The Case Against Sugar l Doctor's Farmacy with Mark Hyman, M.D. EP12

So welcome, Gary. You know, we're here in Switzerland at the conference that's put on by the British Medical Journal about the science and the politics of food, both of which you have written extensively about and are passionate about. And the first article that I ever read by you was back in 2002 in the era when we were still pretty focused on a high carb, low-fat diet is a solution to all of our ills. And you wrote a very radical, radical article which turned all that upside down saying that maybe it's wrong. What if it's all been a big fat lie? And this had a big steak and butter on the COVID of the New York Times magazine. And I read that, I was like, I see this in my practice. I've been reading Dr. Ludwig's work who you quoted in the article. How did you come to kind of have this aha moment? Because it was sort of bucking the tide. Now every book on the bestseller list is a ketogenic high fat diet, but back then it wasn't like that.

Yeah, okay. So I had done a couple of investigative pieces for science. First on the idea that salt causes high blood pressure, the evidence for which is poor, to put it mildly. And that got me into this question about the low fat diet and heart disease. And while I was interviewing, doing interviews for the low fat, for the fat story. I interviewed an administrator at the National Institutes of Health who said to me, I remember we were sitting in a Starbucks in Potomac, Maryland, and he said, 20 years ago, 15 years ago, we put everyone on this low-fat diet and we thought if nothing else, they would lose weight, right? Because fat has the densest calories. You tell people not to eat it, they'll lose weight.

Right, it has more than twice as many calories as carbs.

Yeah, and 15 years later, we've got an obesity epidemic and people stopped eating fat and started eating carbs. and it looks like they got fat. So I was living in New York. I was pitching, I had a New York Times magazine editor I used to meet. It's going to be Restaurant Specific and a wonderful cafe and a village that we both haunted. We would pitch stories back and forth and I said, let's do a story. How about a story on what started the obesity epidemic? You know, it was new enough at the time and there were basically two obvious suspects. One was high fructose corn syrup, which was introduced in 1977, took over the market by '84, and the other was this sort of institutionalization of the low fat, high carb diet as a healthy diet, and the transition of the carbohydrate from being thought of as fattening in the 1960s to heart-healthy diet foods in the 1980s.

Yeah, that was a food pyramid, right? Fat and oils only sparingly at the top and Six to 11 servings of.

Bread, rice, cereal, pasta every day. Exactly. And I, you know, we lived through it. So you remember when suddenly baked potatoes and pasta became health foods?

Yeah.

Because they put butter on them and bagels. Like bagels used to be Sunday morning, maybe, and suddenly they were every day. So that was it. That was the pitch. And I looked into it. And as I was doing the research, I came upon five studies that had been finished and submitted for publication but not yet published all trials of the Atkins diet, the ketogenic diet, versus low-fat American Heart Association diets. They all found the same thing. And this is kind of fundamental idea that people still don't get. In this whole nutrition debate, the ketogenic diet is what scientists would call the anomalous observation. So we have a hypothesis that says dietary saturated fat causes heart disease. sort of ketogenic diet, it's traditionally prescribed, the Atkins induction phase is full of saturated fat, so it should make heart disease, risk factors, or again, meat, you know, lobster Newberg, the whole thing. And then we have a hypothesis that people get fat because they eat too much and it's an ad libitum eat as much as you want diet. So if you randomize people to a diet with a lot of saturated fat and a lot of meat that you could eat as much as you want, versus a diet that's low in fat and low in saturated fat and mostly plants.

And calorie restricted.

And calorie restricted. People should be dropping dead on the Atkins diet. And not only do their heart disease risk factors improve compared to the low fat diet. And this was the case in all five of these studies. But they lose more weight. Yeah. So if this were a sort of rigorous science instead of arguments between competing religious factions.

Which, yeah, unfortunately science has become. I had this view of science as this pure elite, above politics and prejudice and bias that would give us the true answer of what nature is about. Boy, was I wrong.

Yeah, no, that's a very idea. I mean, it's fun. I've been spent much of the last two years reading a lot of memoirs on scientists. It's always been full of these. You come to a conclusion and somebody else disagrees with you. One of you is right and one of you is wrong. One of you is smart and one of you is not. It's hard not to get very smart.

And somebody having opposite views.

Not only two very smart or two reasonably smart, but two people have been rewarded their whole lives for what they've done, who have gotten copious feedback that they know what they're doing and they're good at it. two people who are at the height of their professions, one is right, one is wrong. One is good, one is bad. It's just a situation for Vitriol. Anyway, getting back to this, the whole point of that article is what these studies are telling you, what this Atkins ketogenic diet thing is telling you, is there something wrong with the conventional way we think about heart disease? Obesity. And I had a background in science, not medicine, and I had been trained earlier in my career, mentored by some very brilliant scientists in my first two books, and I don't use the word brilliant lightly or often. And they had taught me to, I hope, to think critically and rigorously about this, and when you have that kind of observation, you don't dismiss it.

Right.

Examine it. It should make you curious. It should make you want to learn more. And that was basically, that's been the last, you know, 16 years of my life.

Unless the true activity of science is, you know, you find something that doesn't fit and you go, why?

Yeah.

And you try to dig in and figure it out instead of go, well, no, we've got to bolster our current viewpoint because it's dogma and we don't challenge it.

It's very easy for us, too, and everyone does this. I mean, It's human nature to say, when you say why, you go, oh, well, wait, they did this. Here's a reason I could dismiss this. And we all do that every day. And the best scientists, again, you know, Francis Crick talks about this. If you find a scientist who isn't dismissing experiments that he doesn't like, he's not doing his job, because clearly a lot of them have been done poorly. And when you've got, you know, it's never white and black, it's always shades of gray, and you have to figure out which studies you're going to believe and which you aren't, and that's part of the job of doing science.

It's also that the scientific studies only give you answers to the questions that are asked.

Exactly.

And so sometimes the questions aren't formulated properly, the design of the study isn't awesome, it doesn't provide the conclusions that are valid, and that's on the best day. On the worst day, these studies are corrupted by industry influence and bias and all sorts of things that allow you to prove, for example, that smoking has nothing to do with lung cancer.

