13 Whats causing the constant feuding between the

CICO and anti-CICO camps?

By Alan Aragon

Copyright June 1st, 2014 by Alan Aragon

Home: www.alanaragon.com/researchreview
Correspondence: aarrsupport@gmail.com

Internal vs. external cues: science, theory, &

practical application.
By Jordan Syatt

The effects of a ketogenic diet on exercise

metabolism and physical performance in off-road
cyclists.
Zajac A, Poprzecki S, Maszczyk A, Czuba M, Michalczyk
M, Zydek G. Nutrients. 2014 Jun 27;6(7):2493-508.
[PubMed]

Prostate cancer and the influence of dietary

factors and supplements: a systematic review.
Mandair D, Rossi RE, Pericleous M, Whyand T, Caplin
ME. Nutr Metab (Lond). 2014 Jun 16;11:30. [PubMed]

The effects of water and non-nutritive sweetened

beverages on weight loss during a 12-week weight
loss treatment program.
Peters JC, Wyatt HR, Foster GD, Pan Z, Wojtanowski AC,
Vander Veur SS, Herring SJ, Brill C, Hill JO. Obesity.
2014 May;22(6):1415-21. [Wiley Online]

11 Why you never seem to reach your weight loss

goals (and what to do about it).
By Armi Legge

Alan Aragons Research Review June 2014

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Page 1

Conversely
Internal vs. external cues: science, theory, & practical
application.
By Jordan Syatt
____________________________________________________
An Introduction to Coaching Cues
An overwhelming amount of attention has recently been directed
towards the science & application of coaching cues and,
specifically, their impact on markers of performance.
Seemingly arbitrary nuances in word choice, research both
experimental and anecdotal is consistently finding reason to
believe some cues are more effective than others.
Specifically, external cues have consistently proven to be more
effective than internal cues at improving performance through a
variety of mechanisms such as decreased antagonistic muscular
co-contraction, improved full-body coordination, and enhanced
reflexive movement efficiency.1-10
As a result, it is now common among strength coaches to tout an
external focus as the end-all-be-all of coaching cues while
ostracizing an internal focus by deeming it a useless waste of
time.

External Focus Cues direct the athlete to think about how their
body moves in relation to the environment. For example, during
the squat, commonly used external cues are:
Show me the logo on your shirt! (in place of the chest
up cue)
Spread the floor apart!
Drive the floor away!
Whats the Difference? The fundamental difference between
internal and external focus cues lies in where the athlete focuses
their attention. With internal cues, the athlete directs their
attention towards their own body in an attempt to complete the
movement. With external cues, however, the athlete directs their
attention towards their environment and the subsequent
movement effect.
Reviewing the Literature
When the goal is to improve performance in a given movement,
external focus cues are unquestionably better than those with an
internal focus. Period. End of story.
Whether the movement is a maximal effort squat, long jump,
basketball free throw, golf swing, or even throwing
dartsexternal cues are the superior coaching tool. 1, 7, 12, 13, 14

But where is the context? Is one type of cue inherently better

than the other or does it actually depend on the individual and
their specific needs and goals? Once again, here we find fitness
dogmatism at its finest.

Why are external cues inherently better than internal cues at

improving motor control and movement performance? The
answer lies in what is known as the constrained action
hypothesis. As explained in a study by Wu and colleagues,7

Considering this topic is still in its infancy, Im sure many

coaches will vehemently disagree with my conclusions and
recommendations. That being said, the readers of AARR tend to
be the most un-biased, open-minded individuals within the
fitness realm, so Im excited to present my findings here first.

...consciously focusing on the movements of a motor action

disrupts automatic motor control processes that regulate
coordinated movements. When athletes actively focus and
consciously control their movements, they interrupt automatic
nonconscious motor behavior processes that normally control
movements in an efficient manner. In contrast, directing
attention externally to the movement effects allows the motor
control system to naturally regulate and organize motor
actions. As a result, movements are unconscious, fast, and
reflexive.7

Drawing upon the scientific literature as well as my personal

experiences, by the end of this piece you will fully understand
the differences between internal and external focus cues, as well
as how to use them to achieve the best results with yourself and
your clients.
Defining Internal & External Cueing
When verbally instructing an individual to perform a given
movement you can either use an internal focus cue, external
focus cue, or a combination of the two.11 Allow me to define
each of these terms, below:
Internal Focus Cues direct the athlete to think about how their
body moves in relation to itself.
For example, during the squat, commonly used internal cues are:
Chest Up!
Knees Out!
Arch!

In laymans terms, using an internal focus causes the athlete to

move in a less efficient and fluid manner due to various
disruptions in what should be natural and unconscious
processes.
Conversely, external cues tend to improve movement efficiency
as they reduce conscious thought processes and facilitate natural,
reflexive movement patterns. Plain and simple, external cues are
the absolute best tool to use when the goal is improved
movement performance. This includes all athletic and/or skillrelated competitions such as powerlifting, golf, sprinting,
jumping, ping pong, free throw shooting and countless other
events of the sort.
What if the goal is NOT to improve movement performance?

As you can see, each of these cues cause the athlete to think
about how theyre creating movement in relation to their body.

That is to say, what if the goal revolves around something else

like increasing muscle hypertrophy or improving muscle

Alan Aragons Research Review June 2014

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activation in a rehabilitation setting? Are external cues

unquestionably better for achieving all training-related goals or
could internal cues play an important role after all? Lets
investigate.
Rehabilitation
Call me crazy, but Id venture to guess not everyone cares about
increasing their max squat, vertical jump, free throw, or other
performance-based movements.
Take, for example, those in a rehabilitation setting. Whether
theyre in pain, recovering from an injury, or a combination of
the twotheir priorities tend to revolve around optimizing
muscle recruitment patterns including frequency, intensity, and
duration of contraction.
Taking the above into consideration, we need to ask ourselves if
external cues are more effective than internal cues in a
rehabilitation setting. The answer: probably not. While research
has consistently found external cues to be optimal for improving
movement performance, internal cues have proven to be
extremely effective at increasing and/or decreasing muscular
activity in specified muscles.15-18 To name a few
Lewis and Sahrmanns 2009 study found internal cues to
be more effective than external cues at increasing gluteal
EMG and decreasing hamstring EMG during prone hip
extension.
Karsts 2004 study found participants were more
effective at recruiting the specified rectus or oblique
abdominis when provided internal cues.
In 2009, Snyder et al found trainees were better able to
increase latissimus dorsi activation when given internal
cues.
Why is this important? Learning to use the right muscles at the
right time is a major component of nearly all rehabilitationfocused programs. Through using internal cues we can actually
increase activation of specified muscles which, needless to say,
is of the utmost importance in a rehabilitation setting.
But Wasnt This Research Conducted Using EMG?
Naysayers of the aforementioned research will say EMG is
riddled with flaws and cant be used to make definitive
statements. Theyre absolutely right.
EMG, like all research, has its own set of methodological faults
rendering it subject to the possibility of error. For example,
surface EMG is influenced by a variety of factors outside of
simple muscular activation such as cross talk (nearby
musculature), blood flow, fiber type, and fatigue. 19 Clearly, it
isnt perfect.
That being said, there is no such thing as perfect research. There
will always be flaws no matter what methodology we use. As
such, its important to understand both the pros and cons in order
to make the most intelligent decision based on a variety of
experimental and observational research.

