The Dr. Hyman Show - INTERVIEW: The Evolution of Diabetes Treatment with Gary Taubes

Episode Date: June 5, 2024

View Show Notes From This Episode Get Free Weekly Health Tips from Dr. Hyman Sign Up for Dr. Hyman’s Weekly Longevity Journal Approximately 1.2 million Americans are diagnosed with diabetes each year​. Understanding the complex nature of this disease is crucial to tackling this widespread health issue. Award-winning science and health journalist Gary Taubes joins me to delve into the history of diabetes and modern treatment options. Together, we explore the use of ketogenic diets, the impact of drugs like Ozempic, and the need to reassess our approach to diabetes management.  In this episode, we discuss: The evolution of diabetes treatment Assumptions about diabetes and the influence of dietary choices The role of calorie intake and exercise in diabetes management The limitations of current drugs used to treat diabetes Clinical trials and their impact on our understanding of diet and health The choice between drug therapy and dietary changes in managing diabetes Join us to discover how bias and ingrained beliefs can obstruct progress in understanding how to treat this chronic illness. This episode is brought to you by Rupa Health, Pique, and BIOptimizers.  Streamline your lab orders with Rupa Health. Access more than 3,000 specialty lab tests and register for a FREE live demo at RupaHealth.com.  Enjoy Pique's Sun Goddess Matcha. Just head over to piquelife.com/hyman with code HYMAN for 15% off + Right now, get up to 15% off + a complimentary beaker and rechargeable frother.  Tackle an overlooked root cause of stress with Magnesium Breakthrough. Visit BIOptimizers.com/Hyman and use code HYMAN10 to save 10%.

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Welcome to Doctors Pharmacy. I'm Dr. Mark Hyman. That's pharmacy with an F, a place for conversations that matter. And if you have diabetes, you know someone with diabetes, or you have prediabetes, or you're overweight, which probably counts for 75% of you listening, you're going to love this conversation because it's with an investigative journalist, Gary Taubes, who has done a lot of work in trying to understand the nature of diabetes. He's an investigative science and health journalist. He's the author of this new book, Rethinking Diabetes, which we're talking about today. He's also written The Case for Keto, The Case Against Sugar, Why We Get Fat, Good Calories, Bad Calories, which is amazing.

It was published in the UK as The Diet Delusion. He's a former staff writer for Discover and a correspondent for the journal Science. His writing has also appeared in the New York Times Magazine, The Atlantic, Esquire, and he's been included in the numerous best of anthologies, including the best of the best American science writing. And he's received three Science in Society Journalism Awards from the US National Association of Science Writers. And he's a recipient of a very prestigious Robert Wood Johnson Foundation Investigator Award

in Health Policy Research. He went to Harvard. He's got a master's degree in engineering from Stanford, a journalism degree from Columbia. And he's an incredible man who's done a lot of work in trying to understand why we are overweight, why we have diabetes, and what we can do about it. I know you're going to love this conversation because we got deep into the history of how we began to understand nutrition and nutrition therapy in diabetes. And back in the day, we talk about in the 1700s and 1800s and early 1900s,

we were using very high fat, what they called animal diets to treat diabetes. And we talk about how that all changed with the discovery of insulin, when we loaded up people with carbohydrates and lots of insulin and how that has led to some significant complications. We also talk about how some of the science that has been done is really not translated into the policies or the recommendations from the American Diabetic Association.

We talk about some really fascinating research that's been done by Sarah Hallberg and others looking at ketogenic diets to not just manage diabetes, but to reverse it. So I think you're going to love this conversation with Gary and let's jump right in. Well, Gary, it's great to have you back on The Doctor's Pharmacy again. Mark, it's great. It's funny. I just have to, the last time we talked, you were in Hawaii and I was in Oakland. Oh, that's right. That was the COVID shutdown era. The time before that, we were both in Geneva.

Yeah, that's right, in Geneva. Was it Geneva? Wait, Geneva. Yeah, it was a food conference. And we were talking all about the things we're talking about today, which is how food affects our health and the epidemic of diabetes and controversies about nutrition. And it was kind of the Illuminati of the diet, nutrition, diabetes world. That was a big day.

Yeah, it was really powerful. Zurich, now that I think about it, wasn't Geneva. Got to get that straight. That's right. Got to get our facts right. So yeah, Gary, it's so good to have you back. For those who don't know Gary, I did the intro, but he wrote this article that kind of broke through the zeitgeist

called What If It's All a Big Fat Lie in 2002 in the New York Times Magazine. I read it. I didn't even know who you were at the time. And I was like, wow, this really doesn't fit with what I learned in medical school. And it really started the conversation going about the quality of the food we eat, the quality of the calories we eat, and how they affect our metabolism and our hormones, and how maybe weight loss wasn't all about eating less and exercising more. And you've been deep in this for a long time. You've written so many books about it. And your latest book, which is why we're having the

conversation today, is called Rethinking Diabetes. And I have loved this book. I've just been savoring it every night. It's like a mystery novel about the history of diabetes and what's gone wrong in our approach to this condition. And it's really the biggest scourge today on the planet. I would say diabetes, pre-diabetes, metabolic dysfunction is really at the root of so much of the suffering we're seeing. Everything from heart disease to diabetes, obviously, to cancer, to dementia, even things like depression, infertility, even acne can be related to the dysfunctions that we have with our metabolic health. And recent data from the NHANES trial show that 93.2% of Americans are metabolically unhealthy, which means there's somewhere in the continuum of insulin

resistance where they have a high blood pressure, high blood sugar, high cholesterol, have had a heart attack or stroke already. 93%. No, 93.2%. Oof. So, you know, 75% overweight. So this book has really kind of turned a lot of our ideas upside down about diabetes. And I've been thinking about this for a lot. So I didn't really have to do a lot of rethinking. But I think a lot of people are going to read this book and go,

oh boy, we got it all wrong about diabetes. And you kind of talk about how really this journey for you, and I'll just quote you, it says, it begins with the regrettable observation that we are in the midst of a diabetes epidemic, a disease that was vanishingly rare in the 19th century that now affects one in every nine Americans. and that all attempts so far to rein it in have failed. And it's incumbent upon someone to ask the question why. So you took that upon yourself to ask that question, and I think we're going to get to the answer today. And did we fail because the current situation was inevitable, meaning the result of a food

industry out of control perhaps, or a nation of individuals who can't say no to what's next and tasty and the next ultra-processed snack, or maybe because we made the mistakes and the diabetes specialists got it wrong and public health authorities maybe allowed this to happen. So we're kind of in a disastrous situation where one in four teenage boys has prediabetes or type 2 diabetes. One in nine now, you said, have diabetes. Some

populations have one in four. The current view, and this is what I learned in medical school, was this is a progressive disease. It ain't going away. You have to, quote, manage it. You have to manage it with medications and you have to use ever increasing amounts, dosages, and frequencies of medications, including insulin, to control the disease. And yet there was a trial that happened that got me completely switched in my thinking. It was called the ACCORD trial. And this was a trial done many years ago on 10,000 diabetics. And what they said was, look, sugar is the problem.

So if we really want to fix diabetes and the complications from diabetes, we need to be very aggressive in controlling blood sugar. So they use very aggressive insulin doses, very aggressive drugs called oral hypoglycemics, which raise insulin. And the consequences of that therapy were that more people died and more people had heart attacks than who didn't have the intensive therapy. And Accord was one of three similar trials. All of them found the same thing. So basically we're talking about a disease that we have been treating in the wrong way

that has really been focused on trying to use more insulin to treat what has been thought of as an insulin deficiency. But in fact, it really isn't. It's mostly a disease of insulin excess in 95% of the cases, not if you're type 1 diabetes. So maybe, Gary, you could talk about this book from the beginning, because I think the history is really fascinating, just to kind of give us a brief overview of the history of the thinking about diabetes. Because in the 19th century, it was like a rare disease. Like if you had this in

the hospital, all the residents, the medical students, the attendings, they all come running, oh, wow, there's this rare case. And like we'd have syphilis now. I'd never seen a case of syphilis in my life, right? But I read about it, you know? So then it was rare, but it was happening. And so the doctors then had a very interesting approach that kind of happened upon the right answer in many cases using a dietary approach that restricted carbohydrates and used basically a ketogenic diet before they had insulin. So can you talk about how that developed and then what happened after insulin was discovered by Banting and Best in 1921? Yeah. Okay. And I'm happy to do that. Let me, before we do, they'll give you just a brief

explanation for why this kind of research is necessary. And in the book and rethinking diabetes in the epilogue, I talk about the history of the evidence-based medicine movement. Oh, I want to hear about that. Yeah. So until the 1970s, basically, you know, what a doctor did with the treated a patient was based on what he had learned in med school and what the authority figures in his life said, maybe what his textbook suggested and maybe what his colleagues were doing, but there wasn't really a lot of evidence. It was apprenticeship, basically. Yeah. And now, uh, in the 1970s, a few smart young doctors came along and they decided they

would, one of them, a guy named David Eddy, who at the time had left medicine, was getting his PhD at the Duke Stanford University in computational physics or something. And they had asked him to, he was going to give a talk on why doctors were prescribing for something. And he looked into it. He chose mammography as a subject. Then he went back into the literature to look at the evidence-based, why people recommend mammographies and what the benefits of them are. And he thought this would explain various sort of operating systems, charts, and how you go through different branches to decide what to do.

