INTERVIEW: The Evolution of Diabetes Treatment with Gary Taubes
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And if you have diabetes, you know someone with diabetes, or you have prediabetes, or you're overweight, which probably counts for 75% of you listening, you're going to love this conversation because it's with an investigative journalist, Gary Taubes, who has done a lot of work in trying to understand the nature of diabetes. He's an investigative science and health journalist. He's the author of this new book, Rethinking Diabetes, which we're talking about today. He's also written The Case for Keto, The Case Against Sugar, Why We Get Fat, Good Calories, Bad Calories, and

which is amazing. It was published in the UK as The Diet Delusion. He's a former staff writer for Discover and a correspondent for the journal Science. His writing has also appeared in the New York Times Magazine, The Atlantic, Esquire, and he's been included in the numerous best of anthologies, including the best of the best American science writing. And he's received three Science in Society Journalism Awards from the U.S. National Association of Science Writers. And he's a recipient of a very prestigious Robert Wood Johnson Foundation Investigator Award in Health Policy Research.

he went to harvard he's got a master's degree in engineering from stanford a journalism degree from columbia and he's an incredible man who's done a lot of work and trying to understand why we are overweight why we have diabetes and what we can do about it i know you're going to this conversation because we got deep into the history

of how we began to understand nutrition and nutrition therapy in diabetes. And back in the day, we talk about in the 1700s and 1800s and early 1900s, we were using very high fat, what they called animal diets to treat diabetes. And we talk about how that all changed with the discovery insulin, when we loaded up people with carbohydrates and lots of insulin and how that has led to some significant complications. We also talk about how some of the science that has been done is really not translated into the

policies or the recommendations from the American Diabetic Association. And we talk about some really fascinating research that's been done by Sarah Hallberg and others looking at ketogenic diets to not just manage diabetes, but to reverse it. So I think you're going to love this conversation with Gary and let's jump right in. Well, Gary, it's great to have you back on The Doctor's Pharmacy again. Mark, it's great. It's funny. I just have to

The last time we talked, you were in Hawaii and I was in Oakland. Oh, that's right. That was the COVID shutdown era. That's right. And the time before that, we were both in Geneva. Yeah, that's right, in Geneva. Was it Geneva? Wait, Geneva. Yeah, it was a food conference. And we were talking all about the things we're talking about today, which is...

how food affects our health and the epidemic of diabetes and controversies about nutrition. And it was kind of the Illuminati of the diet, nutrition, diabetes world. That was a big day. Yeah, it was really powerful. Zurich, now that I think about it, wasn't Geneva. Got to get that straight. That's right. Got to get our facts right. So yeah, Gary, it's so good to have you back. For those who don't know Gary, I did the intro, but he wrote this article that kind of broke through

called "What if it's all a big fat lie" in 2002 in New York Times Magazine. I read it, I didn't even know who you were at the time. And I was like, wow, this really doesn't fit with what I learned in medical school. And it really started the conversation going about

The quality of the food we eat, the quality of the calories we eat, and how they affect our metabolism and our hormones, and how maybe weight loss wasn't all about eating less and exercising more. And you've been deep in this for a long time. You've written so many books about it. And your latest book, which is why we're having the conversation today, is called Rethinking Diabetes. And I have loved this book. I've just been savoring it every night.

It's like a mystery novel about the history of diabetes and what's gone wrong in our approach to this condition. And it's really the biggest scourge today on the planet. I would say diabetes, prediabetes, metabolic dysfunction is really at the root of so much of the suffering we're seeing. Everything from heart disease to diabetes, obviously, to cancer, to dementia, even things like depression, infertility, even acne. Yeah.

can be related to the dysfunctions that we have with our metabolic health. And recent data from the NHANES trial show that 93.2% of Americans are metabolically unhealthy, which means there's somewhere in the continuum of insulin resistance where they have a high blood pressure, high blood sugar, high cholesterol, have had a heart attack or stroke already. 93%? No, 93.2%. Oof.

So, you know, 75% of our weight. So this book has really kind of turned a lot of our ideas upside down about diabetes. And I've been thinking about this for a lot. So I didn't really have to do a lot of rethinking, but I think a lot of people are going to read this book and go, oh boy, we got it all wrong about diabetes. And

And you kind of talk about how really this journey for you, and I'll just quote you, it says, it begins with the regrettable observation that we are in the midst of a diabetes epidemic, a disease that was vanishingly rare in the 19th century that now affects people

one in every nine Americans, and that all attempts so far to rein it in have failed. And it's incumbent upon someone to ask the question why. So you took that, find yourself to ask that question. And I think we're going to get to the answer today. And did we fail because the current situation was inevitable, meaning the result of a food industry out of control perhaps, or a nation of individuals who can't say no to what's next and tasty and the next ultra processed snack, or maybe because we made mistakes in

And the diabetes specialists got it wrong and public health authorities maybe allowed this to happen. So we're kind of in a disastrous situation where one in four teenage boys has prediabetes or type two diabetes. One in...

I think nine now, you said, have diabetes. Some populations have one in four. The current view, and this is what I learned in medical school, which is this is a progressive disease. It ain't going away. You have to, quote, manage it. You have to manage it with medications, and you have to use ever-increasing amounts, dosages, and frequencies of medications, including insulin, to control the disease.

And yet there was a trial that happened that got me completely switched in my thinking. It was called the ACCORD trial. And this was a trial done many years ago on 10,000 diabetics. And what they said was, look, sugar is the problem. So if we really want to fix diabetes and the complications from diabetes, we need to be very aggressive in controlling blood sugar. So they use very aggressive insulin doses, very aggressive drugs called oral hypoglycemics, which raise insulin.

And the consequences of that therapy were that more people died and more people had heart attacks than who didn't have the intensive therapy. And Accord was one of three similar trials. All of them found the same thing. So basically we're talking about a disease that we have been treating in the wrong way that has really been focused on trying to use more insulin,

to treat what has been thought of as an insulin deficiency, but in fact, it really isn't. It's mostly a disease of insulin excess in 95% of the cases, not if you're type one diabetes.

So maybe, Gary, you could talk about this book from the beginning because I think the history is really fascinating. Just to kind of give us a brief overview of the history of the thinking about diabetes. Because in the 19th century, it was like a rare disease. Like if you had this in the hospital, all the residents, the medical students, the attendings, they all come running, oh, wow, there's this rare case.

and like we'd have syphilis now. I'd never seen a case of syphilis in my life, right? But I read about it, you know? So then it was rare, but it was happening. And so the doctors then had a very interesting approach that kind of happened upon the right answer in many cases.

using a dietary approach that restricted carbohydrates and used basically a ketogenic diet before they had insulin. So can you talk about how that developed and then what happened after insulin was discovered by Banting and Best in 1921? - Okay, and I'm happy to do that. Before we do, though, give you just a brief explanation.

for why this kind of research is necessary. And in the book, in Rethinking Diabetes, in the epilogue, I talk about the history of the evidence-based medicine movement.

Oh, I want to hear about that. Yeah. So until the 1970s, basically, you know, what a doctor did with the treated a patient was based on what he had learned in med school and what the authority figures in his life said, maybe what his textbook suggested and maybe what his colleagues were doing, but there wasn't really a lot of that. It was apprenticeship basically. Yeah. And now in the 1970s, if you've

Smart young doctors came along and they decided they would, one of them, a guy named David Eddy, who at the time had left medicine, was getting his PhD at the Duke Stanford University in computational physics or something. And they had asked him to, he was going to give a talk on genetics.

why doctors were prescribing for something. And he looked into the, he chose mammography as a subject. Then he went back into the literature to look at the evidence-based, why people recommend mammographies and what the benefits of them are. And he thought this would explain various sort of operating systems, charts, and how you go through different branches to decide what to do. Like an algorithm, right. And he thought that he would...

find that this procedure was based in concrete evidence. And he said instead what he found out was that it was based on Jell-O.

Jello. There was just nothing there. It was just this technology that had come along that people thought might be beneficial and they started to do it. And the more they did it, the more other people did it and they never tested it. Yeah. And this was the beginning of the evidence-based medicine movement. So what you do when confronted with a dilemma as a journalist or a physician who's interested in the bigger picture is you always ask the simple question, what's the evidence?

Why do we do this? Diabetes has exploded in prevalence, the increase just since 1960 is 600 or 700% increase. If this was any other disease... Not genetic. Not genetic, something about our lifestyles has made this explode.

