The Dr. Hyman Show - Gary Taubes on the Case Against Sugar

Episode Date: August 1, 2018

My guest in this episode of The Doctor’s Farmacy is Gary Taubes, one of the most accomplished health journalists in the world. In addition to being an investigative science and health journalist, Taubes is the co-founder of the non-profit Nutrition Science Initiative, which aims to reduce the individual, social, and economic costs of obesity, diabetes, and their related diseases by improving the quality of science in nutrition and obesity research. He is also the author of The Case Against Sugar (2016), Why We Get Fat and What to Do About It (2011), and Good Calories, Bad Calories (2007). Taubes is the recipient of many prestigious awards in the fields of both journalism and health, and he has graduated with degrees from Harvard, Stanford, and Columbia. Tune into this brand new episode of The Doctor’s Farmacy for more! Don't forget to leave a review if you love this podcast - it helps more people find us! For more great content, find me everywhere: facebook.com/drmarkhyman youtube.com/drhyman instagram.com/markhymanmd

Welcome to The Doctors Pharmacy. I'm Mark Hyman and that's Pharmacy, F-A-R-M-A-C-Y, a place for conversations that matter. Coming up next in The Doctors Pharmacy is a great conversation with Gary Taubes about sugar and fat and everything in between. Stay tuned for this great conversation that's coming up next on The Doctor's Pharmacy. So welcome, Gary. You know, we're here in Switzerland at the conference that's put on by the British Medical Journal about the science and the politics of food, both of which you have written extensively about

and are passionate about. And the first article that I ever read by you was back in 2002 in the era when we were still pretty focused on a high-carb, low-fat diet as a solution to all of our ills. You wrote a very radical, radical article which turned all that upside down, saying that maybe it's wrong. What if it's all been a big, fat lie? This had a big steak and butter on the cover of the New York Times magazine. And I read that. I was like, I see this in my practice. I've been reading Dr. Ludwig's work, who you quoted in the article. How did you come to kind of have this aha moment? Because it was sort of bucking the tide.

Now, every book on the best service is a ketogenic, high fat diet but back then it wasn't like that yeah okay so i had done a couple of investigative pieces for science first on the idea that salt causes high blood pressure the evidence for which is poor to put it mildly and that got me into this question about the low-fat diet and heart disease and um while i was interviewing doing interviews for the low for the fat story i interviewed a administrator at the national institute of health who said to me i remember we were sitting in a starbucks in potomac maryland and he said you know 20 years ago 15 years ago we put everyone on this low-fat diet and we thought if nothing else they would lose weight right because fat has the densest calories. You tell people not to eat it, they'll lose weight.

Right, and it's more than twice as many calories as carbs. Yeah, and 15 years later we've got an obesity epidemic and people stopped eating fat and started eating carbs and it looks like they got fat. So I was living in New York, I was pitching out a New York Times magazine editor I used to meet. It's going to be restaurant specific and a wonderful cafe and village that we both haunted. And we would pitch stories back and forth. And I said, let's do a story. How about a story on what started the obesity epidemic?

You know, it was new enough at the time. And there were basically two obvious suspects. One was high fructose corn syrup, which was introduced in 1977. Took over the market by 84. And the other was this sort of institutionalization of the low fat, high carb diet as a healthy diet. And the transition of the carbohydrate from being thought of as fattening in the 1960s to heart-healthy diet foods in the 1980s. Yeah, that was a food pyramid, right?

Fattened oils only sparingly at the top and 6 to 11 servings of bread, rice, cereal, and pasta every day. Exactly. And we lived through it. So you remember when suddenly baked potatoes and pasta became health foods. Yeah. And bagels. And bagels. Like bagels used to be Sunday morning, maybe,

and suddenly they were every day. So that was it. That was the pitch. And I looked into it. And as I was doing the research, I came upon five studies that had been finished and submitted for publication, but not yet published, all trials of the Atkins diet, the ketogenic diet,

versus low-fat American Heart Association diets they all found the same thing and this is kind of fundamental idea that people still don't get in this whole nutrition debate the ketogenic diet is the what scientists would call the anomalous observation so we have a hypothesis that says dietary saturated fat causes heart disease and the sort of ketogenic diet it's traditionally prescribed the Atkins induction phase is full of saturated fats which would make butter heart disease risk factors for him eat you know right lobster Newburgh the whole

and then we have a hypothesis that people get fat because they eat too much and it's an ad lib and a eat as much as you want diet. So if you randomize people to a diet with a lot of saturated fat and a lot of meat that you could eat as much as you want versus a diet that's low in fat and low in saturated fat and mostly plants. And calorie restricted. And calorie restricted. People should be dropping dead on the Atkins diet.

And not only do their heart disease risk factors improve compared to the low-fat diet, and this was the case in all five of these studies, but they lose more weight. So if this were a sort of rigorous science instead of arguments between competing religious factions. Which, yeah, unfortunately science has become, you know, I had this view of science as this pure elite, you know, above politics and prejudice and bias that would give us the true answer of what nature is about. Boy, was I wrong. Yeah, no, that's a very idea. I mean, it's funny. I've spent much of the last two years reading a lot of memoirs on scientists, and it's always been full of these.

You know, you come to a conclusion, and somebody else disagrees with you. One of you is right, and one of you is wrong. One of you is smart, and one of you is not. It's hard not to get... It's very rare that somebody can say... Not only two very smart, or two reasonableness but two people have been rewarded their whole lives for what they've done have gotten copious feedback that they know what they're doing and they're good at it two you

know people who are at the height of their professions and one is right one is wrong one is good one is bad it's sort of it's just a situation for vitreo anyway getting back to this um if so the whole point of that article is if these you know what these studies are telling you what this atkins ketogenic diet thing is telling you is there something wrong with the conventional way we think about heart disease and obesity? And I had a background in science, not medicine, and I had been trained earlier in my career, mentored by some very brilliant scientists in my first two books.

And I don't use the word brilliant lightly or often. And they had taught me to, I hope, to think critically and rigorously about this. And when you have that kind of observation, you don't dismiss it. Right. You examine it. It should make you curious. It should make you want to learn more. And that was basically, that's been the last, you know, 16 years of my life.

