David Heber MD, PhD on the Great Debate about Protein

This is Dr. Mark Hyman. Welcome to the doctor's Pharmacy, a place for conversations that matter. And today's guest is Dr. David Heber, who is an extraordinary physician, an inspiration of mine who's been teaching at the Institute of Functional Medicine conferences for years and has really pioneered the idea of food as medicine. He was the OG in this space. He has done some amazing work in the fields of nutrition, metabolism, obesity, internist and endocrinologist, but he's so much more than that. He's published really essential seminal research articles on the causes of obesity, weight loss strategies, and how obesity is connected to heart disease and cancer and much more. He's the founding director of the UCLA Center for Human Nutrition at the University of California. So stay tuned. That conversation is coming up next on the Doctor's Pharmacy. So Dr. Heber, you are an unusual character in medicine. You're an internist, you're an endocrinologist, you're a scientist, and yet somehow you're focused on food, which almost no other doctors are. How did that actually happen? Wow, that's a really good question.

So I was a medical student at Harvard, and my advisor was a late George Cahill at the Joslin Diabetes Center. And he wrote an article, a review article on the physiology of starvation in 1970 in the New England Journal of Medicine. And I was a chemistry major at UCLA as an undergraduate, worked on space science on the lower atmosphere of Venus, of all things. And so I came to Harvard Medical School with a pretty strong scientific background. And I couldn't understand medical jargon. I used to read through the medical cases in the New England Journal of Medicine, try to teach myself the language. But what I did understand was nitrogen, carbon, hydrogen. And there was a book called the Body Cell Mass by a famous surgeon called Francis Moore at the Peter Bent Brigham Hospital. Great book. And said how much nitrogen there is in the body, how much carbon. And I was always into the metabolic things, the biochemistry. And so when I read this Physiology of Starvation, I was fascinated by it. And actually my first job- Wasn't that from like the '30s or something? It's actually right after World War II. During World War II, there's a Professor Keys at Minnesota who took Hans Selye's objectors and he actually starved them for six months. There was no human subjects committee at the time. And he documented what happened to all the elements in their body and they became depressed, they got hunched over, they didn't do any extra movement. And it was really interesting because humans are very well adapted to starvation, very poorly adapted to over nutrition. So by studying starvation, I was able to understand the flip side of obesity. And my first area of work was actually nutrition and cancer because cancer patients would lose weight even though they were taking in adequate amounts of calories. So this was a fascinating thing. How does this happen? And we did studies in the early 80s on what are called futile cycling, where you break down amino acids and glucose and just run them around in the body. And we found out that it was all due to inflammation because at that time the cytokines had never been discovered.

So a tumor is like- Cytokines are.

The messengers of inflammation. Correct, I'm sorry about it. Like things like tumor necrosis factor and so forth. And what we found out was that the tumor was like an infection your body couldn't clear. and AIDS, which was then discovered in about 1983, very similar problem. And there was a lot of nutrition around AIDS. And then, of course, when the retroviral drugs were discovered, you know, but even before that, the people who lifted weights and who ate healthy diets did better in terms of AIDS. And the important point about protein and muscle in the body, there's a fellow named Don Kotler at Columbia University, and he could state the date at which an AIDS patient would die by their total body potassium going down by 50%. So if you lose half of your body cell mass, it's not compatible with life. die of is a simple, complicating infection, as you know. So protein is at the center of the adaptation to starvation. We conserve protein. Now, thirst will of course kill you in a matter of days, so you've got to be adequately hydrated. But you can live six months on adequate water, electrolytes, and vitamins because your body will reduce the rate at which your protein in your body breaks down.

So we have- you- go into a hibernation state.

Yeah, it really is. And you know, the ketosis that we talked about with your ketogenic diet is one of the most important things in that process because you can only, the brain and the red blood cell require glucose. They can't use fat as a fuel. So when you are sleeping, half of the glucose in your blood comes from an amino acid called alanine that comes out of your muscle. And so in the first few days of starvation, before you adapt, you are breaking down 75 grams a day of muscle protein. With an adaptation, by about 10 days, you're only breaking down 20 grams a day. And that is because your ketones in your blood go up a hundred folds.

As you said this morning.

But your brain can run on ketones. Yes, it adapts to it over a period of time.

So we think the brain can only run on glucose, which isn't actually true.

Right, but it's only true early. But in the first few days, or if you have an infection or a tumor and you can't do this biochemical adaptation, then your brain will use sugar. And so somebody in intensive care unit might only live 30 days. So protein and fruits and vegetables are the key elements in the diet. I haven't yet seen anybody who's fatty acid deficient. You need about 5% of your total.

Calories from linoleic and linolenic acids. Well, we see a lot of, we measure omega-3 and omega-6. Well, that's different. We see low levels of the essential fats for sure.

Right, right. But you don't see the skin disease or the dermatitis of essential fatty acid deficiency if somebody has an intact GI tract.

Yeah.

However, imbalances of fat, you're 100% correct. We see tremendous impacts of the imbalance of omega-6 and omega-3 fats in the body. And this is where we're gonna get.