Still seen after, you know, 104 years, 103 years of pharmaceutical therapy, it's still seen as a progressive chronic disease. The biggest challenge to successful treatment, according to an ADA panel a few years ago, is the resistance of physicians to do what you said has to be done, which is continue to

raise doses, add new drugs to the therapy. So that's what they're saying the problem is, we're not treating it aggressively enough? You're not treating it aggressively enough. You're letting blood sugar rise out of control in patients. So the question I asked as a journalist was, basically, as I said, as you read that quote from me, is this inevitable? And if it's not, what's the evidence base for the decisions? And when you start asking that question, you start going back in time.

So you start looking for clinical trials and the clinical trials you find will reference other clinical trials or other observational studies and you just keep going back in time. And nowadays, because of the internet...

It was like a time travel going to reading that book. I mean, everything's available. Yeah. One way I describe this is 1920s when our philosophy of how to treat this drug was originally founded and it's still with us today. The physicians who crafted that philosophy had imagined that the whole world of diabetes therapy and diet and lifestyle is like a thousand piece jigsaw puzzle. And they had maybe 50 pieces of

And they weren't just 50 pieces in one corner. They were 50 pieces scattered throughout the jigsaw puzzle. And that's how they were making their decisions. Now you can go back in time and because of the internet and all these repositories of journal articles and documents and books, Google Books allows you to find all the textbooks. If you can't,

get them on Google Books, you can find bookstores that sell them. My office is full with like, you know, multiple editions. Moldy books from 1925. 80-year-old textbooks and the third edition and the fourth. Anyway, now you can get, say, 950 pieces of that thousand-piece jigsaw puzzle. You can see everything they should have seen.

But didn't. Hindsight is 20-20. So you can go back and not only describe what they did, but what they missed. And you could say they did this because they saw that.

or they had a patient that experienced this. They wrote about it and they gave a talk about it in 1927 at this conference in New York to physicians, and here's the talk. It allows you not just to piece together the history of this field, and I think historically this book is something that's never been done before, diabetes therapy, but also to see what was missed and how the thinking evolved considering what was missed. So as you said...

In diabetes, you could go back 2,000 years to when it's identified in ancient texts or Indian texts, but the modern history starts in 1797. Okay, a guy, a British doctor named John Rollo working for the military has a patient named Colonel Meredith Bell.

Meredith has diabetes, he shows up, he's lost a lot of weight, he's hungry, he's thirsty all the time, he's peeing constantly. Back then they would have their assistant taste the urine. This was a diagnostic technique. And if the urine was sweet, that was the identification of diabetes.

And Rallo thinks- Isn't that what mellitus means, is sweetness? Sweetness. Like honey. Honey, yeah. So Rallo thinks if there's sugar in the urine, he's not metabolizing the sugar properly. The sugar comes from plant foods. So I'm going to feed him a diet of animal meat and recommend to see what happens. And he puts them on, he calls it the animal diet. It's actually fatty rancid meat, blood sausages. I mean, it sounds awful. Disgusting. But Meredith gets better. It worked. It worked.

And he ends up living for, I mean, at that stage in time, he probably had type 2 diabetes because he had been overweight and obese, but they don't show up and they don't manifest the symptoms. One of the symptoms of being sick is losing a lot of weight. So at that point his pancreas was failing, but he still lives 12 more years. Amazing. Rollo tries it on a different patient, a general, he was in the army. That patient also gets better, but he doesn't stick to the diet. He goes home, eats what he wants and dies. So Rollo publishes a pamphlet. That's right.

disseminates it throughout the United Kingdom and says to people, this is, look, I seem to have come up with a way to cure this diabetes. If you've got any patients, consider trying it with them. This is medicine before clinical trials. Okay. And it's still medicine where we don't have clinical trials. It certainly is. Yeah. So,

few dozen physicians write back to them and almost, I mean, the ones who write back at the diet works. They don't understand it. Like the patient will get better and then they'll let them eat whatever they want. Then the patient will get worse and they'll put them out or they'll have kids. There's a 12 year old girl who gets better, but she keeps cheating and she knows she just can't stop eating sweets. But the gist of it is it works. And by the mid 19th century,

this animal diet, they get rid of the rancid meat and the blood sausages and basically just becomes fatty meat and green leafy vegetables, so it is in effect a ketogenic diet. Paleo, keto-ish. And it becomes a standard of care for treating diabetes. So it could keep patients with type 2 diabetes alive indefinitely, their symptoms effectively go away if they don't eat carbohydrates. And patients with type 1 who are insulin deficient,

It'll delay their demise, slow it down, but it's not going to stop it. You have no idea how much it slows it because you don't know how long the person would have lived anyway. The leading Italian diabetes specialist, he's a guy named Cantani. He's locking his patients away for two months now.

to make sure they don't eat any carbohydrates and they only eat this animal diet. The Germans are doing it, the French are doing it, the British. I mean, every major, basically you can't be a diabetes specialist. And again, it's a rare disease. There aren't many of these guys without using this animal diet. As the 19th century turns into the 20th, it becomes richer and richer with fat.

Because again patients show up in the doctor's office having lost a lot of weight and if they're type 1 and they're young they're emaciated. So the doctors thought we want to put weight back on them and we want to feed them as much food as we can. And since you can't give them carbohydrates we can give them fat. There's a Swede named Petran.

feeding patients 95% fat diets. I mean, a German comments that the diet is unbelievably effective with his patients, but he can't get Germans to live on cucumbers and butter the way the Swedes were. I mean, Petrin wouldn't even let his patients eat bacon because there's too much protein. Some of the protein gets converted into amino acids, get converted into glucose. So...

This is a standard diet. There's a brief blip from 1914 onward for six years when this Harvard, Harvard's done a lot of damage in these worlds. This Harvard doctor starts advocating. No, this is Fred Allen. Oh, yeah. He's a friend of Jocelyn's. Yeah, yeah. Starts advocating for this starvation diet. So the idea turns out that with the young type 1 patients, if you starve them,

you can keep them alive longer. Yeah, so this is standard of care. So basically...

by accident, some observant physician made the conclusion that carbohydrates were causing sugar in the urine and maybe we should not eat them. And that became the standard of care until, including with Dr. Jocelyn, until 1921 when insulin was discovered. Right. So Jocelyn, just for background, Jocelyn is a Harvard grad. His mother has diabetes. His aunt had diabetes and died from it. He's obsessed. Type 1.

Well, again, they were probably both type 2 because they remember at that point in time they were overweight. Yeah. And then they... You don't... You got it as an app, right? You're not getting blood tests, right? Right, right. Nobody has any idea what their A1C is. Right. So they only manifest as diabetes when their pancreas starts to fail. And you get the weight loss and all these other... Yeah. The hunger, the thirst, the peeing. So...

Jocelyn opens the first diabetes clinic in the United States in Boston dedicated to diabetes. So this is a period in time. It's still there. It's the Jocelyn Diabetes Center at Harvard. It eventually became the Jocelyn Diabetes Center. And because he's got the only dedicated clinic, he's seeing more patients than anyone else. So by 1916, when he writes the first edition of his textbook at

It's Jocelyn's diabetes mellitus based on a thousand cases. And probably nobody else in the United States had seen more than 30 or 40. And then in 1917, he's got based on 1300 cases and he just keeps releasing the textbook. And he kept his mother alive on this high fat carbohydrate restricted diet. She thrived, lived longer than any of her other healthy relatives ever.

Because he had gone to Germany, learned what the Germans were doing with all the butter and the meat and the no carbs. And she was a stern New England stock and she would do whatever he told her to do and she thrived. And then he buys into this Alan thing with the starvation therapy. And the starvation therapy, you're restricting not just carbs, but fat also. And calories, right. And calories. So now he kind of begins to blame fat as Alan did for...

the disorders that would kill these diabetics because you're feeding them high fat diets and he thinks they shouldn't die. Anyway, 1921 insulin is discovered. First used therapeutically in January 1922 on a 13 year old boy named Leonard Thompson. It's a tremendous success. I mean, Thompson was so weak.

He weighed, I think, 65 pounds. He was 13 years old. His father had to carry him to the hospital bed. 50 years later, the med students and residents in this Toronto hospital said they were sure he was dead. Like this was, you know, he had weeks to live. Insulin brought him back to life. I mean, just within days, it was a miracle cure. Eli Lilly begins to produce insulin and they make it available to

doctors around the US and Canada who had been treating a lot of diabetes patients, they were becoming diabetes specialists and it's a miracle. It's like they've never seen these patients are resurrected. - But then what happened was something interesting, which is they somehow shifted from this idea that we should restrict carbohydrates, that we should actually feed them a lot of carbohydrates and just cover it with insulin. - Well, so this is an extremely powerful

I mean, it's a hormone, right? - A peptide, like Ozempic. We'll talk about that in a minute. - For all intents and purposes, there was no such thing as low blood sugar, hypoglycemia until insulin was discovered.

