Getting their volunteers to add a thousand calories of fat to their daily diet also proved surprisingly difficult. Throughout their numerous publications, Sims and his colleagues comment on the “difficult assignment of gaining weight by increasing only the fat.” Those fattening upon both carbohydrates and fat, on the other hand, easily added two thousand calories a day to their typical diet. Indeed, subjects in some of his studies, Sims and his colleagues reported, experienced “hunger late in the day…while taking much greater caloric excesses of a mixed diet”—as much as ten thousand calories a day.

Sims and his collaborators evidently did not wonder why anyone would lose appetite—develop “marked anorexia,” as they put it—on a diet that includes eight hundred to a thousand excess fat calories a day, and yet feel “hunger late in the day” on a diet that includes six to seven thousand excess calories of fat and carbohydrates together. It would seem there is something about carbohydrates that allows the consumption of such enormous quantities of food and yet still induces hunger as the night approaches.

By perceiving obesity as an eating disorder, a defect of behavior rather than physiology, and by perceiving excessive hunger as the cause of obesity, rather than a symptom that accompanies the drive to gain weight, those investigators concerned with human obesity had managed to dissociate the perception of hunger and satiety from any underlying metabolic conditions. They rarely considered the possibility that hunger, satiety, and level of physical activity might be symptomatic of underlying physiological conditions. Imagine if diabetologists had perceived the ravenous hunger that accompanies uncontrolled diabetes as a behavioral disorder, to be treated by years of psychotherapy or behavioral modification rather than injections of insulin. These researchers simply never confronted the possibility that the nutrient composition of the diet might have a fundamental effect on eating behavior and energy expenditure, and thus on the long-term regulation of weight.

There is one way to test this latter notion, and, in fact, such tests were done from the 1930s onward. Alter the proportion of fats and carbohydrates in experimental diets and see what happens. Test low-fat diets versus low-carbohydrate diets, keeping in mind that a diet low in fat must be high in carbohydrates and vice versa. This would test the notion that these nutrients have unique metabolic and hormonal effects that influence weight, hunger or satiety, and energy expenditure. Such trials provide the means of answering these fundamental questions: What happens when we eat a diet restricted in carbohydrates, but not calories? Do we lose or gain weight? Are we as hungry as we are when calories are restricted? Do we eat more or less? Do we expend more or less energy? And what about when fat is restricted, but carbohydrates or calories are not? What are the effects on hunger, energy expenditure, and weight?

Chapter 19

Chapter Nineteen

REDUCING DIETS