Looking at T2 Diabetes Through a Different Lens - Transcript

Dr. Mark Hyman
Coming up on this episode of The Doctor Hyman Show.

Gary Taubes
Patients do well if you don't feed them carbs.

Dr. Mark Hyman
Isn't it?

Gary Taubes
How weird is that? It's a disorder of carbohydrate metabolism.

Dr. Mark Hyman
If you don't

Gary Taubes
tell them not to eat it, they do fine.

Dr. Mark Hyman
You don't take the toxin, you don't need the antinote. Now before we jump into today's episode, I'd like to note that while I wish I could help everyone by my personal practice, there's simply not enough time for me to do this at scale. And that's why I've been busy building several passion projects to help you better understand, well, you. If you're looking for data about your biology, check out Function Health for real time lab insights. And if you're in need of deepening your knowledge around your health journey, check out my membership community, the Hyman Hive.

And if you're looking for curated and trusted supplements and health products for your health journey, visit my website at DrHyman.com for my website store for a summary of my favorite and thoroughly tested products. 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 basic 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, you know, 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 two diabetic, they're going to do really well if I do that.

Gary Taubes
And a little bit of carbohydrates might prevent them from doing really well.

Dr. Mark Hyman
Yeah.

Gary Taubes
I think one of the points that I've made in my other books is we do everybody is different. And we definitely evolved to cope with the proteins and fats in our diet. The idea that the foods that we didn't, the new foods of modern life- Ultra processed food.

Dr. Mark Hyman
That's not even food.

Gary Taubes
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. You know, Michael Pollan called them food like substances. Right, right. I prefer that.

It's more to the point. But they don't meet

Dr. Mark Hyman
the actual criteria of the definition of food if you look at We didn't

Gary Taubes
have time to adapt 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

Dr. Mark Hyman
Evidence is confusing for sure.

Gary Taubes
There's a certain absence of human clinical trial.

Dr. Mark Hyman
Oh, just like sugar, you know, when you think about sugar, we never had exposure to the amount of sugar we're eating historically as species. We never had 10% of our diet being refined soybean oil before. It's a new phenomenon for humanity. Maybe it's okay, maybe it's not, but I think it should be questioned.

Gary Taubes
Yeah, it certainly should be questioned. And that's the thing. So you can propose that those are problems. With the sugar and refined grains, you could see what happens when you take them out of people's lives. And we have clinical trials.

Dr. Mark Hyman
So can you talk about that? Like you talk about the Virta Health work and Sarah Hallbug's work and the sort of work on advanced type two 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.

Gary Taubes
Yeah. Well, this is getting back to the history a bit. We get to the 1970s, '80s. The diabetes community, their credit, did some really ambitious clinical trials. And what they find out in effect is that this disease, as 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 two diabetes can stick with one drug monotherapy. And the answer is ten percent. So as 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 forget the other names of the other two trials.

Looking at intensive insulin therapy and they find that it does more harm than good at the very best. And then they do this huge look ahead trial, dollars 200,000,000 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.

And they get them to lose weight and it doesn't make a damn bit of difference. A trial has ended for futility, a $200,000,000 trial. 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 But this is

Dr. Mark Hyman
an important point. They lost weight and they got worse. So No.

Gary Taubes
They lost weight and they didn't get better.

Dr. Mark Hyman
So they

Gary Taubes
lost 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 impact.

Dr. Mark Hyman
Was it because of how they lost weight? Well, it

Gary Taubes
could have been because of how they lost weight. And in fact, back around 02/2003 when I first heard about this trial from one of the principal investigators, was in a conference. They 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

Dr. Mark Hyman
Mediterating diet, right?

Gary Taubes
Well, this was pre Mediterranean. I mean, was yeah. It was just classic low fat. But in low fat, they're also saying you're eating fruits, vegetables, whole grains, you

Dr. Mark Hyman
know? Sure.

Gary Taubes
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 like buy Atkins Diet Revolution book and lose 40 pounds on Atkins. Yeah. And a few of these doctors are open minded. They don't know if Eric Westman and David Ludwigger, they say, I'm going to look into this. I'm going 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 and starts reading diets. The doctor's going to

Dr. Mark Hyman
the bookstore to read self help books because it's not in the textbooks.

Gary Taubes
You know, it's not, not, not today. I definitely don't get good grades for this in med school. Anyways, I think she found protein power. She sounds insane.

Dr. Mark Hyman
That's right.

Gary Taubes
The age my age. And tries it on herself 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 two 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 take these patients because they're ill. She says since this so associates with obesity, let's do it. And not only do these patients lose a lot of weight on the diet, but their type two diabetes gets better on this high fat, low carb, Atkins, small protein power diet. So you start getting this groundswell. This is this movement of doctors who are reading these articles in the literature and saying, look, you know, diet really seems to help.

They they don't know this deeper history, although Eric at Duke is looking into it. It's just patients do well if you don't feed them carbs. Isn't it? How weird is that? It's a disorder of carbohydrate metabolism.

Exactly.

Dr. Mark Hyman
You just

Gary Taubes
tell them not to eat it, they do fine.

Dr. Mark Hyman
You don't take the toxin, you don't need the antidote.

Gary Taubes
So Steve Finney and Jeff Volek too. Yeah. Steve is a PhD nutritionist who trained at MIT and is out at UC Davis and he's been 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 that we could just convince insurance companies and employers that they could save money.

Is diabetes an expensive disorder? It's costing

Dr. Mark Hyman
us It's the most expensive disease.

Gary Taubes
Yeah. Thousand dollars a year in medical bills. If they could save 80% of that by getting these people on a diet, wouldn't they wanna do that? So they'd become the clients, not the patients. We'll go after the payers of the insurers, Kaiser's and Blue Shields of the world.

And they create this company. They get this brilliant CEO, Sami Inkinen, who is a world class Stanford MBA, Made millions creating the website. I always forget whether it was Trulia or one of the real estate websites. And it's a world class triathlete who's was diagnosed with prediabetes. Yeah.

Despite having come in first in his age group in the Ironman Triathlon. Yeah. And Sammy goes to Steve and Jeff for advice on how to treat the prediabetes and also how he wants to this is Sammy Inkin. He wants to row to Hawaii from San Francisco to Hawaii with his wife, Meredith, and he thinks they could do it with

Dr. Mark Hyman
He's like a fun

Gary Taubes
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 wrote to Hawaii and they break the record and they don't need any carbohydrates on the whole trip. I think it was 24 miles.