Now, if you overdose, you've got to balance the insulin to the carbohydrate. So there's no way to know what the proper dose is. Everybody's different. And insulin will control blood sugar. It'll de-sugarize the urine, which was their target. Let's get rid of the symptoms and get the sugar out of the urine. But we don't know how much to give. And how much we give depends on how many carbs they eat. And suddenly, you're having these patients who,

are getting hypoglycemic episodes, are going into what they call at the time insulin shock or insulin overdose, and that can be fatal. Yeah, it can. So the cure, the great miracle drug is a cure for a chronic condition or an acute condition, type 1 diabetes, but the side effect is that it can be fatal within hours.

Right. Serious side effects. So suddenly you have to feed patients carbohydrates. You have to make sure they eat enough carbohydrates to protect them from the treatment. Yeah. That's, you know, protecting them from the absence of insulin or too much. Doctors realized pretty quickly this...

trying to figure out how much insulin to give and how much carbohydrates to feed is really difficult. And with children, this disease is when you're diagnosed, it's bad enough diagnosis without telling kids they shouldn't eat ice cream ever again or they can't have cereal in the morning like their friends. Yeah, they don't want to restrict them. So very quickly they decide, look, it's just easier to let the kids eat whatever they want. They're going to do it anyway and we'll cover it with insulin. Yeah.

And from the 1920s to the 1930s, it goes from children to adults, both type 1 and type 2. And everyone just says it seems to work. The patients seem to, some patients at least, seem to feel better. They all get fatter, which is a side effect. People need to know, when you start taking insulin, you gain weight because insulin is a fat storage hormone. Insulin is a fat storage hormone. And

some people knew that and some people didn't. Then we'll talk about how that got confounded by the conventional thinking on obesity. I hope we will. What they didn't know, this is a part of the issue with

so evidence-based medicine movement that I had mentioned in the 1970s, the idea was if you want to know if you've got a therapy and you want to know whether it's better than nothing, whether it's better than what we're already giving patients, you do a randomized controlled trial and you randomize patients, you give one of them the new therapy and one the old and one the new therapy and one group the placebo, and then you run them forward long enough in time not just to see whether it's more effective but to see whether it's safe or not or safer. Yeah.

And you go with enough patients and long enough so you could see whether they have more or less of complications, heart disease, cancer, dementia, whatever you might be. They didn't have that in the 20s. The concept of randomized controlled trial hadn't been discovered until they developed this therapeutic philosophy for treating their patients.

And then as you get about 5, 10 years down the line, they start to see this, they refer to it as kind of tidal wave of diabetic complications. These patients whose lives might be saved by insulin, resurrected, brought back from the dead at 9, 10, 12 years old, are now 22, 25, 27, and suddenly all the familiar complications of diabetes are gone.

atherosclerosis or arteriosclerosis. They're getting sclerotic plaques all through their body. They're dying of heart disease and strokes. Blindness and kidney disease. Kidney disease and neuropathies or having their limbs amputated. And when you read the records, and there's a wonderful book by a

a pediatrician turned medical historian named Chris Feutner called Bittersweet, where he got a hold of Jocelyn's records from his early years. And these patients would be thriving. And then over the course of a year or two, their bodies would just fail them. Was it because they were taking too much insulin or because they were eating too many carbohydrates or both? You have no idea, right? So their assumption...

as they're trying to wrestle with these complications, is that the patients aren't doing a good enough job controlling blood sugar. So it's the patient's fault? Possibly, yeah. There are patients who seem to take their drug therapy seriously and rigorously seem to do better. So the idea was the blood sugar control is the issue. And the answer, again, when you think like that, is more...

Insulin. Insulin or more regular use of insulin or more. But what they didn't know, they didn't actually know if that was true. Because all they know is that it could have been the uncontrolled blood sugar, which is what they assumed. It could have been the diet that they were allowing them to eat with the, that was in part responsible for the uncontrolled drug therapy. It could have been the insulin therapy. Yeah.

You can't differentiate with the information they had because they didn't do the right clinic. They didn't do any clinical trials. Their assumption was poorly controlled blood sugar. So you move into the Second World War with that as the assumption, come out of the war, and out of the war you start seeing the first arrival of these hypoglycemic oral, the holy grail of the field is a drug that can lower blood sugar. Like guanides, yeah.

and take it by mouth. You don't have to use a damn needle. This catches on pretty quickly. As soon as they established that it's safe and it lowers blood sugar, people started using these drugs. And they work by raising insulin.

They work by stimulating insulin secretion. But if you look at the label, the warning that's mandated by the FDA, it's got a black box warning on these drugs. A black box warning is essentially an alert that this has got serious side effects. And for oral hypoglycemics, the black box warning is,

It's going to help your diabetes, but it's going to cause you to have a heart attack and stroke. Well, so this is the very first randomized clinical trial they do in this field. It was called the University Diabetes Program, and it starts around 1960.

And it starts because there's a congressman whose daughter is diagnosed with diabetes and she's put on one of these horrible hypoglycemic drugs. And the congressman asks, he's in Ohio, so he asks the leading authority at Case Western, you know, do these drugs, do they help? And he says, I don't know.

Right. Who knows? Maybe yes, maybe no. So they actually get $30 million together to do a clinical trial. $30 million in 1960 was a load of cash. Yeah, it was a big trial. It went for 10 years and it was these oral, this drug tobutamide and oral hypoglycemic and then insulin and then diet alone. And they added...

Fen-fen, one of the fens of the fen-fens fiasco. I forget which one. Anyway, in 1970, the results are leaked to, I think it was the Wall Street Journal. I mean, not only does the oral hypoglycemic agent not do anything, not keep people alive any longer than diet alone, and the diet was a bad diet. I mean, it was a carbohydrate-rich diet they were giving them. Insulin doesn't do any better either. Yeah.

Okay, it's completely useless. And this was a huge controversy. Of course, half the, most of the-- - When you say better either, do you mean in terms of like reducing death, heart attacks, strokes? - Deaths, heart attacks, whatever they looked at. I forget what the end points of the study were, but the drugs didn't help. And again, it must've been, it might've been mortality. They didn't play up the insulin. They played up the, you know, the oral hypoglycemia. But this is what doctors, this was what therapy was.

I went to medical school in 1983, that's what I learned how to do, is give these drugs. - Yeah, so you give them drugs. - And it was interesting, Gary, I'm just reflecting back on my training, and what I learned was, I would see these patients come in who were eating a lot of carbohydrates, and they were taking 100 or 200 units of insulin, and we thought that was fine, to give them as much insulin as necessary to keep their blood sugar under control.

but it never occurred to me was what was the normal amount of insulin that's produced by the pancreas every day in someone who doesn't have diabetes? - Yeah, and it's like 20 to 60 units, depending on how many carbs. - Yeah, it's like depending on what you eat, like it can be 10 to 20 or more units.

So giving all this extra insulin can help control the blood sugar, but it's actually having all these adverse effects of weight gain and inflammation. The reason you have to give so much is because, again, this gets back to the story, they're insulin resistant. The problem isn't that they're insulin deficient, which is type 1 diabetes. They have too much insulin already. And then there's double diabetes. Now you're adding more, yeah. What's interesting, again, going back to the history, we were talking about Jocelyn.

And when insulin first came in, this really launched Jocelyn to his fame because he embraced it, he talked about it in chapters in his textbook on how to use it. Jocelyn thought the way to use it is you've got to minimize doses. They started patients on one unit and then they went to two units and three units and in the early 1920s they might have been using 10, 20 units of insulin on patients, then you have to strictly control their diet

so that minimal insulin can... -Can work. -Can de-sugarize urine, which was there. And as time went on, other doctors were pushing for much greater doses. There was a Sansom in Santa Barbara who was pushing for 50, 100 units, 150 units, and he would show, he said, "My patients are thriving." But in his papers you could see his patients had gained like 50, 80 pounds in a year.

So they start off emaciated and then they maybe put on 40 pounds to get back to normal and then the extra 40 is obesity. And there's a British diabetes specialist, Lawrence, who had type 1 diabetes himself and his life had been, he was dying in Italy when insulin was discovered. His doctor back in the UK said, if you can make it home, I can save your life.

And it did. And he became, he co-founded the British Diabetes Foundation with H.G. Wells, famous science fiction writer who had diabetes. And Lawrence tried these higher doses and he was like, this is crazy. You know, it's like, I don't want to blow up like a balloon. I,

- We know that if you start a patient on insulin, their blood pressure goes up, their weight goes up, their triglycerides go up, their cholesterol goes up. We know this and so insulin is not-- - But we got drugs for everything. We got statin for the cholesterols, we've got blood pressure-- - We call it comorbidities. We call it comorbidities. Like treat them all separately with drugs. You got a blood pressure drug, cholesterol drug, diabetes drug.