Yeah.

It's funny because today, Predimed's in the news again. And so the Predimed trial turned out that they had problems with their randomization scheme that was pointed out to them by an astute, on a website apparently by an astute researcher who said, you know, the results they claim here are statistically impossible, implausible. so they have actually retracted the paper, really, reassessed it and republished it and luckily they came to the same conclusion. They were right all along.

So that study was one of the few randomized controlled trials comparing a low fat to a high fat diet in a Mediterranean context where they gave the fat group olive oil a liter a week or a couple of big handfuls of nuts every day. and the nuts and the fat group had dramatically lower heart disease, mortality, diabetes, all kinds of things, even though they were eating more fat. And they had to stop the study 'cause it was unethical to continue because.

The people who were not eating the fat were dying. Right, that's the, but again, what you just described was one of the problems with the trial. There were a lot of problems with the trial. If you're giving one group nuts and olive oil and the other group nothing, every week or every month or every quarter, you're telling one, two of the groups, eat healthy. Here, here's your nuts, here's your olive oil, eat healthy. And every time they reach for the olive oil, or every time they take a handful of nuts, they're reminding themselves that they're in a clinical trial and they have to eat healthy and whereas the other guys are out, you know, McDonald's or the, I mean, I've been to Spain, they're McDonald's. So you've got a study that's got a very poor control group.

But free living humans, those pesky free living humans.

But here's the point is, what you said is that you only get the answer for the question you ask. So the question that was asked was, Mediterranean diet, unquote, better than a low-fat American Heart Association type diet? And the answer was, if you ignore all the problems with the study, yes. But it doesn't tell you that the Mediterranean diet is better than...

Compared to what?

So this morning at this conference, I looked in on the breakfast room, and they're serving a classic Swiss hotel breakfast, which is fishes, herring, salmon, meat. Yeah, exactly. It's got nothing to do with the Mediterranean diet and the Swiss have one of the longest life longevity, highest longevity numbers in the world.

And they had bread, but you had to cut it with like a meat slicer.

Yeah, yeah, yeah. It's hard. It ain't wonder bread.

No.

And so it's an entirely different diet. And so what we have though is a medical community that now says we have to tell everyone to eat a Mediterranean diet because we did a study on the Mediterranean diet and it did well. Right.

But compared to what? To what, right? That's like the joke my sister used to tell. She says, when the Vermont farmer was asked, how's your wife?

He goes, Compared to what? It's true.

Are we comparing a low-fat to Mediterranean to a ketogenic diet to a extremely low-carb diet? I mean, how do we then begin.

To sort through those questions? And if you don't ask those questions, and again, I think in general physicians aren't trained as scientists. You're not trained, journalists aren't either, I'll acknowledge that. But it's vitally important to know what question was asked because that's the only answer you're getting in that trial.

It's true. You know, I was recently in a meeting, food leaders meeting, our friend Dariush Mozaffarian was there, Francis Collins was there, the head of the NIH, and they had an interesting debate conversation because the head of the NIH says, well, we really don't know much about nutrition research and what the science is and about calories. And Dr. Mazar, who's the head of Tufts, who's going to be on this podcast, is the head of Tufts School of Nutrition, Health and Policy and Science. He said, we do know. And I think there's this debate about, you know, what makes people fat. And you wrote a book called why We Get Fat. And I read it, and it's a short little book, and it's brilliant in that it actually distills the obvious into almost, to me, an inarguable thesis, which is that the reason we get fat is not because we eat too many calories, but because we eat the wrong calories, and they have different effects in our biology. And the science of obesity we do know a lot about. So can you break down what is that science and why did we get it so wrong? And how do we not sort of stay stuck in this idea that all calories are the same. Because you also have addressed that in Good Calories, Bad Calories.

And I'm going to address it in the next book as well, because until we get this point, nobody still believes it, right?

It's still not the prevailing dogma and recommendations of the government.

It's a conference today, and then the, so the conference is a BMJ Swisse conference about called Food for Thought, right? And there's going to be a paper published in the BMJ this week that's going to be presented today on obesity and it sees obesity as an energy balance problem, calories in minus calories out. So the history of that idea, which I've discussed in my book, is fascinating because it's a hypothesis. It's not a fact of life. And it comes out of the history of modern nutrition, which starts in the late 1860s in Germany. I'd love to make a short story long and I apologize. Sorry for the nutrition.

I don't have time to write a short one in Mark Twain's say.

Yeah, exactly. Which is basically could have been the epigraph of my first book. Anyway, the point is for 50 years in nutrition from the 1860s onward, all of the entire science of nutrition was measuring the calories in food and the calories expended by humans. That's one thing they could measure because they had this device called a calorimeter. Yeah. It was invented in the 1860s. And then you could study vitamin and mineral nutritional deficiencies. You could study protein deficiencies, fiber deficiencies, things like that. This is what nutrition science was. So by the early 19th century, early 20th century, when it comes around to developing a hypothesis of obesity, it was hard to see how vitamins and minerals and protein could be involved. So, but you had these calories thing and you had physicists talking about the laws of thermodynamics.

Yeah.

So you come out with a, you're measuring energy in and energy out. As we just said, your answers to problems depend on the questions you ask, and the questions you ask depend on the technology available to ask a question. So you come out with this energy balance hypothesis, 'cause all you can measure is energy. And then the science of nutrition doesn't kick up the science of endocrinology. So you know how foods, how much energy is carried into the body, you don't know how foods influence hormonal states because you can't measure hormones. It's not until 1922 that insulin's discovered. The whole science of endocrinology is this sort of inchoate thing that most physicians and researchers know nothing about. I mean, the problem with the law.

Of thermodynamics is not that it's false.

It just doesn't tell you anything about why we get fat. It's true.

It's physics. It's not biology.

So when you mix physics and biology, it gets confusing. Yeah, I've been thinking about questions I could ask at this conference today of the sort of conventional wisdom experts on obesity. And one of them I would ask is you've got this disorder of excess fat accumulation. It's a simple way to describe it. Why aren't there any discussion in your paper, your books, or your articles about the hormonal enzymatic regulation of fat accumulation? Like if we were talking about height disorders, you know, why someone is a eight feet tall or four feet tall, fully grown, all we're talking about is growth hormone, growth hormone receptors, insulin-like growth factors, receptors, you know, the hype.

