#328 - AMA #66: Optimizing nutrition for health and longevity: myth of a "best" diet, complexities of nutrition science, and practical steps for building a sustainable diet

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Peek of the Ask Me Anything episode. Welcome to ask me anything AMA episode 66. I'm once again joined by my co host Nick Stenson. In today's episode, we cover a topic.

That is generally one of the most.

Talked about topics and also one that comes with a lot of confusion and that is nutrition. Given this, we wanted to do a special episode to answer any and all questions that routinely come in on this topic. So in this conversation we speak about nutrition and weight loss and weight maintenance and how nutrition compares to exercise, the complexities of nutrition research, what, if any, is the so called best diet and how to think about choosing the right diet for oneself. We talk about protein, we talk about processed foods, and much more. We discuss what questions you as an individual can ask yourself to try to identify the best diet for you. If you're a subscriber and want to watch the full video of this podcast, you can find it on the Show Notes page. If you are not a subscriber, you can watch a sneak peek of the video on our YouTube page. So without further delay, I hope you enjoy AMA number 66.

Peter, welcome to another ama. How you doing?

Doing very well. Thank you for having me back.

I haven't talked to you yet today, so what kind of mood would you say you're in today?

Oh, well, given the subject matter, surprisingly good mood. And you know, I've taken a couple beta blockers before, so I'm riding the cool wave, man.

That's good. I was curious if we were going to get Diplomatic Peter or Spicy Peter on this episode.

I don't know, actually.

To be determined.

Yes. Tbd.

Perfect. So for today we are covering a topic that, as you hinted at, is not one of your favorite, but we probably get asked the most amount of questions on in some form or another. It's a massive topic. It's nutrition. And we've done a ton of podcasts on this, ton of newsletters on this, and so we're not going to be able to cover everything as it relates to nutrition. But what we did is we pulled the most common questions, themes that we get asked and we pulled them together for this episode. So we are going to talk about nutrition, its relationship in weight loss and weight management, how you think about it compared to exercise, the complexities of nutrition research, which is why often when we send emails tearing apart studies, they are typically on nutrition. What you think of as, quote, unquote, the best diet, if we can even answer that, how that's different from a healthy person to someone who's trying to manage chronic disease, how people can think about choosing the best diet for themselves. Obviously, we can't do nutrition without protein, which is one thing you do genuinely like to talk about. And we'll also hit some other hot button issues, such as processed food. So with all that said, anything you want to add before we get rolling?

No, let's jump into it.

Perfect. Starting off nutrition, why do you hate talking about it?

Well, look, it wasn't always this way. There was a day when I really enjoyed talking about nutrition and writing about nutrition. In fact, you could argue I cut my teeth on that. That was my very first foray into doing anything publicly back in 2011, was blogging, and it was blogging mostly about nutrition. But I would say there are a handful of reasons that my interest in continuing to obsessively talk about it has sort of diminished. So you've alluded to some already. So the problem with nutrition research is that it doesn't really lend itself to having rigorous discussions on the topic. I read a really interesting and timely article the other day on LinkedIn, and it was titled Something to the Effect of Food can't be Medicine until we can research it like medicine. In fact, we should link to that article in the show notes. I mean, it was so spot on. It's like everyone loves to probably misquote Hippocrates with the Let food be thy medicine line. And yeah, it makes sense in a way. They're molecules. You put the molecules in, they clearly have an effect on your body. The problem is there's no relationship whatsoever between food and medicine, the nature of which we can do controlled studies with medicine is completely different. The homogeneity of medicine.

Right.

If we're gonna study a medication, you're getting the same molecule every time. And that's the one molecule that you're studying.

Right.

I mean, there are a few exceptions to that. If you're taking, for example, desiccated thyroid hormone, where you have kind of a hodgepodge of pig thyroid gland mixed up, you're getting some T3, some T4, some T2, et cetera. But for the most part, when you take a drug, you're taking a single molecule. That's obviously not the case with food. So all of that notwithstanding, the real issue I have, because that's just, I think, a function of food, what rubs me the wrong way is that the ratio of certainty with which people speak about this subject matter to the quality of data. So take that as a ratio. So on the top you have certainty, on the bottom you have quality of data that is really, really high. That's a really big number. Meaning there's people have tons of certainty despite a paucity of data or quality of data. You don't have a paucity of data, you have a paucity of quality data. There's nothing that compares to this. There is no discipline of science or engineering for which our magnitude of certainty is so high relative to such poor quality data. And then I think the final point I would make of many, but I don't want to spend the whole time on this is that the zealous extremes and the cultish religious buffoonery that goes on in this space is just very off putting to me. Whether we're talking about one end of the spectrum of carnivore to vegan, when people speak about their diet as the one true diet, I find it very off putting. Which is not to say that a person who's vegan is off putting. I mean, I've met many people who say, look, this is kind of the thing that works for me, or this is my belief system. I just can't bring myself to eat animals. I'm not saying there's anything wrong with that. What I'm talking about is sort of the really cultish people who will tell you with absolute certainty that if you are eating anything other than this diet, and this diet can be any diet, you're going to go to hell. Basically. There's a warm place in Hades that's waiting for you. And of course they're not saying that, but the point is they're speaking with such conviction about something for which such conviction is impossible.