And I mean, it's, you know, it sounds facile to say so, but I mean, that was basically, you've got a pharmaceutical industry that's working hard to provide these drugs. And then, you know, there are people with high blood pressure and high cholesterol. It's a bonanza. They don't have diabetes. So you've got the drugs, use them. Yeah. And nowhere along the line do people say, wait, wait, wait, why?

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with the cone hymen 10. I mean, your book basically rethinking diabetes challenges all of our assumptions about diabetes. Uh, it pretty much does, which makes it a difficult thing to swallow. If you're somebody who believes the assumptions, the oddness about that book is it's basically written for precisely those people who won't read it. Yeah. No, it's true. The reason they won't read it is because they're convinced their assumptions are correct.

And, you know, I have an odd sense of...

commercializing my intellect. Yeah, I mean, you have to question your assumptions. And I think John F. Kennedy had a great quote about this. I don't know if you remember. Essentially, it was like, most people are not willing to challenge their assumptions and the discomfort of thought. Well, it's also not just challenging your assumptions, but it's challenging your assumptions on which you have built your career. Yeah. So you get to the pinnacle of your career because you basically embrace the conventional thinking of the disease. As soon as you...

embrace an unorthodox approach, then you get excommunicated from your church. So the field selects out people who agree with the conventional thinking.

They become professors, heads of departments, heads of associations. They serve on prestigious committees. They're the people you go to when the New York Times runs an article. They're the people who we consider experts and authorities. The guidelines. And the same has been said of me, and it's true. It's like, at what point can you say everything I believe, everything that not only made me

the person you see for that reason I'm on Mark Hodman's podcast but the people you like and respect all think the same way it's literally it is quite like a church you all have a certain religion kind of a cult yeah I was interesting I was interviewing a 80 year old nutritionist that they

at Baylor University this past week. The interview very quickly deteriorated into just an extremely pleasant two-hour discussion about good and bad science. But he used the phrase allegiance bias. And I said, I stopped him. Which camp you belong to, right? Yeah, I'd never heard that before, but it's exactly right. And so you have a certain allegiance bias and it's just, not only does everyone you know and respect think like you do, but...

It's what made you the person you are today and now you're supposed to

It's true. I mean, I think Chris Gardner is a great scientist, but they have a plant-based research. We have a different conception. Okay, well, he's a Stanford. He's a smart guy. He's a good guy. I like him. He's a nice guy. And they have a plant-based research institute, which seems ideologically biased right from the get-go. Yeah, although to Christopher's defense, I assume what he's trying to do is demonstrate that

that a plant-based diet is not harmful. So what is the phrase they use in clinical trials in medicine for non-inferiority trials? If you can demonstrate that it's not inferior to ways of eating with

animal products and then you can recommend that people do it if they're for ethical reasons or environmental reasons, they can eat this way and have confidence they won't be harming themselves. - Right. - Or they can feed it to their children. So I think that's how he would defend it. - I mean, okay, but-- - But still, it's sort of-- - Is there a meat-based diet initiative or-- - Yeah, no, exactly, exactly. - Is there maybe a fake meat-based diet initiative?

But, you know, I think you're hitting on something really important, Gary, which is that the way we've done science is really kind of skewed and biased in many ways. And we don't challenge our assumptions. And we look at the world in a certain way through certain lenses. Artie Lang said this. He said, scientists can't see the way they see with their way of seeing.

So when you look at the horizon, we're in LA, you go to Venice Beach, you look out and the earth is flat. You can confirm it with your own eyes and there's no doubt about it. And not only that, undeniably the sun is revolving around the earth. Absolutely. But neither of those are true. And until somebody started to question those assumptions and some of them are called crazy or were put in jail or worse, you know,

we didn't really change our thinking and what we have to do and we must do because this disease is really going to decimate humanity. It's decimating our children. It's decimating our population. It's, it's crippling our, our economy. The federal deficit is in large part due to this phenomenon of insulin resistance and the consequences of it in our society, including chronic disease that are just such a burden. And I think,

We have to get it right. And your book is about challenging our assumptions to get it right. And a lot of people would argue with you that, you know, no, no weight gain and obesity and diabetes, which is a consequence of obesity are really simply the result of eating too much food and not exercising enough.

And, you know, you've talked a lot about this. You wrote about this in your book, Good Calories, Bad Calories. You had a whole research initiative called NUSI about this where you funded large studies. David Littwig was a friend of ours. Did some really powerful trials looking at

do different calories matter and affect your hormones, metabolism, weight? And he found that they did. And there's just a huge body of evidence around this. Virta Health, which I know you were very close to, and Sarah Halberg, who's a friend of ours, recently died from breast cancer. She does some really pioneering research looking at ketogenic diets and reversing type 2 diabetes. And yet the American Diabetes Association and most endocrinologists are still saying you should have half of your diet as carbohydrates.

So what is the truth about this? Are all calories the same? And is it just about energy balance? It's funny. When I first wrote about this, I mean, the first book in Good Calories, Bad Calories, and it was critically reviewed in the New Yorker by their science health reporter, Gina Collada, who I knew well. I'll say no more. You know, well, Gina made some interest. She said, first of all, you never know what I left out, which is true of all books.

You just never know what the author. Yeah, sure. Selection bias, we call it. It is selection bias. And when you're writing a book, you're also selecting for story and you're trying to select the most, the information that really you believe has to be in the book because a book can't be 2000 words pages long. And then she said that diabetologists, diabetes specialists had been proven. Yeah.

that a calorie is a calorie. And when I wrote back in the Times, it was kind enough to run a lengthy letter of mine in response, which they don't often do to book reviews. And I said, look, diabetes specialists of all people know that a calorie isn't a calorie, except for Peter Attia, who no longer knows that. But it's, you know, you know that every macronutrient, proteins, fats, carbohydrates, they prompt a different hormonal response in the body.

And so a different metabolic response and that the hormonal response includes a different, you know, different effects on fat storage and fat mobilization and fat,

metabolism, burning fat, whether you're going to burn fat or carbohydrates or whether you're going to use protein for fuel, which you could do, or for tissue repair and cellular repair, which is how you'd like to prioritize it. All these things are determined by the hormonal response, which is different from all of them. And so the argument I began making in Good Calories, Bad Calories, and as you point out, it's been in every one of my books and it's in this one too because it's, to me, clear as day.

And this was worked out beginning in the 19-teens. German and Austrian clinical investigators, researchers, they were doing the best medical science in the world, bar none, until World War II. Things went south a little bit in Germany then. Yeah. You know, fat storage is...

regulated independently from how much you eat and exercise. You know, your fat cells that make up fat tissue, they can't tell how much you're eating or exercising. So they only see certain things. They see the fats in the blood. I mean, see is a metaphor. They're aware of the fats in the blood and the hormones in the blood and the glucose and the triglycerides and all kinds of other molecules, but they're not

not how much you're eating and exercising. And by the 1950s, it was pretty clear that they were responding primarily to insulin. So you raise insulin, you...

dry fat accumulation. You inhibit, primarily you inhibit the escape of fat, the mobilization of fat. We call it lipolysis, it's the breakdown of fat. So basically it's like a one-way turnstile in a subway where the calories get stored in the fat tissue, but they can't get out. They can't get out. They need this process of lipolysis. They need to be broken up into small pieces so they can get out of the fat. So an insulin prevents that from happening. And

Apparently no cell in the body is as sensitive to insulin as fat cells. So if there's a tiniest bit of insulin in your circulation, it's gonna shut down mobilization of fat. - That's interesting. Just to point out something that our friend David Ludwig said to me once, which really sort of highlighted that it's more than just calories. He said in a type one diabetic, when they're untreated and they're first diagnosed, they could be eating 10,000 calories a day and losing weight.

So that's because they have no insulin and they can't store those calories. They can't get in the cells. They can't get it. So the problem with the, you know, there's always two different ways to see everything. Yeah. So the way the community saw it is because they're losing, they're peeing away all those calories.

That's why they're not gaining weight. So it's still to them, it's still an energy in, energy out thing. They're just losing all the calories in their urine. There are ways to study this and it was studied and to pick apart exactly what's happening. And what's happening is that without insulin, they can't keep fat in the fat tissue. So that's the primary effect. Yeah, what's interesting, like I said, as they start giving insulin therapy, the more insulin you give, the fatter patients became. Yeah.