Come back to that. Yeah, we need to come back to that. We're gonna come back to that.

We'll come back to how we're gonna-.

I wanna dig into the protein story. We start in the protein story because protein, I just It's framing the first nutrient. I want to just frame it a little bit before you get into it, because I think there's just a debate about protein in this sort of community now. Because if you look at the vegan community, they say, well, you don't need that much protein. We're over proteined. And that plant protein is good enough and that you should really eat beans and grains and that's all you need. And there's others that are saying, no, you need more protein. Some scientists are now suggesting we need even more than we thought we need that we're getting in America. And that especially as we age, it's more important and that we we even need protein from animals because the vegetable protein isn't having the right balance of amino acids to actually synthesize protein. So can you help us through that debate? Sure, sure. 'Cause I think everybody's confused. Even I'm confused. Like, I'm like, you know, do I wanna eat, you know, 1.6 or 1.8.

Grams per kilo of protein or do I wanna have 0.8 or what do I wanna have? Okay, so let's go through that. So first of all, the first mistake ends up with what's called the NHANES survey of the US Department of Agriculture. So they'll look at the total protein per day that someone's taking in and they'll say, oh, perfectly adequate. Actually, it turns out to be sort of at the lower limit of adequacy, but it's the distribution that's terrible. People eat very little protein at breakfast, a little more at lunch, and a huge amount at dinner, some of which is not metabolized.

It's excreted, it's deaminated and excreted. So let me ask you before you join on to that. So is it true that you need like about 30 grams of protein per meal in order to create protein synthesis?

If you eat less than that, it's just run as calories, and if you eat more than that, you don't use it. Yeah, the studies at McMaster University, we don't have a lot of data on this yet, but in 18-year-old kids who exercise for 45 minutes, they take protein within 30 minutes to an hour after exercise, they need a minimum of 20 grams to get maximum protein synthesis. Then it's a flat plateau. So at 30, you're certainly safe. Larger amounts may help with satiety, but they don't increase the protein synthetic rate anymore. Now, what we haven't done is we haven't done football players. We haven't done people with huge amounts of protein. We haven't done little people who don't need as much protein. So in my view, the protein requirement is based on your body's lean body mass, which also determines how many calories you burn at rest. So if I know that a woman has 100 pounds of lean, she burns 1400 calories. Her husband with 150 pounds of lean burns 2100 calories. Put them both on the same diet. The husband loses weight and the wife does not. He turns to her and says, you know, honey, your problem is you don't have any willpower. And the real problem is she has less resting metabolism. And so it's really hard to lose weight when you're only burning a thousand calories. That's why exercise is so much more important for women who have a low metabolism. That 200 or 300 calories is huge percentage for that woman who's trying to lose weight. So the way the misimpression came up is that part of the adaptation to starvation is that when you lose protein in your body, you stop turning it over. So you'll notice a lot of vegans and vegetarians have reduced lean body mass. Yes, I've seen that. Look at the body type of Bill Clinton since he's become a vegetarian. So I think the thing about protein is I am a fan of plant.

Protein and you can combine plant proteins.

To make a complete protein, but you have to do it carefully. What do you mean beans and grains or do you mean something else? Oh, there's beans and grains, nuts and nuts and grains as well. But you need a scientist somewhere in the mix to kind of come up with what is the proper complementarity. And there is a status that's used called PD-CAS. It's a digestibility index in humans, not in animals. So we all in medical school learned biological value. Wait, I just want to stop you.

There for a minute to go back because you're talking about so many great things. I don't want to miss these points. You basically said something that was pretty provocative, which is vegans have lower body muscle mass.

Often.

And that is because they're eating grains and beans, they're getting protein, but not the right mix.

And not the right times.

Is it because they're not timing it right? Is it because they're not eating the right foods?

It may be their choices. We had a vegan lasagna the other day for our Sunday conference.

A small piece of white flour, white.

Cheese, white noodles, and a couple of peppers. Now that I wouldn't call a balanced meal, okay? But it's definitely vegan. So that's what I'm saying. So people will have, you know, just pasta or just in their attempt to avoid these things. So I think we have to identify the plant-based proteins that are so important. And I know that soy is a four letter word to a lot of people, but it's got the best combination of, of amino acids of any plant protein. Now, you could take quinoa and hemp and pea protein and sesame protein and mix them together in the right way to get a very good protein mix as an.

And they'll have enough leucine, which is that amino acid that you need that mostly from meat that and higher amounts in meat that's needed for building muscle, right?

That's correct. But, you know, it's not deficient in it, it's a limiting ingredient. So you can build muscle on soy protein.

You know, if you look at- so do you have to add leucine to these plant proteins?

You can. Some people, you know, will fortify with methionine or other amino acids that are limiting. That can be done. Or you can mix another protein. You know, I'm not a big fan of industrial dairy farms, as you're not also, but whey protein, which was a side product of making cheese, has become all the rage among muscle builders because it's a hydrolysate and it's rapidly absorbed within 30 minutes into the body. So you can mix whey and soy together and get kind of the best of both worlds. But then you're eating animal protein. But then you're eating animal protein and not something I'm in favor of. So, you know, we have all these new technological things that are coming up and who knows, we may be able to come up with a way that we can improve the quality of soy protein.

