0:00

man, I'm gonna piss off some people. I

0:03

think seeing food as medicine

0:05

is wrong on several fronts. It's

0:07

not a great way to

0:10

look at food on several fronts.

0:12

In this episode, I sit

0:14

down with Kevin Klatt, PhD and

0:16

RD, who is a research

0:18

scientist and instructor at UC Berkeley's

0:20

Department of Nutrition Sciences and

0:22

Toxicology. He's earned his PhD in

0:25

molecular nutrition from Cornell University

0:27

and completed his dietetic internship at

0:29

the National Institutes of Health Clinical

0:31

Center. Basically... He's the guy

0:33

who actually reads, teaches,

0:36

and performs the nutrition studies

0:38

everyone loves to quote. We

0:40

dive into great detail throughout

0:42

our conversation unpacking why nutrition

0:44

seems messier than ever, focusing

0:46

specifically on the viral claims

0:48

around eggs, seed oils, and

0:50

the food as medicine mantra. Kevin does

0:52

a great job in laying out the

0:54

guardrails you can trust amidst all the

0:56

noise. What I'd like for you to

0:58

pay special attention to is how he

1:00

answers my complex questions. He rarely

1:03

gives a simple soundbite answer

1:05

like your typical podcast bro guest.

1:07

Instead, he focuses on the

1:09

nuance to make sure you're getting

1:11

the most accurate and unbiased

1:13

information. That's what experts are supposed

1:15

to be doing. Anyway, I hope you

1:17

learn as much as I did throughout this

1:19

conversation. Please welcome Dr. Kevin Klatt to

1:22

the Checkup Podcast. Nutrition.

1:27

It's become

1:30

a bit of a buzzword. Least

1:32

controversial topic. Right? Most

1:34

people agree nutrition is

1:37

important, but they

1:39

agree for vastly different reasons. Participated

1:42

in vastly different food camps. It

1:47

used to be left, now it's right,

1:49

then it's left, then it's right. I

1:52

think the field of nutrition

1:54

is the most confusing it's ever been. You're

1:57

an expert in the field. Although

2:00

people don't like the word expert.

2:03

But unlike most

2:05

podcasters these days, or

2:08

health gurus, or health

2:10

podcast guests, You truly

2:12

are an expert because you've actually put

2:14

in the time to do the research, to

2:17

understand what is being said, to understand

2:19

when someone quotes a research article, what was

2:21

studied, what was missed, where the limitations

2:23

are. What's

2:25

your gut take

2:27

on the field of nutrition right now

2:29

if you were to give a banner

2:31

for it? Oh

2:34

my goodness. I mean, the field

2:36

of nutrition, I feel like is

2:38

often very separate from like the popular

2:40

understanding of nutrition. Like we have

2:42

an NIH nutrition roadmap that was released

2:44

a couple of years ago that

2:46

heavily embraces like precision nutrition, understanding

2:48

inter individual variability, understanding more

2:50

about food composition, how it

2:52

affects health, both in the long term

2:54

and chronic disease. And then in

2:57

the short term, like how in the hospital do

2:59

we feed patients better to improve outcomes? I

3:01

think the popular conception of nutrition is very much

3:03

what we would think of as like nutrition and

3:05

chronic disease. So I would, you know,

3:07

people are like, nutrition doesn't know anything is like a

3:09

very common perception. And I'm like, Well, we

3:11

know all the essential nutrients. We

3:14

do have great, very evidence -based

3:16

supplementation and feeding programs, things in

3:18

global health, and a lot of

3:20

implementation science there. There's a lot

3:22

we do know in nutrition, but

3:24

there is just this, I think,

3:26

the methods in nutrition always

3:28

leave a little bit of uncertainty

3:30

more than you'd get with

3:32

drug trials and these sorts of

3:35

things. How

3:37

does what I'm eating now affect something

3:39

that's happening? 20 years down the

3:41

road, you know, long latency periods to chronic

3:43

diseases before they manifest for the most

3:46

part. Um, and

3:48

so yeah, nutrition, it's, I

3:50

think there's a lot that gets lost in translation. Um,

3:53

there's a lot of people, I became a

3:55

dietician and did my PhD nutrition, not cause

3:57

I didn't want to write prescriptions. But then

3:59

I think the public is always looking

4:01

for a prescription of like how many

4:03

milligrams of this and how many

4:05

servings of this, um, or eggs, good

4:07

or bad. And it's all like

4:09

a yes, no thing. And I think.

4:12

anytime your question doesn't have a

4:14

definitive answer like it's it's gonna forever

4:16

fuel a media cycle and people

4:18

putting out information about it that seems

4:20

contrasting to whatever official dietary guidance

4:22

is and it's a never -ending loop

4:24

and so sometimes the questions aren't I

4:27

think adequate things like are eggs

4:29

good or bad you know that's

4:31

always in the media and that

4:33

like there's so many first principles

4:35

in nutrition science that I think

4:37

are violated by that question

4:39

on its own, like a nutrition, if you're, I always

4:41

take these questions and turn them into a study

4:43

design. And you have to ask, like, you know, if

4:45

you're going to do a trial of like, are

4:47

eggs good or bad? You really have to ask like,

4:49

well, what are people eating instead of the eggs?

4:51

And so like, are eggs good or bad

4:53

are going to be immediately be a

4:55

relativistic answer of like, are eggs

4:57

good or bad relative to lentils or to

4:59

red meat? And like, there's an infinite number

5:02

of these trials that you could do that

5:04

I think gets at like a major issue

5:06

in nutrition. We don't have a placebo in

5:08

our trials. And so you have essentially infinite

5:10

pairwise comparisons across foods and nutrition

5:12

is inherently interested in the dose

5:14

response relationship. You know, like in

5:16

pharma studies, you're trying to do

5:18

all of your pharmacokinetics early on

5:20

to optimize for the dose that's

5:22

going to like lower your target

5:24

and then not have side effects.

5:26

In nutrition, we care about high, medium,

5:28

and low and everything in between there. And

5:32

so you have, you can imagine, you know,

5:34

this egg question, you've got now infinite

5:36

comparators across many different doses and you can

5:38

quickly come into a 65 arm trial.

5:40

It's never going to happen. And

5:42

so like, and even then, like that

5:44

would only be certain for the population that

5:46

you studied it within. Are they high

5:48

risk at baseline? Um, are they

5:50

going to be somebody who's like a hyper

5:52

responder to dietary cholesterol on their blood cholesterol

5:54

levels? Um, there's all these

5:57

like effect modifiers and but that

5:59

I think illustrates like the questions

6:01

that we're asking sometimes are not the

6:03

right ones in both in the

6:05

literature and then also kind of in

6:07

the public sphere. So will

6:09

we never know our eggs good or bad?

6:12

I think the question is like it's

6:14

like our eggs good or bad for like for

6:17

who and their eggs are like

6:19

nutrient dense foods that I

6:21

think I'm not here to endorse

6:23

any food in particular but

6:25

like Um, the impact of

6:27

them on a dietary cholesterol, like on

6:29

LDL cholesterol is like quite small. And

6:31

I think, you know, if you're somebody

6:33

who's at elevated risk, you might be

6:35

counseled to consume less. Um, and if

6:37

you're somebody who's not, like the general

6:39

population data largely doesn't implicate them as

6:41

like, at least anywhere near the top

6:43

of like nutritional priorities, anybody should be

6:45

coming up with. And they're important sources

6:47

of nutrients that are. Like I did

6:49

my PhD in choline, which eggs are

6:51

uniquely a rich source of and that's

6:53

quite important during pregnancy. And so I

6:55

think we lose some of the nuance

6:58

of like, like nutrient, nutrient needs and,

7:00

um, optimal food patterns and things

7:02

vary a bit across the lifespan

7:04

and with different reproductive states, for

7:06

example. See, I find you as

7:08

an expert being at a tremendous

7:10

disadvantage here because if I asked

7:12

that question to a carnivore

7:15

diet expert. I

7:17

use that term loosely there. Someone who's

7:19

a proponent of the carnivore diet,

7:22

someone who's a podcast host, they'll

7:24

give you a very short

7:26

and simple answer that doesn't have

7:28

any of the nuance that you introduced. And

7:31

to the general public, that feels

7:33

like they're telling the truth, but

7:35

almost like as if you as the expert

7:37

won't tell them the truth. Why

7:40

is that not the reality? I

7:42

think we might be at a

7:44

point where the public is Getting

7:47

tired like you can go find anybody to

7:49

say anything is good or bad in this

7:51

sort of a deterministic way You know we're

7:53

at the point now where you turn on

7:55

social media and everything from vegan to carnivore

7:57

is the optimal way and it's just like

7:59

well that just can't be true and I

8:01

think at some point you have to Start

8:03

to bring science to at least provide

8:05

not a prescription But some like guidance and

8:07

guardrails around like what we think of

8:10

as being relatively healthy in the diet But

8:12

I think I would like like the public

8:14

to just be a bit less prescriptive

8:16

and also look at diet as sort of,

8:18

we can't know the things. Like we don't have

8:20

the precision in our research tools to know things

8:23

as like deeply and specified as people would

8:25

want to. And

8:27

I think like

8:29

the general guard rails

8:31

essentially is what nutrition science is going to

8:33

provide you and like eating more fruits and

8:35

vegetables, eating more legumes and nuts and seeds. If

8:38

you have a specific problem, then like

8:40

tailoring the diet around that with the help

8:42

of like a dietitian physician can like

8:44

allow for the more specifics. But a lot

8:46

of the hyper specification of things I

8:49

think is just to sell you a brand

8:51

or a product or whatever. And so

8:53

it's, there's a huge financial incentive to be.

8:55

seen as like offering the way the

8:57

truth and the light around diet and it

8:59

for it to be what looks like

9:01

anti establishment quite often. And that's not

9:03

to say that there's nothing wrong. Like there's

9:05

a lot of a nutrition official nutrition advice has

9:08

a lot of flubs along the way. I

9:10

understand the lack of like trusted nutrition science and

9:12

there's polling to show that there's lack of

9:14

trust in it. I think a lot of that

9:16

starts with like some humility from the field

9:18

about like how deeply we can know things. I

9:20

think there's some people who think that we

9:22

just need to like shout it louder and say

9:24

that the data is stronger than it is.

9:26

And that'll get the public to kind of adhere

9:28

to what official dietary guidance is. And I'm

9:30

not, I don't fully appreciate, or I don't

9:32

fully agree with that approach. Yeah,

9:34

I don't either. I think the more

9:36

transparent you can be, even though

9:38

it's flawed, the more buy in longterm

9:40

you'll get. Yeah. So what you

9:42

said that we have made significant strides

9:44

in nutrition research. What do we

9:46

know with a higher level of evidence

9:48

about nutrition that would be valuable for someone

9:50

to know? Yeah. I

9:53

mean, so we know the general

9:55

like. essential nutrients, which is great.

9:58

I think we should stick like, I

10:00

always like to couch this as like,

10:02

most people care about nutrition and chronic

10:04

disease and they're not like interested in

10:06

like acute inpatient nutrition care or have

10:08

like RCTs and things, but nutrition knows

10:11

different things in different sectors, but in

10:13

nutrition and disease kind of health outcomes, there's

10:16

things like women of reproductive

10:18

age should take folic acid to reduce the

10:20

likelihood of having a neural tube defect, like

10:22

the evidence is pretty solid on that front,

10:24

not perfect but solid. There

10:26

is a lot, you know, early

10:28

in around the 1950s, 1960s, you

10:30

start to get the emergence of

10:32

the basic cardiomanabolic disease risk factors

10:35

of elevated body weight,

10:37

elevated blood cholesterol, elevated blood

10:39

pressure, and then sort of

10:41

insulin resistance and blood glucose diabetes sort of

10:43

emerge beyond that. And so

10:45

there are a lot of controlled

10:47

feeding trials where we can

10:49

in a short term setting manipulate the diet

10:51

under very controlled like everything weight on

10:53

a gram scale to the 0 .1

10:56

gram precision for anywhere from like two

10:58

weeks to sometimes you get longer than

11:00

you definitely get longer than that for

11:02

sure like out past six weeks and

11:04

some control on the diet up for

11:06

like up to 12 weeks and where

11:08

we know that changing the diet composition

11:10

particularly the fat composition can influence blood

11:12

cholesterol levels. Changing sodium can influence

11:14

blood pressure levels, same with potassium. And

11:18

then we have, so

11:20

we know a lot about dietary fat

11:22

composition and blood lipids, basically, because they're

11:24

like a major risk factor that change

11:26

independent of weight. So just changing the

11:28

composition of the diet has a pretty

11:30

substantial effect on lowering total and LDL

11:32

cholesterol. We know things like

11:34

the dash diet, which sort of

11:36

takes our knowledge of not only sodium,

11:38

but other elements of the diet

11:40

is the dietary approaches that stop hypertension,

11:43

but there's big New England Journal of

11:45

Medicine landmark trials on the DASH

11:47

diet, basically showing you can get close

11:49

to first line pharmacological blood pressure lowering

11:51

with diet by combining a number of

11:53

elements. So it's like reduced sodium, elevated

11:55

potassium, like seven plus

11:57

servings of fruits and vegetables a day, a

12:00

few servings of nonfat dairy, and

12:02

that all these things combined have

12:04

sort of like an additive effect. On

12:07

the DASH diet, I think it's one of my

12:09

points I always bring up with patients is it's like

12:11

It's like seven or eight things in the diet

12:13

that all cumulatively add up, but no one of them

12:15

is like make or break it. Yeah.