We're good at talking about height, but not width.

But when you talk about width, it's like how much we eat and exercise. And it's, even if that's true, why isn't there some discussion about why the hormones that regulate fat accumulation, we've known what they are, for going on 80, 100 years and known the system, the well for 50 years, why aren't we discussing it? If nothing else to say, this is how we know they're not involved. So that's, you know, what happened in this field is you get this energy balance idea that comes out of Germany. And when endocrinology starts to emerge as a viable science in the 1920s, Nobody's really, the endocrinologists really aren't thinking in terms of obesity. It's not something they sway.

Not a big issue.

It was like the World War II, everybody was starving. And then World War II comes along and everyone's starving. It's not an issue. And by the time that 1950-960 when a technology is invented that allows you to measure hormones in the bloodstream accuracy, there's something called the radioimmunoassay. Two New York researchers, Rosalyn Yalow and Solomon Berson, Yalow gets the Nobel Prize for this after Berson dies. It's a revolution in the science of endocrinology, because now you could actually measure hormones. Hormones. And you could figure out their effect on endpoints, tissues, organs in the body. The field of obesity is basically dominated by psychologists and psychiatrists who are trying to figure out why fat people eat so much and it's a moral failing. Some more, well, they might not think about it that way, but they're gonna try and- Because you have no willpower. They treat it as much, yeah. You don't have willpower. And so how can we get fat people to eat less? That's what they're doing. That's what they care about. And they're not endocrinologists. They don't care about hormones. They believe that a hormonal explanation of obesity is like an excuse for fat people to get to do whatever they want. And you have this, sort of monstrous. I mean, it would be trivial if it would be science. This stuff happens in science all the time. People get the wrong answer. They push wrong hypotheses for decades. But in this case, there are huge implications for us.

Yeah.

And for obesity and the prevention and treatment.

So then when you sort of started thinking about this, you sort of realized it was this whole body of literature that was pointing in the wrong direction from where we're going.

Right.

But it was sort of ignored. And so, years been really bringing that information research to light.

But that's, yeah.

And explaining how we get fat has nothing to do with energy balance, which is yet what all nutritionists, doctors, scientists, governments, and food industry are all telling us. There's no good or bad calories. You have big gulp, which has 46 teaspoons of sugar and 750 calories. It's exactly the same as 21 cups of broccoli, which has a half a teaspoon of sugar and 35 grams of fiber. and they're exactly the same.

Yeah, no, or even a fifth grader.

Could figure that out. It's not true.

Well, what's crazy too is because obesity and type 2 diabetes go hand in hand and so diabetes specialists are endocrinologists. So all they, you know, it's completely, it's clear as day to them that different foods have different effects on hormone status and the hormones, particularly insulin, which is a hormone that's sort of driving the fat accumulation.

And they tell you if you eat more carbs, just increase your insulin.

Just increase your insulin. So it's sort of this perfect storm of bad science and inconvenient facts that the diabetes specialists in the 1920s, as soon as insulin's discovered, it's a lifesaver, right? And it is. For type 1 diabetics, it's clearly a lifesaver. And just at the same time that insulin's discovered, there's a physician in Minnesota who's publishing papers saying, we're trying these low-carb, high-fat diets ketogenic diet's in effect on diabetics, and they're doing terrific. I mean, he's publishing this in major medical journals. And Elliot J. Joslin, who's the god of diabetes. This was like 100 years ago. This is 100 years ago. So we've finally gotten back to where we were 100 years ago. But his studies, 1920-21, so insulin's discovered, I always forget if it's 21 or 22, it's embarrassing, but it's- Remember, you-'re close enough. I don't eat enough- In the 1920s. In the early 1920s. Eliot Joslin at Harvard is a god of diabetes, becomes a god of diabetes because of his expertise with insulin therapy and he's a wonderful clinician. He starts using this ketogenic diet for his patients, but then boom, he got insulin. It's like, it's a miracle drug. And because of the art of dosing insulin, was it unknown at the time? You often get too much and then you get hypoglycemia and you want to give people sugar to bail them out. Sugar and carbs become a way to, basically a way to allow you to use insulin to save their lives. So the diabetes community is just, you know, suddenly we're like, that was the.

Standard treatment back then for diabetes. So it used to be 70% fat, 20 something percent protein and like 5% carbs. That was the diet.

Yeah, because you can't tolerate the carbs, that's what diabetes is. But now we have insulin, which is keeping the type 1s alive, but they're not really differentiating well enough.

So wait a minute, are you saying that obesity is a disease? of carbohydrate intolerance?

It's a hormonal regulatory disorder that's triggered by, yeah, you could call it carbohydrate intolerance. So there are people who are gonna get obese anyway because of hormonal disorders, dysfunction, but the carb content of the diet is always gonna promote that.

So you were on an interview video with a panel with a trainer from the Biggest Loser who was saying that weight gain is all about calories in, calories out. such a pervasive myth. And this is just a math problem. It's energy balance, calories in, calories out. And you're proposing a different idea, which is often called the carbohydrate insulin hypothesis or the hormonal hypothesis, which suggests that it's not about the calories, it's about what calories you eat. So can you take us down into how that works? If someone's listening, they want to know, well, what should I eat? What should I not eat? What's going to actually liberate fat from.

My fat cells and what's going to store fat?

And how do I understand this? new science of why we get fat.

Well, this old science, which is actually.

By the way, gaining traction again. In fact, much of this conference is about examining some of this new science. There's a whole section on diabetes revisionism, which is the idea that our view that diabetes, type 2 diabetes, is a one-way street, it's an irreversible chronic progressive condition, is being turned on its head and saying, no, no, wait, we can cure this disease.