So you think vegans can actually have adequate muscle mass by combining the right proteins and getting muscles in this? But aren't they gonna have to eat like three cups of beans to get.

30 grams of protein? Well, you know, yeah, the calories may be higher. So you got 100 grams of carbs. Yeah, the same amount of protein in a cup of rice and a cup.

Of beans versus a cup of soy. You're looking at 250 calories maybe against 650. So there's a difference. The issue is, you know, so when you do that, you're eating a lot of carbohydrates. Right. and so if you're insulin resistant and you're eating enough grains and beans to actually meet your protein requirements, you're getting also this byproduct of carbs. Even if they're whole, they still have a higher glycemic index than protein.

That'S correct. And if you don't eat enough protein, you will eat the balance as carbohydrate and fat. So one of the problems with a low protein diet is it keeps you, you're more hungry. It's the old joke about going to the Chinese restaurant and being hungry to the Chinese American restaurant being hungry two hours later, right? Right. so it's because the high carb, high fat diet doesn't have the satiety effect of protein. So protein is the most satiating macronutrient. You thought it was fat. No, fat does have some satiation. But protein is far more satiating than fat. Fat in the lower intestine is actually a product from Unilever called Fabuloss, which is an oat emulsion that ends up in your lower intestine in the ileum and causes some fullness. If you take enough of it, you really get nauseated. But it doesn't, you know, it slowly moves out of the stomach, you know.

When you have a high fat meal. I just remember from school, that fat for satiety. That was like the message.

No, as a matter of fact, it's not. It's actually the hidden fat and hidden sugar and salt are the three problems I could identify in the American diet right now in many of the processed foods you're talking about that people just don't know about.

Okay, so we'll come back to the fat because I want to dig into that. Sure, sure, sure. But the protein issue is sort of trying to get to the bottom line here, which is do we need animal protein or not? can vegetable protein be okay or is it too high glycemic?

No, no, I think vegetable protein is fine, but I think we need to have some products now like tofu that will concentrate the protein compartment.

Yeah, so tempeh and tofu are highly.

Protein, low carb foods. Exactly, great foods, and a great choice. And I think you can build. Now remember, if you're building muscle, you've also got to exercise, so the protein doesn't do it by itself. Where the misimpression came from was in 1973, the late Vernon Young, who's a great nutrition authority, took some medical students to the cafeteria at MIT and fed them egg white. And he came up that they were in positive nitrogen balance at 0.8 grams per kilogram body weight. I see. Or actually 0.6. So everybody, at 0.8, everybody was in positive balance. At 0.6, they were zero balance.

So now all the ministries of health.

Around the world use 0.8 grams per kilogram body weight. Right, that's right. That's where it came from, right? That's where it came from, 1973. So in 1989, they did endurance athletes, and guess what? It was 1.0. Then in 1992, they did weight lifters, and it was 2.5 grams per kilogram body weight. because body weight could have a different composition of fat versus muscle. The more muscle you have, the more protein you need. And that's where I came up with this idea of matching the body protein with the protein in the diet. Now, the opposite also happens. So, I put you on a zero protein diet. Your body will start to conserve its protein mass and you'll end up with a smaller body mass, but a lower rate of turnover of protein. It's kind of a first order thing. It's like that, you know, flask of colored liquid that you learned about in chemistry. the amount of liquid determines the rate at which it flows out of the flask. So that's where the protein comes in. I'm a huge believer in protein, 30 grams per meal, three to four times a day, depending. And even if you're gonna have after dinner eating, binge eating, and 25% of obese people have protein after dinner. And obviously low fat protein or. But think about it, if you're doing.

Beans, that's eight cups of beans or nine cups of beans a day.

I know, I know.

So how, I mean, that's where I sort of struggle with it. Right, right. get four to six ounces of chicken or fish.

Well, that's where I get into the soy protein. And I know we had a little bit of discussion about isolated soy protein, but let's find out what is the best, healthiest way to do that. But you've got to separate the protein compartment from the starches. Because in ancient times, we worked so many hours in the fields. We needed those carbohydrates for energy. But as you said, the USDA is six to eight servings of carbs on the bottom. I call it a prescription for obesity. In 1997, I put my own pyramid together at UCLA, and the public health people told me, well, people are gonna starve on this 'cause there's nothing but fruits and vegetables at the bottom. And I said, look, starvation is not our major problem in the United States today. It's overweight and obesity. So I think by putting in seven servings a day of colorful fruits and vegetables from seven different color groups, you get 500 calories per day. You get your protein, let's say it's 100 grams, that's 400 calories, or you get 150, 600 calories. So you have plenty of room here to add in some carbs and have flavorful food and cook beautiful food. but the basic building blocks just need to be there.

That's a very interesting message. And on a practical level, are you suggesting people move more to plant proteins and away from animal proteins?

Yes, I would.