And often they would become obese and type 2 diabetes is so closely associated to obesity and they knew this even as the specialists 100 years ago weren't thinking of it as type 2 diabetes. They didn't want patients to become fat because they knew that made diabetes worse. Worse, right. So you give them massive doses of insulin, you tell them to get fatter and then you tell them they got to eat less. Yeah. I like type 1 diabetics.

get also type two called double diabetes. Right. So you, you, you, you give them enough carbohydrates and enough insulin, they become insulin resistant. And so they need massive doses of insulin and it's like they get, they literally get double diabetes. Yeah, no. And it's, it's along this way. I mean, one of the other things is the whole science of, well, it's called endocrinology hormones and the hormone related diseases. And it's,

Also sort of born in the late 19th century, but it's very primitive and it's growing and then evolving through the 20th century. And these doctors are realizing there are diseases of, you know, excess hormone. And if you have too much of a hormone, then you've got to lower it.

And if you have too little, you got to add it. But the problem is they can't really measure hormones in the bloodstream accurately until 1960. So we're giving insulin to everyone whether they have too little insulin or too much. Because all we're trying to do is lower blood sugar. And then if patients have side effects or complications, they get all the diseases that associate with it, you say, well, the problem is uncontrolled blood sugar.

But you're giving the problem in type 2 is insulin resistance and hyperinsulinemia, too much insulin and you're treating it with more insulin.

- It's like the boy who cried wolf, you keep knocking at the door to try to get someone to pay attention, but it doesn't actually work, right? - It doesn't actually work. So what you do, you have more boys banging on the door. - So Gary, we're in this moment now where we really, I think, have begun to really understand the biology of diabetes and the biology of insulin resistance and poor metabolic health. And more people than ever are suffering from this.

And we now have this drug, Ozempic. Right. So is obesity an Ozempic deficiency? Quite possibly. I mean, what's going on here? The issue with the drug is fascinating because part of the thinking here. So one of the ways this was captured was

This was originally an epigraph in the beginning of the book. And then I decided if I put it in the beginning of the book, I'm giving the whole book away. Nobody has to read. I took two epigraphs out. That's too bad. Yeah.

So what were they? One of them was from 1870s, 1870s. This British physician was talking about a patient who came in, a woman in her 70s, very healthy, plump, robust. And she came to see him because she had type 2 diabetes and she had it completely under control by diet. And he thought, this is terrific. Why are you seeing me? And it's because she didn't want to be on a diet anymore. Right.

And he's like, are you crazy? You know, you're as healthy as can be with a disease that for other people is chronic. I forget why we took that one. The other one was a story that was told to me by, well, from my perspective, a young man. He was diagnosed with diabetes in his 30s. This was like 2017. He was a teenager.

chef, he became a journalist. He actually interviewed me for my sugar book and told me I had type 1 diabetes. And I said, I got to interview you for my diabetes book. So when you're diagnosed with diabetes, particularly type 1, it's like you go from

maybe never having thought of this disease in your life, unless a friend or a relative had it, to being dropped into this world where now you have to learn as much about it as you can, as quickly as you can, because you're going to pretty quickly die. Like within a day, you're going to be injecting insulin.

And the doctor is briefing him. And he says, what we're going to do is you've got this insulin deficiency disease. It's type 1. And so we're going to give you insulin. And you can no longer metabolize carbohydrates safely. So in order for you to do that, we're going to give you insulin. And then you're going to eat, get 50% of your calories from carbs. And you're going to regiment them. So a certain amount for breakfast, a certain amount for snacks, a certain amount.

And he says to the doctor, well, wait a minute, let me get this straight. What you're telling me is that carbohydrates are now toxic to me and insulin is the antidote. And you want me to eat the toxin and take the antidote. That's right. Why don't I just not eat the toxin?

And of course the doctor has never thought about it this way in his life. He's like, "There's got to be a reason, right?" And the reason is, "Well, that's too hard to do." And he actually says, "Well, wait a minute, if I told you I was going to now exercise an hour a day, you would say that's terrific even though the hour a day is going to be like 30 minutes getting to the gym and 30 minutes taking a shower. But as I tell you, maybe I shouldn't eat the toxin, that's going to be too difficult to do. What's the problem?" That's very funny.

As soon as we had insulin, the idea was eat the toxin, take the antidote. And if the antidote didn't work well enough or...

There would always be a new antidote also. So 1937, long-acting insulin is discovered in the Nobel Nordisk in Copenhagen. That was the beginning of the... We're now making Ozempic. We're now making Ozempic. And so this is the long-acting insulin generation. Then post-World War II, you have the oral hypoglycemics. And then by the 1970s, you've got insulin pumps...

And now you've finally got blood sugar monitors, so you can monitor blood sugar. And there's always a new drug. And then we have the trans insulin made from molecular biology. Recombinant. Yeah, recombinant DNA insulin. And so there's always a new drug.

- Yeah, human insulin. - So the idea is, yeah, sure-- - Because we're using pig and beef insulin, we were before. So now we had human insulin, we could synthesize it. - We're gonna need vegan insulin, it's undeniable. But the-- - Gosh, if you're a vegan and you type one diabetes and didn't have human insulin, what would you do? - Anyway, but the idea is always like, yeah, we'll acknowledge that therapy isn't great now and there's room for improvement. It's always better than it was, which is true.

But we also see other drugs coming down the pipeline. And there's always other drugs coming down the pipeline. So now the latest drug, the GLP-1 agonist, again, Bozempek, Wagovi, Manjaro, terrific drugs. Are you being facetious? I mean, they seem to...

Are they the solution? Wonderful things? No. Why? Because they're still treating the symptoms. Yeah. As you put it, it said we don't have a GLP-1 agonist deficiency disease with obesity. I mean, maybe we do on some level, but who knows? Yeah. Certainly you can treat it. A lot of, actually a lot of the ways we eat in the process that we eat actually lowers GLP-1. GLP-1 is something our bodies make. It's a peptide. It's a natural thing like insulin. Right.

And we're just making something that acts more than our body can actually produce and make. Yeah, and acts and slightly is kept alive in the circulation so it's not degraded as quickly. But so this is always the issue is we can treat the symptoms.

We don't have to... People don't... So along the way as the obesity community was failing to treat obesity, failing to understand obesity and failing to provide a dietary therapy that worked. This is the convention, the establishment, not the diet doctor world because, you know, we think they got it right. But they created all these mindsets, belief systems,

that would allow them to continue doing what they were doing without feeling, and ultimately they'll blame the patient, but the idea was nobody wants to be on a diet. That was a message with the kids from the early 1920s. Nobody wants to be on a diet. They're not going to stick to a diet. Fair enough, but people would if you give them a chance. Well, it's got to be the right diet, and that's the point. So if you give them the wrong diet, why would they stick with it? Or if you're giving them a diet just to prevent the appearance of,

delay the appearance of a disease 10, 20 years down the line. Like if I tell you eat a low-fat diet to delay heart disease,

prevent heart disease, assuming it works, you don't never actually see prevention happening. You don't experience the prevention of a disease. And when you, if you get the disease 30 years later, you don't know that maybe you would have gotten it 10, 20 years later if you had eaten the way you used to eat, or maybe you'd get it 40 years later. You have no idea. There's no feedback on prevention. It's one of my issues with the whole longevity world is

How do you know? Even if you have a drug that keeps dogs alive longer, like maybe. If I live to 120, Gary, I think that'll prove a point. If I think that would be, if you see a strong enough signal, like suddenly there's a whole world of people who have been taking a drug and live to be 120, but. It's going to take a minute. It's going to take a while to establish that observation. It's better be clear. Yeah. Because those same people are probably doing a lot of other things too. Yeah.

So anyway, but that's the issue. So nobody sticks with the diet. And as long as nobody sticks with the diet, drug therapy is always better. Yeah, but it's not really because it ends up causing other complications. Well, and this is what you have to find out. Again, I have an essay sitting at The Atlantic that I hope by the time this is aired, maybe we'll have made it. About Ozempic?

And it's, you know, so. So what's your take on it? Well, this is what scared me when we talked about the history and that tidal wave of diabetic complications. If you think of insulin, 1922, it's a lifesaver. It's a miracle drug. First miracle drug. Undeniable. I mean, people at the brink of death and it brings it back. It takes this intractable disease and it makes it tractable. Like those that pick in obesity. Patients do better. They clearly live longer.

It's clearly minimizing diabetic complications. I mean, the complications for the first five or 10 years. The acute complications, yeah. Yeah.

