THE JOYFUL REDUCTION OF UNCERTAINTY

Recommendations vs. Guidelines

Medicine loves guidelines. But everywhere else, guidelines are still underappreciated.

Consider a recommendation, like “Try Lexapro!” Even if Lexapro is a good medication, it might not be a good medication for your situation. And even if it’s a good medication for your situation, it might fail for unpredictable reasons involving genetics and individual variability.

So medicine uses guidelines – algorithms that eventually result in a recommendation. A typical guideline for treating depression might look like this (this is a very over-simplified version for an example only, NOT MEDICAL ADVICE):

1. Ask the patient if they have symptoms of bipolar disorder. If so, ignore everything else on here and move to the bipolar guideline.

2. If the depression seems more anxious, try Lexapro. Or if the depression seems more anergic, try Wellbutrin.

3. Wait one month. If it works perfectly, declare victory. If it works a little but not enough, increase the dose. If it doesn’t work at all, stop it and move on to the next step.

4. Try Zoloft, Remeron, or Effexor. Repeat Step 3.

5. Cycle through steps 3 and 4 until you either find something that works, or you and your patient agree that you don’t have enough time and patience to continue cycling through this tier of options and you want to try another tier with more risks in exchange for more potential benefits.

6. If the depression seems more melancholic, try Anafranil. Or if the depression seems more atypical, try Nardil. Or if your patient is on an earlier-tier medication that almost but not quite works, try augmenting with Abilify. Repeat Step 3.

7. Try electroconvulsive therapy.

The end result might be the recommendation “try Lexapro!”, but you know where to go if that doesn’t work. A psychiatrist armed with this guideline can do much better work than one who just happens to know that Lexapro is the best antidepressant, even if Lexapro really is the best antidepressant. Whenever I’m hopelessly confused about what to do with a difficult patient, I find it really reassuring that I can go back to a guideline like this, put together by top psychiatrists working off the best evidence available.

This makes it even more infuriating that there’s nothing like this for other areas I care about.

Take dieting. Everybody has recommendations for what the best diet is. But no matter what diet you’re recommending, there are going to be thousands of people who tried it and failed. How come I’ve never seen a diet guideline? Why hasn’t someone written something like:

1. Try cutting carbs by X amount. If you lose Y pounds per week, the diet is working. If not, you’re probably resistant to cutting carbs because [two hours of mumbling about insulin] and you should move on to the next tier.

2. Try cutting fat by X amount. If you lose Y pounds per week, the diet is working. If not, you’re probably resistant to cutting fat because [two hours of mumbling about leptin], and you should move on to the next tier.

And so on until Step 7 is “get a gastric bypass”.

I agree nobody can ever make a perfect algorithm that works for all eventualities. But still. Surely we can do better than “Try the Paleo diet! I hear it’s great!”

What information do guidelines carry beyond a recommendation?

First, they have more than one recommendation. It may be that the Paleo diet is the best, but the guidelines will also include which is the second-best, third-best, et cetera.

Second, because they have more than one recommendation, they can tailor their recommendation to your specific circumstances. The person with depression and comorbid anxiety may want to start with Lexapro; the person whose main symptom is tiredness may want to start with Wellbutrin. Since I love bread, does that mean I should avoid carb-cutting diets? Does that mean it’s extra-important that I cut carbs? Does it not matter, and really it depends on whether I have a family history of diabetes or not?

Third, they acknowledge that some people might need more than one recommendation. If you hear “try the Paleo diet”, and then you try it, and it doesn’t work, you might believe you’re just a bad dieter, or that all diets are scams, or something like that. Guidelines implicitly admit that everyone is different in confusing ways, that something that’s expected to work for many people might not work for you, and that you should expect to have to try many things before you find the right one.

Fourth, because they admit you may need to try more than one thing, they contain (or at least nod at) explicit criteria for success or failure. How long should you try the Paleo diet before you decide it doesn’t work? How much weight do you need to lose before it qualifies as “working”? If it’s been three months and I’ve lost four pounds, should you stick with it or not?

Fifth, they potentially contain information about which things are correlated or anticorrelated. The depression guidelines make it clear that if you’ve already tried Lexapro and Zoloft and they’ve both failed, you should stop trying SSRIs and move on to something with a different mechanism of action. If I’ve tried five carb-cutting diets, should I try a fat-cutting diet next? If I hate both Mexican food and Chinese food, is there some other category of food which is suitably distant from both of those that I might like it? Guidelines have to worry about these kinds of questions.

My impression is that once you understand a field really well, you have something like a Guideline in your mind. I think if nobody had ever written a guideline for treating depression, I could invent a decent one myself out of everything I’ve pieced together from word-of-mouth and common-sense and personal experience. In fact, I think I do have some personal guidelines, similar to but not exactly the same as the official ones, that I’m working off of without ever really being explicit about it. Part of the confusion of questions like “What diet should I do?” is sorting through the field of nutrition until you can sort of imagine what a guideline would look like.

So why don’t people who have more knowledge of nutrition make these kinds of guidelines? Maybe some do. I can’t be sure I haven’t read dieting guidelines, and if I did I probably ignored them because lots of people say lots of stuff.

But I think that’s a big part of it – making guidelines seems like a really strong claim to knowledge and authority, in a way that a recommendation isn’t. Some idiot is going to follow the guidelines exactly, screw up, and sue you. I just realized that my simplified-made-up depression guidelines above didn’t have “if the patient experiences terrible side effects on the antidepressant, stop it”. Maybe someone will follow those guidelines exactly (contra my plea not to), have something horrible happen to them, and sue me. Unless you’re the American Psychiatric Association Task Force or someone else suitably impressive, your “guidelines” are always going to be pretty vague stuff that you came up with from having an intuitive feel for a certain area. I don’t know if people really want to take that risk.

Still, there are a lot of fields where I find it really annoying how few guidelines there are.

What about nootropics? I keep seeing people come into the nootropics community and ask “Hey, I feel bad, what nootropic should I use?” And sure, eventually after doing lots of research and trying to separate the fact from the lies, they might come up with enough of a vague map of the area to have some ideas. But this is an area where “Well, the first three things you should try for anxiety are…” could be really helpful. And I don’t know of anything like that – let alone something that tells you how long to try before giving up, what to look for, etc.

Or let’s get even broader – what about self-help in general? I don’t really believe in it much, but I would love to be proven wrong. If there were a book called “You Are Willing To Devote 100 Hours Of Your Life To Seeing If Self-Help Really Works, Here’s The Best Way For You To Do It”, which contained a smart person’s guidelines on what self-help things to try and how to go about them, I would absolutely buy it.

This entry was posted in Uncategorized and tagged . Bookmark the permalink.

Leave a Reply

274 Responses to Recommendations vs. Guidelines

  1. RavenclawPrefect says:

    I really like this categorization; I’m realizing that a lot of the reason I’ve enjoyed the more advice-y posts on here (e.g. this) is because they tend to skew in the guideline direction of things.

    This seems very similar to flowcharts in terms of the kind of structure you want here? Searching for “flowchart [topic]” might pull up some decent results for this kind of thing; I know I’ve seen some good ones on e.g. picking a first programming language to learn, although they’re usually lacking in terms of “here’s what to do if that failed” other than “try a different branch.” (And where there isn’t anything available out there, the comments section ought to have a fair bit of combined knowledge to produce some useful first approximations.)

    • pkinsky2014 says:

      To follow the programming language analogy, flowcharts are similar to pure functions (eg: \x -> x + 1) in that they are evaluated entirely based on their input, which in these cases would be the user’s state at the time they traverse the flowchart. Medical guidelines as described above, however, can include stages that interact with the outside world. You can’t just follow an arrow on a flowchart, you actually need to run an experiment (prescriptions, dietary interventions, etc). These are thus most similar to functions that produce an action (or series of actions) acting on the outside world (eg: \x -> print x).

      • RavenclawPrefect says:

        I think you can run an experiment while following a flowchart; there’s no reason you can’t have a “Did that work? Y/N” box, and searching explicitly for depression the first thing I found does this (though it’s not super informative or actionable). I’d agree that most flowcharts I’ve seen don’t do this as much as could be useful, though.

        • Eternaltraveler says:

          The reason there aren’t nice flowcharty guidelines for nutrition, nootropics, and self help in general is because the data is not sufficient to make them. It is still very much an active debate if nootropics (other than stimulants) do anything for any healthy people. And for some authority to make a consensus guidline over when the paleo diet is appropriate they would first have to agree it is ever appropriate. Drugs like escitalopram and bupropion achieve this first step by completing a phase 3 clinical trial.

    • fr8train_ssc says:

      I just realized that my simplified-made-up depression guidelines above didn’t have “if the patient experiences terrible side effects on the antidepressant, stop it”. Maybe someone will follow those guidelines exactly (contra my plea not to), have something horrible happen to them, and sue me. Unless you’re the American Psychiatric Association Task Force or someone else suitably impressive, your “guidelines” are always going to be pretty vague stuff that you came up with from having an intuitive feel for a certain area. I don’t know if people really want to take that risk.

      Likewise, I saw significant omissions in that chart, where if one wants $$$ by updating legacy systems, or is a hobbyist that would like to learn how it was done on legacy systems (and by that I don’t mean the hard way, I mean here’s a 386 have fun) then C would be the best first language to learn…

      • poignardazur says:

        My school teaches C first, precisely because it gives students a good idea of the internal layout of the machine they’re working on.

      • Anthony says:

        The programming flowchart didn’t have “Because I want to perform calculations that are too hard for Excel”, which is the thing that actually got me to start learning R.

        Why R? Because it’s free (as in beer), has a decent IDE, works on Windows, and doesn’t require Office. (I wouldn’t be able to convince my boss to let me expense Visual Studio.)

  2. joncb says:

    I can relate to this.

    If you talk to the IT consultants out there, it’s almost a certainty that the initial answer to any given question is “It depends” (A couple of the IT meetups that I go to have explicit humour around this, no-one laughs harder than the consultants). The bad consultants (that you should stop paying) will treat that as a conversation stopper. The good ones start asking questions.

    I wonder how much of this is because it’s difficult to translate from implicit to explicit and how much of this is about job security.

    • Antistotle says:

      A firearms instructor I take classes from once said that “For the beginner it is always never. As you learn it becomes sometimes, maybe. For the master it becomes ‘it depends'”.

      • nameless1 says:

        The beginner programmer is never allowed to make changes in a live system. The advanced programmer may do changes that do not modify data, pretty sure adding a column to a report cannot really screw things up beyond that report. The master understands that even adding a column to a report could mean something like a performance hit and deadlocking other users. But he says fuck it and does it anyway because he is paid, not that well, for solving problems users and managers know about and not for avoiding causing problems they don’t know about. In fact, he can fully admit three days later that his change caused the performance hit and fix it and only gain kudos – users and managers do not see this as a mistake as they have no idea if it was foreseeable or not, but he gets kudos for promptly reacting and fixing it.

        I suppose it does not work with firearms. “Yes I accidentally shot that guy but I gave him expert first aid afterwards!” is probably not going to be treated that “thank you for your prompt fix!” way.

    • nameless1 says:

      When a Microsoft Dynamisc NAV specialist is asked during a sales demo “Hey, can I see in this software which purchase orders I received are waiting for quality control? Jim in purchasing would really like that because salespeople are asking him where their stuff is?” the following thoughts are racing through his mind:

      1) “Technically speaking, in the current status of the software as released, it would be a no.”

      2) “But it would take me 60 seconds to make a dropdown field “Quality Control Status: Not yet started,Passed,Failed” in fact I may just do this for free for the next sales demo we are doing here so maybe I should just stall now?

      3) “But that wouldn’t be a proper solution, I should look into exactly what data they need for it, write a use case, develop it, document it, do some acceptance testing and then either charge them $3000 because that took 3 days or do it for free and try to get Microsoft to certify this as a part of an add-on we can sell licences for. So saying yes now would be actually a lie? What should I say? I cannot say no, he will take it as impossible when in reality I could get it done on a basic level while he goes out taking a pee.”

  3. Sniffnoy says:

    I believe the process of getting at and making explicit experts’ implicit decision-making algorithms is known as “knowledge engineering”. Might be something worth looking up.

  4. Squirrel of Doom says:

    Well, who makes these “guidelines” in the medical field, what are their incentives, support structure etc, and what part(s) of that are missing in the dietary and other fields?

    Are there competing guidelines? How do they get updated? Who did the first ones?

    • Froolow says:

      I write NICE guidelines for a living. Happy to answer questions on the process that won’t identify me specifically.

      NICE is a UK government QANGO with the remit to produce evidence-based guidelines on topics referred to them by the UK’s Department of Health. I don’t think America has anything similar, especially because NICE considers both clinical and cost-effectiveness and considering cost-effectiveness is illegal in America. Guidelines are developed in a big multidisciplinary team of (usually) three systematic reviewers, an information scientist and health economist, around 10-15 clinical experts in the field and a bunch of project management types. They normally take about two years to produce from referral to publication.

      We are paid just for turning up to work, so we have no incentive to spice up our guidelines with anything but what we think is the truth (although I imagine if we repeatedly produced guidelines that were utterly wrong or incendiary towards government policy we would find our funding cut). There is quite a large element of ensuring no stakeholder in a particular guideline feels left out in a way that might invite a later legal challenge though, so often the sorts of things we perform systematic reviews on reflect public concern rather than strict clinical necessity. I don’t really understand what you mean by ‘support structure’, but I guess it helps that most clinicians agree that what we produce is usually helpful, which means that we can weather the occasional controversial recommendation.

      In general there are two ways guidelines are produced; a systematic method favoured by NICE, SIGN and other evidence-based bodies and a consensus-based method favoured by professional medical groups. I think the NICE method is unequivocally superior, but it has the drawback that you can only produce guidelines in fields where there is already a lot of evidence. Obviously there is no equivalent of NICE in the dietary field, but there is an equivalent of NICE in the field of – say – social care, but guidelines are much less well regarded there and I am not sure why. Equally there is no reason at all why the British Society of Nutritionists couldn’t produce their own consensus-based guidelines as other professional bodies might, except perhaps a general distrust of guidelines that seems to persist in all but the hardest of sciences. I think you’ve really put your finger on the most important question here; there needs to be a certain acceptance of guidelines as a process before it is worth spending public money on producing the really gold-standard ones, and I don’t know why medicine is so far ahead of other areas.

      There are no competing guidelines to NICE, realistically. NICE only makes recommendations it can justify on the basis of evidence or overwhelming clinical consensus, which means that any guideline which contradicts a NICE guideline is either wrong or out of date (or the NICE guideline is out of date, perhaps). However there are a lot of guidelines which fill in gaps where NICE can’t make recommendations because of this restriction – for example a lot of NICE guidelines explain how to treat a particular condition but not identify it in primary care, and so Royal College of General Practitioners guidelines are often used by GPs to fill the gap. The most recent actual clash I know of is that a few years ago the World Health Organisation produced a guideline recommending a different blood-glucose level at which to begin screening for gestational diabetes, based on a slightly different statistical interpretation of the evidence. But both guidelines are sufficiently uncertain on the point that they are not really contradictory, and neither guideline development group is paid more if their guideline is adopted so they are not really ‘competing’.

      Every four to six years every guideline is re-read by the ‘Updates Team’ at NICE. If clinical practice has changed significantly, new evidence has been published or there is public interest in updating the guideline for other reasons then the process starts again; either the guideline will be developed completely from scratch again or certain bits of the guideline will be re-reviewed and the recommendations there get updated. EDIT: Adding just because it is interesting; this process also identifies gaps in what you might consider to be a ‘big flowchart of all human disease’. So we might have a guideline looking at asthma in children, and a guideline looking at asthma in the elderly – this process would identify that there is a gap which might be usefully filled and commission a guideline on that topic.

      I don’t know who did the first one, but I think NICE were the first government body to produce one for the explicit purpose of considering clinical and cost-effectiveness together.

      Like all government-aligned work there is a lot that I think we could do more efficiently, but I’m very proud of what we achieve given the many ways guidelines are superior to simple recommendations.

      • Thanks for this detailed and informative comment.

      • eggsyntax says:

        What an incredibly awesome job! Modulo the usual bullshit that comes with working in a public-sector bureaucracy (which I know all too well first-hand) that sounds like just enormous amounts of fun.

      • Squirrel of Doom says:

        Thanks!

        So by this account, guidelines are products of large, well financed and prestigious institutions. Not individual experts willing to share their knowledge. So the reason we only see them in medicine, might be that it’s the only field big and prestigious enough to support them.

        I am curious though: NICE makes guidelines for the UK. Aren’t there other bodies making guidelines for other countries? Comparing them might be very interesting!

        • Froolow says:

          Yes – some countries make their own and some countries adapt existing guidelines (often NICE in the EU, don’t know about the US). These guidelines will sometimes differ for obvious reasons (like a country has a different cost-effectiveness threshold), and I suspect they will also often differ for reasons that are difficult to explain without invoking the ‘animal spirits’ of the medical establishment.

          I don’t know of any attempt to compare guidelines across countries, but you’re right that such an attempt would be absolutely fascinating!

      • behrangamini says:

        Could you provide a citation for “considering cost-effectivenes is illegal in the US?”

        I work on a healthcare guideline-writing sub-committee in the US, and while we are instructed not to consider cost, I was under the impression that that was a preference of the organization, not a law.

        Thanks

        • Edward Scizorhands says:

          It’s not out-and-out illegal, but every time the government funds anything related to health outcomes, they nearly always tack on a rider that says to ignore cost effectiveness. Here’s one example:

          https://www.nytimes.com/2014/12/16/upshot/forbidden-topic-in-health-policy-debate-cost-effectiveness.html

          In fact, we in the United States are so averse to the idea of cost effectiveness that when the Patient Centered Outcomes Research Institute, the body specifically set up to do comparative effectiveness research, was founded, the law explicitly prohibited it from funding any cost-effectiveness research at all. As it says on its website, “We don’t consider cost effectiveness to be an outcome of direct importance to patients.”

          • armorsmith42 says:

            Wow… I had not realized this. Is it odd that I’m feeling like this seems the easy answer to the question of “Why is cost disease?” ?

      • Simon_Jester says:

        Wait, someone actually named a QANGO “NICE” in the United Kingdom?

        O_o

        https://en.wikipedia.org/wiki/That_Hideous_Strength

  5. Michael Watts says:

    Why are we calling these “guidelines” rather than “flowcharts”?

    • textor says:

      I assume the difference is that guidelines were independently introduced, might not have a neat visual representation i.e. a chart, and are prescriptive rather than descriptive. Besides, the «guideline» is a good enough word – if a bit narrow, since here we’re really talking about forking paths. But sure, flowchart can represent such a guideline as well.

    • taradinoc says:

      Or “algorithms”? I mean…

      So medicine uses guidelines – algorithms that eventually result in a recommendation.

      An algorithm is literally just a finite set of steps that eventually produces a result.

      Perhaps the difference is that the result produced by a guideline is specifically a recommendation — a prediction about what might work. It tells you where to look next, but that might not be where you end up.

      When Jack Sparrow said in Pirates of the Caribbean that the pirate code is “more what you’d call guidelines than actual rules”, he meant (roughly) that the answer you get by consulting the code isn’t guaranteed to be correct, and a pirate with more experience may realize the correct answer is to do something else.

      • Simon_Jester says:

        Good point. The humor there being, mainly, that the “correct” answer is being judged within the standards used by pirates. That is to say, by ruthless, amoral men who have made a career out of committing predatory violence against all and sundry. “The rules are rules until I should get away with breaking them because utilitarian reasons” becomes “the rules are rules until I CAN get away with breaking them…”

  6. userfriendlyyy says:

    Naked Capitalism had a link to what you are looking for on diets a month or two ago but since they crapify google I can’t find it. It scientifically went through a bunch of diets; pros and cons of them, but the main takeaway was minimize your consumption of processed foods.

    • MNH says:

      There’s something that feels ironic about summarizing a “main takeaway” here

    • Aapje says:

      @userfriendlyyy

      My googling shows that Naked Capitalism has blamed processed foods for the last couple of years, so it seems that they already had drawn that conclusion. Not that this makes them wrong, however, it makes me doubt whether they actually did an unbiased comparison.

      • sclmlw says:

        Bias is probably the reason you don’t see guidelines for something like weight loss. The whole field has been polarized for decades, with one side or another taking over official government panels recommending The One True Healthy Diet. It’s funny, because if you get a handful of people in a room who each swear by a different approach they’ll all complain at each other claiming they tried the paleo, low-fat, calorie-cutting, Hollywood juice, ultra-marathon, intermittent fasting, parsley-only, or bacon cleanse diet and not only didn’t it work they gained weight!

        The spokesperson for each diet then discounts the individual experience of that one person and claims that their anecdotal evidence suggests the bacon cleanse diet will work for everyone (with some minor exceptions due to genetic outliers). The discussion of weight loss has, at least implicitly, come with pseudo-moral connotations for decades. “You’d lose weight if you’d just listen to your doctor when she recommended you become an ultra-marathoner.” Perhaps this is a major source of polarization in other fields?