Even though you need the protein, which is hard to get. I mean, so I don't think the average person can eat nine cups of beans a day. No, no, no, I wouldn't recommend that. Unless that means you have to have processed protein. Correct. Which is, you know, an industrial food.

Product, which kind of goes against some other values around whole foods. Right, I know, I understand. But, you know, talking about economically, look at where the obesity epidemic is. It's at the lower lower socioeconomic levels. It's on the street. And Adam Drewnowski is a friend of mine at University of Washington, runs the Public Health Nutrition Program. He teaches the economics of nutrition. And basically, high nutrient density isolated protein is one of the least expensive ways to get protein around the world.

And we're going to go to an alternative protein session. It may be algae, it may be.

Insect protein, God knows what it's going to be. But I think- Memphis meat, which I don't know.

Well, that's- Stem cell meat.

That's a stretch. To me, that's still a Stretch. But I think that, you know, there was this movie called Soylent Green.

It was the last movie of Roger Corman.

I heard about that movie. Yeah, they named a food after it.

Which I couldn't believe.

But I saw the movie. It was Ground Up Humans, right? That was the punchline in the movie. It was Ground Up Humans. And in that movie, only the richest people had this tiniest little piece of.

Meat in a cabinet. And it was an amazing, amazing film, if you get a chance to see it. I wanna see it, yeah. So are you saying we should eat.

Less meat because it's unhealthy or because you're worried about about the climate or environmental impacts? I am worried about the environmental impact and I always, even at a conservative recommendation I was making back in 2001 was half plant protein, half animal protein.

I would now go more for the plant. But it's more for the environmental issues. In other words, if you could eat wild elk, would that be okay?

Oh, absolutely. So you're not saying meat is bad from a health point of view? No, absolutely not. As a matter of fact, that's a very good point, because I was talking to the folks that have the bison and the regenerative agriculture. And you know, when we do studies of wild elk or any kind of wild animal, the omega-3 levels are much higher. So I always say if you can't be a vegetarian, vegetarian. So they eat grass, they concentrate these omega threes, their total fat level is lower. People don't know, the average cow on an industrial farm is fed corn and they don't like corn, so they mix it with molasses, they then ferment it, so the poor animal is running around.

Half drunk, blowing out methane into the atmosphere. And then they give them antibiotics to.

Kill the bacteria that are causing their stomachs to blow up. They've got them standing next to each other, urinating, defecating, all this horrible stuff. and it's just awful how we treat, you know, my father grew up in rural Poland and born in 1901 and he told me on the farm, every cow had its own house. And so they treated their animals with a lot more respect than what we do today. And so I think it's a lot about what you're talking about, taking care of the earth and taking care of ourselves.

So it's not that from a scientific point of view, meat is unhealthy, it's factory farm meat that's unhealthy.

Yes and no. I mean, when we get into the lipid part, those animals that we call saturated fat animals, they're actually high in omega-6. because they're fed these grains that are high in omega-6 fatty acids.

Let's take an idealized world where we shift to regenerative agriculture, where all animals are grass-fed all the way through the cycle, where they actually are creating more soil, they're reversing climate change, they're helping sequester water and carbon. Is it okay to eat that?

Yeah, absolutely. From a health point of view. From a health point of view, absolutely. Now, there's one thing about animal protein that's different than plant protein, and that's the content of organic acids like sulfuric and phosphoric acid. Put a greater strain on the kidney. So, soy protein doesn't affect glomerular filtration rate at all, but animal proteins in large amounts do have some effects on the internal endocrinology of the kidney.

But isn't that only for someone who has kidney failure? Yeah, it is.

So, if your kidneys are working normally, you're able to handle it. Absolutely. The number one thing you can do to reverse failing kidney is control blood pressure. And changing the type of protein, in a very big study in 1985, didn't have have much of an effect whether you went to essential amino acids or mixed essential and non-essential.

And blood pressure is controlled by insulin resistance and inflammation, which is driven by carbohydrates.

Yeah, the big medical message here is that two-thirds of the people today in dialysis units are type two diabetics, which relates to the obesity epidemic. Exactly. When I was an intern in 1973-74 at Beth Israel Hospital, which by the way was written up as the house of God, I'm actually the character Hyper Hooper.

Oh, you are? Yes, I'm Hyper Hooper. Amazing. Absolutely. For those of you who don't know, the House of God was a sort of a novel about being a resident and an intern in a major hospital in Boston, and it was kind of a muckraking expose.

Yeah, absolutely. We really, because Medicare had been approved in 1964. So by 1974, people were being admitted to the hospital just as a diagnostic maneuver, you know, rule out gas, you.

Know, for seven days. Yeah, we called it the suitcase sign. The family would bring their family members with the suitcases to the emergency room.