Unless the true activity of science is, you know, you find something that doesn't fit and you go, why? Yeah. And you try to dig in and figure it out instead of go, well, no, we've got to bolster our current viewpoint because it's dogma and we don't challenge it. It's very easy for us to, and everyone does this, I mean, it's human nature to say, when you say why, you go, oh, well, wait, they did this. Here's a reason I could dismiss this. And we all do that every day.

And the best scientists, you know, Francis Crick talks about this. If you find a scientist who isn't dismissing experiments that he doesn't like, he's not doing his job because clearly a lot of them have been done poorly. And when you've got, you know, it's never white and black. It's always shades of gray. And you have to figure out which studies you're going to believe and which you aren't. And that's part of the job of doing science. It's also that the scientific studies only give you answers to the questions that are asked.

And so sometimes the questions aren't formulated properly. The design of the study isn't awesome. It doesn't provide the conclusions that are valid. And that's on the best day. On the worst day, the studies are corrupted by industry influence and bias and all sorts of things that allow you to prove, for example, that smoking has nothing to do with lung cancer. It's funny because today, Pred know, predamids in the news again. Ah. And so the predamid trial turned out that, uh,

they had problems with their randomization scheme that was pointed out to them by an astute, uh, on a website, apparently by an astute researcher said, you know, the results they claim here are impossible, statistically impossible, plausible. Um,

so they have actually retracted the paper. Really? Reassessed it and republished it and luckily they came to the same conclusion they were right all along so that study was a one of the few randomized controlled trials comparing a low fat to a high fat diet in a mediterranean context right where they gave the fat group olive oil liter a week and or a couple of big handfuls of nuts every day and the nuts and the fat group had dramatically lower heart disease mortality diabetes all kinds of things even though they were eating more fat and they had to stop the study because it was unethical to continue because the people who were not eating the fat were dying right that's that's there but again what you just described was one of the problems with the trial

there were a lot of problems with the trial if you're giving one group nuts and olive oil and the other group nothing every week or every month or every quarter you're telling one two of the groups eat healthy here here's your nuts here's your olive oil eat healthy and every time they reach for the olive oil to cook a meal or every time they take a handful of nuts they're reminding themselves that they're in a clinical trial they have to eat healthy and whereas the other guys are out you know mcdonald's or the i mean i've been to spain they're mcdonald's um so you've got a can a study that's got a very poor control group but free living humans those pesky free living humans but here's the the point is what you said is that you only get the answer for the question you asked.

So the question that was asked was, is the, quote, Mediterranean diet, unquote, better than a low-fat American Heart Association type diet? And the answer was, if you ignore all the problems with the study, yes. But it doesn't tell you that the Mediterranean diet is better than... Compared to what? So this morning at this conference, I looked in on the breakfast room and they're serving a classic Swiss hotel breakfast,

which is, you know, fishes, herring, salmon, meat. Bressola. Yeah, exactly. It's got nothing to do with the Mediterranean diet and the Swiss have one of the longest life longevity, highest longevity numbers in the world. They had bread, but you had to cut it with like a meat slicer. Yeah, yeah.

It's hard. It ain't wonder bread. No. And so it's an entirely different diet. And so what we have, though, is a medical community that now says we have to tell everyone to eat a Mediterranean diet because we did a study on the Mediterranean diet and it did well. Right.

But compared to what? To what? Right. It was like the joke my sister used to tell us when the Vermont farmer was asked, how's your wife? He goes, compared to what? So it's true. Are we comparing a low-fat Mediterranean to a ketogenic diet to an extremely low-carb

diet? I mean, how do we then begin to sort through those questions? Yeah, and if you don't ask those questions, and again, I think in general physicians aren't trained, scientists, journalists aren't either, I'll acknowledge that. But you're vitally important to know what question was asked because that's the only answer you're getting in that trial. It's true.

You know, I was recently in a meeting um food leaders meeting our friend dari mazafarian was there francis collins was there the head of the nih and they had an interesting debate conversation because the head of the nice is well we really don't know much about nutrition research and what the science is and about calories and dr mazaf who's the head of Tufts, who's going to be on this podcast, is the head of Tufts School of Nutrition, Health and Policy and Science. He said, we do know.

And I think there's this debate about, you know, what makes people fat? And you wrote a book called, Why We Get Fat. And I read it and it's a short little book and it's brilliant in that it actually distills the obvious into almost to me an inarguable thesis, which is that the reason we get fat is not because we eat too many calories,

but because we eat the wrong calories and they have different effects on our biology and the science of obesity we do know a lot about. So can you break down what is that science and why did we get it so wrong and how do we how do we not um sort of stay stuck in this idea that all calories are the same because you also have addressed that in good calories bad calories and i'm going to address it in the next book as well because until we get this point nobody still believes it right

it's still not the prevailing dogma and recommendations of the government. This conference today, so the conference is a BMJ Swiss Reconference called Food for Thought, right? And there's going to be a paper published in the BMJ this week that's going to be presented today on obesity. And it sees obesity as an energy balance problem, calories in minus calories out. So the history of that idea, which I've discussed in my book, is fascinating because it's a hypothesis. It's not a fact of life. And it comes out of the history of modern nutrition, which starts in the late 1860s in Germany.

I'd love to make a short story long, and I apologize. Modern nutrition begins... Sorry for the long letter. I didn't have time to write a short one, and Mark Twain said it. Exactly. modern nutrition begins exactly which is basically could have been the epigraph of my first book um the uh anyway the point is for 50 years in nutrition from the 1860s onward all of the entire science of nutrition was measuring the calories in food and the calories expended by humans that's one thing they could measure because they had this device called a calorimeter. It was invented in the 1860s.

And then you could study vitamin and mineral nutritional deficiencies. You could study protein deficiencies, fiber deficiencies, things like that. This is what nutrition science was. So by the early 20th century when it comes around to developing a hypothesis of obesity it's hard to see how vitamins and minerals and protein could be involved so but you had these calories thing and you had physicists talking about the laws of thermodynamics yeah so you come out with a you're measuring energy in and energy out as we just said your answers to problems depend on the questions you ask and the questions you ask depend on the technology available to ask a question so you come out with this energy balance

hypothesis because all you can measure is energy and then the science of nutrition doesn't kick up the science of endocrinology so you know how foods how much energy is carried into the body. You don't know how foods influence hormonal states because you can't measure hormones. It's not until 1922 that insulin's discovered. The whole science of endocrinology is this sort of inchoate thing that most physicians and researchers know nothing about. I mean, the problem with the law of thermodynamics is not that it's false. It just doesn't tell you anything about why we get fat. It's true. It's physics.