duration of muscle activation, and even a somewhat reliable

approximation of the amount (or intensity) of muscle activation.
Through using this knowledge (while bearing in mind the
possibility of error) we can grasp a better understanding of
which muscles were using at which times and with what
intensity.
Needless to say, this is pretty damn important. In fact, prominent
researcher and physical therapist, Mike Reinold, utilizes EMGbased research in the development of his own pre/rehabilitationbased programs. Specifically, Reinold has conducted a number
of studies examining the rotator cuff and surrounding shoulder
musculature and subsequently helped to identify which drills are
most effective at improving shoulder health and function. 20, 21
Considering Reinold works predominantly with elite athletes,
one might even argue that, in this instance, internal cues could
be better than external cues at improving performance.
What about Muscle Hypertrophy?
Enough of the boring rehabilitation stuff. Whats better for
increasing muscle hypertrophy: internal or external focus cues?
Lets find out.
The Mechanisms of Muscle Hypertrophy
Thanks to extensive research done by AARR regular, Dr. Brad
Schoenfeld, we know there are three primary factors responsible
for inducing muscle hypertrophy from resistance training. 22
Mechanical Tension
Muscle Damage
Metabolic Stress
Without going into excruciating detail (you can learn about these
3 factors in Brads famous research article HERE), suffice to say
each of these factors are of the utmost importance and balancing
all three, rather than focusing on only one or two, will allow you
to achieve the best results.
Internal vs. External Cues for Hypertrophy
A number of prominent strength coaches have been quick to
jump on the external cues are ALWAYS better bandwagon and
have even gone so far as to make unsubstantiated claims
regarding the superiority of external cues in hypertrophy-focused
programs. The reality, however, is that we have no clue.
The research pertaining to coaching cues and muscle
hypertrophy is currently scant and it would be misleading to
make definitive statements for or against either type of cue. That
being saidwe can dig a little deeper.
The Mind-Muscle Connection

Despite the flaws, EMG has proven to be extraordinarily useful

in that it can give us insight into patterns of muscle activation,

For years, some of the worlds most successful bodybuilders

have continually referred to the importance of the mind-muscle
connection. Even Arnold, arguably the most respected and
successful bodybuilder of all-time, is one of the foremost
proponents of the mind-muscle connection and has been quoted
as saying you need to put your mind in the muscle to build
bigger muscles.

Alan Aragons Research Review June 2014

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Essentially, training using the mind-muscle connection entails

visualizing the muscle being trained and feeling it work through
a full range of motion. As you may have guessed, this is a form
of internal cueing as it causes the lifter to think about how their
body moves in relation to itself. Training in this fashion has been
said to increase muscle recruitment, potentially leading to
greater muscle hypertrophy.

importance of using internal cues to maximally contract

specified muscular in order to optimize muscle hypertrophy.

In accordance with this train of thought, Bret Contreras has

performed his own EMG-based research and found comparable
results. Specifically, through using the mind-muscle connection
Contreras drastically manipulated gluteal activation when
performing a standard back extension. Without concentrating on
the glutes, gluteal activation reached just 6% of maximum
voluntary isometric contraction (MVIC). However, when
actively focusing on using the glutes to complete the same
movement, EMG activation rose to 38% MVIC.23

Having said that, Im also an experience guy. Theres something

to be said for those who spend years upon years working in the
trenches, coaching athletes, and actually lifting weights. In my
opinion, real-world experience is equally as important as
experimental research. One without the other is decentbut put
both of them together and youve got a recipe for serious #gainz.
Unless Im mistaken, Im the first person ever to use a hashtag in
AARR. #Winning. [Editors note wow, lol]

Snyder et al (mentioned earlier) noticed a similar phenomenon

regarding increased latissimus dorsi activation when instructing
participants to feel their lats while performing a pull down. The
authors noted concentrating on the target musculature resulted
in greater activation of this muscle.

Back to the topic at hand, Im a coach and a strength athlete. Ive

worked with hundreds of individuals and helped numerous
lifters achieve extraordinary levels of strength. Ive worked with
and trained under coaches such as Louie Simmons and Eric
Cressey, and I hold several IPA Powerlifting world records
including a raw 485lb deadlift at a bodyweight of 132lbs.

Does Increased EMG Lead to Greater Muscle Hypertrophy?

EMG skeptics are quick to point out that increased muscular
activity does not necessarily lead to greater muscle hypertrophy.
Theyre absolutely right. Increased muscular activity does not
automatically result in greater muscle hypertrophy. If that were
the case, wed all be getting jacked from E-Stim treatments at
our local PTs office and rushing to get those vibration belts that
allegedly melt fat off our abs.
God, I hate fitness marketing...I digress.
Increased muscular activity alone does not lead to greater muscle
hypertrophy. We know this from Dr. Schoenfelds extensive
researchas well as common sense. However, as Dr.
Schoenfeld has previously mentioned, establishing a strong
mind-muscle connection (as utilized in posing by seasoned
bodybuilders) can improve neuromuscular control and improve
your ability to maximally contract your muscles thereby
allowing you to generate more force during your lifts.24
Considering mechanical tension (a key factor in the hypertrophy
equation) is largely influenced by force production, it stands to
reason that using a mind-muscle connection to learn how to
maximally contract your muscles could potentially lead to
greater hypertrophic gains.
SoInternal or External Cues for Hypertrophy?
Based on the current available research its impossible to say
with absolute certainty which is better or worse. However,
considering the information outlined previously, as well as the
experiences of some of the most successful bodybuilders of all
time, my gut instinct leads me to believe that internal cueing is
more effective than external cueing for improving muscle
hypertrophy.

My Personal Experience
Im a science guy. I understand and appreciate the importance of
research as well as the implications it holds in real-world
performance.

I say this, not to brag, but to let you know from where the
following information is coming. Im not some random desk
jockey sitting in my dark and creepy basement trolling on
Reddit. I lift. I coach people to lift. And I do this every single
day. Thus, Im excited to share with you my personal
observations from experimenting with internal and external
focus cues.
There is a major difference between performance and practice.
If theres one thing you take from this article, let it be this:
performance and practice are two entirely separate entities and
should be treated as such. Allow me to explain.
Lets say youre competing in a powerlifitng meet and youre
about to take your 3rd and final squat attempt. This is a
performance. You will use the strength and skills acquired
during recent months of training in an attempt to perform your
best. This is NOT the time to change your technique.
Conversely, during the months leading up to the meet you are
practicing. You are practicing the movement, making
alterations, and tweaking things to find what works best for you.
See the difference?
The main goal of practice is to engrain the optimal movement
pattern so when it comes time to perform the movement you
dont think you just do.
Which Cues are Best for Practice and Performance?
Performance (i.e. competition) is the ideal time to utilize
external cues. The well-established benefits of external cues are
most valuable at this time as they facilitate the best execution of
a pre-learned movement.

As the body of research grows Im more than willing to change

my opinion but, as of right now, I whole-heartedly believe in the

Practice (i.e. training), however, is the ideal time to utilize both

internal and external cues. During this period of time the main

Alan Aragons Research Review June 2014

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Page 4

goal is to engrain the optimal movement pattern in preparation

for the performance. As such, its wise to experiment with both
types of cues to see which ones resonate with each individual.
Start with Internal, Progress to External
I like to keep things simple. Likereally simple. Too often
coaches assess a clients movement pattern like the squat, for
example and throw 17 different cues at them in a matter of 12seconds. This benefits no one. Its confusing, frustrating, and
neither the coach nor athlete gets any better.
To keep things as simple and effective as possible, I use one cue
at a time and generally start with internal cues before
progressing to external. For example, if a clients chest caves
during the squat the first thing Ill say is, get your chest up nice
and high! Shocking, right? Very scientific. Usually this cue is
sufficient and we can move on to correcting other aspects of the
movement.
In cases where this cue doesnt work, however, I will progress to
an external cue such as, I want to be able to read the letters on
your shirt throughout the entire movement! or show your
nipples to the ceiling the entire time!
By this point the client almost always understands what I want
them to do and, more importantly, how to replicate the
movement time and time again.
Once the movement has been engrained, it then becomes
exceedingly easy to cue the lifter using only one or two words at
a time. For example, if the athlete gets lazy and allows their
chest to cave all I need to say is chest up! or nipples! and
theyll fix the movement immediately.
Your Takeaway: Keeping things simple will make training a far
more enjoyable (and effective) experience for both you and your
clients. Along these lines, I recommend beginning with internal
cues and progressing to external as you see fit.
Internal Cues Are Better for
DrillsExcept When They Arent.