What do you think caused you to make a switch on nutrition? So you cut your teeth on this subject. When we met 12 or so years ago, you were deep in this subject. Was it a slow progression or do you think it was like more of a quick switch?

No, I think it was pretty gradual. There's not a moment I'll point to that says when that happened or when I read that one study or meta analysis or article, I had a change. I think it was in Part maybe as my clinical experience grew and I saw more and more patients and realized more and more the complexity of nutrition and the heterogeneity of people's response to different nutrition, in other words, how 10 people could respond in six different ways to given nutritional inputs, that you start to realize. Well, a couple things are true. One is that the body is remarkably adept at dampening the effects of nutrition. So it's like if you think of an engineering system, there are some systems where when you put a signal in to the box, the box amplifies the signal. So you put something in that's a 2 out of 10 and it amplifies it to like an 8 out of 10. And sometimes you want that, sometimes you need a signal amplifier, but then you have the opposite is true, where you put something in and it dampens the signal. So you put something in that's like a blinking 8 out of 10 and the thing gets attenuated, it gets dampened, it comes out at a 2 out of 10. And in many ways the body is that way with nutrition. And so a lot of the things that people pontificate about on the margins end up being really not that important. And I've talked about this a bunch and maybe we'll even speak about it a little later today. But once you get beyond total energy consumption or total energy content of the food, total calories, protein content and the essentials within minerals and nutrients, most of the rest doesn't matter that much. The body's pretty resilient. You have to hit certain minimums on fat to avoid severe malnutrition and problems that occur there. Carbohydrate tolerance is staggeringly variable. You can get away without eating any carbs and still function. And you can get away with eating a ton of carbs and still function. So that's actually kind of amazing is our variability on that one particular macronutrient. But beyond those big, big principles, there's very little that can be said with high certainty. And one might even ask the question how much really, really matters. I mean, we're now talking about fourth and fifth order terms on a polynomial here. And those don't tend to really sway the outcome because the first, second and third order terms are really clearly set.

And so I think the next follow up question would be what measures of health, if any, that relate to nutrition can an individual monitor on their own to kind of understand where they're at health wise?

Well, I think there are many. Obviously, nutrition plays a huge role in anthropometric data. So using a DEXA scan, which will tell you how much lean mass you have, how much body fat you have, and if the scan is calibrated correctly, at least give you a good estimate of how much visceral fat you have. That's a great readout of nutrition. You could go even detailed in that and actually do scans of the liver specifically to look for liver fat. Also a fantastic readout of nutrition. Quite specifically, you could look at biomarkers that pertain to metabolic health and specifically to glucose regulation or glucose homeostasis. So if you look at either impaired or enhanced glucose disposal and other markers of metabolic health, this is everything that would range from how your CGM performs, your hemoglobin A1C, things like uric acid, things like liver function tests, your oral glucose tolerance tests, all of those things are going to be very important. Readout states of nutrition. Now, of course, those markers are also readout states of other things. They reflect your sleep and exercise quite a bit as well. But there's no doubt that those are reflections of your nutritional status. In some cases, we would say otherwise unexplained inflammation could probably be driven by nutrition. We certainly see that outside of very extreme examples. For example, celiac disease is a pretty extreme and specific case. But even absent something like celiac disease, there's clearly an intolerance to wheat on the part of many people. And it only shows up in a biochemical assay that surveys for inflammation, such as a C reactive protein or a slight change in the white blood cell count or things of that nature. And we know this because when we do empirical elimination, selective elimination and reintroduction of these things, we'll see those inflammatory markers move. So there's no question that food plays a role in that as well. And then obviously, we can measure certain deficiencies and or excesses in the blood most commonly, but also in the urine or even in the hair. So in other words, you could give you an example, right? You could see a person who is B12 deficient. That's a very common finding in people who don't eat meat. And similarly, you can see an excess of mercury, which would be considered quite toxic if it gets to a high enough level for someone who, for example, is eating a lot of seafood, and especially seafood that is coming from really large fish who are high enough on the food chain that they're eating a lot of other fish and accumulating mercury themselves. So I would say probably those would be the big four categories of things where nutrition is easy to read out in testing.

One of the questions we see come through a lot is kind of the relationship or the difference between nutrition and exercise as it relates to weight loss, weight maintenance or gaining weight? What do we know about kind of those two things, nutrition and exercise as it relates to weight?

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