Like an algorithm, right. And he thought that he would find that this procedure was based in concrete evidence. And he said, instead, what he found out was that it was based on jello. Jello? There was just nothing there. It was just this technology that had come along that people thought might be beneficial. And they started to do it. And the more they did it, the more other people did it. And they never tested it. And this was the beginning of the evidence-based medicine movement. So what you do when confronted with a dilemma as a journalist or a physician who's interested

in the bigger picture is you always ask the simple question, what's the evidence? Why do we do this? Why, as you put it, diabetes has exploded in prevalence. The increase just since 1960 is 600% or 700% increase. I mean, if this was any other disease. Not genetic. Not genetic, not something about our lifestyles has made this explode. Still seen after 104 years, 103 years of pharmaceutical therapy, it's still seen as a progressive chronic disease. The biggest challenge to the successful treatment, according to an ADA panel a few years ago,

is the resistance of physicians to do what you said has to be done, which is continue to raise doses, add new drugs to the therapy. So that's what they're saying the problem is? We're not treating it aggressively enough? You're not treating it aggressively enough. You're letting blood sugar rise out of control in patients. And so question I asked as a journalist was, you know, basically, as I said, as you read that quote from me, is it, you know, is this inevitable? And if it's not, what's the evidence base for the decisions? And when you start asking that question, you start going back in time.

So you can start looking for clinical trials and the clinical trials you find will reference other clinical trials or other observational studies. And you just keep going back in time. And nowadays, because of the internet, first of all, all the- It's like a time travel going to reading that book. I mean, everything's available. Yeah. One way I describe this is 1920s when our philosophy of how to treat this drug was originally founded and it's still with us today. The physicians who crafted that philosophy had imagined that the whole world of diabetes therapy and diet and lifestyle like a thousand piece jigsaw puzzle and they had maybe 50 pieces and they weren't just 50 pieces in one corner they were 50 pieces scattered throughout the jigsaw puzzle and they that's how they were making their decisions now

you can go back in time and because of the internet and all these repositories of journal articles and documents and books google books allows you to find all the textbooks. If you can't get them on Google Books, you can find bookstores that sell them. My office is full with multiple editions. Moldy books from 1925. 80-year-old textbooks and the third edition and the fourth.

Anyway, now you can get, say, 950 pieces of that 1,000-piece jigsaw puzzle. You can see everything they should have seen but didn't. Hindsight is 2020. So you can go back and not only describe what they did but what they missed. And you could say they did this because they saw that or they had a patient that experienced this. They wrote about it and they gave a talk about it in 1927 at this conference in New York to physicians, and here's the talk. And it allows you not just to piece together the history of this field. And I think historically, this book is something that's never

been done before, diabetes therapy, but also to see what was missed and how the thinking evolved considering what was missed. So as you said, in diabetes, you could go back 2000 years to when it's identified in ancient texts or Indian texts, but the modern history starts in 1797. Okay. Guy, British doctor named John Rollo working for the military has a patient named Colonel Meredith. Meredith has diabetes. He shows up, he guy, a British doctor named John Rollo, working for the military, has a patient named Colonel Meredith. Meredith has diabetes. He shows up. He's lost a lot of weight. He's hungry.

He's thirsty all the time. He's peeing constantly. Back then, they would have their assistant taste the urine. This was a diagnostic technique. For sure. And if the urine was sweet, that was the identification of diabetes. And Rollo thinks— Isn't that what mellitus means, is sweetness?

Sweetness. Like honey. Honey, yeah. So Rallo thinks if there's sugar in the urine, he's not metabolizing the sugar properly. The sugar comes from plant foods. So I'm going to feed him a diet of animal meat and recommend to see what happens. And he puts them on, they calls it the animal diet it's actually fatty rancid meat blood sausages i mean it sounds awful disgusting but meredith

gets better it worked and he ends up living for i mean at that stage in time he probably had type two diabetes because he had been overweight and obese but they don't show up and that they don't manifest the symptoms one of the symptoms of being sick is losing a lot of weight. So by that point his pancreas was failing, but he still lives 12 more years. Amazing. Rollo tries it on a different patient, a general. He was in the army. That patient also gets better, but he doesn't stick to the diet.

He goes home, eats what he wants and dies. So Rollo publishes a pamphlet. That's right. Disseminates it throughout the United Kingdom and says to people, look, I seem to have come up with a way to cure this diabetes. If you've got any patients, consider trying it with them. This is medicine before clinical trials. And it's still medicine where we don't have clinical trials.

It certainly is, yeah. So a few dozen physicians write back to him. I mean, the ones who write back at the diet works, they don't understand it. Like the patient will get better and then they'll let them eat whatever they want. And then the patient will get worse and they'll put them out or they'll have kids. There's a 12 year old girl who gets better, but she keeps cheating and she knows she's, she just can't stop eating sweets. But the gist of it is it works. And by the mid-19th century, this animal diet, they get rid of the rancid meat and the blood sausages and basically just becomes fatty meat and green leafy vegetables.

So it is, in effect, a ketogenic diet. Paleo, keto-ish. And it becomes a standard of care for treating diabetes. So it could keep patients with type 2 diabetes alive indefinitely. Yeah. Their symptoms effectively go away if they don't eat carbohydrates. Yeah. And patients with type 1 who are insulin deficient,

it'll delay their demise, slow it down, but it's not going to stop it. You have no idea how much it slows it because you don't know how long the person would have lived anyway. The leading Italian diabetes specialist, a guy named Cantani, he's locking his patients away for two months to make sure they don't eat any carbohydrates and they only eat this animal diet. The Germans are doing it, the French are doing it, the British.

I mean, every major, basically you can't be a diabetes specialist. And again, it's a rare disease. There aren't many of these guys without using this animal. Yeah. As the 19th century turns into the 20th, it becomes richer and richer with fat. Because again, patients show up in the doctor's office having lost a lot of weight. And if they're type one and they're young, they're emaciated. So the doctors thought we want to put weight back on them and we want to feed them as much food as we can. And since you can't give them carbohydrates, we can give them fat. There's a Swede named Petran feeding patients 95% fat diets. I mean, a German comments that the diet is unbelievably effective with his patients, but he can't get Germans to live on cucumbers and butter the way the Swedes were.

I mean, Petrin wouldn't even let his patients eat bacon because there's too much protein. Some of the protein gets converted into amino acids, get converted into glucose. So this is a standard diet. There's a brief blip from 1914 onward for six years when this Harvard, Harvard's done a lot of damage in these worlds. This Harvard doctor starts advocating. No, this is Fred Allen. Oh, yeah.

He's a friend of Jocelyn's. Yeah, yeah. Starts advocating for this starvation diet. So the idea turns out that with the young type 1 patients, if you starve them, you can keep them alive longer. Yeah, so this is standard of care. So basically, by accident, some observant physician made the conclusion that carbohydrates were causing sugar in the urine, and maybe we should not eat them. Yeah.

And that became the standard of care until, including with Dr. Jocelyn, until 1921 when insulin was discovered. Right. So Jocelyn, just for background, Jocelyn is a Harvard grad. His mother has diabetes. His aunt had diabetes and died from it. He's obsessed. Type 1.

Well, again, they were probably both type 2 because they remember at that point in time they were overweight yeah and then they you don't you're not getting blood tests right there nobody has any idea what their a1c is so they only manifest as diabetes when they their pancreas starts to fail and you get the weight loss and all these other, the hunger, the thirst, the peeing. So Jocelyn opens the first diabetes clinic in the United States in Boston dedicated to diabetes. So this is a period in time. It's still there. It's the Jocelyn Diabetes Center at Harvard. It eventually became the Jocelyn Diabetes Center. And because he's got the only dedicated clinic, he's seen more patients than anyone else. So by 1916, when he writes the first edition of his textbook, it's Jocelyn's diabetes mellitus based on 1,000 cases.

And probably nobody else in the United States had seen more than 30 or 40. And then in 1917, he's got based on 1300 cases and he just keeps releasing the textbook and his, he kept his mother alive on this high fat carbohydrate restricted diet. She thrived, lived longer than any of her other healthy relatives because he had gone to Germany, learned what the Germans were doing with all the butter and the meat and the no carbs. And she was a stern New England stock and she would do whatever he told her to do and she thrived. And then he buys into this Allen thing with the starvation therapy and the starvation therapy, you're restricting not just carbs, but fat also. And calories, right. And calories.

