Understanding the science and politics of diabetes treatment with Gary Taubes

Let's Say Hello

[00:01:25.040] – Allan

Hey, Ras.

[00:01:27.310] – Rachel

Hey, Allan. How are you today?

[00:01:28.930] – Allan

I'm doing all right. I'm doing all right. Things are busy at Lula's. We're getting into February here, and we're doing well now. But there's this couple of months where we weren't. It has its toll. You're running a business, and you're like, okay, what we would have had for a year would have been an awesome year. It turned out to not be such an awesome year. But that's fine. It's fine. It is what it is. We're running a business. We're going to keep running it the best we can. And my hopes are now we've got a good January, a good February going. So 2024, It looks like it's going to be a much better year.

[00:02:02.340] – Rachel

Awesome. That sounds great.

[00:02:04.490] – Allan

How are things for you?

[00:02:05.910] – Rachel

Good. Still cold up here in Michigan. Yeah. But we're doing well. I mentioned earlier, my daughter is engaged to be married, and we're making some good plans. We've got a date. It'll be in June. She's got her dress, and we're just ticking off all the boxes, getting stuff done. So that's pretty exciting.

[00:02:22.430] – Allan

Well, good. Good. Now, so you're going to hit this transition in life where you're not only an empty nester, but your daughter doesn't have the same last name anymore.

[00:02:29.880] – Rachel

That's right. I got to learn how to spell the boy's last name. It shouldn't be too hard, but it's different.

[00:02:35.150] – Allan

I'll tell this story. My daughter was getting married, and I had met her, her boyfriend, her fiance at the time. And so I go into the place. She wants all the guys in the wedding had to wear the same suit. This was the place that sold the suit. I'm going in to get the suit sized because it just happened to timing. So I think she was going to get married in. I think she got married in November, and this was August. And so I walk in and I go in and I say, okay, I'm here to buy a suit. And they're like, Okay, who's the wedding? I said, It's Becker. And she's, What's the groom's last name?

[00:03:04.180] – Rachel

Oh, my gosh. Did it take a minute?

[00:03:06.950] – Allan

Yeah, I was like, Oh, my God. I don't even know the guy's last… I knew his first name, but I didn't even know his last name. So I'm sitting there going back and forth. I'm like, It's Jay and Becker, Jay and Becker. And they were flipping through their papers, and they found it. Unfortunately, it was one of the largest orders because he had, I don't know, 13 groomsmen or something like that. That's a big order. And because of that, then because of that, Then she had to at least try to even it up so it didn't look like this weird flock of geese flying north.

[00:03:36.160] – Rachel

Oh, boy. That's awesome.

[00:03:38.340] – Allan

Anyway, so, yeah, I had to learn his name. And even today, I was sending something to her, and I had to write her name. I was like, Okay, this is the first time I've actually written that last name. The new last name. They've been married now for over a year. Oh, boy, oh, boy. But it's the first time I've had to physically write it down, which was interesting.

[00:03:54.460] – Rachel

Oh, my goodness. That is funny. Yeah, got to get used to that. Changes.

[00:03:57.900] – Allan

There's some new things coming on, but All right. So you're ready to talk to Dr. Ta… I mean, Mr. Taubes. I always want to call him a doctor because he is so smart. He does so much research that I just think of him as a doctor because- For sure. Of all the things he does. For sure. But no, it's Gary Taubes. You ready to have that conversation?

[00:04:18.450] – Rachel

Sure.

Interview

[00:04:48.730] – Allan

Gary, welcome to 40+ Fitness.

[00:04:51.040] – Gary

Thank you for having me, Allan.

[00:04:52.750] – Allan

So your next book has to be on Stress Management now, right? We had so much trouble getting on this call. But today, the book we want to talk about is Rethinking Diabetes: What Science Reveals About Diet, Insulin, and Successful Treatments. When you started laying this out and saying this was a history book, I was a little like, okay, I just want Gary to tell me how to eat because I know he does his research. But I'm really glad that you did take the time to lay that out because there were so many layers to this that I went through a lot. I went through moments where I was just, okay, if I had I met that guy in person, I'd choke him out. And then there were moments where I want to shake someone's hand, and then it would flip. And then the person I wanted to shake their hand, now I want to choke them out. This whole convoluted story of science and medicine, food, diabetes, and treatment, it's a can of worms.

[00:05:51.310] – Gary

Yeah, that's a good way to put it. Let's talk about why I wrote a history of medicine book, basically on diabetes therapy. And how diabetes researchers… I'm going to refer to anyone who studies diabetes or medical practice specializes in diabetes as diabetologist, since that'll simplify everything. But one of The issue is with being a journalist and writing books challenge conventional thinking in medicine and nutrition is you have to establish on what basis you think you have a right to do that, that you think you know better. So my expertise throughout my career has always been the one subject I've studied, I've written multiple books on, and I think I know better than probably anyone else alive is good science and bad science. I mean, good scientists know that implicitly, but I have studied it explicitly. And when you look into the history of these fields, you could see why people came to believe certain assumptions were true. You could see whether or not they tested their assumptions to see if they were true, whether they adjusted their thinking when their assumptions failed the test, and whether assumptions were grandfathered into how we think about this disease and therapy without ever being tested.

