I am thrilled to have Gary Taubes back on the show . (He was with me before on episode 137). Gary is an investigative science and health journalist whose work has been pivotal in catalyzing the low-carb keto movement. He has written many books, including his most recent, Rethinking Diabetes, and his articles are in many of the best anthologies. He has also received many science awards.
Today's discussion is particularly significant, given the recent report from the American Diabetes Association revealing that the annual cost of diabetes in the United States reached a staggering $412.9 billion in 2022, with individuals diagnosed with diabetes now representing one in every four dollars spent on healthcare.
In our discussion today, we dive into the history of diabetes, pertinent statistics, the prevailing standard of care, and the transformative influence of insulin on diabetes management and reactive hypoglycemia. Gary provides insights into his reactions to GLP ones, the integration of medical and nutrition science into the medical field, and the influence of organizations such as the American Diabetes Association, AHA, USDA, and NIH. Our discussion also extends to the effects of pharmaceuticals, the shortcomings in our approach to diabetes management and existing models, and the challenge the low-carb community faces.
IN THIS EPISODE YOU WILL LEARN:
Rethinking Diabetes is a groundbreaking exploration of diabetes diagnosis, management, and treatment
Gary discusses the evolution of evidence-based medicine
Why the traditional medical approach to treating diabetes is inadequate
How the guidelines of the American Diabetes Association were based on outdated assumptions
How medical treatments compare with lifestyle changes for managing diabetes
Controversies surrounding how the pharmaceutical industry has influenced the way medical associations have shaped their diabetes management policies
How medical guidelines and dietary advice have evolved
What constitutes a healthy diet?
How patients often have trouble following diet recommendations, despite their best intentions
Is obesity a hormonal disorder or caused by overeating?
“You can do a vegan or vegetarian low-carb, high-fat diet but it's very hard to do. So it is easier to deal with animal products because meat, fish, and fowl are composed of fat and protein, not carbs.”
- Gary Taubes
Connect with Cynthia Thurlow
Check out Cynthia’s website
Submit your questions to support@cynthiathurlow.com
Connect with Gary Taubes
Rethinking Diabetes is available from most bookstores or on Amazon
Transcript:
Cynthia Thurlow: [00:00:01] Welcome to Everyday Wellness podcast. I'm your host, nurse practitioner, Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent is to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.
[00:00:30] Today, I was joined by Gary Taubes. This is a very special episode, especially given a recent American Diabetes Association economic report revealed that the total annual cost of diabetes in the United States in 2022 was $412.9 billion and people diagnosed with diabetes now account for one out of every four healthcare dollars in the United States. Gary last joined me on the podcast for Episode 137. He is an investigative science and health journalist whose work has catalyzed the low-carb keto movement in the United States. He's the author of many books, including, most recently, Rethinking Diabetes, and his articles have been included in numerous best anthologies, he's received numerous science awards as well.
[00:01:20] Today, we spoke at great length about the history of diabetes, relevant statistics, the standard of care, how the advent of insulin changed the way we manage diabetes, as well as reactive hypoglycemia, his reactions to GLP-1s, the weaving of medical and nutrition science into medicine, the impact of the American Diabetes Association, AHA, USDA, and NIH, and the impact of pharmaceuticals, why we are failing our patients with diabetes management and current models, and the backlash against the low-carb community. This is a particularly relevant and important conversation. I know you will value this discussion as much as I did recording it.
[00:02:09] Welcome back to the podcast, Gary. Such a pleasure to have you back on. I've really enjoyed reading your book, which, as I was stating earlier, I think must have been a labor of love.
Gary Taubes: [00:02:20] Well, thank you for having me, Cynthia. And as I said, I was kind of a labor of obsession, more so than love, but revelatory in doing this research and also just doing something that had never been done before, which is part of the advantage of living in the 21st century is we can actually do these things with the literature that had never been, and we have access to everything. So, part of the message, this is a history of the sort of diabetes therapy and how that influenced how physicians think and what was tested and what wasn't and how things changed or didn't change with revelations about the disease.
[00:02:58] But at any one time, the physicians doing this research and coming to these conclusions had maybe 10% of the literature available to them, like whatever journals they had subscriptions to, and if they were associated with the medical school, whatever their medical school might have, whatever languages they might read, and now, so, it's like you had this thousand-piece jigsaw puzzle, and they were coming to conclusions based on maybe 50 pieces. And now, because of these Internet repositories, and as were just mentioning, the AI programs that can translate, we can see like 800 or 900 pieces. And so not only can we see what they should have seen, but we can see how they misinterpreted what they did see, because they were seeing such a small proportion of what was out there.
[00:03:43] And for this next book I'm writing, it's even weirder, because you can see the good researchers, physicians, academic authors, cite their sources well, less well now than they used to. And so, you could see how their interpretation of the evidence depended not only on who they read, but when they read them, because the science is changing quickly. So, if they read like a 1926 article by this guy, they might interpret, they’re like think, "He knows what he's talking about. I'm going to trust his judgment and interpret my literature from-- my results from that perspective." But by 1932, that guy had changed his perspective because the science was changing, it's crazy. If they read a textbook chapter from 1926, they might interpret their literature if they read the same textbook, but a chapter written by a different author in 1932 or the same author writing it with what he had learned between 1920. If these were German textbooks and you're in the US, you didn't have all the editions, you only had one edition. And so, you could see, you can actually see how they came to the wrong conclusions based on not just who they read, but when they read them, it's sort of a surreal experience.
Cynthia Thurlow: [00:04:55] I bet. Well, and for me, reading it as a clinician, reviewing what you had read and understand the painstaking detail that you put into this book, I mean, this is a groundbreaking explanation, exploration of diabetes management, diagnosis, treatment, and perhaps starting the conversation thinking about why it's so important to understand the history of thinking around diabetes is a good place to begin, because in many ways, these clinicians were doing the very best with what they had at that time. And as you very appropriately discussed, and kind of allow us to navigate the trajectory of diabetes diagnosis, management, treatment, where things kind of unravel, because I found the history of it really, really interesting and also with the lens of understanding that a degree of cognitive dissonance, I think all of us can be guilty of that, you know we get focused on one thing and that derails that scientific method to a degree that it has a large impact on patient care and management.