So now he kind of begins to blame fat, as Alan did, for the disorders that would kill these diabetics because you're feeding them high-fat diets and he thinks they shouldn't die. Anyway, 1921, insulin's discovered. First used therapeutically in January 1922 on a on a 13 year old boy named leonard thompson it's a tremendous success i mean thompson was so weak he weighed i think 65 pounds he was 13 years old his father had to carry him to the hospital bed like 50 years later the med students and residents in this toronto hospital said they were sure he was dead. Like this was, you know, he had weeks to live. Insulin brought him back to life. I mean,

just within days, it was a miracle cure. Eli Lilly begins to produce insulin and they make it available to doctors around the US and Canada who had been treating a lot of diabetes patients. They were becoming diabetes specialists and it's a miracle. It's like they've never seen these patients are resurrected. But then what happened was something interesting, which is they somehow shifted from this idea that we should restrict carbohydrates, that we should actually feed them a lot of carbohydrates and just cover it with insulin. Well, so this is an extremely powerful drug. I mean, it's a hormone, right? A peptide, like ozempic. We'll talk about that in a minute. For all intents and purposes, there was no such thing as low blood sugar, hypoglycemia,

until insulin was discovered. Now, if you overdose, you've got to balance the insulin to the carbohydrate. So there's no way to know what the proper dose is. Everybody's different. And insulin will control blood sugar. It'll de-sugarize the urine, which was their target. Let's get rid of the symptoms and get the sugar out of the urine. But we don't know how much to give. And how much we give depends on how many carbs they eat. And suddenly you're having these patients are getting hypoglycemic episodes or going into

what they called at the time insulin shock or insulin overdose. And that can be fatal. So the cure, the great miracle drug is a cure for a chronic condition or an acute condition, type one diabetes. But the side effect is that it can be fatal within hours. Right. Serious side effects. So suddenly you have to feed patients carbohydrates. You have to make sure they eat enough carbohydrates to protect them from the treatment that's protecting them from the absence of insulin or too much. Doctors realized pretty quickly this cocktail, trying to figure out how much insulin to give

and how much carbohydrates to feed is really difficult. And with children, this disease is when you're diagnosed, it's a bad enough diagnosis without telling kids they shouldn't eat ice cream ever again or they can't have cereal in the morning like their friends. Yeah, they didn't want to restrict them. So very quickly, they decide, look, it's just easier to let the kids eat whatever they want. They're going to do it anyway, and we'll cover it with insulin.

Yeah. And from the 1920s to the 1930s, it goes from children to adults, both type 1 and type 2, and everyone just says it seems to work. The patients seem to, some patients at least seem to feel better. They all get fatter, which is a side effect. Yeah, people need to know when you start taking insulin, you gain weight because insulin is a fat storage hormone. Insulin is a fat storage hormone, and some people knew that and some people didn't. Then we'll talk about how that got confounded by the conventional thinking on obesity. I hope we will. What they didn't know, this is a part of the issue with so evidence-based medicine movement that I had mentioned in the

1970s. The idea was if you want to know if you've got a therapy and you want to know whether it's better than nothing, whether it's better than what we're already giving patients, you do a randomized controlled trial and you randomize patients. You give one of them the new therapy and one the old, and one the new therapy and one group the placebo. And then you run them forward long enough in time, not just to see whether it's more effective, but to see whether it's safe or not or safer.

And you go with enough patients and long enough so you could see whether they have more or less of complications, heart disease, cancer, dementia, whatever you might be. They didn't have that in the 20s. The concept of randomized controlled trial hadn't been discovered until they developed this therapeutic philosophy for treating their patients. And then as you get about five, 10 years down the line, they start to see this, they refer to it as kind of tidal wave of diabetic complications. These patients whose lives might be saved by insulin, resurrected, brought back from the dead at nine, 10, 12 years old, are now 22, 25, 27, and suddenly all the familiar complications of diabetes are

atherosclerosis or arteriosclerosis. They're getting sclerotic plaques all through their body. They're dying of heart disease and strokes. They're getting blindness and kidney disease and neuropathies or having their limbs amputated. And when you read the records, and there was a wonderful book by a pediatrician turned medical historian named Chris Feutner called Bittersweet, where he got a hold of Jocelyn's records from his early years. And these patients would be thriving.

And then over the course of a year or two, their bodies would just fail them. Was it because they were taking too much insulin or because they were eating too many carbohydrates or both you have no idea right so their assumption as they're trying to wrestle with these complications is that the patients aren't doing a good enough job controlling what's the patient's fault uh. It's, you know, the, the, there are patients, the patients who seem to take their drug therapy seriously and rigorously seem to do better. So the idea was the blood sugar control is the issue. And the answer again, when you think like that is more.

Insulin. Insulin or more regular use of insulin or more. But what they didn't know, they didn't actually know if that was true. Because all they know is that it could have been the uncontrolled blood sugar, which is what they assumed. It could have been the diet that they were allowing them to eat that was in part responsible for the uncontrolled drug therapy. It could have been the insulin therapy.

You can't differentiate with the information they had because they didn't do the right clinic. They didn't do any clinical trials. Their assumption was poorly controlled blood sugar. So you move into the Second World War with that as the assumption, come out of the war, and out of the war, you start seeing the first arrival of these hypoglycemic oral the the holy grail of the field is a drug that could lower blood sugar yeah and take it by mouth you don't have to use a damn needle this catches on pretty quickly as soon as they establish that it's safe

and it lowers blood sugar people start using these drugs and they raise they work by raising insulin but but they work by stimulating insulin but They work by stimulating insulin secretion. But if you look at the label, the warning that's mandated by the FDA, it's got a black box warning on these drugs. A black box warning is essentially an alert that this has got serious side effects. And for oral hypoglycemics, the black box warning is, it's going to help your diabetes, but it's going to cause you to have a heart attack and stroke. Well, so this is the very first randomized clinical trial they do in this field was called the University Diabetes Program. And it starts around 1960.

And it starts because there's a congressman whose daughter is diagnosed with diabetes and she's put on one of these horrible hypoglycemic drugs and the congressman asks he's in ohio so he asks the leading authority at case western you know do these drugs do they help and he says i don't know right who knows maybe yes maybe no so they actually get 30 million dollars together to do a clinical trial 30 million dollars in 1960 was a load of cash. Yeah, it was a big, and the trial went for 10 years. And it was these oral, this drug tobutamide and oral hypoglycemic and then insulin and

then diet alone. And they added fen-fen, one of the fens of the fen-fens fiasco. I forget which one. Anyway, in 1970, the results are leaked to, I think it was the Wall Street Journal. I mean, not only is the oral hypoglycemic agent not do anything, not keep people alive any longer than diet alone, and the diet was a bad diet. I mean, it was a carbohydrate-rich diet they were giving them. Insulin doesn't do any better either. Yeah.

Okay. It's completely useless. And this was a huge controversy. Of course, half the, most of the- When you say better either, do you mean in terms of like reducing death, heart attacks, strokes? Deaths, heart attacks, whatever they looked at. I forget what the end points of the study were, but the drugs didn't help. And again, insulin, it must've been, it might've been mortality. They didn't play up the insulin. They played up the, it might've been mortality. They didn't play up the insulin. They played up the, you know, for the oral hypoglycemia. But this is what doctors,

this was what therapy was. I mean, I went to medical school in 1983. That's what I learned how to do is give these drugs. And then we, it was interesting, Gary, you know, I'm just reflecting back on my training. And what I learned was, learned was, I would see these patients come in who were eating a lot of carbohydrates. They were taking 100 or 200 units of insulin. And we thought that was fine to give them as much insulin as necessary to keep their blood sugar under control. But it never occurred to me was,

what was the normal amount of insulin that's produced by the pancreas every day in someone who doesn't have diabetes? Yeah, and it's like 20 to 60 units. Yeah, it's like Depending on what you eat. Like we can eat 10 to 20 or more units. So giving all this extra insulin can help control the blood sugar, but it's actually having all these adverse effects of weight gain and inflammation.

The reason you have to give so much is because, again, this gets back to the story, they're insulin resistant. The problem isn't that they're insulin deficient, which is type 1 diabetes. They have too much insulin already. And then there's double diabetes. Now you're adding more, yeah. What's interesting, again, going back to the history, we were talking about Jocelyn. And when insulin first came in, this really launched Jocelyn to his fame

because he embraced it. He talked about chapters in his textbook on how to use it. Jocelyn thought the way to use it is you've got to minimize doses. They started patients on one unit and then they went to two units and three units. And early 1920s, they might've been using 10, 20 units of insulin on patients. Then you have to strictly control their diet so that minimal insulin can work. So they have to have low carbohydrate. Can de-sugarize urine, which was there. And as time went on, other doctors were pushing for much greater doses. There was a Sansom in Santa Barbara who was pushing for 50, 100 units, 150 units. And he would show,

he said, my patients are thriving but in his patients in his papers you could see his patients had gained like 50 80 pounds in a year you know so they start off emaciated and then they maybe put on 40 pounds to get back to normal and then the extra 40 is obesity and there's a british diabetes specialist um Lawrence, who had type 1 diabetes himself. And his life had been, he was dying in Italy when insulin was discovered. And his doctor back in the UK said, if you can make it home, I can save your life. And it did. And he became, he co-founded the British Diabetes Foundation with H.G. Wells, famous science fiction writer who had diabetes.