So this is, you know, again, the idea that obesity is just a hormonal regulatory disorder. So it's, and this was a, another German idea. It was gaining traction. It had actually sort of won over the German research community. And by the late 1930s, when, you know, the Germans and austrians were doing the best medical research in the world, and then the war comes and it just evaporates. But the idea is it's got to be a hormonal regulatory disorder, and there are all kinds of ways. that's clear. You know, you just look at how people fatten differently. Men and women fatten differently. So men get fat above the waist, women below the waist. It tells you that sex hormones are playing a role. You could have sort of isolated areas of fat accumulation.

We all know where they are on our body. Although now women drinking soda and sugar.

Have fat above the waist too. It is interesting. No, it's funny. I was at a family member had surgery at Stanford. About four years ago, and I was sitting in the waiting room waiting for her, and it was fascinating to see that, yeah, all the women, all of them had upper body obesity, and it used to be, you know, that men had upper body obesity. So the question is, in effect, what regulates fat storage in different fat depots in the human body? And clearly hormones are playing a role, and everyone always knew insulin played some role. because type 1 diabetics who lack insulin can't store body fat. Yeah, and they can't metabolize the fat, they can't burn the fat that they eat, they can't, so they can't store it.

Like as a doctor treating type 1 diabetic, when they come in, they're producing zero insulin, they're eating 10,000 calories a day, they're starving, they're hungry, and they're losing weight even though they're eating 10,000 calories a day.

So how could that be? Yeah, and that also tells you that there's a disassociation between caloric intake and fat accumulation, and that insulin is in that pathway. And so the 1960s, I said you get this science of endocrinology suddenly, and by 1965 or so it's been pretty well worked out how insulin regulates fat accumulation. It does it through the whole sort of sea of enzymes and receptors and that it upregulates the lipoprotein lipase on the fat cell, which pulls fat into fat cells, it downregulates hormone sensitive lipase, which should liberate fat from fat cells.

And sort of locks it in the.

Fat cells and they can't get it out. Exactly. And this is textbook medicine. It's in the endocrinology textbooks, it's in the biochemistry textbooks. If you look up what makes a fat cell fat, It's insulin. High insulin, low glucagon. You could include glucagon.

It's so startling, Gary, to me that the science is so clear and yet the practice of medicine is so far from the science.

Well, because the practice of medicine has always been about energy balance. So the same textbooks that will say fat cells get fat because of elevated insulin will tell you that obesity is caused by taking in more calories than we expend. There's this disconnect, this energy balance paradigm. And again, we're going to see it at this conference when the presentation on obesity is going to all be about energy balance. And I would love it if somebody like you, so I don't have to ask all the questions.

We'll ask the questions.

What about, you know, insulin is in this pathway. Yes. And macronutrients influence insulin differently. So carbohydrates stimulate insulin secretion, protein stimulates in a little bit, fat does not. So you could drink a liter of.

Olive oil and your insulin would not go up.

No.

You will store that.

And you won't store it?

No, you will. That's the interesting thing. So it's sort of the one of.

The- if you don't eat carbs, you'll.

Store it or only when you eat it with carbs. Well, you're so, you're gonna have to clear it out of your bloodstream. Anyway, you don't want it floating around in your bloodstream. Yeah, it's gonna be stored on some level, even with low levels of insulin, but then it's gonna be mobilized. Yeah. So you basically, you think of your fat stores as like the wallet that you go to the ATM, you take money, out of the ATM, that's the food you're eating and you got to do something with that's how you put it in your wallet. But you got to be able to get it out of your wallet freely when you need it. And insulin doesn't let you get it.

Out of your wallet. So as long as you're eating a high starch sugar diet, you can't get the money, namely the fat out of.

Your wallet or mainly your fat cells. You know, what happened is, and there was a lot of discussion back then that carbohydrates are turned into fat. when you eat excess carbs and they're not really turned into fat. That's a difficult process for your body to do when it's energy expensive and it doesn't do it that much. But what your body does is make sure you burn the carbs and when insulin is elevated, that's what you're burning. So it's not only telling your fat tissue to store fat, it's telling your lean tissue, your muscles and your organs.

To burn carbohydrates and not to burn fat.

Yeah.

So doesn't a carbohydrate increase what we call lipogenesis, which is our own fat production factory. That's why we get fatty liver.

In the liver, but again, that could be sugar, the fructose and sugar dependence. So, that's the case against sugar story.

We're gonna get to that soon.

So, in pretty well done controlled studies, the amount of what's called de novo lipogenesis, so making fat out of nothing from carbohydrates was very low and less. You had sugar in the diet, which is one reason why sugar might be key to this process. Because like 90 million Americans have fatty.

Liver, it's one of the most prevalent diseases in it linked to heart disease, cancer, diabetes. Yeah, which right 20 years ago, liver.

Failure, nobody knew existed. If you were diagnosed with fatty liver disease 20 years ago and you told your doctor you didn't drink alcohol, then your doctor would assume you were lying. and then it starts showing up in kids. And suddenly it's like, okay, these kids are probably not heavy drinkers.

So, oh, drinkers of soda.

Yeah.

I met, I met at a obesity conference, a pediatric gastroenterologist, and I'm like, well, what are you doing here? He says, well, I focus on fatty liver disease in kids, and we're seeing it in three-year-olds and five-year-olds and I'm like, wow, they're needing transplants as they get a little older.

And I'm like, wow.

So.

And then, then huge pharmaceutical effort to, you know, come up with a drug that you can give those kids for the rest of their lives. That's a great Market.

Yeah.

Or you could maybe just cut out the sugar by that.

Cut out the sugar, the fatty acid, which can help reverse that.

Yeah. Yeah.

So anyway, it's. That's the. The gist of the science is you elevate insulin, you store fat. if you want to get rid of the fat, you have to drop insulin.

So how do you do that?

That's the good calories, the bad calories. What are the bad calories? So the good calories by this paradigm, and it's very much a paradigm, are fat, healthy fats, and we could discuss what those are and what aren't, and the bad calories are going to be carbohydrates, the more refined and fructose rich, the bad calories and more. They're going to work to elevate insulin and keep fat locked away. And that's simple.

Okay, well you jumped in there a couple of times with this fructose thing and you said we didn't really even have it until the 70s and then probably in the 80s and now it's a big portion of our sugar consumption. So how is that different and why should we be worried about fructose?