Coaching

Activation

As previously discussed, research has repeatedly shown internal

cues lead to significant increases in specified muscular
activation.
For the most part, my experience has also found this to be true.
For example, when performing a side-lying clam many
individuals have trouble feeling the glute medius contract.
However, if I palpate the glute med and instruct the client to lift
with that part of their butt (internal cue) they almost always feel
it working.
Same goes for isolation movements like bicep curls and tricep
extensions. When I instruct an individual to focus on the muscle
being contracted (refer to mind-muscle connection), they almost
always feel the desired muscle working more than if I had
presented them with an external cue.
Having said that, there are similar situations in which Ive found
external cueing to be superior. For example, when performing a
Alan Aragons Research Review June 2014

standard glute bridge, beginner trainees often have difficulty

feeling the glutes contract. Despite palpating the glutes and
telling them to squeeze, they often dont feel them working as
they should. To expedite the process and get them using their
glutes more effectively, Ill tell my clients to imagine cracking a
walnut in between their butt cheeks while hitting the ceiling with
their hips (external cue). More often than not, this solves the
problem immediately and drastically increases glute activation.
Your Takeaway: Dont feel locked into a single type of cue.
Some cues work better than others in a variety of situations for
seemingly inexplicable reasons. When one doesnt work, try
another and keep trying until you find the one that eventually
makes things click.
Never Underestimate the Value of Demonstration
Sometimes, no matter what cue you give, the client just wont
understand what the hell youre talking about.
This happens to every coach at one time or another and, more
often than not, has absolutely nothing to do with their coaching
competency or skill level; rather, it mostly has to do with the
client and their individual learning style.
To accommodate for differences in learning style, its important
to understand verbal cues (those with an internal and/or external
focus) arent the only way to teach an exercise. In fact,
sometimes were better off scrapping verbal cues and using a
completely different approach altogether.
For example, if verbal cues just arent cutting it for a certain
client, get in there and physically show them how its done!
Of course, using a variety of verbal cues along the way will
likely be more beneficial than not, but often times simply
demonstrating the movement will help the client master the drill
in the shortest period of time.
Your Takeaway: Internal and external cues are obviously
phenomenal coaching tools given the right situation, but dont
forget there are other ways to teach proper movement patterns
that are equally, if not more, effective.
Different People Respond to Different Cues
As a subscriber to AARR, you know and understand that
individualization is key. You fully appreciate the fact that each
and every person responds better or worse to various stimuli and,
as such, requires an individualized approach. Coaching cues are
no different. Some people respond better to internal cues
whereas others respond better to external cues. Per usual, there
is no absolute right or wrong way to coach all exercises.
Rather, whatever constitutes the best cue is almost entirely
dependent on the individual and their specific needs.
Wrapping Up
Similar to how people want to know which is the single best
supplement, food, or exercise to help them get shredded, many
coaches and athletes want to know which type of cue is
inherently best regardless of the situation.
Unfortunately, thats not how it works.
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Per usual, the answer lies in a clear understanding of the fact that
there isnt an innately optimal coaching cue. To recap,
external cues are unquestionably better at improving specific
movement performance. Whether youre competing in
powerlifting, football, baseball, basketball, golf, darts, or any
other athletic and/or skill-related activity, external cues will help
you perform pre-learned movements in the most efficient
manner.
Internal cues, on the other hand, are better at improving
specified muscular activation which may be of greater benefit in
a variety of settings such as rehabilitation and hypertrophyfocused programs.
Practically speaking, a combination of both internal and external
focus cues is likely more effective than either one alone.
Regardless of whether youre working with a large client
population or simply coaching yourself, remember to
incorporate both internal and external cues to find what works
best for the individual in question.
Never Minimal. Never Maximal. Always Optimal.

7.

8.
9.

10.

11.
12.
13.
14.

-J
___________________________________________________
Jordan Syatt is a strength training &
nutrition consultant and an IPA world
record powerlifter. He is Precision
Nutrition and Westside Barbell Certified,
has a B.S. in Health & Behavioral
Science, and is the owner of
www.syattfitness.com. Fitness aside,
Jordan is an avid traveler, selfproclaimed nerd, and unashamed of his
obsession with the Harry Potter series.

____________________________________________________

15.

16.

17.
18.

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The effects of a ketogenic diet on exercise metabolism

and physical performance in off-road cyclists.
Zajac A, Poprzecki S, Maszczyk A, Czuba M, Michalczyk M,
Zydek G. Nutrients. 2014 Jun 27;6(7):2493-508. [PubMed]
PURPOSE: The main objective of this research was to determine
the effects of a long-term ketogenic diet, rich in polyunsaturated
fatty acids, on aerobic performance and exercise metabolism in offroad cyclists. Additionally, the effects of this diet on body mass and
body composition were evaluated, as well as those that occurred in
the lipid and lipoprotein profiles due to the dietary intervention.
METHODS: The research material included eight male subjects,
aged 28.3 3.9 years, with at least five years of training experience
that competed in off-road cycling. Each cyclist performed a
continuous exercise protocol on a cycloergometer with varied
intensity, after a mixed and ketogenic diet in a crossover design.
RESULTS & CONCLUSIONS: The ketogenic diet stimulated
favorable changes in body mass and body composition, as well as in
the lipid and lipoprotein profiles. Important findings of the present
study include a significant increase in the relative values of maximal
oxygen uptake (VO2max) and oxygen uptake at lactate threshold
(VO2 LT) after the ketogenic diet, which can be explained by
reductions in body mass and fat mass and/or the greater oxygen
uptake necessary to obtain the same energy yield as on a mixed diet,
due to increased fat oxidation or by enhanced sympathetic
activation. The max work load and the work load at lactate
threshold were significantly higher after the mixed diet. The values
of the respiratory exchange ratio (RER) were significantly lower at
rest and during particular stages of the exercise protocol following
the ketogenic diet. The heart rate (HR) and oxygen uptake were
significantly higher at rest and during the first three stages of
exercise after the ketogenic diet, while the reverse was true during
the last stage of the exercise protocol conducted with maximal
intensity. Creatine kinase (CK) and lactate dehydrogenase (LDH)
activity were significantly lower at rest and during particular stages
of the 105-min exercise protocol following the low carbohydrate
ketogenic diet. The alterations in insulin and cortisol concentrations
due to the dietary intervention confirm the concept that the
glucostatic mechanism controls the hormonal and metabolic
responses to exercise. SPONSORSHIP: None listed.

Study strengths
This study is innovative since its the first to ever examine the
long-term effects of ketogenic diet on training adaptations and
exercise performance in trained endurance athletes (in this case,
competitive off-road cyclists with a minimum of 5 years training
experience and a minimum VO2max of 55 ml/kg.min). Diets in
both conditions were designed by a dietitian, and the nutritional
specifics of each (targeted) diet were reported in detail, including
fatty acid types.

confounding the results. As acknowledged by the authors, the

sample size was small (8 subjects) and the body composition
assessment method (bioelectrical impedance) was crude. They
also mentioned that the ketogenic condition lacked a 2-3-day
carbohydrate loading phase prior to testing.
Comment/application
The ketogenic diet (15% C, 15% P, 70% F) outperformed the
mixed diet (50% C, 20% P, 30% F) in several parameters.
Compared to the mixed diet, the ketogenic diet resulted in lower
body fat & body weight, greater increase in oxygen uptake
(VO2max) at the lactate threshold, which was speculated to be
due to increased sympathetic activation or increased fat
oxidation. Furthermore, there was a reduction in triglycerides
and greater increase in HDL-C at rest and during exercise. LDLC was higher at all points in the ketogenic diet, but not to a
statistically significant degree (with the exception of 45 minutes
during exercise, where the LDL-C of the ketogenic diet did
reach statistical significance). Its notable that the ketogenic diet
in this study was specifically designed to contain a high
proportion of unsaturated fatty acids, including a significant
proportion of omega-3 fatty acids, and its this characteristic to
which the authors attribute the favorable changes in lipids and
lipoproteins during the ketogenic diet.
On to the unfavorable effects of the ketogenic diet. Although
cortisol levels were lower at rest, they were higher at all time
points during exercise. Resting and during-exercise testosterone
levels were lower as well. Perhaps the most critically adverse
aspect of the ketogenic diet was its ergolytic effect on highintensity exercise performance. Specifically, the mixed diet
resulted in higher maximal work load as well as a higher lactate
threshold work load; in other words, the ketogenic diet resulted
in compromised high-intensity work output. This forced the
authors to concede that, Low carbohydrate ketogenic diets
decrease the ability to perform high intensity work, due to
decreased glycogen muscle stores and the lower activity of
glycolytic enzymes, which is evidenced by a lower LA
concentration and a maximal work load during the last 15 min
of the high intensity stage of the exercise protocol.