Dr. Mark Hyman
And how he got the pre diabetes was he was using all those goos and energy things that athletes use to fuel their bodies.

Gary Taubes
I know that Sammy believed that a low fat diet was the healthiest way to eat. He had been told that. And Sammy is, I think he's Norwegian. And as he put it, not that being Norwegian matters, but and 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.

It's 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 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, is a physician in Indiana, amazing woman 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

Sami Inkinen
she

Gary Taubes
goes down the rabbit hole and she experiences this, you know, based on jello revelation. And she realized that the only people who seem to be having effective who seem to be effectively getting their patients to lose weight are these people like Wesman who are advocating for these Atkins low carb keto diets. And so she goes and spends time with Wesman. 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 to randomize people for type two diabetes, with type two diabetes, either this nutritional ketosis, keto with smartphones and personal and

Dr. Mark Hyman
Adjusting their medications if they need to.

Gary Taubes
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. 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. 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.

There's all kinds of problems with it. It wasn't randomized. Actually, probably said randomized and I should not. It was 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 a diet.

Again, whether you eat the toxin.

Dr. Mark Hyman
That's true. I mean, practice at the Ultra Woman Center, seen that over and over again. People just go on insulin, get off insulin, on meds, get off meds, normalize their weight, normalize their metabolism. Their A1C goes down. They went from 11 to five and a half in a few months.

Gary Taubes
I mean, it's quite remarkable. It's quite remarkable. And so by the end of the book, my ample mean, again, I this book does not advocate. It's a it's a dense historical Yeah.

Dr. Mark Hyman
It's a mystery novel.

Gary Taubes
And a mystery novel.

Dr. Mark Hyman
Whodunit and who didn't do it?

Gary Taubes
Yeah. 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 are always been two levers to pull to keep blood sugar under control. There's diet or drugs.

Right. Until 1921, we only had diet. And for patients with type two diabetes, it was effective. Yeah. Don't eat these foods.

You'll be fine. Yeah. Once we had drugs, you had two lovers. And the idea was use the drugs. Give the drugs.

You know, we're gonna say that diet is integral, the cornerstone of therapy, but we're gonna 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 one, we're going to you're going to eat, you know, at specific intervals, specific amounts to allow us to maximize, you know, craft a diet to maximize efficiency of the drug therapy. And there's all these complications we know are going to ensue. So you're going have an increased risk of heart disease and stroke and dementia and blindness and retinopathy. 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 Right.

Dr. Mark Hyman
It's a patient's fault.

Gary Taubes
Say that or you can do this diet. Now what it means is no more bread, potatoes, sweets.

Dr. Mark Hyman
Yeah. Which people love.

Gary Taubes
Sugary beverages.

Dr. Mark Hyman
Which people crave. It's hard because they crave those foods when they have insulin resistance.

Gary Taubes
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.

Dr. Mark Hyman
Amazing. I mean, spend a

Gary Taubes
billion dollars take two or three months. It might take you might love it immediately. It might take two or three months to get used to it. In which case, you know, like somebody who's quit smoking, you won't miss cigarettes after a while.

Dr. Mark Hyman
Right.

Gary Taubes
You will at first, you won't after a while. It's your choice. Yeah. 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.

Dr. Mark Hyman
Yeah.

Gary Taubes
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

Dr. Mark Hyman
do it It's such a it's such a simple notion, and yet it's it's it's, you know, bucking against the the establishment paradigm that we should be using drug therapy and high carbohydrate diets in diabetics. I mean, I think the ADA is starting to come along, American Diabetic Association, but it's really tough.

Gary Taubes
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 and there'll be like eight or 10 of these documents. 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.

Dr. Mark Hyman
Everything.

Gary Taubes
And then when they're revising it, the discussion 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 it? Let's try a different approach. 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 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.

Dr. Mark Hyman
I mean, I don't know. I mean, I think, 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.

Gary Taubes
Well, this is-

Dr. Mark Hyman
And then if you use the dietary therapy, it goes away. You know, I think people might be listening going, know, Gary, you're giving these people a ketogenic diet with 75, 80 percent 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.

Gary Taubes
Part of the Virta study.

Dr. Mark Hyman
And they were all improved. Actually, they got better. And I've seen this over and over. 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 total cholesterol was over 300, very high insulin levels, rising blood sugar.

And I'm like, why don't you try a ketogenic diet? And she did it. Not only did she lose 20 pounds, but her cholesterol dropped a hundred points. Her triglycerides dropped 200 points. Her HD1 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 ketogenic 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.

Gary Taubes
But we don't know how harmful that is.

Dr. Mark Hyman
We don't. We don't, unless we look inside your arteries and then we can

Gary Taubes
Yeah.

Dr. Mark Hyman
So it's just fascinating. Think this is really important moment in history because we have this craze of Ozempic and Wagoi, Mounjaro. It's the 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.

Gary Taubes
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. And, you know, it's really complicated.

I've read a lot of the you know, the literature of mostly women, but not entirely women with obesity. They're so confused. Yeah. They know it's not a willpower problem.

Dr. Mark Hyman
No, it's not a willpower problem.

Gary Taubes
And often these authors will say, I tried every diet, none of them worked. And I want to reach out to them and say,

Dr. Mark Hyman
what they You didn't try the right one.

Gary Taubes
Or what 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, you know, it's just one of these books I read recently. It's you know, I don't wanna go through my life not eating a doughnut. Right.

Well, I I understand. I

Dr. Mark Hyman
get that. Get that.

Gary Taubes
But, you know, I was I mean, 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.

Dr. Mark Hyman
Well, no. And we know the, you know, there's real addiction with these foods particularly the, what do we 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 you have to use willpower to fix it. Use science. When you have diabetes, you become carbohydrate intolerant. They're not, it doesn't mean all of us are born that way, but we become that way because we live in a sort of a soup of sugar and starch that's washing over us for decades.

That leads to the development of this metabolic dysfunction. And the solution is to kind of reverse that trend by restricting carbohydrates and increasing fats. And, and, and tell us sort of how that works and why we kinda got so far away from it, because it was the treatment, you know, a hundred years ago, and now we're coming back to it as the treatment. And explain the biology behind the science of, of ketogenic diets as a diabetes reversal treatment.