Gary Taubes: [00:06:08] Yeah, I think one of the interesting, as the epilogue of the book, I was also included a brief history on the evidence-based medicine movement. So today, everything's supposed to be evidence based. And when I first wrote-- I was the first journalist to ever write about the evidence-based medicine movement in the United States, this was in the 1990s, and I always thought it was kind of ironic, like, "Well, what did physicians base their treatments on prior, if it wasn't evidence?" And the answer was, it was basically what authorities told them was right and what everybody else was doing, occasionally based on what they saw in their patients, but for the most part, it was, they did what they were told to do and what their authorities-- Then medical school professors might say, "Look 50% of what we are teaching is wrong," But they didn’t know which 50% that was, so they just did what they had been taught.
[00:06:55] And then in the 1980s, these physicians come along and they decide to look into some of the evidence base of the practices, assuming that they're going to find that it's set in really concrete evidence. One of the pioneers in this movement, in his memoir, said-- When his revelation was that it wasn't set in concrete, it was set in jello. And then the idea was the meaningful evidence, the evidence he could trust had to come from the great extent from clinical trials. So, there's some clinical experience which you see in your patients, but informed by-- For any long-term treatments that have long-term effects, benefits and risks, you need clinical trials because you can't see those.
[00:07:34] So, the interesting thing is medicine then changes, it embraces clinical trials and we've grown up in that clinical trial era. But what we didn't realize is that in some cases, assumptions were sort of grandfathered into the clinical trial era, particularly in diabetes therapy and obesity therapy, which themselves had never been tested and may or may not have been right, so they never were tested because the physicians grew up with them and just assumed they were right and they didn't have to do anything different, and because they were about diet, they seemed commonsensical, there was no reason to really adjusting the primary one, by the 1970s, 1980s, was this idea that in diabetes, you pretty much allow the patient to eat what everyone else eats, carbohydrate-rich diets, you have the patient in an effect way that estimate the calories of carbs they're eating, and then they have them covered with drugs, so insulin or hypoglycemic agents, blood sugar lowering agents, and that's pretty much all we've ever done.
[00:08:37] So even today, when you look at the American Diabetes Association guidelines, the advice is to pretty much let the patient do what they've always done. And if you tell the patient to do what they've always done, you kind of have faith that they'll follow your advice. The ADA says that's a good thing, right? If they follow your advice, then you can add the drugs to cover what they're doing. And they simultaneously acknowledge that diabetes is a chronic degenerative disease, which means patients can be expected to get worse over time. They acknowledge that what they see as the biggest challenge to successful treatment is the resistance of physicians to keep adding new drugs or increasing doses.
[00:09:16] They acknowledge that, for instance, in type 1 diabetes, the patient's blood sugar control has been getting, on average, worse over the years rather than better, despite these remarkable new technologies and insulin delivering systems and blood sugar monitoring systems that have come in, and they never question their assumptions that again have been sort of grandfathered in with the evidence-based medicine movement, so maybe it's not a good idea to tell patients with diabetes that they can eat whatever they want because they shouldn't eat whatever they want because they'll be healthier and stay healthier, which is actually important to people longer, so there're all these issues.
[00:09:54] Field is going off the rails all the way along because of the problems with doctors trying to sort of do science based on what they're seeing in their patients and the primitive tools available, but in the 1970s, it just drives off a cliff, and we've been living with that ever since.
Cynthia Thurlow: [00:10:12] Yeah. It was interesting when I was reading the book, and there was a lot of discussion around diabetes and diabetics and what they should and shouldn't eat. And I'm sure that we'll touch on this, but a great deal of what the physicians were saying was, "Patients are happier and healthier and more compliant when they're able to consume more carbs, which we will cover with insulin and trying to avoid having them consume carbs seems unnecessarily puritanical and is too much trouble." And I thought to myself, "Wow." I mean, understanding that type 2 diabetic already has a carbohydrate handling problem and then encouraging them just to continue consuming exactly the type of food that's worsening their insulin resistance and hyperinsulinemia, and then just to tell them to cover it with more insulin to me they're not even forward thinking, it's just, "We'll have this temporary stopgap measure because we don't want to reinforce these lifestyle modifications that would have greater net impact than just encouraging them to cover with more insulin or oral anti-hypoglycemic drugs." To me, I found that so troubling. And it really typified this really poor understanding of diabetes and the progression of diabetes.
Gary Taubes: [00:11:26] And this is, again, and I look at this from a historic perspective. So, from 1797, effectively till 1914, the treatment for diabetes. There is no drug available. So, we don't know about insulin. We know a hormone like that must exist, but we don't know what it is, it hasn't been purified, there's no insulin therapy. They know that there are kind of two different types of diabetes. There's a type that strikes kids young and is acute and kills quickly and it's terrible. And then there's a type that associates with age and with weight and seems to be more of a chronic type of the disease, but they don't have the terms type 1 nor type 2, or adult onset or child onset, or non-insulin dependent or insulin dependent, they just have this awareness, physicians that they're seeing two types of patients.
[00:12:15] Beginning in 1797, you have this. Dr. John Rollo comes along, British-military physician. He gets a patient with diabetes, a guy named Meredith, colonel in the military. He decides that the problem is-- This is back in an era when they only said physician might see one case of diabetes in a lifetime. Rollo actually saw three. In the second one, Meredith, he realized that the problem is sugar in the urine, that's how they diagnosed it. They'd actually taste the urine back in that era. And if it tasted sweet, that clarified that the other symptoms you were seeing hunger, thirst, urinating all the time, were diabetes. If it was too much sugar, maybe that meant they couldn't metabolize sugar. He somehow couldn't digest it properly, so let's feed him a diet without. Sugar comes from carbohydrates, let's feed him a diet without carbs and called it the animal diet. And originally, it was fatty, rancid meat, and green leafy vegetables. And they decided maybe the rancid was beyond the pale, so it was just fatty meat. And through the 19th century, this is a standard of care for diabetes because it works. I mean, it keeps the type 1 patients alive longer. And the type 2 patients, if they adhere to it, can survive indefinitely, they could live normal lifespans. It was clear that if they didn't eat carbohydrates and they got their calories from mostly fat, they'd be fine. And so, the French used it, the German authorities used it, the Italian authorities used it and everyone.