[00:07:13.630] – Gary

And so when you do that, when you go back in time to look at the evidence base for what we believe about ideal therapies for diabetes, you end up telling a history. You say, look, this is what we believe that this point in time. This is why we changed our beliefs. This was the actual evidence on which the beliefs were changed. This was what happened when we tested them. So I end up in writing, rethinking diabetes with not just the history of the relevant diet, drug, disease relationship. But coming to conclusions about what perhaps these people should have concluded had they known then what we know now. We have the benefit of hindsight. And the benefit of doing this in the 2020s is that because of all these Internet repositories, you can basically get all this research, either downloaded or delivered to your doorstep, say, 90% of what should have been known about the science back when people were making decisions on 5 or 10 or 15%. The doctors would make decisions about diabetes therapy based on what they read in the journals that they got subscriptions to, in the languages that they could read, maybe what their local libraries had.

[00:08:38.630] – Gary

And now we can see almost all of it. And it's as though we have a thousand-piece jigsaw puzzle, and physicians and diabetologists were making decisions based on 50 to 100 pieces that they could access. And we can now see 950 pieces. We can and have a very solid idea about what image is on this puzzle when they were in effect guessing and then locking in their guesses over time.

[00:09:10.680] – Allan

Yeah. And then that's where personality gets involved and science can go out the door.

[00:09:17.010] – Gary

Yeah. One of the fundamental issues here is doctors are not trained to be scientists. They're trained to be doctors. They often look down on people with PhDs as FUDs. That's how they were called by my doctor friends when I was young. Being a scientist requires this very delicate balance between believing a hypothesis to be true or likely to be true and then being rigorously, extravagantly skeptical of your own thinking so that you can abandon that hypothesis if it's not true, even if you've built your career on it. And then doctors just say, you're confronted with Patients. Doctors are confronted with patients. They have to make decisions in the moment about what they think the best evidence shows. And the problem is, based on their decisions, they also come to conclusions about what they think the disease is, what it's telling them. Then, like I said, once you've made a decision, you've decided this is likely to be true, you lock yourself in after that, especially if you've acted on it, into believing it was true because you don't want to believe that you actually did people harm or that you made mistakes mistakes along the way.

[00:10:31.100] – Gary

And it becomes a can of worms, would be the phrase you use, the kind way to put it. So, yeah, the book is as much about the conflict between medicine and science and how doctors think versus how they should think to establish reliable knowledge and what happens when these assumptions are established as truth, as dogma, without really being rigorously tested. Not just being rigorously tested, surviving the tests.

[00:11:01.470] – Allan

Yeah. Well, and some of them were. I think that's one of the good takeaways here, where there were some really good doctors in this history. Diabetes started really hitting the scene around 100 years ago. And they were seeing a lot of type 1 diabetes, then type 2 was starting to come around. And so there was this, okay, what's going on here? This is different. And they didn't have exogenous insulin to shoot the folks up. They didn't really know insulin existed. And so they were, like you said, they were, I would say, practicing because they do call it a medical practice. But they would practice on a few patients and see what was happening and then adjust and adapt and come up with another way. They were sharing information with other doctors, which I was actually glad to see because I think that's how you learn how many cases you're going to see, how many they're going to see. And over time, you can build a body of experience that one doctor could never, never have experienced himself. So can we talk a little bit about treatments and things people were doing before exogenous insulin existed.

[00:12:06.250] – Gary

Okay. So apparently the first example, the first case in which a physician seemed to put a case of diabetes into remission was 1797. It was a British doctor named John Rallo. He's got a patient. He's in the military. He's got a patient in the military, Colonel Meredith. Meredith has recently lost a lot of weight. He's showing all the symptoms of diabetes, which are this extravagant hunger, thirsty all the time. He's peeing constantly. He goes to Rauh, Rauh. Back then, this is 1797, it was common for a physician to taste the urine, to make diagnosis. He tastes the urine, the urine's sweet, so he can diagnose his diabetes. And he decides that since the urine's sweet, it's got too much carbohydrates in it, too much that it shouldn't be there that's making it sweet. So carbohydrates from plants. And so he decides he's going to basically feed him a diet without a lot of plant matter. And he prescribes this diet, which is fatty, rancid meat, blood, sausages, and some green vegetables. And he's also giving him drugs. He's giving him… Morphine was a common treatment back then. And Meredith does better. His thirst goes away, his hunger goes away.

[00:13:26.810] – Gary

He gained some more weight back. And Raleigh writes a pamphlet about this. He also treats a general with the same diet, and the general seems to do better, but the general goes home, falls off the diet, and dies. So Rala decides if you stay in the diet, it'll probably cure diabetes. He writes a pamphlet, distributes it throughout the England, the United Kingdom, to physicians to suggest they try it on their diabetic patients, and it seems to work. And through the 19th century, the standard of care is what's called the animal diet. They drop the rancid meat, French doctor, Baudenaire, gets involved, and the Pollinaire, I forget his name at the moment, then brings a little French cuisine into it. By the end of the 19th century, they're realizing that they want to give their patients who tend to be losing a lot of weight, or if they have what we today would call type 1 diabetes, they're emaciated. And young, you want to build up their bodies. You want to give them as much calories as possible. So by the early 20th century, the idea of 1900, 1905. It's like, feed them as much fat as you can.

[00:14:34.470] – Gary

And Elliot Jocelyn, who starts the first diabetes clinic in the United States. He's a Harvard trained doctor. He specializes in diabetes in Boston. His clinic eventually becomes a Jocelyn Diabetes Center at Harvard, says, look, the secret to keeping these people alive is getting them to eat as much fat as they can. He actually learns that from the German diabetologist who have the most clinical experience in the world at that point. That's the diet. It's today we would call it keto. Back then, it was the high fat animal diet. Jocelyn is actually one of the reasons he's so interested. His mother has diabetes. And again, probably a type 2 diabetic whose pancreas eventually fails her, so she loses a lot of weight and is diagnosed. And she stays alive longer than any of her other family by rigid adherence to this high fat animal product-rich diet. And there's a brief interlude from 1914 to 1921, where another Harvard doctor, Fred Allen, decides the best way to treat patients is to semi-starve them. And you have this starvation therapy that takes patients who are… One of the diagnostic criteria of diabetes is ravenous hunger at the time, and then you starve them further.