Okay, so we actually, there was a, there's always been a lot of sugar and not always since the 18, 19th century sugar intake goes from five pounds per capita per year at the beginning of the 19th century. That's like Coca-Cola's worth of sugar once a week to 90 pounds by the end of, by 1900 and 100 pounds by 1920. And then it stays relatively stable because when people are consuming a lot of sugar, they're getting, tend to get fat. So it tends to be self-limiting. And then the 1980s, it shoots up again because we start blaming everything on fat and high fructose corn syrup comes into the same time. Yeah, so high fructose corn syrup sugar, and this is where this is what Elliot J. Joslin didn't know, this was.

The.

You know, very specified silo. knowledge basis. So, a physician who's not a biochemist might have taken biochemistry courses.

You become a physician, but you're not a biochemist. It's basically biochemistry.

Yeah.

I only looked back and looked in.

My first year med school biochemistry text, but it's all there. Yeah, it's all there. I'm like, okay. So, sugar, sucrose, the white powder is a molecule glucose bonded to a molecule. Half and half. Yeah, they're both carbs. They're both Simple, well sugar is a simple carb, the fructose is the sweetest of all the carbohydrates, so any sweet substance naturally occurring is going to have, except mother's milk, is going to have fructose in it. The fructose, glucose is metabolized by virtually every cell in the body, so it gets into your bloodstream, you secrete insulin in response to it. You know, they talk about high GI foods, they're foods that break down into glucose quickly. The fructose is metabolized not by every cell in your body, but it goes through the small intestine and into the liver.

And.

In high doses it's converted into fat in the liver. So the way I think about it now is our livers evolved to see the fructose in fruit. So a very small amount of fructose in fruit month or two a year.

Yeah.

And bound up in the fruit, so with all the fiber in the fruit, so you would get, you know, a small amount of the substance, it would take a long time to digest it, and then they wouldn't have to make it through the portal system. The portal system, it may or may not do it. There was a paper that came out this summer that says at low doses, at least in rats, fructose is not going to make it through the small intestine. Then as we increase our sugar consumption and worsen that trend, once we start drinking sugary beverages in huge doses, so the soft drink industry begins in the 1870s and 1880s with Pepsi and, well, Dr. Pepper, Coca-Cola, Pepsi in that order. Now you're suddenly drinking this stuff and you're drinking it between meals and 50% of the calories are fructose and there's no fiber to slow down the digestion. and you're getting massive amounts compared to what we would have gotten otherwise.

It was also high fructose, which is more than the glucose.

Well, the high fructose corn syrup is high, it was called high fructose because there were lower fructose corn syrups that had been developed over the years.

But it's 55% up to 75% fructose.

Yes, true. And may or may not make a difference. I just don't know. But the liquid sugars are a problem compared to, so you're getting them between meals. you're getting sugar from basically breakfast through dessert. So, rather than drinking alcohol on an.

Empty stomach, you get the buzz faster.

You get the buzz fat and you get it all day long. And that's all your liver is doing all day long is basically processing fructose to doses that's never been designed, never evolved to see before. Like any machine that's asked to do a job it wasn't designed. it to do, it doesn't pour it. And then making it do it year in and year out, constantly. Remember, a little bit of fructose dribbled into the liver over the course of a couple of months. Summer, yes.

Binge on some fruit. Okay, fine. It's just the daily and repetitive doses.

That are the problem. Breakfast, lunch and dinner. Breakfast, lunch and dinner and in between. Because remember, we're drinking the Coca-Colas not just at our meals but between meals. And then, like you said, the 1980s with the low-fat dogma, or the 1960s with sugary cereals come in, they start coming in late 1940s and by the 1960s, it's, you know, there's an entire industry from the cereal companies to Madison Avenue, to TV shows that we grew up loving, you know, Rocky and Bullwinkle was created to sell cereal, sugary cereals.

It's true, right? I mean, even Fred Flintstone was promoting cigarettes back in the day.

And was it Froot Loops?

Which is good like a cigarette should. Fruity pebbles, right?

It's, it's, yeah.

So, it's frightening. So, the case against sugar is your next big tome. It was, I thought, incredibly well researched, really historical, and sort of caught us up to date on why we have this sugar glut and actually what it's doing to us. Tell us more about this sort of case against sugar and should we be having any sugar and is it- well, so that's okay.

So there are two issues here, as there always are multiple issues. When in talking about the case against sugar, I'm implying that there's a crime that's been committed and that sugars. So the question is, what's the crime?

Yeah.

So the crime is obesity and diabetes epidemics worldwide. Recently, described by the director general of the World Health Organization as slow motion disasters, although in some places there's nothing slow about it. So these epidemics occur whenever a population transitions from whatever its native diet is to a Western diet. So it doesn't matter what the native diet was. It could be Southeast Asia where it's mostly carbohydrates, a lot of rice and wheat, could be Inuit diet where it's seal meat and whale meat and caribou. It could be a pastoral Masai diet, warrior diet in Kenya where it's the blood meat and milk from the cattle. It could be a Native American diet that's primarily carnivorous or a Native American diet that's primarily agricultural. Add a Western diet and lifestyle, you get obesity, diabetes, and like I said, some populations like in the famous Pima Native American tribe in Arizona, diabetes appears in the course of a decade, just explodes in this population.

80% in the 1960s. They have diabetes by the time they're 30.

So, the question is what are you adding? It's not the native, it's not the baseline diet. and it's probably simple because you add it to anything, any baseline diet, you get obesity and diabetes. And conventional wisdom is so... I mean, Michael Pollan talks about this in In Defense of Food, in a book that I disagree with almost entirely. But we're working from the same observation, which is, what is it that causes this disease of Western diet?

He says don't eat food like substances.

Which is processed foods. Well, so one answer is processed foods. And a lot of people like that. It's a simple answer. We don't have to be wrong about the saturated fat thing. So it's an interesting issue because in the US when we focused on saturated fat, it's because researchers like Ancel Keys and other researchers were asking, Merman, the question determines the answer. So the question is, why do we have such high levels of heart disease in the US? We live in the US, what we see, is massive amounts of heart disease, what's causing that? We'll do studies to try and figure that out. And the answer we come up with.