[00:13:43] William Osler, the father of modern medicine in the United States, claimed that it cured many of the patients. And then 1914, a Harvard doctor, there's a lot of bad Harvard medicine throughout this field. I mean, they could definitely win an award for-- Anyway, I've been accused of being a self-hating Harvard alumni. [Cynthia laughs] A Harvard doctor says, "The type 1 patients, the young kids particularly are going to do much better if you don't feed them high-fat diets, you basically starve them." So, they come in with this disease or one of the symptoms is they're both emaciated and ferociously hungry all the time, they're starving, and then you basically feed them, you starve them further, and it definitely kept them alive. Some people questioned whether it was worth it or not. It just seemed like a horrible choice to make these kids starve so they could live longer. But towards the end of the 19 teens, as we moved into the insulin era, insulin was discovered in 1921, some of the kids who were kept alive by starvation, lived long enough to be kept alive by insulin, and everybody else got these high-fat animal diets.
[00:14:51] So, insulin was discovered, purified in 1921 at the University of Toronto. It's first used in therapy in January 1922, it's a miracle drug. Like, you have these kids 15-year-olds, who weigh 40 pounds, 45 pounds, whose growth is stunted, who look like living skeletons, who are on the brink of death, and you give them insulin therapy, and within days, you can see them filling out and becoming healthy, and it's tested by sort of beta testers among the diabetes community, the leading authorities, clearly is a miracle drug. It was basically medicine's first miracle drug.
[00:15:29] And the problem is, as soon as you start giving them insulin, you can lower their blood sugar too much, so now you create this disorder called hypoglycemia, which is such a burden to the life of patients with type 1 diabetes, and they can die from it. So, this didn't really exist prior to insulin therapy, it's called insulin shock. And in order to prevent it, you have to get them to eat carbohydrates. So, you take these patients who were on the animal diet or who were being starved, and now you feed them carbohydrates so you can give them the cure, the insulin, without the cure killing them and it makes perfect sense at the time.
[00:16:06] And through the 1920s, particularly with children, physicians who had children said, "Look, it's just easier if we give them insulin and let them eat what they want, and the kids will thrive, they'll do great, they'll be happier, and they'll appear healthier, and they don't actually need that much more insulin." So as the years go by with insulin therapy, the belief is, let's just give them more and more carbohydrates, let them eat what they want.
[00:16:30] In the 1930s, there's what's called a free diet movement, where very respected physicians were saying, just, "Have you ever seen a kid with diabetes eat a birthday cake?” The euphoria makes up for everything. And the problem is, they have no idea about the long-term complications. They don't know what it's like to live with this disease for a long time, because before insulin, people didn't, particularly kids, they don't know what the long-term complications of poorly controlled blood sugar is, they don't know what the long-term complications of insulin therapy are. So by the 1930s, they start seeing this tidal wave of complications, heart disease, kidney failure, blindness, neuropathy, nerve damage, and amputations. And these kids who were saved from immediate death, diabetic coma, ketoacidosis, and death when they were like 12 years old and put on insulin therapy and got to experience this miracle are now dying 10, 15, 20 years later, still very young in their 20s, early 30s, from the long-term complications of the disease.
[00:17:34] So meanwhile, we've sort of baked in this belief that nobody wants to go on a diet. Kids don't want to eat differently from their siblings, parents don't want to cook different meals for the kid with diabetes and the kids without. Living with disease is a burden, letting these children eat what they want is a blessing. So, this is now all conventional wisdom.
[00:17:59] And then as they see that these kids in their 20s and 30s are dying horrible deaths and that this disease is still taking 20, 30, 40 years off their natural life, nobody asks the question, is it the diet? Maybe, it's unfortunate, but maybe these kids would prefer to be healthy and not eat pasta, potatoes, and rice than to be unhealthy, get to eat the pasta, potatoes, and rice, and have to take these drugs that might in turn also be doing damage to cover. It just sort of never crosses their mind, they just think we need better drug therapy, where the kids who have these complications should have done a better job of using drug therapy, the insulin, to control their diabetes. So, the question is always, how can we change drug therapy? Assuming that diets are given and there's always a new drug in the pipeline.
[00:18:51] Beginning in 1936 with better, longer-lasting insulins, this protamine zinc insulin, and then, so there’s better drugs, there's better delivery systems, there's better ways to get insulin into the system. And even today, the argument against my book is "Why do we care about diet? We have better drugs now. We've got these wonderful GLP-1 agonists like Wegovy and semaglutide, and that's going to solve everything.” And maybe it will, but even if it does, maybe it would solve it better without needing to cover the damage done by the diet. So, you've got a disease that's a disease fundamentally characterized by the inability to eat this one macronutrient group safely to metabolize carbohydrates safely.
[00:19:40] Now, everybody wants to eat carbs, I mean, who wouldn't? But if you were given this trade off, you have two choices, you eat the carbs, you take the drugs, you suffer the side effects later now than you would have 30 years ago and probably 20 years from now, we even handle the complications better still or you decide to live without the carbs, they may not need any drugs or very low doses, and then if there are complications to the drugs, they'll be less, because you'll be taking fewer of them in lower doses, and you won't suffer the complications from eating the carbs because you won't be eating them. We never offered them that choice because the assumptions were always given, nobody wants to go on a diet, everybody wants to eat pasta.