Dr. Greeshma Shetty
So, you know, for, in the trial, our patients were on a well formulated ketogenic diet, which is very low carb, so 30 grams. But practically in our clinical workflows, we do a lot of low carb and not everybody's in well formulated ketogenic diet. So, we really try to sort of meet patients where they need to be. And there's a lot of heterogeneity in type two diabetes, right? We've In genome wide association studies, we now know there's hundreds of different types of type two diabetes.

But sort of like the end result or the goal is to preserve beta cell functional mass, right? And the beta cells are those cells that make insulin. And so, we can do to de stress that beta cell and keep its insulin production up is critical. And when we eat high carb diets, we add to cytokine release, inflammation, gluco toxicity, all of these things stress out the beta cell. And so, that sort of accelerates the destruction of beta cell function and mass over time.

And that's when you start seeing the one way trolley for type two diabetes. So, if you can reset that and change that, pathway, you can definitely improve insulin, secretion and also decrease while you're losing weight, decrease the insulin resistance at other target organs, like liver and your muscles. So, you also spare the beta cell from having to produce more insulin to do the same job. So, multiple layers of de stressing the beta cell through the nutritional intervention directly, but also indirectly by affecting other parts of metabolism. I mean, homeostasis is so complex.

I have so much humility. You know, I started my fellowship training studying adipokines. I was in a lab where I was studying leptin and adiponectin. And like there are so many other cascades and they all interact with the gut, the microbiome, the brain, your satiety centers, your pancreas. So, there's so much complexity.

So, really thinking about it simplistically, though, is really preserving and de stressing that beta cell.

Dr. Mark Hyman
And the way you do that is by basically restricting carbohydrates and adding a lot of fat. Now, it's not the bacon and, you know, kind of cheeseburger diet, right? There's a healthy way to do this. It doesn't mean you have to be eating a lot of food that may not be great for you. And so I think people are often thinking, fat is bad.

You know, fat makes me fat. In fact, you know, if we eat fat, you get fat. And there's this whole mythology we had about that. And in fact, that was the sort of the prevailing theory for so long. And and now it's shifted.

And we understand that that actually for these metabolically dysfunctional people, which is most

Gary Taubes
of

Dr. Mark Hyman
America, that were eating way too many refined starches and sugars. I mean, carbohydrates are also vegetables, so there's no harm in eating vegetables. But the starch and sugar and the refined carbohydrates are the ones that are driving this problem. So the solution is restricting those. And you're saying you don't always have to be fully ketogenic, you can be very low carb.

And I've seen this too. I mean, I had a patient at Cleveland Clinic who was type two diabetic, on insulin for ten years, you know, had heart failure, had kidney starting to fail, fatty liver, hypertension, had multiple stents put in for cardiac disease, and was on 20,000 of coping medications. Her body mass index was forty three, which is a huge person. And her A1C blood sugar average was 11.2. And we just didn't put her on a keto diet, but since she just took her off, you know, grains and beans, sugar, processed food, put her on lots of good fats, olive oil, avocado, some nuts and seeds, healthy protein, lots of veggies, fiber, and was about 50% fat, not 75 or 85% fat, which is what most ketogenic diets are.

And within three days she was off her insulin, and three months she was off her medications. Her A1C went from 11.2 to 5.5, which is normal. Her ejection fraction went to normal. Her kidneys got better. Fatty liver got better.

Her blood pressure got better. In a year she lost like 116. So without Ozempic, without a gastric bypass, simply by getting the group support, which we did, and by using kind of a very kind of low carbohydrate diet that was a very anti inflammatory diet. So what I'm hearing you say is it doesn't have to be always ketogenic, but it has to sort of be matched to that person's state of metabolic dysfunction. And the more sick you are, the probably the higher dose of drug you need in a sense, right?

Sami Inkinen
I would also add that, we haven't published this. Actually we published some, but we actually have very interesting dose response data. So pharmaceutical companies usually do a, what they have to do, like a dose response study. So here's the molecule, you add more of that molecule and then see what happens in terms of safety and in terms of outcomes. And obviously you can then tease out the correlation and causation like, oh, more of this acetaminophen, unless you have pain and whatnot.

We actually have very interesting dose response data to carbohydrate restriction and seeing what happens to weight, glycemic control and getting off the meds. And, I guess the punch line is the more insulin resistant you are, the more of that dose, the better, basically without sharing all of our secrets. But it's fascinating because we literally have dose response curves and it kind of tells the story. The other thing I wanted to add, Mark, when I listened to you and I was thinking those patient outcomes and what you had seen, If I wasn't, if I did not have the ten year history of building Virta and seeing exactly the same results now with a hundred thousand plus Americans, I would still be like, oh, I'm sure nutrition can work, but come on, like these are the like the grandfather who was one hundred pounds overweight and then ran a marathon. Like we always hear these stories like, Oh, it's a one anomaly, one out of a million.

But I think really what the world needs to hear, this is individuals, business decision makers, policy decision makers, scientists, is that these results are systematically possible, absolutely systematically possible. And this idea that we have two hundred million sick American adults metabolically unhealthy, and the best we can do is manage symptoms with medications is ridiculous. It is so ridiculous. And so we really have to get the message across that there is a way, nutritionally,

Gary Taubes
you don't have

Sami Inkinen
to be a superman or superwoman, ordinary person, there's a systematic way to achieve those results. Obviously it's a distribution. Some are hugely successful in terms of moderately successful, but that message hasn't broken through yet. And it has to. And that's why I'm grateful to be on this podcast too, because it's ridiculous.

There's no other way out of this metabolic health mess. GLP-one's in tap water is not going to solve

Dr. Mark Hyman
this mess. No. No, and it's interesting, when you're talking about how you, you're sort of able to execute on things in the sense that you learned in your research around these hormones and molecules that regulate appetite, like adiponectin and leptin and the inflammatory molecules that are produced by your fat cells. And that was sort of where your research was. What we're learning is that the application of the right nutritional approach in metabolic dysfunction actually automatically regulates those hormones.

Rather than having to take Ozempic, which artificially does this, your body can naturally change the levels of the appetite and fullness hormones that are driving this overeating behavior that is driven by the carbohydrates. So like when you eat more sugar and starch, you want more sugar and starch. When you eat that, I mean, I would say nobody can, you know, eat, you know, 12 avocados, but anybody can eat, you know, a whole bag of Chips Ahoy cookies, right? So there's just like no limit on that. And I think the body has its natural ability when you feed it in a way that it's designed to work, it actually resets and it's not willpower, it's just science.