12:17

And it's sort of a good example of

12:19

like diets, effects tend to be really small,

12:21

but like adding up a bunch of dietary

12:23

changes and then doing that for a really

12:25

long period of time, cumulatively is like a

12:27

net win. And I think that helps orient

12:30

people to like expectations around

12:32

effect sizes. Cause you've got everything you

12:34

turn on social media and like. this supplement

12:36

or this nutrient that we're all missing

12:38

is evil. Yeah. And it's

12:40

like that. I, those things are great as

12:42

a researcher who has to do a

12:44

power calculation for doing the clinical trial. Like

12:46

I wish the effect size was so

12:48

large. I needed to enroll six participants because

12:50

I'd see this magical effect of a

12:52

magnesium or whatever, but the effect sizes are

12:54

always quite subtle. Yeah. So we should

12:56

elaborate on that. You,

12:59

in order to see the

13:01

impact of changing this one

13:03

ingredient in someone's diet. And

13:05

then to see the impact, you need

13:07

to have a significantly higher number

13:09

of participants in that research. Yeah.

13:11

Or like it needs to

13:14

be a big intake differential that's occurring.

13:16

So like some of the work I

13:18

did in my PhD is on pregnancy,

13:20

which we think of as like a

13:22

uniquely stressed state for choline availability. And

13:24

the choline intakes are relatively modest or

13:26

low and that you can intervene and

13:29

significantly sort of alleviate that choline stress.

13:31

So like obviously a vitamin supplementation is

13:33

going to do. a whole bunch more

13:35

if somebody is like deficient at baseline

13:37

and you need a lot fewer participants

13:39

because you just expect a bigger effect.

13:42

But in like a well nourished population

13:44

like the US, like I think a vitamin

13:46

A supplementation is going to be like a

13:48

magical whole necessarily. So you need a huge

13:50

number of participants. Yeah, you need a lot

13:52

more participants to see that much smaller effect

13:54

and to handle all the variation that exists.

13:56

And so same with. chronic diseases, like it

13:58

depends on are you recruiting people with high blood

14:00

pressure at baseline, how high, the more

14:02

modest and closer to like a relatively,

14:05

you know, where homeostasis is maintained, a relatively like

14:07

healthy state, like to see diet effects, you

14:09

tend, they tend to be much smaller and you

14:11

need a bigger sample size to see them

14:13

confidently. And so that's a

14:16

problem for like our nutrition research

14:18

infrastructure, the ability to like recruit

14:20

hundreds of patients like you would

14:22

do for pharmaceutical trials. extremely

14:24

difficult. It's very, very hard to do

14:26

that in any meaningful timeframe with the

14:28

current way that we fund nutrition science

14:30

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16:57

is. do you think there's

16:59

so much disagreement when it comes

17:01

to the consumption of,

17:03

let's say animal products or

17:05

saturated, high saturated fat

17:07

content foods and its impact

17:09

on cholesterol and thereby

17:11

impact on cardiovascular disease? Yeah.

17:14

I mean, I think there's few

17:16

people debate that like saturated fat raises

17:19

LDL cholesterol. There's a bit of

17:21

an effect modification by the food matrix

17:23

there. So we talked about these

17:25

nutrients, but like. you can get saturated

17:27

fat from meats or dairy and

17:29

different types of dairy. And the relative

17:31

effect of saturated on LDL varies

17:33

a bit with those foods. But I

17:35

think most people, you'll find very few

17:38

people arguing that like replacing saturated sources

17:40

with mono and polyunsaturated sources isn't going

17:42

to reduce LDL. I think a lot

17:44

of people question the second part of

17:46

that. Yeah. Does that change in LDL,

17:48

meaningfully reduced cardiovascular events, which can be

17:50

influenced by its effect size. You

17:53

know, it can be small in some individuals. It's

17:55

quite. quite variable, the degree to

17:57

which somebody, when they change their

17:59

diet, the effect size that they're going to

18:01

see. And I

18:03

think, you know, there's, there's old

18:05

trials in this literature that are suggestive

18:07

of that replacement, lowering cardiovascular events,

18:09

but they're like pre statin era, people

18:11

have a total cholesterol is like

18:13

in the 200s and 300s. So people

18:15

question, like, is this added LDL

18:17

lowering really all that beneficial for reducing

18:19

cardiovascular events? Like, calculating a number

18:21

needed to treat is really tough in

18:23

this space because you don't have

18:25

a really rigorous data to do it

18:27

all that often. Um, and

18:29

then there was always concerns that

18:31

just because LDL is lowering, I think

18:33

medicine, there's a lot of hard learned

18:35

lessons that you can see the biomarker

18:38

go down in the direction that you

18:40

wanted to, but there's like an off

18:42

target effect. And so there's always concerns

18:44

that like, particularly in the, we're in

18:46

the era of everyone thinks seed oils

18:48

are toxic. And so. current recommendations are

18:50

to replace saturates with more omega six

18:52

rich polyunsaturated vegetable oils, particularly high in

18:54

linoleic acid, but we recommend a mix

18:56

of omega threes and omega sixes. And

18:59

those, you know, there's a concern that, you

19:01

know, you might see LDL lowering, but those

19:03

might have an independent bad effect. And

19:05

so that's always, you see that. For

19:07

the past 40 years and guidelines, people

19:09

don't really recommend more than 10 % of

19:11

total calories coming from Pufa because

19:13

of theoretical concerns of harm. And there's just

19:15

not populations that are eating much higher

19:17

than that, that you can go and

19:19

observe that they're totally fine. So

19:22

the recommendations are slightly more cautious,

19:24

but yeah, you don't, you don't

19:26

have huge blockbuster trials that say

19:28

like we swapped. Saturates

19:30

for Poofas across a dose response range across

19:32

these diverse populations and at lower cardiovascular

19:34

events and all of them like that's really

19:36

really high bar for the field to

19:39

reach so we know I think we're out

19:41

of a compliment that Saturates being replaced

19:43

by Poofas lowers LDL We don't see a

19:45

strong evidence of harm in any marker

19:47

that you look at. There's a little bit

19:49

of added improvement in blood glucose and

19:51

insulin for that and liver fat. And

19:53

you can see this in these small trials

19:56

that the field has strung together. And

19:58

then you have epidemiological data. So like the

20:00

observational evidence where you give

20:02

out people either food frequency questionnaires

20:04

or in some of it there's

20:06

24 hour dietary recalls, but it's

20:08

mostly food frequency questionnaires. And those

20:10

you can estimate how much energy

20:12

you're getting from saturated fat versus

20:14

polyunsaturated fat and do kind of

20:16

replacement modeling algorithms that sort of

20:18

mirror what's happening in the RCTs.

20:21

And you can see a similar

20:23

often, like it's a very

20:25

analogous, you see reduction in LDL in

20:27

the control trials, you see often a

20:29

reduction in cardiovascular events in most the

20:31

epidemiology. And that's sort of the

20:33

two strongest types of evidence that nutrition

20:35

is going to put for it. There's a

20:37

little bit of primate data that's going

20:39

to show that replacement of saturates with PUFA

20:41

is also a lower cholesterol and reduces

20:43

atherosclerosis size. But

20:46

yeah, you have all these individual lines

20:48

of evidence that have like, they're

20:50

impactful, but they're missed. They're not

20:52

like a smoking gun sort

20:54

of thing. So finding trial data

20:56

where people have reduced saturated

20:58

fats. replace them with Pufas

21:00

and actually follow people to have

21:02

cardiovascular events. There are older

21:05

trials that did this. They typically relied

21:07

upon more captive populations where you had

21:09

control of the diet already. And so

21:11

the mental hospitals were big ones. Um,

21:13

you had, um, like LA, the

21:16

LA veterans study is one example where

21:18

veterans used to be housed and

21:20

the diet was controlled. So anywhere somebody

21:22

was institutionalized, um, and the diet

21:24

was being controlled, you could do some

21:26

interventions and people, um, did that

21:28

back mostly in like the 60s. And

21:30

they just by modern

21:32

trial standards weren't always the best.

21:35

A lot of times they intervene on,

21:37

they changed the intervention diet, but didn't

21:39

really do anything to the control. And

21:41

so they're like slightly imbalanced. A lot

21:44

of them are done during the era

21:46

of trans fats being in the food

21:48

supply. And so they lowered the intervention

21:50

group either. There's endless debates in the field

21:52

about this where the intervention group, sometimes the

21:54

intervention reduced saturates at the same time it reduced

21:56

trans fats. And so people, when they

21:58

like replace it with poofa, um,

22:00

and so people are like, ah, you've overinflated

22:02

the benefits of replacing saturated fats because you

22:04

also lowered trans at the same time at

22:06

the same time. And then you have other

22:08

intervention studies that intervened with high poofa diets,

22:11

but they used a margarine that probably had

22:13

some trans fats. And so they're like, ah,

22:15

maybe you didn't see the mortality benefit because

22:17

you just did a trans fat intervention at

22:19

the same time you did a poof intervention.

22:21

So. There are these endless debates from that

22:23

really limited literature base. You'll see

22:25

like the American Heart Association has a

22:27

position statement on this where they use like

22:29

four core trials that they rely

22:32

upon. Three of them are

22:34

adequately randomized. And, you

22:36

know, they point to like what

22:38

we would expect that mostly soybean

22:40

oil replacing saturated fat sources in

22:42

the diet, lower cardiovascular events. It's

22:45

like a composite of all cardiovascular events,

22:47

which a lot of the evidence -based medicine

22:49

people don't like composite endpoints. They want to

22:51

break it out by individual event type. And

22:55

again, there's these limitations that I mentioned

22:57

around. And the timeline of it all, right?

22:59

Yes. Over what period of time is

23:01

this? Well, they're like usually like four to

23:03

four, they're over two years long was

23:05

the inclusion criteria that American Heart Association relied

23:07

upon. But those trials are just. I

23:09

look at them as being like, they don't

23:11

point to like a strong signal for

23:13

harm, but they are not gold standard necessarily.

23:16

So it would be amazing if we as

23:18

a society had like, you know, people

23:20

who could basically just be like live in

23:22

paid research participants five years, living in

23:24

some capacity long -term where we can control

23:26

their diet, but that's so hard

23:28

to do. Can we take the

23:31

data that we've gotten from statins,

23:33

their effect on impacting

23:35

LDL cholesterol and in general the

23:38

cholesterol profile. Seeing

23:40

the reduction in the

23:42

ASCVD risk score and

23:44

events and then say well

23:46

if we're seeing these

23:48

substitutions

23:51

in certain fats lower

23:53

the LDL cholesterol and

23:55

the cholesterol profile shouldn't we

23:57

expect to see the same or does not not

23:59

as simple as that. I think

24:01

that's one supporting line of evidence, but

24:03

it's not a direct one to

24:05

one. So all drugs, lower

24:07

LDL, like there's many drugs out there.

24:09

They lower it through different mechanisms. We

24:12

even 100 % know the

24:14

mechanisms by which dietary fat

24:16

composition changes lower LDL. They

24:19

do a similar thing of like,

24:21

obviously there's enhanced clearance of LDL from

24:23

the plasma compartment by the liver.

