November 16, 2016

Obesity is (mostly) a Hormonal Issue: Let's Stop Pretending it's Solely About Calories

When doctors or nutritionists see someone with gigantism or acromegaly, is their first thought, “Clearly, that person just needs to grow less and shrink more”? No. Obviously not. Because it is clear—like, crystal clear, beyond-the-shadow-of-a-doubt, smack-you-upside-the-head clear that these conditions result from hormonal irregularities. You can no more control what results from the hormonal effects of a pituitary tumor hemorrhaging human growth hormone than you can control what results from the hormonal effects of a fourteen year old boy who found a special magazine hidden away in his dad’s nightstand. (Do kids still do that these days, or do they just find it on the interwebz instead?)

People with gigantism or acromegaly aren’t abnormally tall or large because they want to be, or because they somehow willed themselves to be. They are at the mercy of hormones. Like I said, to anyone with half a brain, this is obvious. No one questions this. No one blames these individuals for needing custom-made clothing or other accommodations. No one says, “Well, if they had just not grown so much…if only they hadn’t let themselves get so tall, they wouldn’t be in this situation.” “They'd be fine if they were just less tall and more short. No one says idiotic things like this because people understand that this is not within someone’s control.

So why, then, when it comes to the outward, rather than upward, expansion of the human body, does it all of a sudden become about willpower, discipline, and “calories?” Why is not more widely recognized that the horizontal growth of the body results from hormonal irregularities just as the vertical expansion does?

Why do so few people get this?

Someone who does get this (besides me, and probably you, dear readers) is the very brilliant registered nurse who goes by the pseudonym “Woo” (whom I introduced you to here).  She rants writes about this frequently. (Here are two of my favorites that are relevant to this topic, both with supremely awesome titles: CICO: why do we even entertain this idea? It's obviously wrong; and Semi-weekly reminder: CICOtards = myopic. If one rejects the neuroendocrine basis of adiposity, you will always be WRONG.) Quick warning if you happen to give those a read: Woo has truly unique and fascinating insights into all this, but her style takes some getting used to if you’re new to it.  ;-)
Someone else who gets it is Dr. Jason Fung. In fact, he has a fantastic blog series called The Hormonal Theory of Obesity. (It’s up to over 20 parts now, each of which is both educational and hilarious, and fortunately Dr. Fung is much more succinct, so reading all of that series would take you about as long as reading two or three of my posts, haha!)

Dr. Fung has pointed out on podcasts that certain medications are known to cause weight gain. Prednisone, for example, which is a synthetic steroid/synthetic cortisol. Why does it cause weight gain? It has no calories. If weight gain is the result of eating more calories than are expended, why does a pill with no calories cause weight gain? Why does natural cortisol cause weight gain? People with Cushing’s syndrome (or Cushing’s disease, resulting from a pituitary tumor that results in the adrenals pumping out high levels of cortisol) tend to be overweight. Why should high cortisol cause weight gain? Cortisol has no calories. Why does chronic sleep debt contribute to weight gain? Insufficient sleep has no calories. Talk to someone whose thyroid is on the fritz and can’t lose weight no matter how hard they exercise and how tightly they manage their diet. Why should this be? Low thyroid hormones have no calories. What all of these things have in common is they change the hormonal milieu of the body.

This has nothing to do with willpower and discipline (W&D). I have written about this over and over and over again. (Okay, yes, it does have to do with W&D in the sense that in order to change the hormonal milieu, you have to avoid foods and behaviors that contribute to out-of-whack hormones, and that definitely requires some W&D. More on this in a bit.)

I mentioned cortisol and thyroid hormone. We could add testosterone, growth hormone, DHEA, estrogen, and progesterone into the mix, as well as other hormones that affect what the body does energetically. (That is, what it does with the energy it gets from food. I’m not talking “energetically” like balancing your chakras and all that…) So there are multiple hormones at work here, but let’s focus on the one—the one—over which we have the most control. It’s pretty difficult for us to have direct influence over our level of DHEA or progesterone. I’m not saying these aren’t important, but in terms of having the biggest influence over fuel partitioning in the body, and being one that we, ourselves, can exert the biggest influence over, there’s really only one game in town.

