig
    Boston Children’s Hospital

    • July 29, 2022 at 12:14 pm, Ted said:

      David, thanks for taking the time to share your further thoughts.

      I genuinely admire your persistence. I see nothing wrong with promoting (or selling) your ideas. I certainly promote ideas in which I believe. So far as repetition becoming tiresome, that’s entirely in the eye of the beholder.

      I freely admit that I’m a bit tired of debating whether CIM or EBM is the best model for obesity. I think we need to consider a much wider range of thinking, consistent with your advocacy for welcoming alternate views.

      So thank you for that advocacy. It’s much needed.

  3. July 30, 2022 at 2:37 pm, Todd I. Stark said:

    To David, thank you for your efforts in being a persuasive and valuable dissenter in the obesity research community. We need more people like you in research questioning assumptions and driving new ideas.

    In response to David’s comment, I think his statistics are a valuable contribution that point out two things: (1) insofar as a theoretical framework the carbohydrate insulin model has not yet been invested in very much by researchers outside of a small dedicated subcommunity (although the popular support seems much wider considering all of the commercial products that appear aimed at assisting in carb restriction), and (2) it seems to me there are strong divergent opinions on why that is the case. It may be because many obesity researchers don’t consider it promising on technical grounds so far or it may be more because of social factors. From my perspective, realistically probably some mixture of both.

  4. August 05, 2022 at 3:26 pm, Glen Duncan said:

    This is a great site, and I really enjoy the perspectives shared, so thank you for the work you do.

    I agree with your comment re: being tired of debating whether CIM or EBM is the best model for obesity. I disagree that nobody has this thing figured out though, because you hit the nail on the head with this statement “As a matter of fact, obesity has more than one factor driving it”.

    Obesity is an intractable public health problem that is caused by multiple factors and thus only solutions that address these multiple factors will lead to succcess. It’s our genes. It’s our SES. It’s our individual behaviors. It’s our interpersonal relationships. It’s the community we live in. It’s the larger built and natural environment. It’s policy. It’s all of these factors and it’s all of these factors interacting in a dynamic way as we carry out our daily lives.

    Multifactorial problems demand multifactorial solutions, so hopefully we can stop talking about THE factor driving obesity or THE approach to addressing obesity because that thinking will no doubt fail.

    • August 05, 2022 at 3:47 pm, Ted said:

      Thank you for your good and thoughtful comments, Glen.