        For example one person says, “You’ve got to pray to Jesus in this One True Way and then you’ll have this great spiritual awakening and it’ll change your life!” A couple friends try it, and for some it works and their lives are changed. They’re converted, and there’s an enduring following, because some of the principles work for some people. Others try it and it doesn’t do anything for them. They try something else, and that works, so they fight with the first group about how they’re Wrong About How to Talk to God. And on and on until you have hundreds of religions.

        Some people watch hours of Jordan Peterson, they turn their lives around, and they proclaim they’ve found the One True Path to Success. Some other people try it, and it doesn’t work for them. The first group says, “You didn’t go all-in, like I did. You did it halfheartedly. Go more extreme at it and you’ll be successful.” And they’ll keep saying that even if it means they’re recommending ten times the effort they put in.

        Meanwhile, the group that approach doesn’t work for says, “Screw this, I’m trying something new.” A friend helps them past a major hurdle, they prosper, and they declare that the One True Path to Success is generosity toward the less fortunate. Anyone recommending anything else is a clueless moralizer who uses excuses to avoid truly helping the poor.

        Another person gets assistance, finds motivation difficult because things are easier, and ends up living in their parents’ basement. They aren’t able to get ahead until the help dries up, they’re kicked out of the house onto the street, and they’re forced to say, “Screw this, I’m trying something new.” They pull themselves up by their bootstraps and demonize those who told them they needed a handout. That handout held them down! Down with all handouts!

        Meanwhile, if we’d just admit to normal human variation, and recommend some guidelines, could we reduce the fighting to a more manageable level?

        • deciusbrutus says:

          I tried admitting to normal human variation, recommended some guidelines, and got mobbed by all the other people, but when I insisted that what worked for me was the only way for anyone to succeed I started to fit in and got along as well as anyone else.

          • sclmlw says:

            Guideline for guidelines:

            1. Are you speaking to a more rationally-centered, or more tribal individual? If more rationally-centered, attempt to speak in terms of guidelines.

            2. If #1 doesn’t work, attempt to identify with a strong in-group the person you are speaking with identifies as a member of. Multiple in-group identifications are preferred. Solidify your common grounding with this in-group before returning to the original subject.

            3. In light of the aforementioned in-group, suggest variation within the in-group (for example, “sure, we’re both trans-humanists from Indianapolis interested in deep-sea treasure hunting, but some members of this group do not respond to ketogenic diets.” List examples.)

            4. If #3 does not work, abandon bridge-building and join the in-group you wish arbitrarily to be affiliated with.

    • CatCube says:

      This does lead to something I’ve wondered: what is the exact “processing” that people are complaining about? I presume that they’re not expecting us to slam handfuls of raw wheat, even though grinding grains into flour and cooking are both processing. (Or even finely chopping–hence “food processer”).

      It’s always seemed like “chemical-free”, where it doesn’t really seem to mean anything once you think about it, but maybe I’m missing something.

      • Anonymous says:

        It’s probably the issue of industrially refined deliciousness. There are limits to what you (practically) can do in a home kitchen, working with raw ingredients. The results probably won’t be as overeat-able as commercially produced food. Not every “processed” food is a problem, but many are, and there are things you can easily produce at home which are horrid, but most aren’t. For instance, fruit juices are a horrid problem; even absent any additives, they are basically sugar water. Eating too much whole fruits is hard, because they fill you up, but snarfing up entire cartloads is easy if it’s in the form of extracted juice. And never even mind adding flavour enhancers to the mix.

        • Nancy Lebovitz says:

          Do people really overdo with fruit juice? The answer is probably yes, but if I do fruit juice, it’s almost always a jar in the refrigerator. I take a swallow or three from it when I go past, and it takes me days to go through a quart.

          On the other hand, I actually like water. It’s my default beverage, and I’m beginning to think that’s unusual, or at least I keep seeing people say they don’t like water.

          • Anonymous says:

            Do people really overdo with fruit juice?

            I can easily drink a 2L carton per day. If I ate all the apples (say) required to make that juice (about 30 medium sized apples, AFAIK), I probably couldn’t eat anything else, because I would be stuffed.

          • Antistotle says:

            > Do people really overdo with fruit juice? The answer is probably
            > yes, but if I do fruit juice,

            Yes, people do. Mostly with children. Soda (sprite in this example because giving a 4 year old caffeine is like pouring gasoline on dynamite) has 12 calories of (mostly) sugar per ounce. This is BAD, so we give them apple juice which has about 15 calories per ounce, mostly sugar.

            We have been sold on the notion that “fruits are good for you[1]”, and if one cup is good a 32 ounce smoothie MUST BE ABSOLUTELY AWESOME.

            No, no it’s not. You CANNOT lose weight by putting in more easily absorbed calories in your body. Note that there is a difference between what goes in your mouth and what your body can absorb. This is partially why juice and “processed” foods are not good for weight loss.

            Your body is AWESOME at absorbing simple sugars, but can only absorb protein by first breaking it down into amino acids, and then there is only a small section of your intestine that handles those. You can only absorb about 10 grams of amino acids from protein per hour (IIRC). So your body has a mechanism that for *some* proteins (NOT whey, and IIRC casein) where it slows down *digestion* of those proteins. So this is, in part, why high protein diets “work” for some people–you fill the stomach with stuff that takes longer to digest (sticks to the ribs) and can’t be absorbed fast enough.

            You know how hamburger “goes bad (salmonella)” faster than Steak right? Surface area. Take a fist sized piece of wood and set it on a fire and watch (won’t need to time this) how long it takes to catch fire and burn. Now take a double handful of fine sawdust (or flour[2]) and toss it at a fire. You might want to wear safety googles and non-flammable clothing.

            Or, for a something really interesting, take a small piece of steel (or iron) and put a lighter to it. Now take a piece of steel wool (dry) and put a lighter to it. Yeah, steel WILL burn, if it’s fine enough. Rapid oxidation. Flame front propagation. Get it moving fast enough and it’s an explosion.

            This is the problem with fruit juice–you get the water and the sugar, neither of which westerners really need more of in their diet. You don’t get the fiber, and you miss out on a lot of the micro-nutrients (smoothies generally have all of the that in them, but see the sawdust thing above)

            As to drinking water, do you KNOW what fish do in that?

            There are some places where the tap water actually tastes /bad/, so I can see that.

            Many people are conditioned by all the other stuff they eat (which is what this sub-thread is discussing) to expect a flavor explosion every time they put something in their mouth–many of our drinks and packaged foods are *designed* to trigger our inherent reward systems.

            Water is, at best, designed to not be buggy.

            I get bored with plain old tap water, so I drink unsweetened coffee and tea. My wife also gets (lightly) flavored spring and mineral waters that I’ll drink.

            [1] The stuff in fruits that is good for you is in the brightly colored berries, and the amounts you need are generally in smaller quantities. They are also present in vegetables, generally with less sugar overhead.
            [2] A pound of flour, properly mixed in the air, can cause a TREMENDOUS explosion. No, really.

          • Nornagest says:

            A pound of flour, properly mixed in the air, can cause a TREMENDOUS explosion. No, really.

            You’re basically creating a fuel-air explosive — carbohydrates are considerably more energetic per unit weight than gunpowder or TNT (though less so than gasoline), and they’ll deflagrate enthusiastically if thoroughly mixed with air. The mixing is the hard part, but not so hard that silos don’t sometimes spontaneously blow up. It’s also possible to do improvised demolitions with flour or fine sawdust if you’ve got an enclosed space to work with.

          • CatCube says:

            @Antistotle

            There’s a video about a dust explosion at Imperial Sugar in Georgia from the US Chemical Safety Board (kind of like the NTSB, but for chemical and industrial plant accidents). They’ve got a YouTube channel for videos they produce about some of their investigations, which I hesitate to link to because for me it’s kind of like TVTropes, where I end up saying, “Huh. I should have gone to bed an hour ago.”

            They’ve got further videos about dust explosions due to iron at a powdered metals plant in Tennessee, and an explosion of powdered zirconium in West Virginia.

            If dust explosions aren’t your thing, DuPont had an accident that killed a worker with phosgene, which was the third accident in 33 hours at that plant (though the only fatality)

            * If you don’t like videos, they’ve got the text report here: https://www.csb.gov/assets/1/20/Imperial_Sugar_Report_Final_updated.pdf?13902 All of the videos have accompanying reports, if you do a web search for CSB + accident name.

          • Deiseach says:

            Do people really overdo with fruit juice?

            It’s easily done, especially if you think “Well, I’m supposed to have five seven servings of fruit and veg a day, so surely a glass of juice counts as one!” Drinking a glass of orange juice is quicker, tidier and more convenient than eating a whole orange.

            I think I really hurt myself when switching from “give up all those unhealthy fizzy drinks, even the diet version” and changed to “surely fruit juice and smoothies are the healthy alternative” and discovered too late “Argh, there is all this sugar!!!!” in them.

        • Antistotle says:

          What is really sad is that “they” are *adding* sugar to apple juice.

      • A1987dM says:

        I guess non-processed food = food you need to prepare yourself before eating (so that you wouldn’t bother to unless you’re really hungry) or bulky low-calorie food such as fresh fruit.

        (By this definition, dried fruits (incl. nuts), hard cheeses, and dark chocolate count as “processed”. These are indeed things you don’t want to have lots of in your apartment when trying to lose weight, but may not be among what the author(s) had in mind as “processed foods” so I might be steelmanning the definition.)

        • Anonymous says:

          dried fruits

          Dried fruits are probably OK, so long as they aren’t sweetened. I have, ahem, observed the results of overeating dried apples (easy to do, yes), and what comes out doesn’t seem particularly well digested.

        • onyomi says:

          Yeah, I feel like “don’t eat processed foods” sounds colloquially like if you just shop at Whole Foods, as opposed to the gas station, and eat artisanal cheesecake with all organic, farm-raised ingredients you’ll be okay.

          But actually I think it would be a pretty good guideline if taken literally, as most forms of cooking and food preparation actually amount to something like “pre-digestion,” that is making large amounts of nutrients easily absorbable. Like, you could get fat drinking milk, but it’s easier to get fat eating butter, i.e. refined milk fat (there are, of course, a few processes, like making skim milk, aimed mostly at dieters and rarely with the intent of enhancing flavor, that take calories away). But you can only eat so much butter before feeling a bit ill… yet emulsify it with a little lemon juice and an egg and yummy hollandaise sauce you can suddenly eat even more of!

          None of this, of course, speaks to the topic, which I largely agree with… though I think it’s a bit like shooting fish in a barrel to go after dietary recommendations (because this area seems unusually full of BS).

        • Anthony says:

          85% dark chocolate is ok if you’re trying a low-carb (but not a no-carb) diet. A 100 g bar of 85% chocolate has only 15 g of carbs. And has *way* more flavor than a standard grocery-store-checkout-aisle candy bar.

      • bayesianinvestor says:

        I don’t think there’s any consensus on what kinds of processing are most important, but the two I worry most about are: 1) did the processing discard some nutrients that were in the original organism (e.g. juice with no fiber, or butter without the potassium that milk has); and 2) how high a temperature was it processed at. Then there are more complications due to claims that some fats are more damaged by high temperatures than other fats or carbs.

        • Antistotle says:

          It’s primarily four things that make “processed food” such a bugaboo:
          1) Increasing the surface area of the item, which increases the speed of digestion and absorption.
          2) Producers add flavor–which usually means sweeteners or oils/fats–intended to trigger reward circuits in our brains.
          3) Serving sizes that are in excess of what is good for you to eat, but not quite enough to save for later “Clean your plate there’s people in $COUNTRY who are starving…”
          4) “Processed” sounds bad, much like “Chemicals”. Washing and slicing an apple is JUST as much processing as washing and pureeing it. Trimming a steak is processing just like grinding it into hamburger.

      • Freddie deBoer says:

        Removal of fiber is a big one.

    • nameless1 says:

      Sigh. What is a processed food? Carrots peeled and washed, ready for eating, are considered processed? Or only mystery meat like spam? Are Yorkshire puddings processed? Sliced salmon? Sliced salmon, smoked? If it is also cured with sugar and salt, like the famous gravadlax, is it then considered processed? There are good and bad kinds of processing.

      I think what he wants to say is do not food that tastes good in a cheap simplistic way. Simplistic good taste is a result of sugar, salt and fat. Healthy food either tastes bland or is made good tasting in a different, more sophisticated way like spices, herbs and complicated cooking techniques.

  7. Douglas Knight says:

    Has anyone done experiments on designing these guidelines?
    eg, (1) everyone says that SSRIs take a month to kick in, but maybe you should wait longer to evaluate a drug? (2) Is it actually useful to try more than one SSRI? Of course they have different side effect profiles, but if the first one fails at the main effect, does trying a second one beat staying with the first or placebo?

  8. sustrik says:

    In sysops world we have “playbooks”: If this kind of problem hits, check this. If that’s not the problem look here. And so on. I guess people like firefighters must have something similar. And I am pretty sure that emergency medics do have such guidelines w.r.t. triaging and such.

    • Garrett says:

      I volunteer in EMS. We have a lot of protocols. You can get some idea here of what they look like. I suggest the ALS protocols for maximum confusion.

      The big challenge in medicine (in my experience) isn’t the treatment part, it’s the diagnostic part. You’ll note that Scott’s example started with an explanation that it’s a guideline for the treatment of depression. The trick is knowing that it’s the psychiatric condition known as depression and not eg. a thyroid problem, a tumor anywhere, a dietary problem, etc. If you’ve ever dealt with the public, you’ll discover that everybody is happy to diagnose themselves based on Wikipedia (or worse: Dr. Oz).

      • Nancy Lebovitz says:

        And a big one is the difference between depression and bipolar 2. Bipolar 2 is bipolar that just has a smidge of mania– but the drugs for bipolar work for it and drugs for depression make it worse. (Information from a friend with bipolar 2.)

      • sustrik says:

        Have you seen this article?

        http://epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/

        One thing it illustrates is the efficient usage of rough “guidelines” to handle a chaotic situation. The second it the write-up itself. In sysops worlds we call it “postmortem”. It serves both as an educational material and as a basis for further improvement of guidelines.

        • Garrett says:

          Yes, I’ve read that. I think it’s great (more details to come). For something in a similar light, I suggest Code Yellow: Hospital At Ground Zero. For an idea of what my clinical experience was like, you can watch Emergency Room: Life + Death at VGH.

          The article you reference could be the jumping off point for many, many discussions.

          The guidelines (mostly) went out the window. The only reason he could get away with what he did is that he had MD after his name, it was an MCI, and *nobody* wants to dissuade outside-the-box thinking in times like that. But if a JACHO auditor was there that night, it wouldn’t surprise me if the hospital would lose its accreditation.

          Police transport. There is no way there would be sufficient EMS available for the required transport, and it sounds like the police did the right thing in this case. But police scoop-and-dump frequently runs into a lot of problems. In the Philadelphia Train derailment case, the police took patients without regard to their severity to hospitals not necessarily set up to handle the types of injuries they had. Do you know which hospital(s) in your area are accredited trauma facilities? Stroke facilities? Burn facilities? Equipped to handle pediatric trauma? Barotrauma? (Even in the middle of Iowa I can guarantee you *someone* will find a way to get the bends). Also, transportation to the nearest facility can easily result in a small hospital becoming completely overwhelmed with patients.

          Reorganizing beds so the doc can intubate. Guess who else is trained to intubate? Paramedics. Yet there’s an ongoing fight with nurses about whether paramedics should be able to practice in the hospital or not. At least in my area, nearly all of the techs in the ER also happen to be paramedics. In a case like this, delegate the tasks to others who can perform them.

          Running out of monitors, etc. We like to think that civilization is set up with unlimited capacity. But it isn’t. An event like the LAs Vegas shooting is clearly beyond the reasonable capability of most hospitals. But the closest ER to where I volunteer frequently runs out of IV pumps. It’s stupid stuff like this that unless you look deeply at, you don’t realize how fragile civilization and our institutions can be.

          • CatCube says:

            But if a JACHO auditor was there that night, it wouldn’t surprise me if the hospital would lose its accreditation.

            What did he do that would prompt this? To a layman, everything in that article seemed pretty reasonable for a MASCAL. I’m a little surprised that his response didn’t fit within whatever guidelines exist.

  9. Alkatyn says:

    A precondition of being able to write good guidelines of 5 that sort is having lots of good data available. Which doctors have from their own experience in practice and from clinical trials. In other fields the best you can get is a combination of confusing anecdotes and conventional wisdom. Which isn’t always going to be very useful. (e.g. Random person on a nootropics forum has a few small studies of questionable value, and lots of self selected people talking about how one particular thing was great for them.) I guess the solution to that would be to gather more data, but that’s always hard

  10. outis says:

    A more general issue is how hard it is to get personalized diagnostics or treatment. Other aspects of it are:

    1) Many pieces of information that are relevant to one’s “health profile” are held in separate silos, and it’s difficult to put them together. For example, the gut flora seems to affect a lot of things, and it seems likely that digestive issue or symptoms would be useful to diagnose or narrow down treatment for seemingly unrelated issues, even psychiatric ones (e.g. depression?).

    If I go see a doctor for a specific ailment, they’re going to focus on that problem. Maybe there are other related problems that don’t come up. But I can’t just list everything mildly wrong with me every time, either.

    2) A lot of information that could be useful is hard to collect or even to notice. For example, maybe the dry skin I have sometimes is related to something I ate, but I don’t track my meals, so I have no idea. Maybe it’s related to stress, but I don’t track my stress, either. Do I suffer from stomach problems because of some particular foods? Do I just have mild IBS? Is this a “normal” level of bad digestion? Is it affecting my mood too? I have dry eyes sometimes, is that related to anything? I have no idea.

    A few years ago I heard about a “quantified self” movement/fad that I think was based on the idea of logging a lot of information like this for the purposes of optimization. But I haven’t heard anything about it in a while. Perhaps it’s just too much effort to collect all of this information if you don’t know what you’re looking for.

    I would pay _a lot_ of money (relative to my finances) to see a “super diagnostician” who would gather every health fact about me, connect everything, tell me which things to try and which additional data to collect, and basically help optimize my entire health. But does such a service even exist? I assume really rich people can hire someone to do that, but even if I were really rich, I wouldn’t know where to look for something like that, and how to know whom to trust.

    • Glen Raphael says:

      @outis:

      A few years ago I heard about a “quantified self” movement/fad that I think was based on the idea of logging a lot of information like this for the purposes of optimization. But I haven’t heard anything about it in a while.

      The guy who was pushing that idea the hardest was a Berkeley psychologist named Seth Roberts, perhaps best known for the Shangri-La Diet. Alas, the movement lost its champion – and substantial vigor – when Seth passed away in 2014.

      • skybrian says:

        Although, it’s still around in the form of fitness trackers (Fitbit, Apple Watch, etc.). “Quantified self” is a sort of intense homebrew version of that.

        For me, the lasting effect is that I track my weight in a spreadsheet and keep a journal.

  11. textor says:

    Re: self-help. There’s a peculiar book aptly named Psychological Self-Help that’s freely available here. It was recommended many years ago on Lesswrong and I can testify that it’s comprehensive, though outdated and unfinished. It’s as close to a guideline set material as can be. In fact, Chapter 2 is explicitly algorithmic.

    Considering the spitit of the times, perhaps it would be reasonable to fork it, update and convert into an expert-curated (Scholarpedia+stackexchange-style) self-help guideline generator; it could plausibly incorporate nootropic recommendations and the like. But this would be a lot of work, the kind I can only dream about being able to pull of or even start.

  12. Guy says:

    “Guidelines” as you call them, or a “decision tree” as I call it, may be super helpful to a doctor, but when implicit or when the path is uncommunicated, they are downright infuriating as a patient who actually wants to make informed decisions. And not “do whatever my doctor says to do”, that’s not informed. 😀

  13. tentor says:

    Does this personal finance flowchart qualify as a guideline?

    I think part of the problem is that to create such guidelines you need someone who has sufficient knowledge about all options without ideologically sticking to his favorite.

  14. medusawearsyogapants says:

    got me thinking–the fact that drugs affect different people in different ways is one of the most mysterious facts in psychiatry.

    • Glen Raphael says:

      @ medusawearsyogapants:

      got me thinking–the fact that drugs affect different people in different ways is one of the most mysterious facts in psychiatry.

      In the past (before discovering SSC) I always resolved that mystery by assuming none of the drugs do anything and regression to the mean does all the work. My story was: people go see a shrink when they are suffering to an unusual degree so some number of months later (if they’re still alive) they are likely to feel better. Following the guidelines, we try drug A for a while, then drug B, then a higher dose of B, then drug C until eventually by pure random chance or aging or change of circumstance or change of seasons they happen to feel a lot better and when that happens we decide that whatever drug we last put them on, must be working.