We invented a whole language of medicine, which all interns and residents know. No, Gomer, get out of my emergency room and all that. Gomer, Gomer, which is a female Gomer. But anyway, all those kind of things. And we had a lot of fun. It was at midnight supper that we did this when they fed us all the food they couldn't sell during the daytime. We sat there and kind of had a Saturday night live moment. And it was a lot of fun. But I think that at that time, the only people getting dialysis were people with autoimmune renal disease. And then in 1972, I think a General Motors worker said that if he could get dialysis, he could go back to work and support his family. So the Senate said, you cannot die of kidney failure in this country. You're gonna get dialysis, regardless of whether you have diabetes or whatever. And then we trained a whole cadre of nephrology fellows, opened up dialysis centers. There are now 570,000 Americans on renal dialysis. Amazing. All of which is preventable.

Preventable, yeah. And then they die of heart disease.

In a very short period of time, just several years. But like you said, a lot of it's driven by the high carbohydrate. Exactly.

Sugar and starch.

That's right. It all goes back to the nutrition and sedentary lifestyle. So people lose their muscle over time by eating too many carbs and not enough protein and they get what's called sarcopenic obesity, which I named in 1993. Otherwise known as skinny fat. Yeah, you can be thin on the outside, fat on the inside. And as you lose your muscle, your metabolism goes down. So eating the same amount of food, you gain weight. And I would say many, many 40-year-old women or middle-aged women have come to my office and said, Dr. Hibbard, I don't understand why am I gaining weight? I'm eating the same amount food I ate before, but you're now a much more metabolically efficient machine because you have less muscle. And so the answer to that is get into the gym, workout, resistance training for women and for men, it's not just for men. And also the only thing that builds bone density is all these osteoporosis drugs that we had, not very good in terms of building good strong bones.

Vitamin D in that, yeah.

Vitamin D, calcium, and exercise.

And protein. So take home on this is we we need regular protein throughout the day to maintain and build our muscle. It has to be high quality protein and it could be healthy grass-fed or wild animal protein or the right combinations of nut seeds and grains and beans.

Right, and it's a total daily thing. So there's very poor protein which is from collagen, but if you had that as a snack and the rest of your protein throughout the day was good, it wouldn't be so horrible. So your body integrates all the amino acids that you have and there's some of them that are essential, there's nine.

Essential ones and the others you interchange sort of like a pack so do you have to eat like diet for a small planet said you have to eat grains and beans at the same meal or is that true or can you have grains and breakfast and beans at lunch?

I probably would have them at the same meal just because I realize that's going to sit there for about two hours in your stomach getting digested. And that's what the liver is going to see is that mix of proper amino acids that you want to see.

And you touched on collagen, you said it swam right by but a lot of it is a whole collagen craze now. Yeah, there is. Having collagen protein, what's your take on that?

There's a little bit of data on collagen for skin synthesis as a cosmetic thing. It's very popular in small amounts. The dangerous thing was in the 1970s, they had weight loss diets that were totally based on collagen and big shampoo bottles. 80 women around the United States died of heart disease, of a sudden arrhythmia, because the heart is a muscle as well as an electrical system and their muscle in their heart broke. And they had a characteristic abnormality and it was because they were on these 400 or 500 calorie diets of very poor quality protein. So it's very important to maintain your protein so that your heart works normally and you have the right muscle mass.

Because there's huge businesses that are launching around collagen protein.

Right, but in small amounts, these are.

Usually supplements, but not- They're protein shakes.

Yeah, but not all day.

But you're saying it's not a great quality protein.

No, but you'll see many companies that have shakes will make a clear shake. Those are usually made from collagen. Those have 15 grams protein, it looks like red Kool-Aid.

That will be collagen.

Protein.

Fascinating. All right, next topic.

Yes, sir.

Fat.

Okay.

I I'm fearing we might have a difference of opinion. I don't know. But my understanding that, that, you know, you're focusing on vegetables and protein as the core foods we should be eating.

Correct.

And, and fat, you're, are you thinking that the data that's coming out around fat showing that it's not a driver of heart disease, that it's something that helps reduce appetite, increase metabolism, and. and increased lipolysis, all that, you think that that's not right?

Well, it depends what you're substituting for. So what you're saying is, I always joke about this, the protein is a requirement in my mind. As far as the carbs and the fat go, now I found that when we did the Women's Health Initiative, I did a study on low fat diet, because we were part of this whole low fat movement. Yeah, yeah, sure. And what I found was about half.

The women raised their triglycerides.

Yes, they did. And they became insulin resistant and diabetic. That's right, and it was about half the women. So there is a genetic component here, as you mentioned, this morning. So I think that fat can go up to 40%, say, of calories. Carbohydrate could go down to 10%. There's no real requirement for carbohydrate.

There's no essential carbohydrate.

That's correct. You can make carbs.

There are essential fats and essential amino acids, but no essential carbs.

And yet, they call them the concrete of the diet when USDA talks about it. So I am not against it. I think if people can take a low-carb diet, say 10%, that's fine. you need obviously glycogen for your muscle and in your liver, a very limited amount, about 300 grams in muscle and liver, and that's only 1200 calories. It's a very poor way to store energy. Glycogen loading, I agree with you, does not work. Most athletes don't like it. It causes water bloating because the water comes along with it.

And high insulin.