[00:15:57.490] – Gary

And again, with patients with type 1, these young kids, you could keep them alive longer by doing so. And then 1921, insulin is discovered. And insulin is the hormone that the pancreas should be producing. And University of Toronto researchers Discover it, purify it, use it as therapy, and find that they could basically bring these kids at the brink of death, emaciated 15-year-olds who weigh 50 pounds and could restore them to life. They would talk about it as almost literally a resurrection, like a biblical experience. And as soon as you start giving patients insulin, you create the disease of low blood sugar, hypoglycemia. And that can be deadly. That can be fatal, very quickly fatal. So you have to get the patients to eat carbohydrates so that they don't die of low blood sugar. So your cure creates a new disease. And simultaneously, you go from diets that basically had the patient abstaining entirely from carbohydrates to telling them to eat carbs, and telling them to eat carbs at regular intervals, and they should have them at breakfast, and they should have them at snacks, and they should have them at lunches. And that way, when the insulin covers them, you won't kill them with low blood sugar.

[00:17:25.830] – Gary

And as this is happening, physicians are making decisions visions about what this says about the diet. And the one thing they don't know is what the long term consequences of any of this are. So you imagine they created a drug like an anti-cancer drug that could cure some horrible cancer. And in the short run, it works tremendously. It keeps people alive, but you have no idea what the long term benefits of this diet is. And by the time those… Excuse me, not just the long term benefits, the long term risks. And by the time those risks and benefits start to wash over these patients, this wave of diabetic complications that we're so familiar with today, which are heart failure, atherosclerosis, nerve damage, amputations, and gangrene, and retinopathies, damage to the eyes, and blindness, kidney failure. You're so far along in treatment, 10, 15 years, that you don't know what's causing it. And that's what we've been living with ever since. These decisions made in the 1920s and '30s about how to treat the disease with no real understanding of how they affect these long term complications.

[00:18:44.690] – Allan

I've talked on here a lot about homeostasis and how our body likes to stay in balance. And it has all these, in some places, very complex relationships between things to help make that happen. And I think insulin Insulin and glucagon is maybe one of the easier ones to understand, but it is extremely complex when you get down to the true science of how it happens in the body. Could you just give us a little bit of a primer on insulin and glucagon and how the two of them, both coming from the pancreas, work together to keep us in a good place or should keep us in a good place?

[00:19:22.850] – Gary

Okay. There's, again, a lot to unpack and what you just said. So homeostasis is one of the most important Certain concepts ever discovered in medicine. Dates to, again, 1865, a French physiologist, very famous, named Claude Bernard. The idea is basically that everything our bodies do is to try to keep relatively constant. The conditions, he called it the milieu interior, the interior milieu, but the conditions right outside the cell walls because your cells are basically living in that environment. They have to stay alive. And all they're seeing are the the nutrients in that environment, the vitamins and minerals right outside the cell walls and the cellular fluids and the fluid circulating through the bloodstream. And they're seeing hormones and signaling molecules and inflammatory molecules. Our body is working through this system of hormones and the nervous system to keep that constant. One more message, and then I'm done. The hormone that's in diabetes in 1889, a German physician, a researcher named Minkowski realizes that the pancreus is a problem in diabetes, because when you remove the pancreas from dogs, if you keep them alive, they become diabetic. 1921, as we said, these University of Toronto researchers led by Banting and Best, realized that the hormone that's missing is insulin.

[00:20:51.760] – Gary

So the idea is that insulin controls blood sugar, and without it, you have high blood sugar and all the symptoms of diabetes. You give insulin, you lower blood sugar, as we discussed. And forever after, effectively diabetes is seen as a disorder, or at least for the next 40 years of insulin deficiency. While researchers are studying insulin and focusing on its effect on blood sugar. Other researchers have established that the pancreas actually seems to secrete two hormones that work together. And one of the messages was how our endocrine system, our system of hormones, controls homeostasis, keeps us in homeostasis equilibrium, is it does it by not just secreting hormones that have certain effects, but having those hormones in turn react with counter regulatory hormones that have the opposite effects. Anything that's working to do one thing, there's guaranteed to be another hormone that's working to do the opposite. And these hormones are going to be linked. And the idea was that as these researchers began to realize that blood sugar is controlled not just by insulin telling cells to take up blood sugar and use it for fuel. So insulin lowers blood sugar, and you get to utilize, but also this hormone glucagon, which is secreted by neighboring cells in the pancreas, that actually tells the liver to create and effect glucose, blood sugar, and secrete that glucose into the bloodstream to keep blood sugar up.

[00:22:30.710] – Gary

So we have this dual hormone system, insulin being secreted by cells called beta cells, glucagon being secreted by cells called alpha cells, which are right next to the beta cells. The mechanisms in the cells are very similar. Glucose stimulates insulin secretion and inhibits glucagon secretion. So glucose is blood sugar in effect. Insulin itself inhibits glucagon secretion, and glucagon inhibits insulin secretion. And these have to work perfectly. But diabetes researchers and physicians are so focused on insulin that they pay virtually no attention to glucagon. And glucagon, while secreted from the pancreas, is doing the bulk of its work in the liver, which is the organ that's secreting glucose into the circulation and working to rise blood sugar. So in an ideal world, glucagon and insulin are working together, and they're working to keep blood sugar stable, which is what is relatively stable in those of us who don't have diabetes. And if you don't have enough insulin, you're going to have too much glucagon. If you have too much glucagon, you're not going to have enough insulin. And if you have too much insulin, you're not going to have enough. It's hopelessly connected. And vitally important to this is that the insulin and the glucagon are both secreted by the pancreas.