No indication was made that dietary journaling or compliance

was enforced. No mention was made of dietary accountability or
assessment aside from the assignment to the respective
conditions at the outset of each trial. This study involved a crossover design, yet no specifics were mentioned of a wash-out
period between trials. Its possible that in the absence of a
washout period that is, if the subjects immediately proceeded
from one diet to the next for each of the successive months
there could have been an order effect or carry-over effect

This endurance performance-enhancing capability a lowcarb/high-fat diet has been equivocal, and thus controversial,1
especially for high-intensity bouts. The most recent example
aside from the present study is Lima-Silva et als finding that
compared to a 70% CHO diet for 48 hours, a 25% CHO diet
lowered performance and total aerobic energy provision during
supramaximal exercise.2 Prior to that, Havemann et al found that
a 6-day high-fat diet (68% of total energy) followed by 1 day of
carb-loading (8-10 g/kg) lowered sprint power output compared
to a high-carb diet (68% of total energy).3 Prior to that, a review
by Phinney4 reported a similar phenomenon, stating that the
sprinting capability of his subjects on a ketogenic diet in an
earlier study5 remained constrained during the period of
carbohydrate restriction. This consistency of research showing
detrimental effects of low-carbohydrate dieting on high-intensity
work casts a strong shadow of caution against the presumption
that this diet would maximize endurance race performance, and
certainly performance in sports involving more even mix of
moderate and high intensities.

Alan Aragons Research Review June 2014

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Study limitations

Page 7

Prostate cancer and the influence of dietary factors

and supplements: a systematic review.
Mandair D, Rossi RE, Pericleous M, Whyand T, Caplin ME.
Nutr Metab (Lond). 2014 Jun 16;11:30. [PubMed]
BACKGROUND: Prostate cancer is the second most common
cause of cancer worldwide after lung cancer. There is increasing
evidence that diet and lifestyle plays a crucial role in prostate cancer
biology and tumourigenesis. Prostate cancer itself represents a good
model of cancer in which to look for chemopreventive agents due to
the high disease prevalence, slowly progressive nature, and long
latency period. Dietary agents have gained considerable attention,
often receiving much publicity in the media. AIM: To review the
key evidence available for potential chemopreventive nutrients.
METHODS: The methodology for this review involved a PubMed
search from 1990 to 2013 using the key-words "diet and prostate
cancer", "nutrition and prostate cancer", "dietary factors and
prostate cancer", "prostate cancer epidemiology", "prostate cancer
progression". RESULTS: Red meat, dietary fat and milk intake
should be minimised as they appear to increase the risk of prostate
cancer. Fruit and vegetables and polyphenols may be preventive in
prostate cancer, but further studies are needed to draw more solid
conclusions and to clarify their role in patients with an established
diagnosis of prostate cancer. Selenium and vitamin supplements
cannot be advocated for the prevention of prostate cancer and
indeed higher doses may be associated with a worse prognosis.
There is no specific evidence regarding benefits of probiotics or
prebiotics in prostate cancer. CONCLUSION: From the wealth of
evidence available, many recommendations can be made although
more randomised control trials are required. These need to be
carefully designed due to the many confounding factors and
heterogeneity of the population. SPONSORSHIP: None listed.

My commentary

inclusion to high-quality evidence, Scottish Intercollegiate

Guidelines Network (SIGN) clinical guidelines were employed.7
Here is their summary of the current evidence on the relationship
between dietary factors and supplements and risk of prostate
cancer:
1.

Well-done meat is associated with increased risk of prostate

cancer; consumption of red meat should be limited to <500
g per week.
2. High fat intake (mainly saturated fatty acids and linoleic
acid) appears related to increased risk of prostate cancer.
3. Milk intake appears to be associated with increased risk of
prostate cancer and its intake should be minimized.
4. Tomatoes and tomato-based products may be preventive in
early prostate cancer.
5. Cruciferous vegetables may be beneficial but they currently
cannot be advocated for prostate cancer prevention due to
the paucity of randomized trials.
6. Pomegranate may have a role in both prevention and
delaying progression of prostate cancer, but available data
are often conflicting.
7. Soy-containing products may be chemopreventive in
prostate cancer but further studies are warranted to clarify
their impact on PSA, testosterone, and sex-hormone binding
globulin levels in men with, or at risk of, prostate cancer.
8. Green tea appears a chemopreventive agent in prostate
cancer, but there is inconclusive benefit in patients already
with prostate cancer.
9. Selenium supplementation is not recommended in
chemoprevention of prostate cancer and very high levels
may indeed be pro-carcinogenic.
10. Vitamin A is not recommended as part of chemopreventive
diet to prevent prostate cancer.
11. Supplementation with vitamin D is not advocated unless the
patient is vitamin D deficient. High levels of vitamin D may
be associated with a worse prognosis.
12. There is no evidence regarding benefits of pre- or probiotics
in prostate cancer.

The present systematic review is important since according to

the American Cancer Society, prostate cancer is the second
leading cause of cancer death in men in the world (lung cancer is
in the lead), and its estimated that 1 in 7 men will be diagnosed
with prostate cancer in his lifetime.6 The authors assert that
prostate cancer is an ideal form of cancer for investigating
therapeutic interventions since it has a high prevalence, slow
progression, and long latency period. As such, its reasonable to
speculate that diet may play a significant role in the etiology of
this disease. The present review included observational and
experimental studies from 1990-2013. In an effort to limit

Here are the summary points that I found interesting. Point #1

isnt too surprising, but is not without challenge. Relatively
recently, Alexander et al conducted a meta-analysis of
prospective studies (15 red meat studies and 11 processed meat
studies) and did not find an association between red or processed
meat and prostate cancer.8 Point #3 is interesting because
although milk intake was found to increase prostate cancer risk,
its also been associated with a decrease in the risk for bladder
cancer9 and colon cancer (which is the second most prevalent
cancer worldwide).10 Point #11 mentions that vitamin D
supplementation is not necessary without deficiency. This is
reasonable, but its also noteworthy that the prevalence of
vitamin D deficiency (defined as sedum D3 levels 20 ng/mL)
among US adults is high: 41.6% overall, 69.2% in Hispanics,
and 82.1% in Blacks.11 The authors push the dial further by
stating that high vitamin D levels could increase the chances of
prostate cancer, but this should be viewed cautiously. Its based
on a single case-control study by Ahn et al, who found that
circulating vitamin D levels may be associated with increased
risk of prostate cancer at both the lowest and highest quintile.12
This U-shaped curve therefore indicates that prostate cancer risk
is not solely centered around high vitamin D levels, as implied
by this summary point (which fails to mention the risk
associated with low levels as well).

Alan Aragons Research Review June 2014

[Back to Contents]

As a systematic review, this paper doesnt lend itself well to the

typical breakdown of design strengths & limitations seen with
controlled interventions. What I find interesting about this paper
right off the bat is that its published in a journal produced by the
Nutrition & Metabolism Society, an organization dedicated to
promoting low-carbohydrate dieting and adjacently, high-fat
dieting with an emphasis on saturated fat. The irony about the
publication of the present paper in N&Ms journal is that much
of its findings and conclusions are at odds with the values and
objectives of the N&M Society. Ultimately, its refreshing to see
journals publish opposing outcomes and perspectives instead of
maintaining a single-track bias.

Page 8

The effects of water and non-nutritive sweetened

beverages on weight loss during a 12-week weight
loss treatment program.

statistically significant. Furthermore, decreases in total and

LDL-C were significantly greater in the diet beverage group. No
significant between-group differences were detected in waist
girth reduction, glucose, blood pressure, triglycerides, and urine
osmolality (indicating hydration status).

