Diet and Disease

Gary Taubes joins John Tierney to discuss his book Rethinking Diabetes: What Science Reveals About Diet, Insulin, and Successful Treatments. 

Audio Transcript

John Tierney: Welcome back to the 10 Blocks podcast. This is John Tierney, a contributing editor of City Journal, and joining me today is Gary Taubes, who’s an investigative science and health journalist. And he has been a great voice for challenging conventional wisdom for decades now. He’s one of the most admired science writers in the country. His latest book is Rethinking Diabetes. But before that, his background is he wrote about good calories, bad calories, about the low-carbohydrate diet. That was published as the Diet Delusion in the United Kingdom. That was back in 2007. In 2011, he wrote Why We Get Fat and What To Do about It, and then The Case Against Sugar in 2016. And now his latest book, really, it’s a remarkable book in that it just challenges half a century’s worth or a century perhaps of thinking about diabetes.

Well, I should also mention that Gary, he’s I think the first journalist to win the National Association of Science Writers Science in Society Journalism Award, he’s won it three times. And he’s written for the leading magazines in the country, the New York Times Magazine, in addition to these really massively researched books and really smart books too. So today we’re talking about Rethinking Diabetes: What Science Reveals About Diet, Insulin, and Successful Treatments. And so Gary, do you want to just tell me briefly what got you into this and what the book’s about?

Gary Taubes: Okay, well, I got into this because all my work going back to the ‘80s has been about good science and bad science and how easy it is to make mistakes in science and how hard it is to get the right answer. And about 25 years ago now, I stumbled into the nutrition field where, the science is so bad that it’s kept me busy ever since. The diabetes story is simple, but you have to kind of keep two concepts in your mind simultaneously, which is one is that we have better drug therapy and devices and treatment than ever before in history. So if you’re diagnosed with diabetes today, whether type 2, which is the common form that associates with age and weight, the older you are, the heavier you are, the more likely you are to get it. And then type 1, which is the acute form that strikes primarily adolescents and children.

If you’re diagnosed today, you will get better therapy than ever before—you’ll live longer and healthier—and yet we have a diabetes epidemic that’s out of control. The prevalence of this disease has increased 600 percent since the early 1960s. It’s still considered a progressive chronic disease, which means that once you are diagnosed, the expectation is that you will never get your blood sugar under control, that you will need either more drugs or newer drugs or higher doses as time goes on. And it’s most prevalent for lower socioeconomic status groups, which means the underserved members of society get it worse. The lower your education, the worse you’re going to do. Ultimately, it’s a mess.

John Tierney: And it’s an incredibly expensive mess as you point out. I was shocked to see that one out of every four healthcare dollars in this country is spent on diabetes, is that right?

Gary Taubes: Yeah. Over, well, $300 billion a year is the current estimate for direct medical care costs, over $400 billion in total in lost productivity. Patients with this disorder will spend, depending on estimates, on average $12,000 to $16,000 a year in medical care. It’s still sort of the leading reason for amputations in this country. There was a heartbreaking piece in the New York Times, just I think it was yesterday, on an amputation crisis in San Antonio, Texas that’s directly the cause of poorly controlled diabetes. So the question I asked in doing this book is how do we get here? And it seems something that any public health authority or investigative journalist in my case should ask, which is, were there mistakes made somehow along the path to getting here that might explain why therapy is still so inadequate, why people are still doing poorly, why it’s so expensive, and what are we going to do about it ultimately? How do we rein this epidemic in and how do we get better treatment to patients?

John Tierney: Yeah, and you talk about, I mean, it’s amazing to read this. How wrong the field seems to have gone, and I understand people think, well, what does a science journalist know about this against these experts? But I tend to think that there’ll be more people receptive to this after what we’ve seen—so many fiascos, the latest being all of the quote “science” we were told on Covid, and people I think have realized that health establishments can really go terribly wrong. So tell us how we went wrong on diabetes.

Gary Taubes: Okay, so you can think of diabetes, fundamentally it’s an inability to control blood sugar and that’s how we diagnose it, by high blood sugar. And there have always been two levers you can pull to control blood sugar. One is your diet, and the other is drug therapy. Those are the two choices. So from 1797 to 1921 when insulin was discovered, the only available therapy was diet, and type 2 diabetes could be kept under control by avoiding the carbohydrates that prompt our blood sugar to go up. Once the hormone insulin was discovered in 1921, and type 1 diabetes is a disorder of insulin deficiency, then insulin therapy made it possible to keep the patients with type 1 diabetes alive apparently indefinitely and made it possible for them to eat carbohydrate-rich foods, the kinds they had to avoid, without causing immediate problems.