And Lawrence tried these higher doses. And he was like, this is crazy. with H.G. Wells, famous science fiction writer who had diabetes. And Lawrence tried these higher doses and he was like, this is crazy. It's like, I don't want to blow up like a balloon. I mean, we know that if you start a patient on insulin, their blood pressure goes up, their weight goes up, their triglycerides go up, their cholesterol goes up. We know this. And so insulin is not- But we got drugs for everything. We got statin for the cholesterols. We've got blood pressure for our medications. We know this. And so insulin is not- But we've got drugs for everything.

We've got statin for the cholesterols. We've got blood pressure or medication. We call it comorbidities. We call it comorbidities. Like treat them all separately with drugs. You've got a blood pressure drug, cholesterol drug, diabetes drug, right? And I mean, it sounds facile to say so, but I mean, that was basically, you've got a pharmaceutical industry that's working hard to provide these drugs.

And then there are people with high blood pressure and high cholesterol who don't have diabetes. So you've got the drugs, use them. And nowhere along the line do people say, wait, why? Today's episode is brought to you by BiOptimizers. Did you know that hormonal balance could be due to low magnesium? Magnesium deficiency affects more than four out of five people. But even if you don't have a magnesium deficiency, just having suboptimal levels can contribute to your symptoms. And that's because magnesium is involved in more than 300, maybe even 600 enzymatic reactions in the body, many of which directly influence the production of key steroid hormones, including

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It's a simple, effective solution to a problem that's just more common than you may realize. And right now, my listeners can try it for 10% off. Just use the code HYMAN10 at bioptimizers.com slash hyman. That's B-I-O-P-T-I-M-I-Z-E-R-S.com forward slash hyman and save 10% with the code HYMAN10. I mean, your book, basically, Rethinking Diabetes, challenges all of our assumptions about diabetes. It pretty much does, which makes it a difficult thing to swallow if you're somebody who believes the assumptions. The oddness about that book is it's basically written for precisely those people who won't read it. Yeah. No, it yeah no it's the reason they won't read it is because they're convinced their assumptions are correct and you know yeah i have an odd sense of um commercializing my my intellect yeah i mean you have to question your assumptions uh and i think ken and john f kennedy had a great quote about

this i was going to remember essentially it was like you know most most people are not willing Yeah, I mean, you have to question your assumptions. And I think John F. Kennedy had a great quote about this. I don't know if you remember. Essentially, it was like, most people are not willing to challenge their assumptions and the discomfort of thought. Well, it's also not just challenging your assumptions, but it's challenging your assumptions on which you have built your career. Yeah. So you get to the pinnacle of your career because you basically embrace the conventional thinking of the disease.

As soon as you embrace an unorthodox approach, then you get excommunicated from your church. So the field selects out people who agree with the conventional thinking. They become professors, heads of departments, heads of associations. They serve on prestigious committees. They're the people you go to when the New York Times runs an article. They're the people who we consider experts and authorities. The guidelines. And the same has been said of me, and it's true. It's like, at what point can you say everything I believe, everything that not only made me the person, you see, for that reason I'm on Mark Hodman's podcast, but the people you like and respect all think the same way.

It's literally, it is quite like a church. You all have a certain religion. Kind of a cult. interviewing a um uh the 80 year old nutritionist at valor university this past week the interview very quickly um deteriorated just a extremely pleasant two-hour discussion about good and bad science yeah but he used the phrase allegiance bias uh-huh yeah and i said i stopped him i said right yeah i'd never heard that before but it exactly right. And so you have a certain allegiance and bias, and it's just not only does everyone you know and respect think like you do, but it's what made you the person you are today,

and now you're supposed to. It's true. I mean, I think Chris Gardner is a great scientist, but they have a plant-based research. We have a different conception. Okay, well, he's a Stanford. He's a smart guy. He's a good guy. I like him. He's a nice guy. And they have a plant-based research institute, which seems ideologically biased right from the get-go. Yeah, although to Christopher's defense, I assume what he's trying to do is demonstrate that a plant-based diet is not harmful. So what is the phrase they use in clinical trials in

medicine for non-inferiority trials? If you can demonstrate that it's not inferior to ways of eating with animal products in it, then you can recommend that people do it. If they're for ethical reasons or environmental reasons, they can eat this way and have confidence they won't be harming themselves. They can feed it to their children. So I think that's how he would defend it. I mean, okay, but still, it's sort of... Is there a meat- based diet initiative or yeah

there are and there's maybe a fake meat based on initiative but you know i think i think you're hitting on something really important gary which is that the way we've done science is is really kind of skewed and biased in many ways and we we don't challenge our assumptions and we we look at the world in a certain way through certain lenses uh rd lang said this he said scientists can't see the way they see what their way of seeing so when you look at the horizon we're in la you go to venice beach you look out and the earth is flat it's you can confirm it with your own eyes and there's no doubt about it and not only that undeniably the sun is revolving around the earth. Absolutely.

But neither of those are true. And until somebody started to question those assumptions and some of them were called crazy or were put in jail or worse, we didn't really change our thinking. And what we have to do and we must do because this disease is really going to decimate humanity. It's decimating our children.

It's decimating our population. It's crippling our economy. The federal deficit is in large part due to this phenomenon of insulin resistance and the consequences of it in our society, including chronic disease that are just such a burden. And I think we have to get it right. And your book is about challenging our assumptions

to get it right. And a lot of people would argue with you that that no, no weight gain and obesity and diabetes, which is a consequence of obesity, are really simply the result of eating too much food and not exercising enough. And you've talked a lot about this. You wrote about this in your book, Good Calories, Bad Calories. You had a whole research initiative called NUSI about this, where you funded large studies. David Littwig, who's a friend of ours, does some really powerful trials looking at,

do different calories matter and affect your hormones, metabolism, weight? And he found that they did. And there's just a huge body of evidence around this. Virta Health, which I know you were very close to, and Sarah Halberg, who's a friend of ours, recently died from breast cancer. She does some really pioneering research looking at ketogenic diets and reversing type 2 diabetes. And yet the American Diabetes Association and most endocrinologists are still saying you should have half of your diet as carbohydrates. So what is the truth about this? Are all calories the same?

And is it just about energy balance or it's funny when i first wrote about this i mean the first book in good calories bad calories and it was critically reviewed in the new yorker by their science health reporter gina colada who i knew well you know well gina made some interest she said first of all you never know what i left out which is true of all books um you just never know what the author- Yeah, sure. Selection bias, we call it. It is selection bias. And when you're writing a book, you're also selecting for a story and you're trying to select the most, the information that really you believe has to be in the book, because a book can't be 2000 words, pages long. And then she said that diabetologists,

diabetes specialists had been proven that a calorie is a calorie. And when I wrote back in the Times, it was kind enough to run a lengthy letter of mine in response, which they don't often do to book reviews. And I said, look, diabetes specialists of all people know that a calorie isn't a calorie, except for Peter Attia, who no longer knows that. But you know that every macronutrient, proteins, fats, carbohydrates, they prompt a different hormonal response in the body. And so a different metabolic response. And that hormonal response includes different effects on fat storage and fat mobilization and fat metabolism, burning fat, whether you're going to burn fat or carbohydrates or whether you're going to use protein for fuel,

which you could do, or for tissue repair and cellular repair, which is how you'd like to prioritize it. All these things are determined by the hormonal response, which is different from all of them. And so the argument I began making in Good Calories, Bad Calories, and as you pointed out, it's been in every one of my books, and it's in this one too, because it's, to me, clear as day. And this was worked out beginning in the 19-teens. German and Austrian clinical investigators, researchers, they were doing the best medical science in the world,

bar none, until World War II. Things went south a little bit in Germany then. Yeah. You know, fat storage is regulated independently from how much you eat and exercise. You know, your fat cells that make up fat tissue, they can't tell how much you're eating or exercising. So they only see certain things.