Is saturated fat, which wasn't based on.

Cause and effect, just a bunch of patterns in the data that turn out to be wrong. We've probably done clinical trials. So British researchers, they have the British Empire, they're all over the world, right? Missionary colonial hospitals all over the British and the remains of the British Empire are asking a different question. Why is it that we have obesity and diabetes epidemics appearing in all these different populations all over the world? And they're coming to the conclusion that it's refined grains and sugars. The only caveat with that is that the same thing happens to populations that are already eating refined grains. Southeast Asia, right?

Although they're also working in their rice paddies 12 hours a day.

And that's one possibility.

So, if you want to exercise 12 hours a day, it's fine to eat more carbohydrates.

Quite possibly, quite possibly. So, that's one, and that's the first time I heard this story from an epidemiologist at Harvard who is Chinese. And his answer to this question, because I asked him, what about China? They're eating, it was, they're peasants, they're out in the fields all day long, so it mitigates, ameliorates the problem. although it clearly doesn't, because there are people who are working all day long who still get obese. Actually one of the first observations of interest here in the Pima back in 1902. So the Pima had been through 30 years of famine. Horrible, devastating famine. And towards the end of this period, a Harvard anthropologist comes to live with the Pima and study the Pima. He actually had tuberculosis, so he wanted to go to Arizona in an effort to cure the tuberculosis, which didn't work. But he spent six months, nine months with the Pima and writes a seminal book about it. He takes a photo of a Native American Pima. He points out that they have a high level of obesity in the tribe, particularly in the older population, particularly in the women. There's a photo in the tribe of a woman he calls Fat Louisa, who's clearly obese. And he asks us, it's sort of the interesting thing is, the older population, they had lived through the famine. 30 years of famine is 30 years of calorie restricted diet, right? And it's very high carb and low fat. And the question is, why are these people fat anyway? And then of course you start looking what's happened. They're on a reservation. They've been introduced to Western foods. They've been to commodities, which are at the time was mostly white flour, some powdered sugar, some Shorten. Lard.

By the way, they have a word for Native Americans who eat those commodities on the reservations and get fat. It's called Kamad Bod.

Oh, that's interesting. I didn't know that.

I learned that from a Hopi chief.

So, anyway, the simple way to answer this question is you say it's food-like substances, it's processed food in general. Now you don't have to think more deeply about it. So, you want to know what causes yellow fever, malaria, you blame it on miasma, bad air from from swamps. This was the miasma theory of disease, which was like, 'cause the people who lived in low-lying areas and cities and coastal areas tended to get these diseases, and the rich people lived on hills, so they'd be away from the bad air and the bad water, and they wouldn't, and you could, you know, avoid the disease with the miasma theory, but it didn't tell you what was causing it. They were mosquito-borne illnesses, that they were viral. And once you know it's a mosquito-borne illness, you can save the poor people too. Sure. The ones who can't afford to move.

Away from the water.

Yeah.

So they were poor.

Then you spray them all with DDT.

And they get sick.

Yeah.

Or you could spray DDT. So yeah, this is a refined processed food thing is to me like a miasma theory. It's great, but it doesn't, you know, there is an agent here. It may be multiple agents, may be physical inactivities involved, may be.

But it turns out your conclusions were that it was sugar.

Yeah, so I conclude it. Sugar is the simplest possible explanation and the obvious explanation. And for two reasons... Flour, because we.

Also have seen a spike in flour consumption, right?

Well, you do. But so here's the issue. Again, because remember we got all those Southeast Asians. I had your buddy David Ludwig and I argue about this about once a year. And I say, I am not willing to ignore two billion possible black swans to my flour theory on the basis that they're out there in the field. They're not all out, you know. So, Even in Southeast Asia, you see an increase. So obesity and diabetes are now manifesting themselves. And these are always low sugar consumers. So to me, it's a simpler hypothesis. And there are two. So we have the fatty liver link, but there's also a link with insulin. So type 2 diabetes is a sort of insulin resistance fundamentally. And one of the arguments I make in my books and David makes and others and has now been embraced is that that, and actually Rosalyn Yalow and Solomon Berson suggested in 1965, is that the root from health to obesity and diabetes doesn't go health and leanness, obesity, diabetes, it goes health and leanness, insulin resistance and hyperinsulinemia to obesity and type 2 diabetes. Yeah, absolutely.

And as a doctor seeing patients and testing all this stuff for 30 years, I would completely agree.

Yeah, and so, and a significant amount of evidence, laboratory research in animal evidence in the 50s, 60s, 70s, and 80s implicated fat accumulation in the liver in insulin resistance. And once we start talking fat accumulation in the liver, if I'm an investigator, I'm gonna start wondering about sugar, the fructose. And there's a link between insulin resistance and fatty liver disease, Again, these aren't.

All the same problem.

It's all the same problem. But the liver's role in all this tends to implicate something unique to hepatic metabolism of something, and fructose is just the prime suspect. And the argument I make in the book is I'm just arguing it's a prime suspect. And you go back to the late 19th century. So you can actually see diabetes when you go to hospital records from the 19th century. There are hospitals like Massachusetts General Hospital in Boston, Pennsylvania Hospital in Philadelphia that keep their records. And if you're a researcher or an author, you could contact their archivists and they will do this research for you. Amazing resource. You can see diabetes rate, you can see the diabetes epidemic begin in those hospital series. It's like seeing Ebola patients come into a hospital in Zaire or something for the first one and then three more from a village. In this case, there are years, like in Mass General, there are years from 1925 or so to 1825 to 1850 where there are no cases. Zero cases. And this is the major urban hospital.

And now it's the main diagnosis in medical care.

I'm almost as sure or later on.

One in three Medicare dollars is for type 2 diabetes.