[00:24:00.070] – Gary

So the highest doses in any cell's fee are in the pancreas, and the next highest doses are in the liver, down the portal vein. If you just inject insulin, as we do with insulin therapy, exogenous insulin, as you call it, you're putting insulin eventually into the circulation. So it has to, by the time it gets to the pancreas, it's seeing an entirely different dose. The pancreatic alpha cells are seeing a very different dose than they would if insulin was secreted from the pancreas. And these are all revelations that are made by really good researchers, physiologists studying these systems through the 20th century. And the implications are profound for how we treat the disease. And yet when you look back at this history, you see that the way we treat this disease never really changes in response to a changing understanding of the disease itself.

[00:24:52.150] – Allan

And even when it does, it's three decades later.

[00:24:55.490] – Gary

It's three decades later. But even today, we have these wonderful new drugs, GLP-1 agonists, Receptor agonists, that are used to treat both diabetes and are considered wonder drugs for obesity. And the way the researchers think about those drugs working is purely through the insulin system because they think, Oh, these drugs reduce, they bring blood sugar under control. Therefore, they must be stimulating insulin secretion. And in cell cultures, they will indeed stimulate insulin secretion. But when you actually… They are called glucagon-like peptides for a reason, because they are very much like a glucagon, and they're the proteins in their shape and configuration, and they have an effect on glucagon as well. And what you could be seeing is a glucagon-related effect, not an insulin-related effect. But that's not how people think about it. One of the messages with the research I've done is that when you talk about all the mistakes that were made in medicine along the way, they don't tend to become trivial. They tend to become compounded with time. They pollute the science ever after because people just embrace these things as the correct way to think about it.

[00:26:19.680] – Allan

I want to jump ahead a little bit here. Now, obviously, okay, so a wonder drug, if you will, or basically a hormone, is starting to help people live a lot longer than they would lived otherwise. And so as a result, now they're actually starting to see some of the downstream effect of folks with diabetes that live a little bit longer and or maybe even the effect of insulin itself when it's injected this way. And that's heart disease, atherosclerosis, and some of the other diseases that are out there. Can you describe why there's such a huge correlation between diabetes and heart disease and the other metabolic diseases?

[00:26:57.500] – Gary

Well, again, it gets As soon as we get into it, it gets complicated. So it happened, like I said, once insulin is discovered and insulin therapy is initiated almost exactly 100 years ago, you can suddenly keep patients with diabetes a lot longer. And this alive a lot longer than otherwise. So this includes not just young kids who are diagnosed with type 1 diabetes or at the brink of death, and now you can keep them alive indefinitely. But the folks with the chronic form of the disease that associates with obesity and aging, a type 2 diabetes who wouldn't show up into the doctor until they had lost a lot of weight and were clearly suffering insulin deficiency. So now you're giving them insulin, you're keeping them alive. And then by the late 19 '20s, early 1930s, you start seeing this wave of complications comes in the medical community. So all these… And kids who might have been diagnosed at age 12 and kept alive for 20 years by insulin, which is the miracle aspect of it, are now dying in their early, late '20s, early '30s of heart disease, kidney failure, blindness. They're getting all these awful complications.

[00:28:13.110] – Gary

It's still tragic. They're still dying way too young. It's as though they're aging too quickly because they're getting these diseases that strike the rest of us in our '50s, '60s, '70s, and '80s. They're getting them in their '20s and '30s. And the physicians are confronted with this now. And I should say, as this has been happening, the physicians have been liberalizing the diet evermore because they think of insulin as a miracle drug. And they think rather than tell people to restrict the carbohydrates they eat, and minimize your doses of insulin, they're saying, Why don't we let people, particularly kids, eat whatever they want and cover it with insulin? So the insulin doses get higher and higher. The drugs do a very poor job of controlling insulin, but the physicians can't. Excuse me, controlling blood sugar, but the physicians can't really measure. They can't measure blood sugar in any meaningful way, so they don't know that. And when these diabetic wave of complications washes over their patients, they don't really know what to do about it. They assume it's because their blood sugar is poorly controlled. They never think that it might be related to the insulin they're giving them as well.

[00:29:30.070] – Gary

It's hard for physicians to think that the drugs they're giving them are also creating complications. And by the time the medical community starts using randomized control trials to test drugs and diets to see what works and the long term risks and benefits. That's 1950s, 1960s. This belief system that we should let patients eat carbohydrate liberal diet. We should let them eat whatever everyone else eats. They have to count it. They have to count their carbs at breakfast, lunch, and dinner, so they know how much they're eating, so they know how much insulin to take. They have to take specific doses of carbs at snacks, so they cover that insulin. And the insulin covers the carbs, but we're not going to tell them they can't eat pasta, bread, potatoes, because they're not going to listen to us anyway. So these are all assumptions that are embraced. And this diet never gets tested. And through the 1970s and onward, as a diabetes community starts doing ever larger and more rigorous tests to test their assumptions about keeping blood sugar under control by drugs. The assumptions almost invariably fail to be confirmed by the study. So they find it's just harder.

