About the Guest: Dr. Orrin Devinsky is a neurologist and Professor at the New York University School of Medicine.
Episode Summary: Nick and Orrin Devinsky, MD discuss: dietary consumption trends in the US; processed vs. whole foods; vegetable oils & polyunsaturated fats; relationship between saturated fat, dietary cholesterol & heart disease; history of medicine in the US; obesity & diabetes; sugars, fructose, and metabolic health; ketogenic diet & ketosis; whether or not we can trust our public health institutions; and more.
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Episode transcript below.
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Orrin Devinsky 5:11
Yes, I'm a neurologist, I went to medical school, and then did training in neurology, and then subsequently subspecialty training in epilepsy. And I have directed the NYU Epilepsy Center for the past three decades or so. But I have a fair number of other interests from evolutionary biology to nutrition, which I think we'll be discussing here to the history of science, and many of them come together on this topic.
Nick Jikomes 5:35
Yeah, you.
We're gonna talk basically about one paper today and some related topics, but you have this paper come out not so long ago, called United States dietary trends since 1800. Subtitle is lack of association between saturated fatty acid consumption and non communicable communicable diseases. So, you know, very briefly, your neurologist, you've got all these other interests, but what actually got you to write a paper about this particular subject.
Orrin Devinsky 6:09
So it's interesting, I think, going back 12 or more years ago, I took a family vacation in Mexico. And a good friend of mine bought me a book by Gary Taubes called good calories, bad calories. It was a big paperback. And having lots of time on a chair on the ocean, I read it cover to cover and it kind of blew my mind. It just completely shocked me that I was reading about parts of history that I just assumed were black and white, factual that we're not and things I was taught in medical school, my medical training and career had been wrong. And actually, we read the book during that vacation and since then, have become friends with Gary. And that led me to a deep dive into nutrition and health. Yeah, I mean,
Nick Jikomes 6:58
in a vague way, you know, I've had, you know, somewhat of a similar experience. So, you know, my background, you know, my PhD is in neuroscience, but I actually worked in the department of diabetes, endocrinology and metabolism at the Beth, Beth Israel, Deaconess Medical Center in Boston. So you know, I spent a lot of time thinking about feeding and metabolism and stuff like that. But I had sort of no knowledge of the history of the dietary recommendations and how all of the things that I thought were just the cold, hard facts of medical nutrition that I grew up with, and that I was taught, you know, as I grew up, about what to eat, what not to eat, I had no idea what the history actually was. And we're gonna get into some of that. Just to sort of start to set the stage for some, folks, before we get into the trends of the things you analyze in this paper. I want to talk about a few different things, and put put some historical context here for people. So roughly speaking, when we think about things like the obesity epidemic, the rise and diabetes, roughly when did these things start to clearly rise in the United States? So
Orrin Devinsky 8:05
I would say Eliot Joslin, who founded the Harvard Diabetes Center, where you worked was America's preeminent diabetologist, at the turn of the 20th century, going from the late 1800s, into the early 1900s. And he actually observed an epidemic, as he referred to it, of diabetes in his little hometown of Oxford, Massachusetts, where all of a sudden, many people were developing adult onset. So it was called at the time diabetes. So I think the these have been slowly creeping, but exponential epidemics of obesity and diabetes, probably going back centuries. I think it began in the wealthy class of people. So if you go back to the Middle Ages, and you look at who, you know, the fat, the fat was a not uncommon eponym after King so and so the fat and the only people who could be fat in the Middle Ages, were royalty, because they were the only ones who could afford the processed foods that could make you fat. So
Nick Jikomes 9:10
it was an eponym was actually probably a marker of status because it was so hard to actually do
Orrin Devinsky 9:17
that. And I think people didn't even understand obesity. There's one terribly racist but informative line from a doctor you trail he was one of the English what they called colonial physicians in the 20th century. So I think going into like 1920 1930 He went from England to East Africa, worked mainly in Tanzania and Kenya, and was one of the early members of the East African Medical Association. And he writes it really kind of eerily that during World War Two in the mid early 40s. He says we knew how to fatten a chicken for the pot. But despite taking 1000s of x rays of Africans and tested
And we couldn't figure out how to fatten an African for battle. So here we are 1942 1943. Here's an English physician. In East Africa, this is a British colony, many able bodied, black young men who they would love to have sent in North Africa for the, you know, desert fight against the Germans. And they couldn't, because they were underweight. And they did not know how to fatten them. So traveled goes and goes back to England. And I think he spent some time in Philadelphia, he returns to East Africa in the 50s. And he shocked to see an epidemic of obesity and diabetes has taken over the land. Now, they don't know how to keep an African from from getting obese. So over a period of 20 years in this specific area of East Africa, they literally they didn't know how to have black individuals reached the body weight of the average Englishman, and then shortly afterwards, they couldn't keep them thin.
Nick Jikomes 11:02
So so we've got, you know, now now we live in a world where, you know, we literally talked about the obesity epidemic. And, you know, we're gonna get into some of some of the potential factors that influence that. The other thing I want to talk about, for historical context purposes, is something called the Diet Heart hypothesis. And before I even knew this, as as the name and the person behind it, and some of the history here, you know, I can remember growing up, so I was born in the late 80s. So I grew up in the 90s and early 2000s. And came of age, it was common knowledge at school, from physicians from adults, it you know, in all parts of my life, don't eat too much saturated fat, don't eat too much cholesterol, don't eat things like red meat, you know, too much. Because these are the things that cause heart disease, that, you know, until I was, you know, young adults, at least, that seemed like cold, hard facts of medical knowledge, like we knew. Yeah, yep. So where did this where did that those ideas come from? When did they start and at the time they were formulated, How strong was the evidence.
Orrin Devinsky 12:18
So the evidence is never been good. We are left with a relic. So unfortunately, the American Heart Association probably represents the most diehard advocate. And I think it would be wonderful if they would go back and do a deep dive over the history, which we'll touch on here. So I think the man who brought us the Diet Heart hypothesis was a scientist Ancel Keys. He is a remarkable man. So I think one thing I personally don't love is that there are either the Ancel key fanatics who just treat him as if he was God. And there are the Hanse, Ancel, keys, devil, that he's the one who messed up all of American medicine. And I don't give him credit for either of those things. I think he was a very brilliant card working remarkable individual, who made some enormous mistakes. And as most people do, put the force of his power behind his personal views, and advocated them and really confused, I think, opinion in science and I can get, I think there's one, one or a couple moments where the we've just got it wrong as a nation, and I'll see if I can just start. So the story of Ancel Keys, and it's been told before, there's a video at the University of Minnesota where he spent most of his academic career that highlights his career. And he was the person who invented the key rations of World War Two, they had actually asked him because he'd studied altitude medicine in South America in the Andes to help design meals for pilots. And as he said, this kind of crazy, he knew nothing about nutrition at the time, he'd studied oxygen concentrations when you're up high in altitude. So he devised some, you know, simple meals that could be stored for long periods. And they turned out to be pretty high in sugar. He was funded by the sugar foundation early on in the 40s. And these became known as the K rations or keys rations, and they were used by many, many G eyes throughout World War Two. And they traveled well, they preserved well, and the soldiers who were relatively happy with them. So he became somewhat famous for that. Then towards the end of World War Two is as the United States and the allies were preparing for hopefully victory, but also the recognition that there was going to be terrible food shortages all throughout Europe that, you know, many of the greeneries had been destroyed, and that there was, you know, going to be poverty and many countries that like Italy that were battered by the war, that they were thinking about how How do they how do they figure out the health of nutrition. And so Ancel Keys was funded by the government to do what was still probably the largest study of semi starvation ever done. He did this on conscientious objectors in at the University of Minnesota. And they gave him very low calorie diets, they hit a mark like five miles a day. And he documented all the changes, which had been documented before and documented subsequently, but a large two volume book, the biology of human starvation, and it showed their sex drives diminished, they became ravenous, they would fight each other over crumbs. It just what happens to young healthy men when they don't eat enough calories and enough food. So in that process, he wrote this two volume set and again, became very well respected internationally, because it was probably the best contribution to the study of the science of human starvation. So because of that, he got appointed in the late 40s, to the United Nations Food and Agricultural Organization Committee, and went there and got a, I think, a Fulbright or one of those scholarships to be in Oxford for a couple years. And while he was in Oxford, there was a ration on heat, fuel. He and his wife Margaret were freezing even though they came from Minnesota. They were freezing in Oxford. And he had heard from a colleague, a cardiologist or medical doctor in Naples, that whereas the rest of the world in Europe seems to be having a heart disease epidemic. People in Naples, we're not getting heart disease. So Ancel Keys and his wife, Margaret, who actually did the cholesterol measurements, decided to take a trip, and they took their car, and they literally drove across Europe and went down to Naples. And