You’ve probably figured out by now that I’m talking about insulin. (Remember: It’s the insulin, stupid.) Insulin helps orchestrate the partitioning of nutrients either toward oxidation (“burning calories”), or toward storage, and if toward storage, then favoring storage as triglycerides in adipose tissue. (Insulin is also necessary for “storing” amino acids in the form of skeletal muscle, but that’s not really storage in the same sense as adipose, and it’s not really what we’re focusing on here anyway, so forget I even mentioned it. I only wanted to point out that insulin does some good things and some very necessary things [e.g., building muscle], since I tend to only focus on its detrimental effects.)

High insulin levels result in the accumulation of body fat. We know this. Doctors know this. (At least, high insulin levels result in the accumulation of body fat in some people. There are, indeed, some special snowflakes who, for whatever reason, don’t gain body fat in the presence of chronically elevated insulin, but remember, as I’ve ranted written about, this does not mean they don’t experience other poor health outcomes stemming from chronic hyperinsulinemia.)

Why do insulin injections cause type 1 diabetics to stop breaking down their own adipose tissue and losing fat uncontrollably? (That is, it helps them maintain and even add to their fat stores.) Why should insulin do this? Insulin has no calories.

So can we please stop pretending that the maintenance and accumulation of body fat stores is driven solely by calories, and if we can just get people to ingest fewer calories, all will be well?

Okay, so, insulin. We know insulin causes (many) people to gain body fat, and acts as a big obstacle to them losing that body fat. Therefore, gaining body fat is (for many people) a hormonal issue.

So what?

The big “so what” here is that, unlike individuals with gigantism and acromegaly, who cannot control their levels of growth hormone, we can control our insulin levels. Some people’s bodies do this better than others naturally, while others among us have to work at it. (And we’ll have to continue to work at it for the rest of our lives.) Regardless of how easy or difficult it is, barring the rare case of an insulinoma (insulin-secreting tumor), we can control it. By hook or by crook, with low-carb or ketogenic diets, with fasting, with exercise, and/or with medication, we can get our insulin levels down to a level at which adipose tissue lets go of stored fat (fancy science word for this: lipolysis), so that other cells can use it for fuel.

Yes, folks, insulin isn’t just for regulating blood sugar. Another of insulin’s starring roles is inhibition of lipolysis. Doctors know this. Endocrinologists know this. Heck, I’m “just” a nutritionist, and I know it. And if insulin inhibits the breakdown of stored fat, and someone has a goal of losing some of their stored fat, then perhaps I’m a simpleton and things are much more complicated than I think they are, but it seems like reducing insulin levels should be a primary strategy for fat loss, no?

The part I can’t figure out is how someone can reduce their insulin levels when medical and nutrition professionals insist that they consume several servings of grains and other starchy foods each day -- you know, precisely the foods that raise insulin the most. Sure, exercise and medication can help, but again, unless I’m oversimplifying things to the point of inaccuracy, it seems like the easiest, most convenient, and most effective strategy would be to simply stop consuming the foods that raise insulin the most. I mean, call me crazy, but…

Aaaaanyway, this is where willpower and discipline come into the picture. (I said we’d come back to them, and look, it only took me 10 paragraphs!) Reducing one’s insulin levels does require a bit of W&D, but not in the traditional sense. That is, it’s not like: “Hey, fatty, you need to exercise some willpower to not eat so goddamn much. Lay off the bacon cheeseburgers and order a salad, you greedy pig. And while you’re at it, have the discipline to go to the gym and run a few miles on the treadmill before you eat that salad, lardass. Better yet, make it several miles. You’ve gotta earn that lettuce, Humpty-Dumpty!”

Yeah, NO. 

It’s more like, “Right now, your body is a ‘sugar-burner.’ This means your body is dependent on frequent infusions of carbohydrates in order to give you energy. But since all those carbohydrates are wreaking havoc on your insulin levels, and high insulin levels directly inhibit the breakdown of your stored body fat, we need to find a way to keep those insulin levels lower. But because you’re dependent on frequent carbohydrate infusions, in order to break this dependence, you’re going to have to be strong and say no to what are probably some of your favorite foods: bread, cookies, pasta, bagels, sugary sodas and coffee drinks, mac & cheese, peanut butter & jelly sandwiches, donuts, and more. I know, it sucks, but the cool thing is, if you can muster that bit of W&D for a few days (or a few weeks, for some people), you’ll find that you crave those thing less and less, and once your insulin levels get lower, you’ll be feeding off of your own body fat, so you’ll actually have a lot more energy than you ever had when you were chained to the carbs and your blood sugar was all over the map. Oh, and did I mention that while you muster up all this willpower and discipline, you can eat bacon, ribeye steaks with melted butter or blue cheese on top, ham & cheese omelets, prosciutto, roasted vegetables with garlic and olive oil, lamb sausages, and extra-dark chocolate?”

