Relatedly, there is evidence that certain types of "resistant starch" can help reduce visceral fat. This starch comes from green bananas, potatoes, legumes, etc. It has to be either raw (there are supplements for this) or cooked and cooled.
"Resistant starch intake facilitates weight loss in humans by reshaping the gut microbiota"
sample size n=37 of which recruitment only happened in Shanghai without any real control for confounders, only evaluated over a period of two weeks with no longterm follow-ups, the dosage of 40g RS/d is very high (would take about 4-5 large potatoes daily for equivalency or ingesting likely expensive supplement), the crossover compares RS vs CS in the same participants with only a 4 week washout which is a weakness since fermentable fiber persists >4 weeks, also the supplement they used was industry-provided by a starch manufacturer which was weirdly not disclosed
this is a great study if you are an overweight/obese adult without overt metabolic disease, willing and able to consume 90 g/d of starch supplement within a controlled diet, and living in Shanghai with similar baseline fiber intakes endemic to that population. it is extremely not generalizeable to you or even me though I fit more of those characteristics than I care to admit
a starch is not fiber and generally not broken down the same way in digestion afaik
fiber is great and under-consumed (especially soluble) and is very well-studied on modern populations [0]. we don't really need to make mechanistic reasonings about evolutionary adaptations that occurred hundreds of thousands of years ago or rely on studies of a small, homogenized population whose lived realities are far from yours and mine
plus, following the the hierarchy of evidence, mechanistic guesses are considered extremely low quality, only ranking above things like mouse studies [1]
We shouldn't assume that because we are a great ape that we eat the same as other great apes. Humans spent two million years away from the jungle evolving in the savanna, with very different food sources. Our guts changed quite a bit in that time, and our digestion doesn't work the same.
Fiber is not a supplement, or at least it’s not just a supplement. It’s the primary thing that makes fruits and vegetables healthy.
We’ve already known fruits and vegetables are healthy. Fiber is the reason why eating an orange is good, but drinking a glass of orange juice is about equivalent to a bottle of coke. That’s not an exaggeration, by the way, it’s about the same sugar content.
If you want to eat the recommended 35g of fiber a day, you won’t be able to reach it with just supplements. You need to be eating fruits and vegetables at every meal. For my entire life, everyone has been saying to eat fruits and vegetables at every meal in large quantities.
Also, the authors claim the starch "inhibited lipid absorption." They do not argue why they used surrogate blood biomarkers instead of residual energy output in fecal samples (which is a better measurement).
You can just go on a calorie deficit and it will reduce your visceral fat when you start getting lean enough.
But obviously, most people are a lot more interested in finding a magic food which does this rather than a proven calorie deficit, which is highly effective.
Purely behavioral lifestyle interventions have the lowest long term success rates of all available treatments for obesity. It's especially unreliable if you have weight loss targets higher than 15%.
They are of course still widely recommended due to numerous benefits other than weight loss, but "highly effective" is just wrong in the context of obesity treatments.
Hasn't it been found that the best diet is the one you'll actually do?
I seem to remember a meta analysis a decade ago or so finding that the particulars (high protein, atkins, paleo, whatever) didn't really matter so much as the the willingness and commitment to the change.
This problem literally did not exist until the 80s. I don't think the human brain/body evolved much since then so surely there is another problem. The only solution is behavioural, everything else is cope.
It's the same thing for the mental issues epidemic... you can't build a completely hostile environment to human life and well being and then say "welp, I guess we need drugs to make you feel normal now", now they'll sell us the drug and the cure, and you'll be clapping and thanking them for saving you, truly amazing.
I think the cope is actually believing that some magic thing made people more lazy between now and the 80s.
You’re right we didn’t evolve since the 80s. But our food has certainly changed. It’s not like some God from above put laziness in peoples brains just now. No… people were always lazy.
It’s just that you could be accidentally skinny before. You can’t be accidentally skinny now, it has to be intentional.
Speaking from experience diet back then was pretty shit, what's changed the most is the levels of physical activity.
Many jobs used to involve physical labour, huge number of us now are desk jockeys. Decades of prioritising motorists and increasingly large vehicles over active transport mean walking, cycling are a fraction of what they used to be [0].
> this problem literally did not exist until the 80s.
Henry VIII might have a word for you on that one, as would many other of history’s aristocrats. The only thing that’s really changed is the cost of food that used to be reserved for kings.
Nah, what changed is preponderance of highly processed junk food.
When I lived, in my childhood, in communistic Bulgaria/Czechoslovakia, nobody was starving. Yes, we did not have bananas and Argentinian steaks, but there was enough basic food, including the protein-rich one (eggs, cheese, even meat, although the best cuts were 'under the counter'). Still, few people were really obese; those were obviously sick.
Nowadays, there is plenty of junk food. The food is not really cheap (especially with the recent inflation), even the junk one. Still, being obese is (almost) the new normal. You can see that everywhere.
Yes, people spend more time indoors - but even in the old times people tended to spend a lot of time behind TV.
My hypothesis is that the junk food just does not have enough real nutrients, just mostly empty calories. So the body signals 'I need more nutrients', to which the typical response is 'here you have more empty calories'.
Funnily enough, I also grew up in Communist Czechoslovakia and I have a Bulgarian father. Wouldn't expect anyone else here to fit into the same narrow box, but here we are, two of us.
"I don't think the human brain/body evolved much since then so surely there is another problem."
What really changed is the foodscape. And quite thoroughly so. Even basic agricultural products like wheat, corn or fruit are different from the variants 50+ years ago, there was a concerted effort to make them bigger, pesticide-resistant, more sweet, more energy-dense...
I remember the apples of the 1980s. Nowhere near as sweet as today, some were thoroughly sour. And these are considered the healthy choice now.
"The only solution is behavioural, everything else is cope."
This is like, your opinion, man. An opinion that can make you feel smug, but that is no victory. In practice, GLP-1s are doing what a generation of preachers like you could not - making people more thin and healthier.
In a sense, it is you who is coping hard and defending a "solution" which provably never worked on a population scale.
> In practice, GLP-1s are doing what a generation of preachers like you could not - making people more thin and healthier.
Alright, then let's continue making food worse and worse over the years, let's keep building a system that is less and less viable for humans. When we'll all be on GLP-1, + depression + ADHD drugs to just cope with days to day life maybe we'll finally wake up and ask ourselves how we ended in such a shit show.
> Purely behavioral lifestyle interventions have the lowest long term success rates of all available treatments for obesity.
What? Surely changing one's behaviour - particularly the parts of behaviour that caused the obesity in the first place - is a sure way to stop being obese.
Effectiveness is two parts: does it work in isolation, and are people able to do it.
Running a marathon a month is a sure way to improve your health. However, less than 1% of people would be willing to do that. So it’s not an effective solution.
It’s an effective solution if we just ignore life, sure. But solutions are rooted in pragmatism.
It's a lifestyle, the optimal basic lifestyle, the one were you don't shorten your life/healthspan by decades. It's how thing were intended to be really.
It's funny how proposing an healthy diet is unrealistic and watching fatties eat themselves to death is the new normal, complete value inversion and looser mentality
> Of course, that assumes your goal is to actually help the fatties
I don't believe that's possible. They have to choose a healthier lifestyle by themselves.
It's not that people are fat because no one told them to eat healthy and exercise sometimes. They're fat because they have ignored that advice for a long time.
They aren't missing information about diet and exercise, they're missing diet and exercise.
You don't believe it's possible? Obviously it's possible! Look around, we have what are essentially miracle drugs available, and you are still pushing ideas that have mostly failed for the last 50 years!
Well, the proposed solution works basically 100%, the problem is, as with most issues, people. Tell folks they should not eat sweet things for rest of their lives and half go catatonic when they realize reality of it. The other half go medicating such induced stress with a bucket of ice cream or similar. This is not problem of underlying solution per se, its the problem of expecting too much out of most people.
But you are right with the fact that at the end, it mostly doesn't work. But those who stick with regime, it works 100% and positive changes in life, quality, happiness etc are massive.
The real solution - treat underlying mental issues. They are always there with obese people, they are massive (no pun intended), and they manifest as obesity, among plethora of other mental issues.
Frankly, a "solution" to a human problem that does not work with most humans, does not deserve to be called a solution.
Mental issues is a broad category as well. Are food cravings a "mental issue", or a "physiological/hormonal issue"? No clear difference between those two, and given how GLP-1s quench cravings in general - not just food cravings, plenty of people on those report losing their compulsive behaviors, even such as gambling or shopping - the hormonal variant sounds quite plausible.
Which may be actually good. We are a lot better in treating hormonal issues than mental issues.
> If you change your lifestyle temporarily, the effects are temporary.
Not quite.
If the lifestyle deteriorates, then weight regain is expected. However, people might regain only a fraction of the weight lost. It is possible for some of the weight loss to be permanent.
Also, even temporary changes in lifestyle can produce benefits that outlast the intervention, like lower risk of disease such as diabetes. Exercise is notable for providing numerous benefits that persist even if weight is completely unmodified.
> If you change your lifestyle permanently, the effects are permanent.
No. It improves your odds of success, but does not guarantee it.
Body adapts significantly over time when subjected to weight loss. There are compensatory physiological adaptations that favor weight regain, such as changes in energy expenditure and appetite. Even with sustained effort, maintaining the initial weight loss may become progressively more difficult because of those changes. This shows up in research as results like mean weight loss of ~9% at year 1 and ~5% at year 8.
Sad reality is, very few people have the resolve to do permanent changes to their behavior, the older the worse. Too deep in their comfort zone without even realizing this, even with looming heart attack or other massive health issues. Its much easier to end up seeing a grown man crying about how he has to eat that next snickers bar rather than sustaining resolve with some healthy trend.
For the love of god or any other deity I can't grasp this, its trivial for me to muster a tiny fraction of discipline and simply change direction from now on. But people out there are vastly different than me, thats pretty obvious, ie many people detest sports or even sweating. Addictions, and over-eating is an addiction (or some form of stress-coping mechanism) have a way to grasp core of one's existence and not let go.
My wife sees such overweight folks with not-so-much-time-remaining-on-earth as GP regularly. As she says - they basically over-ate themselves into mental disorder (or started with it and their body over time aligned with behavior). To actually fix this, that mental disorder needs to be tackled, no gastric operations or wegovy injections provide permanent solution. But they sure make pharma companies richer and give this warm fuzzy feeling of achieving actually something visible, even if temporary.
If you opt for it, then yes of course, abstinence-only sex education is a sure way to stop ten pregnancy.
Similarly, if you opt to change your lifestyle and start living healthier, and follow through, it will work.
If someone tries to force you, of course it will fail (in both of these cases). There is no way to stop someone else from being fat. We can only change ourselves.
It's not even a case of internal/external motivation. Even internally motivated attempts often fail. You can always claim that they just didn't want it enough or lacked willpower, but it still reduces the effectiveness of the approach. You can claim any approach for solving a problem works if you reject all the cases where it doesn't.
Being fit and maintaining the normal weight is not the same thing as reaching a BMI of 50 kg/m² then losing it. I've seen fitness influencers take up that challenge only to find that "changing oneself" is significantly harder than it used to be when they were fit.
To do it right it requires quite an effort to no go too much into calorie deficit.
It definitely is not "you can just go on a calorie deficit", that is how jo-jo effect works.
For average person that has children, full time job, and whole range of adult responsibilities it is hard. Not impossible but hard, this is why people are looking fo easier solutions.
I think what's important is to consider the difficulty of making these choices, and to set up your environment so that it's easier to make the right choice.
I've lost weight and kept it off by making sure I don't have sweets and other types of food that I know I'll down in ten minutes. But if I don't have any on hand, I won't eat any.