Cynthia Thurlow: [00:20:27] Well, I think that concept of fully informed consent, allowing the patient to have a say in the process. And you mentioned in the book, you're making the comparison to the GLP-1s being game changers, just like when the advent of insulin came in, right now, whether it's semaglutide, Wegovy, any of these GLP-1 agonists, many individuals are saying that this is completely revolutionizing the way that we view modern day medicine. And we're starting to see some side effects. We don't know the long-term impact, that's something to consider. And yet, so much of these lifestyle-mediated disorders, and I'm speaking to the type 2s, not the autoimmune component type 1s, in so many ways. If there were lifestyle changes, whether it's carbohydrate restriction, whether it's emphasis on healthy fats and protein, the thought of someone not having fully informed consent to understand, like, "Here are your choices, option number one is here, option number two is here, but if you pick the carbs and you just cover with insulin,” “Do you ultimately know what it's like to have an amputation? Do you know what it's like to go blind? Do you know what it's like to be on dialysis?” Obviously, in a modern-day environment. But when we look at end-stage renal disease and cardiovascular disease and all these things that are the long-term sequelae of hyperinsulinemia, one would think that most people, if they fully understood the choices that they're making, they would opt for the dietary changes and less medicine. But I think--
Gary Taubes: [00:21:57] But by the time you fully understand it, it may be too late, it's often too late. The issue is and the reason I wrote the book is the physicians have to understand it, and they don't. So, and at the end, I talked about four physicians who themselves had type 1 diabetes, which is a more extreme case, so it's easier to talk about. I mean, the complications are more difficult to discuss the complexity of the case. But anyway, these were all-- And one of them said to me, he was a radiologist, and he had type 1. He thought he had well-controlled blood sugar. And then he started to get retinopathies, eye problem, macular degeneration, that therapy is-- And he has to be able to see to do his job, he has to be able to see well and the therapy, these injections of these drugs in the eyeball.
[00:22:43] Physicians, that is, optometrist or ophthalmologist is about to do this, he says, "Wait, wait, wait, before we do the injections in the eyeball thing, I might experiment with this ketogenic diet idea, I know it's quackery, but I really could live without the injections in the eyeballs." And it's sort of an extreme case, he goes on the diet, he expects it's going to kill him. He's got great trepidation, and within a day, he feels so good that he knows he's never going back, and he ends up with his eye issues clear up, wouldn't necessarily happen, but it did in his cases. His eye doctor cannot understand it and says, like, "I don't know what happened to you, but you don't need the injections anymore, you're fine, let's just monitor." And now when I spoke to him, it was like 15 years later, and he still has terrific eyesight. He's been healthy. The trade-off is worth it, but he understood the trade off, and he was knowledgeable enough, and he had enough faith in his own judgment.
[00:23:41] I had interviewed another physician and when he told his doctor that he wanted to try handling his diabetes. His endocrinologist, he wanted to try handling it with a ketogenic diet, a low-carb, high-fat diet, the doctor fired him, said, "I can't allow you to do this, not under my care, and sent him a very polite letter saying, you're going to have to find another endocrinologist, because I think what you're doing is dangerous." Again the reason I wrote the book is much for physicians, arguably more so than for patients, because I think it's a terrific history, but it's far more than a patient needs to might want. I wanted them to understand that when you look at the decisions made and on the basis that they were made and sort of what the jello was and what the concrete might have been, that they should open their minds to this, learn as much as they can about it, because some significant portions of their patients are going to want to make a different trade off than injections in the eyeballs, that's what it comes down to.
Cynthia Thurlow: [00:24:40] Yeah. Well, on the incentive that physician was thinking to himself, this is not what I want to be doing having injections into my eye. Now, the American Diabetes Association, the American Heart Association, how have they played into the evolution of the current policies surrounding diabetes management?
Gary Taubes: [00:24:58] Okay, so there are two schools of thought about this, and I have friends who think that because these associations tend to get most of their funding from the pharmaceutical industry, they rely, they end up giving guidelines that are drug friendly. And from the pharmaceutical industry perspective, the worse the patients do on diet, the more drugs they sell and the more effective the drugs are, so that's one perspective. I don't actually buy that, although, I acknowledge that the drug companies have enormous influence. I can't see the people, the doctors who put together the guidelines saying, "Well, Pfizer said, gave us $5 million if we push this drug, and I just think," I don't know anyone like that.
[00:25:42] My friends say I’m naïve but the other perspective is you've got these controversies, very active controversies about how best to treat these diseases, what are the dietary causes of these diseases, and these associations, they both became very active and powerful influential right after the second world war, they raised a lot of money, they funded research, and they wanted to give out the best guidelines available, and so the way you do that is you choose influential physicians who have become influential by virtue, in effect of believing the conventional wisdom and maybe helping to propagate them. And then you have them give the guidelines and they take a scientific controversy and they collapse it down into what we're going to now tell patients. And then they commit the associations to whatever they start to tell them at the point in time and there's a very active scientific controversy about what the right thing is.
[00:26:41] So, the classic example in the heart disease is in 1961, there's a physician, University of Minnesota researcher, PhD nutritionist, named Ancel Keys, who's been created the idea that saturated fat raises cholesterol and that's the cause of atherosclerosis. And so, Keys gets on a panel of the American Heart Association and promotes this belief when really no clinical trials have been done to test it. So, you have no idea if it's right or wrong, but now the American Heart Association, because of this Keys led committee, six members, one of the other members was the second most active promoter of this hypothesis. Now, the American Heart Association is committed, and now people start thinking about, and the press assumes that the American Heart Association is authoritative, unbiased body on these issues that could exist, so the media buys what the AHA is saying. And when they start doing tests, everybody has a real motivation and interest to see the tests support what they've been telling people is true. And when the tests don't, well, you figure out a reason why you did the test wrong, and test after test, clinical trial after clinical trial, fails to confirm this, and the AHA digs in deeper and deeper, and by 1971, with one failure after another, there's now like a half a dozen failures, they're telling everyone in the country over the age of two, everyone old enough to walk, to eat low-fat, low-saturated fat diets. $250 million worth of two trials are done between them in 1984. Finally, in 1984, one of them shows a little bit of a benefit for men with very high cholesterol. And when I say a little bit, like, you'd live three weeks longer if you take this drug than if you don't, but it's a cholesterol-lowering drug, and the AHA jumps on, and then by this time, the US government is pushing this idea too based on no experimental tests.