24:25

There's also some debates about whether there's

24:27

reduced cholesterol synthesis for the mechanism of

24:29

how they actually lower blood cholesterol. But

24:32

we would expect that LDL

24:34

lowering to produce beneficial effects. I think

24:36

the big question becomes like, what are potential

24:38

off target effects of the diet? So

24:40

if you go like, super high in polyunsaturated

24:42

fatty acids you might create a new

24:44

problem. Yeah. There might be a toxic effect

24:47

at some point and finding the dose

24:49

response data there is pretty limited. You're often

24:51

relying on epidemiology. I know the cardiology

24:53

world is kind of like right now at

24:55

the point where it's like the lower

24:57

the battery on LDL and diet is like

24:59

recommended as a major way to as

25:01

a lifestyle way to help control LDL. But

25:04

that effect size is going to vary quite

25:06

a bit. And I don't think you

25:08

can do anything with diet to get down

25:10

to like less than 30 or 40.

25:12

There's these old sort of like Simeon diet,

25:14

like sort of mirroring this like super

25:16

high plant -based diets, lots of

25:18

soy protein, lots of

25:20

high Pufa oils. And

25:23

people can get like pretty substantial

25:25

like 15 plus percent lowering an LDL

25:27

cholesterol from these diets. But like

25:29

that's not getting you down to like

25:31

below 40 necessarily. Well, it's also

25:33

the same when I screen people for cholesterol

25:35

and I find their LDL to be above

25:37

200. I'm almost telling to them, like, this

25:39

is probably not because of your diet. This

25:41

is a genetic issue because to get it

25:43

that high is, it's, yeah, it's tough. I

25:45

mean, there are like, we've seen it in

25:47

the era of carnivore keto diets where people

25:49

are getting like, if you're getting 80 % of

25:51

your calories from fat and you're skewing Puffa's,

25:53

then the natural fat composition of the foods

25:56

you're eating is getting you like 40 plus

25:58

percent of calories from saturates. And so

26:00

we've seen people get like

26:02

super really high. Um, and

26:04

like it comes down with, you

26:06

know, dietary switches, but apart from

26:08

those like obscure scenarios, um, I

26:11

try and orient people like, let's see if

26:13

we can get down like 10 to 20

26:15

points with a lot of dietary changes and

26:17

people vary like the nature of the genetic,

26:19

uh, issue that they have. It's leading to

26:21

their cholesterol being high. Like sometimes it's responsive

26:23

to diet. Sometimes it's not, there's not like

26:25

a great way to predict that necessarily. There's

26:29

random things in diet that can, like

26:31

I had a patient one time who, like

26:34

boiled coffee contains these plant

26:36

terpenoid compounds that raise LDL.

26:38

And they're like good data

26:41

on this and makes coffee

26:43

epidemiology, old coffee epidemiology really

26:45

messy because study to study

26:47

done across different countries. We're

26:49

showing different relationships to cardiovascular

26:51

mortality. And it turns out

26:53

like, if you're drinking like six cups a

26:55

day of a boiled coffee, like a Turkish

26:57

coffee, you can be

26:59

like it raises LDL quite a bit. And so I've

27:01

had patients drinking for a coffee, not putting it

27:03

over a filter that are just interesting. Tons of terpenes

27:05

and they stopped that and their cholesterol goes down

27:07

20 points, but they were like

27:09

high consumers of this like obscure

27:11

thing. So ever like diet through

27:14

many different mechanisms, it's mostly fat

27:16

composition type of fiber, a little

27:18

effective dietary cholesterol, obscure things like,

27:20

like terpenoids that can really impact

27:22

LDL, probably the polyphenols impact LDL

27:24

a tiny bit. But

27:26

they all work through potentially slightly different mechanisms

27:28

and your patients all have LDL being

27:30

raised for slightly different reasons. So a lot

27:32

of like when I talk with patients,

27:34

it's very much setting the scene for like,

27:37

you might see magic, you might

27:39

see nothing. We just like, I want

27:41

to be clear that we know the

27:43

like general average effect, but there's quite

27:45

a bit of variability, which underlies a

27:47

lot of the academic enthusiasm for precision

27:49

nutrition of like trying to predict why

27:52

is there so much inter individual variability

27:54

in their response to diet. Yeah. Um,

27:56

I'm going to ask this next question,

27:58

not with your thinking cap on surrounding

28:01

acute hospitalized

28:03

medical interventions. Thinking

28:06

more chronic disease, average person who

28:08

wants to lower their risk

28:11

or perhaps lose weight or something along those lines.

28:15

Is the notion of food, is

28:18

the notion of using food

28:20

as medicine overrated and

28:23

really not very valuable? Oh

28:27

man, I'm going to piss off some people. I

28:30

asked it in this very specific

28:32

manner specifically. I

28:35

think seeing food as medicine is wrong

28:37

on several fronts. There's not a great

28:39

way to look at food on several

28:41

fronts. Like the totality of

28:43

diet can have medicinal effects for

28:45

sure. And nobody's denying that,

28:47

but like we're not. studying food as

28:49

medicine for the most part. Like if

28:51

you want food, a lot of people say

28:53

food is medicine. And then you ask

28:56

them, okay, well, where are the randomized control

28:58

trials with the heart disease endpoints for

29:00

foods? And it's, I mean, you have like

29:02

the predimate study is like one single

29:04

example, but most people don't want to study.

29:06

We don't have the level of evidence

29:08

to back up the statement that food is

29:10

medicine that we have for actual medicines

29:12

in almost all cases. And so I think

29:14

that's. bit of overstating the

29:16

efficacy of food -based interventions. I

29:18

think a lot of the food as medicine stuff

29:20

comes from the idea of like, we should do

29:23

healthy food prescriptions and this sort of stuff, which

29:25

there's active trials on going around that. I'm curious

29:27

to see what the evidence is. I have no

29:29

idea how it's going to turn out necessarily. But

29:33

food as medicine also like

29:35

tends, I see a lot of

29:37

hyperbole around it that makes me quite cautious.

29:39

Like, oh, olive oil. polyphenols

29:42

are going to like cure you of

29:44

breast cancer. And I'm like, it comes

29:46

with this like weight of having this

29:48

like massive treatment effect. And there is

29:50

again, Evan, it's like the dash diet

29:52

having like close to first line pharmacological

29:54

therapy for blood pressure lowering. And like,

29:56

I don't want to undersell that at

29:58

all. And I want people to appreciate the

30:00

like what they're eating on their plate

30:02

every day, like does impact their health. Um,

30:05

but it's definitely like overstating it. And I

30:07

think. makes it very prescriptive

30:09

when there is a lot of flexibility. Nutrition

30:11

has not always done a good

30:14

job of tailoring the diet to

30:16

an individual's culture or preferences. There's

30:19

a lot of ways that you can

30:21

take dietary interventions and adapt them to

30:23

whatever your socioeconomic status is, whatever your

30:25

religious beliefs are. Food

30:27

is medicine sort of takes the very

30:29

small subset of foods that we have

30:31

studied, which are mostly like there's a

30:33

lot of like love for the Mediterranean

30:36

diet. And there's nothing like that we

30:38

know of that's like so uniquely amazing about

30:40

the Mediterranean diet is that like nutrition

30:42

is like science. Happens to study it. Yeah.

30:44

Science is founded in like Western traditions.

30:46

And so they got interested in the Mediterranean,

30:48

but like. you could probably have a

30:50

Japanese traditional Japanese diet, traditional African diet, all

30:52

the, if we put the money and

30:54

resources into understanding those foods, the food composition,

30:57

the design trials around it, um, that

30:59

you would find similar benefits to the Mediterranean diet

31:01

when you look compositionally at the foods, there's

31:03

no reason to believe it. Like it's all

31:05

that magical. So it puts a

31:07

bit too much mysticism around

31:09

food for me. And it's like, it's

31:11

not about the food. It's about. the totality

31:13

of a number of interventions across

31:16

their nutrients. Like a food lifestyle. Yeah.

31:18

Yeah. It's, I, I want something

31:20

like that conveys a similar message, but

31:23

like more timid. Cause

31:25

I food almost as medicine. Cause I,

31:27

you, clinically you see the dark side

31:29

of this. And so I did my

31:31

clinical training at the NIH clinical center,

31:33

which you don't get there until you've.

31:36

gone through many specialists, particularly to like

31:38

there's a lot of oncology patients

31:40

and they are there on like

31:42

a cartesial therapy is like a

31:44

last ditch treatment after several others

31:46

have failed and you see patients,

31:48

family members spending their last dollar

31:50

on food and supplements that

31:52

they think and magical dietary regimens,

31:54

green juice, fasting and they

31:56

have really bought into this like

31:58

food is medicine and I

32:01

can't tell a patient, there's no randomized

32:03

controlled trial data to support really any

32:05

of this. And I

32:07

can't tell you the number needed to treat,

32:09

number needed to harm. I've seen harms of

32:12

it like anecdotally as a clinician where patients

32:14

who definitely did not need to lose weight

32:16

and were already wasting away, got put on

32:18

a green juice fast and they are now

32:20

emaciated even more three months later than they

32:22

probably would have been if they had drank

32:24

an Ensure. And

32:27

so, yeah, I think that is where, I know

32:29

you said, don't go into the inpatient setting. And

32:31

I just went to the inpatient setting, but I

32:33

think that's a very concrete, clear example. I

32:36

just meant don't go into the

32:38

inpatient setting because I know it's very

32:40

easy to start saying, well, if someone congestive

32:42

heart failure or you want to put

32:44

strict limitations on their sodium or you have

32:46

someone who has calcium oxalate stones, right?

32:48

You want to tell them to avoid spinach,

32:50

you know, like there are some times where

32:52

like, cause we just did a video with a

32:54

famous chef. where I presented a case to

32:56

him and he had to guess, I guess, because

32:58

he's not a doctor or anything, what

33:00

the presentation was and what the

33:02

treatment would be with his cooking. So

33:04

we used food as medicine there.

33:06

Oh, nice. Okay. But it was, I

33:09

presented him a pirate story who

33:11

had scurvy and he created a citrusy

33:13

meal or a celiac patient where

33:15

he took out, used specific noodles that

33:17

didn't have wheat in them. Right.

33:19

Like a patient with PKU that's on a

33:21

restricted fetal colony diet. That's like real

33:23

where really food is the medicine. Um, I

33:26

think there's like food has beneficial

33:28

effects for health, but this is where I

33:30

worry about calling it medicine. I think if

33:32

you go ask dieticians who work in different areas,

33:34

like inpatient dieticians love to

33:36

say food is medicine, but they mean

33:38

the ensure that is preventing the amount

33:41

of nutrition in the patient is

33:43

the medicine. which if you go out

33:45

to the, you know, the regular

33:47

general population, they think ensure is poison

33:49

because it's seed oils and corn syrup

33:51

solids or multidextrin. Um, and so

33:53

I think the vibes of food is medicine

33:55

are good. If you've got people in a

33:57

room and ask them to define, okay, well,

33:59

which foods are medicine at which doses and

34:01

for which populations you'd come up with 85 ,000

34:03

different answers. Unlike if you ask, what is

34:05

this that? And it is pretty obvious.

34:07

It's standardized. Yeah. Yeah. I

34:10

think those. two schools of

34:12

thought really need to be hammered

34:14

into the minds of people when

34:16

they watch content surrounding nutrition. Because

34:19

food is medicine for someone working on

34:21

the inpatient side, which is why I

34:23

wanted to avoid that, not avoid it,

34:25

but like initially in that answer was

34:27

because it's different than food is medicine

34:29

as it's talked about colloquially, like

34:31

amongst friends. So I

34:33

think that that is an important takeaway because

34:35

what does it mean that food is medicine?

34:37

Can you really eat an anti -cancer diet? Like

34:40

what the hell does that mean? I

34:42

would love for the U .S. to

34:44

fund research to know if there

34:46

is a diet we should be feeding.

34:48

One patients have specific types of

34:50

cancer and doesn't have any effect. And

34:52

even that. It's very hard to do.

34:54

It's hard to do. And that's

34:56

in a specific population. Now

34:58

extrapolate that even further

35:00

for a person that

35:03

is healthy almost not having

35:05

cancer in a screening

35:07

way. So you're taking a healthy population,

35:09

you're saying prevent them from getting cancer. Talk

35:12

about making it 10 times more complicated

35:14

than already the complex picture you tried

35:16

to do. I mean, that's where I

35:18

think like general guardrails are fine without

35:20

getting hyper prescriptive, like high fruit and vegetable

35:22

diets, maintaining a healthy body weight. It

35:25

was like general guidance from the World Cancer

35:27

Research Fund and the IACR that put

35:29

together these like monographs of diet for cancer.