They see the fats in the blood. I mean, see is a metaphor. They're aware of the fats in the blood and the hormones in the blood and the glucose and the triglycerides and all kinds of other molecules. But not how much you're eating and exercising. And by the 1950s, it was pretty clear that they were responding primarily to insulin. So you raise insulin, you drive fat accumulation, you inhibit, primarily you inhibit the escape of fat,

the mobilization of fat. We call it lipolysis, it's the breakdown of fat. So basically it's like a one-way turnstile in a subway where the calories get stored in the fat tissue but they can't get out they can't get out they need this process of lipolysis they need to be broken up into small pieces so they can get out of the fat cell and insulin prevents that from happening and apparently no cell in the body is as sensitive to insulin as the fat cell so if there's a tiniest bit of insulin in your circulation,

it's going to shut down mobilization of fat. It's interesting. So just to point out something that our friend David Ludwig said to me once, which really sort of highlighted that it's more than just calories. He said in a type one diabetic, when they're untreated and they're first diagnosed, they could be eating 10,000 calories a day and losing weight. So that's because they have no insulin and they can first diagnosed they could be eating 10 000 calories a day and losing weight right so that's because they have no insulin and they can't store those calories they can't get in

the cells they can't get it so the problem with the you know there's always two different ways to see everything yeah so the way the community saw it is because they're losing they're peeing away all those calories that's why they're not gaining weight. So it's still to them, it's still an energy in, energy out thing. They're just losing all the calories in their urine. There are ways to study this and it was studied and to pick apart exactly what's happening. And what's happening is that without insulin, they can't keep fat in the fat tissue. So that's the primary effect. Yeah. What's interesting, like I said, is they start giving insulin therapy, the more insulin you give, the fatter patients became. And often they would become obese, and then type 2 diabetes is so closely associated to obesity, and they knew this, even as the specialists 100 years ago weren't thinking of it as type 2

diabetes. They didn't want patients to become fat because they knew that made diabetes worse. Worse, right. So you give them massive doses of insulin, you tell them to get fatter, and then you tell them they got to eat less. Yeah. And then type 1 diabetics get also type 2, called double diabetes. Right. So you give them enough carbohydrates and enough insulin, they become insulin resistant.

And so they need massive doses of insulin, And it's like they literally get double diabetes. Yeah, no. And it's along this way. I mean, one of the other things is the whole science of, well, it's called endocrinology, hormones and hormone-related diseases. And it's also sort of born in the late 19th century, but it's very primitive. And it's growing and then evolving through the 20th century. And these doctors are realizing there are diseases of excess hormone.

And if you have too much of a hormone, then you've got to lower it. And if you have too little, you've got to add it. But the problem is they can't really measure hormones in the bloodstream accurately until 1960. So we're giving insulin to everyone, whether they have too little insulin or too much. Because all we're trying to do is lower blood sugar. And then if patients have side effects or complications, they get all the diseases that associate with it, you say, well, the problem is uncontrolled blood sugar. Yeah. But you're giving the problem in type 2 is insulin resistance and hyperinsulinemia, too much insulin,

and you're treating it with more insulin. It's like the boy who cried wolf. You keep knocking at the door to try to get someone to pay attention, but it doesn't actually work, right? It doesn't actually work. So what you do, you have more boys banging on the door.

So Gary, we're in this moment now where we really, I think, have begun to really understand the biology of diabetes and the biology of insulin resistance and poor metabolic health. You have more people than ever are suffering from this. And we now have this drug, Ozempic. So is obesity an Ozempic deficiency? Quite possibly. No. right so is obesity an ozempic deficiency quite possibly no um i mean really what's going on here the issue with the drug is fascinating because part of the thinking here so one of the ways this

was captured this was originally an epigraph in the beginning of the book and then i decided if i put in the beginning of the book i'm then I decided if I put it in the beginning of the book, I'm giving the whole book away. Nobody has to read. I took two epigraphs out. That's too bad. So- What were they? One of them was from 1870s, 1870s. This British physician was talking about a patient who came in, a woman in her 70s, very healthy, plump, robust. And she came to see him because she had type 2 diabetes. And she had it completely under control by diet.

And he thought, this is terrific. Why are you seeing me? And it's because she didn't want to be on a diet anymore. And he's like, are you crazy? You know, you're as healthy as can be with a disease that for other people is chronic. I forget why we took that one out. The other one was a story that was told to me by, well, from my perspective, a young man. He was diagnosed with diabetes in his 30s.

This was like 2017. He was a chef. He became a journalist. He actually interviewed me for my sugar book and told me he had type 1 diabetes. And I said, I got to interview you for my diabetes book. So when you're diagnosed with diabetes, particularly type 1, it's like you go from maybe never having thought of this disease in your life, unless a friend or a relative had it, to being dropped into this world where now you have to learn as much about it as you can,

as quickly as you can, because you're going to pretty quickly die like within a day you're going to be injecting insulin and the doctor tells is briefing him and he says so what we're going to do is you know you've got this insulin deficiency disease it's type one and so we're going to give you insulin and you can no longer metabolize carbohydrates safely so in order for you to do that, we're going to give you insulin. And then you're going to eat, you know, get 50% of your calories from carbs. And you're going to regiment them. So, you know, a certain amount for breakfast, a certain amount for snacks. And he says to the doctor, well, wait a minute.

Let me get this straight. What you're telling me is that carbohydrates are now toxic to me and insulin is the antidote and you want me to eat the toxin and take the antidote that's right why don't i just not eat the toxin and of course the doctor has never thought about it this way his wife is like there's got to be a reason right the reason is the reason is, well, that's too hard to do. And he actually says, well, wait a minute. If I told you I was going to now exercise an hour a day, you would say that's terrific, even though the hour a day is going to be like 30 minutes getting to the gym and 30 minutes taking a shower. But as I tell you, maybe I shouldn't eat the toxin. That's going to be too difficult to do. Right. What's the problem?

That's very funny. As soon as we had insulin, the idea was eat the toxin, take the antidote. And if the antidote didn't work well enough, there would always be a new antidote also. So 1937, the long-acting insulin is discovered in the Nobel Nordisk in Copenhagen. That was the beginning of the— We're now making Ozempic. We're now making Ozempic. And so this is the long-acting insulin generation.

Then post-World War II, you have the oral hypoglycemics. And then by the 1970s, you've got insulin pumps. And now you've finally got blood sugar monitors. You can monitor blood sugar and there's always a new drug. And then we have, you know, the trans insulin made from molecular biology. Recombinant. Yeah. Recombinant DNA insulin. And so there's always a new drug. Yeah. So the idea is, yeah, sure. Because we're using pig and beef insulin we were before so now we had human insulin we could synthesize it we're gonna need vegan insulin but um the uh gosh if you're a

vegan and you type one diabetes they didn't have human insulin what would you do anyway but the idea is always like yeah we'll acknowledge that therapy isn't great now and there's room for improvement. It's always better than it was, which is true. But we also see other drugs coming down the pipeline. And there's always other drugs coming down the pipeline. So now the latest drug, the GLP-1 agonist, again, Gozempic, Wagovi, Manjaro, terrific drugs. I mean. Are you being facetious?

I mean, they seem to do some wonderful things. Why? Because they're still treating the symptoms. Yeah. As you put it, it said we don't have a GLP-1 agonist deficiency disease with obesity. I mean, maybe we do on some level, but who knows? Yeah. Certainly you can treat it

a lot actually a lot of the ways we eat in the process we actually lowers glp-1 glp-1 is a something our bodies make it's a peptide it's a natural thing like insulin right and we're just making something that acts more than our body can actually produce and make like yeah and acts and slightly you know is is kept alive in the circulation so it's not degraded as quickly. But so this is always the issue is we can treat the symptoms. We don't have to, people don't. So along the way as the obesity community was failing to treat obesity, failing to understand obesity, and failing to provide a dietary therapy that worked. This is the convention, the establishment, not the diet doctor world.

Because, you know, we think they got it right. But they created all these mindsets, belief systems, that would allow them to continue doing what they were doing without feeling, and ultimately they'll blame the patient, but the idea was nobody wants to be on a diet. That was a message from, with the kids from the early 1920s. Nobody wants to be on a diet. They're not going to stick to a diet. Fair enough, but people would if you give them a chance. Well, it's got to be the right diet and that's the point. So if you give them the wrong diet, why would they stick with it? Or if you're giving them a diet just to prevent the appearance, delay the appearance of a disease 10, 20 years down the line.

Like if I tell you eat a low-fat diet to delay heart disease, prevent heart disease, assuming it works, you don't and never actually see prevention happening. You don't experience the prevention of a disease. Right. And when you, if you get the disease 30 years later, you don't know that maybe you would have gotten it 10, 20 years later if you had eaten the way you used to eat, or maybe you'd get it 40 years later. You have no idea. There's no feedback.

Right. On prevention. It's one of my issues with the whole longevity world. Yeah. Is. How do you know? Even if you have a drug that keeps dogs alive longer, like maybe. Well, if I live to 120, Gary, I think that'll prove a point.