It's not biology. So when you mix physics and biology, it gets confusing. Yeah, I've been thinking about questions I could ask at this conference today of the sort of conventional wisdom experts on obesity. And one of them I would ask is you've got this disorder of excess fat accumulation. It's a simpler way to describe it. Why isn't there any discussion in your paper, your books, or your articles about the hormonal enzymatic regulation of fat accumulation?

Like we were talking about height disorders, why someone is eight feet tall or four feet tall, fully grown. All we're talking about is growth hormone, growth hormone receptors, insulin-like growth factors, receptors, you know. We're good at talking about height, but not width. But when you talk about width, it's like how much we eat and exercise. And even if that's true, why isn't there some discussion about why the hormones that regulate fat accumulation, we've known what they are for going on 80, 100 years and known the system well for 50 years. Why aren't we discussing it?

If nothing else to say, this is how we know they're not involved. What happened in this field is you get this energy balance idea that comes out of Germany. And when endocrinology starts to emerge as a viable science in the 1920s, nobody's really, the endocrinologists really aren't thinking in terms of obesity. It's not something they study. It was like the World War II, everybody was starving. And then World War II comes along and everyone's starving. It's not an issue. And by the time that 1959, 60, when a technology is invented that allows you to measure hormones and the bloodstream accuracy, there's something called the radioimmunoassay. It's two New York researchers, Rosalind yellow and solomon burse and

yellow gets the nobel prize for this after burse and dies it's a revolution in the science of endocrinology because now you could actually measure hormones yeah and you could figure out their effect on you know endpoints tissues organs in the body uh the field of obesity is basically dominated by psychologists and psychiatrists who are trying to figure out why fat people eat so much and how to stop them. It's a moral failing. It's a moral, well, they might not think about it that way, but they're going to try and- Because you have no willpower.

They treat it as much. Yeah. You don't have willpower. And so how can we get fat people to eat less? That's what they're doing. That's what they care about. And they're not endocrinologists. They don't care about hormones. They believe that a hormonal explanation of obesity is like an excuse for fat people to get to do whatever they want. And you have this sort of monstrous, I mean, it would be trivial if it would be science. This stuff happens in science all the time. People get the wrong answer. They push wrong hypotheses for decades. But in this case, there are huge implications for us.

Yeah. And for obesity and the prevention and treatment. So then when you sort of started thinking about this, you sort of realized it was this whole body of literature that was pointing the wrong direction from where we're going. Right. But it was sort of realize it was this whole body of literature that was pointing the wrong wrong direction from where we're going right but it was sort of ignored and so you've been really bringing that information research to light but that's yeah and explaining how we get fat has nothing to do with energy balance which is yet what all nutritionists doctors scientists governments and food industry are all telling us there's no good or bad calories you've have big gulp which has 46 teaspoons of sugar and 750 calories

is exactly the same as 21 cups of broccoli which has a half a teaspoon of sugar and 35 grams of fiber and they're exactly the same and yeah now or even a fifth grader could pretty figure that's not true it's crazy too is because then you know obesity and diabetes type 2 diabetes go hand in hand. And so the diabetes specialists are endocrinologists. So all they, you know, it's completely, it's clear as day to them that different foods have different effects on hormone status and hormones, you know, particularly insulin, which is a hormone that's sort of driving the fat accumulation. And they tell you if you eat more carbs, just increase your insulin dose.

Just increase your insulin. So it's sort of this perfect storm of bad science and inconvenient facts that the diabetes specialists in the 1920s, as soon as insulin is discovered, it's a lifesaver, right? And it is. For type 1 diabetics, it's clearly a lifesaver. And just at the same time that insulin is discovered, it's a lifesaver, right? And it is. For type 1 diabetics, it's clearly a lifesaver. And just at the same time that insulin is discovered, there's a physician in Minnesota who's publishing papers saying, you know, we're trying these low-carb, high-fat diets.

Ketogenic diets have an effect on diabetics, and they're doing terrific. I mean, he's publishing this in major medical journals. And Elliot Jocelyn, who's the god of diabetes. This was like 100 years ago. This was 100 years ago. So we've finally of diabetes. This was like 100 years ago. This is 100 years ago. So we've finally gotten back to where we were 100 years ago. But his studies, 1920, 21. So insulin's discovered.

I always forget if it's 21 or 22. It's embarrassing, but it's my memory. You're close enough. I don't eat enough carbohydrates. In the early 1920s. Elliot Jocelyn at Harvard is a god of diabetes, becomes a god of diabetes because of his expertise with insulin therapy, and he's a wonderful clinician.

He starts using this ketogenic diet for his patients, but then, boom, he got insulin. It's like it's a miracle drug. And because of the art of dosing insulin, was it, you know, unknown at the time, you often give too much, and then you get hypoglycemia and you want to give people sugar to bail them out so yeah sugar and carbs become a way to basically you know a way to to allow you to use insulin to save their lives so the diabetes

community is just you know suddenly that was the standard treatment back then for diabetes, which was 70% fat, 20-something percent protein, and like 5% carbs. That was the diet. Yeah, because you can't tolerate the carbs. That's what diabetes is. But now we have insulin, which is keeping the type 1s alive, but they're not really differentiating well enough. So wait a minute. Are you saying that obesity is a disease of carbohydrate intolerance? It's a hormonal regulatory disorder that's triggered by, yeah, you could call it carbohydrate intolerance? It's a hormonal regulatory disorder that's triggered by

yeah you could call it carbohydrate intolerance. So there are people are going to get obese anyway because of hormonal disorders or dysfunction but the carb content of the diet is always going to promote that. So you were on an interview video with a panel with a trainer from The Biggest Loser who was saying that weight gain is all about calories in, calories out. It's such a pervasive myth. And this is just a math problem. It's energy balance, calories in, calories out. And you're proposing a different idea, which is often called the carbohydrate insulin hypothesis or the hormonal hypothesis, which suggests that it's not about the calories.