But then you get to see the long-term complications of people not just living with this disease that used to kill them, but living with the disease and the drug therapy and the dietary approach that had been adopted along with it. And you cannot separate them out. And by the 1930s, you're seeing these people suffering the tragic consequences that they might not have had to suffer. People really understood what's going on now. And so the question is,

Is that happening with Ozempic? Are we now in this golden era of Ozempic like we were with insulin and giving it to everybody without really any kind of thought of what's going to happen next? Just like insulin, they're going to have to be on it for the rest of their lives. So it's not just you've got some clinical trials that have tracked people out three, five years and looked at specific complications that might stand out from the background. And we're seeing them.

Pancreatitis, bowel obstruction. Yeah, so the question is what happens after 10 years and 20 years? And what happens when people try to get off? We also have clinical trials that show that after a year or two people get off these treatments, the weight comes back if you're doing it for weight. So we know that. But what happens if you try to get off after 10 years or 20 years or 30 years?

What happens if somebody does these drugs? Obesity for most people is an intractable condition. I mean, we both think that very low-carb, high-fat ketogenic diets will do probably the best approach, the most effective approach, dietary approach for treatment, but we really have no idea for how many people...

It may work for some, but not for others. I just don't know, those studies have never been done. So for many people and for children, obesity can be an incredible burden. So she was winning 5-year-olds and 12-year-olds on Ozempic? Yeah. That's what the American Academy of Pediatrics is recommending. Yeah, now you're going to have kids who are going to be on these drugs for 40, 50, 60 years. And what about the girls?

who then get married in their 20s and want to get pregnant. So what do these drugs do? We know there's this concept of fetal programming in which basically the mother's metabolic health is passed on to the child through the womb. And it's an effect that you, I mean, it manifests itself as larger babies. Yeah. But...

for the most part you can't really see the effects for literally generations until these kids are middle-aged and adults and then you see the explosion of diabetes and obesity. These are the epigenetic changes that are really programmed disease in utero for obesity, diabetes and heart disease. So now you've got this very powerful drug that for all we know might reverse this. I mean maybe it's a be a godsend. Kids, you know, mothers take this drug during pregnancy, the kids...

Maybe it's not, there's no way to know. And if the mother goes off the drug to get pregnant, that means she's gonna be gaining weight back while she's pregnant, which we know is a problem for fetal- - Unless people change what they're eating. - Unless they change. So I think about the way Jocelyn thought about insulin in the early years. What if you use the lowest doses

And this was Richard Bernstein's revelation and type 1 diabetes in the 70s. Let's use the lowest doses.

and craft a diet that allows those lowest doses to be effective. Which is basically lower starch and sugar and higher fat. We have a friend in common who is a type 1 diabetic, who's a doctor, who basically uses one or two units of insulin a day because she's on a ketogenic diet. So she needs very, very low doses. She needs a little, but not that much. Yeah, and we know it can be done with that. And it can probably be done with these drugs, maybe.

And it's quite possible that with the right dietary approach and dose, maybe people can get off the drug, get to a maintenance weight, a weight they're comfortable with, and then

- I mean, I think it's possible, but really that's not what's happening with the drugs. They're just being prescribed with no lifestyle change, no dietary advice, no regimen of exercise to prevent muscle loss. - Well, then the question is are people, if you don't need the diet advice, I was just, Oprah just had her special on,

how Zempik and how it's changing obesity. And I haven't checked. An ally out there emailed me and said, you should watch it and see if the word sugar is ever mentioned. Yeah, right. So if you can, I mean, again, apparently these drugs do inhibit appetite. That's an effect. I don't know if it's a direct effect or an indirect one. And they might inhibit specific things.

tastes for carbohydrates and sweets, I wouldn't be surprised. People feel full with the drug, right? And they get nauseous. Yeah. But it's, you know, to have a drug just explode like this. And our history of pharmaceutical therapy is full of examples of drugs that were wonder drugs that ended up, you know,

thalidomide well thalidomide was an extreme example because you could see it but benzodiazepines for instance yeah i mean the world is full of people who took them on prescription as prescribed and got to the point where either the complications became unbearable or they became inured to the dose and they didn't do anything anymore and then couldn't get off it yeah and then you have nightmare cereal i actually had a tenant who was um

sent off to a rehab center for a month to break his clonopin habit and had a mental breakdown afterwards. What do you do if the drug helps 80% of the patients?

Yeah. And causes intractable harm to 20% and you don't find out for 10 years. Yeah. Whether you're in the 80% or the 20%. Well, we're going to see that. I have no doubt. I mean, I think it's going to be a boon to some people and I think it's not a bad drug like any drug. It's how it's used, who it's used with, how long it's used, what dose it's used. And the extent of the problem that you're using it for. Right.

But I've had so many patients, Gary, who've lost 100, 200 pounds without that by just giving them proper nutritional advice and in many cases restricting carbohydrates. But again, we have a world of ways to think about it. I mean, one of the diagnostic criteria of an eating disorder is not eating an entire food group.

And there are people, you and I, saying, "Well, the problem is the carbohydrate content of the diet. So we don't need carbohydrates. There are no essential carbohydrates. Don't eat them, you'll be fine." That was basically what I'm arguing for diabetes. You don't need these foods. So you don't need to take all the medications, the pharmaceuticals that are prescribed to you to treat the symptoms that come from eating them. I just want to stop you there for a second, because what you said is really important.

There are essential fatty acids. There are essential amino acids. There are no essential carbohydrates. So the body actually does not need them biologically to thrive, even though it's our main fuel source. So historically we've been adapted to a whole range of diets from the Inuits and the basically ketogenic diet to the Pima Indians who were 80% carbohydrates, but it was all high fiber plant based carbohydrates that were really nutrient dense.

So the body can survive and thrive on many different things and the quality of the calories matter, which is really the thesis of your book, "Good Calories, Bad Calories." And I think most people don't understand that they actually can regulate their biology if they figure out what their particular metabolic type is, 'cause everybody's different. And for example, I need a little more carbohydrates 'cause I'm kind of thin and if I don't eat them and I go keto, I'll lose too much weight.

But if I take a patient who's overweight and type 2 diabetic, they're going to do really well if I do that. And a little bit of carbohydrates might prevent them from doing really well. Yeah. That's the – I think one of the points that I've made in my other books is we do – everybody is different. And we definitely evolved –

to cope with the proteins and fats in our diet. The idea that the foods that we didn't have, the new foods of modern life. Ultra processed food. That's not even food. Yeah. I'm not wild about the term ultra processed because it's sort of like the miasma theory of all these kind of vague things that we're going to throw in. Michael Pollan called them food-like substances. I prefer that. It gets more to the point. But yeah.

- Well, they don't meet the action criteria of the definition of food if you look up-- - But we didn't have time to adopt to high levels of sugar in our diet and sugary beverages in our diet. These things didn't exist. We didn't have time. I mean, I'm agnostic about the seed oil issue. I don't find the evidence. I mean, I can easily believe that these things are toxic, but I--

- The evidence is confusing for sure. - There's a certain absence of human clinical trial. - Just like sugar, when you think about sugar, we never had exposure to the amount of sugar we're eating now historically as species. We never had 10% of our diet being refined soybean oil before. It's a new phenomenon for humanity and maybe it's okay, maybe it's not, but I think it should be questioned. - Yeah, it certainly should be questioned. And that's the thing, so you can propose that those are,

And with the sugar and refined grains, you could see what happens when you take them out of people's lives. And we have clinical trials. - Can you talk about that? Like you talk about the Virta Health work and Sarah Halberg's work and the sort of work on advanced type two diabetes.

where they actually were able to reverse it, not just slow it down or delay the complications or to manage the disease, but literally to reverse it. Yeah, well, so this is, you know, getting back to the history a bit. We get to the 1970s, 80s. The diabetes community, their credit, did some really ambitious clinical trials.

And what they find out in effect is that this disease, by their treatment, is a chronic progressive disorder. It just gets worse. A famous British trial where they show they start people on...

diet only and then they add one drug and then they go and they see how many of the patients diagnosed with type 2 diabetes can stick with one drug monotherapy and the answer is like 10 percent yeah so as time goes on you keep on having to add drugs to keep the blood sugar under control they do these we set a cord and uh i forget the other names of the other two trials um

at intensive insulin therapy and they find that it does more harm than good at the very best and then they do this huge look-ahead trial, $200 million to demonstrate that if you lose weight, you'll...

reduce diabetic complications. It's a fundamental pillar of thinking with diabetes. Just get your patients to lose weight, they'll be fine. And they get them to lose weight and it doesn't make a damn bit of difference. A trial was ended for futility, a $200 million trial. And a great quote in the New York Times from a Harvard diabetes specialist named David Nathan, who says, we have to have an adult conversation about this.

and they never do. Yeah. But while this is happening... But this is an important point. They lost weight and they got worse. So... No, they lost weight and they didn't get better. So they lost weight... The idea was you lose weight, you'll have fewer complications, you'll reduce heart disease, you'll reduce strokes, you'll reduce mortality from this disease. It didn't make any difference. Was it because of how they lost weight? Well, it could have been because of how they lost weight. And in fact, back around 2003, when I first heard about this trial...