So can you explain how that works?

Dr. Greeshma Shetty
Yeah. So, when folks increase their fat intake and certainly when people achieve nutritional ketosis with higher ketone levels, the hormones that drive appetite are naturally suppressed and, the hormones that signal satiety go up. So endogenous GLP-one, CCK, go up and then, you know, things like, ghrelin go down. So again, so exactly like harnessing nutrition to appropriately do that positive feed loop that's towards, improving health and decreasing hunger. It drives with just the nutritional changes.

Dr. Mark Hyman
So what's interesting is that is that you you said something that I wanna sorta highlight and double click on, which is that when you eat in the right way, you naturally increase your GLP-one peptides, which are regulating your appetite, and that you don't have to take Ozempic. And what you also said, Sammy, earlier was that you're achieving Ozempic like results without taking the drug, without all the side effects and without all the costs. And so can you kind of explain what, and we talked about this when we were hanging out in person in Aspen, you know, the the data that shows that, you know, out there, the pharmaceutical companies are funding billions of dollars of research on these GLP-one agonists and other related peptides around a whole spectrum of diseases, from depression to autoimmune disease to neurodegenerative diseases to longevity to, obviously, weight loss and diabetes to cardiovascular disease. And they're trying to get all these studies done to get indications for these other applications of these drugs. But what you're saying, what I heard you say, was that using this nutritional approach, can actually achieve all the same types of outcomes.

And it's not the drug itself, it's actually the change in your metabolic health. It's it's can you explain more about that, maybe, Rishman, how that how that works?

Sami Inkinen
Yeah. Absolutely. And and first, upfront, I wanna say that this may sound like, oh, this guy is so antipharmaceutical. No. I'm a physicist by training.

I believe in, science. I believe in Western medicine. And then also these GLP-one drugs, you know, first one was, I think in America approved for treating type two diabetes, two thousand and five. And it's a tool in a toolkit. It is a tool in a toolkit for type two diabetes and in some cases for obesity.

So I just want to be very clear. Obviously, Virta, our providers practice evidence based medicine. So anything I say next isn't going to be like, oh, you know, drugs are bad in all cases. No, that is not the the case. But to answer your question specifically, and this is all data that's published in peer review.

So if anyone wants to sort of double check, you can go to vertohealth.com/research and find out and publish superior results. But indeed, so what we've been able to show is that as we run our nutrition programme, among our patients, the following things either improve or get reversed. Obviously, type two diabetes, so that's glycemic control, so blood sugar comes down. Hypertension, so blood pressure comes down. Inflammation comes down.

So this is CRP, C reactive protein, a white blood cell count. And we also have an unpublished paper looking at 16 inflammation proteins of which almost all improve, which is unheard of, better than Humira. That's unpublished, so that's a caveat. Yeah. Depressive symptoms improve, sleep apnea improves, gets reversed, knee pain goes down.

Cardiovascular disease risk markers and twelve year cardiovascular risk goes down. Kidney and liver function improve, so we looked at eGFR. And we can't really say that we can, it would be a little bit overreaching to say we reverse kidney disease, but we have shown that we improve kidney function and same with liver function. So when you look at these broad spectrum metabolic health improvements, it's basically the same list that the GLP-one manufacturers are now showing, that we either improve or reverse, and we've already published this data. So what can we conclude?

Again, I'm not the medical doctor here, so maybe Chris can kind of cover me up here a little But basically what we can show is it is possible to achieve the same broad metabolic health improvements as GLP-1s may or may not, nutritionally, 100% nutritionally. Therefore, it is not the exogenous molecule that is achieving these results alone, because it's possible to achieve the same results nutritionally. Now we can still debate the mechanism. Is it all about the weight loss or are there other things in play? And our hypothesis is there are other things in play, but again, such as information, reduce information.

But we can achieve the same things nutritionally, which I think again is a very important message to be heard because in the next year and two, there's going to be headlines, oh, GLP-one's now improve the eighth new thing.

Dr. Mark Hyman
And the

Sami Inkinen
answer is, guess what? Nutrition improves all those things. And then finally, I will say, again, there's a place for these drugs. GLP-one is a tool in a toolkit. But I think this statement holds true, which is we don't know the short, the midterm and long term side effects of exogenous drugs, but we know the side effects of healthy food.

Guess what?

Dr. Mark Hyman
They're all

Sami Inkinen
Happier, better, longer life.

Dr. Mark Hyman
That's right.

Sami Inkinen
Like healthy food. It's tough to say, like, what's bad about that? Not much.

Gary Taubes
That's right.

Dr. Mark Hyman
Yeah, no, I think, I think you're right. I think, and I'd love to hear your perspective as an endocrinologist, Squishma, about the GLP-1s and, you know, the utility, but also the risks. And I sort of whether or they're really necessary if we actually got our nutrition right and we got the delivery system right, which is this continuous care model to support people and behavior change, because that's the biggest thing. And I, you know, I'm sure this sort of conversation you just were mentioning, Sammy, reminded me of a study I read that looked at gastric bypass, and they did a controlled study where they took a group of obese patients. Half of them got bypassed and half of them didn't.

But the diet that the bypassed patients got after their surgery was the same diet that the non bypassed patients got. And they both reversed their diabetes within a couple of weeks. It wasn't dietit wasn't the surgery, it was the food. And I hear you saying the same thing about the GLP-one. So I'd love, Rishman, to sort of share from an endocrinologist perspective, you know, what your thinking is about this, you know, where they play a role.

Actually, is this approach of you know, very aggressive nutritional intervention with the continuous care model of lifestyle support and behavioral change, you know, actually better? How do we think about that?

Dr. Greeshma Shetty
Yeah, no, I think that's a great question. And it kind of hits on something we spoke about earlier during this call with insulin and how we sort of, I think we missed an opportunity of marrying some of the nutritional sciences to patients who were able to receive insulin. And when you think of like even type one diabetes, of course, was lifesaving, but because we didn't really invest in figuring out the right nutritional, now we have a lot of folks with type one diabetes who we say they have double diabetes, which is type one with insulin resistance, because we've just let people eat whatever they want, even if it doesn't work for their body. So I like that par like to think of that as an analogy for GLP ones, you just can't what eat whatever you want just because there's a new medication, because guess what? Again, the energy homeostasis is super complex.