It's about what calories you eat. Can you take us down into how that works if someone's listening they want to know well what should I eat what should I not eat what's gonna actually liberate fat for my fat cells and what's gonna store fat and how do I understand this new science of why we get fat well this old science was all science which is actually by the way gaining traction again in fact much of this conference is about examining some of this new science. There's a whole section on diabetes revisionism, which is the idea that our view that diabetes, type 2 diabetes,

is a one-way street, it's an irreversible, chronic, progressive condition, is being turned on its head and saying, no, no, we can cure this disease. So this is, you know, again, the idea that obesity is just a hormonal regulatory disorder. So it's, and this was another German idea. It was gaining traction. It actually sort of won over the German research community. And by the late 1930s, when the Germans and Austrians were doing the best medical research in the world, and then the war comes and it just evaporates. But the idea is it's got to be a hormonal regulatory disorder and there are all kinds of ways that that's clear you know you just look at how people fatten differently men and women fatten differently so men get fat above the waist women

below the waist it tells you that sex hormones are playing a role you could have sort of isolated areas of fat accumulation we all know where they are on our body. Although now women drinking soda and sugar have it is above the waist too. No, it's funny. I was, um, I was at a family member had surgery at Stanford, uh, about four years ago. And I was sitting in the waiting room waiting for her. And it was fascinating to see that. Yeah. All the women, all of them had upper body obesity. And it used to be that men had upper body obesity. So the question is, in effect, what regulates fat storage in different fat depots in the human body? And clearly hormones are playing a role. And everyone always knew insulin played some role because type 1 diabetics who lack insulin can't store body fat. Yeah. And they can't metabolize the fat. They can't burn the fat that they eat they can't so that's right they can't

store it like as a doctor treating type 1 diabetic when they come in they're they're producing zero insulin yeah they're eating 10 000 calories a day they're starving they're hungry they're losing weight even though they're eating 10 000 calories a day so how could that be yeah so yeah and that also tells you that there's a disassociation between caloric intake and fat accumulation and that insulin is in that pathway yeah and so the 1960s i said you get this science of endocrinology suddenly and by 1965 or so it's it's been pretty well worked out how insulin regulates fat accumulation it does it through a the whole you know sort of sea of the enzymes and receptors and on that it up regulates the lipoprotein lipase on the fat

cell which pulls fat into fat cells it down regulatesotein lipase on the fat cell, which pulls fat into fat cells, it down-regulates hormone-sensitive lipase, which should liberate fat from fat cells. Sort of locks it in the fat cells and they can't get it out. Exactly. And this is textbook medicine. It's in the endocrinology textbooks. It's in the biochemistry textbooks. If you look up what makes a fat cell fat, it's insulin. High insulin, low glucagon.

You could include glucagon. It's so starling, Gary, to me that the science is so clear, and yet the practice of medicine is so far from the science. Well, because the practice of medicine has always been about energy balance. So the same textbooks that will say fat cells get fat because of elevated insulin will tell you that obesity is caused by taking in more calories than we expend. There's this disconnect, this energy balance paradigm. And again, we're going to see it at this conference

when the presentation on obesity is going to all be about energy balance. And I would love it if somebody like you, so I don't have to ask all the questions. We'll ask the questions. What about insulin is in this pathway? And macronutrients influence insulin differently yeah so carbohydrates stimulate insulin secretion protein stimulates in a little bit fat does not and you could drink a liter of olive oil and your insulin would not go up no you will store that and you won't store it no you will that's the

interesting thing so it's sort of one of the if you don't eat carbs you will store that and you won't store it no you will that's the interesting thing so it's sort of one of the if you don't eat carbs you'll store it or only when you eat it with well you'll sell you're gonna have to clear it out of your bloodstream anyway you don't want it floating around in your bloodstream yeah that said it's going to be stored on some level even without with low levels of insulin but then it's going to be mobilized yeah so you basically you think of your fat stores as like the wallet that you go to the atm you take money out of the atm that's the food you're eating and you got to do something with that so you put it in your wallet but you got to be able to get it out of your wallet freely when you need it and insulin doesn't let you get it out of your wallet

so as long as you're eating a high starch sugarred sugar diet, you can't get the money, namely the fat, out of your wallet or namely your fat cells. So what happened is, and there was a lot of discussion back then, that carbohydrates are turned into fat when you eat excess carbs. And they're not really turned into fat. That's a difficult process for your body to do when it's energy expensive and it doesn't do it that much. But what your body does is make sure you burn the carbs and when it elevates that's what you're burning so it's not only telling your fat tissue to store fat it's telling your lean tissue your muscles and your organs to burn carbohydrates and not to burn fat yeah so it's a carbohydrate increase what we call

lipo genesis which is our own fat production factory? That's why we get fatty liver? In the liver, well, but again, that could be sugar, the fructose and sugar dependence. So that's the case against sugar story. We're going to get to that soon. So in pretty well done controlled studies, the amount of what's called de novo lipogenesis,

so making fat out of nothing from carbohydrates, was very low unless you had sugar in the diet, which is one reason why sugar might be key to this process. Because like 90 million Americans have fatty liver. It's one of the most prevalent diseases, and it leads to heart disease, cancer, diabetes. Yeah, and which, which right 20 years ago liver failure nobody knew existed if you were diagnosed with fatty liver disease 20 years ago

and you told your doctor you didn't drink alcohol the doctor would assume you were lying and then it starts showing up in kids yeah and suddenly it's like okay these kids are probably not heavy drinkers so drinkers of soda yeah i met i met a at a obesity conference um a a pediatric gastroenterologist and i'm like what are you doing here he says well i focus on fatty liver disease in kids and we're seeing it in three-year-olds and five-year-olds and i'm like wow they're needing transplants as they get a little older. And I'm like, wow. So and then a huge pharmaceutical effort to come up with a drug that you can give those kids for the rest of their lives. That's a great market.