From one of the principal investigators, I was in a conference. He invited me to talk in Houston. I remember saying to him, look, are you doing a low-carb arm? Okay, just do a low-carb arm. Make it not just low-calorie, low-fat, fruits, vegetables, whole grains, the usual story. Mediterranean diet, right. Well, this was pre-Mediterranean. I mean, this was...

Yeah, it was just classic low fat. But in low fat, they're also saying you're eating fruits, vegetables, whole grains, you know, cut back on meat, exercise. No, they never crossed their mind to do a low carb diet because that was still considered quackish. But as the diabetes community keeps learning about how ineffective their treatments are and how their belief system is

falling apart on top of them and not having an adult conversation about it, which is maybe we're making some mistakes here. Other physicians coping with this increased obesity in their patients are confronted with patients who don't take their advice and instead like buy Atkins Diet Revolution book and lose 40 pounds on Atkins. Yeah. And

A few of these doctors are open-minded enough, Eric Westman and David Ludwig, they say, I'm going to look into this. I'm going to actually do a clinical trial. So they start doing clinical trials. There's a big study at the Philadelphia VA. And there, the

A woman named Linda Stern is frustrated by how much, her inability to help her patients. So she literally goes to like a Brentano's bookstore and she sits down in the diet section, starts reading diets. The doctor's going to the bookstore to read self-help books because it's not in the textbooks. You know, it's not, not, not, not. They definitely don't get grades, good grades for this in med school. Anyways, I think she found protein pathogen.

hour and she tries it on herself and this is effortless to lose weight so they put together a clinical trial and this is a veteran's administration's hospital so there are a lot of vets they're not just obese have metabolic syndrome and type 2 diabetes and instead of

cutting them out of the trial as you would, you know, the inclusion criteria in a pharmaceutical trial is going to say we're going to not take these patients because they're ill. She says, since this so associates with obesity, let's do it.

And not only do these patients lose a lot of weight on the diet, but their type 2 diabetes gets better on this high fat, low carb, small protein powered diet. So you start getting this groundswell, this movement of doctors who are reading these articles in the literature and saying, look, you know, diet really seems to help. They don't know this deeper history, although Eric Westman at Duke is looking into it, but

It's just patients do well if you don't feed them carbs. Isn't that weird is that? It's a disorder of carbomiger metabolism. Tell them not to eat it, they do fine. - You don't take the toxin, you don't need the antidote.

So Steve Finney and Jeff Volek too. Steve is a PhD nutritionist who trained at MIT and is out at UC Davis and he had studied ketogenic diets and Jeff Volek is an exercise physiology PhD then at the University of Connecticut and they start working together and publishing on this and they helped start this company, Virta Health.

I remember Steve's idea, I think it was, is we could just convince insurance companies and employers that they could save money. Diabetes is an expensive disorder. It's costing them $12,000, $15,000 a year in medical bills. If they could save 80% of that by getting these people on a diet, wouldn't they want to do that? So they'd become the clients.

Not the patients. We'll go after the payers, the insurers, the Kaisers and blue shields of the world. And they create this company. They get this brilliant CEO, Sammy Inconin, who was a world-class Stanford MBA, made millions creating the website. I always forget whether it was Trulia or one of the real estate websites. It's a world-class triathlete.

who was diagnosed with prediabetes despite having come in first in his age group in the Ironman triathlon. And Sammy goes to Steve and Jeff for advice on how to treat the prediabetes and also how he wants to, this is Sammy, he wants to row to Hawaii from San Francisco to Hawaii with his wife.

wife Meredith and he thinks they could do it with a fun diet. Jeff and Steve can coach him and they start talking about this idea and they start this company Virta Health. Meanwhile, by the way, Sammy and Meredith do grow to Hawaii.

and they break the record and they don't need any carbohydrates on the whole trip. I think it's 24 miles. And how he got the prediabetes was he was using all those goos and energy things that athletes use to fuel their body. Not only that, Sammy believed that a low-fat diet was the healthiest way to eat. He had been told that. And Sammy is, I think he's Norwegian. And as he put it, not that being Norwegian matters, but if he's Finnish, I apologize. Yeah.

He's just got the best... If somebody tells him not to eat fat, he doesn't eat fat. I mean, this is an extraordinarily...

The man has an extraordinary strength of will and then he's diagnosed with prediabetes. So there's something wrong. This is a common phenomenon that happens to many people in our world, right? You're doing what's supposed to be the right thing and it doesn't work for you. And then you do the wrong thing, which in this case is low-carb, high-fat ketogenic diet.

animal diet and you get better and you say, wait a minute, if it's wrong for me, maybe it's wrong for a lot of people, if not everybody. So they start this company, Virta Health. They realize they need a clinical trial to convince and they meet Sarah Hallberg, who is a physician in Indiana, an amazing woman to whom the book is dedicated.

who has been asked to run an obesity clinic at Indiana Health and has to learn everything she can about obesity. And she starts reading all the literature and she goes down the rabbit hole and she experiences this, you know, based on jello revelation. And she realized that the only people who seem to be

who seem to be effectively getting their patients to lose weight are these people like Westman who are advocating for these Atkins low-carb keto diets. And so she goes and spends time with Westman. She goes and starts advocating for this at her obesity clinic and she meets Jeff and Steve and they put together a clinical trial where they're going to randomize people for type 2 diabetes, type 2 diabetes, type 2 diabetes,

keto with smartphones and personal coaching and support and telemedicine. Adjusting their medications if they need to. Yeah, because you're going to have to adjust medication. If you stop eating the toxin, you're going to have to lower the dose of the antidote. And it's either that or the American Diabetes Association standard of care, which is drug therapy. And

They do the trial and after a few years, they report one-year results. And after three years, they report two-year results. Yeah. And for patients who comply with the diet, they seem to put this progressive chronic disease into remission.

So it's not a progressive chronic disease. No. It's only a progressive chronic disease if you're eating the toxin. Yeah. If you're not eating the toxin, you don't manifest the symptoms. And it's not the ideal clinical trial. Yeah. There's all kinds of problems with it. Mm-hmm.

wasn't randomized. Actually, I probably said randomized and I should not. They let patients choose whether they wanted the diet or the ADA standard of care. But even with those constraints, it demonstrated beyond a shadow of a doubt that a disorder which is considered chronic and progressive is not necessarily chronic and progressive and that the defining factor is the diet. Again, whether you eat the toxins.

That's true. I mean, our practice at the Ultra Wellness Center, I've seen that over and over again. People just don't, on insulin, get off insulin, on meds, get off meds, normalize their weight, normalize their metabolism. Their A1C goes down. They went from 11 to five and a half in a few months. I mean, it's quite remarkable. It's quite remarkable. And so by the end of the book, my Apple, I mean, again, I...

This book does not advocate. It's a dense, historical, critical. Yeah, it's like a mystery novel. And a mystery novel. Who done it and who didn't do it? I think it's a very good book. The question is, imagine a scenario where everybody, every physician was taught not just the proper drug therapy.

but how effective this dietary therapy was. Because there have always been two levers to pull to keep blood sugar under control. There's diet or drugs. Until 1921, we only had diet. And for patients with type 2 diabetes, it was effective. Yeah.

Don't eat these foods, you'll be fine. Once we had drugs, you had two lovers, and the idea was use the drugs, give the drugs. We're going to say that diet is integral, the cornerstone of therapy, but we're going to pay lip service to it because we got the drugs. What if confronted with a new patient, you give them the diagnosis, you have type 2 diabetes or type 1 diabetes, and you say, look, we can do this. We can treat your symptoms with drugs. You can continue to eat exactly the way you want.

Or if it's type 1, you're going to eat at specific intervals, specific amounts to allow us to maximize your appetite.

craft the diet to maximize efficiency of the drug therapy. And there's all these complications we know are going to ensue. So you're going to have an increased risk of heart disease and stroke and dementia and blindness and retinopathies. And for some of you, no matter how well you manage your blood sugar with these drugs, those complications are going to happen anyway. Yeah. At which point, we're going to blame you. But... Right, it's the patient's fault. They don't have to say that. Or...

you can do this diet. Now, what it means is no more bread, potatoes, sweets. Yeah, which people love. Sugary beverages. Which people crave. It's hard because they crave those foods when they have insulin resistance. Yeah, which is fascinating. If you eat this way, as far as we can tell, you'll be fine. No drugs, no

complications of drugs, no needing more doses or new doses, no waiting for new drugs to come along, no dialysis. As far as we can tell, if you eat this way, you'll be fine. Amazing. I mean, we spent a billion dollars. And it'll probably take two or three months. You might love it immediately. It might take two or three months to get used to it, in which case, like somebody who's quit smoking, you won't miss cigarettes after a while. Right. You will at first. You won't after a while.