35:31

And it's overwhelmingly prospective cohort data. We

35:33

don't have like. for cancer, it's a bad

35:35

one because we don't have like biomarkers

35:37

really that we can readily control the diet

35:39

and assess and people come up with

35:41

ones, but they have kind of questionable prognostic

35:44

capacity. So for certain outcomes,

35:46

we have like, I think just naturally

35:48

more robust evidence where you can measure

35:50

blood pressure, you know, blood lipids take only

35:52

a couple of weeks to reach a new

35:54

sort of homeostasis. And so like you

35:56

can do a dietary intervention study in just a

35:58

few weeks and see, okay, blood cholesterol dropped like

36:00

15 % or whatever. Great. And

36:03

that. persist over time with

36:05

those changes. And so there's different

36:07

biomarkers, different diseases that we can

36:09

say a bit more confidently that

36:11

like the totality of dietary changes

36:13

has an effect that is. potentially

36:15

relevant for prevention. Uh, and

36:17

in other disease states, we don't have as much

36:19

data or we only have one type of data. Um,

36:22

so it's, it's, yeah, I don't want to

36:24

undersell like people get really in the weeds

36:26

and a lot of stuff. And it's like,

36:28

we've had the diabetes prevention program, like landmark

36:30

trial that used, you know, the supposedly poisonous

36:32

low fat diet. If you go on the

36:34

internet, but there's a low fat diet to

36:36

counsel on weight loss, get like an average

36:39

of rounds, have them present weight loss. And

36:41

you see huge improvements in people who were

36:43

pre -diabetic at baseline kind of. Uh, not

36:46

progressing to type two diabetes diagnosis.

36:48

So like, which is something you spoke

36:50

about with my recent interview with Dr.

36:52

Jason Fung, where he said that it

36:54

wasn't part of diabetes sort of management.

36:56

Yes. That was interesting history that was

36:58

told. Well, because I wasn't around then

37:00

it was hard for me to understand

37:02

that, but what is the actual reality

37:04

when it came to the early 2000s

37:06

of management of type two diabetes? Yeah,

37:08

you get the diabetes prevention program in

37:10

the like trial in the nineties and

37:13

you know, a few publications that come

37:15

out from it that start to show that like. you

37:17

know, the degree of adherence to the low

37:19

fat diet and the weight loss is like

37:21

highly predictive of not progressing on the type

37:23

two diabetes, like to late nineties, early 2000s,

37:25

you see these publications pop out. And so

37:27

by like 2002, 2004, ADA is putting out

37:29

their position statements and you can track it

37:31

across the nineties. They always kind

37:34

of said beyond the evidence, at least

37:36

with the way that we look at it

37:38

now, like lifestyle is important and weight

37:40

is probably a risk factor, like counsel and

37:42

weight loss, but it gets more, I

37:44

think the impetus for it and to focus

37:46

on the guidance, like. really starts to

37:48

get hammered in in around 2002 where they're

37:50

like, we've got the DPP trial now,

37:52

which is still a super landmark trial you

37:54

look back on. We know that it

37:56

randomized either to lifestyle or to metformin

37:58

or just to control. And the

38:00

lifestyle in Metformin do quite similarly

38:02

and quite well in preventing a

38:04

large majority of individuals from progressing

38:06

from prediabetes to diabetes. And that's

38:08

Prevention 101. If you want to

38:10

call that food as medicine, but

38:13

all those people are eating different

38:15

foods, they were all had sort

38:17

of their lifestyle counseling individualized to

38:19

what their current state was. And

38:21

just again, it focused a lot on

38:24

weight loss. Um, and there were

38:26

like other dietary goals, but it would, this

38:28

was like even pre there where like there was

38:30

a big focus on like reducing sugar sweetened

38:32

beverages. Like that was not like a major component

38:34

of the DPP per se.

38:36

Um, so yeah, like the

38:38

people I think want this

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like fine tuned hyper prescriptive

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If you've done all the big think things

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41:36

Or 1. or 1. Um, and you know, maybe like you individually will like benefit a ton

41:38

from the supplement. That's great. And I'm not

41:40

here trying to like gaslight. Yeah. If you think

41:42

something does something amazing, but for the population

41:44

at large, the tools of nutrition research

41:46

can at best for the most

41:48

part give you some of the. broader

41:51

guard rails that you should be following. And

41:53

then it's, you know, it takes more

41:55

and more trialing and one type stuff. If

41:57

you want to like fine tune the

42:00

details later on, and then you should be seeing a

42:02

medical professional if you have like very specific

42:04

issues or concerns. Yeah.

42:06

Yeah. This is where doctors

42:08

take a lot of smack talk

42:10

where they say doctors don't know

42:12

anything about nutrition or my doctor has

42:14

never talked to me about nutrition. And

42:18

I'll talk to a patient and I'll give

42:20

the general guardrails about like increasing fruit

42:22

and vegetable intake, lean cuts of meat. If

42:24

they do consume meat, you know, like

42:26

just some very basic things, trying to get

42:28

some fish into the diet to get

42:30

omega threes. Um, and then people

42:32

say, well, it sounds like you're just telling

42:34

me to eat in moderation. And

42:36

I'm like, I kind

42:38

of am very sexy. Yeah.

42:40

And I know that's like what

42:42

grandma used to say. And. you

42:45

know, a patient will come and say, is it

42:47

terrible that I have ice cream once a

42:49

month or I have a hot dog? Cause I

42:51

saw this study from some classification that

42:53

said process meets increased rates of

42:55

colon cancer by X percent. And

42:58

I'm like, look, like it kind of

43:00

is in moderation, but like what moderation means to

43:02

you might not be what moderation means to someone

43:04

else. So we have to be careful about how

43:06

we say it. But in

43:08

reality, when I'm

43:10

talking to patients who are living

43:12

In real life and when I

43:15

say real life, I mean not

43:17

the concierge medical population that are

43:19

millionaires and billionaires that have a

43:21

chef traveling with them. Yeah,

43:23

exactly. So that is

43:25

kind of a unique population because it's

43:27

not real life. Like I'm talking to

43:29

people who have jobs, who have children,

43:31

who have multiple jobs, multiple children and

43:34

are stressed out and what is right

43:36

for them. Yeah. And for me, it's

43:38

more about trying to remove some of

43:40

the bad habits or limit some of

43:42

the bad habits rather than think about

43:44

boosting immune system or boosting health or

43:46

health hacking. And people view

43:48

that negatively on social media because

43:50

they say, oh, it's cause you're

43:53

not as advanced as the experts on

43:55

the Huberman podcast. You don't understand

43:57

the research that they're looking at and

43:59

you're just being simplistic. What

44:02

is the counter to that? So

44:05

can use it in the future. Yeah. Yeah. Oh,

44:09

what? I mean, there's not like a quick counter, which I

44:11

think it's gets back to this problem. But

44:14

I mean, to like unpack that, I think, you

44:17

know, people are, I guess the other

44:19

experts that are providing hyper prescriptive advice, I

44:21

would just always encourage people like in

44:23

real, in real, like clinical nutrition, where I

44:25

mean, you're getting five minutes to talk

44:27

about diet, maybe max, like even when nutrition,

44:29

you have an hour, like a dietitian

44:31

has an hour with a consult for a

44:33

patient. You're doing like a

44:36

whole diet history, a whole assessment of all

44:38

of their, whatever they've had clinically done

44:40

to them, their biochemical labs, their body,

44:42

what we call anthropometrics of body waves

44:44

or come waste circumference, anything that might

44:46

inform upon their nutritional status before we

44:48

then talk about like what are your

44:50

values and preferences and preference and kind

44:52

of what foods do you even have

44:54

available to you? And like then thinking

44:56

about like what changes can we make?

44:58

And so I'm always even with all that

45:01

data. It's how drastic are the changes

45:03

that you're making? Well, so they're just, they're

45:05

just super tailored. Like what you're paying

45:07

for essentially with the dietitian is to like

45:09

be like, let's think about it's triage

45:11

of all the, like the, there's thousands

45:13

of products out there and thousands of influencers who,

45:15

if you went out and did every single

45:17

thing that they confidently told you to do, you'd

45:19

be broke. Even the like rich millionaires from

45:21

how you'd be spending 10 ,000 bucks a month

45:23

on supplement because there's always, I

45:25

mean, there are, I've had patients taking

45:27

more than 45 supplements. And like

45:29

that is not an upper limit by any

45:32

means. And so if you actually want to

45:34

like figure out, well, what is the most

45:36

likely to benefit me? It takes a pretty

45:38

detailed assessment and then really tailored to

45:40

you as the individual. And that's what

45:42

I think you should want out of

45:44

it. Somebody who at baseline is cookie

45:46

cutter saying, take 250 milligrams magnesium, take

45:48

200 milligrams of turmeric, 95 % cocoon,

45:50

whatever that they're going to say, like over

45:52

and over to every single person. That's not. It

45:55

might seem hyper -specific, but it's the

45:57

least individualized thing as possible. It's just

45:59

as generic to me as the general

46:01

guidelines. I agree, but this is how

46:03

people get tricked, and I see this

46:05

in the real world play out a

46:07

lot. They go see a doctor or

46:09

specialist, someone. They do

46:11

some kind of tests.

46:13

Yes. Because you're doing tests

46:15

that are validated, that have some

46:18

logic behind them. They'll do some

46:20

tests. And they'll say, I tested

46:22

you. I'm the expert. Here's what

46:24

you need. Almost.

46:27

I'm probably going to get in trouble for saying this. People

46:30

will watch a lot of chiropractor

46:32

videos. You've seen them online. Yeah.

46:35

The thing to me that's most

46:38

interesting is the people who very

46:40

much support, let's say chiropractic

46:42

medicine for relief of pain, for relief

46:44

of symptoms are usually people who

46:46

are interested in natural remedies, natural cures,

46:48

don't want to be on medications. Totally

46:51

reasonable. I think that's a

46:53

good general standpoint

46:55

to start on But

46:57

then those people also want individualized care

46:59

because they want to be treated

47:01

like an individual they understand human bodies

47:03

are different and Pharma oftentimes misses

47:05

that and in the day and age

47:08

where it's run like an assembly

47:10

line all those negative things that they

47:12

say about modern medicine agree now we're

47:14

on the same page then if you

47:16

watch any chiropractor video

47:18

on Tik Tok, whatever They're

47:21

always doing the same three things. It

47:23

doesn't matter if you have knee pain. It doesn't matter

47:25

if have toe pain. It doesn't matter you have neck

47:27

pain. It doesn't matter if you've been in an

47:29

accident, not been in an accident, play sports, don't

47:31

play sports. They're doing the same three things. And

47:34

that's what it comes down to some of these

47:36

influencers where it's like, yeah, they evaluated you, but

47:39

was that evaluation actually valuable enough

47:41

for them to specify what treatment

47:43

they're selling you? How do we decide

47:46

that? How was a

47:48

reasonable person supposed to know I

47:52

think that's a million dollars. If I knew the

47:54

answer to that, we would, I would be much

47:56

wealthier than I am. Yeah.

47:59

I mean, the nutrition world has

48:01

eight million versions of that where it's

48:03

like everybody's got a gut reset

48:05

program and they've got in nutrition, like

48:07

laboratory testing. It's so hyper context and

48:09

specific that like sometimes a plasma nutrient

48:11

level does or doesn't inform and it

48:14

depends upon your state and all these

48:16

sorts of things that like I as

48:18

a. PhD trained dietitian needs like I'm

48:20

like, I know what the DRI said.

48:22

I know the validation data, but you

48:24

can go out. I've had patients come

48:26

to me with IgG food

48:28

sensitivity testing, a spectrocell micronutrient lab from white

48:30

blood cells, like all these things that

48:32

are being used by other practitioners to like

48:35

guide their diet and I think it

48:37

just kind of hooks people in for longer

48:39

because you do the baseline testing, do

48:41

a follow -up test, and then you make

48:43

tweaks. And then when things don't move in

48:45

the right direction, you do another change.

48:47

And like it's, it hooks people in for

48:49

a much longer consultation with that practitioner,

48:52

which helps them build up rapport.