Or you could maybe just cut out the sugar. Which can help reverse that, yeah. Yeah, so anyway, that's the gist of the science is you elevate insulin you store fat if you want to get rid of the fat you have to drop insulin so how do you do that well that's a good calorie and that's the one of the bad calories so the good calories by this paradigm and it's very much a paradigm um our fat healthy fats and we could discuss what those are and what aren't and the bad calories are going to be carbohydrates are more refined and fructose rich the bad calories the more they're going to work to elevate insulin and keep fat

locked away and that's it's a simple okay well you jumped in there a couple of times with this fructose thing and you said we didn't really even have it until the 70s and then probably in the 80s and now it's a big portion of our sugar consumption well so how is that different and why should we be worried about fructose okay so we actually there was a there's always been a lot of sugar and not always always. Since the 18th, 19th century, sugar intake goes from five pounds per capita per year at the beginning of the 19th century. That's like Coca-Cola's worth of sugar once a week to 90 pounds by the end of 1900 and 100 pounds by 1920. And then it stays relatively stable because when people are consuming a lot of sugar,

they tend to get fat, so it tends to be self-limiting. And then the 1980s, it shoots up again because we start blaming everything on fat. And high-fructose corn syrup comes into the group. So high-fructose corn syrup, sugar, and this is what Elliot Jocelyn didn't know this was the you know the very specified siloed knowledge basis so a physician who's not is not a biochemist might have taken biochemistry courses right become a physician but you're not right right it's basically biochemistry yeah so i booked it back and

looked in my first year med school biochemistry text but it's all there yeah it's all there i'm like okay so uh sugar sucrose the white powdered you know is is a molecule glucose bonded to a molecule fructose and half yeah they're both carbs they're both uh simple well sugar is a simple carb the fructose is the sweetest of all the carbohydrates. So any sweet substance naturally occurring is going to have, except mother's milk, is going to have fructose in it. The fructose, glucose is metabolized by virtually every cell in the body, so it gets into your bloodstream. You secrete insulin in response to it. You know, we talk about high GI foods.

They're foods that break down into glucose quickly. The fructose is metabolized not by every cell in your body, but it goes through the small intestine and then into the liver. And in high doses, it's converted into fat in the liver. So the way I think about it now is our livers evolved to see the fructose in fruit. So a very small amount of fructose in fruit a month or two a year. Yeah. And bound up in the fruit. So with all the fiber in the fruit, so you would get a small amount of the substance.

It would take a long time to digest it. And then it would have to make it through the portal system. It may or may not do it. There was a paper that came out this summer that says at low doses, at least in rats, fructose is not going to make it through the small intestine. Then as we increase our sugar consumption, and worse in that turn, and once we start drinking sugary beverages in huge doses, so the soft drink industry begins in the 1870s and 1880s with Pepsi and come on dr. pepper coke colon Pepsi in that order arm the now you're

suddenly drink you're drinking this stuff and you're drinking it between meals and 50% of the calories are fructose and there's no fiber to slow down the digestion and you're getting massive amounts compared to what we would have gotten was also high fructose which is more than the glucose well the high fructose corn syrup is high it was called high fructose because there were lower fructose corn syrups that had been developed over the years but it's 55 up to 75 for some of these drinks true and may or may not make a difference and i just don't know but the liquid sugars are a problem compared to, so you're getting them between meals. You're getting sugar from basically breakfast through dessert.

It's like drinking alcohol on an empty stomach. You get the buzz fat and you get it all day long and that's all your liver is doing all day long is basically processing fructose at doses it's never been designed never evolved to see before like any machine that's asked to do a job it wasn't designed to do it does it poorly and then making it do it year in and year out constantly like remember a little bit of fructose dribbled into the liver over the course of a couple of months summer you binge on some fruit okay fine it's just the daily and repetitive doses that are a problem breakfast lunch and dinner breakfast lunch and dinner and in between yeah because we're remember we're drinking the coca-cola is not just at our meals but between meals and and then like you said the 1980s with the low-fat dogma or the

1960s with sugary cereals come in they've come start coming in late 1940s and by the 1960s it's you know there's an entire industry from the cereal companies to madison avenue tv shows that we grew up loving you know rocky and bullwinkle was created to sell cereal, sugary cereals. It's true, right? I mean, even Fred Flintstone was promoting cigarettes back in the day. And was it Fruit Loops? Fruity Pebbles.

Winston takes good like a cigarette should, right? So Fruity Pebbles, right. So it's frightening. So the case against sugar is your next big tome. That was, I thought incredibly well-researched, really historical, and sort of caught us up to date on why we have this sugar glut and actually what it's doing to us.

So tell us more about this sort of case against sugar. And should we be having any sugar? Well, so that's okay. So there are two issues here, as there always are multiple issues. In talking about the case against sugar, I'm implying that there's a crime that's been committed and that sugar is. So the question is, what's the crime?

Yeah. So the crime is obesity and diabetes epidemics worldwide, recently described by the director general of the World Health Organization as slow motion disasters, although in some places there's nothing slow about it. So these epidemics occur whenever a population transitions from whatever its native diet is to a Western diet. So it doesn't matter what the native diet was. It could be Southeast Asia where it's mostly carbohydrates,

a lot of rice and wheat. It could be Inuit diet where it's seal meat and whale meat and caribou. It could be a pastoral Maasai diet, warrior diet in Kenya where it's the blood, meat, and milk from the cattle. It could be Native American diet that's primarily carnivorous or a native american diet that's primarily agricultural right um add a western diet and lifestyle you get obesity diabetes and like i said some populations like in the famous uh the pima native american tribe in arizona the diabetes appears in the course of a decade, just explodes in this population.

80% now. 1960s, yeah. Diabetes by the time they're 30. So the question is, what are you adding? It's not the native, it's not the baseline diet. And it's probably simple because you add it to anything, any baseline diet, you get obesity and diabetes. And the conventional wisdom is so i mean michael

pollan talks about this and in defense of food in the book that i disagree with almost entirely we're working from the same observation which is this what is it that causes this disease of western diet he says don't eat food like substances which is well so one answer is processed foods and a lot of people like that it's a simple answer we don't have to be wrong about the saturated fat thing so it's an interesting issue because in the US when we focused on saturated fat it's because researchers like Ancel Keys and other research we're asking murmur the question determines the answer the question is

why do we have such high levels of heart disease in the U.S.? We live in the U.S. What we see is massive amounts of heart disease. What's causing that? We'll do studies to try and figure that out. And the answer, we come up with the saturated fat. Which wasn't based on cause and effect, just a bunch of patterns in the data that turned out to be wrong. Yeah, and some poorly done clinical trials. So British researchers, they have the British Empire. They're all over the world, right? Missionary colonial hospitals all over the British Empire, the remains of the British Empire are asking a different question. Why is it that we have obesity and diabetes epidemics

appearing in all these different populations all over the world? Yeah. And they're coming to the conclusion it's refined grains and sugars. The only caveat with that is that the same thing happens to populations that are already eating refined grains. Southeast Asia, right? Yeah. Although they're also working in the rice patties 12 hours a day. They are. And that's one possibility. If you want to exercise 12 hours a day, it's fine to eat more carbohydrates. Quite possibly. quite possibly. So that's one, and that's the first time I heard this story from an epidemiologist at Harvard who is Chinese.