It's your choice. Yeah. We're happy either way. Yeah. Okay, because we want you to be healthy. But this way, chronic progressive disease, diabetic complications, more and more drugs, complications of drugs. This way, as far as we can tell, and we can't, you know, there are unknown unknowns here. As far as we can tell, if you eat this way, you'll be fine. Yeah. You choose. Yeah. And if you do eat this way, let's make sure you do it right. Yeah.

And if you choose the drugs, we'll make sure you're doing it right. I mean, it's such a simple notion. And yet it's bucking against the establishment paradigm that we should be using drug therapy in high-carbohydrate diets and diabetics. I mean, I think the ADA is starting to come along, the American Diabetic Association, but it's really tough. Well, they're starting to come along, but if you see how they do it,

So they put out these standard of care documents and every year, every January, there'll be like eight or ten of these documents. And what they do is they revise based on what research came out in that past year. So they really have no mechanism by which to say, let's just rethink this. Everything.

And then when they're revising it, the discussion of diet is buried, is inside in this document where it's sort of you can do this or you can do that or you can try this diet. We have this research for this or this research for that. They don't have any mechanism to say, can we just try it? Let's try a different approach. Yeah. Okay? Let's divide the world up. Let's say this is what we can be achieved with diet and this is what can be achieved with drug therapy. And this is the complications that we know of with diet. Yeah.

Not many. And these are the complications we know with drug therapy, chronic progressive disease. Um,

Many people might choose drugs. Maybe they're right. I mean, I don't know. I mean, I think when you look at the data, to me it's pretty clear that if you use drug therapy, that it is a progressive chronic disease and you can mitigate or slow the complications, but it's not going to prevent them. And if you use the dietary therapy, it goes away. And I think people might be listening going, Gary, you're giving these people a ketogenic diet with 75%, 80% of their diet is fat. What about their heart?

and maybe save their diabetes. But actually, they looked at over 20 cardiovascular biomarkers as part of the Virta study. And they were all improved. Actually, they got better. And I've seen this over and over. I had a patient which was really struggling with weight loss and she had prediabetes. She had triglycerides of three plus hundred or HDL was very low and her total cholesterol was over 300. Very high insulin levels, rising blood sugar. And I'm like,

- Well, I think you're gonna try a ketogenic diet. She did it. Not only did she lose 20 pounds, but her cholesterol dropped 100 points, her triglycerides dropped 200 points, her HDL went up 30 points, her blood sugar normalized.

Now, that may not work for somebody else who's a thin guy who is an athlete. And I've seen people who use the Skeetogenic diet like that who actually don't do well. And I'm one of those guys. If I eat too much of the wrong fats, my cholesterol goes off the rails. But we don't know how harmful that is. We don't. We don't. Unless we look inside your arteries and then we can tell. Well, you can, yeah. Then...

- Yeah, so it's just fascinating. I think this is really important moment in history because we have this craze of Ozempic and Mugabe, Manjaro, it's the golden child of the moment of pharmacology. And nobody's really talking about the issue that matters, which is what we're eating and why we're eating what we're eating. - And that's because we have this mindset that people with obesity,

We're not going to blame it on willpower. We're going to acknowledge that it's a disease now. This is what Oprah was saying. But we're also going to assume that they won't change their diet. Yeah. And, you know, it's really complicated. I've read a lot of the literature of mostly women, but not entirely women with obesity. They're so confused. Yeah.

They know it's not a willpower problem. No, it's not a willpower problem. And often these authors will say, I tried every diet, none of them worked. And I want to reach out to them and say, well, they... You didn't try the right one. Well, or did you... Because they always include Atkins in the list. Did it not work for you? Or are you some... But then they'll say, you know, it's just one of these books I read recently. It's, you know, I don't want to go through my life not eating a donut. Right. Well...

I understand. I get that. I get that. But, you know, I was, I've been biased by my history as a cigarette smoker. There was a period in my life where I couldn't imagine going through my life without a cigarette. Yeah. And in fact, my next cigarette was what pulled me forward into the future. Um, uh,

Maybe it's an inappropriate metaphor. I'm not sure it is or not. - Well, no, I mean, we know there's real addiction with these foods, that the, whatever you call them, food like substances or ultra processed food or high starch and sugar foods, they activate the brain centers for pleasure. And we can map that on brain imaging studies. So there's no doubt that these have biological effects on the brain that drive our behavior, our cravings, our appetite. But I think what's really remarkable as a doctor treating these patients is that when you do the right thing,

their brain chemistry changes, their hormones change, their metabolism changes, and they don't actually have those cravings. It's not like they have to use willpower to fix it, use science. And this is really what your book is about. It's challenging the orthodoxy, challenging the science, making us rethink diabetes and come up with a new vision for how we can deal with this obesity crisis rather than spending $5 trillion on those Zempik for the population, which is what it would cost

if we gave everybody who was overweight ozambric well this is the idea that this will somehow impact the obesity epidemic is insane right because um oh i suppose if it gets off label and people can buy you know if it's cheap even if it's cheap is it safe but then then yeah then the question is what are the side effects what are the complicated will there be a tidal wave or a

you know, a wave of complications down the line that are going to make a whole host of people wish they had never started. I think there is. I mean, I think the data is already coming out that the longer you're on it, the more likelihood you're going to have complications. Not everybody will, obviously, but... What's interesting is even these studies, the studies that looked, that I looked at, that looked at, um,

long-term use. And again, they went out about that they had patients in them who had been on the drugs for like five years and they were looking at specific possible complications. But they would also say these were for lower doses.

And for diabetes, not for obesity. And then they would say, well, 60% of the patients discontinued use. Yeah, because they had nausea, serbomity. And the question is, yeah, why did they discontinue? And what happened when they did? Because if when they did, they then fell out of the system. They were no longer in the clinical trial. So nobody has any idea. Was it difficult to discontinue use? Did things get worse that then had to be treated with other drugs?

Well, what happens when you take these drugs is you lose muscle and fat and you gain back the weight, usually gaining back this fat. And so your metabolism is slower at the end of the process than at the beginning. And you need to eat less food in order to just maintain the same weight. And this is... It's a real problem. Unless you eat a lot of protein and do a lot of strength training while you're taking these drugs, you're going to be in trouble. You know, I've been an athlete, a jock my whole life. And I...

You know, I've lifted weights my whole life. And the idea that you can solve the muscle loss problem by going into the gym, eating protein and lifting weights. It's like, do you have any idea how hard that is? Well, you can do it. You can do it. Look at you, you're buff and you're 67. You know, yeah, but it's...

The muscle that comes off easy with the drugs is not going to be put back on. No, no, that's right. That's an important point. It's easy to lose, hard to gain. And as people get older. Yeah, it's even harder. The gaining is also dependent on the hormones and weighing with dogs.

- Totally. Well, Gary, this has been such a fascinating conversation. I think your book is a kind of a pivotal book in helping us literally rethink diabetes and challenge our orthodoxy, challenge our assumptions,

poke the bear a little bit and say, "Hey, let's get real with this and let's look at the data. Let's look at the science and not go along with the current recommendations," which are in many ways, I believe, harming people. And I think we have a moment to change that. So thank you for writing it. It's a beautiful book. It's beautifully written. It's very entertaining. It's not a dense medical book like mine. So I think you'll all like it. I encourage you to get it. It's called "Rethinking Diabetes."

And also I would encourage you to check out his newsletter called Unsettled Science on Substack. He writes it with Nina Teicholz who wrote a book called The Big Fat Surprise, also another great book. And it's really a great way to sort of get another point of view about nutrition that you might not be hearing through a conventional channel. So Gary, thanks for being on the podcast again. Thanks for what you've done. Thanks for having the patience to weed through all those thousands of pages of information

historical data and illuminating us with the history of diabetes and hopefully paving the way toward a future that is much better than what we've had in the past. Thank you, Mark. Thanks for listening today. If you love this podcast, please share it with your friends and family. Leave a comment on your own best practices on how you upgrade your health and subscribe wherever you get your podcasts. And follow me on all social media channels at DrMarkHyman. And we'll see you next time on The Doctor's Pharmacy.

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