48:54

And I get a lot of patients who are five

48:56

years in having tried various of these practitioners and

48:58

are just frustrated and tired of people selling

49:00

them like. a quick and easy

49:03

solution. Because I think they start,

49:05

right? The skeptical modern medicines like hiding

49:07

something from them about like a quick

49:09

and easy solution. And then eventually kind of

49:11

to come to be frustrated with the

49:13

alternatives that are all very confidently providing

49:15

them with, I know the way

49:17

the truth and the light about diet

49:19

and supplements and natural medicines. All

49:23

I try and do is arm people with

49:25

like, what should make you skeptical? encourage

49:28

folks to be skeptical of pan practitioners

49:30

as in they practice and everything

49:32

like Pan is an all yeah, and

49:34

I get people coming to me

49:36

as dietitian who are like, okay Well,

49:38

what's my exercise plan? And I'm

49:40

like do it that's the exercise but

49:42

they're going to people who are

49:44

giving them entire like lifestyle overhauls on

49:46

this is your supplement routine This

49:48

is your diet routine. This is your

49:50

you know exercise routine and it's

49:52

just at some point I think Folks

49:55

need to realize that very few people are

49:57

experts in all those things. I

49:59

am very big on scope of practice. Even within

50:01

nutrition, there are domains I try not to touch

50:03

on at all because it's just outside my field

50:05

and I'm not up to date with the most

50:07

relevant data. But

50:09

we're seeing that everywhere on social media where

50:12

people are pretending that they can walk in

50:14

five lanes and be an expert in everything.

50:16

It's just not possible. I

50:18

would always encourage people to look at

50:20

the totality of what's out there. It's

50:23

fine to want to get somebody's opinion

50:25

on a single supplement, but just

50:27

also realizing that there are many, many

50:29

other practices you could go see that are

50:31

going to tell you with the same level

50:33

of impetus and confidence that this other supplement

50:36

is going to do the same thing and

50:38

that there's dozens and dozens and dozens of

50:40

supplements out there on the marketplace. And

50:42

just so going in,

50:45

being skeptical and having, trying

50:47

to think about like, okay, I'm going to, if

50:50

I'm going to try something, I need to know How

50:52

am I going to decide when I'm going to try work

50:54

with a practitioner who's willing to kind of do that

50:56

with you and not just like confidently selling you one thing

50:58

that they're also doing for every other patient that walks

51:00

into the door. Um, and

51:03

having like some sort of test set up

51:05

to like, okay, what do I need to

51:07

know a priori needs to improve? Like I

51:09

need to, how am I going to objectively

51:11

know that I feel better, sleep better, whatever

51:13

it is, whether it's like through a log

51:15

or something that you're doing and give it

51:17

three months and see if anything meaningfully changes

51:19

and be real with yourself because that's. If

51:21

you're not walking in skeptical of the practitioner

51:23

and the products that they're selling you, you're

51:25

going to end up on selling tons of

51:27

money, saying a bunch of different people on 45

51:29

different things and having no idea at the

51:31

end, you're going to be in this soup of

51:34

like, well, maybe I feel better, but I

51:36

don't know which of these 45 products was doing

51:38

it. Um, but we are sort of in

51:40

this like wellness capitalist, the capitalist hellscape out there

51:42

where you can just sell anything. You know,

51:44

if we allowed farmer to make the claims that

51:46

supplement makers are doing and supplement makers aren't

51:48

even making themselves. It's not illegal. um,

51:50

to have your influencers who have an

51:52

affiliate code doing all the illegal marketing for

51:54

you nowadays. So, um, I

51:56

don't know that there's a way to combat the

51:59

one on one, like good feeling you get

52:01

when a practitioner is listening to

52:03

you, you start to trust them and

52:05

then they have the, like the

52:07

answer for you other than to convince

52:09

people that like, that's not real. Yeah.

52:11

It's, it's, it's a good feeling. in

52:14

the moment and I wish modern medicine

52:16

could combat this by not having six

52:18

minutes spent with your doctor trying to

52:20

address everything. I wish

52:22

there was referrals for dietitians. Most

52:24

insurances will not cover dietitians or

52:26

maybe just a couple of visits

52:29

at best. A lot of

52:31

times you have to have type 2 diabetes

52:33

or chronic kidney disease, but like we as practitioners,

52:35

I think we get the 30 minutes to

52:37

an hour to sit and develop a rapport and

52:39

trust and individualize with patients, but a lot

52:41

of people are looking to their doctors. who

52:43

have six minutes to cover their entire,

52:45

everything clinically they need to cover

52:47

to somehow cover nutrition. That it's just,

52:49

it's an impossible task that, um, until

52:51

things change and you can actually go

52:54

see a nutrition practitioner and it's accessible

52:56

and affordable to people. It's, I

52:58

think it's a big losing battle for

53:00

folks. I have a specific question

53:02

and a very interesting question that

53:04

I don't understand the nuance

53:07

of specific question is. your

53:10

patients that were jumping around from

53:12

those providers that were encouraging

53:14

to take 45 supplements or follow

53:16

their protocol, what have you, if

53:20

you can, and you've seen them harmed

53:22

by it, right? Yes. So you

53:24

can go back. It's usually why they're at my

53:26

doorstep. They're like, I have all these nonspecific

53:28

symptoms that we can't figure out which of the

53:30

45 supplements is the problem. So

53:32

if you can go back to

53:34

before that person went to

53:36

see those providers, and

53:39

say something to them in

53:42

order to prevent them from falling into the strap.

53:44

What would you tell them? I

53:47

don't think I would tell them anything specific. I

53:49

would just listen to them, hear what their

53:51

problems are and talk about like, be like, I

53:53

will talk about any data diet you want to

53:56

talk about that you want to try, support you in

53:58

it. That's what I like. Nutrition

54:00

guidance for the public is like almost a losing

54:02

battle because everybody has different reasons that they

54:04

eat. Whereas like with a patient, it's

54:06

just a matter of, I think a lot of

54:08

people go to alternate practitioners because they just don't

54:10

feel heard by their doctor. And sitting down and

54:12

saying, what are you feeling? What have you

54:14

heard? What have you read? Let's talk about it.

54:17

And I've a very select patient population,

54:19

but this is from my experience

54:21

of folks coming and they're like frustrated

54:23

and just, I think, feel relief

54:25

from somebody listening to them. explaining

54:28

the nuances, the logic behind and the data,

54:30

you know, because everybody's now is a PubMed

54:32

ID and their Instagram bios or in their

54:34

Instagram posts saying like there's science to back

54:36

this up. Taking a little bit of time

54:38

to walk through all this is what the

54:40

science said. This is where there's uncertainty in

54:42

it, where there's not uncertainty in it. And

54:45

what it might suggest and doing

54:47

that for all the things that they're

54:49

hearing about just to make them

54:51

feel empowered and know going in whether

54:53

something is. likely to work or

54:55

likely to not and they can call it quits in

54:57

three months if they don't like it. I think is

54:59

most of the solution here is

55:01

just listening to patients and helping them

55:03

feel empowered in a situation where when you

55:05

turn on Instagram, it's like the least empowering

55:08

thing in the world. You have dozens of

55:10

people who are telling you that you can

55:12

take control of your life and they all

55:14

have different solutions for it. Again, vegan to

55:16

carnivore and that puts this pressure on

55:18

to patients. And I think people feel it

55:20

more and more that it's just pressure

55:22

on the general population that like they

55:24

have to put in the work to try out

55:26

everything. And then when they fail, when

55:28

it doesn't address their symptoms, like they feel like

55:30

they've failed somehow. And the next person in line

55:32

is going to tell them, well, it's because you

55:34

did this diet and you should have been doing

55:37

this diet. And then it's on them to again,

55:39

undertake a new diet. And so it's this perfect

55:41

cycle where you keep spending money and it's always

55:43

your fault when things don't work out. And I

55:45

think kind of flipping the script on that and

55:47

just being like, I will. I

55:49

will tell you the uncertainties in the data,

55:51

which there are a lot and we

55:53

can come to like you and me together

55:55

and hopefully led by you as the

55:57

patient, like what you want

56:00

do, what you want to try out, how

56:02

we're going to think about setting up some

56:04

sort of a protocol essentially for

56:06

whether this is going to help your

56:08

symptoms or not. going in

56:10

clear headed where I'm never going to lie to

56:12

a patient and be like, yeah, every single

56:14

person needs 300 milligrams. My knees and me or

56:16

sleep will be like massively improved. I'm like,

56:18

because the data just isn't there for that, despite

56:20

it being repeated across all of social media

56:22

a lot. Um, and I think you need to

56:24

have people who are also ready to hear

56:26

that. There are people who are like very much

56:28

in the true believers of

56:30

specific things. That's totally fine. Um,

56:33

everybody's diet has always, you go back

56:35

for thousands of years in every culture. Every

56:37

culture has beliefs about diets. There's a

56:39

ritualistic element of it that almost fulfills like

56:41

a religious thing. And I think that's for

56:44

the most part good until you start getting people

56:46

with like xanthomas from their carnivore diet. Okay.

56:48

It's gone a little bit too far, but I

56:50

think autonomy and choice around food is something

56:52

that we should promote and use the science as

56:54

a garden route and nudge people in directions

56:56

that we think are helpful and then just be

56:58

honest about when there's not data for stuff.

57:00

But that is something that does not make you

57:02

a lot of money as a practitioner. I

57:04

can tell you. Yes. Tying

57:07

to not making it a lot of

57:10

money. It's hard to get that information

57:12

out because the algorithm is sharing things

57:14

people Instinctively lizard brain want

57:16

to click on and share

57:18

and they're not instinctively clicking

57:20

and sharing content from you

57:22

saying Food let food be thy

57:24

medicine is not as cool outside of

57:26

the hospital as you think it

57:28

is they're thinking more I want the person

57:30

who says there is a cure for what

57:33

ails me and they share that that gets all

57:35

the love therefore the good evidence kind of

57:37

gets put into the background. Yeah. And I think

57:39

it wouldn't be really like one, all those

57:41

sites are e -commerce sites at the end of

57:43

the day. If you think social media is just

57:45

for interaction with your friends, everything

57:47

is e -commerce nowadays. They're all trying

57:49

to sell you something. But like

57:51

I have like weird autoimmune stuff that

57:53

doesn't fit into any textbook diagnosis.

57:55

And so like I have been

57:57

there being like, I will buy

57:59

anything that might be helpful. But I think

58:01

that is like. the most, the vulnerable

58:04

populations that need to be the most skeptical. And

58:06

I'm saying that from my own experience of

58:08

like having spent money on random stuff that I

58:10

hope would be helpful. And like sometimes you

58:12

have to learn through experience of like, I

58:14

try this and try this and try this.

58:16

And then five years later, I still have

58:18

the same autoimmune symptoms, maybe slightly better, but

58:20

helping people set that like realistic expectations about

58:23

what you're getting. We have

58:25

so much skepticism around like, how

58:27

does big pharma and big food influenced

58:29

food nutrition guidance? And I think realizing that

58:31

that doesn't make. the little guy on

58:33

Instagram, like somehow free of

58:35

conflicts of interest. If anything, they

58:37

often have more, they're like directly

58:39

benefiting and their whole livelihood is dependent upon

58:41

selling stuff. So it's 2025. People lie

58:44

on the internet. I think it's kind of

58:46

like a theme that we all need

58:48

to just embrace and then navigate that wellness

58:50

landscape. And even if you do have. something

58:53

like a serious condition that doesn't have a

58:55

clear medical treatment for it. I've had those

58:57

patients. I'm like, I will talk you through

58:59

the theory. If you want to try something,

59:01

the safety associated with it, noting

59:03

that there's no randomized control trials that show that this

59:05

is helpful. I think you need

59:07

more practitioners who are just like open

59:09

to listening to patients with where they're

59:12

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59:14

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Four additional terms and responsible

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gaming resources. You

1:01:47

said people lie on the

1:01:49

internet, especially in this healthcare space. Are

1:01:51

you comfortable naming any of your worst

1:01:53

offenders? Or

1:01:56

perhaps if you don't want to

1:01:58

name names, the theories that they've

1:02:00

put forward. That

1:02:03

have tricked the most patients of yours, or perhaps

1:02:05

you've seen the biggest impact on? Yeah,

1:02:07

I mean, you might have interviewed some of the

1:02:09

podcast. I don't know that

1:02:11

like, I see themes. I like truly

1:02:13

try not to track. What

1:02:16

I'm most concerned with is healthcare practitioners on

1:02:18

the internet that are like, just repeating

1:02:20

things that they've heard uncritically. Like there's a

1:02:22

lot of both dieticians, physicians, nurse practitioners,

1:02:25

you know, dancing to cute TikTok videos of

1:02:27

like, these are the five foods to

1:02:29

avoid or whatever. That's what I get sent

1:02:31

a lot. And what I like, I'm

1:02:33

most likely to criticize the big sort of

1:02:35

people who have a brand and

1:02:37

are obviously selling something. I think the public

1:02:39

just needs to be skeptical and there's not, I

1:02:42

don't spend too much time like critiquing those things

1:02:44

all that much. I

1:02:47

think there is general, what

1:02:49

I focus on are like themes

1:02:51

to be skeptical of over

1:02:53

people because all these top influencers have

1:02:55

a PCOS nutrition guideline and now they

1:02:57

all have menopause supplement lines and then

1:03:00

they all have a gut health thing.