      If any drug *really* worked, should it really take 3 months to decide if it’s working?

      Of course now that I read SSC I know that our host thinks the drugs do work better than a nocebo, at least for some people some of the time. I accept that he knows the field better than I do and is probably right. But still, if you’re gonna call it mysterious that the effects are random for different people when “we don’t know what the heck we’re doing so it’s ALL random” is an available hypothesis… 🙂

      • Lambert says:

        Control groups cover reversion to the mean.

        • Freddie deBoer says:

          Yeah the control groups would revert to the mean as well. Also reverting to the mean does not mean reduced variability over time so you’d expect some number of subjects to actually get worse after “treatment.”

        • Glen Raphael says:

          Control groups cover reversion to the mean.

          Comparisons against “actually doing nothing” are possible and a good idea but aren’t all that common. But suppose the control group is taking either either an inactive placebo or some other useless drug and the goal is to find that the new useless drug works better than the control group receiving the old useless drug. All the drugs and placebos involved appear to “work” due to the condition resolving itself. In comparing the control to the test group, sometimes the new drug will win by chance or experimenter bias and get approved, other times some reason will be found why that wasn’t a good test; the dosage levels or protocols will be adjusted and the test is run again until it does win.

          Or perhaps the drug really does work better in carefully controlled trials where the subjects only have one precisely-diagnosed condition and are being closely monitored, but it only works by random chance when applied to normal people with normal problems and normal monitoring.

          My thinking on this was strongly influenced by reading House of Cards (which is hard to google now due to the unrelated dramatic tv series). See also The Control Group is out of Control.

      • scriptifaber says:

        I fear you may be more right than wrong – the evidence for a lot of these drugs does seem weak and the effects do regress over time. However, regression to the mean does not imply that the drugs don’t work. There may be alternate reasons that regressions to the mean regularly occur:

        * Neural receptors are up/down regulated to maintain a general homeostatic balance
        * People feel better and stop taking medication (but lie and report taking meds to their doctors)
        * Something else not listed here

  15. Ketil says:

    “How come I’ve never seen a diet guideline?”

    Because dieting is ruled by greed, fashion, and plain idiocy? And I’d like to see the day somebody sues a magazine after having tried the “lose 20 pounds in five days” diet because it didn’t quite live up to the claims… Of course there are dietary guidlelines, e.g. https://health.gov/dietaryguidelines/2015/guidelines/. But I guess that with diet guidelines, you are looking for an algorithm to lose weight. But I believe that if you follow those guidelines and limit your calorie intake, you will lose weight. I know people will argue and say because of metabolism and syndromes and gluten and blahdiblah, but I’m skeptical. Show me a controlled study quantifying the proportion of people who can eat a healthy diet with <1600kcal/day and still gain weight? The ones I looked at briefly all seemed to show that reduced calories led to weight loss.

    And googling "gaining weight low calorie diet", the first hit (of many!) starts out by promising to explain "Why diet failure isn't your fault". Yeah, sure. It's what people want to hear, and then they want a quick fix for it. A pill to make you slim. Another pill to make you happy. A pill to improve your grades. A pill to improve your sex life. I think the diet guideline you ask for is just going to be an endless cycle of diets that you don't manage to follow, interspersed with consolations that it isn't your fault.

    (I hope this doesn't come across as overly harsh, I certainly don't mean to belittle the effort and discipline needed to follow a diet, or the plight of being overweight. But a lot of the talk and media around dieting comes across as, if not quite dishonest, then at least as wishful thinking.)

    • toastengineer says:

      Of course taking in less energy than you put out will leave you with less stored energy, no-one is arguing against conservation of energy “because gluten.”

      The problem is that the dieter is in fact a tiny neocortex stapled to the brain of a mutant ape, and if the mutant ape decides it wants to eat, you will end up eating. Dietary guidelines are a goal, not a policy; the game is to find a way to stay in those constraints without your midbrain taking over and making you jam two cheeseburgers down your throat.

      • A1987dM says:

        if the mutant ape decides it wants to eat, you will end up eating

        Not if the last time it went to the supermarket the neocortex told it not to buy more food than needed, and now there is no food in the pantry.

        • Anonymous says:

          That worked fascinatingly well for me, even on a potentially extremely unhealthy diet consisting mostly of cheap vanilla ice cream (the stuff that comes in 3L boxes), homemade pizzabread (bread, onion, meat, cheese, oven), gas station hotdogs and many kilograms of cheap apples a week. The healthiest thing was probably the lunch of the day served at the workplace cafeteria. I went to the store almost once a day, buying minimal amounts of what I needed that day, and usually by the end of the day, there wasn’t enough ingredients to make another serving of pizzabread, definitely no more apples. Combined with a little HIIT (biking to and from work in hilly terrain), it made me lose weight without feeling hungry.

          It is hard to apply if you don’t live alone, though.

          • A1987dM says:

            It is hard to apply if you don’t live alone, though.

            True that — I tend to inevitably gain weight whenever I go back to my parents’ more than a few days at a time.

        • Edward Scizorhands says:

          Living in a house without food strikes me as extreme.

          You could live in a house without the super-stimulant food, sure. No chocolate chip cookies and all that.

          My comments on open threads on SSC over the past two years showed me trying to get my brain to accept less food. It gradually worked once I trained myself to not expect to be constantly stuffed. Tracking my food also helped a lot: with smartphones it’s very easy to keep track of your intake. These days I am trying to maintain weight and I often have to make an effort to eat something extra, and I’ll often stare in the pantry saying “ugh, I don’t feel like eating any of this” and/or “I’ve already had a serving of that today, I need to mix it up.”

          Lifting weights also helps. I haven’t done it in a few weeks but I still have the muscle built up so I’m coasting on past effort, essentially.

          • John Schilling says:

            Living in a house without food strikes me as extreme.

            You could live in a house without the super-stimulant food, sure. No chocolate chip cookies and all that.

            My rule is no food that can be eaten* without preparation. At minimum, if I feel the urge for a snack, I have to make a slice of toast. And the promise of toast five minutes in the future is quite a few steps down from an open bowl of Doritos an the super-stimulant scale.

            * For reasonably palatable definitions of “eaten”

      • mdet says:

        Also I’ve read that your body can easily speed up or slow down your metabolism to maintain your weight as your calorie intake changes. So cutting calories could just trigger your body to slow down and be more sluggish without burning very much fat. Citation needed though.

        • Anonymous says:

          This seems to occur if you eat often, but very little (I heard of a study sometime around the world wars, where they had quite a lot of male volunteers restrict calories, but eat often, and it was horrible for the involved – they didn’t have enough energy coming from food, and they couldn’t burn their fat because they were digesting what little was coming in). Fasting (ie. not eating at all for a period) will burn fat.

        • A1987dM says:

          It does to a certain extent, but not arbitrarily much and not arbitrarily fast. I wish it did, so that in hot summer nights I could skip dinner and stay comfortably cool. What actually happens if I do is I’ll wake up at 3 a.m. feeling just as hot as if I had had a regular dinner plus ravenously hungry.

          (It does seem to work better in the other direction, though: if in cold winter nights I eat more than usual I do feel warmer. YMMV.)

          • poipoipoi says:

            FWIW, if you diet for a few days, after those few days:

            1) You won’t poop.
            2) You’ll put on a sweater.
            3) You’ll be exhausted and tired and hungry and won’t be heading to the gym anytime soon.

            As you mentioned, eating more seems to work faster than eating less, but as someone who went from 320 to 235, yeah, I was cold all the time.

          • Edward Scizorhands says:

            If we really did become lethargic after not eating for a few days, our hunter-gatherer ancestors would have died out.

    • Anonymous says:

      Agreed that dietary advice is mostly made-up bullshit these days. The more mainstream and more fashionable, the probably more bullshit.

      My take on it is to look at people who weren’t overweight and are genetically similar to us – our ancestors like 100 years ago. They weren’t fat. What did they do that made them less fat? That’s an excellent question that I would like to see answered. So far, I’ve been able to home in on “not eating all the time” (religious fasting observance used to be much more common and regular), “eating substantial amounts of fats”, “eating mostly food prepared in the home”, “eating way less refined sugars” and Norman Borlaug.

      • bbeck310 says:

        So far, I’ve been able to home in on “not eating all the time” (religious fasting observance used to be much more common and regular), “eating substantial amounts of fats”, “eating mostly food prepared in the home”, “eating way less refined sugars” and Norman Borlaug.

        You left out “working at jobs that required significantly more physical activity than sitting and typing.”

        The first seems unlikely–the most strict Jewish fasting observance includes 4 annual fast days, only 2 of which are full day fasts, and all of which are usually followed up by some amount of feast. Christian fast days are even less common. Muslim fasting mostly consists of Ramadan, which is mostly interesting for its seasonal effect (at a very Northern latitude, fasting from dawn to dusk is much, much easier in the winter than in the summer).

        Eating substantial amounts of fats–probably not a major difference. Meat was much less common 100 years ago, and processed vegetable oils were much rarer. Deep fried food was a much rarer luxury.

        Eating mostly food prepared in the home–likely a major difference.

        Eating way less refined sugars–yes.

        Norman Borlaug–not so much in the first world, unless you’re referring more generally to increased agricultural productivity and decreased food prices throughout the century, in which case yes.

        It’s also important to remember in doing the comparison that as far as problems go, obesity is a much better problem to have than starvation. The Potato Famine was only about 150 years ago; Soviet famines killing over 6 millions were less than a century ago.

        • Anonymous says:

          You left out “working at jobs that required significantly more physical activity than sitting and typing.”

          A fair point, but I don’t think even white collar workers back a hundred years were obese. I saw a video of one of the American cities recently, I think it was from the 60s or so given the obviously early colour tech, low resolution and hippie fashion, and people in the street were not fat. City dwellers, who are by and large not physical workers, not being fat as early as 50 years ago.

          The first seems unlikely–the most strict Jewish fasting observance includes 4 annual fast days, only 2 of which are full day fasts, and all of which are usually followed up by some amount of feast.

          Jews are a tiny minority, and as such irrelevant to the problem of western obesity, except as a cause, if you are conspiratorially inclined.

          Christian fast days are even less common.

          They are uncommon, almost absent, NOW. Take a look at pre-1960s Catholic fasting requirements (strict fast – one full meal, two tiny meals allowed):
          – Wednesday, Friday and Saturday once per quarter, so-called Dry Days.
          – Ash Wednesday, Good Friday (still strict now).
          – All Fridays and Saturdays of Lent.
          – Eve of Pentecost.
          – Eve of Assumption of Mary.
          – Christmas Eve.
          – Eve of All Saints’ Day.

          By my count that’s approximately 30 days of strict fasting annually, give or take some overlap. And that’s not including the restrictions on *what* you can eat, like abstinence from meat or even all animal products, especially during Lent.

          Eating substantial amounts of fats–probably not a major difference. Meat was much less common 100 years ago, and processed vegetable oils were much rarer. Deep fried food was a much rarer luxury.

          Even pre-modern farmers tended to have eggs from chickens, the chickens themselves (what else are you going to do with excess roosters), butter and cream from milk, etc. Pigs and cows weren’t rare.

          Norman Borlaug–not so much in the first world, unless you’re referring more generally to increased agricultural productivity and decreased food prices throughout the century, in which case yes.

          I am. I also referring to the fact that the modern wheat we eat is a product of his efforts, and is not the wheat that pre-Borlaug people back to Christ’s time ate.

          • SamChevre says:

            Take a look at pre-1960s Catholic fasting requirements

            And go back another 60 years, and add “Saturday night until after Mass on Sunday.”

            And don’t forget abstinence–no meat on Fridays all year (except the Octaves).

          • Anonymous says:

            @SamChevre

            Yes.

            AFAIK, Eucharistic fast went from “you must attend Mass without breakfast” to “3 hours before Eucharist” to “1 hour before Eucharist”. Which is another way of saying “don’t eat in the pews”, for the most part.

          • Nancy Lebovitz says:

            If the hypothesis about religious fasting is correct, should Catholics weigh less than Protestants (who, so far as I know, do little or no fasting)? Or at least Catholics weigh less at one time, before the requirements for fasting were loosened?

            Also, I have no idea how complete Catholic compliance was.

          • Anonymous says:

            @Nancy Lebovitz

            If the hypothesis about religious fasting is correct, should Catholics (who, so far as I know, do little or no fasting) weigh less than Protestants? Or at least did so at one time, before the requirements for fasting were loosened?

            You’d have to ask someone with deeper knowledge of Protestant customs. AFAIK, they also had rules and customs against gluttony, but I’m far from a legit heresy scholar.

            Also, I have no idea how complete Catholic compliance was.

            Probably similar to church attendance rates.

          • christhenottopher says:

            @Nancy Lebovitz

            At least in the US, Catholics do seem to have had a somewhat lower obesity rate than most protestants (particularly Baptists). However, notably their obesity rate is still rather high compared to smaller protestant groups, non-religious people, and the Jews. So, maybe fasting prevents Baptist levels of obesity, but Catholic practices aren’t that impressive at obesity avoidance at least since the mid 80s when that data set begins. EDIT: so of course this doesn’t answer if their practices were more effective prior to the 60s, but obesity rates were universally low back then.

          • A1987dM says:

            City dwellers, who are by and large not physical workers, not being fat as early as 50 years ago.

            Nor are present-day Japanese people, for that matter (though that might be partly genetic.)

          • A1987dM says:

            AFAIK, Eucharistic fast went from “you must attend Mass without breakfast” to “3 hours before Eucharist” to “1 hour before Eucharist”. Which is another way of saying “don’t eat in the pews”, for the most part.

            So that’s why people made a big deal of it! In particular I had heard that elderly priests were exempted from that because they would have to do that several times a day and I thought “what kind of health issues do you have to have for it to be a big deal to stay one hour without eating (most of which hour you’re spending celebrating the Mass anyway)?” If the required time used to be longer, then yeah, that does make sense.

          • Anonymous says:

            @A1987dM

            Nor are present-day Japanese people, for that matter (though that might be partly genetic.)

            The Japanese eat very differently from westerners, in particular Americans, AFAIK.

          • Anonymous says:

            From a British friend of mine: http://forums.anglican.net/threads/fasting.605/#post-9778

            Here is the table of days appointed for strict fasting in the Anglican Church in the 1662 Book of Common Prayer, in a more legible modern font.

            A TABLE OF THE VIGILS, FASTS, AND DAYS OF ABSTINENCE, TO BE OBSERVED IN THE YEAR.

            The evens or Vigils before these days (with the date of the Vigil in brackets):

            The Nativity of our Lord (Dec. 24)
            The Purification of the Blessed Virgin Mary (Feb. 1)
            The Annunciation of the Blessed Virgin Mary (March 24)
            Easter-day (Holy Saturday)
            Ascension-Day (Wednesday before)
            Pentecost (Saturday before)
            S. Matthias (Feb. 23)
            S. John Baptist (June 23)
            S. Peter (June 28)
            S. James (July 24)
            S. Bartholomew (August 23)
            S. Matthew (Sept. 20)
            Ss. Simon & Jude (Oct. 27)
            S. Andrew (Nov. 29)
            S. Thomas (Dec. 20)
            All Saints (Oct. 31)

            Note, if any of these Feast-days fall upon a Monday, then the Vigil or Fast-day shall be kept upon the Saturday, and not upon the Sunday next before it.

            ____

            DAYS OF FASTING, OR ABSTINENCE

            I. The Forty Days of Lent.

            II. The Ember-days at the Four Seasons, being the Wednesday, Friday, and Saturday after:

            1. the First Sunday in Lent,
            2. the Feast of Pentecost
            3. September 14
            4. December 13

            III. The Three Rogation-days, being the Monday, Tuesday, and Wednesday before Holy Thursday, or the Ascension of our Lord.

            IV. All Fridays in the Year, except Christmas-day.

            So the Anglicans at least had substantially Catholic-like fasting traditions.

          • Jaskologist says:

            Baptists are kind of a special case, since feasting together on Sunday is a pretty common thing in Baptist culture, which is almost like an anti-fast. And that’s before you even get into the racial demographics of different denominations.

      • Antistotle says:

        They weren’t fat.

        Fewer were fat, but yes, that’s true.

        What did they do that made them less fat?

        100 years ago. 1920 call it:
        * They mostly lived in draft homes that were very indifferently heated by shoveling fuel into a fireplace or furnace[1]
        * Indoor plumbing was still being deployed in the Americas.
        * Refrigeration of food was, if available at all, done with real frozen water in “Ice Boxes”
        * Food was more expensive relative to the paycheck which meant you ate it even if it was a little “off”, leading to higher incidents of what today we would call “food poisoning”.
        * The internet did not exist, nor did telephones (in any great number). If you wanted to talk to someone you had to walk your ass over there.
        * Cars were still not common, and if you wanted to get somewhere you had to ass over there. Or ride your ass over there.
        * No air conditioning to speak of.
        * Entertainment involved doing things (even if it was walking you ass over to the movie theater) not just sitting there watching other people do stuff.
        * Work involved doing stuff with muscles other than those in your eyes and your fingers.
        * Dentistry was not as good, so people dealt with more tooth decay (harder to eat with “bad” teeth).

        [1] https://www.achrnews.com/articles/87035-an-early-history-of-comfort-heating

        • Nornagest says:

          Obesity ratios have been climbing for a hundred years or so, but they only really started taking off in the 1980s, which is not an obvious inflection point for car ownership, prevalence of central heating, refrigeration or A/C, or non-physical entertainment. If anything, I’d expect to see less motor transport then than the ’60s and ’70s, both because that’s about when safety standards for cars started taking off (making them more expensive) and because of the effects of the oil crisis.

          • Anthony says:

            According to Megan McArdle, the median American household spent 30% of its income on food as recently as the 1950s. If it’s not less than 10% now, it’s because we eat out much, much more.

            If the inflection point is the 1980s, I suspect the divorce revolution had something to do with it. People who got divorced drowning their sorrows in food, eating more processed food because it’s easier than cooking for one, etc.

      • AG says:

        Not seriously: global warming.
        Our current climate is degrees colder than the days of the much larger animals, dinosaurs or mammals. Studies show that plants now have increased carbon content (lowering the ratio of nutrients to carbs in salads and such), which were also a factor in why much larger animals could exist in the past.

        Now we just need the research in how to make bone growth match the rest…

    • Nancy Lebovitz says:

      I think dieting is driven by two fantasies: magical transformation and redemption through pain. This is strong stuff, especially a person’s fat percentage has large status effects.

      • Antistotle says:

        The medical cost sharing program we are on charges extra for things like being fat, and having high cholesterol.

        It’s costing me an extra 80 bucks a month to be fat.

    • A1987dM says:

      Of course there are dietary guidlelines, e.g. https://health.gov/dietaryguidelines/2015/guidelines

      Gotta love how (according to the footnotes in Appendix 2) even my walk from my place to the bus stop to go to work and back every day would suffice for me to qualify as “moderately active” by American standards.

      • Anonymous says:

        Ha. Reminds me of the time I was hiking up to Prekestolen with a friend, and the estimated route completion time turned out to be grossly exaggerated. We joked about how the time was obviously meant for American (or Mexican) tourists, not for normal people. 😉

    • Douglas Knight says:

      Just because it has “guidelines” in the title does not mean they are guidelines in the sense of this post. This document has no flowchart and no triage. It recommends a single diet and it doesn’t say how to achieve that diet. Since the diet doesn’t have a goal, there is no way of assessing whether a change worked or failed and so it never recommends that your diet is good enough nor that an attempt failed and you should try something else; is always advising changing your diet to be closer to the recommended diet.
      (It does mention one goal, lowering blood pressure, but it doesn’t have any timeframe or triage there, either.)

      The recommended diet is flexible and it does have a section about how it is broad enough to include vegetarian and mediterranean diets (which is probably false). But you could say the same about most diet advice.

    • Antistotle says:

      pill to make you slim. Another pill to make you happy…. interspersed with consolations that it isn’t your fault.

      One pill makes you happy
      And one pill makes you small
      And the ones your shrink gave you didn’t fix anything at all.
      Alexander knows it, give him a call…

      (sorry).

      Anyway:

      hope this doesn’t come across as overly harsh, I certainly don’t mean to belittle the effort and discipline needed to follow a diet, or the plight of being overweight. But a lot of the talk and media around dieting comes across as, if not quite dishonest, then at least as wishful thinking.

      The problem is, absent one chemical[1], whose name I forgot, NOTHING changes the fact that to lose weight you have to be uncomfortable in a way we’re evolutionary programmed to hate–which is to say being hungry. The one exception to this might be a moderate fat, high protein, low sugar/simple carb diet. for reasons that have to do how we digest some proteins (e.g. slowly).

      And yes, a LOT of the claims made in the supplement industry are out right lies. Which is no different than several other industries frankly.

      [1] Found it. 2,4-dinitrophenol, AKA DNP. The Effective Dose and the LD-50 are about as far apart as a very close thing, and it works by making your cells *less efficient* at converting fat/sugar to energy (sort of) and heats you up as a byproduct. Nasty stuff.