Ditto for normal food: if I increase the portion of filling, low-calorie foods (think salads and other greens), with a lot of protein, I know I won't have cravings later in the day and feel full longer. But if I buy fatty sausage, with a hefty helping of salty cheese, I'll eat until I explode.
If when I'm hungry I have a choice between "a quick bite" of something very palatable, calorie-rich but nutritionally poor, and a "good" meal, I know I'll make the wrong choice. But if my only choice is the good meal, I'll eat that and stay on track.
This also has a positive feedback effect: after a while, not only did I stop craving various junk foods, but they actually don't register as food anymore when I see them in ads or similar. Which, of course, makes it easier to stick to the "diet". Now, when I'm hungry, I crave "actual" food. The other day I couldn't have lunch on time, and all I could think of was a fat bowl of lettuce with some roasted chicken breast and yogurt. Walking in front of the local McDonald's peddling their latest mystery burger didn't do anything to me.
Why not, though? Eating is fun and pleasurable. If we can figure out a way to eat the things that we want, in the quantities that we want, while maintaining our health, why shouldn't we try?
I've lost weight through forcing myself into a calorie deficit, and it works really well, but it's not particularly fun.
> You always end up with the people pushing these foods being those who sell them.
What do you mean by "these foods"? Just buy unprocessed food and 99% of the problems disappear. There is no fake, no people trying to sell you these out of malicious intent. Just buy local food people had access to in 1900 and you'll cure all your problems.
Abstention is commercially a no go zone, eating 'different' is a goldmine. It is why 'going on a diet' in the 1970's still meant eating less, while starting in the 1980's the phrase was turned into just eating the latest industry fad miracle food.
The vast majority of people who lose weight by calorie restriction gain it back, so I wouldn't call it highly effective. Short term yes, but long term, definitely not.
You can induce a calorie deficit by eating foods that fill you up but don’t have many calories. Also avoiding the sugar-spike carbs cause leaving you even hungrier shortly after works also.
A good dietician is worth a few consults if you don’t have the will power to just fast. And as a bonus you don’t lose muscle mass as well because they’ll focus on keeping protein up.
>A good dietician is worth a few consults if you don’t have the will power to just fast. And as a bonus you don’t lose muscle mass as well because they’ll focus on keeping protein up.
Fasting is like using a nuke where a bullet would do.
How will a dietician measure your maintenance calories? How will they continuously update your macros and calories when your maintenance calorie change week to week?
I am making a claim here: most dietician will not be able to track your maintenance calories better than MacroCodex's algorithm.
Many dieticians simply rely on BMR/TDEE static formulas, and the limitation of this approach is that it cannot reliably track a user's actual maintenance calories well through the span of their dieting journey.
People regain those weight. I have gone through many sessions of those, and I have realized that the only effective way to do this is to change the whole lifestyle. My lifestyle nowadays makes my weight stable around 75-77KG.
But changing lifestyle is virtually impossible for parents who also work, and have a bunch of issues here and there. Remaining the current lifestyle without dropping to a worse one is difficult enough.
Metabolism was an excuse when we could not reliably estimate it outside laboratory; today we can do that too, for completely free (we run a public benefit app for this).
In fact, our claim on the app is results within 2-5 weeks for both weight gain and weight loss; I've yet to find a guy who did not achieve success with this.
Calorie deficit is the most effective method for weight loss.
What's funny is when people actually measure their metabolism with this approach, they realize they aren't far off from the average!
The claim is usually that A) people have an inflexible appetite and will be increasingly driven to eat while at a caloric deficit, B) at some point this is almost involuntary and that point differs between people (e.g. consider not eating for three weeks; some people can do it on a hunger strike or a fast, but it really sucks), and C) some people have a slower metabolism which puts them under greater pressure to eat.
I don't disagree that calorie restriction is effective. I just think that you're dropping appetite from the equation when GLP-1 agonists have proven that reducing appetite is effective too.
I'd caution: GLPs reduce your appetite, but they do not fix your diet.
I am not anti-GLP, someone who believes using GLP drugs is cheating and people should achieve that with blood, tears, and sweat. I see it as a "tool" in the arsenal. I've no use for GLP as I've no problem sustaining deficits as large as 600-700kcal for long. But I've met people who can't do this, so for them GLP is a valid choice, but I'd recommend they pair it with proper dieting and lifestyle changes.
You want to eat good stuff and avoid stuff not good for you; blanket reducing appetite may result in loss of both good and bad.
The guide linked in the above post is macrocodex's prototype method, which was later formalized into an app.
I don't want to make strong claims on this, but using GLPs may increase the risk of developing gallbladder stones, as GLPs make it very easy to eat far less than necessary.
A proper macro and calorie balanced diet can give you better results with a smaller GLP dose.
Use GLPs if your actual problem is staying on a "sustainable deficit." Many people who use macrocodex report they do not feel hungry when on such a small deficit, but there are a few who are hungry even at a deficit as low as 300 kcal; for them, GLPs are more suitable, but not a replacement for proper dieting and lifestyle changes.
Most importantly for A) is dropping sugar. Calorie restriction doesn't have to mean being hungry all the time. First drop sugar, you'll be hungry all the time until the withdrawal subsides, then eat at a slight calorie deficit. It doesn't feel different than a slight calorie surplus at this point. I do that and I am in complete control over my weight. This whole discussion seems totally misguided to me.
I'm not quite sure why or how estimating metabolism helps here?
I mean, observing the weightloss / gain or lack thereof itself will tell you whether you need more of a calorie deficit or surplus. What does an independent metabolism estimate buy you?
When a person figures out their maintenance calories and looks for the average metabolic rate / maintenance calories for their height, weight, and gender, they realize they are not "genetically inferior" or have some serious issue which is stopping them from progressing if their maintenance calories are within average range!
Just knowing that there is nothing wrong with your metabolism gives people enough push to continuously walk on this path and achieve their goal.
>I mean, observing the weightloss / gain or lack thereof itself will tell you whether you need more of a calorie deficit or surplus.
You can read app reviews and these will tell you, complete newbies are having great success with this approach.
If you ask a layman on the street, they'll tell you eat less to lose weight, eat more to gain weight.
The question is: what is less, and what is more? How many calories precisely do we need to eat to achieve 1lb per week of weight loss?
Your total calorie burn for the day changes week to week; people don't know how to make the right adjustments.
Many people crash diet; they lose weight, then they cannot sustain it for long, binge eat, and gain it all back.
What key knowledge are they missing? Sustainable deficit. If you apply a sustainable deficit over a longer period of time, you may not "suffer" as much as you would otherwise
I am not saying drastic deficits are not useful; they are to those who are experienced. Let's say an MMA guy or bodybuilder can do it just fine!
Also, for lean bulking in natural bodybuilding, you need a specific rate of weight gain; let's say for a beginner it's a weight gain of 0.25–0.5% of body weight/week. It's hard for many to achieve this precise range because your maintenance calories are changing all the time!
And if you are an advanced lifter, then the rate of gain you want to target is even smaller: 0.1–0.25%/week.
That's why pro natural bodybuilders use Macrocodex and find it useful.
seems like a very reductionist view of human metabolism. human body weight is composed of many factors that don't directly depend on metabolism in the sense of "burning calories", as i am sure you are aware.
for those that aren't, you can't actually measure metabolic rates this way.
they were forced labor camps plagued with disease and malnutrition. so, not a great thing to base an argument of caloric intake and weight loss on, and honestly, a horrific thing to bring up casually as a means to make a point.
How are you defining highly effective? In the sense that a body will definitely lose weight when starved? Or in the sense that counting calories is broadly effective as a weight loss strategy?
The former is painfully obvious and entirely unhelpful, and the latter is provably false.
Counting macros is extremely effective. The general population doesn't have the discipline for it, but amoung sport coaches, actors, models, bodybuilders, this is *the* technique for achieving goals.
Anyway what's cute about this is that this isn't novel phenomenon. There are lots of parallels to this in other fields where often effective solutions do exist, but at a system level don't seem to work.
Telling people to diet doesn't fix population level obesity. Telling people about personal financial management doesn't stop people from accruing too much high interest debt. Telling teenagers to stop idolizing instagram influences doesn't fix body anxiety issues. Telling people to stop smoking/drinking doesn't fix addictions. 3-2-1 data backups absolutely work but people lose files all the time.
"general population doesn't have the discipline for it" — only that this feels somewhat condescending.
Let's agree that counting macros or going for calorie deficit is hard if it is not someones job. General population has other jobs, family, social life, other hobbies they enjoy more than fitness. It is not "just eat less" it is "spend considerable amount of time thinking about and planning your eating".
On the individual level it is a discipline problem. But the fact it has become an individual discipline problem is exactly the core issue.
If you turn things into individual discipline problems then surprise you get population level issues. As you pointed out people have other things to focus willpower on thats not this.
The fault, as it often does, lies in marketing. Turns out heavily marketed, hyper palatable food, designed to be minimally satiating so you maximally over eat is great for profits and terrible for obesity.
> it is "spend considerable amount of time thinking about and planning your eating".
Nonsense. It doesn't take any more time. Just buy unprocessed, basic food, fruit and veg. When you open your cupboard, cook something tasty from what you have.
When you go to the supermarket, just don't walk into the aisles with snacks. Don't buy anything laden with sugar and fat.
Get into the habit of drinking black coffee instead of Starbucks' calorific drinks; it takes less than a week for your taste buds to adjust.
It's not rocket science. Just most people don't want to admit that every excess 100 calories they eat adds 11 grams of fat to their middle. Which adds up week by week, year by year.
This. If I cook a meal with mostly veg and lean meat, I can't overeat. I'll feel full fairly quickly and, most importantly, not think about food 2 hours later.
But even with this kind of food, if I figure "sure, lemme have a sugary ice-cream", two hours later I'll be looking around the fridge and cupboards for some "quick bite".
Just don't buy this crap. I find it's much, much easier to have none at all than to hope to be "reasonable" and only eat a bit.
>In the sense that a body will definitely lose weight when starved?
If your maintenance calories are 2700kcal and you eat 300kcal less than that, is eating 2400kcal starving for you?
Most people cannot tell a difference if they eat 100-150kcal less in a day.
>Or in the sense that counting calories is broadly effective as a weight loss strategy?
Yes, it is, and the reason people fail with it is not because calorie counting doesn't work, but because people's maintenance calorie estimates are often poor.
calorie restriction can cause a reduction in resting metabolic rate through "metabolic adaptation". that is, your body gets used to the deficit (by shedding metabolically active tissue and other things*) and burns less calories at rest. so, paradoxically, restricting or reducing your caloric intake can have no effect whatsoever on your weight.
> Yes, it is, and the reason people fail with it is not because calorie counting doesn't work, but because people's maintenance calorie estimates are often poor.
I would have thought that it would mostly be because they can't resist that extra snack.
Or 'optimistically' underestimate the calories in the not pre-packaged food.
Serious question: Is there a significant variability in how the food calories are absorbed? Maybe different combinations are not absorbed equally efficiently (like with water/oil-based vitamins)
The problem is: average person is bad at counting calories. They overestimate number of calories burnt, and severely underestimate number of calories consumed. Once you get your math right and get into real, not imaginary calorie deficit you'll start losing weight. Rule of thumb: whatever you think the amount of calories is in your current meal, double your estimate.
IMO my only concern is their dats shows they were actually able to maintain a pretty controlled diet for each participant, I wonder how selection was done. I also would've appreciated some bomb calorimetry of fecal samples, similar to [0] which is the widely cited paper that does link general fiber intake to a lower level of caloric/energy absorption.
Baer, David J., et al. "Dietary fiber decreases the metabolizable energy content and nutrient digestibility of mixed diets fed to humans." The Journal of nutrition 127.4 (1997): 579-586.
