Food Is Medicine: Christopher Gardner, PHD On Using Diet To Prevent Disease

28:04So there's no reason to study a fad diet. It's like, no, no, no. Some of these books have been around for a really long time. somebody should study the books say okay so are you going to match the protein and you're going to match this and you know as part of our scientific rigor there's there's things to match and not and my idea was they're selling the books let's just have them read the book let's see what happens and then there's another group saying okay now once they've read the book they'll have to follow exactly what the book said i said i don't think so i don't think a nutritionist comes with the book when you buy it at the bookstore.

28:36They read it and then you have to see what they do. So the fun of this study was it was designed very intentionally so that for the first eight weeks of the one-year study, a dietician would come in and I'm exaggerating, but basically read the book out loud to you, one eighth of the book each time for eight weeks to make sure they had at least read it. Because what we did find, here's a fun anecdote. We put people on the Atkins diet again, which was very popular at the time. And some of them would show up to these classes and say, half my office says they're on the Atkins diet, but I have read it.

29:11And they are not. They say that they obviously don't understand it. I have read the book. And these people say they're on it. And they got like one concept out of the book, not having read it. And they say they're on it. So part of the rigor here was make sure they've read the book. And then after eight weeks, what we told him very intentionally was, we're not gonna help you anymore. If you want moral support or social support, we'll help you if you call us. But if you have questions about adherence to the diet, we're not gonna help you. You read it. We're gonna see what happens. And one of the funniest stories from this for me was, I'm pretty sure it was an email from Barry Sears.

29:51At the end of the study, the Atkins group did a little better at six months. From six months to 12 months, the weight was coming on. faster than the other groups. So I suspect if we carried it out to two years, they all would have been the same. The actual finding of the study was the only two diets that were different from one another were Atkins and Zone. Now this is a little bit of a head scratcher because by picking Atkins is the lowest carb, Zone is the second lowest carb, Learn, which was sort of a health professionals approach and Ornish, which was the highest carb. It was very intentionally a range of low fat to low carb extremes.

30:32So if low fat or low carb were different, it should have been the two extremes that were different, Ornish and Atkins. It wasn't. The only two that were statistically different were Atkins and Zone. Those were the two low carb diets. Zone lost the least and Atkins lost the most. So it's not really an advertisement for low carb. My personal opinion was the Zone instructions were really hard to follow. and Atkins was quite easy, don't eat carbs. Right, so it's an adherence and kind of real world human problem, not so much an issue. It was specifically and intentionally designed not to really pit these three different diets against each other, but to see how actually people behave in the real world when they take in information.

31:18How it works. And so Barry's interpretation of this, when they tried to follow Atkins and fell short, they were pretty close to zone. So he said, my diet wins. And I said, wait, wait, wait. If you wanna be on the zone diet, read the Atkins book, basically. Yes, exactly. And I have a flip side to that, which is Dean Ornish was quite upset. Said, well, I don't, you know, you didn't get them to follow my diet. And I said, Dean, we bought them the book and we gave them a nutritionist and they read it. If you looked, so we did extensive dietary assessment on this at baseline three months, six months and 12.

31:49And if you looked at 12 months, the Ornish diet is 10 % fat. they were at 30 % fat, not 10. If you look - But were they claiming they were still on it? They were assigned to it. I mean, the way I wrote the paper up was they were assigned to this and this is what they did. And I sort of, I have a chart of what the guidelines of the American Heart Association and dietary guidelines for Americans are. In shooting for Ornish, they fell into the dietary guidelines. In shooting for Atkins, they kind of fell into zone. So it's almost like it was a zone versus dietary guidelines study according to how they followed it.

32:29But no, they got assigned to these four different books. And so as you started this conversation, you said it's more about adherence and what real people can do. They couldn't do the extreme diets. They could not do Ornish and they could not do Atkins. And so that is how we wrote the study. We assigned them to this, we got them the book and they read it. Here's what happened. They pretty much lost the same amount of weight at the end, except for Atkinson's own. And our more stunning conclusion was, there's like on average, a couple of pounds difference between them at the end. But what's super cool is how variable they were within each group.