[00:30:48.990] – Gary

And no matter what they do, the complications from the disease seem to be inevitable. And they never test the idea that one of the problems is the diet, that as long as you let patients eat whatever carbohydrates they want, they are going to get complications and these long term chronic effects. And that the other problem might be the insulin and the drugs they're giving as well. And that's never really embraced. When it's tested, the tests seem to demonstrate that that's what's happening, but that's not how these physicians are thinking. So you've got a situation. In fact, there's two ways to think about treating this disease. And there were two ways to think about it back in the 1920s. One is the symptoms only appear when people eat carbohydrate-rich foods. So I'm not talking green leafy vegetables, but starches, potatoes, grains. And if they minimize consumption of those or abstain from those foods, they either won't manifest symptoms of the disease or the symptoms can be controlled with very low doses of drugs. Patients with type 1 diabetes will always need a little some insulin, but they'll need a lot less if they don't eat carbs.

[00:32:07.860] – Gary

Patients with type 2 diabetes might not need any drugs at all if they abstain from eating these foods. And then the other way to think about it is the way we did, which is you let them eat whatever they want. Although maybe you say you got to, again, rigorously count the calories, the carb calories in every meal so you know how much drugs you should be taking, and then you cover it with drugs. And we never actually… The point I'm making in this book is that when you look at these clinical trials and you look what was tested over the past 40 years, when we really started doing these tests, This is a degenerative chronic disease that requires more and more drug therapy as time goes on if you're eating a carbohydrate-rich diet. And it very likely is not, if you're not if you're abstaining from those carbs.

[00:33:02.310] – Allan

As you went through it in the book, it was one of those moments where I was like, there were doctors that got it with that minimum effective dose. Let's not give them more than they need. Let's put it together with eating That's a concept I haven't seen in medicine a lot at all. And particularly, start talking about heart disease, you start talking about other things. There really isn't enough conversation, at least in my opinion, about how food is medicine, even though that concept has been around for quite some time, it doesn't seem to be practiced as much. I saw a lot more of that in this book than I expected to see in the history. So let's say you happen to go to the doctor and they told you, Hey, Gary, your numbers are up. Your A1c is starting to hit that point. We're going to call this prediabetes. What are you going to eat from that point forward? You probably already eat that way.

[00:33:58.640] – Gary

I do already eat that way because one of the messages from all my books, and again, which is based on arguably doing more research in the literature than anyone alive up to a certain point in time.

[00:34:12.610] – Allan

I think you got the meta study down.

[00:34:16.000] – Gary

Yeah, it's a cluster of chronic diseases that associate together. And by that, I mean, they associate together in populations. They appear in populations together. They become epidemic together. And And they appear in patients. If you have one, you're much more likely to have the others. And this is obesity and diabetes and gout and heart disease, and cancer is one of them, and dementia is one of them. Basically, all the chronic diseases that are likely to shorten our lives and kill us and make our old age, our oldest age, very uncomfortable are diseases that are associated with Western diets and lifestyles. And when you look into the history of this idea and the research, And the conventional thinking is it's caused by eating too much and maybe being sedentary and maybe the fat in the diet causes heart disease and the salt in the diet causes hypertension. And so strokes, cerebrovascular disease, and maybe the red meat and the alcohol cause gout, and every disease has a different trigger. And the other hypothesis that was always out there is these are caused basically by the refining of sugar and grains. Highly processed grains and sugars. And once you live in a population where that's a staple of your diet, these diseases are going to manifest themselves, they're going to be passed on from mother to child in the womb, so they're going to get worse with each generation.

[00:35:46.740] – Gary

And it seems to be what we're suffering from today. And the dietary therapy that that hypothesis implied, and that had been in many ways, conventional thinking for 200 years, is that if you avoid these carbohydrate-rich foods, you will be relatively healthy. This isn't really food as medicine, so much as some foods are simply toxic to some ever larger proportion of the population. And if we want to be healthy, we can't eat them. The Atkins diet, beginning in the 1960s, was a carbohydrate-restricted high fat diet. The animal diet for diabetes that was used from 1797 till insulin came in was a carbohydrate-restricted high fat diet. It was considered a very effective treatment for epilepsy beginning around 1920. And there was always significant evidence in the literature that people, some people just couldn't tolerate the carbs in the diet, that for whatever reasons, probably insulin-related and glucagon-related. These foods, when they're refined and they're digested quickly, today, we call them high glycemic index carbs. Again, sugars could be particularly bad for us, that if we don't eat those, we'll be healthy. And again, if you want to keep your calories up, then you have to replace those carbohydrate-rich foods with calories.

[00:37:23.450] – Gary

And inevitably, it's mostly fat. Even sources of protein come with attached unless there's skinless chicken breasts, which I don't think anyone should ever have to eat. So, yeah, all these lines of thinking lead you to believe that we should eat, in effect, if we want to be healthy, a very low carbohydrate diet, replace those calories with healthy fats. And now you're reading something that looks a lot like keto or Atkins or carnival even. And one of the subtexts of everything I write about, it's in the diabetes book as well, is as soon as the medical organizations like the American Diabetes Association, the American Heart Association, and National Institutes of Health, and then the US Department of Agriculture get involved. Once they start taking the conventional wisdom and turning it into dietary guidelines that we should all follow, anything that is divergent from that is treated as a fad diet or a quackery. It's dismissed as dangerous or harmful or something that people won't adhere to because we know people won't stick to a diet. And so the medical community thinks of all ways to convince people not to eat a diet, that this alternative hypothesis, which is based on the literature and the history, says it's probably the healthiest way to eat. It's… And that's how I eat.