1:03:02

And so I think the public being aware

1:03:04

that like these are sort of like hot

1:03:06

gimmicky things. that sure there's a bunch

1:03:08

of microbiome data and nobody's doubting that

1:03:10

the microbiome is like related in some

1:03:12

way to health, but that doesn't mean

1:03:15

that there's testing. It is going to

1:03:17

give you any valuable things. I can

1:03:19

give it a therapy that someone claims

1:03:21

works on the microbiome. It doesn't mean

1:03:23

it's clinically efficacious for anything. And

1:03:26

at the end of the day for nutrition, it

1:03:28

always comes back to like eat. high fiber diet. That's

1:03:31

what I find hilarious about those send

1:03:33

in microbiome tests. Patients will ask me if

1:03:35

they should do them. And I'm like, I can just

1:03:37

give you the advice for free right now.

1:03:39

And it's the same advice. And it'll be

1:03:41

the same advice no matter what bacteria is

1:03:43

in your microbiome. Yep. And if you tested

1:03:45

it tomorrow, it would be very different. Yeah,

1:03:48

exactly. And all those things are like 16

1:03:50

S RNA based for the most part. And

1:03:52

it's like, what does that mean? So that's

1:03:54

how they sequence who is there essentially in

1:03:56

your gut microbes. But it tells you like,

1:03:58

the relative abundance of specific bacterial species essentially like

1:04:00

it doesn't capture fungi and viruses even

1:04:02

so it's not even getting all the microbiota

1:04:04

there. It doesn't tell you what genes

1:04:06

they have. So you need whole genome sequencing

1:04:09

to do that. And then it doesn't

1:04:11

tell you about their function, which you can

1:04:13

start to get at from looking at

1:04:15

their transcriptome or at their metabolome. And so

1:04:17

there are like many different metrics you

1:04:19

can lay out for the microbiome, but knowing

1:04:21

the relative abundance of which bacterial species

1:04:23

are there versus not is like. minimally

1:04:26

informative? It was hot

1:04:28

early on as an early microbiome method, but

1:04:30

a lot of top researchers in the

1:04:32

field who all are saying, we don't know

1:04:34

the best probiotics, we don't know the

1:04:36

best diet to individualize around your microbiome, don't

1:04:38

buy these tests. They're

1:04:40

not even using these things in research because

1:04:43

it's not as advanced as it needs to

1:04:45

be, nearly as much as they were because

1:04:47

they were relying on it early. But there's

1:04:49

a lot of gimmicks out there, things that

1:04:51

are like, I think people want, the feeling

1:04:53

of being on the cutting edge. But

1:04:55

the cutting edge often means we

1:04:57

know very limited about it. And

1:05:00

that's fine if you want to do

1:05:02

a diet or a supplement. experiment or

1:05:04

something. Yeah, but being real with yourself

1:05:06

about cutting edge means high uncertainty. And

1:05:08

I think that gets left out a

1:05:10

lot of times in the marketing and

1:05:13

the hype of things. And that cutting

1:05:15

edge doesn't mean that everything that happened

1:05:17

before is necessarily wrong. there

1:05:20

are blockbuster trials and nutrition

1:05:22

that change nutrition recommendations that

1:05:24

are like, like with, um,

1:05:27

peanut allergy prevention and young kids that used

1:05:29

to be said, like delay. And then

1:05:31

that then blockbuster trial was like, actually no,

1:05:33

earlier is much better. And we, when

1:05:35

there is definitive evidence like that out there,

1:05:37

there was like a huge full court

1:05:39

press for changing. Yeah. Like

1:05:42

no one's secretly hiding this,

1:05:44

like this top information from you.

1:05:46

Um, again, like in.

1:05:48

chronic disease kind of stuff where

1:05:50

it gets uncertain. I think often you'll

1:05:52

see people overstating the relative confidence

1:05:54

we have in the data. And I

1:05:56

understand why that degrades trust, but

1:05:58

there is not like secret blockbusters studies

1:06:00

out there that people are hiding

1:06:02

from you. We don't fund nutrition research

1:06:04

seriously enough to know those to

1:06:07

have those blockbusters like things. Um,

1:06:09

so yeah, it's, I

1:06:11

don't know. Yeah. No,

1:06:13

no, no, that makes a lot of

1:06:15

sense. If I was your patient and.

1:06:17

Like we're sitting side by side like

1:06:19

this and I say, doctor, like this,

1:06:21

this microbiome test came or this blood

1:06:23

test came and they told me like

1:06:25

if I do this, they'll be able

1:06:27

to tailor my nutrition around that. Should

1:06:30

I do this? I

1:06:33

would say no. Well, I'm curious what

1:06:35

the conversation would look like. Why would

1:06:37

you say no? I would just say

1:06:39

like, you know, currently no medical guidance

1:06:41

recommends this. tests or like have

1:06:43

limited evidence sort of backing them up. There's

1:06:45

something general to that effect of like, there's

1:06:47

not really data for it. Uh, and I

1:06:49

usually ask patients, do you want to go

1:06:51

into like what the theory is and why

1:06:53

people are pushing it? Um, and some patients

1:06:55

want like the deep dive and some people

1:06:57

just want to hear, no, and there's various.

1:07:00

What's the deep dive of, of why those

1:07:02

things in general fail? So

1:07:04

one of the failure sniff test, I mean. Yeah.

1:07:06

One of the ones that you see the

1:07:08

most common is the food sensitivity tests, which you

1:07:10

can buy now and like target from Everly

1:07:12

well or whatever. Um, and so

1:07:14

they're like IGG based food sensitivity tests

1:07:16

that get sold as like, uh, the

1:07:18

more IGG you have and reactivity to

1:07:20

a specific food, the more like you

1:07:22

are to be like sensitive to it.

1:07:24

And they're not really defining sensitive. It's

1:07:26

just like this nebulous concept of I

1:07:28

feel bad after eating something maybe. Um,

1:07:31

but those are like the science of

1:07:33

IGG is a secure immune system is

1:07:35

constantly Oh, it's in, you have a

1:07:37

immune cells all along your gut and

1:07:39

they're interacting with food drive proteins. And

1:07:41

it's more of IGG is like a

1:07:43

marker of a tolerance. Like you make

1:07:46

antibiotics, antibodies to foods that you've eaten

1:07:48

recently. And so I've had patients who

1:07:50

like, and I use this story a

1:07:52

lot, like where they eat something and

1:07:54

it scores high on their IGG and

1:07:56

test. And then they cut it out

1:07:58

of their diet and then they come

1:08:00

back and then now they get. Totally

1:08:03

new food. There's

1:08:05

not really a time at which you're

1:08:07

not going to have high IGG to something

1:08:10

because that's just a normal response food. are

1:08:12

these companies, why is every, every well? Every

1:08:14

well. Yeah. Every well. Why are they selling

1:08:16

this? If it's

1:08:18

clearly disproven and doesn't

1:08:20

work. I

1:08:22

think there's like, is it hope that it

1:08:24

might work or like, there was early. in

1:08:27

like attempts at using it. It's like

1:08:29

a, for just anybody who knows about diagnostics,

1:08:31

like the worst thing in the world

1:08:33

has very poor sensitivity and specificity for uncovering

1:08:35

anything. And nobody wants a diagnostic test

1:08:37

that never gives you an answer of no.

1:08:39

Like if you're always diagnosed with like

1:08:41

you're sensitive to something, that is like a

1:08:43

grifter's dream and not a great sensitivity

1:08:45

test. So yeah, I,

1:08:48

I got the people are making

1:08:50

money out of it. There is

1:08:52

anecdotal. like evidence that people are saying, like

1:08:54

I told me I was high on this and I

1:08:56

cut it out. Um, and like those,

1:08:58

the action taken from it may well

1:09:00

be real. Like if you score high on

1:09:03

wheat and then you have like IBS

1:09:05

and you cut out wheat, which like a

1:09:07

major source of FODMAPs, like you might

1:09:09

feel better. Like there's biological plausibility for how

1:09:11

these things could work in a way

1:09:13

for somebody that didn't ever really require the

1:09:15

test, but they also didn't get. maybe

1:09:17

they didn't have access to a dietician or

1:09:19

a physician who knew something. So you

1:09:21

can stumble into, I think, something that works.

1:09:23

But that's like the clock being right?

1:09:25

Yes. The broken clock right? Yes. But

1:09:29

like, I don't want to gas like

1:09:31

people who have done it and say that

1:09:33

they had a benefit from it, but

1:09:35

it doesn't mean that it's indicated for the

1:09:37

entire population. And there are ways to

1:09:39

find out about foods not working well with

1:09:41

your body that are not that unscientific. Well,

1:09:43

yeah. I mean, the gold standard in

1:09:46

GI. like clinical diabetic practice is just like

1:09:48

food, food logging and then like symptom

1:09:50

logging and then trying to like review that

1:09:52

after some time and then trial and

1:09:54

elimination diets. Um, so it's not,

1:09:56

it's like not high tech. I think just

1:09:58

very sexy, but like there are other diagnostic

1:10:00

tests out there. Like everyone wants to optimize

1:10:03

around like micronutrients and so people will measure

1:10:05

micronutrients. Like there's like, I think it's spectrocell,

1:10:07

um, but. you can, and there's probably others

1:10:09

now at this point, but I've had patients

1:10:11

come to me with like, I got my

1:10:13

micronutrient panel and all the amino acids, and

1:10:15

it's all from their white blood cells, which

1:10:17

white blood cells are not like a validated

1:10:19

matrix to measure any of these things and

1:10:21

say, like when you measure something in the

1:10:23

blood, you don't really care about the blood.

1:10:26

Usually you care about like how much is

1:10:28

in a tissue and whether that nutrient is

1:10:30

performing the function that it's supposed to perform

1:10:32

for your physical, your health and maintaining your

1:10:34

physiology. Um, and so

1:10:36

measuring the amino acid levels of

1:10:38

white blood cell isn't really telling you

1:10:40

about whether you have enough amino acids in

1:10:42

your liver, but it's or your muscle

1:10:44

tissue or your muscle. Yeah, like it's, but

1:10:47

it's implied that that it's somehow useful.

1:10:49

I think this is something for like laboratory

1:10:51

testing in America. Like there's more regulations

1:10:53

around making sure that you get the

1:10:55

same answer twice than there is about whether

1:10:57

the answer is meaningful. And so we

1:10:59

have a lot of laboratory tests that like

1:11:01

I've had patients come to me with

1:11:03

full cardiovascular risk panels. with

1:11:06

all of these like cytokines and things

1:11:08

I've never even like heard of.

1:11:10

And I go look up the reference

1:11:12

from the laboratory test and it's

1:11:14

like one study shows that it's slightly

1:11:16

improved specificity and sensitivity in predicting

1:11:18

who would have a 30 day readmission

1:11:20

in patients who were like at

1:11:22

risk of who had just had a

1:11:25

heart attack inpatient, whether they'd be

1:11:27

readmitted 30 days later is now being

1:11:29

measured on somebody who's like. just

1:11:31

a normal, generally healthy population. And

1:11:33

like even in those inpatient people, like your

1:11:35

blood cholesterol and your BMI, the majority of

1:11:37

the bulk of it. And so there's no

1:11:39

added value even in the setting it was

1:11:41

tested, but you have to go to PubMed

1:11:43

and understand diagnostic testing. So you're just getting

1:11:45

it sold to you as a product. Yeah.

1:11:47

And I think a lot of practitioners are

1:11:49

not. nearly as like a lot of alternative

1:11:51

practitioners sell this stuff and they're either not

1:11:53

being skeptical or know that it's sort of

1:11:55

as a buy -in to hook people in

1:11:58

for longer. It gives them something to do.