If you add in pre-diabetes, it's probably two out of three Medicare dollars. Yeah, yeah. So, and there are hospital systems like the VA system where one in four patients are diagnosed diabetics. And here, entire years where there are zero cases. And then the 1840s, you have the beginning of the candy and the soft drink, the candy industry and the chocolate industry and the ice cream industry and sugar prices sugar consumption is going up and by the 1850s, 1860s, you just see the numbers in this hospital record. So they go to two to three cases a year, four to seven cases a year. Elliot Joslin sees this in his first paper. And back then, people are saying, well, it could be all this sugar we're consuming. Now they might have said, they didn't, but they might have said, could be all the white flour we're consuming, because you're right, they both They develop sort of simultaneously, but even back then, they're thinking it's a sugar, and then people like Jocelyn talk them out of it because they don't know about the sugar.

I mean, I would suggest that if people cut out all the sugar in their diet and consumed a loaf of bread or two a day, that it's not going to work out.

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

Sugar, absolutely.

So then the second answer is what do we do? It's like why we get fat, what do we do about it?

How do we get thin, right?

How do we get thin? And how do we get thin is like, it ain't gonna work if you eat two... So I'm saying, if we go back to human beings circa 1830 and give them two loaves of white bread a day, it ain't gonna be pretty. But I don't think they're gonna get diabetes. Although, the funny thing about white bread is it's got... White bread can be, I think, up to 12% fructose sugar.

Yeah, and it's higher glycemic index, too.

But it's also higher in sugar. So the difference between French white bread and Wonder Bread is the refinement of the grain. It's more highly refined.

The fermentation process.

And the fermentation process and the sugar content. And so again, we don't know what it is. But we had people back in the 1820s, 1830s, basically living on bread. That's what poor people did.

And not much else. It was, and there's really no processed food.

Yeah. The bread is processed.

It is, I mean it is multifactorial, right? It's our gut microbiome, it's environmental toxins.

-- well, see this is where-- there's.

All these variables in there that are impacting us, right?

--Well, yeah, but there's-- but this is.

The big elephant in the room.

--Yeah, I'm not fond of multifactorial explanations, all often used to A, make everyone happy, because you're not rejecting anything, and B, to say, well, we have no clue what's going on. And we probably got the wrong answer since we clearly haven't been able to stem these epidemics. So it's multifactorial, and complex and anyone who says there's a simple answer is naive and wrong. And my counter argument is you start with a simple hypothesis and reject it when you have it.

I think if you look at the big elephant in the room, you've got to cut down sugar. And I would add to that refined starches, I think.

So that's like the solving the problem thing. Before we get into it, I think the world is full of diabetics who are smart enough not to eat sugar and drink Coca-Cola, right? And are still diabetic. 'Cause they're eating a high carbohydrate diet.

'Cause they're eating a high carbohydrate diet. So you wrote an article with Nina.

Teicholz in the US News and World Report, which was pretty provocative.

Well, it was in the LA Times. It was about that report, right? It was in the LA Times about that report. And their report is sort of an annual report says here are the best diets that you should follow. And they list the Mediterranean diet and the dash diet, which is the dietary approach to stop hypertension. And you and Nina do a major takedown on that and suggest that, you know, compared to what, you know, you didn't, you sort of, that question sort of left out.

So tell us, like, what, what is.

The problem with those diets? And, and what would be your approach to find the right advice around nutrition and figure out what their dietary guidelines should be for America.

Wow.

Okay, do that in small print.

Do that in 10 minutes. What do we have? We only have five minutes. So what was the problem with the, so we live in a world and you live in a world where if you put people on very tightly carbohydrate restricted diets, high in fat, we'll call.

It low-carb high-fat, Not even necessarily keto, but somewhere in that range.

Low carb, high fat. You tell them, don't eat these foods, these foods are fine, and these foods are carbs, and those foods are high in fat, and they're, you know, they get better, right? You see fairly remarkable improvements. We live in a world where doctors offices, if you're in internal medicine or family medicine, your doctor's office is full of basically people with overweight, obesity, diabetes, hypertension, all the concomitant diseases that go with insulin resistance and metabolic syndrome. And the medical community over the years, they had these two hypotheses. One was that salt caused blood pressure, caused high blood pressure, and one was that saturated fat caused heart disease.

They both kind of have flaws.

They've both gone away. And they end up with the two diets that they've kind of the establishment researchers have pushed as healthy diets and have tested a few times in limited trials. This is the Dash diet, Dash stands for Dietary Approaches to Stop Hypertension, and the Mediterranean diet.

And the Dash diet is a low-fat, high plant-based, high complex.

It's actually not that low-fat. That was the thing. fat but not low dairy fat.

Right.

Although it's low fat dairy.

It is low fat dairy.

Low fat dairy, yeah.

And.

If you put together a group of dieticians and nutritionists and health authorities who have grown up without questioning the medical establishment, sort of believing what they've read, which is a reasonable thing to do, you're in that world. And then we have a world of, and these are diets that are given with the hypothesis, not that they'll make you healthier immediately, but that they will make you healthier in the long run.

They'll prevent disease.

If you eat a dash diet, you will lower your blood pressure, which is a good thing, and that will prevent stroke, and there'll be no side effects, no fattening or diabetes or anything else that might happen from the high carb part of the diet. Mediterranean diet is supposed to prevent heart disease and diabetes, so you won't see any real significant changes immediately unless you calorie restrict it. And if you calorie restrict it, you probably won't be able to stay with it. Stay on it.

Right.

Because nobody likes to be hungry. That means being hungry your whole life. Anyway, so these are sort of hypothesis-based dietary approaches. And then there's this low-carb, high-fat thing where you put your patients on it, they lose weight, they're hyper, their blood pressure comes down, their blood sugar control gets much better, they might get off their type 2 diabetes medications.

And always see people get off their cardiac meds, their high blood pressure meds, their kidney function gets better, their testosterone hormones improve, they have improved cognitive function, everything gets better.

Things look good. It's hard to imagine that you're killing people, but then somebody like US News and World Report comes along, and not only do they rank the sort of conventional wisdom diets the highest, of the healthy diets they have, I think it was 38 diets they study, they look at, they assess, and 35th to 38th least healthy are the diets that you're recommending for your patients because you see them get healthy. So there's a disconnect here. And if you ask the question, How.

Do we fix that?

Well, why is there the disconnect? So one possibility is we're quacks.

Right.