Peters JC, Wyatt HR, Foster GD, Pan Z, Wojtanowski AC,

Vander Veur SS, Herring SJ, Brill C, Hill JO. Obesity. 2014
May;22(6):1415-21. [Wiley Online]
OBJECTIVE: To compare the efficacy of non-nutritive
sweetened beverages (NNS) or water for weight loss during a
12-week behavioral weight loss treatment program.
METHODS: An equivalence trial design with water or NNS
beverages as the main factor in a prospective randomized trial
among 303 men and women was employed. All participants
participated in a behavioral weight loss treatment program. The
results of the weight loss phase (12 weeks) of an ongoing trial (1
year) that is also evaluating the effects of these two treatments
on weight loss maintenance were reported. RESULTS: The two
treatments were not equivalent with the NNS beverage treatment
group losing significantly more weight compared to the water
group (5.95 kg versus 4.09 kg; P < 0.0001) after 12 weeks.
Participants in the NNS beverage group reported significantly
greater reductions in subjective feelings of hunger than those in
the water group during 12 weeks. CONCLUSION: These
results show that water is not superior to NNS beverages for
weight loss during a comprehensive behavioral weight loss
program. SPONSORSHIP: The study was fully funded by The
American Beverage Association.
Study strengths
There is a scarcity of controlled interventions directly comparing
the weight loss effects of diet beverages versus water, so this
study is a welcome addition to the skeletal body of literature.
One of the strengths is study the relatively large sample size
(279 subjects completed the trial). Another strength was that the
diets were designed to achieve a realistic weight loss target of 12 lbs per week. Physical activity increases were targeted weekly
and tracked via subjects journaling as well as electronic means
(Body Media arm band). Adherence to the non-nutritive
sweetener (NNS) and water treatments was assessed via journal
records. Subjects attended weekly group weigh-in meetings led
by registered dietitians or clinical psychologists, and meeting
topics included self-monitoring, portion sizes, food labelreading, and physical activity.
Study limitations
Unfortunately, no reporting of dietary intake (in terms of total
energy and macronutrition) was made in the text. This makes it
impossible to assess how the treatments may have impacted
surrounding dietary intake (this would have been useful and
interesting data). The authors acknowledge that based on this
studys limited assessments, its impossible to elucidate a
mechanistic explanation for the results. I would add that
although waist circumference is a fair proxy for body fat change,
it would have strengthened this design to assess body
composition through a more sophisticated means such as DXA.

The chart above shows the differences in proportion of subjects

from each group who achieved at least a 5% weight loss from
baseline, with the diet beverage (NNS) group showing
significantly better results. Whats interesting and ironic is
how diet beverages have been speculated to contribute to weight
gain via increasing appetite. To quote a recent review by Yang:13
Sweetness decoupled from caloric content offers partial, but
not complete, activation of the food reward pathways.
Activation of the hedonic component may contribute to
increased appetite. [...] Lack of complete satisfaction, likely
because of the failure to activate the postingestive component,
further fuels the food seeking behavior. Reduction in reward
response may contribute to obesity.

The results of the present study fail to support Yangs

speculations; in fact, they indicate the opposite. The diet
beverage group not only lost more weight, but they also reported
a slight decline in hunger while the water group reported a slight
increase in hunger. This is the closest this study comes to
suggesting a mechanism by which the diet beverage group lost
more weight. Another interesting finding was the higher dropout rate in the water group (10% versus 5.8% in the diet
beverage group).
The present study extends recent findings of a 6-month trial by
Piernas et al,14 who found that compared to water, the diet
beverage group showed decreases in most caloric beverage
groups and specifically reduced more desserts over the course of
the trial. A unique strength of Piernas et als design was that the
subjects were held unaware of the study purpose until afterward.
This reduced the confounding potential of confirmation bias
effecting the subjects adherence to their assigned treatment.

The main finding was that the diet beverage group lost 1.85 kg
more weight than the water group, and this difference was

On a final note the beverage industrys sponsorship of the

present study has led many to dismiss its validity outright. This
is a bias in and of itself. Ive often said that if youre going to be
dismissive about industry-funded research, you cant be
selective about your dismissals you have to dismiss all of it
(which is a stupid thing since youd be willfully ignoring a huge
proportion of the body of nutrition research).

Alan Aragons Research Review June 2014

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Comment/application

Page 9

1.
2.

3.

4.
5.

6.
7.
8.

9.

10.

11.

12.

13.
14.

Burke LM, Kiens B. "Fat adaptation" for athletic

performance: the nail in the coffin? J Appl Physiol (1985).
2006 Jan;100(1):7-8. [PubMed]
Lima-Silva AE, Pires FO, Bertuzzi R, Silva-Cavalcante
MD, Oliveira RS, Kiss MA, Bishop D. Effects of a low- or a
high-carbohydrate diet on performance, energy system
contribution, and metabolic responses during supramaximal
exercise. Appl Physiol Nutr Metab. 2013 Sep;38(9):928-34.
[PubMed]
Havemann L1, West SJ, Goedecke JH, Macdonald IA, St
Clair Gibson A, Noakes TD, Lambert EV. Fat adaptation
followed by carbohydrate loading compromises highintensity sprint performance. J Appl Physiol (1985). 2006
Jan;100(1):194-202. [PubMed]
Phinney SD. Ketogenic diets and physical performance.
Nutr Metab (Lond). 2004 Aug 17;1(1):2. [PubMed]
Phinney SD, Bistrian BR, Evans WJ, Gervino E, Blackburn
GL. The human metabolic response to chronic ketosis
without caloric restriction: preservation of submaximal
exercise capability with reduced carbohydrate oxidation.
Metabolism. 1983 Aug;32(8):769-76. [PubMed]
American Cancer Society. What are the key statistics about
prostate cancer? Last updated March 12, 2014. [ACS]
Harbour R, Miller J. A new system for grading
recommendations in evidence based guidelines. BMJ. 2001
Aug 11;323(7308):334-6. [PubMed]
Alexander DD, Mink PJ, Cushing CA, Sceurman B. A
review and meta-analysis of prospective studies of red and
processed meat intake and prostate cancer. Nutr J. 2010 Nov
2;9:50. [PubMed]
Mao QQ, Dai Y, Lin YW, Qin J, Xie LP, Zheng XY. Milk
consumption and bladder cancer risk: a meta-analysis of
published epidemiological studies. Nutr Cancer. 2011
Nov;63(8):1263-71. [PubMed]
Ralston RA, Truby H, Palermo CE, Walker KZ. Colorectal
cancer and nonfermented milk, solid cheese, and fermented
milk consumption: a systematic review and meta-analysis of
prospective studies. Crit Rev Food Sci Nutr.
2014;54(9):1167-79. [PubMed]
Forrest KY1, Stuhldreher WL. Prevalence and correlates of
vitamin D deficiency in US adults. Nutr Res. 2011
Jan;31(1):48-54. [PubMed]
Ahn J, Peters U, Albanes D, Purdue MP, Abnet CC,
Chatterjee N, Horst RL, Hollis BW, Huang WY, Shikany
JM, Hayes RB; Prostate, Lung, Colorectal, and Ovarian
Cancer Screening Trial Project Team. Serum vitamin D
concentration and prostate cancer risk: a nested case-control
study. J Natl Cancer Inst. 2008 Jun 4;100(11):796-804.
[PubMed]
Yang Q. Gain weight by "going diet?" Artificial sweeteners
and the neurobiology of sugar cravings: Neuroscience 2010.
Yale J Biol Med. 2010 Jun;83(2):101-8. [PubMed]
Piernas C, Tate DF, Wang X, Popkin BM. Does dietbeverage intake affect dietary consumption patterns?
Results from the Choose Healthy Options Consciously
Everyday (CHOICE) randomized clinical trial. Am J Clin
Nutr. 2013 Mar;97(3):604-11. [PubMed]

Alan Aragons Research Review June 2014

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Page 10

But setting goals can cause four unwanted side-effects.6

Why you never seem to reach your weight loss goals
(and what to do about it).

1. It can encourage you to focus on details, often overlooking the

big picture.

By Armi Legge
____________________________________________________

Example: Obsessing about the weight on your scale, rather

than worrying about developing healthy habits like
preparing your own meals and exercising.

You want to get leaner.

Youve been taught that if you want to achieve something, you
need to set goals.
So you set a goal weight, and a deadline. You follow all of the
typical advice, using the S.M.A.R.T. criteria. You make your
goal

2. If you set multiple goals, it can encourage you to focus on the

easier ones, even if theyre less important.
Example: Trying to get extremely lean and ignoring
relationship problems, financial issues, etc, despite being
healthy.
3. It encourages short-term thinking.