Mark Stache ( https://youtu.be/L-gNdQZorEE?si=nkwAhZOiAFtY2f44 ) just did a 90 day evaluation. The biggest problem at the level they mention is some intense flatulence. He is also in good shape and had mixed results compared to the study.
> The study was conducted in Shanghai, China from 3 July 2013 to 14 October 2016
Figuring out and understanding the physiology of different gut bacteria is not just for people trying to shortcut weight loss while still eating unhealthy food or to be sedentary all day.
Eh, the "real food" of Jamie Oliver and Michael Pollan (shop the peripheries) and such isn't very health promoting. So I'll pass and keep eating a mix of fresh food and cheap food that keeps for a long time like legumes. Kthxbai.
To Michael Pollan it seems they aren't worth mentioning right in the first breath when talking about real food, but perhaps an afterthought. "Shop the peripheries" causes them to be lumped in with potato chips and oreos and other stuff that aren't in the peripheries of a supermarket. I don't accept the same real food dichotomy that they do.
Beans are a direct product of plants. I don’t know what you are on about, but I’m sure even the celebrities you take so much stock in consider them “real food”, too. I wouldn’t know, because I have no idea what you’re ranting about.
They talk so much about freshness. That is an indirect and unnecessary and probably unintentional dig at dry beans, grains, seeds, nuts, etc. While I can entertain the idea that they're more reasonable in their diets this makes them bad nutrition communicators.
For non-invasive heart disease risk prediction nothing beat ECG, period.
Somehow American Heart Association and its European counterpart are in denial, and still pushing dinasour screening mechanism with very low accuracy for heart disease risk prediction.
The standard risk model for CVD based on PREVENT (US) and SCORE-2 (Europe) like parameters are very poor as reported in the recently published paper on the their accuracy performance by the Swedish team [1]. As all CVD risk stratification with cardiologist review (expert-in-the-loop), the most important accuracy metric is sensivity/recall (avoiding false negative that will escape review) of PREVENT and SCORE-2, 26% and 48%, respectively.
The paper alternative proposal increased the sensitivity to 58% by performing clustering instead of conventional regression models as practiced in the PREVENT and SCORE-2.
These type of models including the latest proposal performed very poorly as indicated by their otherwise excellent and intuitive display of graphical abstract results [1].
[1] Risk stratification for cardiovascular disease: a comparative analysis of cluster analysis and traditional prediction models:
I'm not sure how ECG relates, how would ECG predict heart disease risk? I don't see any evidence of that, it's not even mentioned in the article you linked, which is odd considering the whole approach of clustering is gathering as many risk factors and relevant test results as are available.
That's the main contention point, believe it or not current standard for heart diseases risk prediction method do not include the 'elephant in the room' ECG.
There are many related research work with excellent results, patent, etc by biomedical researchers around the world that I'd care to mention, including yours truly. Biomedical researchers even has yearly global competition organized so called CINC that used ECG as one of the main input for heart disease risk prediction since it's readily available [1].
In particular check out work by Prof. Friedman on ECG [2]. Somehow his excellent work is mostly being ignored by AHA and their counterparts because apparently these standard risk prediction models in US and Europe are not including it as part of their parameters.
There are lots of different types of heart disease. An ECG can be useful for diagnosing some of them but you're overstating the relative value. For many patients, a CT coronary calcium score or CT angiogram may be more valuable in terms of detecting the type of arterial plaques that might require medical management or major lifestyle modifications in order to prevent a heart attack. These are also non-invasive, although they do involve some radiation exposure.
GP was talking about screening though, not diagnosis. Coronary angiography are specialized, expensive and require intravenous constrast. Doctors aren't going to order them for everyone who shows up for a routine consult.
Having a CAC done is fairly cheap, ~$100 in the US. Insurance typically doesn’t cover it, but if anyone is concerned, it’s worth calling to set one up.
My dad’s doctor said he should get one, Medicare denied it, but he paid out of pocket to get one anyway. He found out he was 95% blocked pretty much everywhere and had a quadruple bypass. It likely added many years to his life and avoided a heart attack.
If you’re under a certain age (I want to say somewhere in your 50s), there isn’t any guidance for what normal is. If you’re in your 20s or 30s, I wouldn’t run out and get one. But if you’re in your 40s with a family history, or up into your 50s and beyond, it’s worth thinking about. I’ve also heard you’re only supposed to get them every 2-3 years, it’s not a yearly thing, due to the radiation.
It was just added to the recommended screenings list and my doctor expects that insurance will cover it soon because of that. Still at under $100, it was well worth knowing that i don't need aggressive treatment. (Though a quadruple bypass beats a heart attack)
Then again, CAC measures end-stage calcified plaque, not the soft plaque it started as, equally clogged arteries but also able to break off to cause strokes until the body calcified it.
The time to take action is long before you have a CAC score. e.g. Start tracking ApoB regularly, see if you have genetic LPa exposure, and avoid the foods that increase your exposure while ignoring the grifters telling you it's a nonissue.
Emphasis on non-invasive diagnostic screening as invasive testing like angiogram need to be operated by specialist and can take months to be arranged, and only done after incidents e.g heart attack.
ECG is excellent for generic top level CVD anomaly conditions for examples arrhythmia and ischemia.
Huh? I get a blood panel every year and 90% of the things it looks for are normal year after year. But there is always 1 or 2 things flagged that I need to pay attention to.
An ECG if it was just part of the normal yearly panel of things that get looked at I don't think ppl will stop doing it just because it doesn't find something right away
Nobody said anything is worse. Half this thread is satire. But on a serious note. ECG is really time prohibitive, drawing 3ml of blood is relatively quick, and doesn't require specialist training like an ECG does.
This paper is.. not great. Their clusters and risk model were developed and validated on the same sample. There’s no train/test splitting, no cross-validation anywhere. As a result, all the performance metrics they report for their model are optimistically biased. The comparator models weren’t refit to this sample, either, so the comparison between their model and PREVENT et al. is really an internal validation versus an external validation, which isn’t apples-to-apples and disadvantages the existing models from the get-go.
You could say that it’s almost as if their model has a home-field advantage. Because of that fact alone, you can’t really conclude anything about the comparative performance of their models versus the existing ones from this paper.
Get as many scans you can under insurance. Data is king and Claude happens to chew it all pretty well. Apple Health data by itself and family history is enough to make a starter PDF for your cardiologist.
Getting an ECG, EKG, TTE, CAC, carotid duplex US, lipid panel, CMP, TSH, 25-OH Vit D, B12 + folate were what my cardio recommended before appointment #2 on hypertension. Both of us are data guys.
You don't even necessarily need insurance. Some of those tests you listed are pretty cheap so most people reading this can afford to pay out of pocket even if they're not covered by insurance.
I thought this was pretty well known already. Being “overfat” is the problem, not being overweight (though they’re often correlated). BMI is really easy to measure, and is mostly accurate, that’s why it’s so pervasive. However it remains a pretty rudimentary metric (and really should use the third power or your height instead of the second).
> BMI is really easy to measure, and is mostly accurate, that’s why it’s so pervasive.
BMI is easily misunderstood by people who know just enough to see that it’s imperfect, but not enough to understand why it’s still a valuable screening tool.
I’ve been in the “overweight” BMI range with low body fat before. It’s not too hard to get there if you’re lifting weights and paying attention to your diet consistently for years, but it takes a lot of work to get there. It doesn’t happen accidentally except for people who win some genetic lottery to build a lot of muscle and keep body fat low without trying.
Getting all the way to the obese BMI range while having healthy body fat is only happening for people with an extreme dedication to body building and diet (and let’s be honest, a lot of the people in this category are manipulating hormones too).
Yet whenever BMI comes up some people try to dismiss it as too flawed based on these possible edge cases. The edge cases for BMI exist, but that doesn’t mean it’s not useful. It’s a good general purpose screening tool with numbers that are available. If someone has more precise measurements available, those should be used instead. BMI is a really good first pass screener to determine if a closer look should happen.
At a population level, it's great. For individuals, it can fail in all kinds of ways. For me: it is not very good because my body has very strange proportions. I'm 6'2", but my waist is barely higher than my 5'1" wife, and my torso is nearly the same length as my 6'7" brother.
In other words, for my height, I have a very long torso and very short legs. I think it should be relatively obvious that an inch of leg weighs significantly less than an inch of torso, so at a given level of body fat percentage, I'm going to weigh quite a bit more than someone my same height with more typical proportions, and thus my BMI reads me as more overweight than it otherwise would.
My point is not that BMI is bad or useless or anything else. My point is that it was designed as a population statistic and that it can be fraught when one tries to apply it to any individual with no nuance. A high BMI should cause one to consider and examine your health and weight. But it should not over-ride specific details about your physiology that point in the other direction.
> I’ve been in the “overweight” BMI range with low body fat before. It’s not too hard to get there
Did you do that as a natural lifter? It’s hard for me to imagine most guys being able to get into the “overweight” range at < 15% body fat without some assistance.
The farther from average height you are the worse it is. If you are from some part of the world where the average height distribution is near the point BMI based itself you will perceive it to be so much better.
I am only 6' and only an intermediate lifter. I'm overweight, but BMI makes me look obese. It really only takes a normal person a year or so to get to three plates on squat with no supplements other than chicken broccoli and rice if they don't skip workouts. Assuming no injuries. That level of strength easily distorts bmi wildly if you are even a little taller than average.
Yeah, people don't want to understand that your body structure messing with BMI is quite real but only a few points. It's unquestionably "wrong" in scoring me higher than my wife despite the fact that she's the one with a few extra pounds. But it scores us both as normal, the difference doesn't matter.
>Getting all the way to the obese BMI range while having healthy body fat is only happening for people with an extreme dedication to body building and diet
And sumo wrestlers.
The line seems to be drawn at (effortful) activity level more than anything else. And BMI doesn't say anything about that.
I think the vexation comes from the focus on an attribute that is not directly mutable, per one's agency, because that's easier to sell things related to. Versus action that you have a lot more direct control over (social or physical circumstances notwithstanding).
Yes, it is a pretty high level metric with good correlation a bunch of diseases, but really many of these is because it is ALSO correlated to percent of fat, which is often the more relevant metric. But as you said BMI is so much simpler to measure.
Many active gym people have pretty high BMIs but fairly low fat (because muscle is dense), and unsurprisingly have better outcomes than the average person (if you ignore the share that uses/overuses anabolic steroids and co)
> Many active gym people have pretty high BMIs but fairly low fat
I think this is greatly exhaggerated.
Yeah you can put on as much muscle as Arnold and have a FFMI of about 27 then maybe have a BMI of 34 if you have 20% body fat.
But a very gifted natty might cap out at maybe 24 with a BMI of 30 at 20% bodyfat. But let's be realistic. This is not "many active gym people". This is the guy winning the local strongman meet.
Yes a couple of years training for most people can add a couple of points to BMI but I think people exaggerate how much this is. Go look at a 20lb brisket at costco - you don't see people with that much extra muscle all that often.
I very much disagree. Overweight starts at 25 BMI, and obese at 30. Most regular gym goers in my social circles maintain <20% body fat, and are classified as overweight based on BMI. In the US weightlifting is quite popular, and it’s not hard to gain enough muscle mass to classify as overweight. I’ve been “overweight” at 27 BMI going on >10 years now, with actual body fat fluctuating ~12-18%. I’ve had doctors tell me I need to lose weight because my BMI is too high, while I had visible abs. It’s a common theme among other casual weightlifters I know. I don’t think BMI is particularly useful for anyone that has done more than a year of basic barbell strength training cycle.
I do agree to some extent, but really the overweight threshold for BMI is 25. And 30 for obese.