There's no silver bullet. Like, you actually have to eat right for your body. There's so many, like I said, the genome wide, studies have shown that there's a lot of different types of type two diabetes. And if we can get to the root cause, we can help a lot of folks and not look at one target molecule that we're using today, which is, you know, the GLP-one therapy in that. So, I think really thinking more holistically about our patients that these are not magic bullets.

Look, they're great medications for patients with diabetes and other non glycemic indications, like reasons outside of blood sugar control, such as heart disease, heart failure, kidney disease. Mortality and there's outcomes data to support their use. But what about like the millions of people who have not yet developed those complications who have diabetes, and the folks who have pre diabetes and obesity? And this is, you know, diabetes is the tip of the iceberg, right? We have a whole society below that where we need to drive impact because we can't just medicate everybody in the country.

So, really thinking about the root cause and finding the right nutrition for the individual patient. And this is, this is part of precision medicine, right? Personalizing your diet to what works for you. And it's hard work. I mean, what our coaches and clinicians do at Virta, it's, it's a daily, again, like a white glove experience where we're getting that data.

We're doing that positive feedback to make those changes to learn and course correct when things aren't going well, to celebrate when we get those lab reviews. So really, you know, it has to be a very patient centric, holistic approach. But so I think there is a role for these medications, but I think we need a better solution for as a population.

Dr. Mark Hyman
But is belief that if people were able to adhere to a diet that was right for them, that these drugs are redundant?

Dr. Greeshma Shetty
I think so. I think if you could prevent, I mean, I'm, I'm of the mindset prevention is always better. Less is more. So if you can teach people to eat well and keep them healthy, that's better for everyone. They feel better.

They have all the other non forget about just the metabolic risk. Think about neurocognitive risk, cancer risk. There's so many downstream things that just by eating right, we can fix. And then I'll just really quickly say like, even sort of transgenerational, like when young adults who are in their prime reproductive years, when they're metabolically unhealthy, we know there's all this epigenetic changes that drives the next couple generations to have metabolic dysfunction. So, there's real implications for populations when you teach them how to eat correctly.

And the last thing I'll add is diabetes disproportionately affects minority populations and those with less socioeconomic means. Imagine if we could improve that without costly medications and prevent it and close some of the complication gaps and the death gaps that we have in The United States.

Dr. Mark Hyman
Yeah, know, absolutely. Mean, the health disparities are huge, you know, there's a whole food inequity issue and nutrition security issue, and there's all the ways in which, you

Dr. Greeshma Shetty
know- And equity around getting medications. Yeah. Accessing expensive medications and accessing expensive technology like CGM. Like there's, there's all kinds of equity issues. So what, what if we went to the root cause and just helped people be healthier from day one?

Dr. Mark Hyman
So how do we think about type two diabetes from a functional medicine perspective? What's the root cause? Functional medicine is all about root cause. The root cause is something called insulin resistance, And this comes from eating a diet that's high in sugar, refined flour, grains, ultra processed food. There's no doubt about this.

Also from lack of exercise and being sedentary, not moving enough, or being under muscled, right? Muscle is your metabolic spanks according to my friend JJ Virgin. And how do you address that? Will you eliminate ultra processed food, processed grains, refined grains and starches, sweets, sugar sweetened beverages especially, and that improves your blood sugar balance and your insulin sensitivity. What should you be eating then?

Good quality protein and it can be meat, okay? That's my view of the literature, but not my opinion, but it's pretty much evidenced by the randomized controlled trials. Fiber, right? Fruits, vegetables, nuts, seeds, sometimes whole grains if you're not fully blown diabetic. Healthy fats, olive oil, avocado oil, macadamia oil.

None of these will affect your blood sugar. And then you want to use testing to test your fasting glucose, your fasting insulin, your A1C, triglycerides, and other markers to understand of your insulin resistance. Now I co founded a company called Function Health. You can go to functionhealth.com. We've created an initial test of over 110 biomarkers.

It's $4.99 a year membership and includes testing twice a year. And you get all the metabolic markers you need. You get insulin, which your doctor almost never tests, A1C, your blood sugar, but you also look at lipid particle size. We call lipoprotein fractionation, not just your regular cholesterol profile, but whether or not you have small particles, dense particles, larger or small triglycerides or HDL, all these will tell you about your cardiometabolic health. We also measure inflammatory markers like C reactive protein and others, so you get a really good understanding of where you're at.

So if you want to check it out, go to functionhealth.com. You can use the code youngforever if you want to jump the waitlist, but it's really a way to get testing to see what's going on with you and what's going on with your diet. So again, test, don't guess. Now it's no secret that navigating the realm of nutrition has become a challenge for the general public and even for people like me and health professionals who've been studying this for thirty years. One week eggs are good for us.

Only be vilified for allegedly raising cholesterol levels the next week. The narrative on dietary fats is no less tumultuous. And I wrote a whole book on this called eFacAgain. Some experts say that it's a chief culprit beyond heart disease. Others say it's critical for overall health and well-being.

Well, more recently, study made headlines linking red feet consumption to an increased risk for type two diabetes, leaving the public once again confused and understandably so. And that's why in today's Health Bites episode, we're diving deep into the findings from this paper, and then packing the study's design flaws, its inaccuracies, and where the researchers got it straight up wrong. The study was entitled Red Meat Intake and the Risk of Type two Diabetes in a Prospective Cohort Study of United States Females and males published in October of twenty twenty three. Now, this was a type of study design, it's important to understand study design, because you have to understand science before you can interpret science. And you have to understand the type of studies that are done and which can show cause and effect and which can show correlation not causation.

For example, every day I wake up and the sun comes up. It's a % correlated but it's 0% causal. Know if I die tomorrow the sun's gonna keep coming up. If I slept through till the middle of the day, the sun's gonna keep coming up. So it has nothing to do with each other.

And essentially, that's what these observational studies like this particular study did. They looked at correlation, not causation. And that means that we can't prove cause and effect. So when you hear the headline, red meat is linked to causing type two diabetes, it's BS, okay, we have to look at what the data show when it doesn't. And these studies are not wrong, they're not bad to do.

They're done in order to help us understand what might be a useful avenue for further research, right? They're not the end of the research. They're useful for generating hypothesis. For example, in the study of smoking and lung cancer, they did observational studies, right? They weren't gonna do a randomized controlled trial because they're not gonna put half people on cigarettes and half people are not on cigarettes.