So essentially from 1921 onward, we used drug therapy almost exclusively to control the disease. And as physicians realize the sort of terrible long-term consequences of living with this disease, they assume that the problem was inadequate drug therapy. They never questioned their approach to diet. And by today we have this thinking, nobody wants to stay on a diet anyway. Let’s just give them a pill. We see this manifested most obviously with the latest, these obesity wonder drugs like Ozempic and Wegovy, where the idea is these will solve obesity without ever having to tell anyone that they should restrict particular foods that they’re eating. So in general, the story I told them, it was revelatory doing this research and it’s now possible because of internet book and article repositories to do a level of research that was simply impossible previously without spending your life in a medical school library or multiple medical school libraries.

So I realized in doing this time and time again, the diabetes community would come up against the failure of their drug therapies. They would test their assumptions in randomized control trials and their assumptions would fail to pan out in the trials. The largest of these, which was a study called “Look Ahead,” that cost $200 million. When it was ended for futility, the New York Times quoted a Harvard diabetes specialist named David Nathan saying, “We have to have an adult conversation about this.” And time and time again, they simply sort of ignored the failure and plowed on doing the same thing they’d always been doing. And simultaneously, from 1920s onward, one new revelation or another about the sort of fundamental causes of these diseases, the mechanisms involved, even the organs involved and the hormones involved, and those had zero effect on therapy for the disorder. So as they found out, for instance, that you could never really use insulin therapy without causing weight gain, it didn’t stop them from using insulin therapy, they just redoubled their efforts to tell people to eat less once they did gain weight.

Once they found out that it was impossible to use insulin therapy for type 1 diabetics, particularly without causing hypoglycemic episodes, which are episodes of low blood sugar, which are one of the primary reasons why this disease is so burdensome to live with, it didn’t stop them from using and prescribing insulin therapy as they always did. It’s as though the understanding of the disease had no effect on the physicians thinking about how best to treat this disease. In no one.

John Tierney: Now that sounds astonishing, but how does that happen that in a field that people just get so set in their ways? The incentives are all the wrong way, it’s the wrong people looking at it?

Gary Taubes: The people doing the science, the hard science are different than, so you’ve got, say, at any one point in time 1,000 physicians or 10,000 physicians or by today, every physician in every medical clinic in the world having to prescribe medications to treat their ever-growing number of patients with diabetes. There are standards of care that have been created by the diabetes associations, I think always with the best interest of patients in mind. I don’t think corruption or industry influence plays any major role.

And yet, what you learn about the science, so it has kind of no mechanism by which it can enter into the conversation. So I could come along as a journalist and say, let me talk to everyone in the field. Let me read the literature going back to, in this case, the 18th century and let’s see if mistakes were made. But the diabetes associations and the government agencies that fund this research and that promote therapies for the disease have no mechanisms by which to do that. There’s never a place where they can say, even with Nathan saying we have to have an adult conversation, well, the adult conversation should be, what have we missed, and how do we change?

John Tierney: What did they miss and what should they be looking at now and what should diabetics be doing based on your research?

Gary Taubes: As soon as I say this, it’s funny, I used to give lectures on obesity and I would go 45 minutes into the lecture without mentioning the word carbohydrate. Because as soon as you mention the word carbohydrate, especially in medical schools, and I’ve given, I don’t know, a dozen grand rounds, that suddenly physicians who have been following me completely along the way saying, hey, this is a really bright guy and these are really interesting ideas and I’ve never thought of it like this. And then you mention the word carbohydrate and they think, oh, he’s one of these Atkins guys or now he’s one of these keto guys and then they sort of shut down and stop listening.

The disorder is fundamentally an inability to safely metabolize the carbohydrates in the diet. So type 1 diabetes is an insulin deficiency disorder and type 2 diabetes is a disorder where the liver is resistant. It’s a fundamental organ resistant to the hormone insulin, so you have to secrete ever more insulin to have it do its job, and then all kinds of deleterious consequences result. The immediate problem, I mean, the whole homeostatic system of the human body is out of whack in these diseases, but the immediate problem is high blood sugar. And the high blood sugar is a response initially to the carbohydrate content of the diet. So the very first successful attempt to treat this disorder was a British doctor telling his formerly obese diabetic patient in 1797, not just basically to live on fatty meat and green vegetables. It was in effect a ketogenic diet or an Atkins diet circa 1797 and it worked.

And this British physician, John Rollo, published a pamphlet about it and he distributed it to doctors throughout the United Kingdom. And he says if you have diabetic patients, try it with them and let’s see if it’s reproducible. And for the most part it was. And throughout the 19th century, this was a standard of care. That means every major diabetes specialist, and there weren’t a lot of them because it was a rare disease in the 19th century, but every major one in the UK, in Germany, France, Italy, the United States used this what they call the animal diet to keep the disease under control. And for patients with what today we would call type 2, it worked. It kept the disease under control. And that’s the approach that they left out. So the simplest way to think about it is here you have a disease where you can’t metabolize the carbohydrate content of the diet safely, then you don’t eat carbohydrates. And my other books have sort of documented how this kind of simplistic concept got tagged a fad diet and a dangerous diet because one of the things that happens is it’s what’s called ketogenics. So you up your production of these molecules called ketones by the liver, which your brain then uses for fuel, but it’s sort of one preconception after another that then caused them to turn away from the obvious dietary approach for the disease.