[00:38:51.720] – Allan

Okay. The sad story of all this as you go through is they come up with the concept with insulin that you can cover up the carbohydrates, the volume of carbohydrates, and particularly sugar, that the American or the Western diet starts taking on escalates. And so we're no longer covering up 30 pounds of sugar a year, 40, 45 pounds. We're talking over 100 pounds to 150 pounds of sugar that a lot of people are eating in a year. And if you're using insulin to cover that up, we're not talking about five units here, 10 units there. We're talking in terms of a couple of hundred units here and a couple of hundred units there. So I think that sometimes when we think we have a miracle drug that allows us to do things, then everything just flips the other way, which gets me concerned about this glucagon-like peptide stuff that's coming out is that a lot of people are looking at it and saying, oh, well, that's going to help me lose 30 pounds. I'm going to do that instead of eating a diet that's going to help my body naturally get rid of body fat and eat a little bit less, maybe.

[00:40:02.190] – Allan

They're looking to something like that to cover it off, if you will. What are your thoughts about these new wonder drugs? I got chewed a little bit by a doctor that prescribes these because he's like, These are peptides. These are not drugs. These are just natural occurring things, which is probably a little true, but not something you're going to inject. Yeah, not something you're just going to inject. Once you start injecting something, I'm going to call it a drug.

[00:40:27.020] – Gary

Yeah, I think that's it. These are pretty profound variations on the naturally occurring hormones. But I have the same worries. I mean, the good news would be that because one of the effects, whether it's direct or indirect, is to so powerfully inhibit appetite, people are going to be eating a lot less of the foods that I would argue they shouldn't eat anyway. And it may be that these particularly target sweets. So one thing that when they talk about cravings going away, the things we tend to crave are sweets. So I suspect that's a kind way of saying people aren't craving desserts all the time, and maybe they're drinking less sugar, sweetened beverages. So that could balance out. And it's one of the interesting benefits. I do think that the world is full of people who, even if they eat a carnivore diet, would still have considerably more excess fat than they prefer, and that if they want to take care of that, the drugs would be beneficial. But I do worry that insulin to me, reading the insulin story in the literature was horrifying because you see how it could take 10 to 15 years before you really understand the bad things that could happen.

[00:41:46.240] – Gary

And by that time, it's too late. And I keep hoping that maybe I'm just misunderstanding the level, the kinds of clinical studies that have been done today so that somebody could convince me that I shouldn't be anxious that as millions and tens of millions of individuals embrace these drugs, we're not going to see the tidal wave of complications that we couldn't imagine. There are all kinds of other issues, like With pregnancy, for instance, if a young woman goes on the drug like Wegovy and then loses 50 pounds and gets married and then wants to have children, does she stay on the drug while she's pregnant? If she does what happens to the fetus, to the child. And if she gets off the drug before she goes pregnant, she'll be gaining weight back at a very considerable speed while she's pregnant. And we don't know what will happen to the child. And it could take 20, 30, 40, 50 years before we actually know the long term consequences of what happened in the womb. And so there are situations that I don't think we're prepared to deal with. But again, I'm hoping that I'm just naive here, that this is an area I could find the authorities who could convince me that I don't know what I'm talking about.

[00:43:06.080] – Allan

I think just the lesson that I took away from insulin here was it's not a cover. It doesn't mean that you just go full bore and you're free. And you can do what you want to do and you just take more to cover off on it. I look at this the same way and say, what lifestyle changes can you be making to support a lower weight when you get there? And that this is just a helper to get you to a point, like the guy who comes in and he's going into a coma, and that kid's going to be dead in a couple hours if they don't get that shot of insulin. So you give them the shot of insulin, and it revives them, and now you can deal with it. But in this case, again, I hope there's some lifestyle changes that come along with these things.

[00:43:51.030] – Gary

That's a good man. And again, one of the reasons I write these books is history. I'm trying to reach the physicians and the researchers to say, look, I I think if you did what I did, you would come to some of the same conclusions. If you looked at these histories and you saw that when we think about obesity, it's not an over eating problem. It's an effect of carbohydrate and tolerance problem. So if you could use these drugs to lower your weight significantly, but if you have to go off them, you will be… You probably won't gain the weight back if you don't eat these foods that caused you to gain the weight to begin with. And the drug will probably work better. But we don't actually know because these drugs are not tested on those of us who eat low carb, high fat ketogenic diets or testing on people who eat the standard American crap. So we don't even really know if they're healthy for us or as healthy or maybe more healthy. We represent… Our metabolisms run different. We burn fat for fuel. Other people burn carbohydrates for fuel. So there's a whole world of problems that comes with relying on a drug when these chronic disorders might be solvable, might be able to be put into remission with dietary changes that we can be pretty confident, but not absolutely confident, do not have those long term effects because we're eating diets that basically we evolved as a species to eat.

[00:45:22.830] – Gary

Whatever you do once you start talking about long term, 10, 20, 30, 40 years on a drug or a diet, we don't really what's going to happen.

[00:45:31.560] – Allan

We'll get back together and we'll do that podcast episode, okay?

[00:45:34.100] – Gary

With luck. I think the odds are better for you than for me.

[00:45:39.410] – Allan

We'll see. You're going to write the book anyway. Gary, I define wellness as being the healthiest, fittest, and happiest you can be. What are three strategies or tactics to get and stay well?