So basically, they found that there was a 20 fold increase, maybe 10 to 20 fold increase in the risk of lung cancer in smokers. Now to put that in perspective, that's a thousand to two thousand percent increase in your risk of having a particular disease. And that ended up being correct because it was such a strong correlation. Whereas in this red meat diabetes study to cut to the punch, it was about a twenty percent increase, right? Which essentially is relatively meaningless.

Let's just say two hundred percent increase in a correlation study, you pretty much want to ignore the data. And Doctor. Iainides from Stanford has written a lot about this. He's an incredible scientist who's dissected the value of different types of studies and what we can learn from them and what we can't. So we have to start out really understanding that the study was not designed by its very nature, which all scientists would agree to prove cause and effect.

It's just the nature of science. Okay, so let's get into the study. This is what we call a prospective cohort study. And it's an observational study, a population study, an epidemiological study, means the same thing. Essentially, studies a group of individuals over time to look at the association between certain exposures, behaviors, diets, and risk factors on specific outcomes.

So basically, they track 1000s of people over many, many years, looked at what they ate, and saw if there was a correlation with diabetes. And lo and behold, they found one. But let's talk about the problems with why this may not actually be as clear as a study seems to generate. Now in this type of study, basically people are identified based on their exposure status, and then they're followed over time to observe and record outcomes. In other words, what did people eat over many decades?

And what what was that diet? And was it correlated with any bad outcomes later in life? So you follow people for thirty years, you have them track their diet records, which we'll talk about in a minute. And then you see whether or not a particular food or types of food seems to correlate, not cause correlate with some bad outcome like diabetes. And that's what they did.

And basically, goal is just to assess relationships between various insults, exposures, toxins, smoking, diet, whatever, and outcomes. So it essentially looks for things that may be worth further studying with a randomized control, double blind trial. Okay, this was not done here. Now, it can be helpful, but they say, well, we're going to control for variables, call confounding variables, which means things that kind of can throw the study off. In other words, we'll talk about this, but for example, there was a study done many years ago by the NIH and the AARP, the American Association of Retired Persons, that looked at meat eating and chronic disease and death and cancer and so forth.

They found a big correlation. But that study showed also that the people who ate meat didn't care about their health and smoked more, drank more, ate more calories, about in here more a day, were more overweight, didn't eat fruits and vegetables, didn't exercise, just drank more alcohol, didn't take their vitamins. Of course they had more disease. It wasn't because of the meat. It was just a, we'll call it a problem that was shown because of these confounding variables.

And we'll talk about more about that. Now this study was published in the American Journal of Clinical Nutrition, and it was published by folks at Harvard who are great scientists, but they're focused on epidemiology, particularly at the School of Public Health, which is where the study was published out of. Then unfortunately, know, people have bias and the study authors are very biased toward a plant based diet. And so right off the bat, you kind of look at, all right, well, already have a bias and that affects the study, the outcome study. So basically the objective of this study was to assess the link between total processed and unprocessed red meat intake and type two diabetes.

And then to estimate the effect of substituting different protein sources like vegetable proteins, nuts, seeds, beans, grains, for red meat and type two diabetes risk. So we're doing, but again, just a hypothesis generating study. Now again, this was a population study, it was based on the Nurses Health Study, which was about 216,000 participants, the first and the second one, and the health professionals follow-up study, which was including men. Now, the first study started in 1976, female nurses, and then another one in 'eighty nine, female nurses, and the health professional study was started in 'eighty six. And they followed people for a long period of time, they calculate the amount of years and people, and they come up with a number called about 5,400,000 person years.

So that's pretty good. And what they did was really interesting. They looked at something called a food frequency questionnaire. And this is it assesses that people's diet every two to four years from the baseline. Now, can you remember what you had last Thursday for lunch?

Okay, do you remember the amount of this or that you had over the last week? Probably not, right? And so these are flawed tools. And this is a lot of research and science about how flawed these tools are and how imperfect they are, and how often they are very misleading. We see that in this study.

So the study findings, right, just to be clear, and this is association, correlation, not causation. They found between the lowest and the highest red meat intake, there was a risk of diabetes that went up by sixty two percent, right? Not two hundred percent, sixty two percent. Processed meat associated with fifty one percent and unprocessed red meat was about forty percent risk. If you substituted one serving of nuts or beans then your risk was thirty percent lower if you substituted for processed red meat the risk was forty one percent lower and unprocessed meat was about twenty nine percent lower So they're basically saying if you had one serving of dairy for total processed or unprocessed red meat, you had a lower risk of type two diabetes.

Now, this study is really important because it kind of misses a lot of the point. What is the mechanism here? And I'm gonna try to explain some of the mechanisms, but it's pretty weak. We know that the sugar that you eat, sugar and refined carbohydrates is the primary cause of type two diabetes, not red meat. And ancestrally, we've been eating meat for as long as we've been human.

I just came back from the Maasai population in Africa, as I mentioned on different podcasts, and these people ate the blood, the milk, and the meat of their cows. That was their main diet. They were healthy, they were super thin, they were very fit, and they had no diabetes. I recently visited their community and the Coca Cola truck drives up every day, they get processed cookies from the local town that are made by the industrial food system, and now they're gaining weight, and type two diabetes is rampant in this Masai community in Africa, and it's just heartbreaking to see that within minutes, this entire Coca Cola truck, a big truck, just was emptied out by the local population, not knowing what they were doing themselves, and they didn't even know that it was connected. So, you know, this basically, this study fueled a lot of clickbait headlines.

For example, a WebMD said just two servings of red meat per week raises diabetes risk. Well, that doesn't, it shows that it's correlated, but not causing, eating red meat, sir, more than once a week is linked to type two diabetes risk, that's CBS. This is just bad reporting and bad journalism. And the social media was just all over the place, right? Some people were pro red meat, some anti red meat, people were super confused, and then nobody knows who to believe, And everybody's distrusting public health and dietary guidelines, and it's just a mess.

So I'm going to try to unpack it for you. So you really understand how to think about this and also how to actually know what to believe around this whole issue of red meat and diabetes, and what we know. So basically, the problem with this study, as we mentioned, is an observational study. And we just cannot draw conclusions from an observational study, doesn't prove causality. And we have to look at also the limitations of the study, right?

There were a lot of limitations. The study authors, for example, as I mentioned, are very biased toward a plant based diet and veganism, how they pick the participants of the study, which may not be an issue, industry funding, we want to look at, probably was an issue here. But there's this thing called recall bias, which is common with food frequency questionnaires. People are more likely to report healthy food than unhealthy food, and desserts, sugar, sweetened beverages, alcohol are underreported. This was published.