33:05Within each of the four diet groups, somebody lost 50 pounds and somebody gained 10 or 15. And those were not outliers, everything in between. So my epiphany from this study was people getting the exact same advice can have wildly variable results. Ah, that is humanly, personally fascinating. Why are we so complicated? But it was reading a book. It seemed to me a very practical public health approach to this question of weight loss. So extrapolating from that big picture, humans are complicated. There are all kinds of mechanisms at play that must be accounting for this wide variety of results with weight gain and weight loss and other sort of results that you were seeing.

33:59And then also the very sticky problem of like how humans behave. Like just cause you read a book or this says do this. And sometimes I would imagine you see people who say, no, I'm doing it exactly. Like they think they're doing it exactly right. Yes. But in reality, they're not. And then other people who are like, yeah, I know I'm kind of veering off here and there, but I'm trying to make it sustainable. Like, I guess what I'm getting at is different levels of self-awareness around adherence, even within that population of people. Right, yeah. There are people who think they're doing it and you follow up with them and say, this is one of the things we told you not to eat.

34:38Oh, I didn't understand that. I thought it was the other way. But two of my favorite words in my field that you're kind of getting at is effectiveness and efficacy. And so in some of the studies that you do, some of the scientists will publish two things. One is the intention to treat and one is per protocol is one of the ways to frame it. And intention to treat is, here's what everybody did. What if you had somebody that you assigned to Ornish and in the middle, they hated it and they went Atkins and you know they did because you look at what they're eating. you have to include them in the results and you have to keep them in the Ornish group.

35:14So that's intention to treat where there's a lot of variability because of that. Per protocol is we only took the people who did it right. And that's usually a much smaller subset of the population. And it's a quite relevant question. So if you followed it as designed, this would have been the result. So it's nice to know the efficacy results of if you did it, this would happen. And also see, yeah, but when you randomly assign people, most people don't do it. Both of those are important perspectives. Which has to be infuriating for you. I mean, as fascinating and as curious as that is, it's gotta be frustrating.

35:55But it's less frustrating than doing a rat study, keeping them in a cage, feeding them exactly what you wanted and reporting and flipping the news that this thing happened and seeing, yeah, but humans don't do that. And so this isn't helping humans because we have to do this and understand someone got divorced, someone got in a car accident, someone lost their job, life happened to them. And this is what happens in life. Or more realistically, some of those very restrictive diets are good short-term. But personally, I really don't like the word diet in terms of I went on a diet that I'm gonna go off as soon as I get what I need out of it.

36:34Diet should be a noun. This is my diet. I eat this way, I'm gonna eat this way for the rest of my life. And so when you see these really restrictive diets, they have short-term results. But that's because - The practicality. You can do restrictive things for a few weeks or a month, but you can't do them long-term. And when you go back to the old diet, all the things that were plaguing you before come back and it's not effective.

37:07Taking what you can do with mice because you can control their environment a little bit better, that becomes more difficult with people. But Christopher, there is a precedent at Stanford around incarcerating students for the purpose of science. Oh, yes. Yes. You can lock them in the basement. Infamous study. Zimbardo did it. Yeah, you see what - Controversial. Yes. Maybe not in 2023. Okay, yeah, I'm not sure I wanna go there, But yes, that was an experiment gone awry. But this idea of trying to understand this unpredictable variability in weight loss and weight gain that came out of this A to Z study, I gather that that must've been top of mind in trying to design this diet fit study where you're gonna look at some unique factors that maybe hadn't been looked at before, at least with rigor in terms of nutrition and weight loss by pitting low fat, a low fat diet against a low carb diet and looking not just at weight loss, weight gain or some of the typical biomarkers, but by honing in on insulin resistance and metabolic health, as well as genotype.

38:22Yeah, so the fun of finishing that A to Z study again was seeing that variable response and thinking, okay, the cool question here is not which diet is better. It's which diet is better for whom? There must be some, aren't there predisposing factors? So instead of telling the American public or the global community, here's the best diet, what if there's a factor that predisposes you doing better on one than another? Doesn't that make a lot of sense? Yeah, we should go after some of those. And so after we finished A to Z, two things happened. One is a group approached us and said, can we look at your DNA?