At 6 feet / 183 cm that it takes 184 lbs / 83 kg to be overweight. From what I could find, for regular gymgoers the typical weight for people around 6feet is 180-190lbs, which put many people around the overweight threshold. I am myself at 24.9, and while not skinny I am definitely in the skinnier half of the people at my local gym.
My completely made up rule is you get an extra point for every plate you bench (or squat etc). Its not a dramatic difference. If you bench 225 you’re not overwreight till 27 BMI, which iirc used to be the actual cutoff until they narrowed it.
Obese is hard. Overweight is easy if you walk, take the stairs, do the occasional pushup, and play something like hockey once week. Source: my entire life.
But specifically, it requires no gym time. Muscle mass is built with through reps not weight, and there are lots of non-gym-rat behaviors that do that. I'm not winning any comps.
> Many active gym people have pretty high BMIs but fairly low fat (because muscle is dense),
I’ve been in the overweight BMI category with low body fat by being active at the gym and focusing on diet. It takes some work to get there.
If I check the calculators for the obese BMI range, there was no way I could get there without either gaining a lot of fat on top of the muscle. The amount of muscle required to have an obese BMI with healthy amount of fat is absurd.
Not sure I follow the logic here, but happy to be proven wrong if I'm misunderstanding. It's not intuitive to me that a 300 lb. person at 20% body fat is generally at the same risk as a 200 lb. person at 30% body fat.
Fat is inherently unhealthy for you beyond some low baseline level.
Additional muscle is positive for health, but only up to some reasonable threshold. There is no health benefit to having very high levels of muscle, and in fact it may be negative for your health at extreme levels. E.g. many bodybuilders have trouble breathing, sleep apnea etc.
Both people in the example have 60lbs of fat. 1lb of muscle doesn't cancel out the negative health effect of 1lb of fat
The nasty detail is that some people gain relatively more visceral fat than others. These three fats are correlated, but the correlation isn't the same in every human. Some have better metabolism and don't store as much fat inside as others do.
Looking for some references on these claims, thanks! What you're saying registers as "makes some sense, but where's the evidence?" to me. I'm not seeing the connection where total lbs of fat is inherently worse than higher percentage.
The mean height for men at 20-29 is 69.2" and 80+ is 67.1" (measured in 2015-2018, the last data I've found) [1], which could be interpreted as shorter people having lower risk of all mortality. One could say that people are just getting taller over time and 80+ y.o. were shorter at their 20-29, but we also have the median height for 20-29 fro 1970s, when 2018's 80+ were 20-29 - it's actually 69.7" [2], men in the US are getting shorter over time, so unless people naturally shrink 2" with age the data points to shorter people having lower risk of death.
I am not saying that. I am saying that the theory about absolute amount of fat being bad for health, as stated by the comment you responded, seems to be supported by data.
"People typically lose almost one-half inch (about 1 centimeter) every 10 years after age 40. Height loss is even more rapid after age 70. You may lose a total of 1 to 3 inches (2.5 to 7.5 centimeters) in height as you age."
So people DO in fact tend to lose about 2 inches at age 80 versus their younger selves.
The actual studies [1],[2] that tried to measure this came to very different rates of height loss though: 3.6 cm and 6 cm from 40 to 80 in men. This does not look like a serious fact.
Some are more common in short people and some are more common in tall people. Hypertension is one of the ones more common in short people and is significantly more common than the rest combined, so your overall chance of having some form of heart disease goes down as you get taller. However, the forms of cardiovascular disease more common in tall people (e.g. atrial fibrillation) are more likely to actually kill you.
Do you have a citation for that? I've had thoughts in a similar direction (specifically around the upper/lower intervention points) but have had no luck finding data.
Another common misconception is that one is still healthy with high BMI that comes from having lots of muscle. It's not clear that lots of muscle is healthy.
Very very few people are in that category, and usually they have undiagnosed mental disorders. I don't even think it's possible to be leanish and have a BMI in the obese category from muscles without taking steroids or other products.
How accurate is it, in practice, for a given individual? I'm not that out of the ordinary proportion wise. I have a slightly longer torso and arms versus my legs, a somewhat muscular-ish baseline and broad shoulders, but I accumulate fat almost exclusively abdominally. My teenage self, lifetime peak of my fitness, no visible body fat, hyperactive football player, qualified as solidly overweight. If I was to listen to it, I'd be called obese before I noticeably start to show body fat.
I often wonder far from the median I am in this regard. I was under the impression that it was pretty accurate for assessing populations, but fell apart very quickly at the individual level. How many "normal"/otherwise healthy people do fall outside BMI's numbers?
It’s a tool not the tool. If you have obese BMI you can… look in the mirror and see how accurate it is. If you aren’t sure take one of the dozens of other tests. People focus too much on it being a one stop shop - it’s not. It’s the start of a dialogue with your pcp and self on assessing your health that’s highly correlated with poor health outcomes.
I haven't been down in the normal BMI range since 8th grade. And I was measured at 6% body fat my senior year in high school! BMI has always run several points high for me. For that reason, I've always liked waist to height ratio better.
It's not really intended to be applied to individuals at all, but if you're in the "healthy" BMI range then you are probably fine just not thinking any further about your weight and doing something like measuring your body fat percentage would just be a waste of time and a source of stress for some people. If you're outside that range, then it is worth doing some of the more involved things to judge if your weight is healthy.
That was my impression as well. I'm just wondering if there are actual numbers to gauge by how much. I'd find it almost concerning anyone would draw any conclusions from it if it's not significantly any better at predicting health outcomes than a coin toss.
BMI is at best 66% accurate, so "mostly" is correct, but what is mostly good enough for?
BMI has known biases in gender, age, and race. It misclassified Asians, women, elderly w sarcopenia, and people with high body fat to lean tissue ratio.
Yeah BMI is sort of a 'good enough' technique but also has some very obvious areas that it can miss. If you fall outside the typical fat to muscle ratio is a good example.
A muscular person can be "overweight" by BMI standards but not overfat at all. This is the case for many types of athletes, specially in strength disciplines but not only. It is the case in the fitness world that people ignore BMI and are intesterested in body-fat-percentage instead. This is hard to measure accurately so not so useful metric for the general population.
It's also possible to be overfat without being overweight! These "skinny fat" people often look normal enough but they carry very little muscle. It is a concerning condition because a doctor might not recommend a normal-weight person to hit the weights.
I like to think of this as four quadrants around two axes. Low fat/low muscle is simply skinny. High fat/high muscle is the "big guy/gal" look that I associate with laborers. Low fat/high muscle is an athletic look; unhealthy in extremes (bodybuilding) but generally desirable. High fat/low muscle is skinny fat, which I associate with sedentary knowledge workers.
The dominant discrepancies are "expected" fat (boobs, etc), and "unexpected" muscle (cyclists, body builders, hard labour careers, etc). I'm currently around 10-15lb overfat and 40-50lb overweight [0]. Only the former statistic matters.
[0] And that, at least somewhat, tracks visual perceptions. Nobody looks at me with a shirt on and believes I need to lose weight, because 10-15lb isn't _that_ much extra on a tall frame. If I were 40-50lb overfat then that would be painfully obvious regardless.
In my mind, it's equivalent to subtracting a coarse estimate of how much extra muscle by mass I have compared to the median adult male they're using to construct BMI charts.
My actual methodology is pretty crude though -- when I was 15lbs lighter I had borderline visible abs and other visual indicators of being around the 15-20% body fat mark, and aside from gaining weight I don't have any reason to believe I've had any notable muscular atrophy since then, so I'm estimating the actual excess fat in that ballpark. It's be easy for numbers to be off 10lb or more, but even then it'd still indicate the overfat surplus being much less than the overweight surplus.
A better methodology uses calipers and various skin measurements to estimate true body fat percentage.
I've been considered borderline or obese by the standard BMI index for 20 years at least, but for a lot of that had very little to no visible extra weight. A lot of that was just plain having more muscle than the average the standards are built around, but I also suspect BMI gets to be really inaccurate for tall people. I would look anorexic if I had to drop enough weight to be considered not overweight.
"Overweight" can mean the same thing for weight, but it also refers to those with a BMI specifically between 25 and 30, and those with BMIs greater than 30 are classified as "obese".
It's specifically a high level of visceral body fat.
Genetics determines which parts of the body gain fat first as you gain fat overall, and some people have the unfortunate genetics to gain it first viscerally and some people have the fortune to gain it there last (and everything in between).
This means that you can have different people with the same body fat percentage but drastically different disease risks.
But yes this was also known already.
That's why it's been recommended to take a waist measurement alongside BMI to get a much more informative screening tool. Waist-to-height ratios are another alternative.
A nitpick about the title: Not strictly abdominal fat, but visceral abdominal fat, which surrounds the organs. Not all abdominal fat is visceral; in fact, in many people the majority is not.
The article mentions visceral early on, which is the subject.
To put this another way skinny fat just means you are not overweight but you have a high body fat percentage (eg lacking lean mass). So while you might not look like the average American there will still be significant visible abdominal fat, likely love handles, etc
Seriously, you don't think there's a connection between visceral fat and abdominal fat even though there's plenty of evidence that there is along with just common sense?
It's just a particular type of abdominal fat so obviously the more abdominal fat that you can see it means you also have more of the type that can't see as well... It's not that complicated
Subsequent risk of nine cardiovascular/mortality outcomes in >260,000 people followed for ~20 years
To make it even more useful they should have included DEXA scan bodyfat%.
Also, BMI becomes somewhat biased at height extremes because body mass doesn't scale exactly with height². Humans aren't geometrically scaled copies of one another and empirical scaling exponents are often somewhere between 2 and 3. Conventional BMI tends to read relatively high in very tall people and relatively low in very short people. But changing the exponent would only fix one relatively small limitation of BMI
For better height adjusted replacement for BMI itself, one option is Trefethen’s BMI
WHR and WC is positively correlated to bodyfat% but this may get distorted for strongmen or sumo wrestler who tend to have much higher than average lean mass, may also have higher WC and WHR but difference maybe waist to shoulder ratio, they tend to have much bigger and powerful shoulders.
what's interesting is, for sumo wrestlers specifically, WC still correlates strongly with BF% one study reported r ≈ 0.86
There is a category in fitness called "skinny fat" where you are at low bodyweight (so low BMI) but your fat mass is relatively higher when compared to lean mass, so higher bodyfat%
Many skinny fat people refuse to believe they carry higher bodyfat% because they think they've low bodyweight so they can't possibly carry higher fat, which is wrong.
> Studies have shown that visceral fat, which is fat that surrounds the internal organs in the abdominal area, is associated with chronic diseases like heart disease and diabetes, while subcutaneous fat, which is located directly under the skin, is not as strongly associated.
How does one determine if one has an excess of visceral fat?
A DXA (DEXA) scan will quantify visceral fat for you. This is a non-invasive scan which uses a low-dose x-ray. Most cities have some sort of sports medicine facility where you can get one. It's typically not covered by health insurance but fairly cheap to pay out of pocket.
whats wild is there are people who look very fat - who have lots of subcutaneous fat, who don't have visceral fat. The excessive subcutaneous fat can be hard on your joints but doesn't seem to correlate to other health issues.
Thirty years after we learned that abdominal fat distribution matters, large-scale longitudinal evidence shows that waist measurements meaningfully reclassify cardiovascular risk beyond BMI alone.
BMI isn’t a good metric, this has been known for a long time.
For example, I’m 45yo/178cm/93kg and am obese by BMI measurement. However, my body fat is 20% (Dexa), VO2 of 50 (lab) & have the aerobic fitness to run a half marathon after work and not care.
I’m not surprised that you need other metrics like hip/waist ratio, measured body fat, visceral fat, etc to better understand the composition of someone’s body and how it might relate to health outcomes like heart disease.