Insulin, by the way, is a water retaining hormone. Yes. And so people that I have on a diet will go for one meal and they'll say, Dr. Heber, I gained four pounds. I said, you didn't eat 14,000 calories. What happened was your insulin level went.

Up and you retained a couple of quarts of water. Which is actually important because when people stop eating carbohydrates, they go on like my 10-day detox diet or they go on a low carbohydrate diet or ketogenic diet, they'll drop huge amounts of water.

And weight and they'll lose salt and lose- yeah. Because insulin makes you retain salt and makes you retain water. And they'll reduce their sympathetic nervous system. So, if I'm doing work in the summertime, people are coming in sweating after one week on diet, they're not sweating anymore. They're calmer, they're less agitated, their sympathetic nervous system is reduced. So I think that you're absolutely right, high carbohydrate, and I wouldn't even go beyond just high carbohydrate. Another place where I think you and I agree is that sugar can become addictive, highly addictive. And some people, we found with a validated questionnaire in our obesity clinic, 50% of women were self-proclaimed sugar addicts, and many of them had this dopamine receptor polymorphism.

DrD2. DrD2 polymorphism found in alcoholism, and drug addiction.

So, and if you look at that.

And by the way, for those listening, that means in your brain, you have a receptor for dopamine, which is the pleasure chemical. And people who have this genetic variation need more of a substance to create the same amount of pleasure as somebody else. And that's dangerous. So, if you have that and you can measure it through very common gene testing, you're more likely to become addicted.

To sugar or alcohol or whatever. And what does addicted mean? that there are people who eat one thing of sugar and they can't stop. They have to just keep eating and eating because they've got a circuit between the memory part of their brain, the part of the brain that puts out dopamine and their frontal cortex. So they see a piece of cake, that's a cue. They now have an immediate, sometimes unconscious behavior. Up to 200 unconscious food decisions are made every day. And then they get that reward, that high, the sugar high, and that's memorized in their memory center. So the next time they see the cue, they remember the reward and they.

Want to have it.

To have it. If you tell them, don't eat that, it's very hard for them because they start craving it. So that's not the answer. The answer is when that cue comes up, find another healthier solution to deal with it. And it's a very common problem in our society.

And the fat thing, you said 40%, but some people are using ketogenic diets now and having amazing results reversing diabetes. What do you think of all that?

Well, you know, I think the human body is highly adaptable to different diets. I mean, if you look at Eskimos, they eat a very, very high fat diet. So again, there's no requirement for carbohydrate, so you can definitely do that. You can adapt to it. And I think that, you know, there was somebody who was coming out with ketone supplements the other day. And actually to give- They're kind of cheats.

They reduce insulin. Yeah, but you know, that's not something I favor.

I think you, you know, diet and exercise, lifestyle, balanced lifestyle is really the way to go. I don't think you can't cheat mother nature, 'cause a lot of those people, oh, my doc gave me a pill for hypertension, I'm gonna grow the steakhouse, you know?

Right, exactly. So, let's talk about two other controversial areas around fat. One is saturated fat and one is omega-6 refined, we call them vegetable oils or plant-based oils. What's your view on saturated fat and plant-based oils? The way this happened was- Because the government basically tells us to eat more of these plant oils and less saturated fat and so does the American College.

Of Cardiology and Heart Association. And I think there's some conflicting data on that. Well, if you look at the National Institutes of Health, each of the institutes has their own philosophy about nutrition. So if you look at the National Cancer Institute, where I was funded for 21 years, it's mostly fruits and vegetables, seven to nine servings a day, because of what I call phytonutrients. You call them phytochemicals, but I don't think a nutrient necessarily has to provide calories, it just has to provide a positive benefit. We find these now create a healthy microbiome, they inhibit cancer cell growth, et cetera. And so that's part of the NH-LBI is all about cholesterol and blood fats. And they're very staid with that because they're really promoting statin use. It's basically what happened. So we've been sold this whole thing about cholesterol and heart disease forever. You talked about Mark Hegsted this morning in the sugar lobby. Well, it turns out, and for people who don't know that history, we had this whole cholesterol myth for a long time. It turns out that heart disease is really an inflammatory disease. And it has to do do with inflammation in the blood vessels. Alzheimer's disease is inflammatory.

Cancers are inflammatory.

Breast cancer, prostate cancer. Obesity, diabetes. Obesity and diabetes, also inflammatory. The diabetes one is really interesting actually and it's related to your sugar hypothesis. So, every time your blood sugar goes up, your pancreas has to put out a squirt of insulin. There's a little protein called insulin-associated polypeptide which feeds back onto the pancreas to turn off the little squirt of insulin after it goes up. So, if you look at your blood level, it looks like the surface of the ocean, but underneath, you've got all this activity going on maintaining your glucose. And in people who are obese, they excrete a hundredfold excess of the insulin-associated polypeptide, gets back into the cell in what's called the endoplasmic reticulum of the cell and blows it up and kills it over a period of two to ten years. So, a type 2 diabetes, which we never understood in medical school is really caused by obesity. I call it diabesity because 95% of the people are obese. And we can solve this problem tomorrow. We have very large studies, the Diabetes Prevention Program, 5% weight loss, when people already had high blood sugar, very late in the disease.