And his answer to this question, because I asked him, what about China? They're eating, it was their peasants. They're out in the fields all day long. So it mitigates, ameliorates the problem. Although clearly doesn't, because there are people who are working all day long who still get obese. Actually, one of the first observations of interest here in the Pima

back in 1902. So the Pima had been through 30 years of famine, horrible, devastating famine. And towards the end of this period, a Harvard anthropologist comes to live with the Pima and study the Pima. He actually had tuberculosis, so he wanted to go to Arizona in an effort to cure the tuberculosis, which didn't work. But he spent six months, nine months with the Pima, and he writes a seminal book about it. He takes a photo of a Native American Pima. He points out that they have a high level of obesity in the tribe, particularly in the older population, particularly in the women. There's a photo in the tribe of a woman he calls Fat Louisa, who's clearly obese.

And he asks us, it's sort of the interesting thing is, the older population, they had lived through the famine. 30 years of famine is 30 years of calorie-restricted diet, right? And it's very high carb and low fat. And the question is is why are these people fat anyway and then of course you start looking what's happened they're a reservation they're on a reservation they've been introduced to western foods the commodities to commodities which are at the time was mostly white flour some powdered sugar some short lard lard shortening

by the way they have a word for native americans who eat those commodities on the reservations and get fat it's called kamad bad oh that's interesting i didn't know that i learned that from a hopi chief yeah so anyway the simple way to answer this question is just say it's it's food like substances it's processed food in general now you don't have to think more deeply about it so you want to know what causes yellow fever malaria you blame it on miasma bad air from swamps this was the miasma theory of disease which was like because the people who lived in low and lying areas in cities and coastal areas tended to get these diseases and the rich people lived on hills

so they'd be away from the bad air and the bad water and they wouldn't then you could you know avoid the disease with the miasma theory but it didn't tell you what was causing it they were mosquito-borne illnesses that they were by one once you know it's a mosquito-borne illness you can you can save the poor people too sure the ones who can't afford to move away from the water yeah um the refined... But then you spray them all with DDT. Or you could spray DDT. So yeah, this is a refined processed food thing is to me like a miasma theory. It's great, but it doesn't...

There is an agent here. It may be multiple agents, may be physical and activities involved, may be... But it turns out your conclusions were that it was sugar. Yeah, so I concluded sugar is the simplest possible explanation and the obvious explanation and

uh for two reasons because we also seen a spike in flower consumption well you do but so here's the issue again because remember we got those all those southeast asians i had your buddy david ludwig and i argue about this about once a year. And I say, I'm not willing to ignore 2 billion possible black swans to my flower theory on the basis that they're out there in the field. They're not all out there. So even in Southeast Asia, you see an increase. So obesity and diabetes are now manifesting themselves. And these are always low sugar consumers.

So to me, it's a simpler hypothesis. And there are two. So we have the fatty liver link. But there's also a link with insulin. So type 2 diabetes is sort of insulin resistant fundamentally. And one of the arguments I make in my books and David makes and others and has now been embraced is that, and actually Rosalind Yallow and Solomon Burson suggested in 1965, is that the route from health to obesity and diabetes doesn't go health and leanness, obesity, diabetes,

it goes health and leanness, insulin resistance and hyperinsulinemia to obesity and type 2 diabetes. Yeah, absolutely. And as a doctor seeing patients and testing all this stuff for 30 years, I would completely agree. Yeah. And so, and a significant amount of evidence, laboratory research and animal evidence in the 50s, 60s, 70s and 80s implicated fat accumulation in the liver in insulin resistance.

And once we start talking fat accumulation in the liver, if I'm an investigator, I'm going to start wondering about sugar because of the fructose. And there's a link between insulin resistance and fatty liver disease. Again, these aren't perfect correlations. It's all the same problem. But the liver's role in all this tends to implicate something unique to hepatic metabolism of something and fructose is just the prime suspect.

And the argument I make in the book is, I'm just arguing it's a prime suspect. And you go back to the late 19th century, so you can actually see diabetes when you go to hospital records from the 19th century so you can actually see diabetes when you go to hospital records from the 19th century and uh by their hospitals like massachusetts general hospital in boston um pennsylvania hospital in philadelphia that keep their records yeah and you just if you're a researcher or an author you could contact their archivists and they will do this research for you. Amazing resource. You can see diabetes, you can see the diabetes epidemic again in those hospital series. It's like seeing Ebola patients come into a hospital in Zaire or something for the first one and then three more from a village in this case. There are years, like at Mass General, there are years from 1925 or so to 1825 to 1850 where there are no cases, zero cases.

And this is the major urban hospital. And now it's the main diagnosis in medical care. Yeah, I'm almost assuredly. One in three Medicare dollars is for type 2 diabetes. If you add in pre-diabetes, it's probably two out of three Medicare dollars. Yeah, yeah. And there are hospital systems like the VA system where one in four patients

are diagnosed diabetics. And here, the entire year where there are zero cases. And then the 1840s, you have the beginning of the candy and the soft drink, the candy industry and the chocolate industry and the ice cream industry and sugar prices are coming down and sugar consumption is going up. And by the 1850s, 1860s, you just, you see the numbers in this hospital record. So they go to two to three cases a year, four to seven cases a year. Elliot Jocelyn sees this in his first paper.