Specific.
Measurable.
Actionable.
Realistic.
Time-Bound.
You write your goal on a piece of paper and tape it to your
fridge.

Example: Setting an aggressive weight loss goal, pushing

too hard to reach it, and then rebounding up to a higher
weight.
4. Goal-setting can encourage you to view yourself as
inadequate.

You setup a workout and nutrition plan to reach your goal. You
visualize your new body, with veins, abs, and popping muscles.
You think of how good it will feel to take your shirt off at the
pool.

Example: You feel like once you get lean, everything else
will be easier. Youll get more done at work, have more
success with the opposite sex, and have the confidence to
pursue your other goals. You feel like once you reach your
goal, then youll be happy, fulfilled, or accomplished but
youre still not good enough yet.

You follow your plan for a few weeks. You look forward to
every workout. You go to bed on time. You follow your diet
plan exactly.

The truth is that once you get lean, you just stop worrying about
getting lean it doesnt make the rest of your life easier.
Sometimes getting lean makes life worse.

But over time, your motivation wanes. You cut workouts short.
You stop following your meal plan. You stay up watching T.V.
and surfing Facebook.

Im not saying weight loss goals are bad, but theyre overrated,
incomplete, and sometimes counterproductive.

Your progress slows, and you become even less motivated to

reach your goal.

Focus on your daily actions instead of goals.

goals are good for planning your progress and systems are
good for actually making progress. James Clear

Eventually, you stop losing weight. And then you give up.
Thats how most diets end1,2 even for educated, motivated
people, like you.*

Most people set goals and then figure out a system to achieve
them. Thats ass-backwards.
If you want to lose weight, focus on the system, then your goals.

What happened?
You dont lack motivation, and you may be following a great
plan. The real problem was your goal.
Why most weight loss goals dont work.
Studies have shown that people who set goals tend to lose more
weight and keep it off longer.3,4

In the past, youve always focused on your goal weight, and

your new lifestyle as a necessary side-effect to reach it. Even
healthy, motivated people like bodybuilders fall into this trap.
Look at weight loss from the opposite perspective. Focus on
developing the right habits and lifestyle first, and look at fat loss
as a positive side effect.

Focusing on long-term goals can also increase peoples

motivation to stick to the plan.5

The problem is that a lot of people set ambitious weight loss

goals before theyve mastered the basic habits they need to get
lean.

Alan Aragons Research Review June 2014

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Page 11

Heres an example.
Sarah is about 20 pounds overweight, but she loves exercise. She
lifts weights four times per week, goes hiking on the weekends,
and rides her bike to and from work. She prepares almost all of
her meals at home, mostly from whole plants and animals. Sarah
wants to lose those 20 pounds, so she sets a goal weight of 110
pounds.
John has just finished college, and trains with his buddies
whenever its convenient. His schedule is flexible, so he works
out a lot. He eats most of his meals at restaurants, the only dish
he knows how to make is scrambled eggs, and he changes his
sleep schedule constantly.
John wants to prepare for his first bodybuilding show in a year.
Hes tried to get lean in the past, but he always rebounded and
binged. He still binges occasionally, but since hes bulking he
doesnt worry about it.
As a young guy, John doesnt have to work that hard to stay at
12% body fat. But he desperately wants to get down to 5%.
He creates a set of calorie and macronutrient guidelines, weighs
all of his food, adds more cardio, and stops hanging out with his
friends so he can focus on his diet. He sets weight benchmarks to
make sure hes on track for his competition.

In another study, students who visualized themselves studying

did much better than those who visualized themselves getting a
good grade on the test.(7)
Its good to have a general idea of what you want to look like,
but dont get too fixated on specific numbers.
Achieving your goals is a side effect of sticking to the right
habits, not the other way around.
If youre cutting, dont worry about hitting your goal weight at
first. I want to lose weight, is a fine goal to start. Train and eat
to lose the first 3 pounds, and then worry about the next 20.
This might feel uncomfortable at first. Youre used to deadlines
and exact numbers.
So, in the next AARR, Ill give you instructions on how to create
a system for achieving your goals that uses a habits-first
approach for weight loss.
* If youre reading AARR, youre ahead of 99% of everyone
else out there already. Pat yourself on the back.
__________________________________________________
My name is Armi Legge, and Im the editor of
EvidenceMag.com, a website that helps
obsessive people, like you, simplify their
health and fitness. If youd like to see some of
my best articles, click here.

On paper, John is much closer to his goal body than Sarah. But
thats not what matters.
How much do you think Sarah will need to change her lifestyle
to lose weight? Almost none. If shes a little more diligent about
her food intake, shell easily shed fat and probably keep it off
forever.

___________________________________________________

John, on the other hand, will have to work harder.

1.

He might reach his goal weight before Sarah, but what then? He
has no system for maintaining it, and hes probably going to
rebound up to a higher weight after hes ripped. Thats assuming
he can get his binge eating under control and get lean.

2.

Sarah focused on her lifestyle first, and then set a weight loss
goal. John did the opposite.

4.

References

3.

The right way to achieve your goals.

Theres enough research to show that goal-setting is a good idea.

5.

But research shows that people who visualize their goals as

already happening are less likely to achieve them.
In a series of studies, researchers found that people who
visualized themselves getting a good job ended up doing worse.
Two years after college, they had applied for fewer jobs, were
offered fewer jobs, and, if they got a job, were paid less. The
researchers found similar results for people who were trying to
pass an exam, find a romantic partner, or go through surgery.(7)
Alan Aragons Research Review June 2014

6.

7.

Wing RR, Phelan S. Long-term weight loss maintenance. Am J

Clin Nutr. 2005;82(1 Suppl):222S225S. [PubMed]
Wing RR, Hill JO. Successful weight loss maintenance. Annu
Rev Nutr. 2001;21:323341. [PubMed]
Bandura A, Simon K. The role of proximal intentions in selfregulation of refractory behavior. Cogn Ther Res.
1977;1(3):177193. doi:10.1007/BF01186792.
Brown MJ, Sinclair M, Liddle D, Hill AJ, Madden E,
Stockdale J. A systematic review investigating healthy lifestyle
interventions incorporating goal setting strategies for
preventing excess gestational weight gain. PLoS One.
2012;7(7):e39503.
doi:10.1371/journal.pone.0039503.s001.
[PLoS ONE]
Fujita K. Seeing the Forest Beyond the Trees: A ConstrualLevel Approach to Self-Control. Social and Personality
Psychology
Compass.
2008;2(3):14751496.
doi:10.1111/j.1751-9004.2008.00118.x. [Wiley Online]
Ordonez LD, et al. Goals Gone Wild: The Systematic Side
Effects of Over-Prescribing Goal Setting. Hardvard Business
School. 2009. Available at: http://ssrn.com/abstract=1332071
Pham LB, Taylor SE. From Thought to Action: Effects of
Process-Versus Outcome-Based Mental Simulations on
Performance. Pers Soc Psychol Bull. 1999;25(2):250260.
[P&SPB]

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Page 12

Whats causing the constant feuding between the

CICO and anti-CICO camps?
By Alan Aragon
____________________________________________________
So it begins...again!
Those of you living in a cave might be unaware that computer
software programmer-turned diet guru Jonathan Bailor (whose
methods I critiqued in the Nov 2013 issue of AARR) struck up a
partnership with Quest Nutrition. They launched a highproduction video series called The Quest to End the Calorie
Myth, but terminated it as it barely got off the ground. Quest
pulled the series due to an immensely negative response on
social media as well as directly on Quests Youtube channel
where the video was hosted. A major shortsight on Quests part
was not realizing that a large segment of their online market are
fitness and bodybuilding-oriented proponents of tracking
macronutrition and being flexible about the food sources
comprising the diet. IIFYMers (the If It Fits Your Macros
camp) were utterly enraged by Bailors video. This vicious
reaction was justified, just feast your eyes on the following
ridiculous quotes from the video:
Quality of calories, not quantity of calories, is the key to
healing your body and dropping fat.
Those sugar calories cause a hormonal clog that makes it
difficult for your body to burn fat regardless of how little you
eat or how much you exercise.
Eating sugar triggers a release of a hormone known as insulin
that pulls that sugar out of your blood stream, and takes it and
sores it in your fat for later use.