We get people who are on insulin who've been diabetic for 20 years, reversing it in three weeks.

Well, the overuse of insulin is amazing. My first paper in 1977 as a resident was on diabetic ketoacidosis, type 1 diabetics. And for some reason, doctors were using 70-80 units, and we reduced it to like seven or eight units with adequate hydration. Same thing in type 2. People are chasing the glucose control. So, a person comes in with a high blood sugar, oh, let's take some more insulin. More insulin, they deposit more fat, more insulin resistance. Do it again. So, people coming in with 80 to 100 units of insulin. And this is back in the 1980s.

Terrible.

When I first started doing this work at a county hospital and weight loss completely.

Now we don't use the word reverse, but we'll see. Insulin causes weight gain when you give.

It to patients with diabetes. It's a feeding hormone. And it deposits amino acids, it deposits fat and stores glycogen. So the thing about the loss of weight in these people is so obvious. I call it remission, putting it into remission because they have that risk to regain again. But we have had over 2,000 cases in our Obesity Center at UCSF. and there was a myth that diabetics lost weight more slowly than people who are not. And so we took plain obesity, pre-diabetes and diabetes, as long as they came to clinic, they lost weight at the same exact rate over time. We have 2,000 cases of that. And we can actually now in about 75% of people reverse their diabetes within about a month and in three months about 90%. So it's pretty amazing.

And are you using a higher fat diet or what are you using?

No, we actually use a We use a medically supervised, very low calorie diet, but it's not very low calorie because let's say I have a guy who has, I give one gram per pound of lean body mass. So if somebody, and we have two types, we have different types of meal replacements that we use, but I might give 1120 calories and 175 grams of protein to a large man, where a small woman might get six or 700 calories, but 105 grams of protein. But you know, it's interesting, there's data.

That you don't have to restrict calories and you can achieve the same thing by increasing fat and limiting carbohydrates.

Oh, absolutely.

Yeah, which is, you know, there's a lot of ways to skin a cat on the diabetes thing. So, so tell us about the saturated fat story. Do you think we should be avoiding it?

Is it bad? No, I think saturated fat is more vegetable oil.

Saturated fat foods also contain omega-6 because they're fed grains. So I think saturated and olive oil.

Which is a mono and saturated, contains 20% saturated fat. So it's all mixed. Yeah, none of them are pure. I have a little chart in all my textbooks, but I think the Pure saturated fat like stearic acid, which is in chocolate, it's not even absorbed into the body. It actually stays in the intestine. So this whole saturated, and then I don't like the idea of all the unsaturated fats being equal because there's an omega-3, omega-6, omega-9, and there's even omega-7, which is another whole story, but not really important. But I think the omega-3, omega-6 balance is critical. There's a fellow named Bill Lands who's in his 80s from University of Michigan who talks about Nix the six and eat the Omega-3. And he has a program through the NIH that's free on the internet called the EFA program, and he'll actually tell you which foods to avoid and which ones to eat to balance your Omega-3 and Omega-6.

But you know, there are people who suggest that like, at large universities like Harvard and Tufts, that we should be eating more refined vegetable oils like canola oil, safflower oil, sunflower oil. No, I know. Corn oil.

And I'm having trouble with that. Yeah, I do too.

A few years ago, one of the.

Big- and they quote these epidemiological studies. and the funny part about that, so Dr. Mazzaferroni from Tufts was talking with me, he's here at the meeting today, and we were talking in Washington at a public health meeting of the Milken Institute, and he said, we have good data that higher omega-6 actually helps with heart disease. I said, well, did you analyze the carbohydrate intake in those studies? He said, no. So maybe the higher omega-6 is a marker of the fact that people are eating less carbohydrate because we are saturated fat animals. So we take our carbohydrate and we make palmitic acid from it, which is.

16 carbon saturated fat. Exactly. So, but that's, I just want to pause there because what Dr. Heber just said is that we make saturated fat in our blood from carbohydrates, not from eating saturated fat. That's correct. And we all stopped eating meat because it had saturated fat. But in fact, the saturated fat and mean is stearic acid doesn't even raise.

Your cholesterol at all or the saturated fat your blood. That's all correct. I used to have a cartoon I would show where these sharks are circling a man and they decide, I'm not going to eat him, he's too high in cholesterol.

So, you know, we are saturated fat animals. Right. So then that sort of is a massive shift in our policy that needs to happen. And a lot of guys I respect.

Say, no, we should be eating more refined vegetable oils. See, I think epidemiology has never been cause effect. And I think one of the problems, even in cancer epidemiology, is we these large epi studies, they're not cause effective, they get quick headlines. And a lot of headlines. And I remember a study by Alan Crystal at University of Washington where he said fish oil was bad for prostate cancer if you took it in a supplement, but not if you ate fish. Now how do you figure that out from a- you- can't figure it out. You can't, yeah. Was it that the people taking the supplement were sicker or what was it? You know, so there's always uncontrolled factors.