[00:28:41] And the ADA does pretty much the same thing. They're trying to be reasonable. In 1965, the American Diabetes Association produces their first guidelines. And some very smart people say, "Look, we don't really know what's right or not. It would make sense for a doctor who's worried about heart disease in his patient with diabetes to counsel him to change his diet, but we don't actually know if he should tell him to eat less fat or less carbohydrates."
[00:29:06] And then by 1971, physician gets on this committee and becomes a chair of the committee, who fervently believes that the American Heart Association knows what they're talking. They put out guidelines telling patients with diabetes that they should get more than half of their calories from the one macronutrient they can metabolize safely without drug therapy. The guidelines themselves are full of caveats. We don't know this, we don't know that, we have no idea if this is going to make anyone live a day longer, we don't know if it's going to kill them prematurely, but we think this is the best thing to do. It's like a New York Times headline. ADA changes decades of advice to diabetics. Carbohydrates, it seems, don't raise blood sugar, it's crazy and then the ADA is now committed to that.
[00:29:56] And one of the things we don't realize is back then, at least the guidelines could be controlled and basically represented the opinion of a single individual. Now, I would hope that's no longer the case, but they're certainly dependent on who's chosen to be on the committees, and there's enormous amount of groupthink. So that, again, you do this process where you pick somebody influential who's well respected because you think they're the best for running a committee. Man or woman who is picked for this position wants to pick the best doctors and researchers they know. And we all tend to respect people who think like we do, that's kind of the ultimate nature of groupthink, you respect people. The reason we're talking is because we think similarly, so you think, I'm smart and I think you're smart. So, the committee gets stacked just by the choice of who the chair is going to be, then determines what conclusions the committee is going to come to. And it makes perfect sense from the ADA's perspective, from the committee chair's perspective. The end product is you just keep saying the same with variations on the same thing over and over again. And if mistakes were made, if your committee chair grew up believing something that was fundamentally wrong or untested, it never gets tested and that's what happened in the diabetes world. They just decided, nobody wants to go on a diet, and we're going to tell them to eat like this. And our treatment of diabetes is clearly poor. We never asked the question, maybe it's a degenerative chronic disease only in the context of eating a carbohydrate-rich diet, maybe if you don't eat those, it's not a degenerative chronic disease, maybe it could be put into remission, which it clearly can. So, the ADA does as much harm as good ultimately, maybe more.
Cynthia Thurlow: [00:31:44] Yeah, I mean, it's just interesting, as I was reading through the book and looking at American Heart Association and NIH and the American Diabetes Association and even USDA, how over time, they all kind of came to the same conclusion about managing not just diabetes, but managing diet, and not to mention the whole conversation around saturated fat and that cholesterol hypothesis. And in many ways, even during the 1990s, when I was training, a lot of what I used to tell patients in Cardiology was exactly what I had been trained and taught at a very big research institution on the east coast that also begins with an H, but it's not Harvard. And how this evolution-- Even as a clinician, that even though we trained in one kind of dogma, that we can evolve, shift, and change. And so, I think in a lot of different ways, you do such a beautiful job of painting the picture of how we've gotten to where we are right now and how largely as a culture, we're very focused on drugs to address lifestyle-related disorders.
Gary Taubes: [00:32:50] It's funny, I had an epigraph at one point, a quote that I used to begin the very first introductory chapter and eventually got moved to the end for a variety of reasons. One of the problems was kind of gave the book away right up front, but the quote was from a chef turned journalist who was diagnosed with type 1 diabetes, I think he was 31 years of age, and he was describing to me the conversation he had with his physician, endocrinologist, and they were explaining to him what the problem is, what his body is failing to do, and then how they were going to treat it. And he says, "Wait, wait let me understand this. So, what you're telling me is carbohydrates are now a poison to me and insulin is the antidote, and I should eat the poison and take the antidote rather than just not eating the poison." And the guy goes, "No it's nothing about this, it just is way of thinking." The doctor says, "Well, you can't think of it like that, we want you to do what-- We want you to be happy." And the doctor wanted him to be happy and wanted him to be healthy, but the doctor thought one way and a natural response would be to think the other.
[00:33:59] And then the doctor said, "Well, the problem is that it's hard to adhere to not eating the carbohydrates, the poison.” People have trouble complying with that advice. And this young man says, "Well, I don't understand. I mean, if you told me to run, work out an hour a day, which advice I'm also getting, nobody says, you're going to have trouble adhering to an hour a day of working out, which also includes, like, a half an hour a day of getting to the gym or the track or changing and then the showers and everything afterwards. So, because you think that's good advice, somehow that's going to be easy, but just not eating certain foods is going to be hard." And so, we create this mindset and the physicians have it. They walk in thinking nobody wants to be on a diet and nobody adheres to diets. And this has been one of the messages that nobody-- We know that our patients--
[00:34:58] This is why this free diet movement was created in the 1920s and 1930s. And you have these physicians, very smart physicians writing about how they would have a patient come in, and when they'd come in, they'd test the urine for sugar, and the urine would be clear. They'd ask the patient what they ate in the last three days. The patient would say, "Well, I didn't eat this and I didn't eat that and describe basically perfect adherence to the diet." And they'd be so delighted, they congratulate the patient on keeping his urine sugar free. They couldn't measure blood sugar back then or they could, but it was too difficult to do in the doctor's office. And then they'd send the patient out, and then an hour later, they'd go down to lunch in the cafeteria, and there'd be the patient having like an ice cream sundae in the cafeteria to celebrate the fact that they-- It wasn't that they adhere to their diet. You know they'd see the doctor every four weeks, they wouldn't stay on the diet for 28 days, they'd fall off it for 25, and then they'd go on it for the three days prior to the doctor's appointment, so they'd have clear urine, and it's like, "Screw it let's just give them insulin, and everyone's happy."