Same for me, no one considers BMI to be a good indicator of anything, but it is better than nothing, and more importantly, it is super simple.
Any idiot with a bathroom scale and a measuring tape can do it. And by adulthood, height doesn't change significantly and you probably know it, so you may not even need that measuring tape. Other metrics need specialized equipment, error prone or complex procedures, etc... I don't even know how to make a waist measurement. Where exactly? How relaxed should the subject be? How long after eating?...
That's the value of BMI: simple repeatable. Not the best but enough to get and idea and make statistics.
> And by adulthood, height doesn't change significantly and you probably know it ...
But height does change in adulthood [0]. On average people living past 40 gradually lose height. At age 80, it's likely height loss will be >=2 inches. This loss is reflected in higher BMI even when body fat content hasn't changed. Average BMI increase isn't large, but think about a person losing 4 or 5 inches of height while maintaining body fat unchanged.
Self-reported height is generally greater than measured height. Adding 1/2 to 1 inch is common (per experience measuring height). "Height inflation" has modest effect on BMI but problematic in research and workup for medical procedures. In the latter cases, measuring height is necessary.
> Those with obesity and low WC [waist circumference] were not found to be associated with a significantly different risk of outcomes compared with those who had normal weight and low WC, except for all-cause mortality, for which risk was significantly lower.
If I'm reading that right, it sounds like obesity (and therefore BMI) is still a better predictor for all-cause mortality. Perhaps waist circumference is better at predicting cardiovascular risk but BMI is still useful.
Cutting saturated fat to under 15g per day and increasing intake of viscose fibre (e.g. beans) will reduce your LDL particle count in a few weeks, which reduces your CVD hazard ratio. You can measure your LDL and look up the papers yourself. Statins will reduce it a lot too (potentially with side effects). Replace solid fats like butter with liquid fats like olive oil.
Literally any amount of regular exercise, including walking, will decrease CVD HR. The more the better (up until quite a large amount e.g. professional athlete). The more your heart is steadily pumping during exercise the better. Every bit helps reduce CVD risk. Movement is medicine.
For the love of God do not smoke. Literally one of the surest ways to die a horrible death. Stopping smoking reduces CVD risk by a large amount.
Do not give yourself diabetes by eating vast amounts of sugar. If you are doing this, stop. Not having diabetes decreases CVD risk.
Other factors you probably can't change so focus on these.
Doctors, if I got anything wrong please correct me.
> Do not give yourself diabetes by eating vast amounts of sugar. If you are doing this, stop. Not having diabetes decreases CVD risk.
Not eating vast quantities of sugar is good advice, but it's not the direct cause of T2 diabetes. The best evidence suggests that T2 diabetes is caused by the accumulation of fat in the liver and pancreas. See the twin cycle hypothesis. To prevent diabetes, one needs to maintain a weight low enough where the body isn't storing fat in the liver and pancreas (everyone has their own individual threshold for this). If you're pre-diabetic, lose enough weight and most people will regain insulin sensitivity.
I think there are a bunch of states the human body can be in where pathways cause sugar to be converted into fat directly in the liver (via hepatic de novo lipogenesis). This is not dependent on fatty acid transport to the liver.
> Do not give yourself diabetes by eating vast amounts of sugar.
This can help sustain a high level of exercise (the more the better). Certainly don't if you're sedentary, but the sugar during exercise is really helpful for getting in 10+ hours/week of exercise.
I think the recent stance (not really recent in terms of assumptive idea, but now there is evidence) is that not all forms of sugar intake are equal. For instance, habitually drinking beverages with sugar in them (what are called sugar-sweetened-beverages in literature) is associated with a risk of developing T2D, where getting sugar from normal foods isn't really.
Associative population-level sugar trends are basically meaningless for 10+ hour/week exercisers, who are a tiny minority of the population.
(When I say sugar, I mean things like gummies, gels, and sugar-sweetened beverages. If sedentary people habitually eat these, it does increase their T2D risk.)
You said all this like you know something, but you didn’t bring up oxidative stress once. I mean, smoking is the leading cause for increasing oxygen stress in the body so you kind of mentioned it there but oxidative stress can be controlled with nutrients like zinc, copper, and manganese.
For two people that are the same height, one could have X lbs of pure muscle, and one could have X lbs of pure fat, and they would have the same BMI. Color me shocked that it is not always a good predictor of disease.
Cool, I am 185cm and 68kg, work out 6 days a week, and have very little body fat. I am making this argument because it bothers me that this measurement treats visceral fat and muscle as the same thing. It’s often useless, unless you’re measuring degrees of obesity or something.
Yeah because it has an actual correlation, whereas BMI is a ridiculously oversimplified measurement designed for population statistics based on what data is easily available, not individual assessment.
The irony of BMI is that people with plenty of muscle mass are more likely to have a high BMI as well as lowered risk for heart disease.
BMI was never meant to be used as a diagnostic measure. BMI is just a rough filter for large data sets, and entirely dependent on the average height and habits of that population.
Anyone taller than about 6'3" could tell you the recommended weight according to their BMI has always been absurdly low. If it's a printed chart on the wall, they might not even be on it.
BMI is not a good metric for really short and really tall people.
The "ideal weight" of a person is proportional to height to an exponent somewhere between 2 and 3. Simple physics would say 3 but because tall people are not just scaled up copies of small people, it is closer to 2 in practice, maybe around 2.3, but we say 2 because it is easier to calculate.
The downside is that BMI overestimates the "ideal weight" for short people and underestimate it for tall people. But BMI is not great at capturing exceptions anyways, so there is little interest in "fixing" this.
This is a common misconception. BMI while an ok population metric, for individual's the biggest problem with is its poor sensitivity - it fails to classify people as obese who are obese.
Using your 6 3" male as an example, they are significantly more likely to be clinically obese (using waist circumference, body fat % etc) at a weight lower than BMI cut-off of 240 lbs.
BMI is an objectively terrible individual health metric, it's is literally just weight / height². It measures neither body fat nor visceral fat, cannot distinguish muscle from adipose tissue, says nothing about fat distribution, fitness, metabolic health, or organ function, and its interpretation varies with age, sex, ethnicity and body composition.
And these aren't merely hypothetical bodybuilder edge cases. A systematic review found BMI had only ~50% sensitivity for detecting obesity when compared with body-fat reference methods—i.e. it missed roughly half the people classified as obese by adiposity.
More importantly, the 2025 Lancet Commission on clinical obesity explicitly recommended that BMI be used only as a population-level risk surrogate or screening tool, not as an individual measure of health. For individual assessment they recommend actually confirming excess adiposity with waist measurements or direct body-fat measurement.
Which is basically what this study is demonstrating again: where the fat is contains substantially more useful cardiovascular information than the number you get from dividing someone's mass by the square of their height.
Maybe the olympic athletes that are pushing their bodies to achieve the limits of human capability, yes. I think it's obvious why some (not "ALL") of them die young.
You're not going to die of a heart condition if you hit the gym 3 times a week.
Also nobody says "don't eat food" other than thinspo instagram pages. You should eat food, if you don't eat food you die.
"Resistant starch intake facilitates weight loss in humans by reshaping the gut microbiota"
https://pmc.ncbi.nlm.nih.gov/articles/PMC10963277/
Edit: Ah, HN submission 2 years ago: https://news.ycombinator.com/item?id=39592367
this is a great study if you are an overweight/obese adult without overt metabolic disease, willing and able to consume 90 g/d of starch supplement within a controlled diet, and living in Shanghai with similar baseline fiber intakes endemic to that population. it is extremely not generalizeable to you or even me though I fit more of those characteristics than I care to admit
stay skeptical of small studies like this, friend
https://prebioticassociation.org/resistant-starch-research-u...
Several of those are reviews themselves.
But there's already a general advise on this: eat more fiber.
https://med.stanford.edu/news/all-news/2017/08/hunter-gather...
We're a great ape, our body evolved to process a lot of fiber from fruits and starches. It's the modern fiber-deficient diet that's really weird.
90g/day of fiber is similar to the Hadza tribe diet, where they can consume 100-150g of fiber per day.
fiber is great and under-consumed (especially soluble) and is very well-studied on modern populations [0]. we don't really need to make mechanistic reasonings about evolutionary adaptations that occurred hundreds of thousands of years ago or rely on studies of a small, homogenized population whose lived realities are far from yours and mine
plus, following the the hierarchy of evidence, mechanistic guesses are considered extremely low quality, only ranking above things like mouse studies [1]
[0] https://www.uptodate.com/contents/healthy-diet-in-adults#H61... [1] https://en.wikipedia.org/wiki/Hierarchy_of_evidence
Also savannah human diet is chock full of fiber too: baobab pulp, grass seeds, tuber plants, etc
We’ve already known fruits and vegetables are healthy. Fiber is the reason why eating an orange is good, but drinking a glass of orange juice is about equivalent to a bottle of coke. That’s not an exaggeration, by the way, it’s about the same sugar content.
If you want to eat the recommended 35g of fiber a day, you won’t be able to reach it with just supplements. You need to be eating fruits and vegetables at every meal. For my entire life, everyone has been saying to eat fruits and vegetables at every meal in large quantities.
While they're not essential in short-term survival, they're essential for long-term health:
https://www.ncbi.nlm.nih.gov/books/NBK559033/
We have enough peer-reviewed studies on this.
sample size is 37, number of authors 29
But obviously, most people are a lot more interested in finding a magic food which does this rather than a proven calorie deficit, which is highly effective.
Purely behavioral lifestyle interventions have the lowest long term success rates of all available treatments for obesity. It's especially unreliable if you have weight loss targets higher than 15%.
They are of course still widely recommended due to numerous benefits other than weight loss, but "highly effective" is just wrong in the context of obesity treatments.
I seem to remember a meta analysis a decade ago or so finding that the particulars (high protein, atkins, paleo, whatever) didn't really matter so much as the the willingness and commitment to the change.
It's the same thing for the mental issues epidemic... you can't build a completely hostile environment to human life and well being and then say "welp, I guess we need drugs to make you feel normal now", now they'll sell us the drug and the cure, and you'll be clapping and thanking them for saving you, truly amazing.
You’re right we didn’t evolve since the 80s. But our food has certainly changed. It’s not like some God from above put laziness in peoples brains just now. No… people were always lazy.
It’s just that you could be accidentally skinny before. You can’t be accidentally skinny now, it has to be intentional.
Many jobs used to involve physical labour, huge number of us now are desk jockeys. Decades of prioritising motorists and increasingly large vehicles over active transport mean walking, cycling are a fraction of what they used to be [0].
[0] e.g. https://ajph.aphapublications.org/doi/pdf/10.2105/AJPH.2010.... , https://la.streetsblog.org/2023/04/17/exactly-how-much-less-...
Henry VIII might have a word for you on that one, as would many other of history’s aristocrats. The only thing that’s really changed is the cost of food that used to be reserved for kings.
The quality and type of food also completely changed, you can't ignore that.
5% of supermarket aisles are food, the rest are treats and comfort food you should have less than once a week at best
When I lived, in my childhood, in communistic Bulgaria/Czechoslovakia, nobody was starving. Yes, we did not have bananas and Argentinian steaks, but there was enough basic food, including the protein-rich one (eggs, cheese, even meat, although the best cuts were 'under the counter'). Still, few people were really obese; those were obviously sick.
Nowadays, there is plenty of junk food. The food is not really cheap (especially with the recent inflation), even the junk one. Still, being obese is (almost) the new normal. You can see that everywhere.
Yes, people spend more time indoors - but even in the old times people tended to spend a lot of time behind TV.
My hypothesis is that the junk food just does not have enough real nutrients, just mostly empty calories. So the body signals 'I need more nutrients', to which the typical response is 'here you have more empty calories'.