[00:45:51.140] – Gary

Now you're asking a journalist to give advice, and that's never a good idea. Eat the diet that makes you feel healthiest in the short run. So by that, I mean, if you suffer from a chronic disorder, which can be obesity or diabetes or heart disease, a little tougher. But let's stick with obesity diabetes, where you can actually experience the symptoms in the short term. If you can find a diet that makes those symptoms go away, which includes excess weight and high blood sugar and high blood pressure, then that's how you should eat. And in that case, you have to do your research so that you understand what the arguments are for eating this way, this eating pattern, and how to follow it. So that would be the first thing. I believe there's some foods we just shouldn't eat because they're bad for us, and that we'll get over missing them as we get healthy. The others become trivial to me after that. I mean, getting enough sleep and physical activity because I don't know if they'll make us live longer, but they tend to make people happier and emotionally balanced in the short run. So that's true.

[00:47:04.950] – Gary

My expertise is purely diet, and even there as a journalist.

[00:47:09.440] – Allan

Well, thank you. And they say that the value of history is to learn so we don't repeat it. So I'm glad you did take the time to write this book the way you did, because I do think that a lot of doctors can look back and say, okay, here's what we know, and here's what we've learned, and here's what we know we should probably should be doing regardless. And so I think it's a valuable book for anybody, including medical professionals that want to just know why we think the way we think when they really haven't seen any literature that proves what we think. So thank you for that. If someone wanted to learn more about you, learn more about your book, Rethinking Diabetes, where would you like for me to send them?

[00:47:46.640] – Gary

Well, Amazon to purchase a book. I do think it's a typical author. I think it's very much worth reading.

[00:47:54.640] – Allan

I do, too.

[00:47:55.270] – Gary

I have a website, garytaubes.com. I am I have a sub stack now with the wonderful journalist Nina Tysholtz called Unsettled Science, in which we discuss these issues of nutrition and chronic disease and the various influences in the science that perhaps shouldn't be there. And I tweet @garytaubes, although not as often as I should.

[00:48:23.240] – Allan

Well, thank you. Gary, thank you so much for being a part of 40 plus fitness.

[00:48:27.180] – Gary

Thank you, Allan.

Post Show/Recap

[00:48:29.200] – Allan

Welcome back, Ras.

[00:48:30.360] – Rachel

Hey, Allan. That was a really fascinating discussion. There's so much to talk about the history of diabetes. It's just one of those things that I've always just known existed. But I didn't realize that insulin was only invented in 1920 or 1921, I think.

[00:48:44.930] – Rachel

That feels so recent.

[00:48:46.860] – Allan

They found it in the early '20s, 1920s. So it's just a little over 100 years old. That's crazy. And then because they understood what was happening, particularly with, at that point in time, type 1 diabetics, because there weren't that many type 2 diabetics. It just didn't happen as often. It was a type 1. And that's why it's called type 1. It was the first one. They like, okay, they don't have insulin. So what happens is they end up in a coma, and they bring them into the hospital in a coma. And in the past, they pretty much said they're just going to die. And so now they're like, okay, we inject them with this insulin. They didn't know how much. They didn't know anything. They was like, just- Try this.inject them. Yeah. So they injected in and some of them were recovering. And so like, oh, so they need this insulin to do the process. So now they didn't fully understand what all was going on with the process, but they could see the relationship between insulin and blood sugar. And so that's what they started working with.

[00:49:45.490] – Rachel

And it's interesting that they had some dietary protocols until they figured out of what insulin was and how it works. But in the beginning, they did have some very interesting dietary protocol.

[00:49:55.730] – Allan

Well, they did because they understood it was the sugar and not having insulin. So it was like, well, some doctors were, well, if they don't eat, then they should be fine if you don't ever eat. Don't eat. So they were. Some of them were on… They were putting… People were going on starvation diets, realized that the medical system was very different back then. So they could do experimentation on their clients with the patients without really worrying about it. They were just doing everything they could think of to solve a problem. Sharing information with other doctors. Like, I tried this with this client and it worked. This client, it didn't. So this is something to think about because it had worked. But dietary was one of the core ones because there weren't a lot. Metformin didn't exist. Other drugs didn't exist. So really, they didn't have anything. So that's all they could really do was change your behavior or change the way you eat, change your movement, change your output. And so they had done this. There was one doctor that speculated that you could just feed people fat to replace the calories. So protein and fat instead of a more balanced meal.

[00:51:02.480] – Allan

And that was working for a lot of type 1 diabetics. They were staying alive longer. They still would, at some point in time, potentially go into a coma and die because you can't change what someone's eating when they're unconscious and can't eat. And so that would happen. What was so weird, in my opinion, was that the instant we had access to this, we call it a drug, but it's basically a hormone, but a drug, since we had this thing, everybody dropped every every other protocol out there and just move on. Now, that was fine for a while, but the thing was people started living longer. And the other diseases of lifestyle that are associated with diabetes, like heart disease and kidney issues, they still came on. But now you saw them because before, the first time you maybe knew they had a problem was when they showed up in a coma, and then they died shortly thereafter. Here, they're living into their 40s and having heart disease, which compared to a normal average person, might be 10 to 20 years earlier. They were thinking, oh, the high fat diets that these folks are eating are the problem.

[00:52:12.290] – Allan

So we need to make sure they're eating a carbohydrate rich diet. They've got insulin to cover off on it. So don't worry about that. So it's this… And they're trying to solve a problem. So it's hard to look at them and say, you didn't know what you were doing. True, because they didn't know what they didn't know. But we're at a point right now where I just, other than the fact that compliance would always be an issue, it just chaps me that we don't go with medicine as a food first, lifestyle first approach.