  16. Jack V says:

    That’s an excellent question. I guess part of it is, to write guidelines, you need to have the requisite expertise, and be willing — for diets and nootropics, I’m not sure *anyone* has the expertise.

    If you went to the person in the world who knows the most about diets, would they say, “I’ve seen a lot of people with idiosyncratic responses, so lets try A, B and C, and if that doesn’t work, D, E and F, else…” or “I don’t really know, A worked for me, and studies show B and C, but other studies say those don’t work”?

    Conversely, in many other fields, if you’re asking a fairly simple self-contained question like “how do I write this part of the code” or “how do I cook a baked potato”, there’s usually fairly specific answers, there’s not usually the same “try it and see”, or if there is, you can try it repeatedly fairly quickly. Guidelines are needed only for more for bigger fuzzier things like “how do I improve as a programmer/chef” or “how do I improve my workplace culture”. Medicine may be a bit unique in having lots and lots of knowledge which is (a) important but (b) sufficiently nebulous there’s guidelines instead of prescriptions.

    • Aapje says:

      You can also develop expertise by starting with a basic guideline, experimenting when it fails and thereby expanding it gradually.

      Nutritionists might do such a thing for dieting, although there may be reasons why this can’t work very well (like people not being willing to have a long-term, expensive treatment plan, like they do with doctors and that many people choose their diet themselves).

  17. Nate the Albatross says:

    My rough draft of investment guidelines….

    Investment Guidelines

    WARNING: ALL investments and financial advice carries risk. You could lose all your money. If you cannot risk losing all of your money, do not invest. Author disclaims any responsibility for your financial decisions and will not accept any liability, nor proceeds. This is a philosophical exercise intended for the development of investment guidelines. Disclosure: The author owns or has owned or will own index funds which contain thousands of companies all over the world and is not impartial. YMMV.

    1. Does the investor have any money? If yes, proceed to step 2. If no, work out a budget and a plan to pay down debt. If at any point in the other steps the investor is out of money but wishes to invest more, return to this step.

    2. Recommend the investor contribute up to the match percentage in their company 401k. Help them chose index funds with lots of companies and low expenses and steady returns over five, or better yet ten years. Avoid high expense funds, avoid company stock, avoid funds with less than three years of results and avoid funds with high results last year but terrible results in any of the past few years. Does the investor still have money left over? What if the company 401k doesn’t have any low expense funds? Proceed to step 3. If the investor doesn’t have access to a 401k, proceed to step 3.

    3. See if the investor qualifies for a Roth IRA. If yes, recommend they contribute $5,000 to it. Recommend they buy index funds and ETFs with less than 1% expenses and more than 500 companies and five to ten years of steady returns. If the investor wishes to purchase individual stocks, recommend TD Ameritrade as a broker. If the investor doesn’t like TD Ameritrade, search for and online brokerage with low fees. Refer the investor to the Motley Fool to research individual stocks. Show them an article where an author was wrong and the company went bankrupt. Stress that this happens a lot and that individual stocks are for investors who can purchase at least twenty, and preferably fifty different companies and how much reading that involves. If the investor only wishes to purchase funds and can contribute $5,000 a year, recommend Vanguard as a broker. Does the investor still have money left to invest? Proceed to step 4. Does the investor lack confidence to start an IRA? Also step 4. If the investor doesn’t qualify for a 401k, proceed to step 5.

    4. Increase 401k contributions to the maximum allowed. Often this will be $15,000 or up to 75% of their income whichever is lower. Use the same formula for choosing investments as step 2, but choose more investments to diversify unless the other choices are very bad (don’t meet criteria). If the investor still has money to invest proceed to step 5.

    5. Start a taxable brokerage account for all remaining funds to invest. Recommend they buy index funds, REITs and ETFs with less than 1% expenses and more than 500 companies and five to ten years of steady returns. If the investor wishes to purchase individual stocks, recommend TD Ameritrade as a broker. If the investor doesn’t like TD Ameritrade, search for and online brokerage with low fees. Refer the investor to the Motley Fool to research individual stocks. Show them an article where an author was wrong and the company went bankrupt. Stress that this happens a lot and that individual stocks are for investors who can purchase at least twenty, and preferably fifty different companies and how much reading that involves. If the investor only wishes to purchase funds and can contribute $5,000+ a year, recommend Vanguard as a broker.

    • A1987dM says:

      If you cannot risk losing all of your money, do not invest.

      To be pedantic, there is no such thing. “Not investing” amounts to investing in the official currency of your country. In the vast majority of cases that’s way less risky than any other investment you could make, but the probability of a Weimar Republic scenario is never literally zero.

    • Jon S says:

      “with less than 1% expenses” seems like way too low of a bar. If the options in their 401k are really mediocre they might have to settle for that order of magnitude, but for their IRA/brokerage account they should be aiming far lower. For domestic stocks, Vanguard has plenty of funds under 0.1%. Over 30 years, a fee closer to 1% can easily eat through 20% of someone’s retirement savings.

      Edit: 3b. If they do not ordinarily qualify for a Roth IRA, they can still effectively contribute to one. If you google Backdoor Roth IRA, there will be articles explaining how. Also contribution limits are currently $5500/yr, not $5000.

      • Edward Scizorhands says:

        Trying to squeeze extra basis points off of the expense ratio quickly hits time-benefit tradeoffs, particularly for people who aren’t financial wizards.

        “Get under 1% expense ratio, then go worry about something else” is a good guideline for a normie.

        • Protagoras says:

          But a lot of places publish that kind of info these days, and while getting under 0.1% while fulfilling other objectives of balancing a portfolio might require a lot of homework, I don’t think it would be notably difficult to get under 0.5%, or even 0.3%. I’m with Jon that 1% seems an insufficiently ambitious target.

    • Antistotle says:

      Why Vanguard over Fidelity?

      I had 401ks at Fidelity (by fiat, not choice) and have never seen any problems.

      • Edward Scizorhands says:

        I do Vanguard, who pioneered this field, so I will chauvinistically recommend them, but the competitive pressure they brought means that Fidelity is probably just as good.

    • decadence says:

      I think you’re missing the “Mega Backdoor Roth IRA“. By contributing to an after-tax 401(k) plan and instantly rolling over to a Roth IRA, you can get tax-free capital gains on up to $55,000 in investments per year, regardless of your income.

  18. MawBTS says:

    This is where upvote-arranged comment sections kick the shit out of chronologically-arranged comment sections.

    If you’ve ever asked a tech support question on an old-school forum like Ars Technica, you know how it goes. Sixteen different people will give you seventeen contradictory pieces of advice and you’ll have no idea what to do.

    But on Reddit, you’ve got the most upvoted piece of advice to try first, the second most upvoted to try next, and so on. If all the comments are telling you the same thing, well, alea iacta est. Occasionally bad advice gets upvoted due to social dynamics, but even then you’ll usually have at least someone yelling at them in the replies (on forums, it’s worse, as there’s no way to follow chains of conversation and everyone’s talking over each other).

    Plus, nobody types “first!”

  19. Where a guideline would be really useful is in childrearing.

    Consider education:
    1. Try unschooling (long description of what it is and how to do it, with various forking paths contained)
    If that doesn’t work
    2. Try formal education of form X (Montessori?)
    if that doesn’t work

    With clearer definitions of what “doesn’t work” means in practice. Also some forks depending on in what way it didn’t work.

    • Aapje says:

      That seems rather unusable, given the costs of switching schooling and the difficulty to draw quick conclusions.

      • ringmaster says:

        Actually changing schools is ridiculously easy in many states, especially if you are going between some version of homeschool and public school. The public school has to take you, and you can pull kids out to private school any time. Private schools depend on how popular and expensive they are, but I’ve had my kids enter a fancy private school mid-year because we had the flexibility, and other waitlisted folks were “stuck” in their current schools.

    • RC-cola-and-a-moon-pie says:

      This is a tangent, because it relates to the substance of your educational philosophy rather than the methodological topic of guidelines, but is your advocacy of student-driven “unschooling” compatible with an empirical belief that there are substantial prerequisites to intellectual maturity that can in most cases only be traversed by guiding the student across various subject-matter terrains in an interconnected way whose value may not be clear to the untutored student until after the fact? That’s probably vague, but I guess I worry that students at young ages are usually not equipped even to know what they will find most interesting and rewarding upon a substantial investment of time and effort. Obvious point, I guess, but I’d be interested in hearing the main answer to it.

    • Antistotle says:

      We have Homeschooled our child, formally for the last 6 years. That is no longer working, so we’re going the Charter School route. Hopefully a classical academy.

      However we will be watching her curriculum closely and…interacting with her instructors.

      Oh, and it’s more like “When you are no longer making adequate progress” rather than “if that doesn’t work”.

      A big part of the problem with education is making sure the kid is smart enough for the material given and the material is at the child’s level.

  20. zzzzort says:

    But I think that’s a big part of it – making guidelines seems like a really strong claim to knowledge and authority, in a way that a recommendation isn’t.

    I partly disagree; the ability to give multiple recommendations (and implicitly expect failure in many cases) seems like an act of intellectual humility. In the example of diets, many of the diets come attached with a strong theory of how nutrition works as a whole that is incompatible with other diets working. I feel like if more people were willing to say that they had no clue as to the underlying mechanism of the problem they were trying to address (and abandoned their own pet explanations), advice would get a lot more pragmatic.

  21. A1987dM says:

    Have you read The Hacker’s Diet? The gist of it is “in order to lose a pound a week, you need to eat about 500 kcal/day less than in order to maintain your weight, but you’ll have to experiment to find out which of the possible ways you can distribute that number of kcal/day across meals and across macronutrient groups will leave you the least hungry and unhappy (and hence the most likely to stick to it), because it can vary from person to person; also the baseline number of calories you’d need to maintain your weight changes from person to person, so to find out whether you’re underestimating or overestimating it you should weigh yourself daily and compare the rate of change with your target, but any change on a timescale less than a week is probably most a random fluctuation in the amount of water in your body and you should disregard it.” Then he overcomplicates things and introduces exponentially-weighed moving averages and whatnot, but you can ignore that.

    • Tenacious D says:

      I wonder if the author reads SSC?

      • A1987dM says:

        I can’t remember John Walker ever commenting here or on LW, at least not under anything recognizable as his real name, but the third edition came out in 1994, so it sure wasn’t influenced by Scott.

    • Edward Scizorhands says:

      That looks similar to the advice I got. I didn’t read it there but probably from someone who read that.

      1. Track your weight and calorie/protein intake. Even if you change nothing, establish the baseline.

      2. Adjust your calorie intake as needed. (And you will probably eat less carbs to accomplish this without losing the protein, but people are different.)

      3. If lowering your calorie intake by 500 calories/day from baseline, doesn’t make you lose weight, see a doctor.

  22. b_jonas says:

    You know about the guideline for depression because you work as a psychiatrist. Have you tried to ask a nutrition specialist doctor? Maybe they can tell you about the guideline they use when they give advice on dieting.

  23. Anonymous says:

    Why hasn’t someone written something like:

    1. Try cutting carbs by X amount. If you lose Y pounds per week, the diet is working. If not, you’re probably resistant to cutting carbs because [two hours of mumbling about insulin] and you should move on to the next tier.

    2. Try cutting fat by X amount. If you lose Y pounds per week, the diet is working. If not, you’re probably resistant to cutting fat because [two hours of mumbling about leptin], and you should move on to the next tier.

    And so on until Step 7 is “get a gastric bypass”.

    I’d put a “try not eating for a while” near the top.

    • Antistotle says:

      During the 382 days of the fast, the patient’s weight decreased from 456 to 180 lb. Five years after undertaking the fast, Mr A.B.’s weight remains around 196 lb.

      Wow. That’s kind of impressive.

      • quanta413 says:

        Holy hell that’s a long time. Worth noting though that the numbers given fit the ballpark estimates of calories per pound of fat and average calories burned per day impressively well.

        Assume 3500 calories per pound of fat. In 382 days, he lost 276 pounds. That would be 276/382*3500 = 2530 calories per day. Which is reasonably close to what we’d expect a large man to burn at base metabolic rate. We’d typically estimate ~2000 calories for a random male. But most males weigh less than half what this guy did at the start. And we’re only off by 25% from a population average type estimate.

  24. Nancy Lebovitz says:

    One more thing for dieting guidelines– some ways to tell whether you’re heading toward an eating disorder.

    ****

    Mark Ruscio seems to be dong some interesting work with guidelines– for example, putting probiotics into categories so that you can tell which products are redundant to something you’ve already tried.

  25. wfenza says:

    My strong prior is that there are no dieting guidelines because all diets *are* scams and literally nothing works long-term. 95% of diets fail after 3 years, and a large proportion end with people gaining weight (and yes, this includes the “conservation of energy” magic bullet of just restricting calorie intake). The other issue is that almost all diets work in the short term if they are strictly observed, and you only know if it “works” if it’s sustainable for years.

    Given that it’s a scam, I am somewhat surprised that nobody has tried to sell a guideline like the one you described, but I am strongly skeptical that it will be helpful

    • A1987dM says:

      There is a selection bias because if someone loses weight and successfully keeps it off, they won’t show up in a study group again, but if someone loses weight, gains it back, and tries to lose it again, they will.

    • Incurian says:

      This doesn’t exclude the possibility that all diets are good but most people are terrible.

      • A1987dM says:

        It’s reasonable to only call a diet “good” if it also works for actual people, not just for hypothetical non-terrible people.

        • Steve Winwood says:

          I agree, but in fairness most people fail at every attempt they make at lifestyle change. You have to be the sort of person who is capable of change – this is not a trivial requirement at all, imo – to have a shot at successfully losing weight. Think there’s at least some truth to what Incurian says.

        • Incurian says:

          I also agree, but there are different kinds of badness in diets. If a person following the diet reliably loses weight but most people find it hard to follow the diet, that’s a different kind of bad from diets that reliably do not cause people to lose weight even when followed. I would only call the latter type a “scam,” whereas the former type would be “difficult.”

          My belief (based on watching soldiers either fail or succeed at dieting) is that most people will try a difficult diet, not stick to it (even if they think they are – as others have noted it’s hard to keep track of exactly how much you eat and exercise and it’s easy to delude yourself), and label it a scam.

          • a reader says:

            I think the big problem isn’t losing weight – probably anyone who hasn’t serious metabolic problems can do that with any popular diet, if they follow it long enough strictly enough – but staying slim long term, years after the diet ends.

            And here the chances seem extremely slim – at least according to David Wong from cracked.com:

            Fat Is Officially Incurable (According to Science)

            Every study says so. No study says otherwise. None.

            Oh, you can lose a ton of weight with diet and exercise. You’ll gain it back. Here’s one study running the numbers. Here’s a much larger analysis of every long-term weight loss study they could find. They all find the exact same thing: You can lose and keep off some minor amount, 10 or 15 pounds, for the rest of your life — it’s hard, but it can be done. Rarer cases may keep off a little more. But no one goes from actually fat to actually thin and stays thin permanently.

            And when I say “no one,” I mean those cases are so obscenely rare that they don’t even appear on the chart. […] How rare? Well, this person did the math, and as far as they could tell, two out of 1,000 Weight Watchers customers actually maintain large weight losses permanently. Two out of a thousand. That means if you are fat, you are 25 times more likely to survive getting shot in the head than to stop being fat. A more recent study says it’s even worse, for men at least — they found 1 out of 1,290 severely obese males lost weight and kept it off, and 1 out of 677 females.

            My personal experience kind of confirms it. Some years ago I lost 17 kg (37.5 pounds) with Montignac Diet (a French diet popular in Europe, easier to keep) but after that it went like that: I put a few kg in a year, then diet again and put them off, then back on, then back off with diet etc. etc. Now I once again will have to start diet, maybe in May.

    • Anonymous says:

      I think there’s a strong component of culturally/technologically mediated noncompliance for long term success. Our recent ancestors somehow managed to not be morbidly obese like we are. Since genetic drift is probably minimal at the timescale of merely four generations, I submit that the circumstances have changed, not the people in those circumstances.

      For instance, very few (western) people observe religious fasts anymore, and when they do, it’s mostly a fig leaf on what fasting used to mean, like the new Catholic guidelines (no meat on Fridays, reduced food intake two days in the year). The liturgical calendar used to be chock full of fasts. Nowadays it’s mostly like there is a feast all day every day.

      Another issue is that we sure damn aren’t eating what those same recent ancestors ate. Eating out, ordering pizza, or even buying a microwaveable TV dinner are just too convenient. And aside from the last one, they probably beat grandma’s homecooked sourdough bread, potatoes and scrambled eggs. Then there’s the issue that even the things that are purportedly the same, are not – Borlaug’s wheat is quite different from pre-modern spelt wheat, the modern meat chickens are quite different from pre-modern meat chickens, and even the way staples such as bread are prepared (sourdough vs yeast vs baking powder) have changed.

      We are in new circumstances, and it’s unsurprising that we are poorly adapted to them.

      • AG says:

        Microwaveable TV dinners are usually less than what I normally eat per meal, though, especially the ones that do the calorie counting for you. I bet I would lose weight if I ate nothing but a single of the cheapest pot pie for each meal.

        When cooking my own meals, I tend to increase how much a single serving is (what would be portioned out as 5 meals becomes 4 because I don’t want to each something for 5 days in a row, or because I feel more peckish on a particular day, etc.)

        There’s an entire industry for healthy microwaveable dinners now, and some of them are even price-competitive vs. the fast food or junk snack food that is so easy to reach for when cooking seems like too much of a drain.

        • Anonymous says:

          There’s an entire industry for healthy microwaveable dinners now, and some of them are even price-competitive vs. the fast food or junk snack food that is so easy to reach for when cooking seems like too much of a drain.

          I find the claim of these products being “healthy” to be dubious.

    • Steve Winwood says:

      “Diets are scams” seems incompatible with the fact that there are people who have changed their diet, lost weight, and kept it off. I lost 35 pounds and have been at my new weight for five years. I started with specific dietary restrictions (plus exercise) and gradually expanded those restrictions with full knowledge that certain things I eat are unhealthy and need to be done in moderation. I fully anticipate that the changes I made to my diet directly stemming from what I’ve learned about diet and nutrition will persist through the rest of my life.

      I think 95% can seem like a much bigger number than it really is. Most people who try diets have no idea what they’re doing at any level and are hoping to extend an unsustainable willpower burst in perpetuity. Surely SSC readers should at least maintain realistic aspirations of being in the 5% here?

      • Nancy Lebovitz says:

        I think it’s fair to say that diets are mostly scams– there’s a smallish percentage of successful dieters– possibly more than 5%. Most diets fail, and people spend a good bit of money on them.

        There are people who gain weight as a result of dieting. I’m getting this from having read a lot of people’s accounts, so you’re taking your chances with my conclusions. I’ve seen a fair number who say they’ve gained 25 pounds per diet– make that mistake 4 times, and that’s a hundred pounds. I’ve wondered whether some fraction of the obesity epidemic is the result of dieting.

        So far as I know (casual search and asking around), there is no research on what people have done to lose weight and how it’s worked out. You could say “but that research would be really hard” and you’d be right, but I think absence of information is worth pointing out, especially since a lot of people have opinions about how fat people live.

        • Steve Winwood says:

          My concern here is that the “most diets are ‘scams'” prior is going to be *extremely* harmful to any SSC reader who wants to lose weight. It’s a task that takes substantial psychological momentum and will be undermined if, in the back of your mind, there is a fear that you’re as likely to do harm as to do good. And I don’t think that’s realistically true.

          On “gaining weight while dieting”: I don’t doubt that this is a real phenomenon. I do strongly doubt that those people are realistic about their compliance with the diet, and it pattern-matches with people who spend an hour using an elliptical at steady 10% intensity then assume the world is against them when they don’t see results. That is to say: a lot of diet and exercise (arguably most) seems to have the genuine goal not of getting fit or losing weight but of telling yourself you’ve done all you can. “The symbolic representation of the thing vs. the thing itself.”

          I think the prior of “don’t spend a lot of money on diets” is a good one. It’s probably true that 95% of branded diet products don’t help. But the research in favor of generally whole, natural, unprocessed foods, high-fiber foods, and as many vegetables as possible and against refined carbs, added sugars, etc. looks pretty robust, especially when I tie in my personal experience, and any diet that you can stick to that generally follows these principles is way more likely to do good than harm imo.

          • Nancy Lebovitz says:

            No, what I’ve heard about is people gaining weight *after* dieting. They lose 50 or 100 pounds, and then they gain it back plus 25 pounds.

          • Antistotle says:

            No, what I’ve heard about is people gaining weight *after* dieting. They lose 50 or 100 pounds, and then they gain it back plus 25 pounds.

            Doesn’t square with:

            I’ve seen a fair number who say they’ve gained 25 pounds per diet– make that mistake 4 times, and that’s a hundred pounds. I’ve wondered whether some fraction of the obesity epidemic is the result of dieting.