What really changed is the foodscape. And quite thoroughly so. Even basic agricultural products like wheat, corn or fruit are different from the variants 50+ years ago, there was a concerted effort to make them bigger, pesticide-resistant, more sweet, more energy-dense...
I remember the apples of the 1980s. Nowhere near as sweet as today, some were thoroughly sour. And these are considered the healthy choice now.
"The only solution is behavioural, everything else is cope."
This is like, your opinion, man. An opinion that can make you feel smug, but that is no victory. In practice, GLP-1s are doing what a generation of preachers like you could not - making people more thin and healthier.
In a sense, it is you who is coping hard and defending a "solution" which provably never worked on a population scale.
Alright, then let's continue making food worse and worse over the years, let's keep building a system that is less and less viable for humans. When we'll all be on GLP-1, + depression + ADHD drugs to just cope with days to day life maybe we'll finally wake up and ask ourselves how we ended in such a shit show.
What? Surely changing one's behaviour - particularly the parts of behaviour that caused the obesity in the first place - is a sure way to stop being obese.
Running a marathon a month is a sure way to improve your health. However, less than 1% of people would be willing to do that. So it’s not an effective solution.
It’s an effective solution if we just ignore life, sure. But solutions are rooted in pragmatism.
Behavioural changes work, the issue is that most people don't actually change their behaviour.
It's funny how proposing an healthy diet is unrealistic and watching fatties eat themselves to death is the new normal, complete value inversion and looser mentality
It's just that you should probably suggest other treatments in addition to the lifestyle changes that have relatively low long term efficacy.
Of course, that assumes your goal is to actually help the fatties instead of judging them.
I don't believe that's possible. They have to choose a healthier lifestyle by themselves.
It's not that people are fat because no one told them to eat healthy and exercise sometimes. They're fat because they have ignored that advice for a long time.
They aren't missing information about diet and exercise, they're missing diet and exercise.
I wonder what changed in between? Maybe our food and our relation to it? Who knows right?
You believe incorrectly.
> They're fat because they have ignored that advice for a long time.
Ah yes, the medical equivalent of "works on my machine".
You've now shifted from "how effective is this treatment" to "whose fault is it when the treatment doesn't work".
You will be able to help the fatties when you shift back into asking the question that matters.
But you are right with the fact that at the end, it mostly doesn't work. But those who stick with regime, it works 100% and positive changes in life, quality, happiness etc are massive.
The real solution - treat underlying mental issues. They are always there with obese people, they are massive (no pun intended), and they manifest as obesity, among plethora of other mental issues.
Mental issues is a broad category as well. Are food cravings a "mental issue", or a "physiological/hormonal issue"? No clear difference between those two, and given how GLP-1s quench cravings in general - not just food cravings, plenty of people on those report losing their compulsive behaviors, even such as gambling or shopping - the hormonal variant sounds quite plausible.
Which may be actually good. We are a lot better in treating hormonal issues than mental issues.
perhaps you can elaborate on how systemic death spirals are funny?
If you change your lifestyle temporarily, the effects are temporary.
If you change your lifestyle permanently, the effects are permanent.
Not quite.
If the lifestyle deteriorates, then weight regain is expected. However, people might regain only a fraction of the weight lost. It is possible for some of the weight loss to be permanent.
Also, even temporary changes in lifestyle can produce benefits that outlast the intervention, like lower risk of disease such as diabetes. Exercise is notable for providing numerous benefits that persist even if weight is completely unmodified.
> If you change your lifestyle permanently, the effects are permanent.
No. It improves your odds of success, but does not guarantee it.
Body adapts significantly over time when subjected to weight loss. There are compensatory physiological adaptations that favor weight regain, such as changes in energy expenditure and appetite. Even with sustained effort, maintaining the initial weight loss may become progressively more difficult because of those changes. This shows up in research as results like mean weight loss of ~9% at year 1 and ~5% at year 8.
For the love of god or any other deity I can't grasp this, its trivial for me to muster a tiny fraction of discipline and simply change direction from now on. But people out there are vastly different than me, thats pretty obvious, ie many people detest sports or even sweating. Addictions, and over-eating is an addiction (or some form of stress-coping mechanism) have a way to grasp core of one's existence and not let go.
My wife sees such overweight folks with not-so-much-time-remaining-on-earth as GP regularly. As she says - they basically over-ate themselves into mental disorder (or started with it and their body over time aligned with behavior). To actually fix this, that mental disorder needs to be tackled, no gastric operations or wegovy injections provide permanent solution. But they sure make pharma companies richer and give this warm fuzzy feeling of achieving actually something visible, even if temporary.
If you opt for it, then yes of course, abstinence-only sex education is a sure way to stop ten pregnancy.
Similarly, if you opt to change your lifestyle and start living healthier, and follow through, it will work.
If someone tries to force you, of course it will fail (in both of these cases). There is no way to stop someone else from being fat. We can only change ourselves.
Being fit and maintaining the normal weight is not the same thing as reaching a BMI of 50 kg/m² then losing it. I've seen fitness influencers take up that challenge only to find that "changing oneself" is significantly harder than it used to be when they were fit.
It definitely is not "you can just go on a calorie deficit", that is how jo-jo effect works.
For average person that has children, full time job, and whole range of adult responsibilities it is hard. Not impossible but hard, this is why people are looking fo easier solutions.
I've lost weight and kept it off by making sure I don't have sweets and other types of food that I know I'll down in ten minutes. But if I don't have any on hand, I won't eat any.
Ditto for normal food: if I increase the portion of filling, low-calorie foods (think salads and other greens), with a lot of protein, I know I won't have cravings later in the day and feel full longer. But if I buy fatty sausage, with a hefty helping of salty cheese, I'll eat until I explode.
If when I'm hungry I have a choice between "a quick bite" of something very palatable, calorie-rich but nutritionally poor, and a "good" meal, I know I'll make the wrong choice. But if my only choice is the good meal, I'll eat that and stay on track.
This also has a positive feedback effect: after a while, not only did I stop craving various junk foods, but they actually don't register as food anymore when I see them in ads or similar. Which, of course, makes it easier to stick to the "diet". Now, when I'm hungry, I crave "actual" food. The other day I couldn't have lunch on time, and all I could think of was a fat bowl of lettuce with some roasted chicken breast and yogurt. Walking in front of the local McDonald's peddling their latest mystery burger didn't do anything to me.
I've lost weight through forcing myself into a calorie deficit, and it works really well, but it's not particularly fun.
Sure but food doesn't have to equate to consume large quantities of junk food for it to be pleasurable.
We can learn to have a healthy meal with a reasonable portion that is as satisfying.
For the "eat to get slimmer" claim, I think we're at the point where "extraordinary claims require extraordinary proof."
What do you mean by "these foods"? Just buy unprocessed food and 99% of the problems disappear. There is no fake, no people trying to sell you these out of malicious intent. Just buy local food people had access to in 1900 and you'll cure all your problems.
Short term "diets" are nonsense. The solution is permanent lifestyle changes.
A good dietician is worth a few consults if you don’t have the will power to just fast. And as a bonus you don’t lose muscle mass as well because they’ll focus on keeping protein up.
Fasting is like using a nuke where a bullet would do.
How will a dietician measure your maintenance calories? How will they continuously update your macros and calories when your maintenance calorie change week to week?
I am making a claim here: most dietician will not be able to track your maintenance calories better than MacroCodex's algorithm.
Many dieticians simply rely on BMR/TDEE static formulas, and the limitation of this approach is that it cannot reliably track a user's actual maintenance calories well through the span of their dieting journey.
But changing lifestyle is virtually impossible for parents who also work, and have a bunch of issues here and there. Remaining the current lifestyle without dropping to a worse one is difficult enough.
Method here: https://macrocodex.app/knowledge/rethink/adaptive-tdee/
People can find the algorithm here: https://macrocodex.app/knowledge/macrocodex/smart-calorie-bu...
In fact, our claim on the app is results within 2-5 weeks for both weight gain and weight loss; I've yet to find a guy who did not achieve success with this.
Calorie deficit is the most effective method for weight loss.
What's funny is when people actually measure their metabolism with this approach, they realize they aren't far off from the average!
I don't disagree that calorie restriction is effective. I just think that you're dropping appetite from the equation when GLP-1 agonists have proven that reducing appetite is effective too.
I am not anti-GLP, someone who believes using GLP drugs is cheating and people should achieve that with blood, tears, and sweat. I see it as a "tool" in the arsenal. I've no use for GLP as I've no problem sustaining deficits as large as 600-700kcal for long. But I've met people who can't do this, so for them GLP is a valid choice, but I'd recommend they pair it with proper dieting and lifestyle changes.
You want to eat good stuff and avoid stuff not good for you; blanket reducing appetite may result in loss of both good and bad.
Here's what GLP users say about the macrocodex method: https://www.reddit.com/r/tirzepatidecompound/comments/1omfgx...
The guide linked in the above post is macrocodex's prototype method, which was later formalized into an app.
I don't want to make strong claims on this, but using GLPs may increase the risk of developing gallbladder stones, as GLPs make it very easy to eat far less than necessary.
A proper macro and calorie balanced diet can give you better results with a smaller GLP dose.
Use GLPs if your actual problem is staying on a "sustainable deficit." Many people who use macrocodex report they do not feel hungry when on such a small deficit, but there are a few who are hungry even at a deficit as low as 300 kcal; for them, GLPs are more suitable, but not a replacement for proper dieting and lifestyle changes.
I mean, observing the weightloss / gain or lack thereof itself will tell you whether you need more of a calorie deficit or surplus. What does an independent metabolism estimate buy you?
How difficult is it? Just eat below the orange line to lose weight and eat above the orange line to gain weight: https://macrocodex.app/assets/hero-tdee-line.v3.1b8c60c2271f... In the image, you see the app continuously updates maintenance calories from observed evidence; on the homescreen, it provides the calorie and macro targets you need to follow: https://macrocodex.app/assets/flow-targets.v3.edc3f34458a1.p...
It was never this easy, imho. Many people used TDEE calculators in past, which suffer from the limitation described here: https://macrocodex.app/knowledge/rethink/adaptive-tdee/#tdee...
It's useful for both Newbies and Pros.
When a person figures out their maintenance calories and looks for the average metabolic rate / maintenance calories for their height, weight, and gender, they realize they are not "genetically inferior" or have some serious issue which is stopping them from progressing if their maintenance calories are within average range!
Just knowing that there is nothing wrong with your metabolism gives people enough push to continuously walk on this path and achieve their goal.
>I mean, observing the weightloss / gain or lack thereof itself will tell you whether you need more of a calorie deficit or surplus.
You can read app reviews and these will tell you, complete newbies are having great success with this approach.
If you ask a layman on the street, they'll tell you eat less to lose weight, eat more to gain weight.
The question is: what is less, and what is more? How many calories precisely do we need to eat to achieve 1lb per week of weight loss?
Your total calorie burn for the day changes week to week; people don't know how to make the right adjustments.
Many people crash diet; they lose weight, then they cannot sustain it for long, binge eat, and gain it all back.
What key knowledge are they missing? Sustainable deficit. If you apply a sustainable deficit over a longer period of time, you may not "suffer" as much as you would otherwise
I am not saying drastic deficits are not useful; they are to those who are experienced. Let's say an MMA guy or bodybuilder can do it just fine!
Also, for lean bulking in natural bodybuilding, you need a specific rate of weight gain; let's say for a beginner it's a weight gain of 0.25–0.5% of body weight/week. It's hard for many to achieve this precise range because your maintenance calories are changing all the time!
And if you are an advanced lifter, then the rate of gain you want to target is even smaller: 0.1–0.25%/week.