he went to a rotary club dinner. And there he had an epiphany. He was watching the wealthy businessmen of the Rotary Club, eat their roast beef and desserts. And recognize that the poor people in town were eating simple bread with vegetables. And when his wife measured their cholesterol, the wealthy Rotary Club members who are eating the beef and the end of the deserts had very high cholesterol, and the poor Labor's had very low cholesterol. And in his mind, it was the fat, a light bulb lid off that the big difference between these wealthy guys eating roast beef and dessert was the fact that they were eating, and that the poor people were eating the simple food that was just carbohydrates and vegetables, and essentially very, very, very little fat. And that was one way to interpret the data. And it was not an unreasonable way to do it. The problem is, he completely ignored the role of processed carbohydrates, sugar, white flour, that also distinguish those two groups of individuals. And I would say distinguished almost all groups of individuals who do and do not have obesity in the world or populations. But I think, if I can, so he took this, and he created a hypothesis back in 1952 53, called the Diet Heart hypothesis. And his first seminal paper was in the Mount Sinai Hospital journal in 1953. And that's where he really proposed the Diet Heart hypothesis. And the idea was, was really simple. He showed correlations if you picked, and he did this selectively six or so countries that have high rates of fat consumption. They also turned out to be the countries that have high rates of heart disease now, later criticized terribly for this because there were probably 22 countries with data available. And he chose the six that fit perfectly into this relationship. You could have chose another six that showed the opposite correlation, where the more fat they ate, the less heart disease they got. But he chose quite wisely to support his hypothesis. And again, this is 53 Before Data Selection was quite as big a deal in science as it is today. But I think the critical piece of data, which I'm going to talk about here, I don't think it's really ever made it into the Gary Taubes and, and other books of that genre is that he quotes and there's a looking at the paper right now it's table 14. And he gets data from a woman. I think her name was Elizabeth Flippered, from the USDA, on the percentage of total calories that are fat in the US diet. So just to do another caveat. The data from 1910 and 1920 and 1930 are terrible. We just don't have good data. Keep in mind and 1920, half of America lived on farms, or within five miles. So the USDA was not good at tracking. If you ate a piece of pig from the guy who's your next door neighbor. They can't track that degree they could track if it went to a big meat processing plant. In Chicago, but not if it came from the former mile away. The bottom line is between 1910 When the average American 830 2% fat in their diet in 1950, when the average American 840 2.2% of fat in their diet. And so he said, look what's happened from 1910 to 1950, our fat consumption has gone up 25%. And there's been an explosion of heart disease. What's going on in the arteries of these people who have died from heart attacks, they've got fat, they've got cholesterol. So in his mind, I think the pieces just fell in so perfectly to this little jigsaw puzzle. What no one goes back and does is look at flippers data, or, more importantly, what Ancel Keys found. And what he says is from the statistics and the USDA, it's clear, the biggest contributor to the fats in the American diet are fats and oils, excluding butter, which are nearly 46, and a half percent of the total meats, poultry and fish combined to make a poor second at 22%. And it is I'm quoting Ancel Keys, any attempt to reduce the total fat intake must then begin with cooking fats and oils. So that's what he said back in 53. The problem was, they then started doing feeding studies. And it turned out, giving people cholesterol didn't raise their cholesterol much, it did a little bit, still a little bit, giving them polyunsaturated fats, the canola oils, which is rapeseed oil, or other oils, like that, also barely budged the needle on cholesterol. And they found out during the mid 1950s, the only thing that really raised total cholesterol, were saturated fats. So he's pivoted from this early position where it was total fats. And that's caused heart disease. And indeed, the only thing that changed the American diet, were oils and fats, not butter, not Lord, as I discussed in the paper, but cooking oils, that was the explosion of the 20th century in the American diet for fats. And that's what was associated with the rise in heart disease.
Nick Jikomes 22:20
But because he was fixated on this cholesterol levels that made him go, Okay, well, it's got to be the saturated fat here. Correct. He
Orrin Devinsky 22:29
pivoted from the early mid 50s, to the late 50s. And then he took over the American Heart Association nutrition committee, and got this to become national policy. I
Nick Jikomes 22:39
see. So So part of the trajectory here is, I don't want to I don't want to spend too much time on Ancel Keys. Everyone's everyone talks about him. But smart guy motivated guy probably like being right, probably thought he was right. And he wasn't it wasn't, you know, like this was coming out of nowhere. It was based on what he was seeing. But he was also good at getting into positions like, you know, being the chair of committees at the AMA. And that was probably a key factor in why his ideas were able to spread through institutions and radiate outwards. So, so effectively,
Orrin Devinsky 23:11
correct. Yeah, even like when Eisenhower his heart disease, heart attack. White who is the head cardiologist at Harvard became Eisenhower's cardiologist and, and he got to write a large piece of the New York Times on the front page. And Ancel Keys was the only scientist he calls out and did so several times in that article. So keys, you know, was a very influential figure. Having said that, white towards the end of his career and days, wrote a long biography and barely mentions Ancel Keys. So you know, Keyes was one of those people who could ingratiate himself, but he may not have remained on everybody's most popular list. Okay,
Nick Jikomes 23:51
so just so it's top of mind for listeners, in plain language. What was the Diet Heart hypothesis that he formulated,
Orrin Devinsky 24:00
the Diet Heart hypothesis morphed over time, but it began with the idea from this 1953 paper, that heart disease is caused by too much cholesterol in your blood, it congeals in the arteries, and causes heart attacks. That's essentially the hypothesis and that the most important factor determining cholesterol levels is diet. In 1953, as I just said, he thought it was all fats that caused cholesterol buildup in heart disease. By the late 1950s, when the feeding studies had clearly shown that the only fat that really raised cholesterol was saturated fat. He pivoted to that. And although saturated fats the only fat that also raises HDL what's known as the good cholesterol, He ha ignore that. That's like, talk about it.
Nick Jikomes 24:52
Yep. So don't hurt hypothesis. Basically, heart disease comes from your cholesterol levels being too high, your cholesterol levels being too high, widely believed to be Coming from saturated fat, therefore donate saturated fat to raise your cholesterol levels and then get heart disease. Exactly. In parallel to that, what is, you know, because we're going to talk about obesity as well. What is the inner energy balance hypothesis of obesity.
Orrin Devinsky 25:18
So the energy balance hypothesis, which was I was taught in medical school. You know, it's touted as being consistent with the laws of thermodynamics. And thermodynamics works beautifully. Well, for physics, biology is more complicated. So the energy balance hypothesis is that you know, you're an adult male, I'm making this up, but you weigh 175 pounds, your basal metabolic rate, if you just you know, sit in a chair and read a book all day and go to sleep, let's just say you burn, you know, 1500 calories, but you're not a couch potato, you walk a couple miles a day, you lift some weights, so you burn 2400 calories a day, you're an average man. And the energy balance says, if you have a basal metabolic rate of 1500, you burn 900 and exercise, then if you take into 2400 calories a day, you'll be weight neutral for the rest of your life. If you take in 20 450 calories a day, that 50 is just a teeny weeny bit, but multiply it by 365 days, times 10 years, and you'll gain 10 pounds or whatever that number comes out to over 10 years. That's the energy balance hypothesis. And I think it's mainly wrong, I think there's certainly shortage of truth thermodynamics is true. The problem is our bodies are not engines. They are metabolic engines, but they're much more complicated. The simplest example, it's almost comical is that the amount of calories in something like four and a half ounces of a ribeye steak, and four and a half ounces of diesel fuel, and four and a half ounces of gasoline, may all have the same calories. And for an engine that could burn all three, they are energetically identical. However, you will die. Of course, if we took the gasoline or diesel, we would be barfing or having diarrhea or probably both and get very sick and get no beneficial calories from it. Our engines don't burn gasoline, in the same way a gasoline car will die after a couple of miles on diesel. So you know, the idea that it's just calories is just way too simplistic. We have microbiomes that influence our metabolic rate. Not all of us are able to digest the same foods in the same way. But we also have these things called hormones that greatly influence where we put calories, how we put calories. And you know, examples are men and women, you know, men and women after puberty distribute calories very, very differently. Men have a greater muscle mass. Women have larger breasts and larger hips and obviously, reproductive reasons why those things happen. They're present in all human populations. But it's not that kids grow because they eat too much. It's well because hormones tell them to grow.
Nick Jikomes 28:12
Is it fair to say that the energy balance hypothesis is essentially just saying it's about calories in calories out? And a calorie is a calorie, but alternative hypotheses are saying, well, no, a calorie is not a calorie, your body uses different calories in different ways. Exactly.
Orrin Devinsky 28:28
And I think they're both true to some degree. I think, you know, many of my friends and I'm on their side that I think the energy balance hypothesis is way too simplistic for human beings or any animal quite frankly, by the same token, you know, if you eat junk food, or you eat healthy food, and you have 7000 calories a day, you're gonna probably gain weight. Even if you're eating, you know, broccoli and asparagus. It's going to be hard because it is just a crazy overload of of energy that your body can use. But it's simplistic. Yeah,
Nick Jikomes 29:01
so yeah, so So I don't think anyone's saying calories in calories out doesn't matter at all. It's just whether or not that is sufficient to explain.