            If I weigh 210 pounds, and lose 8, then gain back 2, then lose another 10 and gain back 2, and do that 2 more times I’m at 178, which is overall a 32 pound weight loss and what I weighed in 1997.

            Of course in my case I’ve been stick at the “gained back 2” for the last three weeks. 🙁 Of course I’m trying the “change my lifestyle” thing more than just calorie restriction.

            Or if I weighed 400, lost 100, gained 25, Lost 100, gained 50, lost 100 and gained 50 I’m still 225 which is WAY better.

          • Nancy Lebovitz says:

            Antistotle, I’m sorry for the lack of clarity. When I talked about people gaining 25 pounds per diet, I meant net gain per diet cycle, but that wasn’t at obvious.

            This is what I really meant.

            “No, what I’ve heard about is people gaining weight *after* dieting. They lose 50 or 100 pounds, and then they gain it back plus 25 pounds.”

          • wfenza says:

            My concern here is that the “most diets are ‘scams’” prior is going to be *extremely* harmful to any SSC reader who wants to lose weight. It’s a task that takes substantial psychological momentum and will be undermined if, in the back of your mind, there is a fear that you’re as likely to do harm as to do good.

            I sincerely hope this happens. Anyone who considers the self an aspiring rationalist should recognize the facts re: dieting, in particular the following:

            (A) diets have extremely low probability of success (where “success” means significant weight loss sustained over 3 years);
            (B) it is much more likely that a diet will result in long-term weight gain (as Nancy said, many dieters gain their weight back, plus extra, which is obviously what she meant);
            (C) exercising and eating healthy is really, really good for you, but probably won’t result in weight loss;
            (D) fat people who have a healthy lifestyle are just as healthy as thin people with a healthy lifestyle;
            (E) fat people who lose weight are the *less* healthy than both fat people and thin people who haven’t experienced significant weight loss.

            By far, the better thing for fat people to do is to make peace with the fact that they are fat and accept that about themselves. If anyone reading this decides not to diet because of this discussion, I will consider that a good thing.

          • Glen Raphael says:

            @wfenza:

            Can you elaborate on point (E)? Specifically when you say fat people who have lost weight “are less healthy” than fat people who haven’t, is this claim measurable at the level of an individual person?

      • Anonymous says:

        Most people who try diets have no idea what they’re doing at any level and are hoping to extend an unsustainable willpower burst in perpetuity.

        Humans are not adapted to food being overly plentiful and delicious. They have no reason to be. Historically, modern times are a huge anomaly wrt how much food costs, how much there is, and how accessible and delicious it is. Our instincts are wired to binge whenever we have the opportunity… which is good, except in the one situation, where it would tell us to binge all the time. Which is the case nowadays.

        Surely SSC readers should at least maintain realistic aspirations of being in the 5% here?

        They should, and I would expect that those highly gifted in self-discipline are overrepresented here.

    • Antistotle says:

      I one way you’re right–“Diets” are a scam.

      What you need to do, and what some people (not me) have successfully done is to change their diet and lifestyle. That is a LOT harder because you have many other factors (social, religious, occupational) playing in.

      • wfenza says:

        Eating food is not a lifestyle. Eating less doesn’t involve lifestyle change, just changing what/how much you eat.

        • Anonymous says:

          Eating less doesn’t involve lifestyle change, just changing what/how much you eat.

          Not necessarily true.

          For instance, if someone else prepares your food – like your mom/dad/grandma/whatever – they may be resistant to fulfilling your dietary wishes, and loading you as much as you want on the plate. Storing too much food in the house is also a problem that can very easily be fixed if you live alone, but not so much when you live with other people.

    • cuke says:

      How much of this result I wonder is because many of us still think of “diet” as something you do for awhile to lose weight before going back to what we did before? While losing weight and keeping it off depends on changing how one eats in the same way stopping problem drinking or stopping smoking entails upholding a continuous behavioral change from now to eternity.

      (ETA: I’m not speaking to one’s health status or genetics here. I know there are lots of people who eat well regularly and still have more fat on their bodies than they or their doctors would like. I’m just talking about the segment of folks who might think dieting to lose weight is a temporary state, like training for a marathon might be for others).

      • Nancy Lebovitz says:

        cuke, I keep hearing that losing weight and keeping it off requires a permanent (and generally will-power driven) behavioral change rather than just doing enough to lose the weight, but I have no idea how many people actually believe just losing the weight is all that’s needed.

        I find it as least as plausible that maintenance is more work than a lot of people are willing to put in, but they didn’t know that. As for why, as some do, they keep making the same mistake, I could speculate, but I’m not sure that I should.

  26. Disillusioned9 says:

    I take issue with the specific guideline you laid out for diets for one big reason: you are enacting a much bigger behavioral change than, say, taking a medication twice a week (even that can be hard for some people), and making behavioral changes is really, really hard. Doctors can’t easily track what exactly patients are eating beyond observing weight and physiological fluctuations. It takes weeks, if not months to develop a habit, everything in you will fight against change, and if you don’t adequately address the root causes from depression or obesity, any progress you make will get erased in the long term.

    That doesn’t mean a guideline isn’t useful, but much more emphasis needs to be placed on setting up the proper environments for behavioral change to maximize adherence, as well as carefully examining and then addressing root causes. For example, with antidepressants, an estimated 50% of the effect comes from placebo, with another 25% coming from natural healing over time. Just 25% comes from the actual chemical effects, and it comes with a host of side effects (when accounting for chemical effects alone, fixing sleep schedules and exercise both outperform on average). To the extent you decide to use them at all instead of placebo, you had better use any temporary buoying from these drugs to resolve underlying problems such as an intrinsic feeling of unworthiness, loneliness, lack of sense of purpose, and extrinsically driven mindsets, and prescribe ways to improve social connection and intrinsic motivation.

    As for obesity, for a signficant number of people (childhood) trauma preceded weight gain. They remain obese not just from lack of willpower, but also because it draws away unwanted attention and implicitly lowers others’ expectations of them. You will need to address these real causes, as well as provide strategies on how to avoid junk food, devise preset courses of action if they are encountered, and how to react to temporary setbacks or habit violations (or anything triggering their root causes).

    (By the way, I really enjoyed Lost Connections by Johann Hari. It mostly addresses the underlying causes and solutions of depression, and that tidbit about obesity came straight from the book).

    • Glen Raphael says:

      As for obesity, for a signficant number of people (childhood) trauma preceded weight gain.

      Hang on: what percentage of people who didn’t gain weight had childhood trauma? How is the childhood trauma being measured/interpreted? This is tricky stuff.

    • cuke says:

      NIH says that about 50% of depression patients are noncompliant in taking antidepressants:

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3398686/

      In my experience as a talk therapist, clients with depression have huge motivation difficulties that are part of the depression and those difficulties work well to keep depression in place — ie, difficulties sticking with medication long enough to see if it works, being willing to make more social connections or engage in other self-care habits, keeping up some regular routines that improve diet, sleep, and school/work habits. This isn’t because depressed people are lazy but because depression wrings motivation out of people and also, as you say, because making behavioral changes is hard even under good circumstances, which having depression definitely is not.

      And as with the ACEs research sparked by the obesity studies you mention, people with depression also have a higher likelihood of trauma history. To further complicate things, early childhood trauma makes people less likely to respond to antidepressants:

      https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5070060/

  27. jimrandomh says:

    For diets, unlike depression medications, there is a large and influential contingent which believes that the only actual failure mode for diets is noncompliance, because something something “calories in calories out”. If that were true, then the main effect of a multi-intervention guideline would to let people skip actually doing their diet, because there’ll be another one later. Meanwhile the effectiveness of all the diets is pretty strongly correlated, because they’re all based on cutting calorie intake; ideology says they *have* to be based on cutting calorie intake because anyone overweight must be eating too much and overweight people with deprivation-based eating disorders don’t exist. (They do exist.)

    Meanwhile if you exit the fucked-up land of nutrition advice for overweight middle aged people and go over to the land of nutrition advice for athletes, you will find that the advice there is diametrically opposed to the advice for people trying to lose weight: gain muscle first, and gain it by a combination of weightlifting (not “cardio”) and eating a very large calorie surplus. (See in particular the book Starting Strength, which has one chapter on nutrition which gives dietary advice that I believe actually works, that is conventional wisdom among bodybuilders, and that would have a very hard time getting past an IRB.)

    • Deiseach says:

      There’s also something about exercise which I only saw recently as a line in a study on blood pressure, which went something like “the exercise needed to get fit is much less intense than the exercise to lose weight”.

      So “fat and fit” can be a thing, where you do the amount of exercise (of whatever variety) that does have a beneficial effect on your cardiovascular system and may tone you up a bit, but to lose the weight you have to drastically up the effort and amount and hours of exercise. Which I imagine most people don’t, since they assume that “getting fit = losing weight” and no, apparently these are not the same thing at all.

      • Anonymous says:

        Strongfat (bear mode) is definitely a thing. I even know a woman who is that – skis for a hobby, but looks like a sumo wrestler.

      • Aapje says:

        @Deiseach

        Many people have a natural tendency to increase their calories to compensate for what they burn. It can be very hard to diet while exercising heavily.

      • A1987dM says:

        That sounds very backwards to me. IME, if I walk at a leisurely speed a hour a day I will lose weight (because I wouldn’t eat that much more) but I don’t think that otherwise improves my fitness all that much, where if I do high-intensity exercise it probably improves my cardiorespiratory/muscular fitness quite a bit but I’ll increase my eating more than enough to compensate for the energy expenditure and won’t noticeably lose weight.

        • Nancy Lebovitz says:

          I think a little exercise is a big advance over no exercise.

          In my case, if I’m extremely sedentary, I get what I call the food jitters. It’s a strong desire to eat– apparently for the sensory stimulation– even if I’m not hungry.

          Fortunately, I have pretty low pain tolerance, so if I’m pretty full, I get irritated that I can’t eat more rather than bingeing.

          • AG says:

            Anecdote: my appetite was slowly increasing, then I went on a couple of huge 10+ mile hikes, on both of which I only had small-ish protein bars for food on, and my appetite shrank quick a bit, and my weight retention (in the belly) seems to have increased.

            When you get your body in the “must use energy efficiently to maintain this level of activity without expected food intake!” endurance mode, exercise decreases metabolism. Some studies show that walking in hot weather does this, as well, which makes sense.

          • Lambert says:

            I suspect hot weather walking is more about hydration.
            It takes a lot of water to digest food.

    • Antistotle says:

      The diet advice in Starting Strength is largely targeted at college age +/- a few years people.

      If I try to GOMAD I’m going to..it’s going to be ugly.

      Also if you’re already well over weight then you don’t need MORE calories, you need protein at the right times, and water soluble vitamins because you have enough of the fat soluble kind. Mostly.

      But that’s really a quibble. And it’s still “calories in v.s. calories out”, it’s just that the calories out side of the ledger goes up in several ways (caloric expenditure in exercise, muscle building, etc).

      The thing about a athletic diet is it presupposes an athletic lifestyle. Changing from a sedentary lifestyle to a very active one is just as uncomfortable as changing from a lots of food lifestyle to a lesser food lifestyle.

      • Freddie deBoer says:

        yeah I think the bigger thing is that different things work for different bodies and the search for one plan of attack for weight loss is misguided

  28. Deiseach says:

    How come I’ve never seen a diet guideline?

    Because people (and I include myself as a failed dieter here) don’t goddamn know what they eat, how much, what’s in what they eat, or what a “serving”, “portion” or other recommended size is. I had my best results when I made a list of exactly how many carbs were in everything, what a serving/portion size of everything really was (not an eyeball estimation, what the damn recommended serving size in grams was, and I can tell you it’s fun trying to translate American “a cup of X” into British imperial into metric measure for everything from potatoes to almonds), set a “maximum grams of carbs per day limit” and worked out things like “five servings of fruit/veg a day, and a serving = eight grapes”. I kept track of everything I ate per day on Excel so I could see from day to day “I’ve hit my maximum/I’m under it/if I have one more serving I’m over it”.

    But life is too busy to count grapes, so eventually I fell off that diet and packed the weight back on.

    “Low fat” options? May be busy trumpeting how they’re 0% fat! on the packaging, neglect to tell you (until you read the tiny print) that they’re packed full of sugars/carbs to replace the fat. Oftentimes you’d do better to go for the full-fat version and simply not eat the entire six-pack of whatever at one sitting.

    People whom nature has blessed with “well I only eat when I’m hungry, never eat to satiation, don’t nibble or snack, and find exercise naturally pleasant and something I want to do, sticking to a healthy weight is so easy, why doesn’t everyone manage it!”, you have little idea how lucky you are 🙂

    • Anonymous says:

      Have you ever tried fasting (intermittent and not)?

      Aside from that Scottish guy to whose study I linked to, I have also found that fasting works for me. This recent Holy Week, I consumed only water, unsweetened tea, vitamin and mineral supplements and Eucharist. Lost 5kg. Was hungry pretty much all the time, but it wasn’t unmanageable.

    • Calvin says:

      That doesn’t explain why there isn’t a dieting guideline who’s first step is “without changing what you eat, track everything you eat on a notepad then look up how many calories everything you ate is”.

      Next steps would be “now do the same thing but carry a mini scale around and weigh your food before writing it down on the notepad”, followed by “do the same thing for a week, then the next week try lower calories by 200-500 from the average of the previous week” etc.

      • Anonymous says:

        That doesn’t explain why there isn’t a dieting guideline who’s first step is “without changing what you eat, track everything you eat on a notepad then look up how many calories everything you ate is”.

        There should be, because self-monitoring is pretty much the be-all, end-all technique to sticking with any resolution.

        https://www.ncbi.nlm.nih.gov/pubmed/19916637

      • Nancy Lebovitz says:

        I’ve seen at least the first guideline.

        And also a recommendation to start by just photographing everything you eat, though I think that one is expected to change behavior.

      • Edward Scizorhands says:

        You don’t need a scale, but it helps.

        If you think “1 piece of chicken the size of a deck of playing cards is 4 ounces, and 4 ounces of chicken is 190 calories,” then you will establish a baseline from where you can adjust.

        Even if your baseline is wrong, as long as you are somewhat consistent, you will be able to adjust from it.

        I need 3000 calories a day, but this isn’t 3000 calories a day as measured by God using a bomb-calorimeter. This is 3000 calories a day as measured by Edward, using Edward’s measuring techniques, of food cooked by Edward and his wife, as processed by Edward’s body, and not bothering to list the no-calorie things. And that’s what’s important, because for the rest of my life I’m going to be using that scale, since I have no other choice.

    • xXxanonxXx says:

      At the risk of sounding like I’m advertising, tracking is pretty easy to do with this app. It has most prepackaged foods, menu items from chain restaurants, etc… You just search for what you’re eating and click on it. Preparing your own food is a bit more of a hassle, admittedly, but still easier than working it all out yourself.

      • bbeck310 says:

        The problem is, if you believe Guyenet, hyper-palatable packaged foods are the problem–and tracking gives you an incentive to prefer those foods because the large corporations that make them provide calorie information that isn’t as easy to figure out if you cook for yourself. I found when I was tracking, I’d prefer to get fast food over cooking at home because it was so much easier to track!

        • xXxanonxXx says:

          I’ve had the same issue honestly. Typically I get out of it by making bulk meals on the weekend which is easy and has the additional benefit of saving money.

          I still say you’re better off tracking and eating those processed foods then cooking for yourself and having no idea how many calories you’re actually consuming. Unless you’re smart about what groceries you buy (and SSC readers aside, I don’t think most people understand even the basics of this) it’s easy to make a meal as calorie dense as anything you’ll get at Burger King.

        • Edward Scizorhands says:

          Until I tried it, I used to think I’d never be able to measure my food, because who knows how much oil my wife used while cooking?

          It turns out this doesn’t matter. I weigh the piece of chicken[1] and put it in my app (not the one listed above but that doesn’t matter) and I can establish a baseline.

          [1] A food scale is a great investment, but if you can’t, some up with a consistent measurement, like “one deck of cards == 4 ounces.” It doesn’t matter if this measurement is wrong, just that it is consistent.

    • Lambert says:

      Maybe meal-prepping and calorie counting at the same time would help.
      Keep everything frozen in boxed labelled with x kCal.
      For things like grapes, where that’s impractical, perhaps keep track of the dates when a punnet is opened and when it’s finished.
      Disclaimer: I eat far too much and still don’t put on weight.

  29. xXxanonxXx says:

    Maybe it’s not what you had in mind exactly, but I see macro tracking as essentially being guidelines. Everything from paleo to eating nothing but candy bars and pizza technically fits within it (even if its proponents will recommend you stay away from the latter). A possible problem could be that it’s too freeform for some. There’s no detailed flowchart to follow. You just track everything and make decisions based on your own psychology. Feel like getting a footlong philly cheesesteak with bacon and washing it down with a liter of beer? Go for it. You can spend the next week eating nothing but grilled chicken and brown rice to get back on track. Or maybe that’s too hard, so you leave room for treats at the end of each day and you’re back on track after two weeks instead of one.

  30. Calvin says:

    If anyone has a nootropics guideline, please share

  31. Zenos says:

    I hope the actual guidelines mention sexual side effects for SSRIs. For this reason I would generally not consider Lexapro a first-line antidepressant for young people.

    • cuke says:

      For awhile it seemed like psychiatrists liked to pair Wellbutrin with an SSRI for young people on the theory that Wellbutrin countered the sexual side effects. I have yet to meet someone who tried this who said it worked. Does anyone have more data points to offer on this?

  32. no one special says:

    Scott, this is a good article, and you should feel good. You should ignore everything I say after this point, because your example has triggered me and I’m going to rant.

    Your guideline for treating depression is missing step 0: Treat with Prozac, Paxil, or Celexa, because those are available in cheap generic form and your patient either A) Can’t afford anything better, or B) Is restricted by his health insurance formulary that they must try treatment with one of those first before they’ll be willing to pay for anything more expensive.

    Also, they probably got a prescription for one of those from their GP first before they ever got near a psychologist, let alone a psychiatrist. And their GP prescribed them a dose so low that it’s never been tested for actually helping with depression, but is only designed as a “maintenance” dose for people who basically need permanent medication!

  33. onyomi says:

    Somewhat related: hasn’t psychological research largely tended toward debunking the idea of different “learning styles” recently? I wonder if this only applies to the idea that there are some “visual” learners and some “auditory” learners, or if also more broadly?

    Of course, there is some disanalogy between mental health, nutrition, and successfully mastering a skill or knowledge set, but if an educator can object to the idea that different people can best learn the same skill using different educational strategies, presumably a dietician can object to the idea (though I imagine he’d be wrong) that there isn’t one “ideal” diet? (This seems even less likely in the case of mental health, but I don’t know if my vague impression that brains are somehow more variable than metabolisms is correct).

    Having some experience as a foreign language teacher, for example, does not convince me that there are actually some language teaching methods that work better for some students and others for others. Rather, there are better and worse students and better and worse methods. The best students will succeed even with crummy methods, the next-best with good methods, etc.

  34. Doesntliketocomment says:

    A few people have already made this point, but I’ll make it again: The primary difficult with dieting advice is that it is based around an impractically mechanical view of weight gain/weight loss, and is ignoring the deeper feedback issues. Yes, it is in fact true that the metabolic foundation is calories in vs. calories out, in the same way that blood pressure is mostly a function of Na+ levels. The thing is, a perfectly healthy and functioning human doesn’t need to count calories any more than they need to precisely measure their salt intake – their body will regulate itself. Understanding how and why that regulation failed is where the real solutions are: the ones that would benefit from the guideline approach. Everything else is just different methods of bookkeeping.

    • Anonymous says:

      The thing is, a perfectly healthy and functioning human

      …is a unicorn. A spherical unicorn in vacuum.

      • Doesntliketocomment says:

        You’re right, I should have just said “a healthy human.” What I was trying to point out is that anytime you need to do record keeping over a biological concern it is a sign of a regulatory malfunction.

        • The Nybbler says:

          A human being in an environment where food is scarce needs no such internal regulatory method. Such times have been quite common in the past. So while it seems likely such mechanisms exist (because not everyone gets fat, even without dieting), there’s no reason to believe their lack in any given person is some sort of failure or lack of health.

          • Doesntliketocomment says:

            I disagree. It is a failure – not a personal failure, not a failure of will – but a failure of a mechanism, in the same way depression is. Of course people have had abundances of food since we had agriculture, what else would you call the harvest? Our ancestors had to look six month’s worth of food in the face and eat a single bowl of it. You would imagine we could handle our refrigerator.
            “Well, they knew that if they ate too much they’d starve” True, but that’s very similar to knowing that if you eat too much you’ll get fat. If it was just about the ability to think long term we shouldn’t be any worse at it today.

          • The Nybbler says:

            Our ancestors had to look six month’s worth of food in the face and eat a single bowl of it.