[00:35:56] By the 1970s, there were studies done looking at dietary compliance on obesity and diabetes. Well, in obesity, they assumed nobody stayed on the diet because their patients just kept gaining weight. And if they were doing what they were supposed to be doing, which is eating less and exercising, they weren't supposed to gain weight, right? So, if they are gaining weight, they must not be following the diet. And then diabetes, it was clear they weren't following the diet.
[00:36:22] What they never thought about is maybe we're giving them the wrong diet, so maybe we're giving them the wrong advice, a sort of silly metaphor, but imagine you wanted to prevent lung cancer, and the way you did it is to tell your patients not to quit smoking, but to stop eating potatoes. If they got lung cancer anyway because they're still smoking, right? Then they're going to probably go off the potato diet, because why not eat potatoes and enjoy them? It didn't do anything prevent. You're giving them the wrong advice because you've got a wrong concept of what's causing the disorder. If you gave them the right advice and actually made them healthier, then maybe they'd follow the diet. Now, the trade off would be obvious. If I eat this way, I feel good, and if eat that way, I don't, as opposed to if I eat the way you want me to do, I don't feel well, and if I eat the way I want to do, I feel better, so I'm going to eat the way I always did, because what you're telling me doesn't help, because it's the wrong advice, and then nobody ever questioned that. The only ones who questioned it were the ones who ended up writing diet books, the quack fad diet doctors. They're the ones who questioned the logic because they were looking for something that would actually make their patients healthier.
[00:37:30] Or in the case of Richard Bernstein, who plays a major role in the 1970s and wrote Dr. Bernstein's Diabetes Solution and sort of pioneered the idea of low-carbohydrate diets for type 1 diabetes. He himself was following the advice, had an engineering mindset, young, diagnosed at age 12 with type 1 diabetes in 1946, goes to Columbia University to study physics, becomes an engineer, then goes into management. By the time he's 30, he's married, he has kids, and he's pretty clearly beginning to suffer this tidal wave of complications from type 1 diabetes and he's been doing everything the ADA has told him to do.
[00:38:18] And he gets access to a blood sugar monitor. So, he becomes the very first person in the world to measure his blood sugar at home. This device where he could prick his finger, put some blood on a strip, see what his blood sugar is, and he can actually see how it responds to the insulin he's taking to his exercise and to his diet. And through methodical self-experimentation work, gets to the point where he realizes and the fact that if he doesn't eat carbohydrate-rich foods, he won't have high blood pressure and he could keep his insulin low. But you have to be outside the medical community to get there or you have to be smart enough to—
[00:38:55] Physician who says, "Look, I know I'm getting to-- my medical societies are telling me this is what I'm supposed to do, but it's not helping my patients." And as soon as you do that, it's like you become excommunicated, you're now somebody who's doing the opposite perhaps of what the medical associations are telling you. And you're seeing in your patients that they're getting healthier, so you're motivated to keep doing it. It seems like you're acting the way physicians should, but now you're outside the system, and other people don't take you seriously because you're outside the system, you've been excommunicated, you're a diet book doctor, especially if you write a diet book. And most of these people said, "Well, look what I see is remarkable, wouldn't it be nice to tell other people other than my patients, and now you're done, now it's like you can get rich, it's true, but you no longer get taken seriously." So that conventional wisdom always holds within the group.
Cynthia Thurlow: [00:39:49] Well, that groupthink, and a degree of cognitive dissonance, and so why do you think that there's been a reluctance by conventional allopathic medicine to embrace a low-carb focused or centric philosophy as it pertains to metabolic health and diabetes management? Because I know that you and I certainly are in alignment with our thought process around this, but I feel like so many of our colleagues really bear the brunt of getting outside that groupthink model and struggling to make sure that the information is propagated and shared.
[00:40:26] And I'll just share one statistic with the Everyday Wellness community, the diabetes industry-- and I want to make sure I quote this properly. The diabetes industry, a comprehensive-- This is a quote from the ADA. The Economic report, which is published every five years, found that the total annual cost of diabetes in 2022 was 412 billion including 306 billion in direct medical costs and 106 billion in indirect costs, so clearly what we're doing is not working.
Gary Taubes: [00:40:55] You would think, and I think in that paper, one out of every four healthcare dollars in America spent on diabetes and the complications of this disease. Again, their perspective is. I don't really understand their perspective anymore, and I've spent 24 years, a quarter of a century working on this. For the most part, it's if people followed our advice, if the doctors-- Remember I said that a resistance to better treatment is considered the doctor's inertial resistance to increasing the dosage or adding new drugs to the diabetic coverage. The resistance against the diet is a series of sort of fundamental assumptions. Nutrition that I've discussed in my other books, and they come back in this book because they've, so one of them is the healthy diet is almost defined by the low saturated fat content. "We know that saturated fat raises LDL cholesterol. We know that saturated LDL cholesterol is a primary driver of heart disease; therefore, a healthy diet is a diet that reduces saturated fat content, which means unsaturated fat is found primarily in animal products, so it's a diet that reduces the consumption of animal products and dairy." By the same token, a healthy diet is mostly plants or plant based and that's sort of a corollary of this and a lot of the reasoning is the same because we're avoiding animal products because of their saturated fat content or they're bad for the environment, for climate change, or it's ethically unacceptable to eat animals, or certainly animals that have been factory farmed, and Lord knows I can understand that perspective and agree with it to some extent.