I mean, the world is full of physicians who are pushing questionable medical procedures and think they're doing good and aren't, and we're just them, what you are, and I'm a bad journalist.

Yeah, I actually thought my career really hit a high point when I was on Quack Watch.

Yeah, exactly.

So the- I only made it.

Yeah. The other possibility is that the way US News & World Report does their diet rankings is by getting experts. And the experts are people who have risen to the top of their professions or were close to the top in this case by reiterating, reiterating and believing in the conventional wisdom. And so they're just going to, they're a way to filter through these diets to recapitulate what the establishment has been telling us for 50 years.

And ignoring the over 70 studies looking at a lot of low-carb, higher fat diets. effective for...

So this is the point Ian and I just wanted to make was that when you actually look at the trials instead of asking the opinion of establishment authorities, you find that the establishment diets are not very well tested. When they are tested, they don't do all that well and you ask very limited questions like is a Mediterranean diet better than a low-fat diet in the context of all the problems we discussed. And yeah, I tried to actually, I contacted the editors at US News and World Report through actually I asked David Katz to make the introduction. Oh yeah. Because David and I are, you know, we don't think very highly of each other, but we're in communication. We're in communication. David was very kind to make the connection and I said, I'm gonna be in Washington, I'd like to meet with you and discuss the rankings. And I've won many awards for my journalism. whatever you think of my beliefs, people think highly of my journalism and were colleagues in that way. And they said, yeah, we'd love to meet you. What do you want to talk about? And I said, I want to talk about potential problems with the diet rankings. And that was the last they would answer an email. And this is what happens with the sort of the whole group thing phenomenon.

Yeah, it's amazing. You know, you think science is about discourse, and debate and cover science.

Good science is. But all this sort of once science becomes, and again, the whole diet thing is kind of religious factions arguing with each other.

How do we fix it and get the right guidelines and change what we're doing? And how would you think about doing that?

Well, we continue doing what we're doing for good or bad. Again, I mean, I've crying out in the wilderness. Well, but we're right, you know, There's more of us. There's a lot more of us. When I first started this, my research, that 2002 article, I'm thinking there were half a dozen physicians in America who were outwardly promoting these diets and they were all writing diet books. And now there's probably a few tens of thousands is my estimate. So that's a tiny percentage of the overall medical community, but it's a huge absolute increase. and they're all people who did it because they learned they experienced what you experienced, which they can make their patients healthier. I mean, I was always recommending low-fat.

High-Carbohydrate diets and didn't see real serious benefits. And yes, I got people off processed food and tried to eat healthier and whole grains and beans.

And.

But it was really clear to me that, you know, I couldn't get people off their insulin. And now within three weeks, I've got someone who's been on insulin for 20 years.

So this is a question. Why wouldn't you want to if you were a patient or a physician? and you heard somebody say that, why wouldn't you want to try that? Let me see what happens. Because I, you know, unless maybe their patients are doing better, but the obesity and diabetes epidemic suggests that we are not handling this problem correctly.

Okay, so you're president king for a day and you can change policy, change businesses, change something that you think would have an impact. and making all this better, what would it be?

Well, like I said, I'd start with getting people to think of sugar kind of the way we think of cigarettes. I don't know if everyone...

So does the new tobacco?

Yeah, I think that's of everything that's the worst. I mean, it brings a huge amount of pleasure, so we have to deal with that.

Well, when you look at the data, obesity and sugar, is far greater killer now than smoking and alcohol and physical inactivity by far.

Yeah.

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

Know, taxation by regulation of substances?

No, I think just by awareness. I'm not a fan of government regulation in general in this country.

But if the hypothesis is true that sugar is biologically addictive, just saying get rid of the sugar isn't going to work. It's like get rid of heroin.

Well, yes and no. I mean, I think for a lot of us, yeah, it takes an act of will, but I think for many of us it's easier. The problem is it's an act of biology. Yeah, it's everywhere. So you have to make it less You know, you gotta get rid of the candy bars and the place in the supermarkets. I mean, stores like Best Buy have candy bars that you have to walk by to get to the cash registers. And 50 years ago, they would have had cigarettes next to the candy bars. And then maybe that's a regulation thing, maybe that's an image thing. But we got into this problem 'cause some very well-meaning liberals like myself thought the government should start telling people what to eat. So, you know, I just, and there are, I have allies in the sugar world who as soon as they get sugar handled would then go after red meat or processed meat and I'm not sure that's a way to make people healthier. It's better for the animals. I buy that, but I'm not sure it's better for the people. And so I would, You know, in my universe, I want to get rid of the sugar, however we do, and then I want to do the best, I want the science to be nailed down. And unfortunately, that requires a universe where it could take 50 years of rigorous science. So if you were thinking for a.

Day, you'd put a few billion into studying this more rigorously.

I would say to have a kind of Manhattan Project-like approach to this. We're very concerted. We're very smart, scientists without preconceptions say, this is what we don't know and this is what we have to study. This is the studies we have to do. And here are new ways we can do the studies and new populations in which we can do them so we can get the kind of rigorous control we need. I mean, this is a real pie in the sky, you know, but we spend, okay, so we're in Zurich, right? We're a few hundred miles from Geneva and CERN, the center for the European Center for Nuclear Research, where they spent $10 billion to build a single particle accelerator to see what's beyond the standard model and ended up discovering a particle when it was there called the Higgs boson. But they were willing to spend $10 billion to find that. We knew what they had to answer. You know, in the past few years, there have been a series of naval destroyers off the Sea of Japan that have run into Local boats and done an enormous amount of damage to themselves. Those destroyers cost a billion dollars each. One of them was a class of 60. So they spent 60 billion dollars building a class of eight destroyers. It's just a matter of... this is a very hard... these studies may be practically impossible. They're certainly difficult, but the societal motivation to do them has to be there. And you have to not have these authorities out there saying, oh, we don't have to do these studies. We know the answer.

So you've been listening to the Doctor's Pharmacy with Gary Taubes about sugar and fat and everything in between. This is a place for conversations that matter. And if you like this podcast, please subscribe wherever you get your podcasts and leave a comment and a review. That really helps us and share with your friends and family. We'll see you next time on the Doctor's Pharmacy.