Orrin Devinsky 29:09
It's not the primary driver, there's no way it's the primary driver, because as I said, go back to you trowel in Kenya 1942. They try that in the same way, find me an obese individual who hasn't tried to reduce their weight by reducing their calories. Find me one. You know, everyone tries it intuitively, you know, you go out to a wedding or it's summertime and you want to lose a few pounds. Everyone just intuitively says I'll eat less and I'll lose some weight. And it's just not that simple. Certainly not for obese people.
Nick Jikomes 29:43
So getting into the paper now, I mean, you know, roughly speaking, right when we carry when we think about some of these questions, diet, heart hypothesis questions and heart disease, obesity questions, metabolic health. One key piece of information to evaluate some of these ideas at least partially is just to Look at how the food supply and how food consumption changed. And you did that? Can you briefly just explain for people? What is this paper? Where did where did the data come from? And, you know, how did you look at it? How good is the data?
Orrin Devinsky 30:15
I think that data is as good as we could get it to be. As I said, as you go back in time, it gets really hard, because you go back to 1920 1930, a lot of the data was collected, I think, at the beginning of World War Two retrospectively. So it wasn't, I mean, the USA, DEA did collect some data, but it was dirty, rough, and you know, would not make scientific merit in today's world as being accurate data. So these are rough estimates. Certainly, we know that, you know, we can go back and look at diaries from places like African slaves in the south. And they, you know, they, we ate huge amounts of pork, and fried bread and things like that. So, you know, we have ideas about what they ate, but America ate a lot of meat. Keep in mind, we had millions and millions, you know, Native Americans had millions of bison, to hunt. And they did, you know, settlers ate bison, too. But in the northeast, you know, people ate steaks for breakfast. And meat was very available in the 1800s. Now, again, these going back to historical records, and who's writing these are often the wealthy people, not the poor people, poor Irish immigrants in 1910, ate a lot of bread and vegetables in New York, I believe. So a lot of it was socio economic. But even in the south, on plantations, in the slavery days, blacks were given pigs to own, the whites pretty much had cows and chickens. So, you know, people had access to meat, but we tried to get all the data we could all the USDA data, all of the published records that were out there, we went through all the papers that looked at dietary trends, tried to get all of their sources, I was fortunate to have several research, students helping me on the paper, and it took well over a year, and we went through many, many hundreds of sources. To compile the best data we could Is it far from perfect, but I think it's about as accurate as we can get.
Nick Jikomes 32:14
Yeah, I mean, it's like I got interested in this topic and related topics. And I just wanted to know, like how diets actually changed over time. And as I was, as I was, you know, digging around online, I started noticing these figures, that all kind of look the same in that same style. And I actually realized that you had sort of put a lot of the stuff in one place. So to give people an idea for some of the major trends here, I just want to go through some of the figures in the paper, and have you give us at least a bird's eye view, but just starting with total calories and macronutrients carbs, total carbs, total protein, total fats, what are the most salient ways that consumption of those things was changing throughout the 20th century?
Orrin Devinsky 32:57
I think overall, we we got better at processing food. So things for example, vegetable, what we call vegetable oils, but they're not vegetable oils, they are industrial process seeds. For mature oils are extracted under high pressure and temperature and things like that. So they're not natural products. So you know, one way to think about diet for me is, and not the first person to say, but if your great grand parent consumed it, then it probably was fairly healthy. But if it had to go through a factory in the Midwest to get to your plate, you should be suspicious of it. So what we call vegetable oils, or seed oils, which make up about 8% of the American diet. Now, they didn't exist prior to 1909 and Crisco. And when Crisco was first commercialized, it was, you know, an oil that was hydrogenated, so it was under pressure. Hydrogen was put in there, and it created a lot of trans fats, as we now know, which are another category of unhealthy foods that can accumulate. They're not natural. There are some trans fats in nature, but they're very, very tiny amounts. But they became a large part of the American diet of my diet. In my childhood, you went to a fast food, McDonald's or Burger King, you bought some, you know, Suzie Q's or Drake's cakes, they had, they all had were abundant and trans fats, and no one was keeping track of it. Obviously, that eventually came out and they've been greatly reduced in the American diet for people like myself in the 60s in my 60s, you know, in when I was 10 years old, 2030 trans fats were just a big part of the American diet. So though, that's one thing, we introduced all these unnatural fats. At the same time, natural fats like butter. Lord SUID, tallow, the cooking fats of our parents generations, have largely gone down 70 80% largely being replaced by vegetable oils? Is that good? You know, maybe good, maybe bad. I don't think we know these are complicated questions, but we do know, the butter. And Lord had a lot more saturated fats than the vegetable oils do. So in principle vegetable oils, we should have seen a dramatic reduction in heart disease if it was really the Lord and the butter that was driving it. But indeed, we saw a rise as vegetable oils displaced Lordan butter.
Nick Jikomes 35:26
Yeah, and you know, one of the one of the things I see here, you know, when I look at just the the trajectory of the supply of total calories, total carbs, total protein total fat, is it? Well, first proteins quite flat over time, protein consumption changed very little compared to the others. Certainly, by about 1970, you start seeing the steep rise in total calories. And that seems to be driven by a rise in both carbs and fats. But then, by about the turn of the millennium, about 2000, things actually start going down. And so that's interesting to me. So things did rise. And you know, obesity would have been rising around this time period 6070s 80s 90s. But then it continues rising, obesity does, and yet total calorie, total carbon total fat start actually going down somewhat after about 99 2000. Is that, is that accurate? That's correct,
Orrin Devinsky 36:17
is the best. And again, the more recent data, I think, is probably more accurate than the data from the 1830s or so. And I think it speaks to the fact that what creating the obesity now, it was what everyone's still, you know, the American Medical Association hardest. If you want to know how to lose weight, reduce your caloric intake, and that's what people will tell you. Unfortunately, it just doesn't work. As I said, most obese people have tried to reduce their calories and losing weight, it's just not that simple.
Nick Jikomes 36:45
Another interesting thing here, you know, related to, you know, the change in the consumption patterns for specific foods like vegetable oils, like butter, lard, etc. is thinking about this in terms of the different fatty acids. So the three main categories here that people will have heard of saturated monounsaturated, polyunsaturated fats, how did those specific fats change relative to one another, over time, since, say, the mid 1900s.
Orrin Devinsky 37:11
I think saturated fats overall have been pretty stable. Heart again, hard to really know truly what they were consuming in 1910 1920. But as best we know, it's pretty stable. The big rise has come from the polyunsaturated fats, which are mainly the vegetable oils we were talking about. And then also the minor ones, saturated fats, which is a laic acid, things like that. And olive oil, which is a more natural product, and obviously has been consumed by Mediterranean populations, like the Greeks and the Italians most famously, and been associated with good health in those populations. But no population, no human population has consumed vegetable oils, historically. And,
Nick Jikomes 37:53
you know, again, for my entire life, for many people's entire lives, even to this day, like when I go to the supermarket, and I look at what are the things that have that heart healthy sticker on them. It's things that contain unsaturated fats and polyunsaturated fats. What Where did that come from? What why? Who considers those to be the healthy fats? And what is the evidence behind calling the unsaturated fats, the heart healthy ones.
Orrin Devinsky 38:22
So I'd say two streams of evidence supported one I've already discussed in the mid 1950s, they started doing very large scale feeding studies, they took young adults, you know, put them in a dormitory, counted everything they ate for a period of a month or so. And those who are given polyunsaturated fats like canola oil or things like that, they found that their cholesterol levels often went down a little bit by having high polyunsaturated fat diets. So in the simplistic view of high cholesterol causes heart disease causes death. Polyunsaturated fats can be associated with a reduction, especially if they replace saturated fats, then yes, total cholesterol will often drop. Now the HDL ratio to LDL may get worse, but the total cholesterol would typically go down and total LDL would typically go down. So that was kind of the simple story. And in public health. The goal of physicians and public health officers is to keep it simple for laypeople don't make it complicated. And they tried to suppress the whole concept of HDL and LDL for a long time saying people would get confused just talking about total cholesterol. So there were journals that wouldn't publish on HDL and LDL in the 60s and suppressed a lot of data on this. So that was one of the areas and the other is that there have been some studies in a limited number, where populations have been put on a quote unquote, medical Mediterranean style diet, where they did reduce saturated fats, they did increase Use polyunsaturated fat consumption. And some of those studies, a limited number have shown some reduction in heart disease. Now, that may not be the only thing that changed in the diet, very few of those people getting put on a Mediterranean diet were eating, you know, Hershey candy bars by the pound. So there are other changes that go with it.
Nick Jikomes 40:20
Yeah. And I also suspect that, you know, key thing, when we think about that body of work is, it's not enough just to think about unsaturated or polyunsaturated fats, for example, you have to go down to the level of individual fatty acids. So you know, the Mediterranean diet, if you were to look at, say, the Omega six to Omega three profile of that, versus a high vegetable oil diet that an American might be consuming, those are very different animals.