[00:42:43] Then a healthy diet should be plant based. And plants store their energy primarily as carbohydrates, so it's hard to eat a plant-based diet that isn't carbohydrate rich. And much of the pushback we get in our books and online is from the vegan and vegetarian community that believes that everyone should eat like they do, primarily for the health of the planet and the health of the animals, and they're assuming that it's the best diet for them because it's low in saturated fat, but that's an assumption, and clearly your clinical experience and my journalistic research suggests otherwise.
[00:43:24] The idea that nobody will stay on a diet, simultaneously the idea that all diets work if you eat less, so they make you eat less if you lose weight, it's because you eat less, that means that any diet would be as good as a low-carbohydrate diet. And by the same token, the belief is that the association between overweight and obesity in type 2 diabetes is the excess weight or the process of gaining weight or the overeating that causes the overweight also causes the diabetes, so you could solve the weight problem by eating less, that could be any diet. Heart disease tells you it should be low animal product, low-saturated fat.
[00:43:59] I mean, a series of assumptions that in and of themselves made sense but were never tested. When they were tested, they failed the tests. But by that time, people were so invested in giving this advice that they just said, "Well, we must have done the tests wrong." I mean, it's a terrible situation, you end up with, like journalists giving dietary advice, which is insane. But the reason it's happened is because the science and the assumptions are so bad, it's that the primary resistance. if you were to pick any physician at random on the street and go up and invite him to coffee and say, "Let's sit down and why won't you advise your patients with obesity and diabetes," if they're in internal medicine or family practice, they are going to dominate this patient population. "Why don't you advise them to eat a low-carb, high-fat, high-protein diet?" And they're going to say, "Well, they're not going to follow my advice, nobody wants to go on a diet, I tried that. Or it's going to cause heart disease [unintelligible 00:45:01] high fat?" and "I'm telling them to eat a plant-based diet because I know that's the healthiest diet," so it's sort of their program with all these beliefs that seem perfectly reasonable.
[00:45:12] For me along these lines. I hope by the time this airs I will have had an essay in Time magazine on this diabetes story. And the editor in theory read my book or skimmed the book and said, "Let's have him do an essay." And I wrote the essay and I say in theory because it's been two weeks since I handed it in, I haven't heard a word, and I tend to write long, and who knows. So they clearly interested in my perspective because I think I'm giving an important perspective on the problems with medical science and nutrition science and how it applies to patients and readers. And then I'm reading through other essays that Time magazine has written because I want to see what they're going to expect from me. And I find an article where there's a throwaway line by one of their health editor. There's a throwaway line, "We all know red meat is bad for us." Well, it's hard to do, you can do a vegan or vegetarian low-carb, high-fat diet, but it's very hard to do. So, it's easier to do it with animal products, with meat, fish and fowl, because meat, fish and fowl are composed of fat and protein, not carbs, so that's what you want to consume, fat and protein. It's very easy to wake up in the morning and make a couple of eggs and be pretty confident that you're eating a low-carb diet because these are animal products. But yet this belief system has just spread. And these journalists and the physicians-- Doctors don't have time to do what I've done and what you've done to some extent, which is actually look to see if their beliefs are based in concrete or in jello. They trust their authorities, their medical associations to do that job for them.
[00:46:51] And if their medical associations are biased or are doing a bad job which physicians don't know and then they're stuck in the uncomfortable position of who do you believe? Do you believe the journalist who says, don't trust the American Diabetes Association or do you believe the American Diabetes Association, who's going to tell you that the journalist doesn't know what he's talking about. And so, everybody's making what seems like a reasonable decision. The patients are being treated terribly as a result, and nobody's even acknowledging that at very least, these things have to be tested, these ideas, because you want your beliefs, especially when you're treating patients and they're trusting you, you want your beliefs to be based on concrete.
Cynthia Thurlow: [00:47:34] Absolutely. And I think know the Hippocratic Oath that first do no harm really plays a role here. I think that when we consider the significant and substantial poor metabolic health that we see here, not just in the United States, but in most westernized countries, which meant that the current system, current medical model is not working. Now, I want to be respectful of your time, but I would love to kind of learn what you're working on next, because there're so many things in this book, we could spend hours talking about it. I so thoroughly enjoyed reading it. What are you working on next? You've been alluding to this, you might not be able to share, but I'm curious, is it evolving beyond the diabetes piece? Is it something similar to what this book is about or something totally different?
Gary Taubes: [00:48:19] It's related, baked in one of the revelations in doing my first book on nutrition, good calories, bad calories, was this realization that obesity isn't caused by eating too much. Okay. It's a hormonal disorder, neurohormonal dysregulation. This was a theory that was had-- The idea that it's energy imbalance, you consume more calories than you expend was a theory that came out of Germany in the 1890s because they could measure how much energy people ate and expended. And by 1910, it had been pretty much tossed aside by researchers and said "Look, there's just no way this theory tells us anything about obesity. And when we actually try to measure how much people eat or measure how much they expend, it doesn't do anything for us." But on the other hand, we have all these examples of obesity, types of obesity that we know are sort of hormonal disorders and they already knew this by 1910. By 1930, this has been kind of accepted in Germany, and then it's--
[00:49:21] A doctor from the University of Michigan comes along in the US and says, "I have proven beyond a shadow of the doubt that obesity is caused by eating too much, it's always caused by eating too much, it's never a hormonal disorder." And starts to get some traction in the US, that Europeans are like horrified by this thinking, pulling their hair out. And then World War II comes and the European medical research establishment evaporates and the guy in the US wins, convinces everyone that obesity is caused by eating too much and that's what we've grown up with, this idea that it's an eating disorder or a psyche. I mean, the latest is it's a subconscious disorder of inability to match intake to expenditure at a subconscious level. And nowhere, almost nowhere, because I heard a delightful example the other day, exception. Does anyone talk about obesity as a hormonal?
