The Low Carb War Continues

Last month, a paper in the British Journal of Medicine on the effect of low carb diets on energy expenditure, with senior author David Ludwig, made a big splash in the popular press and also instigated a mini-Twitter war. The study, which cost somewhere in the neighborhood of 12 million dollars, addressed the general question of whether a person will burn more energy on a low carbohydrate diet compared to an average or high carb diet. In particular, the study looked at the time period after weight loss where people are susceptible to regaining weight. The argument is that it will be easier to maintain weight loss on a low carb diet since you will be burning more energy. Recent intensive studies by my colleague Kevin Hall and others have found that low carb diets had little effect if any on energy expenditure, so this paper was somewhat of a surprise and gave hope to low carb aficionados. However, Kevin found some possible flaws, which he points out in an official response to BMJ and a BioRxiv paper, which then prompted a none-too-pleased response from Ludwig, which you can follow on Twitter. The bottom line is that the low carb effect size depends on the baseline point you compare too. In the original study plan, the baseline point was chosen to be energy expenditure prior to the weight loss phase of the study. In the publication, the baseline point was changed to after the weight loss but before the weight loss maintenance phase. If the original baseline was chosen, the low carb effect is no longer significant. The authors claim that they were blinded to the data and changed the baseline for technical reasons so this did not represent a case of p-hacking where one tries multiple combinations until something significant turns up. It seems pretty clear to me that low carbs do not have much of a metabolic effect but that is not to say that low carb diets are not effective. The elephant in the room is still appetite. It is possible that you are simply less hungry on a low carb diet and thus you eat less. Also, when you eliminate a whole category of food, there is just less food to eat. That could be the biggest effect of all.