In the following discussion, Ill dig into what I feel are the main
elements that keep the calories in/calories-out (CICO) and antiCICO camps at war.
Straw men & false dichotomies
The underlying message of the video was that calories dont
matter as long as they arent carbohydrate calories. This is the
typical war cry of folks who have bought into the dogma that
carbohydrate intake is the prime culprit in the modern obesity
epidemic. A common thread among low-carb diet proponents is
a passionate dismissal of the CICO model of weight loss. A
calorie is NOT a calorie! they scream. What they mean is that
the macronutrients, as well as the foods that contain them, do not
have identical metabolic effects. Heres the irony: no one in the
CICO camp disputes that.
The anti-CICO camp is under the false presumption that their
opponents believe that the macronutrient composition of the diet
has no impact on body weight or body composition. Of course
this is absurd, given the well-established differences between
macronutrients in terms of metabolic and hormonal (thus
behavioral & appetite-regulating) effects. The anti-CICO camp
is also assumes that CICO proponents ignore diet quality. On the
contrary, I have not met a single CICO proponent who thinks
Alan Aragons Research Review June 2014

that diet quality doesnt matter for long-term health. Making the
leap toward thinking CICO folks completely dismiss the variable
effects of the macronutrients is likely due to the normal human
tendency to think in black-white terms. Speaking of which, its
very common for low-carb diet proponents to issue a false
dichotomy. Specifically, they present their case as if there are
only two choices that can be made: an Atkins-type diet, or some
variant of the Standard American Diet (SAD), which is
characterized by a high intake of fast food and refined
carbohydrates, among other things that are actually shared by the
Atkins model (i.e., a high intake of saturated fat).1 So, in the
eyes of the zealots, its either low-carb or high-crap, with no
other choices in-between. This type of false/binary thought is far
too common among preachers of the low-carb gospel.
Blatant denial of the evidence
Ill open this section with an excerpt from Wu et al in one of the
most diligent review papers Ive read in recent years:2
Data from meta-analyses of dietary intervention trials suggest
that some weight-loss diets, such as low-carbohydrate diets,
low-GI/GL diets, and the Mediterranean diet, might be
alternatives to conventional low-fat diets, especially for shortterm weight loss, but have great variability of long-term effects.
Moreover, the difference in weight loss among these diets is
only 1-2 kg or less, which appears to be of little clinical
significance. Thus, overweight and obese people can choose
many different weight-loss diets on the basis of their personal
preferences.

In other words, there is a wide range of diet types (in terms of

both macronutrition and food choices) that imparts similar
results. The weight loss differences in some cases reach a degree
of statistical significance, but in the long-term, these differences
are often too small to be meaningful in the real world.
Conveying the same message is an excerpt from conclusion of
the of a recent meta-analysis by Bueno et al:3
Undoubtedly, the present findings demonstrate that a VLCKD
has favourable effects on body weight and some cardiovascular
risk factors, as stated by Santos et al.(12); however, in the long
term and when compared with conventional therapy, the
differences appear to be of little clinical significance, although
statistically significant.

Keep in mind, these conclusions were reached despite the

examination of diets that did not match protein (I really wanted
to add an exclamation point here). In comparison studies, lowcarbohydrate diets almost always exceed the protein content of
their low-fat comparators by a substantial margin; usually about
40%. This gives the low-carb treatments predictable advantages
in terms of LBM-preservation, satiety, and thermic effect. The
lack of a low-carb advantage for clinical outcomes (not just body
composition improvement) has been seen repeatedly in
controlled interventions that match adequate protein.4,5
Studies conducted in metabolic wards where all food and drink
is provided and monitored have the highest level of control since
the subjects have the least leeway for noncompliance. This type
of research is the antithesis of observational research, and is a far
cry from the confounding potential inherent with free-living
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designs with self-reported intake. A friend and colleague of mine

named Anthony Colpo has done the daunting diligence of
compiling 26 metabolic ward studies comparing isocaloric diets
with widely varying carbohydrate proportions and a minimum 3week duration.6 Of these 26 studies, only 3 showed a significant
weight loss advantage to the lower-carb diets. None of the
studies showed a significant fat loss advantage.
Humorously, high-profile low-carb absolutists have dismissed
the metabolic ward studies. Quoting NuSI (an organization
headed by well-known low-carb/ketogenic diet advocates Gary
Taubes and Peter Attia):7
Metabolic ward studies typically used diets so hypocaloric that
the control group was severely carbohydrate-restricted
compared to a usual diet. [...] Under these circumstances, any
differences might be too modest to detect.

The above quote is essentially dismissing all controlled,

isocaloric studies comparing different carbohydrate content as
long as the conditions are hypocaloric (since the higher-carb
conditions will still not contain a high amount of carbs). This is
an absurd dismissal since the issue at hand is the impact of
carbohydrate within the context of when people are, um...dieting
to lose weight.
Nevertheless, there indeed is metabolic ward research involving
non-severe caloric restriction. A 4-week study by Stimson et al
included a subgroup that compared 2000 kcal of a high-fat, lowcarb diet (30% P, 4% C, 66% F) with a moderate-fat, moderatecarb diet (30% P, 35% C, 35% F).8 This amounts to a
comparison of 80 g versus 175 g carbohydrate. No significant
differences were seen in fat or weight loss between groups. Is it
fair to use NuSIs logic and dismiss this because 175 g is too
carb-restricted to be considered worthy of detecting differences
compared to the 80 g treatment? That question was rhetorical.
Although not a metabolic ward study, Johnston et al carried out
a controlled, isocaloric, adequate protein-matched comparison of
a ketogenic (33 g carb) versus non-ketogenic diet (157 g carb)
and found no weight or fat loss advantage of the ketogenic diet.5
Once again, is it logical to dismiss these results because the nonketogenic treatment wasnt high-carb enough? Thats just
madness.
Collectively, the well-controlled evidence does not support the
idea that carbohydrate is inherently obesogenic or inhibitory to
fat loss at least compared to fat. This means that any proposed
mechanism thereof (insulin flux or other) is irrelevant.
Over-reliance on anecdotes
Personal testimony or anecdote is a common way that low-carb
absolutists attempt to support their case. Anecdotes sit at the
bottom of the evidence hierarchy because they are subject to
multiple internal and external threats to validity. Anecdotes are
often merely case studies of the fulfillment of confirmation bias.
Nevertheless, low-carb zealots love to lean on their personal n=1
(single-subject) case studies, and kid themselves into thinking
they can be presented as objective evidence.
A popular example of n=1 dependence is personal fitness trainer
Sam Feltham, who self-reportedly ate over 5000 kcals per day of
a low-carb, high-fat diet for 21 days, and lost 3 cm of waist girth
Alan Aragons Research Review June 2014