If I think that would be, if you see a strong enough signal, like suddenly there's a whole world of people who have been taking a drug and live to be 120, but. It's going to take a minute. It's going to take a while to establish that observation. It better be clear. Yeah. Because those same people are probably doing a lot of other things too. So anyway, but that's the issue. So nobody sticks with the diet. And as long as nobody sticks with the diet, drug therapy is always better.

Yeah. But it's not really because it ends up causing other complications. Well, and this is what you have to find out. Again, I have an essay sitting at The Atlantic that I hope by the time this is aired, maybe we'll have made it. About Ozempic? So what's your take on it? Well, this is what scared me when we talked about the history and the tidal wave of diabetic complications. If you think of insulin, 1922, it's a lifesaver.

It's a miracle drug. First miracle drug. Undeniable. I mean, people at the brink of death and it brings them back. It takes this intractable disease and it makes it tractable. Like those that pick in obesity. Patients do better. They clearly live longer.

It's clearly minimizing diabetic, I mean, the complications for the first five or 10 years. The acute complications, yeah. Yeah. But then you get to see the long-term complications of people not just living with this disease that used to kill them, but living with the disease and the drug therapy and the dietary approach that had been adopted along with it. And you cannot separate them out. And by the 1930s, you're seeing these people suffering the tragic consequences that they might not have had to suffer. People really understood what's going on now.

And so the question is, you take... Is that happening with Ozempic? Are we now in this golden era of Ozempic like we were with insulin and giving it to everybody without really any kind of thought of what's going to happen next? Just like insulin, they're going to have to be on it for the rest of their lives. So it's not just you've got some clinical trials

that have tracked people out three, five years and looked at specific complications that might stand out from and we're seeing around pancreatitis bowel obstruction yeah there's a there's so the question is what happens after 10 years and 20 years and what happens when people try to get off we also have clinical trials that show that after a year or two people get off these treatments the weight comes back if you're doing it for weight so we know that but what happens if you try to get off after 10 years or 20 years or 30 years what happens if somebody does these drugs you know i obesity is for most people is an intractable condition i mean we both think that that that

very low carb high fat ketogenic diets will do is probably the best approach the most effective approach dietary approach for treatment but we really have no idea for how many people yeah it may work for some enough yeah and you know i mean i just don't know those studies have never been done. So for many people and for children, obesity can be an incredible burden. So she was winning five-year-olds and 12-year-olds on Ozempic? Yeah. That's what the American Academy of Pediatrics is recommending. Yeah.

Now you're going to have kids who are going to be on these drugs for 40, 50, 60 years. And what about the girls who then get married in their 20s and want to get pregnant? So what do these drugs do? We know there's this concept of fetal programming in which basically the mother's metabolic health is passed on to the child through the womb. And an effect that you, I mean, it manifests itself as larger babies. Yeah. But for the most part, you can't really see the effects for literally generations until these kids are middle-aged and adults.

And then you see the explosion of diabetes and obesity. Yeah, these are the epigenetic changes that are really programmed disease in utero for obesity, diabetes, and heart disease. So now you've got this very powerful drug that for all we know might reverse this i mean maybe it's a be a godsend kids you know mothers take this drug during pregnancy the kids maybe it's not there's no way to know um and if the mother goes off the drug to get pregnant that means she's going to be gaining weight back while she's pregnant, which we know is a problem for fetal problems. Unless people change what they're eating.

Unless they change. So I think about the way Jocelyn thought about insulin in the early years. What if you use the lowest doses? And this was Richard Bernstein's revelation and type one diabetes in the 70s let's use the lowest doses and craft a diet that allows those lowest doses to be effective which is basically lower starch and sugar and higher fat and yeah yeah i mean you know we have a friend in the comment who is a type one diabetic who's a doctor who basically uses one or two units of insulin a day because she's on a ketogenic diet.

So she needs very, very low doses. She needs a little, but not that much. Yeah, and we know it can be done with that. And it can probably be done with these drugs, maybe. And it's quite possible that with the right dietary approach and dose, maybe people can get off the drug get to a maintenance weight a weight they're comfortable with and then i mean i think it's possible it needs but really that's not what's happening with the drugs they're just being prescribed with no lifestyle change no dietary

advice no regimen of exercise to prevent muscle loss and and well then the question is are people you know if you don't need the diet advice. I was just, Oprah just had her special on Zempik and how it's changing obesity. And I haven't checked. An ally out there emailed me and said, you should watch it and see if the word sugar is ever mentioned. Yeah, right.

So if you can, I mean, again, apparently these drugs do inhibit appetite. That's an effect. I don't know if it's a direct effect or an indirect one. And they might inhibit specific tastes for carbohydrates and sweets. I wouldn't be surprised. People feel full of the drug, right? And they get nauseous.

Yeah. But it's, you know, to have a drug just explode like this. And our history of pharmaceutical therapy is full of examples of drugs that were wonder drugs that ended up, you know. Thalidomide. Well, thalidomide was an extreme example because you could see it. But benzodiazepines, for instance. I mean, the world is full of people who took them on prescription as prescribed and got to the point where either the complications became unbearable or they became inured to the dose and they didn't do anything anymore and then couldn't get off it. And then you have nightmare. I actually had a tenant who was sent off to a rehab center for a month to break his clonopin habit and had a mental breakdown afterwards um you know it's the what do you do if the drug helps 80 percent of the patients yeah and causes intractable harm to 20 percent and you don't find out for 10 years. Yeah.

Whether you're in the 80% or the 20%. Well, we're going to see that. I have no doubt. I mean, I think it's going to be a boon to some people. And I think it's not a bad drug like any drug. It's how it's used, who it's used with, how long it's used, what dose it's used. And the extent of the problem that you're using it for. Right. But I've had so many patients, Gary,

who've lost 100, 200 pounds without that by just giving them proper nutritional advice and in many of these cases restricting carbohydrates. But again, we have a world of ways to think about it. I mean, one of the diagnostic criteria of an eating disorder is not eating an entire food group. And there are people, you and I, saying, well, the problem is the carbohydrate content of the diet. So we don't need carbohydrates.

There are no essential carbohydrates. Don't eat them. You'll be fine. That was basically what I'm arguing for diabetes. You don't need these foods. So you don't need to take all the medications, the pharmaceuticals that are prescribed to you to treat the symptoms that come from eating them. Yeah, I just want to stop you there for a sec

because what you said is really important. There are essential fatty acids. There are essential amino acids. There are no essential carbohydrates. So the body actually does not need them biologically to thrive, even though it's our main fuel source. So historically, we've been adapted to a whole range of diets, from the Inuits and the basically ketogenic diet to the Pima Indians, who were 80% carbohydrates, but it was all high-fiber plant-based carbohydrates that were really nutrient-dense. So the body can survive and thrive on many different things.

And the quality of the calories matter, which is really the thesis of your book, Good Calories, Bad Calories. And I think most people don't understand that they actually can regulate their biology if they figure out what their particular metabolic type is. Because everybody's different. And for example, I need a little more carbohydrates because I'm kind of thin.

And if I don't eat them and I go keto, I'll lose too much weight. But if I take a patient who's overweight and type 2 diabetic, they're going to do really well if I do that. And a little bit of carbohydrates might prevent them from doing really well. Yeah. That's the, I think one of the points that I've made in my other books is we do think everybody is different and we definitely evolved to cope with the proteins and fats in our diet that the idea that the foods that we didn't have the new foods of modern life ultra processed food that's not even food yeah i'm not wild about the term

ultra processed because it's sort of like the miasma theory of all these kind of vague things that we're going to throw in. Michael Pollan called them food-like substances. I prefer that. It's more to the point. But they don't meet the actual criteria of the definition of food. But we didn't have time to adopt to high levels of sugar in our diet and sugary beverages in our diet. These things didn't exist. We didn't have time. I mean, I'm agnostic about the seed oil issue. I don't find the evidence. I mean, I can easily believe that these things are toxic, but I don't. The evidence is confusing, for sure.

There's a certain absence of human clinical trial evidence. Just like sugar, you know, when you think about sugar, we never had exposure to the amount of sugar we're eating now historically as species. We never had 10% of our diet being refined soybean oil before. It's a new phenomena for humanity. And maybe it's okay, maybe it's not, but I think it should be questioned. Yeah, it certainly should be questioned. And that's the thing. So you can propose that those are problems.