Orrin Devinsky 40:48
Absolutely. And again, you know, if you look at the Blue Zones, whether it's Okinawa, or Sardinia, you know, there are some common themes. Number one, people eat real food, the foods are very different, whether it's Costa Rica, or Japan, but they eat foods that comes from nearby, and it's minimally processed. And they move, and they have family relationships, you know, those are the three key things that are associated with good health and human populations. But I think as far as diet goes, for me, it's the Ultra Refined diet that Americans eat, that's killing them and causing obesity and diabetes.
Nick Jikomes 41:26
Yeah, I mean, another remarkable thing, when you realize it, it's, it's, it's, it's, it's, you know, arguably obvious until, until you just really look at it, you know, as I've thought about the diet stuff is, you know, to echo what you just said, if you look at, say, the anthropological literature on, you know, hunter gatherers in, you know, all over the world, people have radically different diets, some of them ultra high carb, some of them ultra high fat. And in all of these vastly different populations, they still have very, very low levels of chronic disease, obesity, things like this, including
Orrin Devinsky 42:01
kids. So I'll just though, for me, cancers, what my family has too much of, and I was shocked when I started going through this literature as well. I mean to two observations, one, which I think should be a foundation of medical school education. You know, when people like Albert Schweitzer went to West Africa in the 1920s, he started operating on large numbers of people and seeing many, many patients in his clinic on a five, six day a week basis. And he said, after being there a couple of years, I'm sure cancer exists somewhere in Africa. But if it does, I haven't seen it. Hundreds of colonial physicians made that observation in Australia, in China, in Japan, in South Africa, in East Africa, in West Africa, where Schweitzer was, cancer was a rare disease prior to industrialized process food, and indeed, the only animals on the planet that suffer from cancer really, are domesticated pets outside of that, and farm animals for what we feed them doesn't exist. like monkeys in captivity, they get put on an American heart association diet, they get obese, because it's a processed diet. And monkeys aren't fat in the real world.
Nick Jikomes 43:18
Do you think like if you had to, if you had to really, really boil this, maybe getting a little bit ahead of ourselves. But if you had to, like really boil this down for the average person, who doesn't have the time, or the inclination to think about metabolic details and different foods, and you know, different saturated fatty acids, and blah, blah, blah, blah, blah, is the sort of key dichotomy people should keep in mind when they're thinking about healthy eating simply processed versus non processed, I
Orrin Devinsky 43:48
believe so. And within the processed, I would just, you know, the big category of the culprits are sugar, white flour, white rice, and anything that comes packaged, I mean, if you're gonna buy something, throw out the microwave and nuke it and eat it and call it pizza, you're in big trouble. You're eating unhealthy food.
Nick Jikomes 44:09
So you mentioned meat consumption earlier. So for most of us history, you know, people live on or in close proximity, proximity to farms, meat consumption is pretty high. It's readily available, as you said, people were eating, you know, steak for breakfast commonly in the 1800s. One of the striking charts in this paper, too, is basically the change in the meat supply over time in the 20th and 21st centuries. So at a high level, you have a graph that shows red meat, versus poultry versus seafood, fish and shellfish. What are the main trends that we've seen there in the last, you know, several decades? So
Orrin Devinsky 44:48
I think the big, big big ones I mean, red meat has fluctuated a little bit. It goes down during all the world wars because soldiers get priority over the rations to the people at home, but apart from That red meat consumption has gone up and down a little bit, but it's been relatively stable. As best we can tell pork consumption probably down a bit, but cow meat probably up a little bit. So they balance the huge chain and fish and shellfish pretty constant over time, the remarkable change has been chickens. Chicken was kind of a luxury item, either you had a chicken coop nearby at a farm in the in the rural America. But otherwise it was it was kind of a luxury food and just wasn't consumed. It was a lot of work for a little bit of meat, so to speak, think about how much meat is on a cow, or a pig versus on a chicken. And so they were relatively expensive and kind of a luxury item like hens for the upper wealthy class. And then I think with industrial farming of animals, which we have now. And the promotion by the American Heart Association, that chicken meat was considered healthy while cow meat was considered unhealthy. There's been a dramatic rise in the consumption of dairy meat, dairy meat of chicken meat following, you know, really 1950 5560 When Ancel Keys came out with the diet, heart hypothesis, chicken consumption went through the roof.
Nick Jikomes 46:19
And so over time, for for much of the 1900s. Certainly by mid century, yeah, this, this line for poultry is just going up into the right, much more than for red meat and shellfish and fish, which are relatively stable over time. So the ratio of the meats we're consuming is very different by the time you get to the 2000s Compared to earlier in the 1900s. The other factor here that I just want to quickly ask you about that's not in the paper, but I think would have to be relevant here is not only our meat consumption patterns changing, but I imagine the macronutrient profile of the meat itself is changing as we scale up and do more things like factory farming, and we start feeding the animals in a different way. Is there anything worth talking about there?
Orrin Devinsky 47:06
Yes, certainly the one thing that has been well studied is that animals that are cows, for example, that are grass fed have a much healthier Omega three to six ratio than animals that are grain fed on corn. So you know, again, corn, corn fed animals, which is what a lot of our meat comes from, it's a better way to get fat in there. Because corn turns into fat much better than does grass. It's just, you know, the fructose in corn is great for making fat. Fructose is the most fat producing sugar on the planet for a mammal, including us. And so you know that dietary change has changed, not just the, you know, the cow we're eating now is not the cow our great grandparents ate, it's very different. It's got a different fatty acid profile, and, you know, is less healthy, unfortunately.
Nick Jikomes 47:59
And you've already mentioned that, you know, the vegetable or seed oils, they've become much more common over time, when you actually look at this graph, the added fats and oil availability. It's remarkable. You see, you know, the drop in butter, lard and in the animal fats started quite early in the 20th century. But then by the time you get the data in mid century, by the 60s with vegetable oils, when you look at this, it's going up into the right the entire time, basically, but it's going up strongly from mid 1900s, to late 1900s. But then at about the year 2000. It starts accelerating even more. And now it's you know, sort of Off The Charts today compared to these other things. What was actually driving this dramatic rise in vegetable oil, and we just get really good at agriculture.
Orrin Devinsky 48:48
So I think there are a few things, you know, the data from the early part of the century is horrid. And again, a lot of that was just really Crisco. So Crisco launched a big campaign, you know, which would promote themselves as clean. And one of the things that did change meat consumption patterns in America was Upton Sinclair's The Jungle. Written interestingly, as kind of a socialist book depicting the plight of these poor workers in these meatpacking plants who lose fingers and the fingers would end up in the, you know, the meat that goes to the housewives in Milwaukee or wherever. And as in the book became a best seller changed national policy. I think, you know, USDA was revamped at that point to do many more inspections of meatpacking plants. I think Roosevelt was president around that time. And Upton Sinclair said, I shot an arrow at America's heart, and I hit them in the stomach. And what he meant by that is, he wrote this, he wrote the jungle to say how bad the plight was of these American workers. He wanted to hit people in the heart of how much these working class people were suffering. But all he did was hit them in the gut that they were disgusted how was horrible there the meat supply was and what the conditions were that there was urine and feces. And, you know, it was just a disgusting people were you know, the sanitation conditions were horrific. Nowadays they're probably not perfect. But in those days 1909 The truth is in Chicago meatpacking plants, they were beyond horrible.
Nick Jikomes 50:23
And, you know, as we've said, we have this transition away from animal towards plant based fats driven a lot in large part by things like the vegetable oils and away from things like butter, lard, etc, you know that that graph is also dramatic, when you just look at, you have a graph of the availability of vegetable based versus animal based fats and added oils. And you know, by the 1950s, these, these two lines are diverging, and then it just gets really dramatic. And you know, today, it's like, you know, the vegetable oils are way up here. The animal fats are way, way below that. Can you talk a little bit more, so not only are we consuming more vegetable fats today than ever before more of them compared to the animal fats. But let's dig in a little bit more and explain for people how the fatty acid composition of these products differs. So can you give people just a basic one on one there?