We're going to put all the references everything I'm saying in the show notes. So have a look at those. Everything I'm saying is documented, is well researched, and you can kind of dive in, but would take me about ten hours to cover every study detail. So basically, you know, I've got to tell this my practice. If people overestimate how much extra they exercise, and they underestimate how much they eat, it's pretty difficult, like humans are pretty flawed.

Now, a 2012 study from red meat consumption and mortality, looked at prospective cohort studies, from the people who eat a lot of red meat, about the highest twenty percent, had a forty five percent high risk of dying from heart disease compared to those who ate the least red meat, the lowest twenty percent. However, when they looked more closely at the people in these extreme groups, they noticed that besides eating red meat, they had other habits that made them more likely to have heart disease, like don't exercise, they ate too much, they smoked, their cholesterol was worse. So, or they maybe had fish consumption, which affected their, you know, health and risks. For example, maybe the people in their lowest risk group exercised and didn't eat meat, but they also didn't smoke and they also ate healthier food. So you can't quite tell what's going on.

So the study supports the idea that eating a lot of red meat is like the high risk of heart disease. People who choose to eat more or less red meat have other lifestyle issues that influence their health. Now there are other factors, these confounding variables I mentioned. When you look at confounding variables, they try to control for these, but it's really tough, like, and they only control what we just think to control for. And it basically makes it really hard to determine true cause and effect.

Like I mentioned with the AARP study, they smoke more, they drank more, they ate less fruits and vegetables, they didn't exercise, and all these other issues. That's why they had more disease, not because of the meat. So it's basically, know, other issues with the study could be design flaws, and maybe the study population is different from the regular population. So it may not be widely generalizable. And also they do all these weird statistical calibrations to normalize the data.

And we're gonna talk about what that means. And they did this in that study. There was this, I think a scientist named Roger Williams who said, there's liars, damn liars, and statisticians. Or maybe that was Mark Twain, I don't know. But I think it's true.

You can kind of manipulate the data to make it show what you want. And that's clearly been done here. And the other thing this study does is it actually supports dietary guidelines to limit red meat consumption. And why does it say that? Well, I mean, the study basically said, our study supports this current dietary recommendations for limiting the consumption of red meat intake, and emphasizes the importance of different alternative sources of protein for type two diabetes prevention.

But dietary guidelines, just like this study, are heavily based on observational data, the data that can't prove cause and effect. And the systematic reviews and meta analysis of observational data are the weakest types of studies, right? There's confounders, there's bias, there's a lot of problems in the studies. And often the researchers have ties to industry, the expert panels are not independent, it's kind of a mess. So how do we know what to do in science?

Well, randomized controlled trials are the gold standard for drawing causal inferences between exposure and the outcomes. For example, you know, you give people a placebo, or a blood pressure drug who have high blood pressure, and you follow them for three months, and you can see, okay, well, did the people taking the placebo lower their blood pressure, or the people on the pill? That's a randomized control trial and you randomize people so they're not not stacking the deck in favor of you know healthier sicker population. Now they're hard to do in nutrition because you need to control everything and it's really hard to do. It's great in a lab rat but it's not really easy in humans, because they're what call free living and they do whatever they want.

You say, well, I want you to eat a low fat diet, or I want you to, you know, exercise one hundred and fifty minutes a week, or I want you to not smoke, or I want you to sleep eight hours a night or whatever you want, you tell them, they're not gonna probably do it. And it's hard to do. You'd have to basically put people in the locked metabolic ward, and put them there for years, and give them the food that they eat and track everything they do in order to actually know what's going on like a lab rat. But we really can't do that. We can't take, know, 10,000 people and feed them a vegan diet and 10,000 people and feed them a omnibore diet, including red meat and healthy foods, follow them for thirty years and give them all the food and track that it would be billions and billions of dollars and impossible to do.

So it's not practical, it's not ethical, it's expensive, it's hard to recruit volunteers for this, and people just, it's hard to do these nutrition studies. So we have to do the best with the data we have, which are systematic reviews and meta analysis of randomized controlled trials, mechanistic studies, lab studies. There's many different levels of evidence. You have to look at the total cumulative benefit of all the evidence. So now let's dive into this problem of study design, and what was wrong with this paper, and why it does not prove that red meat causes type two diabetes.

So what they did, as I mentioned before, they gave them a food frequency questionnaire, they're highly inaccurate, right? Every two to three years, people get asked, what do they eat? And they got a questionnaire, what's their average intake of food and beverage over the last twelve months? Do you know what you ate over the last twelve months? I couldn't have a clue.

I mean, how often do you remember eating X and Y food, right? Do you eat chicken with the skin on or without the skin? Do you eat hamburgers, hot dogs, processed meats? They give all these questions. They also, you know, kind of weirdly track things like beef, pork and lamb as a sandwich or mixed dish, but no serving sizes were noted.

You know, sandwiches and lasagna have also bread and pasta and processed carbs. So is that part of it? We don't know. So they basically kind of looked at, you know, what they were eating. The second issue is, and by the way, I can go way more into these food frequency questionnaires, but just trust me, based on the data, we'll put the links in the show notes.

They're really highly inaccurate. They really been proven to not be a good tool for looking at nutritional intakes over time, and don't really correlate with a valid metric for tracking outcomes. So right off the bat, it's a tough study to do. The second issue, when I kind of mentioned it, is that the red meat definition included sandwiches and lasagna, which basically were counted twice as processed and unprocessed red meat. Now processed red meat is hot dogs, bacon, meat sandwiches, sausage, unprocessed meat is like hamburgers, beef, pork, lamb, a sandwich.

So it's kind of weird. They kind of included other foods in the meat. You have to be clear the third issue is the serving sizes change over time and why because the the food frequency questionnaires were different in the different parts of the study so one was in 1981 was in '84 one had 61 items and one had 120 and they basically changed the definitions of what a serving is even in these food frequency questionnaires. So it's super confusing. So the nurses in the study asked how often they consume two slices of bacon.

Now the serving size of bacon is one slice, but before it was two slices, right? How they adjust for this? One serving of processed red meat is considered 45 grams. How do they measure it? Did they weigh their lunch meat?