while gaining 1.3 kg. While this is an interesting case study, it

cant be waved around as irrefutable evidence of the miraculous
effects of this diet.
On the other end of the n=1 spectrum we have Chris Voigt,
Executive Director of the Washington State Potato Commission
Voigt ate nothing but potatoes the equivalent of 20 of them per
day (amounting to roughly 2200 kcal) for 60 days. He lost 21
lbs, lowered his fasting glucose levels, cut his triglycerides
nearly in half, and dramatically decreased his LDL-C while
slightly increasing his HDL-C. Thats pretty impressive, and it
brazenly violates every rule of low-carb dieting dogma, down to
his low fat intake of roughly 2 tbsp/day from oil plus the trace
amounts of fat inherent in potatoes. Once again, this is an
interesting case study, but its far from definitive evidence of the
universal superiority of a particular diet.
More on anecdotes and personal testimony: EAS, a sports
nutrition supplement company, runs an ongoing transformation
contest called the Body-for-LIFE Challenge, which began in
1997. Since then, theyve racked up a massive set of beforeafter pics of contestants. On their success stories page, you can
view the pics of nearly 200 transformations. All of them are
impressive in their own right, especially the transformations
from the inaugural contest in 1997 (pics here). So, did these
people follow an all-potato diet? What about a low-carb/high-fat
diet thats widely preached as the savior of humanity? The
answer is neither. The Body-for-LIFE plan is high-protein,
moderate-carb, and low-fat similar to the dietary model that
was popular among competitive bodybuilders in the 1980s and
onward. Expectedly, 2 of the 6 meals per day are EAS meal
replacement products.
To reiterate my point, anecdotes are a dime-a-dozen, and theyre
inevitably subjective, so take these personal testimonies with a
grain of salt. None of the aforementioned case studies can
legitimately claim to be the one size that fits all.
Ignorance of what happens when calories disappear
When folks embark upon a journey to eat more than their
predicted maintenance calories and either maintain or actually
lose weight, they often conclude that CICO is BS. This is yet
another failed line of thinking, since the energy-out side of the
equations still counts in the CICO model, regardless of its
difficulty to predict. An increase in energy expenditure occurs
concurrently with an increase in training volume and/or
intensity. This is a common occurrence alongside the attempt to
eat more. Why? If you have more stored glycogen (the body can
synthesize glucose and in turn glycogen from non-carbohydrate
food sources9) or incoming/postprandial calories, youll tend to
put more into your workouts, since youll have the spare energy
(literally). This decreases the imposed surplus right off the bat.
A lack of net gains in scale weight can also occur through a
simultaneous reduction of fat weight and gain in lean weight.
This is yet another common phenomenon, particularly in novice
and intermediate trainees undergoing novel and more demanding
training stimuli (especially alongside an increase from suboptimal to optimal protein intake).
The other ways calories disappear through routes that are not
necessarily conscious or voluntary. As Ive discussed in recent
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articles, non-exercise activity thermogenesis (NEAT) has been

seen by Levine et al to increase as much as nearly 700 kcal per
day as a result of overfeeding 1000 kcals beyond predicted
maintenance.10 Changes in occupation can also drastically alter
NEAT. In a subsequent review, Levine reported that changes in
leisure-time NEAT and occupational NEAT can increase energy
expenditure by as much as 1000-1200 kcal per day,
respectively.11 As recently seen in Antonio et al,12 an additional
800 kcal of protein seemingly disappeared into thin air.
However, the reality was likely a combination of a greater
thermic effect, an increase in NEAT, a certain margin of
reporting error, and greater excretory losses.
Excretion is a rarely discussed yet common route for the
disappearance of ingested calories. Excreted calories through
urine or feces are essentially unused, hence the necessary
distinction between gross energy and metabolizable energy.
When folks increase fat intake and concurrently increase their
fiber intake, which in low-carb regimes is commonly done
through eating more non-starchy vegetables, nuts, seeds, and
low-sugar fruits like berries, an interesting thing happens: they
lose significantly more fat through feces. For example,
Kristensen et al recently observed that the supplementation of
15.6 g flaxseed fiber per day caused a 50% increase in fecal fat
output, and a corresponding 23% energy excretion compared to
the control condition.13 Combine this with the laxative effect of
beverages such as coffee, and its a great recipe for ramping up
energy lossesstraight into the toilet.
Selective prejudice against the funding source
Low-carb zealots selectively embrace or dismiss research not
just according to whether the results fit their pre-existent beliefs,
but also according to whether or not they feel the sponsor is part
of a conspiracy. Its common to see this camp scroll down to the
studys funding source while skipping all the details, and making
a flash judgment of the studys validity. This is a bias in and of
itself, and its perpetrated by both camps. Its just as foolish to
automatically dismiss research funded by the sugar, grain, and
beverage industries as it is to dismiss research funded by the
beef, egg, fish, nut, etc. industries as well as everything funded
by the Atkins Foundation (and similar entities). Ill close with an
excerpt from a recent editorial by Binks:14
In summary, what are the best practices for ensuring a strong,
unbiased body of obesity research? Certainly not refusing
funding from those who wish to collaborate with scientists in
becoming part of the solution; absolutely not by launching
unsubstantiated attacks on reputable scientists with
longstanding records of ethical conduct and meaningful
scientific contribution; rather, it is first by giving funding source
its proper position among many possible and equally important
threats to objectivity and implementing safeguards to protect
against such bias (and worse yet malfeasance). Second, we
need to redouble our efforts to adhere to the basic principles of
good science like reproducibility, replicability and other core
evaluative procedures that ensure objective and reliable
scientific reporting. Finally, we need to work toward open
access to data regardless of its source. This will require the
cooperation of those in the scientific community and among
potential sources of funding. Ultimately, this type of
Alan Aragons Research Review June 2014

transparency regardless of funding source will deliver a more

robust and complete body of evidence.

References
1. Hsu TM1, Kanoski SE2. Blood-brain barrier disruption:
mechanistic links between Western diet consumption and
dementia. Front Aging Neurosci. 2014 May 9;6:88.
[PubMed]
2. Wu H, Wylie-Rosett J, Qi Q. Dietary Interventions for
Weight Loss and Maintenance: Preference or Genetic
Personalization? Curr Nutr Rep. 2013 Dec;2(4):189-98.
[Springer Link]
3. Bueno NB, de Melo IS, de Oliveira SL, da Rocha Ataide T.
Very-low-carbohydrate ketogenic diet v. low-fat diet for
long-term weight loss: a meta-analysis of randomised
controlled trials. Br J Nutr. 2013 Oct;110(7):1178-87.
[PubMed]
4. Soenen S, Bonomi AG, Lemmens SG, Scholte J, Thijssen
MA, van Berkum F, Westerterp-Plantenga MS. Relatively
high-protein or 'low-carb' energy-restricted diets for body
weight loss and body weight maintenance? Physiol Behav.
2012 Oct 10;107(3):374-80. [PubMed]
5. Johnston CS, Tjonn SL, Swan PD, White A, Hutchins H,
Sears B. Ketogenic low-carbohydrate diets have no metabolic
advantage over nonketogenic low-carbohydrate diets. Am J
Clin Nutr. 2006 May;83(5):1055-61. [PubMed]
6. Colpo A. Table 1, Chapter 1, in: The Fat Loss Bible. Selfpublished, 2012. [Amazon]
7. Nutrition Science Initiative. Review of the literature, 2012.
[NuSI]
8. Stimson RH, Johnstone AM, Homer NZ, Wake DJ, Morton
NM, Andrew R, Lobley GE, Walker BR. Dietary
macronutrient
content
alters
cortisol
metabolism
independently of body weight changes in obese men. J Clin
Endocrinol Metab. 2007 Nov;92(11):4480-4. [PubMed]
9. Berg JM, Tymoczko JL, Stryer L. Section 16.3Glucose Can
Be Synthesized from Noncarbohydrate Precursors. In:
Biochemistry. 5th edition. New York: W H Freeman; 2002.
[NCBI Bookshelf]
10. Levine JA, Eberhardt NL, Jensen MD.. Role of nonexercise
activity thermogenesis in resistance to fat gain in humans.
Science. 1999 Jan 8;283(5399):212-4. [PubMed]
11. Levine JA, Vander Weg MW, Hill JO, Klesges RC. Nonexercise activity thermogenesis: the crouching tiger hidden
dragon of societal weight gain. Arterioscler Thromb Vasc
Biol. 2006 Apr;26(4):729-36. [PubMed]
12. Antonio J, Peacock CA, Ellerbroek A, Fromhoff B, Silver T.
The effects of consuming a high protein diet (4.4 g/kg/d) on
body composition in resistance-trained individuals. J Int Soc
Sports Nutr. 2014 May 12;11:19. [PubMed]
13. Kristensen M, Jensen MG, Aarestrup J, Petersen KE,
Sndergaard L, Mikkelsen MS, Astrup A. Flaxseed dietary
fibers lower cholesterol and increase fecal fat excretion, but
magnitude of effect depend on food type. Nutr Metab (Lond).
2012 Feb 3;9:8. [PubMed]
14. Binks M. Judge the science, not the funding source. Int J
Obes (Lond). 2014 May;38(5):625. [PubMed]

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It is good to have an end to journey toward; but it is the journey

that matters, in the end. Ernest Hemingway

If you have any questions, comments, suggestions, bones of

contention, cheers, jeers, guest articles youd like to submit, or
any feedback at all, send it over to aarrsupport@gmail.com.

Alan Aragons Research Review June 2014

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