38:57And there was a signal in the DNA about a possible genetic predisposition. It had to do with single nuclear polymorphisms, nucleotide polymorphisms, SNPs, and they had these two genotype patterns, a low carb genotype pattern and a low fat genotype pattern. And retrospectively, it looked like it would have worked in A to Z, but that's more of a hypothesis generating approach by digging into old data. And the more rigorous one would be, okay, now that we have these genotype patterns, let's design a new trial and test it. And the idea being that, or the expectation perhaps being that somebody who has a certain genotype for doing well on a low carb diet is gonna fare better versus the vice versa, right?

39:45And it should play out if we conduct this study. And pretty easy to do, just mismatch them. So have some matched and some mismatched. The other one that came out right about the time that we were finishing was a slew of relatively small short-term studies that focused on this insulin resistance idea. And I found this super appealing or just intuitively appealing because I'm trying to look for what would be predisposing factors. And people with insulin resistance have a hard time putting away carbs. And so it doesn't really say it in the name, but every low fat diet is a high carb diet. I don't know if you wanna go here, but protein across many, many different diets, barely budges.

40:26It's almost always 20%. Sometimes the reviewers want to make sure I've matched for protein. And maybe on another day we'll discuss, I don't have to. Like protein always ends up about 20 % of calories if you're just eating a variety of range of foods, even if you manipulate low carb and low fat. So it's all I wanted to do was do low carb or low fat. And if you're low fat, which carbs are you eating? Like you could be eating lentils and squash and whole grains, or you could be drinking Coke and you could be having white flour tortillas and white flour bagels and donuts. So we said, all right, let's do this thing.

41:05Let's only do low carb and low fat and let's do the genotype thing and the insulin resistance thing. And so for insulin resistance, it's actually a trickier term than most people might imagine. I bet a lot of your listeners have heard of insulin resistance. It's not a dichotomous thing. It's not like you are or you aren't. there's a continuum and there's multiple ways to measure it. And some can be done with a fasting blood draw, which is not as accurate as this thing called an oral glucose tolerance test. You probably don't want to get too much into the weeds, but on an empty stomach, you have to drink 75 grams of glucose on an empty stomach.

41:41Glucose just flies into your bloodstream and you can monitor the insulin response to that. And your pancreas freaks out thinking, oh my God, I have to put this glucose away. Here's how much insulin I'm going to spit out to get that put away in cells. And if you're insulin resistant, you see this huge spike in insulin. And you basically have to kind of cut people at the median. There isn't a number that says you're insulin resistant. What you'll find is some people spit out a lot of insulin. Some people spit out very little and put it all away. But you can define it. And so that's what we did. The whole study was designed to say, okay, could genotype pattern or insulin resistance be part of the explanation for this huge variability in what we're seeing.

42:25And one small feeding study did this with 20 people. Another did it with 24 people. David Ludwig did it with 73 young adults. So there's sort of three different studies that had approached this and all reported the same thing, that if you can identify them ahead of time being insulin resistant, then they do better on low carb because they have fewer carbs to put away. Now, one of the things that's really a challenge here is defining low carb and low fat. So one of the ways to do it is just to say lower than yesterday, right? So I've often asked students in my class, okay, what if I put index cards in front of each one of you and I ask you to define low carb or low fat?

43:10Is it a gram amount? Is it a percent of calories? Would you all agree on the same thing? So, and this is true to my nature. I hope this is part of what you were recognizing at the beginning of our talk. I knew not to give it a number. I knew not to give it a gram amount or a percent. And I did this thing that maybe I got away with. And I don't know if your listeners will appreciate this, but this is compellingly what we called it, the limbo titrate quality method, which probably sounds horrible. And let me try to - No, it sounds super sexy. Explain. Here's how sexy it is. We said, okay, we really want you to feel like you are in a weight loss diet study and you are expected to change your diet a lot.

43:53So whatever carb or fat amount you're eating, depending on which group you're assigned to, you have to go to 20 grams of carb or 20 grams of fat. Most people eat 300 grams a day of carbs-ish. So 20 is enormous. Most people eat 100 grams of fat-ish. They had to go down to 20. but we said we have some experience with these really restrictive diets and we know people can't stick with them. So this is almost like we never confirmed or affirmed or anything that they got to 20 and we said we won't be kicked out if you don't get there. We just want to psychologically anchor you so that you know you're in a diet study and you're removing all the sources of fat and carb that you can out of your diet.