And back then people are saying, well, it could be all the sugar we're consuming. Now, they might have said they didn't, but they might have said it could be all the white flour we're consuming. Because you're right, they both, they develop sort of simultaneously. But even back then, they're thinking it's the sugar. And then people like Jocelyn talk them out of it because they don't know about the glucose. I mean, I would suggest that if people cut out all their sugar in their diet and consumed, you know, a loaf of bread or two a day, that it's not going to work out.

No, I agree with you. It's not going to work out. So there were two questions. This is what I meant by multiple questions. One question is what's the fundamental cause of the epidemics? What do you have to add to any diet whether it's refined grain rich to begin with or you know purely carnivorous to begin with what do you add to any diet to end up with diabetes and obesity and my

answer is you got to start with sugar. Absolutely. So then the second answer is what do we do? It's like why we get fat what do we do about it? Well how do we get thin right? How do we get thin and how do we do and it's like why we get fat what do we do about it well how do we get thin right how do we get thin and how do we get thin is like it ain't gonna work if you eat too so i'm saying if we go back to human beings circa 1830 yeah and give them two loaves of white bread a day it ain't gonna be pretty right but i don't think they're gonna get diabetes although the funny thing about white bread is it's got, white bread can be, I think, up to 12% fructose sugar.

Yeah, and it's higher glycemic index than sugar. But it's also higher in sugar. So the difference between French white bread and Wonder Bread is the refinement of the grain, it's more highly refined. And the fermentation process. And the fermentation process and the sugar content. Yeah. And so, again, we don't know what it is. But we had people back in the 1820s 1830s basically living on

bread that's what poor people did it was it was processed food yeah process I mean it is multifactorial right it's our gut microbiome it's environmental toxins well see this is where there's all these variables in there that are impacting us, right? But this is the big elephant in the room. Yeah, I'm not fond of multifactorial explanations. They're often used to, A, make

everyone happy, because you're not rejecting anything, and B, to say, well, we have no clue what's going on. And we probably got the wrong answer since we clearly haven't been able to stem these epidemics. So it's multifactorial and it's complex and anyone who says there's a simple answer

is naive and wrong. And my counter-argument is you start with a simple hypothesis and reject it when you have to. I think if you look at the big elephant in the room, you've got to cut down sugar. And I would add to that refined starches. I think if you look at, you know, the big elephant in the room, you've got to cut down sugar.

And I would add to that, you know, refined starches. I think. Well, this is, so that's like the solving the problem thing. So before we get to that. I think the world is full of people, diabetics who don't eat, are smart enough not to eat sugar and drink Coca-Cola. Right. And are still diabetic.

Because they're eating a high-carbohydrate diet. Because they're eating a high-carb diet. So you wrote an article with Nina Teicholz in the U.S. News and World Report, which was pretty provocative. Well, it was in the LA Times. It was in the LA Times about that report. And their report is sort of an annual report.

It says, here are the best diets that you should follow and they list the mediterranean diet and the dash diet which is a dietary approach to stop hypertension and you and nina do a major takedown on that and suggest that you know compared to what you know you didn't you sort of that question sort of left out. Tell us, what is the problem with those diets? And what would be your approach to find the right advice around nutrition and figure out what their dietary guidelines should be for America? Wow. I did that in 10 minutes. I did that in 10 minutes.

What do we have? We only have five minutes. So what was the problem? So we live in a world, and you live in a world, What do we have? We only have five minutes. So what was the problem with the, so we live in a world and you live in a world where if you put people on very tightly carbohydrate restricted diets, high in fat, we'll call them low carb, high fat. Not even necessarily keto, but somewhere in that range.

Low carb, high fat. You tell them, don't eat these foods. These foods are fine. And these foods are carbs and those foods are high in fat and they're you know um they get better right you see remark fairly remarkable clinical improvements uh and we live in a world where doctor's office if you're in internal medicine or family medicine your your doctor's office is full of basically people with overweight obesity diabetes hypertension all the concomitant diseases that go with insulin resistance and metabolic syndrome.

And the medical community over the years, they had these two hypotheses. One was that salt caused blood pressure, it caused high blood pressure, and one was that saturated fat caused heart disease. They both kind of have flaws. They both have,. They've both gone to have flaws. They've both gone away. And they end up with the two diets that they've kind of, the establishment researchers have pushed as healthy diets and have tested a few times in limited trials.

This is the DASH diet. DASH stands for Dietary Approach to Stop Hypertension, and the Mediterranean diet. And the DASH diet is a low-fat, high plant-based. It's actually not that low-fat. That was the thing. It's low-fat but not low-dairy fat. Right.

Oh, it's low-fat dairy. It is low-fat dairy. Low-fat dairy, yeah. And if you put together a group of dietitians and nutritionists and health authorities who have grown up without questioning the medical establishment, sort of believing what they've read, which is a reasonable thing to do, if you're in that world, you're going to end up with people who think those are the healthiest possible diets. And then we have a world of, and these are diets that are given with the hypothesis not that they'll make you healthier

immediately but that they will make you healthier in the long run it'll prevent so if you eat a dash diet you will you will lower your blood pressure which is a good thing and that will prevent stroke and there'll be no side effects no fattening or diabetes or anything else that might happen from the high carb part of the diet or Mediterranean diet supposed to prevent heart disease and diabetes. So you won't see any real significant changes immediately unless you calorie restricted. And if you calorie restricted, you probably won't be able to stay with it because nobody likes to be hungry. That means being hungry your whole life. Anyway, so these are angry these are sort of hypothesis-based dietary approaches um and then there's this low carb high fat thing where you

put your patients on it they lose weight they're hyper their blood pressure comes down their blood sugar control gets much better they might get off their type 2 diabetes yeah medications and obviously people get off their cardiac meds their their high blood pressure meds. Yeah. Their kidney function gets better. Their testosterone hormones improve. They have improved cognitive function. Everything gets better. Things look good. It's hard to imagine that you're killing people.

But then somebody like U.S. News and World Report comes along. Not only do they rank the sort of conventional wisdom diets the highest of the healthy diets they have. I think it was 38 diets they study they look at they assess and 35th through 38th least healthy are the diets that you're recommending for your patients because you see them get healthy so there's a disconnect here and if you live so you ask the question how do we fix that well Well, why is there the disconnect? So one possibility is we're quacks, right? I mean, the world is full of physicians who are pushing questionable medical procedures and think they're doing good and aren't.