And with the sugar and refined grains, you can see what happens when you take them out of people's lives. And we have clinical trials. can you talk about that like you talk about the virta uh health work and sarah halberg's work and the sort of work on advanced type 2 diabetes where they actually were able to reverse it not just slow it down or delay the complications or to manage the disease but literally to reverse it. Yeah, well, so this is getting back to the history a bit. We get to the 1970s, 80s. The diabetes community, to their credit, did some really ambitious clinical trials. And what they find out, in effect, is that this disease,

by their treatment, is a chronic progressive disorder. It just gets worse. A famous British trial where they just, they show, they start people on diet only, and then they add one drug, and then they go and they see how many of the patients diagnosed with type 2 diabetes can stick with one drug, monotherapy, and the answer is like 10%. So as time time goes on you keep on having to add drugs to keep the blood sugar under control they do these we set a cord and uh i forget the other names of the other two trials um looking at intensive insulin therapy and they find that they it does more harm than good at

the very best and then they do this huge look-ahead trial, $200 million to demonstrate that if you lose weight, you'll reduce diabetic complications. It's a fundamental pillar of thinking with diabetes. Just get your patients to lose weight. They'll be fine. Yeah. And they get them to lose weight and it doesn't make a damn bit of difference. A trial was ended for futility, a $200 million trial.

And a great quote in the New York Times from a Harvard diabetes specialist named David Nathan, who says, we have to have an adult conversation about this. And they never do. Yeah. But while this is happening. But this is an important point. They lost weight and they got worse. No, they lost weight and they didn't get better.

So they lost weight. The idea was you lose weight, you'll have fewer complications, you'll reduce heart disease, you'll reduce strokes, you'll reduce mortality from this disease. It didn't make any difference. Was it because of how they lost weight? Well, it could have been because of how they lost weight. And in fact, back around 2003, when I first heard about this trial from one of the principal investigators, I was in a conference. He invited me to talk in Houston. I remember saying to him, look, are you doing a low carb arm? Okay. Just do a low carb arm. Make it not just low calorie, low fat, fruits, vegetables, whole grains, the usual story.

Mediterranean diet, right. Well, this was pre-Mediterranean. I mean, this was, yeah, it was just classic low-fat. But in low-fat, they're also saying you're eating fruits, vegetables, whole grains, you know, cut back on meat, exercise. No, they never crossed their mind to do a low-carb diet because that was still considered quackish. But as the diabetes community keeps learning about how ineffective their treatments are and how their belief system is falling apart on top of them and not having an adult conversation about it, which is maybe we're making some mistakes here, other physicians coping with this increased obesity in their patients are confronted with patients who don't take their advice and instead buy Atkins' Diet Revolution book and lose 40 pounds on Atkins.

Yeah. And a few of these doctors are open-minded enough, Eric Westman and David Ludwig, they say, I'm going to look into this. I'm going to look into this. I'm going to actually do a clinical trial. So they start doing clinical trials. There's a big study at the Philadelphia VA. And there, the woman named Linda Stern is frustrated by how much,

her inability to help her patients. So she literally goes to like a Brentano's bookstore, and she sits down in the diet section, starts reading diets. The doctor's going to the bookstore to read self-help books because it's not in the textbooks. You know, it's not, not, not, not. They definitely don't get grades, good grades for this in med school. Anyways, I think she found protein power. Yeah, that's right. The Eads, Michael Eads.

And she tries it on herself and this is, they're effortless to lose weight. So they put together a clinical trial and this is effortless to lose weight. So they put together a clinical trial, and this is a Veterans Administration's hospital. So there are a lot of vets. They're not just obese. They have metabolic syndrome and type 2 diabetes. And instead of cutting them out of the trial as you would, you know, the inclusion criteria in a pharmaceutical trial is going to say we're going to not take these patients because they're ill. She says since this is so associated with obesity, let's do it. And not only do these patients lose a lot of weight on the diet, but their type 2 diabetes gets better on this high-fat, low-carb, at-gain, small-protein-powered diet.

So you start getting this groundswell, this movement of doctors who are reading these articles in the literature and saying, look, diet really seems to help. They don't know this deeper history, although Eric Westman at Duke is looking into it. It's just patients do well if you don't feed them carbs. How weird is that? It's a disorder of carbomiger metabolism. Exactly. Tell them not to eat it, they do fine. You don't take the toxin, you don't need the antidote.

So Steve Finney and Jeff Volek too. Yeah. Steve is a PhD nutritionist. I've had them on the podcast too. And he's out at UC Davis And he had studied ketogenic diets. And Jeff Volek is an exercise physiology PhD, then at the University of Connecticut. And they start working together and publishing on this. And they helped start this company, Virta Health.

I remember Steve's idea, I think it was, was if we could just convince insurance companies and employers that they could save money. Diabetes is an expensive disorder. It's costing them $12,000, $15,000 a year in medical bills. If they could save 80% of that by getting these people on a diet, wouldn't they want to do that? So they'd become the clients not the patients we'll go after the payers of the insurers the kaisers and blue shields of the world

and they create this company they get this brilliant ceo sammy inkinen who was a world class stanford mba yeah uh made millions creating the website i I always forget whether it was Trulia or one of the real estate websites. It was a world-class triathlete who was diagnosed with prediabetes despite having come in first in his age group in the Ironman triathlon. And Sammy goes to Steve and Jeff for advice on how to treat the prediabetes and also how he wants to, this is Sammy and Kenny, he wants to row to Hawaii from San Francisco to Hawaii with his wife, Meredith, and he thinks they could do it.

It's like a fun trip for the afternoon. On a ketogenic diet. Jeff and Steve can coach him and they start talking about this idea and they start this company, Virta Health. Meanwhile, by the way, Sammy and Meredith do row to Hawaii and they break the record and they don't need any carbohydrates on the whole trip. I think it's 24 miles. And how he got the pre-diabetes was he was using all those goos and energy things that athletes use to fuel their bodies. Not only that, Sammy believed that a low-fat diet was the

healthiest way to eat. He had been told that. And Sam is, I think he's Norwegian. And as he put it, not that being Norwegian matters, but if he's Finnish, I apologize. He's just got the best, you know, if somebody tells him not to eat fat, he doesn't eat fat. I mean, this is an extraordinarily, the man has an extraordinary strength of will, and then he's diagnosed with prediabetes. So there's something wrong. This is a common phenomenon that happens to many people in our world, right? You're doing what's supposed to be the right thing, and it doesn't work for you.

And then you do the wrong thing, which in this case is a low-carb, high-fat, ketogenic animal diet. And you get better. And you say, wait a minute. If it's wrong for me, maybe it's wrong for a lot of people, if not everybody. So they start this company, Virta Health. They realize they need a clinical trial to convince. And they meet Sarah Hallberg, who is a physician in Indiana, an amazing woman to whom the book is dedicated, who has been

asked to run an obesity clinic at Indiana Health and has to learn everything she can about obesity. And she starts reading all the literature, and she goes down the rabbit hole, and she experiences this based on jello revelation yeah and she realizes that the only people who seem to be having effective who seem to be effectively getting their patients lose weight are these people like westman who are advocating for these atkins low-carb keto diets. And so she goes and spends time with Westman. She goes and starts advocating for this at her obesity clinic, and she meets Jeff and Steve, and they put together a clinical trial

where they're going to randomize people for type 2 diabetes, this nutritional ketosis, keto with smartphones and personal coaching and telemedicine. Adjusting their medications if they need to. Yeah, because you're going to have to adjust medication. If you stop eating the toxin, you're going to have to lower the dose of the antidote. And it's either that or the American Diabetes Association standard of care, which is drug therapy. And they do the trial.

And after a few years, they report one-year results. And after three years, they report two-year results. Yeah. And for patients who comply with the diet, they seem to put this progressive chronic disease into remission. So it's not a progressive chronic disease. No. It's only a progressive chronic disease if you're eating the toxin. Yeah.

If you're not eating the toxin, you don't manifest the symptoms. And it's not the ideal clinical trial. Yeah. There's all kinds of problems with it. Wasn't randomized. Actually, I probably said randomized, and I should not. They let patients choose whether they wanted the diet or the ADA standard of care. But even with those constraints, it demonstrated beyond a shadow of a doubt that a disorder which is considered chronic and progressive is not

necessarily chronic and progressive and that the defining factor is the diet again whether you eat the toxin that's true i mean our practice the ultra wellness center i've seen that over and over again people just don't on insulin get off insulin on meds get off meds normalize their weight normalize their metabolism their a1c goes down down. They went from 11 to 5 1⁄2 in a few months. I mean, it's quite remarkable. It's quite remarkable. And so by the end of the book, my employee, I mean, again, this book does not advocate.

It's a dense, historical, critical. Yeah, it's like a mystery novel. And a mystery novel. Who done it and who didn't do it? I think it's a very good book. The question is, imagine a scenario where everybody, every physician was taught not just the proper drug therapy, but how effective this dietary therapy was. Because there have always been two levers to pull to keep blood sugar under control. There's diet or drugs.