That's why pro natural bodybuilders use Macrocodex and find it useful.
for those that aren't, you can't actually measure metabolic rates this way.
for a way to actually measure it see: https://en.wikipedia.org/wiki/Indirect_calorimetry
How are you defining highly effective? In the sense that a body will definitely lose weight when starved? Or in the sense that counting calories is broadly effective as a weight loss strategy?
The former is painfully obvious and entirely unhelpful, and the latter is provably false.
Anyway what's cute about this is that this isn't novel phenomenon. There are lots of parallels to this in other fields where often effective solutions do exist, but at a system level don't seem to work.
Telling people to diet doesn't fix population level obesity. Telling people about personal financial management doesn't stop people from accruing too much high interest debt. Telling teenagers to stop idolizing instagram influences doesn't fix body anxiety issues. Telling people to stop smoking/drinking doesn't fix addictions. 3-2-1 data backups absolutely work but people lose files all the time.
"general population doesn't have the discipline for it" — only that this feels somewhat condescending.
Let's agree that counting macros or going for calorie deficit is hard if it is not someones job. General population has other jobs, family, social life, other hobbies they enjoy more than fitness. It is not "just eat less" it is "spend considerable amount of time thinking about and planning your eating".
If you turn things into individual discipline problems then surprise you get population level issues. As you pointed out people have other things to focus willpower on thats not this.
The fault, as it often does, lies in marketing. Turns out heavily marketed, hyper palatable food, designed to be minimally satiating so you maximally over eat is great for profits and terrible for obesity.
Nonsense. It doesn't take any more time. Just buy unprocessed, basic food, fruit and veg. When you open your cupboard, cook something tasty from what you have.
When you go to the supermarket, just don't walk into the aisles with snacks. Don't buy anything laden with sugar and fat.
Get into the habit of drinking black coffee instead of Starbucks' calorific drinks; it takes less than a week for your taste buds to adjust.
It's not rocket science. Just most people don't want to admit that every excess 100 calories they eat adds 11 grams of fat to their middle. Which adds up week by week, year by year.
But even with this kind of food, if I figure "sure, lemme have a sugary ice-cream", two hours later I'll be looking around the fridge and cupboards for some "quick bite".
Just don't buy this crap. I find it's much, much easier to have none at all than to hope to be "reasonable" and only eat a bit.
If your maintenance calories are 2700kcal and you eat 300kcal less than that, is eating 2400kcal starving for you?
Most people cannot tell a difference if they eat 100-150kcal less in a day.
>Or in the sense that counting calories is broadly effective as a weight loss strategy?
Yes, it is, and the reason people fail with it is not because calorie counting doesn't work, but because people's maintenance calorie estimates are often poor.
Deficit = maintenance calories (TDEE) - calorie intake
In this, even if your calorie tracking is on point, a deficit requires you to have a decent estimate of maintenance calories.
To throw a monkey wrench into all this, your maintenance calories often shift downward as you progress in your "diet" journey.
see: https://pmc.ncbi.nlm.nih.gov/articles/PMC9036397/
It's already factored in our algorihtm: https://macrocodex.app/knowledge/macrocodex/smart-calorie-bu...
I would have thought that it would mostly be because they can't resist that extra snack.
Or 'optimistically' underestimate the calories in the not pre-packaged food.
Serious question: Is there a significant variability in how the food calories are absorbed? Maybe different combinations are not absorbed equally efficiently (like with water/oil-based vitamins)
Baer, David J., et al. "Dietary fiber decreases the metabolizable energy content and nutrient digestibility of mixed diets fed to humans." The Journal of nutrition 127.4 (1997): 579-586.
> The study was conducted in Shanghai, China from 3 July 2013 to 14 October 2016
Figuring out and understanding the physiology of different gut bacteria is not just for people trying to shortcut weight loss while still eating unhealthy food or to be sedentary all day.
Somehow American Heart Association and its European counterpart are in denial, and still pushing dinasour screening mechanism with very low accuracy for heart disease risk prediction.
The standard risk model for CVD based on PREVENT (US) and SCORE-2 (Europe) like parameters are very poor as reported in the recently published paper on the their accuracy performance by the Swedish team [1]. As all CVD risk stratification with cardiologist review (expert-in-the-loop), the most important accuracy metric is sensivity/recall (avoiding false negative that will escape review) of PREVENT and SCORE-2, 26% and 48%, respectively.
The paper alternative proposal increased the sensitivity to 58% by performing clustering instead of conventional regression models as practiced in the PREVENT and SCORE-2.
These type of models including the latest proposal performed very poorly as indicated by their otherwise excellent and intuitive display of graphical abstract results [1].
[1] Risk stratification for cardiovascular disease: a comparative analysis of cluster analysis and traditional prediction models:
https://academic.oup.com/eurjpc/advance-article/doi/10.1093/...
There are many related research work with excellent results, patent, etc by biomedical researchers around the world that I'd care to mention, including yours truly. Biomedical researchers even has yearly global competition organized so called CINC that used ECG as one of the main input for heart disease risk prediction since it's readily available [1].
In particular check out work by Prof. Friedman on ECG [2]. Somehow his excellent work is mostly being ignored by AHA and their counterparts because apparently these standard risk prediction models in US and Europe are not including it as part of their parameters.
[1] Computing in cardiology (CINC):
https://cinc.org/
[2] The Electrocardiogram at 100 Years: History and Future:
https://www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.1...
https://www.mayoclinic.org/tests-procedures/heart-scan/about...
https://www.mayoclinic.org/tests-procedures/ct-coronary-angi...
GP was talking about screening though, not diagnosis. Coronary angiography are specialized, expensive and require intravenous constrast. Doctors aren't going to order them for everyone who shows up for a routine consult.
My dad’s doctor said he should get one, Medicare denied it, but he paid out of pocket to get one anyway. He found out he was 95% blocked pretty much everywhere and had a quadruple bypass. It likely added many years to his life and avoided a heart attack.
If you’re under a certain age (I want to say somewhere in your 50s), there isn’t any guidance for what normal is. If you’re in your 20s or 30s, I wouldn’t run out and get one. But if you’re in your 40s with a family history, or up into your 50s and beyond, it’s worth thinking about. I’ve also heard you’re only supposed to get them every 2-3 years, it’s not a yearly thing, due to the radiation.
(I am not a doctor)
The time to take action is long before you have a CAC score. e.g. Start tracking ApoB regularly, see if you have genetic LPa exposure, and avoid the foods that increase your exposure while ignoring the grifters telling you it's a nonissue.
Emphasis on non-invasive diagnostic screening as invasive testing like angiogram need to be operated by specialist and can take months to be arranged, and only done after incidents e.g heart attack.
ECG is excellent for generic top level CVD anomaly conditions for examples arrhythmia and ischemia.
(Edit: This is intended to be sarcastic. I agree 100% with the comment)
(Edit 2: Added the smiley face)
A lot, probably. You could sell people on the idea that it should be a part of your yearly health screening.
"And if you really care about your health you should do them every 3 months to catch problems early!"
or some such.
An ECG if it was just part of the normal yearly panel of things that get looked at I don't think ppl will stop doing it just because it doesn't find something right away
I do not consider the average HN commenter to be average.
You could say that it’s almost as if their model has a home-field advantage. Because of that fact alone, you can’t really conclude anything about the comparative performance of their models versus the existing ones from this paper.
Getting an ECG, EKG, TTE, CAC, carotid duplex US, lipid panel, CMP, TSH, 25-OH Vit D, B12 + folate were what my cardio recommended before appointment #2 on hypertension. Both of us are data guys.
Those are the same thing, did you mean to type something else?
BMI is easily misunderstood by people who know just enough to see that it’s imperfect, but not enough to understand why it’s still a valuable screening tool.
I’ve been in the “overweight” BMI range with low body fat before. It’s not too hard to get there if you’re lifting weights and paying attention to your diet consistently for years, but it takes a lot of work to get there. It doesn’t happen accidentally except for people who win some genetic lottery to build a lot of muscle and keep body fat low without trying.
Getting all the way to the obese BMI range while having healthy body fat is only happening for people with an extreme dedication to body building and diet (and let’s be honest, a lot of the people in this category are manipulating hormones too).
Yet whenever BMI comes up some people try to dismiss it as too flawed based on these possible edge cases. The edge cases for BMI exist, but that doesn’t mean it’s not useful. It’s a good general purpose screening tool with numbers that are available. If someone has more precise measurements available, those should be used instead. BMI is a really good first pass screener to determine if a closer look should happen.
In other words, for my height, I have a very long torso and very short legs. I think it should be relatively obvious that an inch of leg weighs significantly less than an inch of torso, so at a given level of body fat percentage, I'm going to weigh quite a bit more than someone my same height with more typical proportions, and thus my BMI reads me as more overweight than it otherwise would.
My point is not that BMI is bad or useless or anything else. My point is that it was designed as a population statistic and that it can be fraught when one tries to apply it to any individual with no nuance. A high BMI should cause one to consider and examine your health and weight. But it should not over-ride specific details about your physiology that point in the other direction.
It still functions well as a measure of load on your circulatory system, joints, you name it.
Your body is working harder than a typical 6'2" person, even if you have a great waist-to-hip ratio.
(But you'd still be better off with a smaller WTH ratio!)
People tend to think in absolutes. Even perfectly rational people fall logically foul to not considering outliers.
Did you do that as a natural lifter? It’s hard for me to imagine most guys being able to get into the “overweight” range at < 15% body fat without some assistance.
I am only 6' and only an intermediate lifter. I'm overweight, but BMI makes me look obese. It really only takes a normal person a year or so to get to three plates on squat with no supplements other than chicken broccoli and rice if they don't skip workouts. Assuming no injuries. That level of strength easily distorts bmi wildly if you are even a little taller than average.
Anything to pretend they aren't too heavy.
And sumo wrestlers.
The line seems to be drawn at (effortful) activity level more than anything else. And BMI doesn't say anything about that.
I think the vexation comes from the focus on an attribute that is not directly mutable, per one's agency, because that's easier to sell things related to. Versus action that you have a lot more direct control over (social or physical circumstances notwithstanding).
(from https://en.wikipedia.org/w/index.php?title=Sumo&oldid=136533...), so I'm not sure this is a counterexample.
Many active gym people have pretty high BMIs but fairly low fat (because muscle is dense), and unsurprisingly have better outcomes than the average person (if you ignore the share that uses/overuses anabolic steroids and co)
I think this is greatly exhaggerated.
Yeah you can put on as much muscle as Arnold and have a FFMI of about 27 then maybe have a BMI of 34 if you have 20% body fat.
But a very gifted natty might cap out at maybe 24 with a BMI of 30 at 20% bodyfat. But let's be realistic. This is not "many active gym people". This is the guy winning the local strongman meet.
Yes a couple of years training for most people can add a couple of points to BMI but I think people exaggerate how much this is. Go look at a 20lb brisket at costco - you don't see people with that much extra muscle all that often.
At 6 feet / 183 cm that it takes 184 lbs / 83 kg to be overweight. From what I could find, for regular gymgoers the typical weight for people around 6feet is 180-190lbs, which put many people around the overweight threshold. I am myself at 24.9, and while not skinny I am definitely in the skinnier half of the people at my local gym.
Yeah really well muscled guy being BMI 27 is probably ok but by 30 it's not natural muscles that are making the scales go up.
And obviously genetics matter, but it look at master level soccer players: athttps://pmc.ncbi.nlm.nih.gov/articles/PMC6239137/
I’ve been in the overweight BMI category with low body fat by being active at the gym and focusing on diet. It takes some work to get there.
If I check the calculators for the obese BMI range, there was no way I could get there without either gaining a lot of fat on top of the muscle. The amount of muscle required to have an obese BMI with healthy amount of fat is absurd.
E.g. 20% bodyfat at 250lbs is still a lot of fat.