1:12:00

I think patients leave always wanting to feel

1:12:02

like they, this is the class of like

1:12:04

the parting gift, right? Yeah, they end up

1:12:06

buying for viruses. Yeah. And

1:12:08

then nutrition, I think it's something similar. And

1:12:10

often it's a huge problem for the scope of

1:12:12

practice of dieticians of like, a

1:12:14

lot of it is education. Like,

1:12:16

I mean, in patient stuff, you're like, have

1:12:18

specific prescriptions for formulas and whatnot. But like,

1:12:20

if you're just educating people on based off

1:12:22

of like what they told you and you're

1:12:24

telling them what you think the diet should

1:12:26

look like. And I think it's always, it

1:12:28

should for good dieticians that we really need

1:12:30

to be trying to like deliver something. Like

1:12:33

I try and have spreadsheets available for patients

1:12:35

where they can see the math that I have

1:12:37

and like just to feel like they're getting

1:12:39

something and do like a little meal plan. I

1:12:41

teach people how to meal plan with like

1:12:43

a coded Excel spreadsheet. If they want that. But

1:12:46

don't feel like you're delivering something because that's

1:12:48

often a lot with the alternative practitioners have

1:12:50

and they get a ton of money out

1:12:52

of like, you know, you have to pay

1:12:54

for those tests and then they're coming back

1:12:56

again and again to review it. And, um,

1:12:58

and, but none of them are really indicative

1:13:01

of like, they're not doing what they say

1:13:03

they're doing. Like they're measuring the status of

1:13:05

a nutrient in your body. Um,

1:13:07

and then there's no trial showing

1:13:09

that like randomizing people to getting this

1:13:11

test versus not are actually improving

1:13:13

any clinical outcome for. the

1:13:15

field of nutrition outside

1:13:17

of doctors. There

1:13:20

exists the field of

1:13:22

nutritionists and dietetics. What

1:13:25

is the difference? Why do

1:13:27

I get so much hate in the comments when I say

1:13:29

it wrong? What is,

1:13:31

what do I need to know? In

1:13:34

America, there are, there's

1:13:37

not like really as many like federal

1:13:39

regulations as you might think. So there

1:13:41

are, it's like very state by state.

1:13:44

Um, dietitians is like, uh, typically

1:13:46

it's a protected title in a state.

1:13:48

And so you have to have gone

1:13:50

through a specific series of unlike, uh,

1:13:52

now it's a graduate curriculum that we

1:13:55

call the didactic program and dietetics. So

1:13:57

your didactic courses and then like a

1:13:59

thousand hours of supervised practice and then

1:14:01

pass an exam and then you can

1:14:03

be a dietitian. Nutritionist is

1:14:05

not. And that's like a masters. Now

1:14:08

it's a masters. It used to be bachelor's entry

1:14:10

level. So you'll see a mix out there, but it's

1:14:12

increasingly all masters. So I teach in

1:14:14

one of the masters programs at UC Berkeley. So

1:14:17

your, yeah, your goal is to

1:14:19

train people who are meeting specific educational

1:14:21

thresholds and clinical thresholds and get

1:14:23

exposure to the general population, everything through

1:14:25

like, you know, people doing nutrition

1:14:28

support, whether either tube feeding or IV

1:14:30

nutrition, like TPN on patients. And

1:14:33

so that's like a protected title and

1:14:35

that you should not be using the saying

1:14:37

you're an RD if you're not actually

1:14:39

an RD. Nutritionist is

1:14:41

not a title. And so I want

1:14:43

to be clear this is specific to

1:14:45

America. Other countries have more protected terminology

1:14:48

around like the UK has like a

1:14:50

registered nutritionist and they have a registered

1:14:52

dietitian credential. We don't have anything on

1:14:54

nutrition. So when someone says they're

1:14:56

a nutritionist, what does that mean? You

1:14:58

can't give you zero information. about the person's

1:15:00

training background. So Sam could be a

1:15:02

nutritionist. Congratulations. No,

1:15:04

but literally like you don't need anything. I

1:15:06

see people like, like they did a two

1:15:09

day workshop on like on the weekend and

1:15:11

then they're like, I'm a nutritionist, a career

1:15:13

changer. And like some of the people who

1:15:15

are like the most influential nutritionists online have

1:15:17

no like formal training in any of this.

1:15:19

A lot of it's like people coming up

1:15:21

like got into bodybuilding and they have like

1:15:23

the physique that. somebody wants and then they

1:15:25

sell nutrition plans and will call themselves a

1:15:27

nutritionist over time, but don't have any like

1:15:29

formal training. We are

1:15:31

actually bad at understanding this as

1:15:33

doctors because we have like

1:15:35

in my program, we

1:15:38

have nutrition students. I

1:15:40

have no idea what that means. I don't

1:15:42

know where they're a student from. I

1:15:44

know that they helped me talk with my

1:15:46

patients when I don't have enough time in order

1:15:48

to give them education about what a carbohydrate

1:15:50

is. Yeah. But. I have no idea.

1:15:52

Are they studying to be an RD or

1:15:54

are they taking some course? I mean, I'm

1:15:56

sure they're not, but I mean, I have

1:15:59

met like deans and the heads of endocrinology

1:16:01

programs. So we go, Kevin, what's the RD

1:16:03

after your PhD? And I'm like,

1:16:05

you probably shouldn't tell me about an

1:16:07

endocrinologist. You don't know what the dietitian is,

1:16:09

but this is a problem. I think

1:16:11

for dietitians too is like a nutrition becomes

1:16:13

its own little insular world. I mean,

1:16:15

it's like a you know, we have the

1:16:17

EARs and the RDAs and the DRIs,

1:16:19

like it's the DGAs. We're like a whole

1:16:21

acronym soup that is not really accessible

1:16:23

unless you've trained in it. That doesn't help

1:16:25

us, but, and even just like, what

1:16:27

is an RD? It's a full acronym soup.

1:16:29

Um, but we, I think RDs need

1:16:31

to get out there and interface more. Like a lot

1:16:33

of what, you know, inpatient RDs even like you might,

1:16:35

how many times did you interact with an RD in

1:16:38

your medical training? So. There was someone

1:16:40

from nutrition that actually came with us on

1:16:42

rounds. So that was a thing, but I

1:16:44

just didn't know that they were in RD.

1:16:46

I would have probably accidentally called them a nutritionist

1:16:48

by accident. And you might have gotten a

1:16:50

tongue lashing. I'm like less cagey about it. I'm

1:16:52

like, call me whatever. The fact you know

1:16:54

I exist, great for me.

1:16:56

I always have a problem because dietetics is like

1:16:59

90 % female. And so I always got

1:17:01

mistaken. They were like, oh, the medical resident. I'm like,

1:17:03

no, I'm the dietetic intern. Got

1:17:05

it. But

1:17:07

yeah, dietitians, I think,

1:17:09

are humble, quiet. They're

1:17:12

thought to be recognized as a clinical

1:17:14

profession. There's a lot of historical sexism. The

1:17:16

field is 90 % female for a reason.

1:17:18

It comes out of the field of

1:17:20

home economics. And then it

1:17:22

really gets launched by the war time,

1:17:24

World War II in particular, where there

1:17:26

was high rates of malnutrition, lots of

1:17:29

concerns about. the readiness of soldiers, making

1:17:31

sure the food supply was adequate for

1:17:33

both feeding people adequately at home and

1:17:35

soldiers. And so dietetics got like a

1:17:37

big launch there. Um, but it's,

1:17:39

I think struggled, you know, back in

1:17:41

biochemistry just was nutrition in like the

1:17:43

1940s. And so there was a very

1:17:45

gendered, like if you are interested in

1:17:47

nutrition and you're a man, you go

1:17:49

become a nutritional biochemist. And then if

1:17:51

you're a woman, you go into dietetics

1:17:53

and a lot of like really badass

1:17:55

women like fought that and you see

1:17:58

like. PhDRDs at various institutions

1:18:00

who have done great work. But I think

1:18:02

in general, the field still struggles to

1:18:04

like be recognized, taken as like a serious

1:18:06

STEM major. A lot of people, like

1:18:08

when you're an undergrad, you don't think, at

1:18:10

least in America, you don't think like,

1:18:12

I might be pre -med or I might

1:18:14

be pre -nerzing or I might be like

1:18:16

pre -diadetics. Like that's just not a thing. So

1:18:19

you have to have heard about. dietetics

1:18:22

in some way. I'm glad we're giving

1:18:24

it a commercial right now. Yeah. Yeah. Exactly.

1:18:26

So should people, if they are listening

1:18:28

to someone for nutrition advice, they find out

1:18:30

they're a nutritionist, should they stop listening? No,

1:18:33

no, I don't, I mean, so dietitians

1:18:35

are like, probably, it'd be great

1:18:37

to go to dietitians. Dietitians are also

1:18:39

like overkill. Like we're like medically trained

1:18:41

professionals who are like, can go and

1:18:43

feed a baby with like short gut

1:18:45

in the NICU who just survived neck

1:18:47

and needs TPN. Like, I mean, there's

1:18:49

like a really advanced skill set of

1:18:51

dietitians and like, Not everybody needs that.

1:18:53

I think you should go to people

1:18:55

that you trust, that you have a

1:18:57

rapport with that are not selling you

1:18:59

a bunch of stuff at every angle.

1:19:01

You feel like you're getting good coaching,

1:19:03

motivation, experience. I want to hammer home

1:19:05

because I know that message is so

1:19:07

important. I know people will, it won't

1:19:10

land correctly. The idea of not paying

1:19:12

for something. You're not saying that because

1:19:14

you're anti that making money or that

1:19:16

you're anti capitalistic or something of that.

1:19:18

You're saying it because there's nothing really

1:19:20

to sell. Well, you

1:19:22

should pay to talk to the

1:19:24

person. Of course, but I'm saying

1:19:26

product -wise, there's nothing

1:19:28

that exists that's proven that

1:19:30

people can sell to make

1:19:32

money, but also help you.

1:19:34

Is that a fair general

1:19:36

statement to make? I

1:19:38

think for the general population, yes. You might

1:19:40

run into something where it's like your diet. is

1:19:42

really low in something you're, you have restricted

1:19:44

diet, you're vegan or whatever. Like they might tell

1:19:46

you to take a B12 supplement and that's

1:19:48

like totally fine. In general, you might not have

1:19:50

much dairy and I might recommend like a

1:19:52

calcium supplement. I think when it's like this person

1:19:54

seems to be pushing their affiliate code link

1:19:56

on every single person that they're interacting with that

1:19:58

you should become a bit skeptical. But like

1:20:01

I've had patients like I with meal planning takes

1:20:03

a lot of time. I'm not going to

1:20:05

do that for free. So if somebody wants to

1:20:07

pay for like a full meal, that's paying

1:20:09

for the service of the thing. But when they're

1:20:11

selling you the products, I think or the

1:20:13

testing, that's when like red flags

1:20:15

should pop up. Not because again,

1:20:17

we're anti them selling those things. It's

1:20:19

just because there isn't even one

1:20:21

that I can think of. You found

1:20:23

like some very specific examples with

1:20:26

vegans and B12 or folic acid in

1:20:28

those who are trying to conceive

1:20:30

or reproductive age. But in general, there

1:20:32

isn't much to sell. And

1:20:34

that's why people judge the doctors are not selling

1:20:36

something. I'm like, no, no, no, those are the

1:20:38

people telling you the truth in the least sexy

1:20:40

way possible, but it's the truth. So

1:20:42

I think that that was just an important

1:20:44

thing to call out. Yeah. No, I don't think

1:20:46

there's anything that I would like think of

1:20:48

every patient that I'm like, Oh yeah, they needed

1:20:50

that. Like every single one of them needed

1:20:52

that. Like it has to be individualized and it

1:20:55

should be like, even in patients, unless it's

1:20:57

like you eat zero B12 and you need B12,

1:20:59

like I'm medically saying. Also, like how rare

1:21:01

is that? Like, no, no,

1:21:03

meaning rare is a specific incident of

1:21:05

that being valuable. Yeah. Oh, it's, it's

1:21:07

definitely the minor case, but like. I

1:21:09

think if somebody is trying to like

1:21:11

it recommends a product to you once

1:21:13

like that. I'm definitely one people walk

1:21:15

away. There's like, it's not a crazy

1:21:17

thing to recommend a product once it's

1:21:19

when somebody is like giving you a

1:21:21

cookie cutter thing that they're not being

1:21:24

on it. They're telling you it's like

1:21:26

a magical benefits like. These are the

1:21:28

red flags I usually encourage people to

1:21:30

look for. Because you telling someone with

1:21:32

folic acid or that's like such a

1:21:34

specific thing, you're not pushing a line

1:21:36

of B12 formulas. That's where it starts

1:21:38

getting weird. For sure. I mean, I

1:21:40

have to be careful with this. I've

1:21:42

done work in like control trials in

1:21:44

choline and it's like one of the

1:21:46

nutrients that I have the most perceived

1:21:48

expertise in. But we had industry funding

1:21:50

for it. But I get all these

1:21:52

patients referred to me to talk about

1:21:54

choline. I have to be careful

1:21:56

to be like, oh, let me not, like I'm, they

1:21:59

want me to come tell them take Colleen and

1:22:01

I'm like, I want you to go see someone else

1:22:03

to be honest. So like somebody, you

1:22:05

should work with somebody that, again, you trust

1:22:07

is clearly minimizing conflicts of interest is not trying

1:22:09

to like push something on you. Um,

1:22:11

it depends like pregnant women, like your practice

1:22:13

should probably should be saying to take a prenatal

1:22:15

and an omega three because that's what's standard

1:22:18

of care. Um, so the, the

1:22:20

product to feel like a single product

1:22:22

being recommended. This, I think maybe this

1:22:24

is where like nutrition and drugs are

1:22:26

really different. So like often patients are

1:22:28

coming to me asking for a product.