Orrin Devinsky 51:15
Sure. So you know, as we've kind of mentioned here, at different times, there are three broad categories of fats. There are the saturated fats, which means there are no double bonds for those who remember their high school chemistry. And so they line up very straight. And they're solid at room temperature. Because they, they're there, they can line up and form not quite crystals, but they're much more solid structures. The unsaturated fats, whether they are mono unsaturated like olive oil, oleic acid, which has one double bond, or the polyunsaturated, poly means many, so there are many double bonds in canola oil or oils like that. Those are going to be liquids at room temperatures. And so one corollary of that, which is always nice to remember, if we talk about Native American Eskimos Inuit, who also can have extraordinarily high fat consumption, but have unremarkable as best we know heart disease prior to the introduction of processed foods. Although that data is not the best in the world, they were eating a lot of their fats came from marine animals. So if you think about it, if you're a marine animal, what's evolution going to do? It's going to put a whole lot more polyunsaturated fats in your, in your fat, as opposed to saturated fats, because if you're mostly saturated fat and your seal, or a whale, in the Arctic Circle, your fats are going to be frozen solid, as if they're polyunsaturated, they'll remain liquid in the cold weather. So much sea mammals by and large, who swim in very cold waters, even even in temperate regions tend to have very high ratios of polyunsaturated fats to fats. Very different than things like cows and pigs, pigs, we live in much warmer environments, they're going to have much higher saturated fat components. But I think people really get mixed up with the fats because pigs lard for example, you know, the classic saturated evil fat, you know, bacon fat is terrible for you. It turns out a lot of bacon fat, number one is mono unsaturated, and a lot of the saturated fat gets turned into our body into mono unsaturated fats. So they these things are not these dichotomous things where lard is evil, saturated fat. I don't think saturated fats evil to begin with, but it's just not that simple. They're all mixtures. There's no animal, whether it's a cow, or a seal, or a pig, who's fat doesn't have mixtures of all three types, saturated, mono unsaturated, and polyunsaturated. Certainly, when you get to the vegetable oils, they can be pure polyunsaturated, or things like olive oil, where it's a mix of a lot of Mono Unsaturated with some polyunsaturated, maybe with a drop of saturated, and then you get to the tropical oils like coconut oil. And those are going to have high amounts of saturated fats and against populations in Polynesia, who ate enormous amounts of saturated fats from coconut oil and things like that they had very low heart disease rates prior to the introduction of processed foods.
Nick Jikomes 54:39
Another dramatic change over time here is you've got a graph of caloric sweeteners. And you know, they all change in different ways, but probably the most dramatic change is the corn sweeteners, high fructose corn syrup, glucose dextrose, things like this. Can you summarize that for people
Orrin Devinsky 54:59
again, I think you know, as this really began with the industrial age in England, which is where the obesity diabetes epidemic began as well. But with industrialization, you know, we were able to power steam engines, we were also able to do large processing of sugar and flour and get it to a higher grade used to be molasses back in the 1800s. It was dark and, you know, much less pure than, than what we can get in our Dominos white sugar box today. So that's all industry, that's all using machines to process food for us. They've done the work, they've done the digestion, we've removed the fiber, we've removed micro micronutrients. And we've enriched the amount of fructose. So in our country, you know, it's just so cheap. There's sugar subsidies. This is one of the places where, you know, unfortunately, I would say government policy has been has been evil and the sugar industry, there are two great quotes just to put the sugar industry in context. One is from FDR and think it was around 1939 or 40. But it was it's a, it's a New York Times article, I can send it to you. But some bill he was desperate to get past was was voted down. And he's quoted in the New York Times in the early 40s. I believe it was his saying, the most powerful lobby to descend upon Washington in my lifetime, has been the sugar industry. That's Nike 40. Jump ahead to like 2000 something. John Boehner, the Speaker of the House, who had the spontaneous, crying episodes. He at one point said that he was like, and I'm gonna misquote a little bit, but the gist will be right on. It was a Friday, I was doing a news conference on something. And I knew you can never go after the sugar industry. They were just too powerful. But I never liked them. And I just felt like what the heck out of the speaker of the house, I can take a little tweak if I want. So it was like a Friday towards the afternoon. And he said, Yeah, and we may add something to the bill that might pull back on the sugar subsidies. He said over that next weekend in his home district. He had more phone calls and letters and outreach from his constituents, not nationally, but from his local congressional district, saying my brother in law delivers for interments, my sister works for this company. And if they don't have sugar, they'll go out of business, you're going to take away my family's jobs. He said in his 30 years or whatever, in politics, he'd never seen a response like that, ever. And they own this country, they were able to get articles published in the New England Journal in the 1960s. By the head of the Harvard School of Public Health, nutrition, division, they are immensely powerful. They control politicians, and you know, they are killing us. And we are relatively powerless medically. Politically, you know, it's like, people won't go against Al Gore wouldn't go against the NRA in Tennessee, if he wanted to get reelected, you know, some of these political groups are just enormously powerful, but the gun industry is terrible. And these mass shootings, I think it's it's horrible and criminal. I think the sugar industry is much worse on a much larger scale as far as debt.
Nick Jikomes 58:22
Interesting. Um, you know, I think I think it's safe to assume that people listening here probably have, you know, some reasonable level of understanding of sugar, insulin resistance, diabetes, and that obviously, certainly at least, that too much sugar is obviously bad. But you said something earlier, you mentioned fructose in particular, and fat synthesis. Can you give us a little bit more detail for those listening? What is fructose as opposed to other forms of sugar? And why is fructose often especially bad when it comes to metabolic health? So
Orrin Devinsky 58:54
I think they're all simple sugars are relatively bad, they're not part of the natural diet, the only place they really did exist in the human diet prior to in the industry is in the form of honey. And there are many human populations, the hodza in East Africa that have honeyguide birds that take them to nests. But keep in mind, they have to work they have to climb a Bow Bow Bow tree to get to those nests. And then they have to fight the bees and get bitten go down. And when they eat the honey, they've got larvae in there, they've got wax in there need them shebang. So they're not just putting down honey the way we do when we go to the supermarket and get a honey bottle. But the radical changes that they're, you know, thinking about carbohydrates, and this is probably one of the great mistakes of medical science of the 20th century. And Jocelyn was probably one of the culprits here in a very big way. They couldn't imagine once they understood some biochemistry, and they understood that starch would get broken down into glucose. And that glucose OHSs which is a simple sugar of six carbons, has the same caloric density is fructose, which is another six carbon sugar. Simple sugar. Fructose is a little sweeter to our tongues. But fructose and glucose are radically different compounds for the human body and all mammalian bodies. As far as I'm aware, the difference is that glucose can be metabolized anywhere your brain runs on glucose. Your heart runs on glucose, your muscle runs on glucose, and your liver can process glucose and turn it into glycogen, which is our storage form of glucose or turned into fat, which is the long term storage for him. Fructose on and the other part of glucose, as you alluded to, is it stimulates insulin release by give you a big candy bar, and check your blood sugar a minute before and 20 minutes after your your glucose is going to spike and right behind it, your insulin is going to spike. If I gave you the equivalent amount of fructose. Your fructose level will go up in your blood, your glucose level won't budge. Your insulin level won't budge one iota. So fructose does not stimulate insulin, which in some ways sounds paradoxical because insulin is one of the drivers of metabolic disease and diabetes. The key issue is that short term fructose and long term fructose are very, very different animals. So that fructose, as I said, is the sugar that our bodily body can most readily turn into a fat. It's much more what was called by the late 1940s. When they studied this, they called it lipo genic live lipo means fat genic means Genesis or make. So if you want to make fat in your body, consume fructose, if you want to really get fat consumed fructose with glucose, the glucose will stimulate insulin. Insulin tells your body we're in a wonderfully energy rich state system, probably just eating, let's lock up all the fat and the fat cells because we got plenty of sugar running around the blood system, we're in the turn of making fat, storing fat and ceiling fat in fat cells do not let the fat out of the fat cells if anything, put more in. And so that's what insulin tells our fat cells to do. And it says the same thing to muscle cells take up insulin, take I'm sorry, take up glucose into your muscle fibers and burn glucose because we got tons. The blood is rich and glucose, take it up, burn it. That's what you should live on full of fuel, do not burn fat. And so when people want to burn fat, they need to not consume sugar, either glucose or fructose, but the metabolic and that's again, we go back to Jocelyn, when they thought in the 1920s, about sugars. They assumed broccoli and a candy bar were identical because they were calories derived from carbohydrates. And they were right about that. But what they were wrong about is that starch is not equal to glucose. It takes your body a long time to digest starch into simple glucose molecules. And glucose is not fructose, they have very different metabolic fates. The only organ in our body that can deal with fructose is the liver, your muscle can't, your brain can't your heart can't. Your pancreas can't. The only thing that deals with fructose is the liver. And it turns it into fat. And that process is part of the American, the world nightmare now of sugar, because we table sugar is 5050, fructose, and sucrose, sucrose, which is 50% glucose and 50% fructose. And that combination of simple sugars is something the world has never seen before prior to industrialization. So
Nick Jikomes 1:03:59
thinking in evolutionary terms here, why is it that fructose is only processed by the liver and liver turns into fat? You know, naively at least you would think, well, we're apes, you know, our other primate cousins oftentimes eat a lot of fruit. Why would this be the way that our bodies deal with fructose? Is there is there like a natural evolutionary reason that that might help us think about that?