            You’re talking about short-term abundance, not long-term abundance. Sure, humans need (and most have) mechanisms to keep us from eating mass quantities in one sitting. But to overeat by a few percent day after day after day… that’s something the environment usually prevented.

          • onyomi says:

            I think people underestimate the extent to which their eating autoregulates through sensations of satiety and fullness… and how quickly they might lose or gain weight were those calibrations changed somehow.

    • xXxanonxXx says:

      Understanding how and why that regulation failed is where the real solutions are

      It seems obvious to me the regulation failed because it evolved in an environment very different than the one we find ourselves now. This means means simulating the old environment (the logic behind diets like paleo), or using some sort of bookkeeping to protect against the excesses capitalism has wrought.

      • Doesntliketocomment says:

        One of my concerns with the paleo diet is that it involves a lot of speculation and logical leaps to try and recreate an allegedly healthier diet from prehistory, when my grandparents weren’t fat and had relatively normal to long lifespans (70-98). It would seem much more practical to just eat what they ate.

        • Anonymous says:

          Precisely, although I would add that grabbing more of their lifestyle in general would probably help more.

          • Randy M says:

            Paleo people I’ve read have all emphasized this–move more, less sitting, get outdoors, lift, interact with people, sleep when you’re tired, etc.

        • xXxanonxXx says:

          That is basically how I eat now barring cheat days. It’s a fridge full of lean beef, chicken breasts, rice, fruit and veggies. I suspect anyone who stocked those items, and ONLY those items (i.e. they didn’t buy butter to cook the chicken in or drench their salads in dressing) would maintain a healthy weight with minimal exercise and without having to track anything. Maybe that’s overly optimistic. Personally I find it easy to stay at a calorie deficit when eating those kind of meals and if anything have the opposite problem. Eating becomes a chore.

  35. arlie says:

    We write things like this in software engineering.

    Sometimes we give them to people who don’t understand them to execute [=follow slavishly]; that’s why “tech support” is often pretty horrible, if you have a non-standard problem, and enough knowledge of the area (more than the person “supporting” you?) to realize that.

    But just as commonly we write them for our peers, expecting them to use their own judgment and commonsense about how and when to apply them.

    And I’ve been known to write them for myself, as a workaround for constant interruptions and other poor working conditions. (I only need to be able to focus well while writing the heuristic process [= guidelines]; I can be in my ordinary distracted state of mind while following them.)

  36. JohnBuridan says:

    Example from my workplace:

    1. If you have a problem with something an employee has done or is doing, ask them why they did it, and allow them to speak to the issue.
    2. If the issue is unresolved go to their team manager and present your issue.
    3. If the issue is still unresolved speak to the boss.
    Addendum: as a manager or the boss redirect complaints and issues back to their appropriate level, before addressing them.

    IMO, this is the mature manner for handling problems and diminishes the power of workplace politics. Has anyone had a system like this? We are fairly fastidious about enforcing it, and I think it made a world of difference the last two years.

    Example from expertise:
    When I grade papers I follow something similar to this. I grade for three qualities style, content, and organization.
    Style is everything from grammatical correctness to word choice and sentence variation.
    Content covers the points of the argument, their coherence, and their relationship to the thesis statement.
    Organization is the use of paragraphs to clarify an idea, the wise choice of those ideas, and the logical sequencing of them.

    The actual guideline I’ve invented when grading increases the stakes, depending on the skill of the author. Although I do not know exactly who wrote each essay (since each has the name replaced by a random string of integers).

    Style1. Does the essay use proper grammar and avoid fragments? If yes, go to Style2. If no, is it egregious, moderate, or seldom? Write a comment showing them where they can improve.

    Style2. Does the essay have appropriate word choice, avoid random tense changes, and include proper citations? If yes, go to Style3. If no, is it egregious, moderate, or seldom? Write a comment showing them where they can improve and praising what they did well.

    Style3. Do the sentences flow together, incorporate action verbs over being verbs, and avoid the passive voice? If yes, student is on the A track; go to Organization1. If no, is it egregious, moderate, or seldom? Write a comment showing them where they can improve and praising what they did well.

    Organization1 etc.

    I had never thought of this formally before, but this is what I do. Now the question, I suppose, how is this different from a rubric? I am not sure. I think of a rubric as a type of checklist, while I think guidelines are more like flowcharts. Does anyone else share this intuition?

    I think when I grade essays, I have flowchart mentality that ups the stakes depending on how well the student is doing. I believe in working the students very hard on writing, so that even the strong writers must improve to maintain an A. I also believe writing is a field where most anyone can improve, since most have verbal ability, basic reasoning, and can follow a method.

  37. TomA says:

    Guidelines are a socially evolved mechanism for codifying and disseminating group wisdom. They should refine themselves over time (slowly) as new information or experience result in improvement. We seem to be losing the ability to efficiently pass wisdom from generation to generation.

  38. rahien.din says:

    I think you may be overselling this, from two angles.

    First, most medical guidelines are not always so neatly algorithmic, or so clearly-evident from the literature.

    Any good guideline will provide grades both for the quality of evidence upon which the guideline is based, and for the strength of recommendation. Something like :

    Classification of Therapeutic Evidence

    Class I. Randomized controlled clinical trial (RCT) in a representative population. Masked or objective outcome assessment. Relevant baseline characteristics are presented and substantially equivalent between treatment groups, or there is appropriate statistical adjustment for differences. Also required: Concealed allocation. Primary outcomes clearly defined. Exclusion/inclusion criteria clearly defined. Adequate accounting for dropouts.

    Class II. Cohort study meeting criteria for Class I or a RCT that lacks one or two of those other criteria. All relevant baseline characteristics are present and substantially equivalent among treatment groups or there is appropriate statistical adjustment for differences. Masked or objective outcome assessment.

    Class III. Controlled studies (including well-defined natural history controls or patients serving as their own controls). A description of major confounding differences between treatment groups that could affect outcome. Outcome assessment masked, objective or performed by someone who is not a member of the treatment team.

    Class IV. Did not include patients with the disease. Did not include patients receiving different interventions. Undefined or unaccepted interventions or outcome measures. No measures of effectiveness or statistical precision present or calculable.

    Classification of Prognostic Evidence

    Class I. Cohort survey with prospective data collection. Includes a spectrum of persons at risk for developing the outcome. Outcome measurement is objective or determined without knowledge of risk for developing the outcome. Also required: a. Inclusion criteria defined b. At least 80% of enrolled subjects have both the risk factor and outcome measured.

    Class II. Cohort study with retrospective data collection or case-controlled study. Study meets criteria a and b (see Class I). Includes a broad spectrum of persons with and without the risk factor and the outcome. The presence of the risk factor and outcome are determined objectively or without knowledge of one another.

    Class III. Cohort or case control study. Narrow spectrum of persons with or without the disease. The presence of the risk factor and outcome are determined objectively or without knowledge of the other or by different investigators.

    Class IV. Did not include patients at risk for the outcome. Did not include patients with and without the risk factor. Undefined or accepted measures of risk factor or outcomes. No measures of association or statistical precision presented or calculable.

    Classification of Recommendations

    Level A rating: One or more class I studies or two or more consistent class II studies
    Conclusion, level A: Established as effective, ineffective, or harmful for the given condition in the specified population
    Recommendation: Should be done or should not be done

    Level B rating: One or more class II studies or three or more consistent class III studies
    Conclusion, level B: Probably effective, ineffective, or harmful for the given condition in the specified population
    Recommendation: Should be considered or should not be considered

    Level C rating: Two or more consistent class III studies
    Conclusion, level C: Possibly effective, ineffective, or harmful for the given condition in the specified population
    Recommendation: May be considered or may not be considered

    Level U: Lack of studies meeting level A, B, or C designation
    Conclusion, level U: Data inadequate or insufficient. Given current knowledge, treatment is unproven.
    Recommendation: None

    Almost all of the guidelines I have encountered will qualify the menu of actions they present. For instance, the American Epilepsy Society’s guidelines for the treatment of convulsive status epilepticus describes the following :

    A benzodiazepine is the initial therapy of choice (Level A)

    Choose one of the following 3 equivalent first line options:
    – Intramuscular midazolam (Level A) OR
    – Intravenous lorazepam (Level A) OR
    – Intravenous diazepam (Level A)

    If none of the 3 options above are available, choose one of the following :
    – Intravenous phenobarbital (Level A)
    – Rectal diazepam (Level B)
    – Intranasal midazolam (Level B)

    There is no evidence based preferred second therapy of choice (Level U)

    Choose one of the following second line options :
    – Intravenous fosphenytoin (Level U)
    – Intravenous valproic acid (Level B)
    – Intravenous levetiracetam (Level U)

    If none of the above options are available, choose one of the following (if not given already) :
    – Intravenous phenobarbital (Level B)

    There is no clear evidence to guide therapy in the third phase (Level U)

    Choices include : repeat second line therapy or anesthetic doses of either thiopental, midazolam, pentobarbital, or propofol

    Notice that there are level U treatments that coincide with or even precede level B treatments. And once you reach a certain point, it is purely the treating doc’s choice.

    Second, insofar as a guideline is algorithmic, there isn’t any distinction between “recommendation” and “guideline.”

    A recommendation is simply something one may decide to do, but, even this thing is composed of component actions. For instance, the decision to test for inborn errors of metabolism is the decision to perform the following meaningful actions :

    1. Perform sterile venipuncture
    2. Draw blood into appropriate transport media
    3. Partition the blood into samples necessary for each test
    4. Perform each test
    5. Potentially, perform reflex testing based on the results of initial tests
    6. Communicate interpretable results to the ordering physician

    Each of these also consists of a set of meaningful actions. But when I test for inborn errors of metabolism, I am not consciously choosing to do each of these and in the correct order. I am choosing to do the test procedure, meaning, I am engaging an algorithm. The actions therein cohere to each other like drops of water on a windowpane.

    It’s like dancing the foxtrot. Dancing the foxtrot is not a set of sequential decisions regarding how one moves their feet. The foxtrot is composed of sequential actions that together form a coherent whole. A guideline is the same way. To the extent that the actions therein follow coherently and in a defined order, a guideline is not a set of independent actions, but rather, a unified procedure.

    So, when I tell my trainees “Test for inborn errors of metabolism” or “Treat the patient’s status epilepticus,” my recommendation is that they follow the procedure set forth in the guideline.

  39. Rusty says:

    This isn’t exactly your point but the diet guidelines seem doomed to failure. It is all ‘reduce calorie intake by following [insert diets A – D]. I gave up smoking it was using a book written by Allen Carr. The Easy Way to Quit Smoking. And it turned out he was right. It was dead easy. It worked because he convinced me I didn’t enjoy smoking. Once believed that it really was easy. Just get over the withdrawal (takes about 2 weeks) and never looked back. But if someone had told me ‘Try the book and if that doesn’t work we have other ways to approach this’ it would have failed. The idea would have been in my head that giving up smoking is really hard (and by inference that smoking must be a big pleasure – and I can resist everything except etc etc) And likewise diets. Of course dropping calories is how it works but if you have a ‘diet’ already you are giving up something that is pleasurable. And I can resist everything except etc etc. So you need be persuaded that the foods that don’t make you fat are in fact the foods that are the most pleasurable. That is how his book on losing weight works. But if you say ‘And if that doesn’t work we he have other options’ the whole thing falls apart. You’d be conceding that someone might not want to eat their favourite foods and if you concede that you pretty much say ‘well maybe these aren’t your favourite foods, we will have to see’. And you’re sunk.

    • cuke says:

      This is a really interesting point to me about how we can rally motivation for behavioral change when exit strategies have been eliminated.

      I had to cut out some foods when I got gut sick years ago. Eliminating those foods wasn’t so hard because every time I ate them I felt worse (ie, it wasn’t pleasurable anymore). Turns out I had an exotic parasitic infection and once treated I could eat more foods, but eliminating those foods keeps my weight steady without having to work at it so I continue to see those foods as not an option in the same way someone who quits smoking sees cigarettes as no longer an option.

      I’ve seen people quit smoking and drinking in similarly tight situations brought about by medical conditions or legal or relationship consequences (not always obviously). So it seems to me there’s something to be said for creating a sense of no exit around a behavioral change.

      Often in that “contemplation” state of behavioral change, a person is accumulating evidence of the costs and consequences of not changing their behavior until it gets to the point that the person feels that they have no alternatives left than to make the change they really didn’t want to have to make. People in the recovery/addictions field may call this hitting bottom, but you can see how it could apply to a lot of other situations. And that having a healthcare provider say, “oh you have lots of things to try if this one doesn’t work” (when it comes to behavioral change) may not be that motivating. Not sure how I feel about that though.

    • Nancy Lebovitz says:

      I took a look at the amazon reviews for Carr’s book about losing weight, and for a lot of people he went a step too far– later in the book, he claims that people should be vegan or vegetarian, and that’s a step too far for many readers.

      This being said, a lot of junk food is engineered to produce desire without satiety, and it might not be too hard for people to convince themselves that those foods actually aren’t much fun.

    • rahien.din says:

      Scott Alexander convinced me in a similar fashion that I enjoy eating healthy more than I enjoy eating junk food.

  40. caethan says:

    Take dieting. Everybody has recommendations for what the best diet is. But no matter what diet you’re recommending, there are going to be thousands of people who tried it and failed. How come I’ve never seen a diet guideline? Why hasn’t someone written something like:

    Showed your post to my wife the endocrinologist. Her response: “Of course there are clinical guidelines for obesity treatment. Want to see them?” So, here you go, in flowchart form:

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5819889/figure/F1/

    And from the full paper, specifically about dietary advice (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5819889/):

    ES2
    A variety of dietary approaches can produce weight loss in overweight and obese adults. All of the following dietary approaches (listed in alphabetical order) are associated with weight loss if reduction in dietary energy intake is achieved:

    A diet from the European Association for the Study of Diabetes Guidelines, which focuses on targeting food groups, rather than formal prescribed energy restriction, while still achieving an energy deficit. Descriptions of the diet can be found in the Full Panel Report supplement.
    Higher-protein diet (25% of total calories from protein, 30% of total calories from fat, and 45% of total calories from carbohydrate), with provision of foods that realize an energy deficit.
    Higher-protein Zone™-type diet (5 meals/d, each with 40% of total calories from carbohydrate, 30% of total calories from protein, and 30% of total calories from fat) without formal prescribed energy restriction but with a realized energy deficit.
    Lacto–ovo–vegetarian–style diet with prescribed energy restriction.
    Low-calorie diet with prescribed energy restriction.
    Low-carbohydrate diet (initially <20 g/d carbohydrate) without formal prescribed energy restriction but with a realized energy deficit.
    Low-fat vegan-style diet (10% to 25% of total calories from fat) without formal prescribed energy restriction but with a realized energy deficit.
    Low-fat diet (20% of total calories from fat) without formal prescribed energy restriction but with a realized energy deficit.
    Low–glycemic–load diet, either with formal prescribed energy restriction or without formal prescribed energy restriction, but with realized energy deficit.
    Lower-fat (≤30% fat), high-dairy (4 servings/d) diets with or without increased fiber and/or low-glycemic-index (low–glycemic-load) foods with prescribed energy restriction.
    Macronutrient-targeted diets (15% or 25% of total calories from protein; 20% or 40% of total calories from fat; 35%, 45%, 55%, or 65% of total calories from carbohydrate) with prescribed energy restriction.
    Mediterranean-style diet with prescribed energy restriction.
    Moderate-protein diet (12% of total calories from protein, 58% of total calories from carbohydrate, and 30% of total calories from fat) with provision of foods that realize an energy deficit.
    Provision of high–glycemic-load or low–glycemic-load meals with prescribed energy restriction.
    The AHA-style Step 1 diet (prescribed energy restriction of 1500 to 1800 kcal/d, <30% of total calories from fat, <10% of total calories from saturated fat).

      • caethan says:

        A) Yes, because BMI is a useful tool that can be easily calculated in 30 seconds in the doctor’s office

        B) If you’d bother to read the full guidelines, you’ll see that supplementary measurements (particularly waist circumference) are used too.

        • Anonymous says:

          A) Yes, because BMI is a useful tool that can be easily calculated in 30 seconds in the doctor’s office

          It doesn’t take much longer to calculate approximate body fat percentage, and that’s a huge improvement over BMI.

          B) If you’d bother to read the full guidelines, you’ll see that supplementary measurements (particularly waist circumference) are used too.

          I’ll pass, thanks.

    • Deiseach says:

      All of the following dietary approaches (listed in alphabetical order) are associated with weight loss if reduction in dietary energy intake is achieved

      The important part is what I bolded – the various diets work IF YOU EAT LESS THAN THE ENERGY YOU EXPEND. So the particular diet doesn’t matter, what matters is “this diet cuts down on calories from [thing] so if you stick to it you lose weight”.

      The problem is, sticking to it. And for some people, low-fat medium-carb will work, for others they’ll be hungry and miserable and tempted to cheat. For some high-fat low-carb will work, for others all that fat will make them nauseous and have diarrhoea. So there isn’t a simple “one diet for everyone, guaranteed to work”, which brings us back to where we started: if a study says “Moderate-protein diet (12% of total calories from protein, 58% of total calories from carbohydrate, and 30% of total calories from fat)” is the diet to go for, and your doctor puts you on it, and for whatever reason you don’t stick to it, then that diet has failed for you. Finding the diet that works for you (which means “one I will stick to”) is the challenge.

      • engleberg says:

        Wiki- William Banting’s Letter’s on Corpulence. Two hundred years old, so he wasn’t a TV shill, but maybe an undertaker trolling for customers.

  41. eggsyntax says:

    re: nootropics — Reddit is very rarely my go-to for authoritative information, but the folks at /r/nootropics have done a fantastic job putting together a pretty comprehensive FAQ, which has a good section for where to start based on what you want to improve.
    It’s certainly not as flowcharty as your simplified depression guideline (it doesn’t really include, “if this failed, try this next”), but it’s by far the closest thing I’ve found on the subject.

    I’d also like to throw out a mention of examine.com. Everything I’ve seen there has been a high-quality summary of the evidence, and they avoid business models that would lead to conflicts of interest (their income is from selling their book on the subject, which IMHO is worth buying — it’s in electronic form, and you get updates as they do more research).

  42. Carl Milsted says:

    Denise Minger has written some very deep posts on why certain diets work for some people and not others. For example, here are some reasons why some people do very poorly as vegetarians while others do fine.

    And here, she makes a case for extreme low fat to a paleo audience. The fifth graphic is both hilarious and enlightening. (Basically, she says there is evidence for both extremes.)

    Finally, Nassim Taleb makes a case in Antifragile for varying one’s diet dramatically. Eat a big steak one day. Go vegan for several days. Indulge some days. Fast others.

  43. skef says:

    Yeah, but what happens to your dieting guideline when your psychiatrist puts you on Remeron?

  44. Jalex says:

    In response to this post, Scott Aaronson has written a set of guidelines for upper bounding probabilities of bad events in theoretical computer science.
    https://www.scottaaronson.com/blog/?p=3712

  45. keranih says:

    I think the primary thing missing from the examination of “why are there not more treatment/usage algorithms in use throughout various fields” is an understanding of the legal status of the people and tools involved.

    Doctors are a special protected class with both privileges and restricted rights, who have a financial and social status that relies on continued adherence to guidelines.

    Medications (esp behavior modifying medications) are tools whose possession and use is restricted by laws.

    In this situation, it is very reasonable for relatively formal guidelines for use to be constructed, particularly for a narrow set of circumstances. I do recommend ‘The Checklist Manifesto’ by Atul Gawande for reading about the utility of guidelines and “if not this, then that”. The book makes it very clear that checklists/guidelines are exceptional tool for distilling expert opinions and admirable thought processes down into something that can be usefully followed by people with less intelligence, expertise, and/or time at hand.

    Out in the rest of the world, when the stakes are not as high as a possibly suicidal patient(*), or a possibly crashing aircraft(**), and when the tools or actors are not as regulated as in medicine (or piloting) the same options channeling doesn’t happen. People wander about the landscape, trying this and trying that, in the hopes that a new and better method will be revealed. This sort of “trying a thing that other people haven’t” is some times called “counter culture” and sometimes “liberty.” (***)Given the lack of understanding of relative constants and relative variables in the environment and in humanity, this sort of experimentation is, I think, the only way we can expect to make progress.

    That, and writing down the results of our mini experiments, so that more indepth investigations(****) can be made.

    (*) Which might ruin the career of the doctor, among other things
    (**) Which might ruin the career of the pilot, among other things
    (***) and sometimes “obsessive people wasting time on things no one cares about”
    (****)another thing which is subject to control, regulation, and guidelines – right, Scott?

  46. melboiko says:

    > Are You Willing To Devote 100 Hours Of Your Life To Seeing If

    I’m doing an experiment where I (wanted to) devote 200 hours of my life to learning German, 4 hours a day(with a grammar book from 1863) (no kink-shaming, please).