[00:52:43.710] – Rachel

For sure. Well, towards the end of the interview, he mentioned the term dietary therapy. I feel like that's a great term because if you have a condition, especially diabetes, if there are certain foods that make that condition worse, why would you want to take them? Even though you have the insulin to cover them up, why put that fuel on the fire if you don't need it?

[00:53:04.180] – Allan

I like that term, too, because at this point, yes, it is effectively acknowledging that food is medicine. Someone said that a long, long, long time ago. So we've known that for a long time. We just ignore it most of the time because it's not cool and you can't sell that diet necessarily. Doctors can't sell it. Pharmaco companies can't sell it. What they want is like, Here's your shot. Go have at it. Do what you want to do. Here's a pill. Go have at it. That's why I wanted to talk about, even though he didn't do a lot in his book about GLP-1s, those are coming out now and they're so popular and it's like, Oh, I'm not hungry, and I lose all this weight, 15% of my body weight is gone. As long as I keep taking these shots, which are like a thousand dollars each, I do that once a week. Chepers. Yeah. So think about that's okay. That's a new car every year.

[00:53:57.810] – Rachel

Oh, my gosh.

[00:53:59.320] – Allan

You know? Yeah. And you're just doing that so that you can maintain a lifestyle that's not what it should be. And so that's where I really struggle with it. So I think you calling it a therapy is going to help some people probably turn on their brain. But then also the problem is, well, then after I'm cured, I stop the therapy, and that could fundamentally backfire as well. So yes, it's life-saving, and it's incredible that insulin was found and has saved lots of lives, extended lives a lot longer than they would have. But if you don't change your lifestyle, then all you've really done is just delayed it and changed the way you're going to die, what you may die of. So heart disease, kidney disease, gangrene, Alzheimer's, all of that. And you're not going to have it when most people would have it. So you're not like in your '70s or '80s or '90s dealing with this stuff. You're dealing with it in your '40s, '50s, and '60s. Too early. Yeah, way too early. So the instant you walk in and the doctor says your A1c is a little high, his next words that are going to come out of his mouth is, I'm not really worried about that.

[00:55:12.590] – Rachel

Right.

[00:55:13.380] – Allan

And the reason is, it's Because of all the patients that come in his office, the vast majority are. I read a survey this week, thing that said by 2030, now that date just sounds hugely far away, but it's seven years. I mean, it's not that far away anymore. Yeah, exactly. He'll be alive in 2030. I hope. But by that point in time, half of Americans will be obese.

[00:55:40.230] – Rachel

That's crazy.

[00:55:42.350] – Allan

Half of us.

[00:55:43.460] – Rachel

That's crazy.

[00:55:44.050] – Allan

Will be obese.

[00:55:45.990] – Rachel

Oh, my gosh.

[00:55:46.960] – Allan

At the current rate we're going. So if you're not going to change your lifestyle, if the doctor tells you, don't worry about it, you're close, you're borderline, it's time for you to implement dietary

[00:56:00.700] – Rachel

Well, that's the needle, okay?

[00:56:03.520] – Rachel

That's the needle. If your doctor says that you're looking at prediabetes, then you can either let that needle go forward straight into diabetes, or you can stop it there and go backwards and reclaim your health through all of the interventions that we talk about all the time. Better diet and exercise.

[00:56:21.180] – Allan

The cool thing about this is we're at a point in time with what they know about genetics and what they're learning and getting some of the judgment out of where things like AI will just go out there and say, if this, then that. And they'll do it at such a crazy level of what your gene expression is at any given point in time. Have these treatments that could extend life not just an extra few years, but like decades and decades. Sure. There's a theory that at some point we could basically almost become immortal. Anyone would want that, but basically that the medical establishment will get ahead of the curve. And with every year, they'll be able to add more than a year of life. So you start thinking about the ability of medical science to add to and extend life. The only reason that it's not going up drastically right now is because of the way we're living our lives with lifestyle things. So if we fixed our lifestyle, we would live much, much longer than our parents. Our kids will live a lot, lot longer than us.

[00:57:27.990] – Rachel

Longer is great, but I want to put in high quality. I don't want to just sit on the couch for decades. I want to be active and moving and being capable of living a high quality of life. I think with the metformin, which is often prescribed for prediabetics as well as insulin, when you get to that point of diabetes, if you're looking at type 2 and not born with type 1. But those are just the tools. That's not the answer. That is one thing that can help you live a healthier life. But I think we often We look at that as the answer, the end, the one thing to do to manage this illness. But it's not. We really need to go back, and like we say every week, Allan, get into an exercise program and eat way better foods to manage and be healthy.

[00:58:17.340] – Allan

And that's why there was the doctor, because so many people have high cholesterol, his solution was, just like we did with fluoride for dental cavities, was to put it in the water, put statins in the water.

[00:58:31.450] – Rachel

Oh, oh.

[00:58:34.110] – Allan

Okay. No, no. Because, again, they do not believe that you can do this. And what I can say is, even just the keto diet or people eating a lot more whole food. That is a fraction of the total way that people eat. But that's getting bigger every year. The number of people who try keto and are successful with it gets bigger every year. And so there is success here, but you have to make that choice. You have to make that effort to make that lifestyle change, or it won't happen.

[00:59:06.510] – Rachel

Yeah, that's absolutely it. Bottom line.

[00:59:09.170] – Allan

Yeah. All right. Well, I'll talk to you next week.

[00:59:11.560] – Rachel

Awesome. Take care, Allan.

[00:59:13.050] – Allan

You, too. Bye.

[00:59:13.940] – Rachel

Thanks. Bye, bye.

Music by Dave Gerhart

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