Orrin Devinsky 1:04:28
It's a good question, you know, exactly. You know, we're primates and, you know, for 60 million years, we've probably been eating fruits, maybe one of the theories of why we have three color vision, unlike dogs and other animals. So we, you know, Primates are definitely attracted to ripe fruits, they're higher and, you know, nutritional content and sugar. But I think part of it was just that the glucose could keep us going now, and the fructose could keep us going in the future. That's probably the simplest way that that evolution has devised a strategy that And again, keep in mind as I was referring to people in East Africa and 1942, those, those they were not the unusual humans, they were the typical humans. For all of our history, human beings were thin animals. Just like if you look at chimpanzees in the wild, or macaque monkeys in the wild, Primates are thin. In general, they don't carry a lot of body fat on them. Humans are probably the fattest of all the apes. But we're still thin prior to industrialized food. So I think he was just a way for if you did get a wonderfully rich meal, you have the ability to have fructose, which could be stored into fat, and was a great device. Because, you know, prior days, hunter gatherers are very good about finding sustenance foods. So again, we don't talk about it much in diet, but the number of edible insects still consumed in the world today, over 2000 species. So humans have been eating foods that we wouldn't like all the time, because they learned how to survive, hunter gatherers don't starve to death. It's industrial population, farming populations that starve to death, when a mold or fungus takes over a potato crop, then everyone's eating potatoes, that's a big problem. But go back, you know, 20,000 years to East Africa, or wherever, and people were fine, it's surviving. They'll eat meat, if they can get if they can't eat meat, they'll eat sugar rich fruits, if they can get them or honey, if they can't get those. They'll eat low quality foods, plants and insects. Although insects have a lot of protein have fat, they're very nutritious. And that's why there are 2000 edible species still consumed in the world.
Nick Jikomes 1:06:41
Why do you refer to plants and insects as low quality foods there?
Orrin Devinsky 1:06:44
I just mean, as far as the caloric density, I say, they have. So I think I shouldn't say low quality, they're not dangerous in any way. They're just, you know, humans are humans, just like you and I. And if I, you know, if I went up to the average 14 year old and said, Would you like a pepperoni pizza? Would you like a piece of broccoli? You know? Or would you like a caterpillar? Or would you like, you know, to chew on the leaves and the plant behind you, which probably have a drop of nutrition but, but terribly little, you know, the pizzas going to is just like a little, you know, it's a steroids.
Nick Jikomes 1:07:21
It's food on steroids. Yeah, so I mean, just, you know, any animal, human or non human right, it's perfectly, you can, it's easy to imagine why they're going to prefer high caloric density, because out in the wild, you know, you don't often know when your next meal is gonna come.
Orrin Devinsky 1:07:37
Exactly. And that's why cooking was such a bonus to the hominid evolution. That's why we have one of the reasons we probably have brain societies we do is because when you cook food, number one, you kill pathogens, number two, you pre digested for your body. So you don't need to speak you don't need to chew as long as gorillas and chimps do, you don't need as much digestive system to process the food you've already heated it denature a lot of the proteins pre digested some of the proteins. And so it's made our lives a whole lot better. And now we can eat a wider range of food and keep it for longer periods of time.
Nick Jikomes 1:08:15
One of the things that's really trendy today, in the dating world is intermittent fasting. And the idea here is if you stop eating for some time, you know, 12 hours, 16 hours a day, two or three days, days, even. You are obviously not eating you're not taking in calories. But then you know, that changes your body, it changes your metabolic state. And one of the one of the things that many people will have heard about is ketosis, and the ketogenic diet. And this is an area that you know a lot about. So before we get into the ketogenic diet, and some brain health questions, I want to ask you, because you've got a lot of expertise here. What is so when you're fasting, what are sort of the key things that are happening in the body, and what's changing when you go into ketosis.
Orrin Devinsky 1:09:02
So our bodies, as I said, primarily, have learned to live on carbohydrates as the main food source, with fats as the backup, that's basically we try not to eat protein, you know, digest proteins because we need them there. For our structural strength, we can digest proteins, the amino acids can give rise to energy, but that's kind of the last failsafe for the for the mammalian organism. So in general, we eat enough balance of sugar, fat and protein, that the carbohydrates whether it's usually starch has been the main carbohydrate that humans consumed. underground storage units, like potatoes, cassava, etc, has been a major source of calories for us. And that's where calories came from. So when we eat fats, we would burn some but we'd store most of them. But we were never overweight because we never had that much food and we were temperate in what we ate. Just again, the human appetite wasn't like it is today, it's hard to imagine, but in in for a lot of populations, they just didn't, they would feast when there was a reason to, but they often didn't have that opportunity. So basically, they burned carbohydrates with a little bit of fats. And that was what humans burned for most of our evolutionary history. If at some point, we either didn't get food at all, or didn't get access to any carbohydrates, and let's just say it was the Inuit, and it is, you know, 1935, and it's winter, and there's no plants anywhere to be seen for months, those human individuals ate largely fat that was there, a little bit of protein, but mainly fat. And they did quite well, but they were in a state called ketosis. So when there's no carbohydrates in the diet, after a couple of days, or even within a day, the body's metabolism shifts gears, and literally goes from consuming primarily carbohydrates to run the average cell to mainly consuming fats to run the average cell. And that ketosis is a state where our bodies by burning fats are producing ketone bodies, fats are long chains of carbon, with hydrogen atoms coming off, there may or may not be double bonds as we refer to. But when our body digests those, we give off carbon, and that carbon, one of them is a ketone body. And those will give an acidic smell to the urine, and even to the breath, sometimes of individuals who are on a very, very low carbohydrate diet. And so that's ketosis. And people will go on that kind of diet to lose weight, and it isn't effective weight loss diet.
Nick Jikomes 1:11:45
I see. So I mean, it might be, it might be counterintuitive to people who don't know about the biology, but it's you're eating a no carb, sort of all fat diet. And that's actually helping you lose body fat. It
Orrin Devinsky 1:11:59
is and it makes perfect sense metabolically, it doesn't make sense from calories in calories out. But keep in mind as they referred to insulin, its job is to go up after you eat a carbohydrate rich meal, and synthesize fats and store fats and tell the body to burn sugar that's in the blood, because we're rich, we just hit the jackpot. And the problem with insulin is if you've become overweight, or even more, so if you become obese, your insulin levels are chronically high. And so the way I would explain it to my patients, and this has been studied by really good metabolism experts is that for the average bodyweight person, let's just say my body weight is average, for a human being over history, historical times might be in my eyes, like 21, or 22. It actually used to be lower. So I'm probably thin for the American society. But I'm probably overweight if you look back 200 years or so. But when I go to bed at night, let's just say I eat mixed dinner of meat and potatoes, whatever for dinner at six o'clock, seven o'clock. And then at 10 o'clock, I go to bed, I haven't eaten for three, four hours, my blood sugar is coming down, my insulin levels are coming down. By the time it's midnight, my insulin levels have almost approached the floor, they're close to zero, they're gone. When the insulin levels get that low, the fat cells open up, because the fat cells listen to insulin more than anything else. And if there's a modest amount of insulin in the in the blood, the fat cells closed down, they say there's plenty of energy. Do not open up your beautiful precious stores of fat, lock it up, lock it up. And so for someone like myself, when I sleep, I burn fat, because I'm thin, and my insulin levels are normal. And I have normal physiology. If you're overweight or obese, your insulin levels are chronically elevated. Your tissues, especially your muscle and your heart and your liver, are relatively insulin insensitive. It's what happens to you know, alcohol, think of it like alcohol. If you drink eight beers a day, you can be relatively insensitive to alcohol. Whereas if I never had an alcoholic beverage in my life, and I had three beers, I will be intoxicated. Yeah, I'm very sensitive to alcohol because I've never seen it before. But if you're living for 20 years with high insulin levels, because you're obese, every cell in your body has become somewhat insulin resistant. The last cells to become insulin resistant are the fat cells. And so the fat cells see high insulin levels at two in the morning. And they say okay, insulin levels are high like all the fat and the fat cells. So fat people unfortunately can't burn fat unless they get there. insulin levels really, really, really low, which takes time. They can't do it in one night because it doesn't happen. And so that's why obese people don't lose weight, because unfortunately, they can eat only 700 calories a day. But if those 700 calories include starches, even healthy starches, like broccoli and baked potato, that's eat, it's keeping the insulin levels up, and they can't lose weight and and they're wondering what the heck's going on. I'm not eating 700 calories a day, and I'm not losing weight. Where's this guy next to me? He's eating a lot more food. And he said, How can that be? And that's why because of insulin,
Nick Jikomes 1:15:37
yeah. And, you know, one thing I want to ask you about, too, is so, you know, two important health concerns, obviously, on the one side, cardiovascular disease, obviously, you don't want people to have heart attacks, you don't want them to die of cardiovascular disease. That's, that's a major concern and has been for a long time. And that's a lot of where this idea that we talked about earlier, of the Diet Heart hypothesis came from like, Okay, people are thinking, including doctors are thinking, heart disease comes from high cholesterol, high cholesterol is coming from dietary saturated fat. This is where you start talking about medications like statins, right? That people are going to be given to lower their cholesterol, because you're trying to avoid the cardiovascular disease. Over here, on the other side, you've got the explosion in metabolic disease, things like obesity and insulin resistance or diabetes is the way that we've done medicine and some of the ways that we've been confused historically about the causes of these things. Has it caused us to actually exacerbate certain problems with the way that we prescribe medications. So for example, I'm thinking here of the potential interplay between something like statins that might be given to lower someone's risk of cardiovascular disease, are those actually making some of the things on the insulin sensitivity side worse?