    I’ve already passed the 100-hours mark. Here are a few observations about devoting 100 hours of your life to seeing if things:

    1. It frigging’ works. It’s incredible. With one month of study, I was able to skip an entire semester at the college course (from A1.2 to A2.2, jumping straight over A2.1)—and my score damn near let me skip two in a row, even. As an unexpected side effect—I’ve been doing the exercises by hand (no kink-shaming, please), and after about a month of 1~2 hours of daily writing, my handwriting has improved dramatically, from “horrid” to “quite decent, really” and well on its way to, dare I say it, “beautiful”. I have had terrible handwriting for my entire life and I though I just lacked some mysterious genetic talent for it. Turns out that practicing things every day makes you good at them. Who would have thought?!

    2. It’s friggin’ HARD. Practicing something a few hours a day every day is an entire other dimension of hardness than reading books about practicing something a few hours a day, fantasizing about practicing something a few hours a day, or half-heartedly starting for a couple days before losing interest. Every minute is mentally intensive and the whole thing leaves you almost physically exhausted, as if after hiking. Hiking every day. About half the time I fall short of my 4-hour/day original goal. The book has 50 lessons and I wanted to finish one per day; this also has proved too optimistic (though I lasted until lesson 30). I have to block myself from the Internet and smartphones completely, or else I don’t have even a chance at concentration. I had to stay up late several times. It has definitely interfered with the rest of my life more negatively than I want to admit. After the 1 month mark I started losing steam. It’s not a torture, most of the time I’m in flow, but I do have to drag myself to it sometimes, and sometimes I fail to.

    “You can do anything but you can’t do everything”, goes the cliché. Actually having the experience of something gives a new epistemic relationship with clichés. I now feel like this is absolutely true and it’s the best thing ever and it’s the worst thing ever.

    I’ve read a lot of self-help books back in my day, and none of them helped me. Then again, I’ve never actually put up the hours for their shiny, bright-eyed life improvement programs. I wonder if I would become happier or less anxious or better at time management if I actually did the things for a change. But the idea of taking up even one more thing to practice daily is now downright terrifying.

    Now if you excuse me I still have a couple hours left today…

    • alchemy29 says:

      Getting good at things really is hard – and people who are wildly successful internalize this in a way that other people do not. Growing up, I would say I never really exerted myself – practicing music meant sitting down for maybe half an hour a day mostly playing things I was comfortable with. Studying meant sitting down for at hour at most memorizing enough to get an A in a class (which was not hard). But getting good at things takes a an incredible amount of drive and patience to fend off the monotony. Some professional musicians practice for literally 10+ hours per day. The best professional Go players will spend most of their waking hours doing problems, studying theory, and playing games – I assume chess is similar. I believe, the same is true for basically any professional endeavor at the highest level.

    • SamChevre says:

      Self-study is HARD; valuable, but hard.

      This kind of studying that you are doing is very typical for actuaries (I’m an actuary). Three months, twice a year, of studying four hours a day, for 5 years, will get most people finished with the exams.

      It took me 15 years.

  47. Phil Goetz says:

    Self-help may get a bad rep because we only call a domain “self help” if it’s one in which experts and laymen both usually fail. “Auto repair for dummies” isn’t in the self-help section.

  48. LepidopteristBB says:

    Scott, you notice that clinical depression is largely a first-world problem.

    I don’t think the root cause of most of it is a bioneurological abnormality. It comes from being conscious, educated–and especially, knowing that other people around you are doing better than you are or have a better result than you ever had a chance to achieve with your resources.

    You don’t see CD in insular tribal cultures, in places where everyone is poor, in subsistence societies where literally the only focus is surviving from one day to the next.

    This is not any kind of knock on you, your profession, or your work in the slightest–but how come society doesn’t tackle depression from that angle?

    • melboiko says:

      Hi. I’m a third-worlder. My family struggled to have enough food, we depended on social support at times, faced unemployment, mom couldn’t stay with me ’cause she was a single teenager working-class mother etc. etc. I have Poor Credentials. I’ve developed clinical depression around the onset of puberty.

      You can find endless metric tons of depressed people in any poor, broken, warring, violent country. They meet at the bar, asylum, or prison. Look for “winos”, “bums”, “vagrants” and so on. They generally tend to self-medicate with vodka, gin, cachaça, or whatever’s the local drink with the highest ethanol-per-monetary-unit rate.

      In fact, it turns out that not only has depression been linked to genetic and neurological factors, it has also been consistently and strongly linked to life issues common to poor people including death, disease, trauma, war, ostracism, discrimination etc., not to mention drug abuse, not to mention certain interesting biogenetic factors like, say, hormonal fluctuations, or Asperger’s, or certain oddly specific medicine like cyproterone acetate, or certain specific environmental conditions like seasonal affective disorder.

      So when we look at falsifiable statements about the world like: “you don’t see clinical depression in places where everyone is poor” or “in subsistence societies” or “depression comes from being educated and feeling envy” and compare them with the actual world, they turn out to be completely wrong! Let’s try one example: imagine the top 10 countries which highest suicide rates. Which did you pick? Japan? South Korea? Europe, the U.S.? Here’s the top 10: Sri Lanka, Guyana, Mongolia, Kazakhstan, Côte d’lvoire, Suriname, Equatorial Guinea, Lithuania, Angola and, only in 10th, South Korea! (The next 10 are Sierra Leone, Bolivia, Central African Republic, Belarus, Poland, Zimbabwe, Swaziland, Russia, Cameroon and Latvia—notice we haven’t even touched Japan yet!)

      Whenever you find yourself asking questions like “I wonder why the consensus of evidence-based medicine [or any other scientific consensus] does this thing instead of that other thing? That other thing makes so much sense”—try and read up on the data, you might be surprised!

  49. Regarding diet my wife recently dove into a thing (it’s a book of course) called “Whole30”. On first description it sounded to me like just another version of paleo, which I regard as basically stupid, so was dubious. But in fact it turns out that Whole30 is not a diet but rather a process…maybe call it a “hard-core guideline.”

    The “30” refers to days. What you do is, for 30 days you follow a very specific and quite restrictive intake rule. Not only no processed sugars or alcohol and gluten and peanut butter and etc but also stuff like no dairy and no legumes. It’s a long list which if meant as a new permanent diet would make frankly no damned sense. (I was like, “beans, really? Beans are bad now??”) No exceptions, if you slip up once you’re supposed to start over.

    But it’s not meant as a permanent diet. The idea is that after the 30-day “purge” that has stripped out basically everything that has been found to cause issues for any noticeable number of people, you start adding things back in one by one and see what happens.

    For my wife this has had immediate benefits. Turns out that her decades of being prone to migraine-type stuff had something to do with cow’s milk and cheese. She misses cheese but is very happy with the trade, and likes almond milk just fine. She also does seem to have some small gluten sensitivity though not strong enough to suspect celiac’s. Other things on the initial Whole30 exclusion list are back in, including the hard ciders that we love, with no ill effects.

    Bonus factor is that she’s lost some inches. It’s not revolutionary in that regard, she’s not becoming one of those “amazing diet success stories” and doesn’t need to. And I as a half-assed Whole30 tagalong have lost a little too which I know because my old jeans and khakis are sagging just enough to be annoying.

    The cost of course is prep — that Whole30 purge month is not easily compatible with prepared foods let alone takeout. (Though not _completely_ incompatible, just a big hassle.) And basically every meal I know how to make at home didn’t fit it. So my wife had to take over the dinnermaking in a completely make-from-scratch mode. There are plenty of tasty Whole30 recipes, that’s not an issue, but of course old-school cooking from scratch takes _time_.

    Also a lot of the ingredients are, frankly, precious. I make a lot of “hand-raised by virgins” jokes when I see the price per pound of the special chemical-free bacon or whatever in the shopping bags. We have spices now that I’d literally never heard of. And yet…our monthly food expenditures went _down_! One more reminder of just how much more it costs to eat out even lightly compared to cooking at home.

    Anyway based on our experience I’d recommend the Whole30 thing, provided that one approaches it in the spirit intended: not as a new set diet but as a selection/sorting process. A guideline, of a sort.

  50. disaureationist says:

    It is like you are simultaneously reading my mind and threading together frustrations that I didn’t even realize shared rhetoric. There are so many areas of my life where I have been frustrated by the fact that people are either hedgehogs for the One Twue Way or utter relativists, throwing together lists of whatever good advice they’ve come across as “options” without any level of discrimination or order.

    But then, in the case of food in particular — I’ve been on (rather: slowly coming off) an elimination diet for the past year two years now, and I cannot tell you how many times I have asked around for even just a “dietary tree” that would tell me when to add what to account for things that people react to that might be common to some foods and not others, so I could have a processual map. I could get this, in micro — individual foods where they might cause a reaction in some forms but not others. I know how to test dairy, in three stages, and the same sort of thing for tomatoes. But for most things — I am flying blind, and I have no way of even noticing patterns as I encounter them, because everything for me is just one individual food at a time, one food a week. And that’s just finding what I’m physically capable of eating. Finding a balance of foods that sustains me without causing my energy levels to crash, on top of that, is just dreadful.

  51. timujin says:

    Why is ECT a last resort anyway? It sounds effective and not very hard. Why don’t we just prescribe it to anyone who is depressed?

    • alchemy29 says:

      Possible reasons – horrible PR, it causes temporary short term memory loss, it hurts, and it’s fairly expensive (any medical procedure is going to be expensive since it costs more clinic/hospital time, staff time, there is extra administrative work, and there is the equipment itself). And perhaps most importantly, insurance probably won’t cover it as a first line option.

    • cuke says:

      I don’t know the official reasons for this, but ECT is a medical procedure that requires anesthesia and way more medical staff and facilities than prescribing a medication does. It has to be done repeatedly over some weeks and so requires the patient to suspend their lives (and often the lives of family members to be on hand to care for them if it’s not being done wholly in-patient). And it comes with a non-trivial risk of permanent memory loss, along with the risks associated with anesthesia and seizure. Most of the side effects of antidepressants are regarded as reversible. So ECT is highly effective for some people who have not responded to all other efforts, but it’s expensive and carries more risk.

    • Freddie deBoer says:

      ECT is a miracle but getting ECT can be a hellish experience even though you’re sedated for the actual procedure.

  52. magicalbendini says:

    I don’t really believe in it much, but I would love to be proven wrong. If there were a book called “You Are Willing To Devote 100 Hours Of Your Life To Seeing If Self-Help Really Works, Here’s The Best Way For You To Do It”, which contained a smart person’s guidelines on what self-help things to try and how to go about them, I would absolutely buy it.

    This sounds like a challenge.

  53. Murphy says:

    I don’t know if Scott or others will be interested in this but there’s someone I work with who’s job is managing human research such as large drug trials worth 10’s to hundreds of millions of $ . One of the things she does is go in and rescue large trials which are on the rocks. So figuring out the sources of problems and getting things back on track.

    I got chatting to her over a few drinks about regulation of research in different countries since she regularly manages international projects that have to deal with regulations in the US, Europe, UK and elsewhere.

    I brought up the outline of scotts old post “My IRB Nightmare” to get her opinion on it and she had some bullet points a bit different to most of the issues raised on here back when that topic was new.

    Mostly I’m paraphrasing but there’s a few direct quotes in there. (though those are also from memory so are only close-enough)

    1: Yes the US way of organizing IRB’s is flawed and has been fixed in the UK. Having a local IRB who are themselves sometimes extremely inexperienced and rarely having to deal with any proposals leads to problems because the IRB’s in places where little research is done often barely know what they’re doing or are supposed to be doing. It’s dramatically improved by having IRB’s deal with a steady stream of proposals from outside their institution so that the board members are more experienced… and so that they don’t feel they should spend all day thinking of “helpful” suggestions for this one proposal because it’s the only one they have in front of them for the entire meeting.

    Her other points were less charitable.

    2: I remember in one of scotts old posts talked about “types” he encountered in his job constantly. Like grandmothers who’s children won’t let see their grandchildren to extort money.

    Clinicians who sort of want to “dabble” in research, want to do it all themselves and who get overwhelmed and can’t push a project through are a *Type* she encounters constantly and mostly their research is not terribly well designed or useful.

    When I outlined scotts research as described in the post her opinion of it was “a fuckin waste of everyone’s time resources and money. he should have done it properly or not at all”

    To flesh that out, had scott got his final results how useful would it have been to other clinicians? not very. Had Scott actually got the final results it wasn’t particularly generalisable. It would have told you that the results Dr. W’s assessments did not line up with the results of this questionnaire… but not much else. Perhaps he has some systematic pattern in how he diagnoses people. Who knows. But by one way of looking at it your sample size could be described as “1, Dr W” because he was doing all the assessments.

    or one interjection of hers “contrary to the beliefs of many clinicians, their consultant is not God”

    3: almost every problem or delay Scott encountered had almost no relation to regulation. Almost every single thing was hurdles put in place by scotts own employer, the company that ran the hospital chain. In her opinion this may have been partly by design. because they don’t really want their doctors spending work hours and resources on research that doesn’t yield much profit for the organization. They may talk about wanting people to do research but what they actually mean is they want people to bring in grant income. If you’re not bringing in grant income they probably don’t really want you doing research.

    4: Her point was that in reality the actual real regulations that are actually in place are much much more minimalist and reasonable than most people believe.

    When she’s called in over a large failing project one of the conditions she sets is that the most senior person linked to the project must personally read the actual laws/regulations about doing the kind of clinical trial they’re doing. Not a summary, not someones opinion piece on it. The actual root text.

    They can take a couple days to do it but it’s entirely tractable to do so in “a couple of evenings”

    Because a common problem she encounters is chinese whispers. People who are sure that the regulations say X must be done when in reality the real regs say that you should consider doing X if there is reason to do so and that gets filtered through layers of people and you end up with someone insisting that there’s no choice, that X must be done because the rules say so.

    Often the fix for a failing project will be to force people to actually read the rules themselves, not delegate or hope someone else will do the work, then to submit a reasonably sane fix to the project to be approved that’s based on the real rules.

    Scotts employers were apparently falling into this hole hard.

    Also, a suggested rule of thumb, if there’s something like that that people don’t seem to want to do within your organization, try to find someone who’s tried before and buy them lunch in exchange for asking them what screwed up their own past attempts.

    5: Scott talked about a single paper and doctors he worked with using the questionnaire clinically but did Scott ever do any kind of systematic literature review to show that it was being used generally, not just in a couple of hospitals?

    If it was being used regularly and Scott could prove that did Scott do any kind of systematic review to show that there definitely wasn’t any more existing research actually showing the questionnaire to work.

    6: If Scott has in fact done both of those then “why the fuck didn’t he contact a real academic in an institution specialized in research to get a real grant and a proper multi-center trial done so that any results would actually be useful to anyone”

    • alchemy29 says:

      Clinicians who sort of want to “dabble” in research, want to do it all themselves and who get overwhelmed and can’t push a project through are a *Type* she encounters constantly and mostly their research is not terribly well designed or useful

      Ouch, I just want to point out that many of these people don’t actually “want” to do research. However, in many academic institutions doing research is a necessary condition for career advancement and moving up the ranks.

      • Murphy says:

        Clinicians are typically separate from academics.

        Clinicians typically have a full time job treating patients and aren’t required to publish research.

        Academics who have to publish or perish are typically on a different org chart.

        Though there is sometimes some overlap with clinicians who also work in academic departments but they typically are working with other academics.

        • alchemy29 says:

          Though there is sometimes some overlap with clinicians who also work in academic departments but they typically are working with other academics.

          I’m referring to these people, and they are not uncommon – at least at top institutions (as designated by US News and world report or similar rankings) they are the majority. It’s uncommon for a fully licensed physician at an academic center to not see patients at all. Some faculty do 80/20 clinical/research time, some do 50/50, some do 20/80. At least part of the reason for dabbling in research is because you want to be promoted to associate or full professor and/or become dean or department chair. It’s resume padding and I suspect part of the reason for uninspired research.

          It’s probably worth noting that this is mostly for prestige and recognition not for salary. You’ll usually make more money by working for a private practice than working in academics, even as a department chair.

  54. spandrel says:

    In the medical field, guidelines are almost always based on randomized trials; in my many years of evaluating guidelines and guideline adherence, I don’t think I’ve ever seen a set of guidelines that was not derived from a trial or a systematic review of trials. I think in dieting, there are far fewer randomized trials that have produce the kinds of evidence that would support a guideline. Not that people don’t do them, but the trials I’ve seen for diet are often small scale and somewhat ambiguous with respect to findings. There are much larger observational studies, but these have so many confounders that you would not want to build guidelines on them.

    Which raises the question of why, when compared with depression medications say, there so few good, large scale randomized trials of diet regimens. I suppose lack of pharma support figures large in the answer to that, but am not sure.

    • Ilya Shpitser says:

      You can do better than give up if all you have is observational data. But support for guidelines would be weaker, of course.

    • Freddie deBoer says:

      I think this overstates the general quality of medical studies, which are as variable in quality as any other. There are more RCTs and that’s good, but there are plenty of studies floating out there with n=3 or questionable selection effects.

      • benjdenny says:

        The selection effect in weight loss studies is much worse than average, I find. Typically they are selecting out of a pool of people who are seeking medical help for weight loss. When your study on a weight loss method is comprised of data drawn from people who are bad enough at following diets that they are seeking medical help, your data isn’t really all that useful. Since that’s about all the data they can usually get and because they are all in pretty much the same boat, I’ve never seen it talked about a lot.

      • spandrel says:

        I don’t think I said anything about the general quality of medical studies, which I agree is typically overestimated. However randomized trials do provide a reasonable standard for making inferences about treatment effects, and in the medical field the RCTs are generally of better quality than in the social sciences (where entire fields of study develop around a single RCT involving 30 students who happened to be taking a class).

    • benjdenny says:

      I think a large part of why there aren’t good, large-scale weight loss studies is because there’s no way to capture a study population that isn’t massively self-selected. Anyone common dieting techniques(CICO, whatever) have worked for isn’t seeking medical help for weight loss, and is too skinny to qualify for diet studies. Everyone who is already eating little enough to be thin can’t be easily studied.

      Once you get past that initial(and probably insurmountable) problem, then there’s no way to see if they actually even tried the treatment – you tell them to diet, they say sure, and then they do or don’t once they leave the office. And we have enough studies on people’s estimations of their own food intake to know they could “lie” without being aware of being dishonest – I tried this diet, and it didn’t work, but I also forgot about all that extra Triscuit intake.

      • spandrel says:

        Good point about selection effects, which would be difficult to design around. Adherence I don’t think is such a problem, I think there are ways to manage it.

  55. benjdenny says:

    Regarding the absence of diet guidelines:

    There is a diet guideline that exists that if followed works >99% of the time and if not followed fails at a somewhat similarly high rate: Calculate your BMR, then undercut it by a similar rate. This works if you don’t exercise. Even if you have a body that burns muscle before fat during a calorie deficit(and you don’t) you would lose even MORE weight, since muscle has less caloric density than fat. For this guideline not to work, conservation of energy has to not work.

    So the chart would look something like this:

    1. Calculate the calories you are eating in a day and use a BMR calculator and the Harris-Benedict equation to approximate your caloric needs.
    2. Undercut your calories by a significant amount, and keep track of the accumulated deficit. Wait a month.
    3. At the end of the month, divide your accumulated deficit by 3500 to get the approximate amount of pounds you should have lost. Check this against your weight loss.
    4. If you lost weight or your pre-diet weight gain rate slowed, skip to five. If you have not lost weight but were not gaining weight pre-diet or have gained weight, double-check the caloric values of the food you eat. If accurate, double check the amounts of them you are eating or if you are not counting certain foods; If you truly ate the amount you thought you ate, your metabolism is slightly lower than the approximation. Cut additional calories from the diet. If your caloric counts are inaccurate, keep closer track of what you eat.
    5. If you stopped gaining weight as quickly or lost weight, adjust caloric consumption downwards slightly or maintain the course respectively.
    7(kinda). You can replace all “eat less” with “exercise more”, assuming you can accurately approximate your caloric consumption while exercising, which is hard.

    In the end this is the only way we know how to lose weight consistently, and if you are doing it and not dead, Isaac Newton says you’ve lost or are losing weight. The reason there’s not a consistent guideline besides this is that the rest of dietary science is hopelessly confounded by money, publicity and a reluctance to judge people. There’s almost certainly some tweaks you can do by not eating this or definitely eating that, but there’s no way to know what it is; the same people who said not to eat fat now don’t want you to eat carbs. They didn’t check the first advice critically, and probably not the second either; even if someone did, he or she looks about the same as the people who didn’t check it seriously but are good at keeping a straight face.