Oh, the deprivation! Oh, gosh, the willpower you’ll have to muster! How ever will you survive?

So yeah, people do need some W&D – at first. But once the “low carb flu” has passed, the worst of the withdrawal is over, and the physical addiction to sugar is (mostly) broken, they won’t need to white-knuckle everything so strongly.

So, the thing is, this is about calories, but only in the sense that the type of calories we consume can have a massive impact on how many of those calories we consume. (Think about gummy bears versus steak: which one will have you feeling hungrier sooner? [And wanting sugar?]) Robb Wolf has a new book about this coming out in spring 2017.

So when the “experts” tell us to eat more of the very things that are driving this vicious cycle in the first place (in case anyone’s confused, I am referring to sugar- and starch-dense foods, especially refined grains [and especially grains doused in sugar, and even more sugar]), well, what do we expect?

What do we do when people follow officially sanctioned advice but don’t get the promised results? What then? Should we “blame the victim?” When people follow the advice and don’t get the promised results, should they follow that advice harder—that is, eat even less and move even more in order to have even fewer calories in and even more calories out—or should they ask themselves if maybe the advice is flawed? If you follow shitty advice and get shitty results, there’s actually nothing wrong with YOU.  

If this is about “calories,” then it’s (mostly) about the calories that raise insulin the most. Or, rather, the foods that raise insulin the most. (The reason I say “mostly” is because, no, you cannot actually consume unlimited amounts of fat and expect to lose weight, even if your insulin levels stay low. Take my word for it; I learned the hard way. [Thanks a lot, mayonnaise!])


Even if the magical formula is calories in < calories out ---> fat loss, low carb still wins. In fact, people who don’t like to admit that low carb has approximately eight hundred benefits that happen even in the absence of weight loss, usually argue that low carbing offers no “metabolic advantage,” as the late, great Dr. Atkins called it. They say the real reason low carb is effective for weight loss is that by way of regulating appetite and satiety signaling, people naturally reduce their total food intake. Umm, yeah: people naturally reduce their total food intake. Isn’t that what the CICO people want us to do? And if it’s much easier to do it by reducing carbohydrates (rather than reducing fat), then this should still be the first-line recommendation for losing fat. (Again, I could be wrong. I nearly failed my mathematical reasoning class in college, so I’m not exactly a logic whiz or anything, but I think I might be on to something here…)

So what, exactly, the hell?

Low carb works. We can debate into the next century (and no doubt we will) about why it works, but when “diabesity” and related disorders are threatening to bankrupt individual families and entire nations, and so, so much quality of life is lost to the resulting physical, psychological, and cognitive degeneration and debilitation, then we need to do something about it now, and that “something” is telling people that one of their best hopes for reversing their illnesses and regaining their vitality is a low-carb diet. It might not be the only effective solution, but when patients are routinely presented with other options, including veganism, a vegetarian diet, a low-fat diet and lots of exercise, not to mention invasive and dangerous surgery—it’s long past time for medical and nutrition professionals to quit their prudish and politically correct backlash against low-carb, and for this way of eating to be recommended just as highly—if not more highly—than any other.

And it’s time to stop blaming people for eating too many “calories,” and start informing them that their excess weight is hormonally driven, and then educating them about how to reverse this hormonal situation by changing the type of calories they consume.

With this in mind, I’ll leave you with an image from the ever-talented Ted Naiman, MD

Just one nuance I would add: changing what we eat can have a profound influence on how much we eat. They are not necessarily independent variables. I guarantee you have experienced this yourself: you could easily polish off an entire (large) package of cookies in one sitting and then still be looking for more, but after a big steak, you're pretty well stuffed for quite some time, and the total calories in a family-sized bag of cookies are probably higher than those from a steak. (So yes, owing to its effects on appetite and satiety hormones, low carb does, indeed, still win.)