And let me tell you just one, originally my book had, there was an epigraph in the beginning, which was a story that was told to me by a chef-turned-journalist who was diagnosed with type 1 diabetes about seven, eight years ago when he was 36 years old. So when you’re diagnosed, you’re just thrown into this world of, this is true of any disease, but suddenly you’re immersed in this world that you never imagined thinking about before so you have no preconceptions. And the doctor explains to him that because of this insulin deficiency problem he has, he can no longer metabolize carbohydrates. So what they’re going to prescribe is that he eat this certain amount of carbohydrates at every meal and then he take insulin to what’s called cover the carbohydrates. And he says to the doctor, well, wait a minute. What you’re telling me is that carbohydrates are now a poison to me and insulin is the antidote, and I should eat the poison and take the antidote? Why don’t I just avoid the poison?

And the problem with having that as an epigraph is if you just phrase it like that, suddenly nobody’s going to read the rest of the book because it’s kind of obvious. But we’ve created a whole world of explanations, the foremost being, you can’t . . . Well, this was the issue beginning with insulin in 1921, you don’t want to tell kids, particularly, who were diagnosed with this pretty terrible chronic disease that they can’t live an otherwise normal life like their friends and family. So you want them to be able to eat whatever their friends eat and their family eats. And then as time went on, it’s just easier to let people eat whatever they want to eat and cover it with insulin. And then as time went on, the logic became, well, no one’s going to stick with a diet anyway.

So by the 2010s, I quote a wonderful British diabetologist writer named Edwin Gale and his colleague talking about how we pay lip service to diet. But nobody really ever bothers to ask the question, well, this disease has pretty terrible consequences and we’re not preventing them with drugs, we may be delaying them, but bad things will happen, they’ll just happen a little less and a little delayed with drug therapy. Why not offer the possibility to not eat the poison and not suffer the consequences of the disease or at least test that possibility?

John Tierney: Right. Now it’s been tested somewhat, and as you said, this disease, diabetes has been classified that it’s chronic and it’s progressive. It’s just going to get worse. And you say that there is some evidence now, and you write about this a lot in the book at great length and very convincingly about actually that the disease doesn’t have to be progressive, that in fact that there’s evidence that people who follow these diets have reversed it. Is that right?

Gary Taubes: Yeah, and that’s clearly the case. We don’t know what proportion of patients reverse it. We don’t know for how long it stays in remission. But one of the fundamental dogmas of the diabetes community is that this is a chronic progressive disease. And other than bariatric surgery, it will only go into remission spontaneously 0.2 percent of cases. That was the number of one 2014 analysis. And now there are trials out there and clinical experience showing that people, rather than getting worse and needing more drugs and newer drugs and higher doses, patients can get off their medications by simply, again, avoiding the foods that they can’t metabolize safely much as they might want to eat cake.

And the reason I raise this New York Times story about the amputation crisis in San Antonio. They’re talking about young Hispanic men and men being in their twenties, thirties, forties who are suffering amputations. And I can’t help but think, I get that certain foods are specific to certain cultures and that the idea of growing up without eating bread or rice or beans sounds like deprivation, but if somebody said it’s that or your left leg, which would you pick?

John Tierney: Exactly. And now the evidence, you say that there have been some studies, not randomized clinical trials, but pretty extensive studies where they followed people and they’ve shown this, right? I think you mentioned that the American Heart Association has actually come to accept some of this in their recommendations? Realizing that diet could actually help . . .

Gary Taubes: Yeah, actually the diabetes associations and the American Heart Association. So in 1971, the American Diabetes Association for the first time started recommending that patients with diabetes get more than half of their calories from carbohydrates. Again, the one macronutrient they can’t metabolize without pharmaceutical help. And again, when I phrase it like that, it sounds insane, but that was the case. And the American Heart Association has always advocated for these low-fat or low-saturated-fat, high-carbohydrate diets as the way to prevent heart disease. Now, these low-carbohydrate, high-fat diets, because you’re trading off basically carbohydrate calories for fat calories in most rational dietary approaches to any disease. These low-carb, high-fat diets have been tested in probably going on 200 randomized control trials for a whole host of virtually every imaginable chronic disease. There’s even a new movement now testing them for bipolar disorder and schizophrenia and the preliminary results are quite startling.