Orrin Devinsky 1:16:51
I don't know if statins make other things worse, I don't know that there is universally wonderful as they're promoted to be, and I worry about it for a few levels. Number one, the history of science and medicine is that wherever billions of dollars are at play by a centers, so I talked about the sugar industry, and that's been extraordinarily well documented. Unfortunately, no matter how well documented, it is, nothing changes. So it's a good example where we know exactly how corrupt politicians and how industry has been. And yet, even the medical establishment of the New England Journal in the 1960s, published a multi article on diet and health and heart disease. And it basically came out saying sugar is fine. Saturated fats are evil. It was paid for by the sugar industry, they have documentation, they literally paid the doctors who wrote it, the scientists, so it's, it's mind boggling. Now, think of statins, how many billions and billions are made every year. The amount of money that is going into promoting one viewpoint on this is overwhelming. Having said that, I don't know how bad the downside is, I will say one concern I have so let me just take you back Framingham Heart Study was the famous heart study done in the 19 starting in the late 1940s went through. And in 1961 They published their first paper on risk factors. That's where the word risk factor comes from the Framingham study. And that was a study that showed, especially men middle aged or older who have cholesterol, total cholesterol is over 260 had higher rates of cardiovascular disease and death. And no doubt, I think that's true. That's been borne out by a lot of research. What no one talks about is that that same Framingham study, and many, many other studies, since it found that very low cholesterol levels in some of those studies have been associated with higher rates of cancer, higher rates of accidental death, and higher rates of suicide deaths. So overall, even in Framingham, for men, whose cholesterol was under 160. total mortality was not terribly different than men whose cholesterol was over 260. But in 1960, it was heart disease, heart disease, heart disease, heart disease, no one talked about nutrition and cancer. And when they eventually did, they just lumped saturated fat with heart disease, and said, well, it must be causing cancer too, because it's got to right there's more cancer now than there used to be. It's got to be saturated fat. The Surgeon General Koop wrote a report that said the evidence implicating dietary saturated fat in causing cancer was stronger than the data implicating cigarettes in lung cancer in the 60s. That was one of the most false statements that a Surgeon General has ever admitted there was no data before he said it. And in the 37 years afterwards, there's no data and the National Cancer Institute which promoted that hypothesis in the 70s and early 80s has completely abandoned it. But we're left with the legacy of it. So I'll go through one more thing just to show how politics gets ugly. A very famous doctor in the Framingham Heart Study, George George man who studied the Maasai, one of those populations where the milk, blood and meat so very, very, very high saturated fat diet, Caesar, Native American native Africans, who are herders, and you know, extraordinarily high fat diet and low heart disease rates again, how well the heart disease was characterized. You could argue about but clearly not high heart disease rates for sure. And he got lambasted you know, he became a persona non grata and eventually lost all of his funding. As part of the fray is his doctorate, Framingham, he did a nutritional study that went for four years from 1956 to 1960. And in a cohort of I think, like 2000, people in Framingham, he and a dietitian, went to the houses, interviewed homemakers about what they cooked, measured things weightings and looked in great detail at what people consumed, and then follow them and looked at what their heart disease rate was mortality, etc, etc. What they found was no correlation between how much saturated fat you ate, and what your cholesterol was, nor any relationship between how much saturated fat you ate and what your heart health was. But what happened to that study, he was forbidden from publishing it. It exists as a supplement the Framingham study that you could not get at any medical library in the United States, I was able to get a microfiche of it as a PDF from the Framingham Natick library. And amazingly, it got published by a statistician who said, I found this incredible study, it's basically been buried, the data is immaculate, the study was beautifully performed. And I feel like it's my duty to write this up. So he wrote it up his supplement, I think 20 For the Framingham Heart Study, I have a copy if you ever want. And at the end, there's a newspaper clipping from the Framingham paper where the head I think, was Thomas dauber, at the time, is quoted about the study and says, don't believe it, you know, fats are still bad for you. So they did the best study they could do in the late 1950s. And because it didn't agree with the dogma of Ancel Keys and his crew, they buried it, and it will remain very exactly as they they being the heart mafia, you know, the American Heart Association, the NIH, the, you know, the National Health Service, I believe, paid for the Framingham Heart Study, our tax dollars paid for the study, and they buried it, they would not allow it to come out. And so
Nick Jikomes 1:22:55
I asked, Why do you think they would behave in that kind of way? Are they thinking, you know, we've got our reputations and our careers staked on this hypothesis being true. And they're afraid that like, they won't be seen as experts anymore. If evidence goes the other way. In combination
Orrin Devinsky 1:23:14
of that, listen, we all have egos we all want. You all want to come home and have your kid or wife be whatever proud of you. So I think there was some ego, just pure old ego, it's also it's my, you know, listen, if you have a hypothesis, the longer you stick with it, the more you're tied to it, baby. You want it to be right, and you'll kill any you know, you'll kill any argument that shows you're wrong. But I think there's another equally sinister part and it goes with all public health. So science is the religion of doubt. In science, you know, Fineman has a great quote, you could be 99% Sure, your hypothesis has been proven by a set of experiments. But as long as there's 1%, I don't care if it's point o one or 2%. But as long as it's not 100%, definite, there has to be doubt. You have to doubt yourself, if you don't doubt yourself, you will always fall in the trap of knowing you're right. Whereas in religion, you know, if you say I'm a Buddhist, or Hindu or Buddhist or Muslim, or Hebrew or Catholic, then part of that is saying, I believe in this doctrine, but there's no evidence, you're not going to ask someone for 100%. You're not even asking him for 5% proof. You're just it's a spiritual thing. And I'll accept that. But that's not science. You want to go to the science side, show me the data. And so what happened with public health is public health should be grounded in science and in large part it is, but the issue with public health and take the COVID vaccine because it's a beautiful example and I am an advocate for the COVID vaccine back in two years ago, when the pandemic was spreading and people were dying all over, I think the risk benefit of the vaccine made good sense. And I also believe in the concept of public health where either large groups of people embrace it, and get the vaccine for herd immunity, or we won't get the benefit, we should hopefully enjoy as a community. So to do that, you've got to promote it, and you want to try to remove doubt. Imagine what would have happened if Tony Fauci in the middle of the pandemic, said, Well, you know, we do worry about these cardiomyopathy deaths. So I must tell you, I can't tell you whether to take the vaccine are not, you know, it could save your grandfather's life, but your kid may get a cardiomyopathy and could end up with a problem. And we don't have all the data yet. So who knows what the right thing is, if Fauci had come out and said that no one would have gotten vaccinated, and we might have another million dead Americans. So I think what he did was right. And I think presenting a unified public opinion, is an important thing to do. At times, it's a dangerous thing to do. Because we never have enough data to be really, really sure of what the outcomes are. I think for COVID, it was the right thing to do. I think for heart disease in 1961, it was a horrible thing to do. And I think the diabetes and obesity epidemics, I think cancer in part has gone up from that from the dietary changes we've done. We've promoted refined carbohydrates, we've eliminated natural meats, like pork, and beef, and replace them with artificial, pre made products that make us fat, and make us obese and make us prone towards gout. And so many other diseases, probably Alzheimer's and cancer, and many, many others. So I think that's this vision of public health, you want a unified message. And that's what they were doing when they suppress the Framingham Heart Study. They felt like if this study came out, and got covered in the New York Times and Time Magazine, well, what are Americans going to think they'll just go back to eating pork for lunch, you know, we don't want that we don't want everyone having bacon for breakfast and hamburgers for lunch and steak for dinner, they're gonna die of heart disease. And they knew they were right in their mind, and they weren't, that's the dangerous part. So,
Nick Jikomes 1:27:13
you know, because our public health institutions have this sort of inherent, this inherent tendency to want to present, you know, a unified message, because, you know, so much of public health does depend on having sufficient fractions of the population, doing things a certain way, that seems to sort of be baked into the nature of a public health institution. You know, given what we've seen with the history of the diet stuff, given where we're at today, you know, no matter how you view questions of vaccine stuff, and Anthony Fauci and and our institutions on that issue, there's a lot of people who've lost faith in these institutions, given what you know, or and about how these things work today, and what the history has been, you know, if you imagine the average American today going to see the average physician and listening to you know, all of our institutions, whether it's the American Heart Association, or others, how much if you were the average person, but knowing what you know, as a physician, and someone who just knows a lot about all of the history here. How much faith and trust would you be placing in these institutions today?