[00:50:12] So even the weight gain during menopause that women often experience at 15 pounds in 15 years, beginning in their early 40s and ending in their late 50s, is still perceived. Despite the awareness since forever that sex hormones play a major role in fat accumulation, it's still seen as somehow a disorder that causes the brain to lose the ability to balance and take an expenditure. And I know this because a few years ago I spent a week doing nothing but interviewing researchers who study menopause, and I kept saying, "You know, that estrogen inhibits fat formation, so when you go through, I've got textbooks from the 1926 that say this, they didn't even really know what estrogen was." Anyway, so and that was a revelation then, it's in every one of my books, in various, like the book I wrote, The Case Against Sugar, there's a chapter called the gift that keeps on giving. Because if you thought of obesity, a disorder of energy imbalance, eating too much, the worst you could say about sugar was that we like it so much, we consume too much of it. And you can never regulate against something just because you like it. You got to have some, you know it's addictive or it's deadly or causes lung cancer, liking it isn't—
[00:51:31] So, the sugar industry has depended on this concept of energy imbalance so that sugar would never be implicated as something that could be regulated. And it's always ignored, it's ignored by reviewers, it's ignored by the idea that I'm arguing that obesity isn't caused by eating too much is either insane or too big to deal with. So, I told my editors, the only way I'm going to get this not ignored is if I write a book only about that idea, okay. It's actually the first half of my book, Why We Get Fat, but everybody always says, "Oh, he tells people not to eat carbs." They never tell them that this implies a different theory of obesity. And we've been getting traction by the way in the medical journals. Articles have been written about these competing hypotheses, but in the lay press, nothing.
[00:52:14] And in my books, whether they've been rave reviews or pans, the idea that the horrible misjudgment has been perpetrated by obesity research we’ve never discussed. So, I want to write a book just about the history of that thinking. And in doing that, I have to write about the history of the hormonal thinking as well, because they're intimately linked, and then how that thinking influenced everything that came after. And as I was mentioning, now I have access to virtually all the world's literature. Thanks to these Internet repositories. And I have AI programs that translated brilliantly, so enough patient I can see. When I wrote my Good Calories, Bad Calories, I had to pay a German researcher to translate five pages from a textbook from 1926, It cost me $5,000. Now, it's like, scan it into the computer, copy into Chat-GPT, paste, and I get an instantaneous translation, and it's just been revelatory. I mean, I feel like one of those Egyptologists stumbling into a tomb. You've got all this wealth of thinking that nobody's really paid attention to, and in this case, over a century, and it's now accessible. And so that's the book that I was hoping I would write in six months, just to give the history is now going to be a three-year project, and we're going to talk three years from now, and you're going to say, "This seems like a labor of love Gary." And I'm going to say, "No, it's obsession."
[00:53:45] My wife used to compare me to Jack Nicholson in The Shining because I go upstairs now and translate German and she's like, "My husband has gone crazy." I've been spending hours just doing nothing, but sort of reading this literature that nobody's bothered to read for a century, and they were smart. I mean, it's like in physics, the best physics in the first half of the 20th century was all done by Germans and Austrians, mostly many Jews. And then they get chased out of the country by Hitler in World War II, they end up in physics, we embrace them because we had atom bombs to build, Manhattan project, and we recognized the value of these people and we needed them, and we gave them positions. The physicists in the Manhattan project, many of them were former European, Jewish physicians who had fled to the US with Nazism and the war and wanted to stop Hitler.
[00:54:40] In medicine, we wanted nothing to do with these people, so they ended up ending their careers and like one of the leading endocrinologists from Vienna. The great university in the world ends up at the College of Medical Evangelists in LA, Seventh-day Adventists organization. His son goes on to be dean of the USC Medical School, but their writing is ignored. They're thinking and the only writing you can get is a writing that was translated into English. Actually, this one fellow, a guy named Julius Bauer, I found out that he had actually written a memoir. I didn't know this and I was desperate to read his memoir. And even though he had been living in the US, when he wrote the memoir for 10 years, he wrote it in German, so I had to find it at a German bookstore. It wasn't online and have it shipped, cut it open, scan it into the computer, and translate it into English, because he wasn't interested enough in Americans to write it in English himself, so that's the next book.
[00:55:34] I want to try and put a stake in this idea that people get that the difference between one of us who's lean and a friend or a relative or a sibling who's obese is how much we eat rather than how much our bodies want to accumulate fat or not.
Cynthia Thurlow: [00:55:49] Well, I find it all so fascinating, and your work is a gift, you are a gift. Thank you for this amazing book that you've written that I think is going to be very, very helpful and influential. Please let listeners know how to connect with you on social media, how to get a copy of your latest book. I know that this podcast will be out around the time of the publication or how to reach out to you in general.
Gary Taubes: [00:56:11] Okay, so the book right is called Rethinking Diabetes, published by Knopf, available at Amazon, obviously and bookstores near you if you still go to physical bookstores. My website is garytaubes.com, and I tweet @garytaubes, and I have a couple Facebook pages I don't look at as nearly as much as I should and I'm not on Instagram, although my wife says, "How can you not be on Instagram." So, yeah, you know, the book, like I said, it was a revelation to write. I think there's nothing like it in the diabetes world. There may be nothing like it in medicine period. We'll find out if the medical community wants such a book. I think it's a good read, but it's not an easy read. And being interested in medicine and history of medicine helps because it's as much about that as it is diabetes. And if you've ever had doubts about the proper diet, it should dispel them, but the point I keep making is, since we don't have clinical trials for long-term benefits and risks of any diet, they've never been done in diabetes. All you can do is see if this makes you feel better and ideally use a lot less drugs, a lot fewer pills. Anyway, thank you, Cynthia.
Cynthia Thurlow: [00:57:30] No, this has been a pleasure. And as I always say, it all starts with food. I think that for many individuals, they initially perhaps buy into the concept that more insulin, more coverage, more oral drugs are going to somehow make things better. And I think that the true simplicity of the lifestyle piece for people that are open to it can really improve their quality of life quite tremendously. Thank you for your work.
Gary Taubes: [00:57:53] Thank you.
Cynthia Thurlow: [00:57:56] You it if you love this podcast episode, please leave a rating and review, subscribe and tell a friend.
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