So yeah, even these associations are now either offering these diets that they’ve never before, that before could never be really fit into their guidelines because the guidelines are always eat low fat and whole grains. And there’s a conception of what a healthy diet is for everyone, which is fruits, vegetables, whole grains, legumes, red meat in moderation, that kind of thing. Now, even the American Heart Association acknowledges . . . It’s interesting because they used to say that these were the hardest. That yeah, maybe it works, but nobody could comply with this way of eating. So we’re going to tell you you can have anything you want, just eat less of it. Now they say, for those people who can’t comply with the eat anything you want, but eat less of it advice, a reasonable, you might want to try these low-carbohydrate diets because you could eat as much as you want.

And definitely making progress on one level, partially because of my work and a whole world of physicians and journalists who have been pushing on these health organizations, they are slowly coming around. You could argue that they’re coming around as slowly as possible, but you still end up with the situation which you would like to avoid, which is depending what page on a website you’re looking at or which one of their guidebooks you want to download, you’ll get entirely different advice and chances are only one of the pieces advice is correct. Only one philosophy is correct and only one philosophy will maximize efficacy and minimize harm. You would never have a situation where you’ve got some cardiac disorder and you go to the American Heart Association website and it says, well, some people say you can take this drug and other people push this drug and some people say that drug, so we’re just going to, each page in our website is going to give different advice. That’s what we’ve gotten to now with diabetes and dietary therapy. We’ll see where it goes from here.

John Tierney: So you would, I mean, the first bit of advice I imagine that you have for any diabetic is of course is to read your book Rethinking Diabetes. What do you hope to see? Do you want to offer general advice or not to diabetics or non-diabetics on diet? And also, I mean, some of the advice that you obviously say is that we need more rigorous clinical trials to demonstrate that, is that right? And there hasn’t been enough research, and there hasn’t been enough attention paid to the researchers there?

Gary Taubes: Yeah, the diabetes community, again, they deserve credit. They’ve done a series of very expensive large clinical trials to test their assumptions, but their assumptions were always based on this idea that patients with diabetes should be told to eat the same healthy diet we’re telling everyone else to eat, and then if they’re gaining weight, they should eat less of it. And that kind of grandfathered in with the evidence-based medicine movement, and that’s the assumption that has to be tested. Clearly at this point there’s a world of advice out there on the internet and in books on ketogenic and low-carb diets where patients with type 2 diabetes can get good advice on what to do.

But these are serious diseases, and nobody should do anything without the physician’s assistance to make sure, because for instance, if a patient even with type 2 diabetes should choose to eat the way I eat, for instance, they’re going to have to cut back on their medication severely and perhaps immediately or they’re going to have side effects. Their medications are going to lower their blood sugar too much. So they need help from their physicians. And one of the criticisms of my book is that they’re dense. My favorite criticism of my first book, Good Calories, Bad Calories, was on Amazon. Somebody gave it one star and said, this is the worst diet book I’ve ever read, and I want to say it’s not a diet book, dude.

John Tierney: It’s a science book.

Gary Taubes: It’s about the relevant med history. I want physicians and the people with the ADA and the diabetes community to understand what happened. Ideally, they do something about this, and I want physicians to inform themselves so when they have a patient who’s newly diagnosed with diabetes or who’s coming in after years of treatment and isn’t doing as well as they should, they can offer them sort of both approaches; the don’t-eat-the-poison approach and eat-the-poison-and-take-the-antidote approach. And give them informed counseling on both and perhaps give them the necessary reading material and explain to them and then be able to help them through it and guide them. So ultimately, it comes down to the physicians, realizing that there’s another approach to treating this that their patients, despite having to restrict an entire food group, may choose because it keeps them healthy and it makes them feel healthy in the short term.

John Tierney: Well, that makes great sense. I hope that many physicians and these associations and diabetics do look at your book. Again, it’s Rethinking Diabetes: What Science Reveals About Diet, Insulin, and Successful Treatments. It’s just a really extensive, thorough review about the history of this disease and the research into it, especially the research that has been neglected by the establishment. Gary, thanks very much for joining me.

Gary Taubes: Surprisingly well-written too.

John Tierney: And very well. That’s very true. I’ve always been a fan of your writing, Gary. So thanks very much for joining us, Gary. You can find a transcript of this podcast at the City Journal website. That’s www.city-journal.org. You’ll find there a link to Gary’s author page. You can follow him on Twitter, which is @garytaubes. And he has a great Substack titled Unsettled Science that he and Nina Teicholz do together. They are two of the great experts on advocates for forcing the establishment to rethink their dietary ideas and to look into low-carbohydrate diets. So again, thank you Gary. And to our listeners, if you like what you heard on the podcast, please give us a five-star rating on iTunes.

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Source: city-journal.org