Until 1921, we only had diet. And for patients with type 2 diabetes it was effective yeah don't eat these foods you'll be fine yeah once we had drugs you had two levers and the idea was use the drugs give the drugs you know we're going to say that diet is integral the cornerstone of therapy but we're going to pay lip service to it because we got the drugs. What if confronted with a new patient, you give them the diagnosis, you have type two diabetes or type one diabetes, and you say, look, we can do this. We can treat your symptoms with drugs. You can continue to eat exactly the way you want, or if it's type 1, you're going to eat at specific intervals, specific amounts to allow us to maximize, craft the diet to maximize efficiency of the drug therapy. And there's all these complications we know are going to ensue. So you're going to have an increased risk of heart

disease and stroke and dementia and blindness and retinopathies. And for some of you, no matter how well you manage your blood sugar with these drugs, those complications are going to happen anyway. Yeah. At which point, we're going to blame you. But you don't have to say that. Or you can do this diet. Now, what it means is no more bread, potatoes, sweets.

Yeah, which people love. Which people crave. Sugary beverages. Which people crave. It's hard because they crave those foods when they have insulin resistance. Yeah, which is fascinating. If you eat this way, as far as we can tell, you'll be fine. No drugs, no complications of drugs, no needing more doses or new doses, no waiting for new drugs to come along, no dialysis.

As far as we can tell, if you eat this way, you'll be fine. Amazing. And it'll probably take two or three months. You might love it immediately. It might take two or three months to get used to it, in which case, like somebody who's quit smoking, you won't miss cigarettes after a while. Right.

You will at first. You won't after a while. It's your choice. We're happy either way. Yeah. Okay? Because we want you to be healthy. But this way, chronic progressive disease, diabetic complications, more and more drugs, complications of drugs. This way, as far as we can tell, and we can't, you know, there are unknown unknowns here. As far as we can tell, if you eat this way, you'll be fine. Yeah. You choose.

Yeah. And if you do eat this way, let's make sure you do it right. Yeah. And if you choose the drugs, we'll make sure you do it right. I mean, it's such a simple notion, and yet it's bucking against the establishment paradigm that we should be using drug therapy in high-carbohydrate diets and diabetics.

I mean, I think the ADA is starting to come along, the American Diabetic Association, but it's really tough. Well, they're starting to come along, but if you see how they do it, so they put out these standard of care documents, and every year, every January, there'll be like eight or 10 of these documents. And what they do is they revise based on what research

came out in that past year. So they really have no mechanism by which to say, let's just rethink this. And then when they're revising it, the of diet is buried is inside in this document where it's sort of you can do this or you can do that or you can try this diet we have this research for this or this research for that they don't have any mechanism to say can we just try let's try a different approach yeah okay let's divide the world up let's say this is what we can be achieved with diet and this is what can be achieved with drug therapy. And this is the complications that we know of with diet, not many, and these are the complications we know of with drug therapy, chronic progressive disease.

Many people might choose drugs. Maybe they're right. I mean, I don't know. I mean, I think when you know, when you look at the data, to me, it's pretty clear that if you use drug therapy, that it is a progressive chronic disease and you can mitigate or slow the complications, but it's not going to prevent them. And if you use the dietary therapy, it goes away. And, you know, I think people might be listening going, well, you know, Gary, you're giving these people a ketogenic diet with 75,

80% of their diet is fat. What about their heart? And maybe say their diabetes, but actually they looked at over 20 cardiovascular biomarkers as part of the Virta study and they were all improved. Actually, they got better. And I've seen this over and over. I had a patient which was really struggling with weight loss and she had prediabetes. She had triglycerides of three plus hundred or hdl was very low and her her total cholesterol was over 300 very high insulin levels rising blood sugar and i'm like well i'm gonna try a ketogenic diet and she did it not only did she lose 20 pounds but her cholesterol dropped 100 points her triglycerides dropped 200 points. Her H2O went up 30 points.

Her blood sugar normalized. Now, that may not work for somebody else who's a thin guy who is an athlete. And I've seen people who use the Skeetogenic diet like that who actually don't do well. And I'm one of those guys. If I eat too much of the wrong fats, my cholesterol goes off the rails. But we don't know how harmful that is. We don't. We don't know how harmful that is we don't we don't unless we look and look inside your arteries and then we can tell well you can yeah

then yeah so it's really it's just fascinating i think this is really this is really important moment in history because we have this is a craze of ozempic and wagobe manjaro it's the you know golden child of the moment of pharmacology. And nobody's really talking about the issue that matters, which is what we're eating and why we're eating what we're eating. And that's because we have this mindset that people with obesity, we're not going to blame it on willpower. We're not going to acknowledge that it's a disease now. This is what Oprah was saying.

But we're also going to assume that they won't change their diet. Yeah. And, you know, it's really complicated. I've read a lot of the literature of mostly women, but not entirely women with obesity. They're so confused. They know it's not a willpower problem. No, it's not a willpower problem. And often these authors will say, I tried every diet, none of them worked. And I want to reach

out to them to say- You didn't try the right one. Well, or did you, because they always include Atkins in the list. Did it not work for you? Or are you some, but then they'll say, it's just one of these books I read recently. It's, I don't want to go through my life not eating a donut. Right. Well, I understand. I get that. I get that.

I get that. But, you know, I've been biased by my history as a cigarette smoker. There was a period in my life where I couldn't imagine going through my life without a cigarette. Yeah. And, in fact, my next cigarette was what pulled me forward into the future. Maybe it's an inappropriate metaphor i'm not sure it is or not well no and we know the you know there's real addiction with these foods that particularly the whatever you call them food like substances or ultra processed food or high starch and sugar foods they activate the brain

centers for pleasure and we can map that on brain imaging studies. So there's no doubt that these have biological effects on the brain that drive our behavior, our cravings, our appetite. But I think what's really remarkable as a doctor treating these patients is that when you do the right thing, their brain chemistry changes, their hormones change, their metabolism changes, and they don't actually have those cravings. It's not like they have to use willpower to fix it. Use science. And this is really what your book is about. It's challenging the orthodoxy, challenging the science, making us rethink diabetes, and come up with a new vision for how we can deal with this obesity crisis rather than spending $5 trillion on no Zempic for the population,

which is what it would cost if we gave everybody who was overweight no Zempic. Well, this is the idea that this will somehow impact the obesity epidemic is insane, right? Because, oh, I suppose if it gets off-label and people can buy, you know, a supply for $3. Is it safe? But then, yeah, then the question is what are the side effects? What are the complicated – will there be a tidal wave or, you know, a wave of complications down the line that are gonna make a whole i think there is i mean they had never started i mean i think the data is already coming out that the longer you're on it the more likelihood you're going to have complications not

everybody will obviously but what's interesting is even these studies the studies that look that i looked at that looked at um long-term use and again they went out about. They had patients in them who had been on the drugs for like five years, and they were looking at specific possible complications. But they would also say these were for lower doses, and for diabetes, not for obesity. And then they would say, well, 60% of the patients discontinued use. Yeah, because they had nausea, serbomity. And the question is, yeah, why did they discontinue?

And what happened when they did because if when they did they then fell out of the system they were no longer in the clinical trial so nobody has any idea was it difficult to discontinue use did things get worse that then had to be treated with other well what happens when you take these drugs is you lose muscle and fat and you gain back the weight usually getting back as fat and so your metabolism is slower at the end of the process than at the beginning. And you need to eat less food in order to just maintain the same weight. And this is. It's a real problem.

Unless you eat a lot of protein and do a lot of strength training while you're taking these drugs, you're going to be in trouble. You know, I've been an athlete, a jock my whole life. And I, you know, I've lifted weights my whole life. And the idea that you can solve the muscle loss problem by going into the gym, eating protein, and lifting weights. It's like, do you have any idea how hard that is? Well, you can do it. You can do it.

Look at you. You're buff and you're 67. Yeah, but the muscle that comes off easy with the drugs is not going to be put back no no that's right that's that's an important point it's hard it's easy to lose hard to gain you know and as people get older yeah it's even harder the the gaining is also dependent on the hormones and wane with time totally well gary this has been such a fascinating conversation. I think your book is kind of a pivotal book in helping us literally rethink diabetes and challenge our orthodoxy, challenge our assumptions, poke the bear a little bit and say, hey, let's get real with this and let's look at the data. Let's look at the science and not go along with the current recommendations,

which are in many ways, I believe, harming people. And I think we have a moment to change that. So thank you for writing it. It's a beautiful book. It's beautifully written. It's very entertaining. It's not a dense medical book like mine. So I think you'll all like it. I encourage you to get it. It's called Rethinking Diabetes. And also I would encourage you to check out his newsletter called Unsettled Science on Substack. He writes it with Nina Teicholz, who wrote a book called The Big Fat Surprise, also another great book. And it's really a great way to sort of get another point of view about nutrition that

you might not be hearing through a conventional channel. So Gary, thanks for being on the podcast again. Thanks for what you've done. Thanks for having the patience to weed through all those thousands of pages of historical data and illuminating us with the history of diabetes and hopefully paving way toward a future that is much better than what we've had in the past. Thank you, Mark. Thanks for listening today.

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