And we're just them, well, you are, and I'm a bad journalist. I actually thought my career really hit a high point when I was on Quack Watch. Yeah, exactly. I only made it yeah the other possibility is that the way u.s news and world report does their diet rankings is by getting experts and the experts are people have risen to the top of their professions or close to the top in this case by reiterating reiterating and believing in the conventional wisdom. And so they're just going to, they're a way to filter through these diets

to recapitulate what the establishment has been telling us for 50 years. And ignoring the over 70 studies looking at the low-carb, higher-fat diets as effective for... So this is the point me and I just wanted to make was that when you actually look at the trials, instead of asking the opinion of establishment authorities, you find that the establishment diets are not very well tested.

When they are tested, they don't do all that well. And you ask very limited questions like, is a Mediterranean diet better than a low-fat diet in the context of, you know, all the problems we discussed. And, yeah, I tried to actually, I contacted the editors at U.S. News & World Report. Actually, I asked David Katz to make the introduction because David and I are, you know, we don't think very highly of each other, but we're... In communication. We're in communication.

David was very kind to make the connection, and I said, I'm going to be in Washington. I'd like to meet with you and discuss the rankings. And I've won many awards for my journalism. Whatever you think of my beliefs, people think highly of my journalism and we're colleagues in that way. And they said, yeah, we'd love to meet you. What do you want to talk about?

And I said, I want to talk about potential problems with the diet rankings. And that was the last they would answer an email it's like and this is what happens with the sort of the whole group thing phenomenon yeah it's amazing you know you think science is about discourse and debate and well science good science is but all this sort of once science becomes and again the whole diet thing is kind of, you know, religious factions arguing with each other. How do we fix and get the right guidelines and change what we're doing?

And how would you think about doing that? I think, well, we continue doing what we're doing, for good or bad. You know, again, I mean, I believe in... Crying out in the wilderness? Well, but, you know... There's more of us. There's a lot more of us.

When I first started my research, that 2002 article, I'm thinking there were half a dozen physicians in America who were outwardly promoting these diets, and they were all writing diet books. And now there's probably a few tens of thousands is my estimate. So that's a tiny percentage of the overall medical community. But it's a huge, absolute increase. And they're all people who did it because they experienced what you experienced,

which is they can make their patients healthier. I mean, I was always recommending low-fat, high-carbohydrate diets and didn't see real serious benefits. And yes, I got people off processed food and tried to eat healthier and whole grains and beans. But it was really clear to me that you know i couldn't get people off their insulin and now within three weeks i've got someone who's been on insulin for 20 years this is a question why wouldn't you want to if you were a patient or a physician and you heard somebody say that why wouldn't you want to try that yeah let me see what happens because i you

know unless maybe they're maybe their patients are doing better but the obesity and diabetes epidemic suggests that we are not handling this problem correctly okay so you're president king for a day and you can change policy change businesses change something that you think would have an impact in making all this better what would it be well like i said i'd start with getting people to think of sugar kind of the way we think of cigarettes you know i don't know if everyone i think the new tobacco yeah i think that's that's of everything that's the worst yeah i mean it brings a huge amount of pleasure so we have to deal with well when you look at the data, obesity and sugar is far greater killer now than smoking, alcohol, and physical inactivity by far.

Yeah. Yeah. So, although I don't buy the physical inactivity stuff, I lived in Paris in the 80s when I've always had among the highest longevity in the world and this is these are not people who were working out um I don't know what they were doing in the afternoons yeah with their their friends wives and husbands that might have been physically rigorous that was but did you know if you saw a jogger in Paris in 1985 it was an American yeah interspersed with all the obese Americans in their Bermuda shorts their backpacks um this is a new phenomenon physical activity for urban populations so anyway but yeah I would get rid of the sugar first and then I would try to get I don't know what taxation

by regulation of subsidies I think just by awareness. I'm not a fan of government regulation in general in this area. But if the hypothesis is true that sugar is biologically addictive, just saying get rid of the sugar isn't going to work. It's like, get rid of heroin. Well, yes and no. I mean, I think for a lot of us,

yeah, it takes an act of will, but I think for many of us it's easier. The problem is it's everywhere. I think it's an act of biology. Yeah, it's everywhere. So you have to make it less it less you know you got to get rid of the candy bars and the you know placed in the supermarkets and i mean stores like best buy have candy bars yeah that you have to walk by to get to the cash registers and um they 50 years ago they would have had cigarettes next to the candy bars and then maybe that's a regulation thing, maybe that's an image thing

but we got into this problem because some very well-meaning liberals like myself thought the government should start telling people what to eat. So, you know, I just and there are, I have allies in the sugar world who as soon as they get sugar handled would then go after red meat or processed meat. And I'm not sure that's a way to make people healthier. It's better for the animals. I buy that, but I'm not sure it's better for the people.

And so I would, you know, in my universe, I want to get rid of the sugar, however we do. And then I want to do the best. I want the science to be nailed down. Unfortunately, that requires a universe where you can take 50 years of rigorous science. If you were King for a day, you'd put a few billion into studying this more rigorously? I would have a kind of Manhattan Project-like approach to this. We're very concerted. We're very smart scientists without preconceptions say

this is what we don't know and this is what we have to study this is the studies we have to do and here are new ways we can do the studies and new populations in which we can do them so we can get the kind of rigorous control we need i mean this is a real pie in the sky. But we spend, okay, so we're in Zurich, right? We're a few hundred miles from Geneva and CERN, the European Center for Nuclear Research, where they spent $10 billion to build a single particle accelerator to see what's beyond the standard model and ended up discovering a particle we knew was there called the Higgs boson but they were willing to spend 10 billion dollars because they knew what they had to

answer yeah you know in the past few years there have been a series of naval destroyers off the sea of Japan that have run into local boats and done an enormous amount of damage to themselves those destroyers cost a billion dollars each and one of them was a class of 60 so i spent 60 billion dollars building a class a class of destroyers it's just a matter of this is a very hard these studies may be practically impossible they're certainly difficult but the societal motivation to do them has to be there and you have to not have these authorities out there saying oh we don't have to do these studies we know the answer you've been listening to the doctor's Pharmacy with Gary Taubes about sugar and fat and everything in between. This is a place for conversations that matter. And if you like this podcast,

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