Orrin Devinsky 1:28:23
You know, I have mixed feelings. I think I love medicine. I think my colleagues are, you know, brilliant scientists and doctors, but they make mistakes. I see my cart, I see my internist, my cholesterol is to 15 because I eat what I want to eat in in my way, I don't eat hardly any sugar, I'm extremely low sugar, low processed white flour. And I don't eat tremendous amounts of fat, but only, you know, naturally made cheeses, I'll eat steaks when I want to. And my cholesterol is to 10 to 15. My HDL was are rockin, they're great. My ratio is fantastic. So I don't worry about my my internist would love to see me on a statin and there's just no way I'm doing it. I think I don't think the benefits for me, I don't think there's any data for my specific profile, that they would be beneficial. And I do fear people like the guy from who wrote outlive Peter, Tia, you know, he would argue that your cholesterol can never be too low. And I would disagree with him strongly. I do not think he has the data to make that claim. And he'll go to Mendel rent Mendelian randomization studies, which is where someone like you are born with a gene where you unfortunately have high cholesterol. I'm born with a different genetic profile, and we eat the identical diets. My cholesterol is 120 Despite eating whatever the heck I want, and you can show that yeah, people like me with cholesterol is 120 indeed do have lower heart disease rates. The challenge is, you know, do I also have lower cancer rates and he's convinced it's not different, but I'm not convinced. I've read those papers, I've downloaded all those papers from his reference section, and my interpretation is not black and white like his is. So I think the challenge for the average person is you should be skeptical. But you've got to try it, you know, the average person can't download 10,000 papers and 500 books like I have. And it's not like I know everything after reading all that I know enough to be skeptical and have a lot of doubt.
Nick Jikomes 1:30:24
Yeah, I mean, I was surprised I actually had an interaction with a family member recently. And, you know, skipping over some detail, you know, I think her LDL was at, you know, 161 70, something like that. But her her HDL was fine. Her her age, her triglyceride to HDL ratio was fantastic. And, you know, she's a middle aged woman, you know, right at the peak of where you expect some of her cholesterol levels to be in being in her demographic. And, yeah, the doctor was like, Oh, absolutely, we need to put you on a statin. And I was just like, I mean, that just seems to be like, Oh, it's above some magic number that we were taught about in medical school 20 years ago, therefore prescribe it, no questions asked without even considering any of the other biomarkers and where they are relative to that. And, yeah, it's just, yeah, I didn't even
Orrin Devinsky 1:31:12
the Mia Hamm data was not nearly as strong for women as men. So for women, you know, there are different biological creature, and they have an overall lower heart disease rates. But you know, when you take away smoking when you take away hypertension, which are risk factors for both men and women, you know, cholesterol becomes much less of an issue for women than men. Not that it's not an issue, and certainly women who have familial hypercholesterolemia with levels of 300 shouldn't be on a statin, but I think for the women who have, you know, high HDL and low triglycerides, they're in a pretty good place.
Nick Jikomes 1:31:49
So I'm switching gears a little bit. So we started to talk about ketosis and the ketogenic diet. You know, one of the major applications there that some people will know about is, the ketogenic diet is actually a treatment for certain forms of epilepsy, but I want to talk about ketosis and ketogenic diet on a broader level. You explained before what ketosis was, and how the ketogenic diet and going into ketosis can help you lose body fat. But in general, if someone goes on the ketogenic diet, what are some of the other health consequences, they're positive or negative.
Orrin Devinsky 1:32:25
So I think positive ones, for example, things like triglycerides will go down significantly. Triglycerides are mainly a measure of dietary carbohydrate, especially refined carbohydrates. So that's one of the beneficial ones, obviously, weight and diabetes, if someone has elevated hemoglobin a one C, which is an early precursor of diabetes coming out, that will go down diabetic, insulin levels will go down. And so and I think weight will go down in weight, of course, when it goes up significantly as a risk factor for cancer or heart disease and premature death. So I think overall, there's there are a lot of health benefits, especially if you're overweight. I think if your normal body weight, I'm kind of agnostic, I'm not sure it's beneficial or harmful, it's perfectly fine. If you enjoy eating a ketogenic diet, I think you'll probably be just fine. Having said that, for the people on really strict ketogenic diets where they really have minimal carbohydrates, they do have higher rates of kidney stones, they certainly can suffer things like constipation. And there may occasionally be nutritional deficiencies depending on what kind of meat they eat, what the balance of vitamins are, but in general, it's a fairly healthy diet, I think you just have to make sure you maintain fluid intake for your kidneys. And just make sure, you know, some things like vitamin D that people may get from milk or depending on what you're consuming may not be in a ketogenic diet. So just be aware of some of the vitamins that might might be missed. Of course, more vitamins can be missed in a purely vegetarian diet, because meat tends to have almost all vitamins except for vitamin C. Given
Nick Jikomes 1:34:04
everything that you know, but But you know, in particular, given some of the trends that we were discussing from that paper you published to do with animal fats and vegetable fats. When we think about the more recent some of the more recent trends, the more recent pushes and the more recent product innovations around things like plant based meat substitutes and moving towards a plant based diet. But what's your overall take on whether or not that makes obvious sense that people should be going further and further into the plant based direction? Is there some merit to that? Do you have some skepticism there? How should people start to think about it? Look,
Orrin Devinsky 1:34:38
I'd look at the plant based thing from two perspectives. One is the environment perhaps and what we're doing to the planet and how much land we're cultivating, etc. And I think there there's an argument that could be made that you know, plants are better as a sustainable food source for the human population ecologically But I think with regards to health, you know, there may in general, if I, if I had to tell someone to choose what to eat, and it was either going to be all plants or all animals, I probably lean a little bit towards the plants, just because especially if they're not processed, but I think they're both healthy. And I think the idea that, you know, vegetarian diets are so much better than diets that include meat is is not supported by scientific data. So the China Study is a book that was written b by t. Colin blockiness. Last Name, Campbell, Colin Campbell. And I think it's probably some of the worst science I've ever encountered in my life. It's amazing. It's sold millions of copies. I've read the book many times, I've interviewed co so it was done is the it was called the China Oxford Cornell study originally. So people from those three universities, institutions were involved. I got to speak to Richard Peto, he was one of the original scientists, he was the Oxford scientist, Richard Peto, and da were among the people who identified cigarette smoking as a cause of lung cancer and the 50. So pedo goes with doll was the older scientist, but pedo when I spoke to a man, oh, five years ago or so was still alive. I hope he still is. But I asked him, how is that that, you know, you're on some of the original tables, all these incredible data I have, in my home, I have the books there. They like Wait 20 pounds are crazy. But I said, but you've never been on a paper, like an academic paper. I mean, most studies like this, they give you know, you look at will at Walter bullets, Women's Health Initiative, or Nurses Health, even rise to 20 New England journal and Jama papers, The China Study, you know, which is such a huge study, hundreds of 1000s of subjects over long periods of time, it's never made it into any mainstream journal outside of a supplement. I said, Why didn't you join any of the publications? And he basically said, I don't think you can draw any conclusions from the data. And he's right, you know, you can read the reviews that came out when the the massive tombs were originally published by epidemiologists. And they showed that the more the more animal meat you ate, in China, the lower the cancer rates, I mean, it's just then which is not like a strong association. But the data was just horrible. And it became this is an example of like, the opposite of Ancel Keys, you know, just someone took a mountain of data and became a prophet. It's like, you took the Webster's Dictionary behind, you wouldn't let anybody see what's in it, went to the top of the mountain and say, I discovered God's truth. And it's all in this book, and you need to listen to me eat plants. That's it. I got the data. It's all in this book. And so I think it's a fraud. I think people should look under the covers. And if they do and take a deep dive, it's it's just the worst science ever.
Nick Jikomes 1:38:03
Well, Warren, I don't want to take too much more of your time. We've covered a lot of ground today, this has been great. Is there anything that you think we've missed, that fits in with what we were talking about, that we should dig into for a minute or anything that you want to reiterate for people that you think is especially important? A
Orrin Devinsky 1:38:18
couple things I think you mentioned brain health, nutrition, I, I have obviously fascinated by nutrition. I've been in irreligious my entire life, I still see patients with neurologic disease. I wish there was data on what foods were brain healthy. I do think probably like everything else, you know, people who ate minimally processed foods, like Native Americans and 1900 had very low rates of Alzheimer's disease, stroke, and a lot of other diseases. So I think we don't know what foods are healthy for the brain. But I would say there's evidence to support the thesis that highly processed foods are unhealthy for every part of your body, including your brain. And then if there's one takeaway from what I've said today is that it's not plants or animals. populations have been, you know, eating what they can get that's high quality, nutritious foods whenever they can get it. But as much as it can be minimally processed, if you're going to get chickens that ran around outside and cook them yourself. You're going to do much better than going to a fast food place and getting some fried chicken. You know, that's just, it tastes good. And there's a reason it tastes good. You know, they've made those fried chickens, and they've made those desserts to make us happy. And they do make us happy, but it's like heroin. It's great in the short run. It's terrible in the long run.
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