Did they take their bologna or salami and put it on a scale? I doubt it. You know, what about chicken, beef, pork, or lamb? They say six to eight ounces was a serving. Today one serving is three ounces.

Did they know this? Did they translate a three ounce serving to a six day ounce equivalent? Probably not. And it creates more error in the studies. Issue four in the study was that this is really crazy.

They use statistics to massage the data to have the outcome they want. It this process calibration. We're calibrating the results using a seven day weighted diet record and food frequency questionnaires from two other population studies. In other words, they kind of acknowledge that frequency questionnaires are not that accurate so they can use other ones to correlate and see if they can kind of create this mishmash of data to show what they want so what they found was that this is kind of crazy the calibration doubled the effect of for total red meat processed meat and unprocessed red meat so before the calibration you know for example one serving an increment of total red meat was associated with a twenty eight percent higher risk of diabetes after the calibration it was forty seven percent before the calibration one serving increment of processed red meat was associated with a fifty percent high risk of diabetes after it was one hundred and one percent so it's like what are you doing here right so guess what number was reported in the headlines not the uncalibrated, but the calibrated number, right? Too much red meat is linked to a fifty percent increase in type two diabetes.

Well, in NPR, they didn't really do a good job of doing a review of the study. They didn't do investigative journalism, which I think is sorely lacking. And basically they found that there's 50% increase in red meat. So like I said, before the calibration was 28%, after it was 47%. So the next issue was the authors compared the lowest intake of red meat to the highest intake, but have historically reported the risk using servings, and for example, which is a more quantitative metric.

So just to explain what that means, in 2011 paper, another one called red meat consumption, the risk of type two diabetes, three cohorts of US adults and updated meta analysis. They reported twelve percent risk of diabetes for one serving and thirty two percent for processed meat and fourteen percent for total red meat. But this paper compared the highest and lowest intakes, claiming a fifty one percent increased risk for eating unprocessed and one hundred and one percent increased risk for processed and forty percent for total. But basically, this method using qualitative versus quantitative generated a lot more headline worthy statistics. So in other words, the way they reported this, it just makes it more sensational and look better for the agenda of having a study show that red meat causes diabetes.

Another thing with the studies, women in this study, the nerve cell study compared to the men in this study, show that the women ate more red meat than the men. Now this is the first study ever to claim this. Now, typically, every other study is shown the opposite. So what does that mean? Well, I don't know, but it just seems to kind of be a clue that maybe the study is a little wacky, and doesn't comport with all the other data we have around meat consumption and being female and male.

The next issue was the total red meat intake had a high risk of diabetes than both processed and unprocessed red meat. So that doesn't make sense, right? How could this the total red meat be worse than the individual types of red meat when the total is a sum of both of them, right? So you don't get like one plus one equals three. It doesn't make sense.

So most studies are looking at the risks associated with red meat show that the processed meat is riskier than unprocessed red meat. In total red meat, the sum falls in between, right? So if you have processed red meat being a higher risk and unprocessed lower risk, the average risk is gonna be lower, right? Kind of a combination. But in this study, they found the opposite, which doesn't make any sense.

If red meat, this process makes you have a higher risk of diabetes and an unpressed recipe lower, then if you add them together, you shouldn't have a higher risk when you combine them. So does it, it doesn't make sense. The next issue of the study was what we call healthy user bias. I think this is really really important. Essentially it's talking about what I mentioned earlier, which is the idea of confounders.

This idea of why were the people in the study having more diabetes or not? Was it because of the meat they were eating or a bunch of other habits, right? The people in this study, when you look at their characteristics, they had much higher body mass index. In other words, they were heavier, they were less physically active, they were more likely to be smokers, and they were less likely to take vitamins, right? So of course they're going to have more risk, right?

So the healthier people didn't eat red meat. Why? Because they thought that red meat is bad. That's the propaganda that we have in our society, is red meat causes heart disease, red meat cancer, so we should be eating less meat. In fact, we are, which is really another really important point.

When you look at the amount of meat we're eating, it's dramatically decreased over the last thirty-forty years, dramatically, because the message in the public health domain has been to eat less meat. But at the same time, what's happened? The risk of diabetes has skyrocketed, right? Just double, triple in different populations. So how could that make sense?

Red meat's going down, diabetes going up. Okay, well, that's a problem. How do we explain that with this study? What was so interesting to me in this study was that they didn't adjust for body weight, or we call BMI. That's nuts, because the group that actually had more diabetes was more overweight.

Now was that attributed to the red meat intake? That's what they say that red meat caused you to gain weight. But there's just no data to support that. I mean, they basically said because the likelihood that weight gain mediates at least part of the association between red and media intake and type two diabetes, we did not adjust for adiposity in the primary analysis. In other words, they did not actually account for the fact that the people who ate more red meat were more overweight.

Now a lot of other things can cause that. And particularly they do, particularly ultra processed foods, sugar and refined carbohydrates. That's clear from the data, not meat. The next issue was grains and sugar were excluded from the characteristics table. That's crazy.

How do you actually evaluate the effective diet if you exclude the very thing that's causing diabetes, namely sugar and refined carbohydrates? They just said, we're not gonna include that. Okay, we're not gonna look at Why? Well, I don't know, but it doesn't make any sense to me. The next problem with the study is that calorie intake was reported extremely low.

Now this doesn't make sense because people we know eat a certain amount of food, they're not starving themselves. And in the study, they basically excluded people ate less than 500 calories a day for women or more than 3,500 calories. They just got rid of them from the analysis. The same thing for men, men who consume less than 800 calories a day or more than 4,200 calories a day were excluded. And you can see, how do you get these numbers?

Because food frequency questionnaires are so problematic. People often do all kinds of things that show that they're not actually truly reporting on how much or what they eat, because they're getting all these extremes. Men are eating 800 calories a day or 4,200 calories day. It doesn't make any sense. But what was really interesting is the average calorie intake for women was 1,200 calories and for men it was 1,600 calories that's not a sustainable diet for people they're not going to eat that much they're gonna be starving all the time so it just shows you the flaw in these food frequency questionnaires they don't show you what people are actually eating You have very low averages for healthcare practitioners people, nursing nurses are on their feet all day.

So that just kind of makes me want to throw out the study altogether, because again how do you rely on data that's so imperfect, where your calorie count is so off. So how do you know what actually people are eating? If you love this podcast, please share it with someone else you think would also enjoy it. You can find me on all social media channels at Doctor Mark Hyman. Please reach out.

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