Disclaimer: Amy Berger, MS, CNS, NTP, is not a physician and Tuit Nutrition, LLC, is not a medical practice. The information contained on this site is not intended to diagnose, treat, cure, or prevent any medical condition and is not to be used as a substitute for the care and guidance of a physician. Links in this post and all others may direct you to, where I will receive a small amount of the purchase price of any items you buy through my affiliate links.


  1. Hi Amy,
    "So, the thing is, this is about calories, but only in the sense that the type of calories we consume can have a massive impact on how many of those calories we consume."

    We have two groups of animals. They consume exactly the same amount of calories, but their diets are qualitatively different. Will they fatten the same?

    Now we have two groups of animals. One of them ingests half the calories than the other group, but there is more sucrose in its diet. Which group will be fatter at the end of the experiment?

    Now we have two groups of animals. Both have exactly the same caloric intake (the same diet in both groups) and they have exactly the same physical activity. But one of the groups receives insulin injections. Will both groups fatten the same?

    (Experiments with animals are absolutely controlled and there is no reason to doubt the results)

  2. It's been done with mice:

  3. Amy, I love your blog! I've read Woo's blog and she's no fan of Jason Fung, that's for sure :).

    1. No, she isn't. And she has some good points. I think he does great work, but if I agreed with anyone (including Woo or Dr. Fung) about *everything,* that would be sketchy. ;-)

  4. Amy,
    As informative and entertaining as always. Thanks much!

  5. what a great rehash of the same thing a million people have already said. hope you didn't spend much time on this one. (eye roll).

    1. Obviously you're not a fan of my writing. Why read it, then? Surely there are better ways to spend your time.

    2. Without people like Amy or Gary Taubes explaining this ideas, once and again, may be I would have never imagined what a big BS the energy balance theory is. The information they give changed my life: from obese 4 years ago, to already 3 years maintaining a perfect physical condition.

      Anonymous, you are obviously a troll, but you are playing with people's health here. Why don't you play troll elsewhere?

    3. It needs to be said. It needs to be said over and over again because we are up against a big, well oiled machine that has greater resources and 50-60 years head start with the low-fat message.

  6. Hi Amy,
    although I liked this article a lot, I have a suggestion for you.

    Calories are a unit of energy. Calories don't have any other property besides energy, therefore there is not such thing as "type of calories" or "more of those calories". Getting fatter is not about calories in any sense.

    Saying that "...this is about calories, but only in the sense that the type of calories..." is incorrect and leads to confusion.

    The type of foods we consume can have a massive impact on how much of those foods we consume.

    Best regards,

    1. Hola Vicente. Did you miss what I wrote under the graphic? I said this very thing. ;-)

    2. A perfect article in that case :)

  7. Hi Amy. I thoroughly enjoyed this blog post- informative and hilarious! You've managed to explain it in a way that made me want to keep reading. I will definitely be checking in to see your future posts. Thank you!

  8. Not just hormones! Though it probably something effects the hormones to change things internally.

    "Still despite eating more while high (by some measures, over 600 extra calories per day), marijuana users' extra intake doesn't seem to be reflected in increased BMI."

  9. My late mother was a teacher from the thirties to the seventies. During that time there might be one or two "fat kids" per class (and maybe as many as one Type 1 diabetic and a couple with asthma or allergies in the whole school).

    It's ironic that in those days obesity was often blamed on "glands" ie. endocrine. No-one mentioned gluttony and sloth at all.

    "Everyone knew" that if you wanted to lose weight you cut back on starches and sugar. Some still called dieting "Banting".

    That was still true when I was young, except for the Banting bit. It's only been since "low fat" diets were invented that obesity grew so rapidly, and blame the patient started.

    Already a lot of doctors and most dieticians are too young to know there was ever a time before the "epidemics" of obesity, diabetes, etc. or that things were ever done differently.

  10. Hi Amy, love your blog and your writing style. Any thoughts on neurotransmitters and supplementing with a few to influence hormonal response for sugar/carbs cravings?

    1. Supposedly, for some people, supplementing with L-gluatmine, tyrosine, tryptophan, DLPA, and other amino acids/compounds can help take the edge off, but I have not experienced any benefit from these, myself. If anything, they have made my emotional issues worse. But that doesn't mean they're not effective for other people. Worth a try if you find your cravings are insurmountable. (Sorry for the delay in replying -- your comment got put into the spam folder by mistake, so I didn't see it!)