1:22:30

They want my take on like this

1:22:32

specific brand of yogurt. Do I buy

1:22:35

it or not? And so

1:22:37

a lot of what nutrition that being,

1:22:39

you have to interface with the marketplace

1:22:41

in a way that like is not

1:22:43

behind a prescription pad. And so people

1:22:45

are going to tell you about. products

1:22:47

all the time if you're talking to

1:22:49

a dietitian or anybody in nutrition. And

1:22:51

that alone isn't a red flag. It's

1:22:53

somebody who's like dying in the hell

1:22:55

of like foyer is better than Chobani.

1:22:57

Like those are the red flags I

1:22:59

want people looking for a bit more

1:23:01

of like this feels off. They're married

1:23:03

to this one thing. There's no flexibility

1:23:05

for me because outside of the PKU

1:23:07

patient where you need to restrict phenylalanine,

1:23:09

nutrition isn't very. hyper

1:23:11

prescriptive. And even on things where

1:23:14

you might think it's prescriptive of like calorie

1:23:16

counts and everything, there's so much error in

1:23:18

our estimates, there's so much error in the

1:23:20

amount that's in food. Like all of it

1:23:22

is, is again, guardrails over prescriptions. And

1:23:24

so yeah, I. That should be the title of a

1:23:26

book for you. Guardrails over

1:23:28

prescriptions. Oh, I like academics so

1:23:30

much more. I'm like, I

1:23:32

want to write my, the book I want to write is

1:23:34

an entire history of like nutrition, like, you

1:23:36

know, something overly wonky that 12 people

1:23:39

will buy. What do you mean? That,

1:23:41

that would be in hype demand right

1:23:43

now. I just wrote a 20 page

1:23:45

review article on all nutritional guidance in

1:23:47

America, dietary guidelines, nutrient reference, all the

1:23:49

things that shaped their evolution over time.

1:23:51

And so. Um, that'll be out eventually

1:23:54

by like, I was like spending hours

1:23:56

on internet archive, like reading 1890s, like

1:23:58

dietary plans from the USDA and like

1:24:00

that's the nerdy stuff that I like

1:24:02

more. So which again, makes no money.

1:24:04

So in due time. Yes. Um,

1:24:07

so if I'm a person that's interested

1:24:09

in learning what I can do with

1:24:11

my diet, should I see I'm trying

1:24:13

to lose weight or I'm trying to

1:24:15

accomplish some goal? Who should

1:24:17

I see? I

1:24:19

mean. A lot of times with a dietician,

1:24:22

it's going to depend on whether you know

1:24:24

somebody or can find somebody locally. Oftentimes like

1:24:26

ideally you would be referred by a physician.

1:24:28

So your primary care that you trust and

1:24:30

have a rapport with, I think is a

1:24:32

good place to lead you in the right

1:24:34

direction of like, if it's just weight loss,

1:24:36

do we have you, they'll know about what

1:24:38

you've done lifestyle wise. Um, and I think

1:24:40

there's more and more of realization. Lifestyle is

1:24:43

going to be a small impact in starting,

1:24:45

you know, something like the GOP ones. So

1:24:47

they might be able to start you on

1:24:49

that. And then you might go see nutrition

1:24:51

counseling on the side as needed. Um,

1:24:54

but it depends, I think a little bit on what your

1:24:56

specific concerns are. I would love to say like go

1:24:58

see a dietician, but I'm also aware that they're like. 100

1:25:01

,000 dieticians in the country. There's not that

1:25:03

many of us. We don't get referral. We

1:25:05

don't get... Well, that's because it seems like everyone

1:25:08

sends someone to a nutritionist, because there's so many more.

1:25:10

Because you doctors don't get taught in medical school.

1:25:12

This is why I want... There's a lot of talk

1:25:14

about nutrition being taught in medical school. And those

1:25:16

ACGME hours are fought after. And the five hours that

1:25:18

you guys end up getting of nutrition, I think

1:25:20

are gonna be great, because you're not gonna become nutrition

1:25:22

experts in that time, but somebody will tell you

1:25:24

at some point, like, this is the difference between RD

1:25:27

and nutritionist. You would think so. So

1:25:29

some of the, I did my postdoc at

1:25:31

Baylor College of Medicine and they have like,

1:25:33

they already had a nutrition education for a

1:25:35

while. And the RDS like teach it. And

1:25:37

I know that they explain those basic differences

1:25:39

of like, when you do run into a

1:25:41

nutrition problem inpatient, outpatient, whatever it is, whatever

1:25:43

your specialty is, like this is who to

1:25:45

refer to. And oftentimes it would be a

1:25:47

dietitian if you want somebody who needs like

1:25:49

a full nutrition assessment, basically. And that's not

1:25:51

a bad place like to. If you're going

1:25:53

to spend 200 bucks on the supplement for

1:25:56

a couple of months, you might as well

1:25:58

just talk to somebody who's going to actually

1:26:00

take a deep look into your diet and

1:26:02

talk about what are some high level goals

1:26:04

that you want to set, maybe some swaps

1:26:06

that would be high impact for whatever your

1:26:08

concerns are, and just orient you

1:26:10

to this kind of landscape that we're

1:26:12

focused in. Why are you skeptical when

1:26:14

doctors say that they talk nutrition with

1:26:16

their patients? Well,

1:26:19

cause you have like three minutes to do

1:26:21

it. And so it's always a bit of

1:26:23

a sound bite. I mean, I as a

1:26:25

patient have had doctors, like I usually hide

1:26:28

that what I do. Cause

1:26:31

otherwise I get like half of the appointment I'm

1:26:33

paying for is talked about the nutritional element of things,

1:26:35

but I feel patients like doctors, like my rheumatologist

1:26:37

was like, yeah, you should go gluten free. And then

1:26:39

I was like, you know, that's like a lot

1:26:41

of work. Are you going to provide me any like

1:26:43

resources on that? And she's like, Oh no, I

1:26:45

just tell patients to do that. And I'm like, Maybe

1:26:48

don't like there's no trial evidence

1:26:50

for that being helpful for you. Like

1:26:52

I get that there's anecdotal evidence.

1:26:54

I don't like actually avoiding all gluten

1:26:56

in the diet. Like you have

1:26:58

to know highly educated on all the

1:27:00

different ingredients and whether they might

1:27:02

be gluten containing or not. It's not

1:27:04

just like a throwaway advice, but

1:27:06

I think that's what happens with doctors

1:27:08

is throwaway advice. You

1:27:11

guys get training, like you'll touch

1:27:13

on vitamins and stuff in your biochemistry

1:27:15

classes and your sort of like

1:27:17

early meds, MS1, MS2, like didactic training.

1:27:20

You touch on nutrition in different ways, but

1:27:22

you never get education in food, which

1:27:24

is the base of nutrition. Like you talk

1:27:26

to doctors about like what food compositions

1:27:28

are, how much B12 is there in different

1:27:30

foods, like. With the fatty acid composition

1:27:32

to different oils like this is all coursework

1:27:34

in becoming a dietitian where you have

1:27:37

to know the food science You do food

1:27:39

preparation like you're taking it's a hodgepodge

1:27:41

career path of like it's like you're taking

1:27:43

anatomy and physiology and organic chemistry and

1:27:45

then you're taking a food science chemistry type

1:27:47

class and then you're preparing food and

1:27:49

you're taking a community nutrition class is just

1:27:51

you get like a broad Array of

1:27:53

like everything and that's like a full four

1:27:56

-year degree the idea that doctors can

1:27:58

do that, can do that. And

1:28:00

then like there is data randomizing people

1:28:02

to like counseling from a dietitian

1:28:04

versus other practitioners, dietitian versus nothing, how

1:28:06

much frequency of dietetic visits do

1:28:08

you need? And it's like typically like

1:28:10

six visits a year, hour long,

1:28:12

like so every couple of months basically

1:28:14

coming back up and that improves

1:28:16

like blood lipids and blood pressure and

1:28:18

weight like meaningfully, but marginally. So

1:28:20

the idea to me that like in

1:28:22

those. hour long counseling sessions that

1:28:24

are hyper individualized with like an assessment

1:28:26

and follow up that like diastasis

1:28:28

are producing solid, but like not massive

1:28:30

effects that a doctor is like

1:28:32

giving out a pamphlet and it's throw

1:28:34

away. And you know, people who

1:28:36

like, obviously like we both know Danielle

1:28:38

Blardo and her patients, I think

1:28:40

do wonderfully. And she's got like tons

1:28:42

of information for them and she's

1:28:44

got really people really like hyped up

1:28:46

that are hyper motivated about lifestyle,

1:28:48

but for the most part for the

1:28:50

average. doctor that's out

1:28:52

there like just a throwaway comment like

1:28:55

it's unlikely to do a lot of

1:28:57

good and I've also seen it do

1:28:59

harm where like people misinterpret the advice

1:29:01

in some way or they say oh

1:29:03

this person told me I'm like I

1:29:05

mean I get on a scary amount

1:29:07

of people physicians calculating what it would

1:29:09

take to be a normal BMI and

1:29:11

what their current BMI is and they

1:29:13

tell them like how many calories to

1:29:16

eat per day, being like some super

1:29:18

low number. And like... Like some

1:29:20

1200 calorie I think. Super low

1:29:22

calories and saying, well, your BMI is 32

1:29:24

right now and you need to lose this

1:29:26

number of pounds to be a BMI less

1:29:28

than 25. And it's like defeating for

1:29:30

the patient, whether like I got no support or

1:29:32

evidence. All he did was tell me that I need

1:29:34

to lose a ton of weight that I have

1:29:36

no idea how to lose. And so

1:29:38

that sort of stuff is has like off

1:29:40

the side effects that I think we don't

1:29:42

want. And so I want doctors to be

1:29:44

advocates for nutrition, like in the inpatient setting.

1:29:46

And to be aware of the field. Yeah,

1:29:48

you should know, we should be able to

1:29:51

have a conversation and it should be not

1:29:53

me teaching you the acronyms and you being

1:29:55

like, what is an argument? Who

1:29:57

are you? Kind of with the

1:29:59

state of nutrition physician interaction is. And

1:30:01

so I've talked with a lot

1:30:03

of nutrition physicians who they themselves are

1:30:05

like, outlier people because you

1:30:07

guys don't have formal fellowship training

1:30:10

and nutrition that often feeds GI

1:30:12

or endocrinology that do like some

1:30:14

nutrition fellowship training, like a one

1:30:16

year of like nutrition focus afterwards,

1:30:18

but they're just a handful. And

1:30:20

so we need more dietitian physician

1:30:22

kind of interaction, you

1:30:24

know, position statements should be written together. I

1:30:26

think there needs to be more advocacy from

1:30:28

the AMA for coverage of dietetic services. There's

1:30:31

a little bit more that's happened

1:30:34

with having like a big push for

1:30:36

diagnosing malnutrition and like the inpatient

1:30:38

setting that requires more physician, dietitian interaction.

1:30:40

And so I have hope for

1:30:42

the future for sure. But like we

1:30:44

have this entire career path that

1:30:46

is like, like you, we want nutritionists

1:30:48

in society. We have a like

1:30:51

a legislated, you know, standardized way of

1:30:53

doing that as the RD. And

1:30:55

for some reason we just like don't use it as

1:30:57

a society. Like you don't. Well, because I feel like they

1:30:59

found a shortcut with nutritionists getting a two day course. You

1:31:02

don't even need the two day course.

1:31:04

I was like, I mean, and so