Of course it's difficult to ever get very high on absolute fat if at 15% or below.
Additional muscle is positive for health, but only up to some reasonable threshold. There is no health benefit to having very high levels of muscle, and in fact it may be negative for your health at extreme levels. E.g. many bodybuilders have trouble breathing, sleep apnea etc.
Both people in the example have 60lbs of fat. 1lb of muscle doesn't cancel out the negative health effect of 1lb of fat
From what I have heard from doctors, there is a clear sequence:
intra-organ fat (really bad) > visceral fat (quite bad) > subcutaneous fat (relatively harmless).
The nasty detail is that some people gain relatively more visceral fat than others. These three fats are correlated, but the correlation isn't the same in every human. Some have better metabolism and don't store as much fat inside as others do.
It’s not the fat that kills. It’s oxidated lipids that kill.
1. https://www.cdc.gov/nchs/data/series/sr_03/sr03-046-508.pdf
2. https://www.cdc.gov/nchs/data/ad/ad347.pdf
As for 2, men in the US are getting shorter because of immigration which adds many confounders.
But also short people living longer has so many more possible explanations than less overall fat.
https://medlineplus.gov/ency/article/003998.htm
"People typically lose almost one-half inch (about 1 centimeter) every 10 years after age 40. Height loss is even more rapid after age 70. You may lose a total of 1 to 3 inches (2.5 to 7.5 centimeters) in height as you age."
So people DO in fact tend to lose about 2 inches at age 80 versus their younger selves.
1. https://pubmed.ncbi.nlm.nih.gov/10547143/
2. https://www.mdpi.com/2072-6643/15/21/4694 (referencing the FHS there, the numbers are hard to find on the study's website).
I often wonder far from the median I am in this regard. I was under the impression that it was pretty accurate for assessing populations, but fell apart very quickly at the individual level. How many "normal"/otherwise healthy people do fall outside BMI's numbers?
https://www.nature.com/articles/s41598-020-69498-7
BMI has known biases in gender, age, and race. It misclassified Asians, women, elderly w sarcopenia, and people with high body fat to lean tissue ratio.
The people most obsessed with "BMI isn't accurate" are overweight people making excuses for themselves.
I like to think of this as four quadrants around two axes. Low fat/low muscle is simply skinny. High fat/high muscle is the "big guy/gal" look that I associate with laborers. Low fat/high muscle is an athletic look; unhealthy in extremes (bodybuilding) but generally desirable. High fat/low muscle is skinny fat, which I associate with sedentary knowledge workers.
[0] And that, at least somewhat, tracks visual perceptions. Nobody looks at me with a shirt on and believes I need to lose weight, because 10-15lb isn't _that_ much extra on a tall frame. If I were 40-50lb overfat then that would be painfully obvious regardless.
My actual methodology is pretty crude though -- when I was 15lbs lighter I had borderline visible abs and other visual indicators of being around the 15-20% body fat mark, and aside from gaining weight I don't have any reason to believe I've had any notable muscular atrophy since then, so I'm estimating the actual excess fat in that ballpark. It's be easy for numbers to be off 10lb or more, but even then it'd still indicate the overfat surplus being much less than the overweight surplus.
A better methodology uses calipers and various skin measurements to estimate true body fat percentage.
"Overweight" can mean the same thing for weight, but it also refers to those with a BMI specifically between 25 and 30, and those with BMIs greater than 30 are classified as "obese".
It's specifically a high level of visceral body fat.
Genetics determines which parts of the body gain fat first as you gain fat overall, and some people have the unfortunate genetics to gain it first viscerally and some people have the fortune to gain it there last (and everything in between).
This means that you can have different people with the same body fat percentage but drastically different disease risks.
But yes this was also known already.
That's why it's been recommended to take a waist measurement alongside BMI to get a much more informative screening tool. Waist-to-height ratios are another alternative.
It is what is called “skinny fat“.
It's just a particular type of abdominal fat so obviously the more abdominal fat that you can see it means you also have more of the type that can't see as well... It's not that complicated
BMI
Waist circumference (WC)
Waist to hip ratio (WHR)
Subsequent risk of nine cardiovascular/mortality outcomes in >260,000 people followed for ~20 years
To make it even more useful they should have included DEXA scan bodyfat%.
Also, BMI becomes somewhat biased at height extremes because body mass doesn't scale exactly with height². Humans aren't geometrically scaled copies of one another and empirical scaling exponents are often somewhere between 2 and 3. Conventional BMI tends to read relatively high in very tall people and relatively low in very short people. But changing the exponent would only fix one relatively small limitation of BMI
For better height adjusted replacement for BMI itself, one option is Trefethen’s BMI
WHR and WC is positively correlated to bodyfat% but this may get distorted for strongmen or sumo wrestler who tend to have much higher than average lean mass, may also have higher WC and WHR but difference maybe waist to shoulder ratio, they tend to have much bigger and powerful shoulders.
what's interesting is, for sumo wrestlers specifically, WC still correlates strongly with BF% one study reported r ≈ 0.86
There is a category in fitness called "skinny fat" where you are at low bodyweight (so low BMI) but your fat mass is relatively higher when compared to lean mass, so higher bodyfat%
Many skinny fat people refuse to believe they carry higher bodyfat% because they think they've low bodyweight so they can't possibly carry higher fat, which is wrong.
If you are interested in knowing more about bodyfat, this may help you: https://aretecodex.pages.dev/knowledge/measure/bodyfat
How does one determine if one has an excess of visceral fat?
https://health.ucdavis.edu/sports-medicine/resources/dxa-inf...
You want to make sure you measure under similar conditions, like in the morning after relieving yourself (for example).
If it's too high, losing a ~0.5-1 lbs per week while strength and endurance training with progressive overload will get it down sustainably.
https://www.barbellmedicine.com/blog/visceral-fat-waist-vs-w...
Thirty years after we learned that abdominal fat distribution matters, large-scale longitudinal evidence shows that waist measurements meaningfully reclassify cardiovascular risk beyond BMI alone.
For example, I’m 45yo/178cm/93kg and am obese by BMI measurement. However, my body fat is 20% (Dexa), VO2 of 50 (lab) & have the aerobic fitness to run a half marathon after work and not care.
I’m not surprised that you need other metrics like hip/waist ratio, measured body fat, visceral fat, etc to better understand the composition of someone’s body and how it might relate to health outcomes like heart disease.
Any idiot with a bathroom scale and a measuring tape can do it. And by adulthood, height doesn't change significantly and you probably know it, so you may not even need that measuring tape. Other metrics need specialized equipment, error prone or complex procedures, etc... I don't even know how to make a waist measurement. Where exactly? How relaxed should the subject be? How long after eating?...
That's the value of BMI: simple repeatable. Not the best but enough to get and idea and make statistics.
But height does change in adulthood [0]. On average people living past 40 gradually lose height. At age 80, it's likely height loss will be >=2 inches. This loss is reflected in higher BMI even when body fat content hasn't changed. Average BMI increase isn't large, but think about a person losing 4 or 5 inches of height while maintaining body fat unchanged.
Self-reported height is generally greater than measured height. Adding 1/2 to 1 inch is common (per experience measuring height). "Height inflation" has modest effect on BMI but problematic in research and workup for medical procedures. In the latter cases, measuring height is necessary.
[0] https://www.uhhospitals.org/blog/articles/2024/10/why-do-peo...
If I'm reading that right, it sounds like obesity (and therefore BMI) is still a better predictor for all-cause mortality. Perhaps waist circumference is better at predicting cardiovascular risk but BMI is still useful.
Cutting saturated fat to under 15g per day and increasing intake of viscose fibre (e.g. beans) will reduce your LDL particle count in a few weeks, which reduces your CVD hazard ratio. You can measure your LDL and look up the papers yourself. Statins will reduce it a lot too (potentially with side effects). Replace solid fats like butter with liquid fats like olive oil.
Literally any amount of regular exercise, including walking, will decrease CVD HR. The more the better (up until quite a large amount e.g. professional athlete). The more your heart is steadily pumping during exercise the better. Every bit helps reduce CVD risk. Movement is medicine.
For the love of God do not smoke. Literally one of the surest ways to die a horrible death. Stopping smoking reduces CVD risk by a large amount.
Do not give yourself diabetes by eating vast amounts of sugar. If you are doing this, stop. Not having diabetes decreases CVD risk.
Other factors you probably can't change so focus on these.
Doctors, if I got anything wrong please correct me.
Not eating vast quantities of sugar is good advice, but it's not the direct cause of T2 diabetes. The best evidence suggests that T2 diabetes is caused by the accumulation of fat in the liver and pancreas. See the twin cycle hypothesis. To prevent diabetes, one needs to maintain a weight low enough where the body isn't storing fat in the liver and pancreas (everyone has their own individual threshold for this). If you're pre-diabetic, lose enough weight and most people will regain insulin sensitivity.
https://en.wikipedia.org/wiki/De_novo_synthesis#Fatty-acid_(...
https://link.springer.com/article/10.1007/s00018-018-2860-6
https://pmc.ncbi.nlm.nih.gov/articles/PMC6213738/
https://drive.google.com/file/d/13sQiOt1tVKDYe8h3bSOL_sazalL...
https://link.springer.com/article/10.1007/s13668-026-00740-w
This can help sustain a high level of exercise (the more the better). Certainly don't if you're sedentary, but the sugar during exercise is really helpful for getting in 10+ hours/week of exercise.
https://link.springer.com/article/10.1007/s13668-026-00740-w
(When I say sugar, I mean things like gummies, gels, and sugar-sweetened beverages. If sedentary people habitually eat these, it does increase their T2D risk.)
> habitually drinking... sugar-sweetened-beverages
Yes, terrible idea, avoid!
(previously at https://news.ycombinator.com/item?id=45857053)
https://en.wikipedia.org/wiki/Waist%E2%80%93hip_ratio (hip to waist)
They need to figure out a way to reliably Measure OXLDL.
just got statin at 44 :(
i am not fat and workout ( although diet can use some improvment)
BMI was never meant to be used as a diagnostic measure. BMI is just a rough filter for large data sets, and entirely dependent on the average height and habits of that population.
Anyone taller than about 6'3" could tell you the recommended weight according to their BMI has always been absurdly low. If it's a printed chart on the wall, they might not even be on it.
The "ideal weight" of a person is proportional to height to an exponent somewhere between 2 and 3. Simple physics would say 3 but because tall people are not just scaled up copies of small people, it is closer to 2 in practice, maybe around 2.3, but we say 2 because it is easier to calculate.
The downside is that BMI overestimates the "ideal weight" for short people and underestimate it for tall people. But BMI is not great at capturing exceptions anyways, so there is little interest in "fixing" this.
Using your 6 3" male as an example, they are significantly more likely to be clinically obese (using waist circumference, body fat % etc) at a weight lower than BMI cut-off of 240 lbs.
It's really good at catching people who are obese who are overweight.
And these aren't merely hypothetical bodybuilder edge cases. A systematic review found BMI had only ~50% sensitivity for detecting obesity when compared with body-fat reference methods—i.e. it missed roughly half the people classified as obese by adiposity.
More importantly, the 2025 Lancet Commission on clinical obesity explicitly recommended that BMI be used only as a population-level risk surrogate or screening tool, not as an individual measure of health. For individual assessment they recommend actually confirming excess adiposity with waist measurements or direct body-fat measurement.
Which is basically what this study is demonstrating again: where the fat is contains substantially more useful cardiovascular information than the number you get from dividing someone's mass by the square of their height.
You're not going to die of a heart condition if you hit the gym 3 times a week.
Also nobody says "don't eat food" other than thinspo instagram pages. You should eat food, if you don't eat food you die.
https://bjsm.bmj.com/content/55/4/206