    You might say “hey, what about slow metabolisms?!” but that’s a relatively small effect. As a for instance, there’s a pretty good study(10.1002/oby.21538) that followed Biggest Loser contestants and compared their measured RMR before and after the competition. These are the absolute worst-case scenarios possible, having gone on a tremendously unhealthy mega-crash-diet after being at unhealthy weights for extended periods of time previously. The average amount their metabolisms were under prediction for their weight at the end of six years was 600 calories. That sounds like a lot, but their six-years-after-competition RMR was 1900 calories, which is an absolutely sustainable caloric amount. They simply overate, underexercised, and gained the weight back.

    None of this is particularly fun to say, and it doesn’t get anybody on the news. But the reason you don’t think there’s a guideline for this is because as a society we’ve decided to ignore the only guideline for it because it’s mean to point out that most people don’t/can’t follow it.

    • Glen Raphael says:

      @benjdenny:
      You’re describing the Hacker’s Diet approach. Have you personally tried this approach and used it in an attempt to lose and keep off a significant amount of weight? Because I have. I used the Hacker’s Diet app on my Palm Pilot, tracked calories, and maintained a 500 calorie daily deficit for a substantial length of time.

      It sort of worked, and I kept off the weight I’d lost (about 20 pounds) for nearly a year, but within three years I weighed more than when I started, as is the typical result of this sort of diet. The reason the diet didn’t work is that following the instructions is unsustainable, and the reason it is unsustainable is that the instructions take no account whatsoever of how hard it is to maintain a substantial calorie deficit below what your body wants you to consume. My experience was that the closer I got to my goal weight the more unpleasant it was. I never actually reached my goal. At the low point that I did reach I was miserable all the time – I had trouble thinking clearly, I was depressed, I was constantly thinking about food. The overall experience was sufficiently unpleasant that the diet was more trouble than it was worth. To keep my job and maintain my sanity, I dropped the diet, returned to an “eat what you feel like eating” regimen and quickly gained back all the weight lost and a bit more.

      This is the typical result of that diet, which is why people are in search of something – anything – better that might be less consistently unpleasant, hopefully to the point of being actually-sustainable.

      You might say “hey, what about slow metabolisms?!” but that’s a relatively small effect.

      No, I’d say “hey, what about limited willpower?” or “hey, what about the fact that to a first approximation absolutely nobody who tries this diet reaches their ideal weight and keeps it off for three years?”

      An actually-good diet would have actually-good outcome statistics. There is not much benefit to a diet that should work in theory but in practice requires a literally superhuman level of sustained effort that lasts for the entire rest of your life. Telling people to keep up that level of appetite control forever is like telling somebody to lift a calf every day until it becomes a full-grown cow. We know for a fact that the willpower will fail before they achieve their goal. Knowing in advance that the advice will fail, makes it bad advice.

      There’s almost certainly some tweaks you can do by not eating this or definitely eating that, but there’s no way to know what it is; the same people who said not to eat fat now don’t want you to eat carbs.

      A number of researchers now think that for the body to efficiently store and keep fat requires both fat and carbs, thus a diet that focuses on nearly eliminating either one makes people skinnier (for a given level of satiation) than would a more “balanced” diet. Given that background info it would seem to make pretty good sense to have “try one of those, and if it seems unsustainable then try the other one” in a guideline; which one is preferred would seem to be an empirical question.

      CICO is in practice a failed strategy. It doesn’t work. And when something doesn’t work, you try something else.

      There exist medical conditions for which you can get a pretty good solution from any random doctor; obesity is not one of them. The current best advice doesn’t really work, so the options people have include:

      (1) give up and adapt to being fat
      (2) take the usual medical advice but try harder knowing failure is 99% assured
      (3) try the latest fad wild-eyed theories in the hopes that it might work
      (4) be your own researcher and invent your own new fad theory to test.

      (I’m mostly in camps 3 and 4 :-))

      • benjdenny says:

        Your post has an implicit “Hey, are you willing to lie to me about basic science for the sake of being polite, since I failed?” in it. I’m not going to do that. I’m aware that popular, magazine-level food science will, but see below.

        Where we disagree the most is the “absolutely nobody keeps off weight with caloric deficits”. I’m aware nobody does this in studies, but the people they pull for studies are people who are seeking medical help for weight loss(I.E. people who have typically failed on conventional diets and are then given ANOTHER conventional diet, told to follow it, and who predictably fail as part of a group specifically self-selected to fail).

        I know literally dozens of people who have kept the weight off for the three year period you suggest while using simple caloric restriction. I’m one of them. None of them would show up in the stats, because nobody who caloric restriction works for would ever be researchable; they literally wouldn’t be able to enter the study, having already lost the weight.

        You say CICO just doesn’t work, but neither does a hodgepodge of fad diets; we are absurdly fat as a society, and we’ve been giving “well, let’s try just marshmallows this time” a very sincere try since the 70’s.

        Again, the worst-case metabolic non-thyroid situations we have really heavily studied are people who have done extreme crash diets, and on average those people could have maintained weight at 1900 calories, or gained a pound every three years at 2000. Saying “nobody could ever realistically have the willpower to eat a completely reasonable amount of food for your size” isn’t compelling for me; I know too many people who do, and have done it too long myself after being much larger to take it seriously.

        Let me restate what you said: “Hey, your diet completely worked then I decided to stop doing it and do stuff that doesn’t work. Your diet doesn’t work”. This doesn’t impress me. But more importantly, it doesn’t change the part where it’s the only thing that makes your body lose weight. That research you mentioned? We’ve tried high fat/no carb and high carb/no fat a bunch of times too, in a bunch of different forms, and there’s no significant evidence that it works for anybody EXCEPT where it causes caloric deficits. Mayo Clinic has a pretty good page on this.

        Again, if you restrict your calories to a reasonable level, physics dictate you will lose weight. If you start eating more calories again, you will gain it. Again, the way medical science researches this excludes everyone this has ever worked for from diet studies. Saying “Well, this worked great and then I stopped” just means you stopped. None of this is fun to say, and you can call me a puritan or say I’m saying all this just to make you feel bad. I’m not. I’m saying it because it’s the only assured victory that exists.

        • Glen Raphael says:

          You say CICO just doesn’t work, but neither does a hodgepodge of fad diets

          For what it’s worth, a hodgepodge of off-the-wall diet ideas did work for me, or at least has so far. At a minimum, my hodgepodge was much more successful and less effortful than was a purer CICO play. (I’m still on the fence over whether I ought to write my own fad diet book… 🙂 )

          The Hacker’s Diet system that I tested and which failed for me was the following:
          (1) identify your break-even calorie consumption level
          (2) maintain a calorie deficit below breakeven to lose weight (this is hard and takes effort of will)
          (3) Having reached the lower weight, you should be able to return to your break-even calorie level and maintain that lower level with much less effort of will than it took to drop to that level.
          (4) through all of the above, the diet composition doesn’t matter at all other than the calorie count.

          Step 3 didn’t work because (in my particular context) the lower my weight was the harder it was not merely to lower it but even to remain there. It was simply not the case that maintaining weight at a lower level was as easy as maintaining weight at a higher level had been. So given an apparent choice between “count calories forever for the rest of your life and be very hungry all the time” or “be (somewhat) fat again”, the latter was by far the better option. No contest at all. I had started the diet under assumptions the diet author had provided; when some of the assumptions proved false the balance shifted against continuing it.

          A never-been-fat person does not need to carefully and consciously count calories – their own hunger inclinations are just naturally in sync with the amount of food they need. People on certain diets (eg, a “whole plants” diet) also can maintain weight loss without carefully calculating calories. Some choice sets regarding what to eat make determining how much to eat far less difficult. Some calories are more filling than others. Some activity patterns are more hunger-inducing than others. Given that people are trying to do a very hard thing, picking easier ways to do it is a win.

          We’ve tried high fat/no carb and high carb/no fat a bunch of times too, in a bunch of different forms

          Near as I can tell, the biggest and best studies have tended to compare “less fat (but still a lot of fat)” to “less carbs (but still a lot of carbs)”, on the theory that one of these should be strictly better and have linear improvement. We can’t seem to get past the idea that a daily “balanced diet” is the goal. I tend to suspect a completely unbalanced daily diet would be strictly better than a balanced one that leans slightly in one direction or another. All the fad diets (The all-potato diet! The nothing-but-meat diet! The banana diet!) are getting at this same idea. Yes, they work because people on weird diets eat fewer calories, but the reason they eat fewer calories is because they feel more full. Which matters.

          I don’t mean any of this to imply a good all-purpose solution exists. We still don’t know why everybody got fat and even a good weight-loss strategy isn’t as good as just not having been fat in the first place. I suspect whatever changed since the 1970s was environmental; some day we’ll figure it out and fix it with something dumb like a childhood inoculation against the “fat virus” or outlawing some industrial chemical or changing our heating and air conditioning strategies.

          But in the meantime we have a range of terrible strategies which do not all merely reduce to counting calories any more than they merely reduce to counting mass. Some strategies work better than others and it’s worth continuing to try to figure out why.

          • benjdenny says:

            We do I think largely agree on one point(or, if you like that you’ve convinced me more of it). I certainly don’t see any problem with “jump around different foods until you find a combination of foods that makes it easier to maintain a lower intake”. That’s just a good thought, and I do it to some extent – a ton of raw brocolli takes up more space, or whatever.

            I also agree that never-been-fats aren’t really relevant here, not even to my initial point(Isaac Newton doesn’t say that nobody can have inefficient fat storage). Also, to be clear, I’m usually not talking about “cosmetically non-optimal but minimal health implications” levels of overweight. I can see it being fairly difficult to maintain the super-strict diet needed to be shredded all the time, particularly if your body wants to have a small amount of fat on it. I’m more concerned with obesity than overweight, if that makes sense.

        • xXxanonxXx says:

          We’ve tried high fat/no carb and high carb/no fat a bunch of times too, in a bunch of different forms, and there’s no significant evidence that it works for anybody EXCEPT where it causes caloric deficits.

          This is one area I think communication could be better from people who promote CICO/macro-tracking. Fad diets, if they work, work because they put you into a calorie deficit without you realizing it. If you’re on an all potato diet and stay away from bacon bits and sour cream you have to eat something like 9 potatoes a day to hit 1,500 calories. It’s hard to believe anyone could do this and still complain they’re hungry. Tired of potatoes, definitely, but not hungry.

          The calorie restriction part of the diet has to coincide with changes in the types of food you’re eating, such that you’re happy enough with your meals you can maintain the pattern indefinitely. I believe this is why people of the “just eat whatever fits your macros” variety often fall off the wagon. Hit your daily limit with a bacon double cheeseburger covered in BBQ sauce and onion rings at lunch and you’re going to be irritable and starving by bedtime. Have a salad with grilled chicken instead and you can still finish off the day with a less insane burger (skip the mayo and bacon maybe) plus desert. That coupled with an indulgence now and again is psychologically sustainable. Less hedonism doesn’t have to mean more suffering.

          • benjdenny says:

            I think that’s a lot of why vegetarians are pretty much a skinny bunch, assuming they cut sugar/grains a bit too. I once did a day on broccoli to see what would happen, and you top out pretty quick(also, farts).

            I think Penn Gillette did potatoes for his monofood diet, actually, and he lost a ton of weight. He also looks like he’s way less healthy, but I’m not sure if that’s nutritional deficiency or just being old and newly baggy.

  56. Nearly Takuan says:

    Software: I have had good experiences with project managers, directors, etc. who follow a “guidelines”-like approach to managing workflow. They’ll typically do something like this:

    1. Find out if what the team has done before is working. If it is, keep doing that until it stops working, then come back here.
    2. Check on our existing commitment schedule(s) with stakeholders; if we’re in close communication with the business side of things and value early feedback and tight delivery schedules, use traditional Scrum; if we’ve promised a big shiny fully-polished thing with a rigid deadline, adopt a Waterfall or SAFe model; if requirements are changing rapidly and dramatically, and engineers are well-equipped and empowered to make smart decisions on their own, use Kanban.
    3. Wait 1-3 months (depending on stakeholder patience, team resources, etc.) If it works perfectly, declare victory (for now). If it works a little but not enough, identify the pain points and make small adjustments to the process to accommodate. If it doesn’t work at all, stop it and try something else, then repeat this step.
    4. Cycle through steps 2 and 3 until you either find something that works, or you and the board (or whoever your boss is) agree that we don’t have enough time, patience, money, or whatever to continue cycling through this tier of options and we want to try another tier with more risks in exchange for more potential benefits.
    5. Have lots of brainstorming meetings and try out crazy stuff to try to find something that seems right for the business. Bring in a super-expensive consultant for exactly 59 minutes. If problems arise due to dysfunction, address these problems before moving on.
    6. Try electroconvulsive therapy.

    I have had significantly-less-good experiences with managers who decided that Methodology X is the Best Way and no other recommendation deserves consideration. I have had far, far worse experiences with managers who decided that Methodology Y (or things that are named Methodology Y regardless of whether the actual execution of it matches the person’s past experiences) is the Worst Way and therefore Step 1 can be skipped.

  57. Lillian says:

    Reading through this thread has lead me to wonder about something. Namely how do other people experience hunger? For me i have three types of hunger, one is a general awareness that i need food, like the low fuel indicator light in your car. It turns on, you know you should do something about it, but you can easily ignore it if you want. The hunger indicator will remain on until i eat sufficient food, though sometimes it malfunctions and it doesn’t turn on when it should. The second type is the physiological effects of low blood sugar, usually headaches, weakness, tiredness, and sensitivity to cold. It’s usually only mildly annoying. Also my metabolism slows down noticeably, to the point that it’s possible for other people to tell whether or not i’ve eaten recently simply by whether i feel warm or cool to the touch.

    The third, rarest, and most unpleasant type are actual hunger pangs, a psychologically painful need that gnaws at me and demands to be fulfilled, causing constant intrusive thought about food. Naturally i very much hate feeling this way, but the paradoxical thing i’ve discovered is that eating more makes the hunger pangs more frequent, while eating less makes them go away. In other words, it seems that indulging the feeling teaches my body that it can coerce me into eating. Since i don’t negotiate with blackmailers, i usually refuse to eat until it fades, which generally only takes an hour or two. This teaches my body that the best way to get calories is to gently nudge me about it rather than trying to force me. It helps that i’m pathologically lazy and making food is work, i hate work.

    The impression i get is that the normal experience for most people is that hunger pangs are not just common, but constant. If the indicator light turns on, the pangs are not far behind, and if the pangs are ignored, they take at least a couple of days to fade, rather than a couple of hours. The effects of low blood sugar kick in only after the hunger pangs have been in play for a while, with the net effect of making the person even more miserable. Is this about right?

    • The Nybbler says:

      I get your second type, but not your first. And an empty painful feeling in the stomach. My understanding is that true hunger pangs are not the same as that feeling, but are a much more painful physiological effect that takes more than the usual time between (first-world) meals to manifest.

      I also get cravings for specific foods, which are different.

    • Nornagest says:

      First sign of hunger for me is its psychological effects: fatalism, irritability, a sort of generally grim aspect hanging over everything. This does not come with a general awareness that I need food; I need to consciously make the connection. Next is physiological effects: dizziness, fatigue, sometimes headaches or shivering. General awareness of needing food sometimes but not always shows up at this stage. I haven’t noticed my metabolism slowing.

      I rarely get cravings, usually after something physically strenuous: a long hike, for example, or a heavy workout. And when I get them I always want something heavy, like a burrito or breakfast food. I think they might specifically be a psychological sign of protein deficiency for me, but that might be broscience.

      I’m not sure I’ve ever experienced actual hunger pangs.

  58. pjiq says:

    Guidelines are almost certainly more likely to succeed than more simple “just always do x” approaches to solving problems, but it is good to remember that complex systems are not always better, and the tendency of people to believe complicated things work just because they’re complicated is a real danger here.

    Another quick counter point is that a lot of morality/ dieting programs have sort of a “dance-like” social quality to them, in that they’re fun/ they work because they make everyone just do the same thing. it’s the chanting of the crowds saying “Paleo is the best thing ever” that actually gives me the will power to try Paleo for more than 5 minutes before saying “wow, cavemen’s lives were horrible” and moving on.

    Another counterpoint to be extremely contrary- guidelines are maybe NOT actually that great. guidelines are a “structured guess and check approach”, meaning they are basically an algorithmic approach to problem solving. but just as we aren’t omniscient enough to just say “you obviously have this disease and should follow this treatment” our guidelines aren’t omniscient either and we can’t actually honestly say “if you play this structured medical game you will definitely end up better than if you did something else.” in a small way it is a bit like Nostradamus predictions- guaranteed to make you seem smart no matter what happens while not actually telling the patient what’s really going on.

    Alright that’s the end of my negativity on the whole guidelines thing, but still, thanks as always for the thoughtful post-

    • Glen Raphael says:

      guidelines are maybe NOT actually that great. […] in a small way it is a bit like Nostradamus predictions- guaranteed to make you seem smart no matter what happens while not actually telling the patient what’s really going on.

      Right, guidelines of this sort are basically an admission that all our treatment options suck. If there were a reliably GOOD treatment option the guideline would just have one step “Do the treatment that works”, and even if you were some rare edge case where the treatment didn’t work it’d be OBVIOUS whether it had worked so we should try whatever the next-most effective option was.

      The platonic ideal of medical treatment is basic dentistry. Suppose your tooth hurts, so you go see a dentist. They take a look, diagnose it as cavities, and FIX the problem. The solution involves some pain and discomfort on your part but (with anesthesia before and pain pills after) not an intolerable amount. Within a week of the operation the tooth no longer hurts and in most cases you can live your life as if the problem had never happened.

      But suppose we treated toothache the way we treat depression. You go to the dentist and say you have a toothache; the dentist says “Here, take this pill every day for the next three months. We won’t know if it’s working for at least a month. If your tooth is still aching just as badly in three months we’ll switch you to a DIFFERENT pill for three months that also might or might not help. Sometimes that doesn’t help either so we up the dose or switch to a different CLASS of pills you take for three months, or maybe we’ll try Mandible-Behavioral Therapy where you learn to eat with just the right side of your mouth (since it’s the left side that hurts most)…”

      …or suppose we treated toothache like obesity! You go to the dentist and say you have a toothache; the dentist tells you “Bang your forehead against a door every morning, just enough that head pain is just a little bit painful/uncomfortable/inconvenient at all times. If you hit your head every morning without fail, in one week your toothache will be about 1% less severe. Sure, that’s not enough to be noticeable, but you just have to keep being in a little head pain every day week after week after week and 6 months from now you’ll have lost nearly half of the tooth pain! Now, as we progress closer to your goal of no toothache at all it’ll get harder to progress further. Almost nobody actually gets down to ZERO toothache and in fact most people eventually find the combination of head-banging annoyance and failure-to-reduce-pain-much annoyance so bad they just give up and all the tooth pain comes roaring back and often at the end of it the tooth pain is even worse than before they started treatment. But just know that if you didn’t reduce tooth pain as much as you would have liked it is all your fault for not having sufficient force of will to keep banging your head hard enough every day for the rest of your life. Remember, head-hitting isn’t just a treatment, it’s a lifestyle change. Given that a few people either never get toothaches or do successfully change their lifestyle to keep hitting their head forever and ever so as to keep away most of their toothache pain – some even claim to enjoy the head-hitting life – the fact that it didn’t work for you is a personal failing on your part that marks you as morally inferior.” 🙂

      • Simon_Jester says:

        People are very bad at recognizing other people’s suboptimal choices as anything other than a moral failing.

        It is one of the reasons I wish there were a technical support department for the human species, as I would like to file a bug report…

    • Simon_Jester says:

      Guidelines are a sign that the problem is too complicated to be trivially identified and solved without effort or tradeoffs. This proves we live in a suboptimal world, but:

      1) We already knew that, and
      2) It sure isn’t the guidelines’ fault!

  59. eddiephlash says:

    This is just flowcharts, right? I agree there needs to be more flowcharts for all sorts of stuff.

  60. Bram Cohen says:

    Not that this helps with your complaint about why there aren’t any guidelines, but your step 1 of a diet guideline is wrong. Step 1 should be (caveat: my opinion only, not real medical advice) ‘drink only sugar-free beverages’. Appropriate caveats have to be given, for example fruit juice and (probably) skim milk are especially bad despite their good reputations, while soy or almond milk and (probably) whole milk and (probably) coffee are fine. The next step then has to branch on whether the patient was able to comply with this level of diet, and then if they did what if any effect it had on their weight. This too might be wrong for the first step of a true diet guideline, but it’s less wrong, and the fact that it’s an unusual piece of advice despite overwhelming evidence that it should be step 1 is a testament to the power of the soda and juice lobbies.

  61. janrandom says:

    I’m surprised it wasn’t posted. But maybe it’s too obvious. Or I’m blind.

    Who does the right thing and uses guidelines instead of a single recommendation?

    EAs of course:
    https://80000hours.org/articles/best-charity/
    https://80000hours.org/2016/12/the-effective-altruism-guide-to-donating-this-giving-season/

    they even went a step further and created an expert system for it aka a quiz:
    https://www.guidedtrack.com/programs/zjnd6ox/run

Leave a Reply