Oh we controlled for everything, but I don't buy that. yeah.

It's good Clues, but you have to.

Do the studies, the randomized trials. I agree. And I think there are some randomized trials around saturated fat and corn oil where the corn oil lowered cholesterol dramatically, but actually increased heart attacks and death. Correct. Which was a 9, 000 mental institution inmates who basically weren't asked what they wanted and have forgiven butter, half corn oil. And the ones who had the saturated fat did better and had less deaths, less heart attacks, even though their LDL cholesterol was worse. So the whole cholesterol hypothesis is really driven by, I believe, a massive shift from marketing around statins and statin drugs because it works for that analyte. Yeah.

And the original studies on statins are interesting. In the New England Journal, they picked the one out of 250 people who have high cholesterol isolated, whereas most Americans have the typicalus Americus lipid panel, which is high triglyceride and high cholesterol, not isolated. So in the isolated, the Statins work great because they worked on that receptor. But diet didn't work at all. Diet was only 5%. Now, had they done it with the mixed hyperlipidemia that we see so commonly in most Americans, they would have seen a big drop in triglycerides and cholesterol.

It's actually true. 75% of people have heart attacks. There's a large study, like 135,000 people, it was like 50 or 60% of all heart attacks in America over five years. 75% had normal LDL cholesterol and 50% had optimal. I think 17% had super optimal and only 10% had normal HDLs, which is normal triglycerides, which is really what's driving it is this metabolic syndrome, pre-diabetes. It's driving- We actually did a paper.

Showing that triglycerides in the blood are the most sensitive index of metabolic syndrome because when your abdominal fat can no longer store the fat, the triglycerides go into the bloodstream. And then they go into the liver and fatty liver is now the number three cause of liver transplant patient in the world today. And so about 40% of overweight people have.

And it's not from eating fat, it's.

From- no, no, it's from carbohydrates and sugar.

Stimulating triglyceride synthesis in the liver. And fats can actually fix it. I saw a study with MCT oil giving MCT oil to rats who are drinking alcohol, giving them the fatty liver, it still reversed it even though they were drinking alcohol.

Which lowered the insulin. Which is the plant oils didn't do that. Like the canola oil or Omega-6 oils didn't actually do that. That's interesting.

So MCT oil is directly absorbed.

Yeah. it doesn't require acyl carnitine transferase to be put into mitochondria to be burned.

So it's actually burned at a higher rate.

It's burned a higher rate.

It's absorbed differently. Yeah.

Right.

So that's amazing. Right. So we learned we need more protein. Yep. That we have to sort of augment plant proteins and that grass finished and maybe wild proteins are better. We learned that the saturated fat myth is a myth. A myth. And that maybe these vegetables that everybody's pushing marching government agencies, scientists, public health organizations are not what we should be consuming. Well, they want us to consume it.

Because after high yield corn was fed to all the cattle in World War II, they were left over with all these silos full of corn. What are we going to do with it? So they crushed it, got this cloudy oil that had a short shelf life, so they took out all the omega-3s. So corn oil is 60% linoleic acid. And this has flooded soybean oil, cottonseed.

Oil, all 10% of our calories. And there's even evidence that they may be linked to homicide, suicide, violence. Absolutely.

I think depression is a inflammatory disease of the brain. I think Alzheimer's is related to this as well. I believe dementia is gonna be the new heart disease with one out of three people over 65 dying of this. And the lack of lutein from green vegetables, lack of fish oils, and having excess abdominal fat and systemic inflammation, I.

Believe is what's driving Alzheimer's, not some.

Single, belly fat, molecular, genetic thing.

Everybody's looking at the wrong It's like.

What happens every time. They're looking for the magic bullet.

There's an old joke about this guy who loses his keys on the street and his friend comes over, sees him looking under this lamp post. He says, what's wrong? He says, well, I lost my keys. He says, where'd you lose them? I lost them down the street. He says, why are you looking over here?

He says, the light's better here. Exactly. We look where we kind of find.

It easy to look, but not actually where the problem is. I said that to a geneticist at an NIH meeting. He wasn't amused.

He wasn't happy.

Happy camper. Well, this is awesome. Dr. Heber, where can people learn more.

About your work and hear more about you? Well, I'm at the UCLA Center for Human Nutrition. I also have an Instagram site with about 60,000 followers. Amazing. Dr. David Heber, all small cap letters. And I have a website, www.drdavidheber.com, and you know, it's been a pleasure working with you. And I said this morning, and I do mean it, if we could clone.

You, I could use thousands of you because you're so Good.

Thank you.

Such a sweet compliment. Thank you. Thank you, everybody listening to the Doctor's Pharmacy, a place for conversations that matter. Please leave a comment if you enjoyed the podcast, share with your friends and family, and we'll see you next time on the Doctor's Pharmacy. Don't forget, there's a way to listen completely ad-free. With Hyman Plus on Apple Podcasts, you can enjoy every episode without any breaks. Just open Apple Podcasts, and tap Try Free to start your 7-day free trial.