44:38That's the limbo phase. We want you to do that in eight weeks-ish. And some type AAAs got there in two weeks. And at eight weeks, some of the people weren't quite there. So kind of all at their own speed. We actually didn't even do any diet assessment at eight weeks. The first diet assessment was at three months because we said, once you got there, as low as you can, stay for a week or two if you can. But if you don't think you could handle that socially, culturally, if you're hungry, if you can't look us in the eye and say, yeah, doc, I could, if this works, I could do this for the rest of my life.

45:14If you're not there yet, add some back, do this titrate thing. So add a little fatter carb back, add a little more. If you're still not there, add a little more. Oh, is the weight coming back on? And you feel like that was fun losing weight and you wanna go back down again. So you can titrate up or down, but try to look us in the eye and say, I found this place and this is it, man. and this is the lowest I could go. And we kind of gave them all an out as they started this study. We said, you're gonna have these classes with a bunch of other folks from your study. And you're gonna look across the table and somebody is gonna say, wow, I'm nailing this.

45:49I got this super low and I feel great. And you're gonna say, man, I'm struggling and I'm not as low as you. Part of this study was because of the genotype thing and the insulin resistance. We're actually betting that some of you you can't go as low as the others. That's part of the study. So don't feel bad. Don't feel like you're psychologically not prepared for this. Think that you're metabolically or genotypically predisposed. That's part of the study. Be okay with yourself and just help us test this. So they all had an out. They were just supposed to go as low as they could, titrate up. And the quality part was really important to me.

46:26And I think is an important part of the conclusion. So he said, and you can't do this with low fat brownies or low carb chocolate chip cookies. You have to go to buy food. You should go to the market, farmer's market and shop. You should try to have a salad every day, both groups, low carb and low fat, should have a salad every day. One of the common themes was, please get rid of as much added sugar as you can. Please get rid of all the white flour that you can, the refined grain. And after that, eat a quality low fat and a quality low carb. And they did. So if you track this out and you read our paper, where you'll see all the diet stuff that they...

47:01And there were ranges. Some people were more successful than others, but they really ate a pretty good quality low-fat and low-carb diet. And at the end, drum roll, after a year, not only was there no difference between low-carb and low-fat, which there wasn't, on average, they both lost 11 to 12 pounds at the end of a year, but the genotype pattern and the insulin resistance thing both failed to be an effect modifier or to predict any of the variability, which stood in contrast to these short-term studies where they fed them food and they did it with 20 people or 70 people. And so writing up the discussion, we have to say, our results differ from those others.

47:47Why would, I actually totally expected this to work. I actually was a little skeptical of the genotype thing. I totally expected the insulin resistance thing to work. and I looked at it again and again and again and it didn't work. And I thought, you know, maybe that's because this low fat group that they were worried about that had high carbs for people who are insulin resistant, they got rid of their added sugars and their refined grains. And so maybe those people who in others, maybe that's what they were eating on some of these other studies and that was part of the reason for the effect they saw that we didn't see.

48:22That was our explanation of why don't these two nutrition studies agree? Well, because not all low carb and low fat studies are the same. You can set up a study, maybe subconsciously, maybe consciously to make a kick-ass diet A and a crappy diet B if you're a diet A proponent. Sure, that happens all the time. Kick-ass B, crappy diet A, if you're a diet B proponent. Our incentive here was, oh God, if everybody loses a hundred pounds, we're gonna be famous. So let's make both diets the best we can. In fact, the health educators that were teaching these health classes had to teach both low fat and low carb throughout the whole study so that even if one of the health educators was more inspiring or motivating in another, both groups were getting that same person.

49:10Yeah, I get it. In other words, what you're saying is if you go in with a bias or you're trying to establish that your camp is better than the other and you're pitting two dietary protocols against each other, the one that you're in favor of, you will design to be very clean and whole food and kind of the best version of what that has to offer. Whereas the competitor will be the low grade version that you know is not gonna do well because it's an uncharitable interpretation of that. But I guess what I, so it's again, like, wow, we didn't figure out what we thought we were gonna figure out and where does that leave us?

49:45And what do we make of this? And what can we extrapolate from this? And what can we not? Like I think about, I would imagine that maybe a critic would say, well, you hear this all the time, like, well, your low fat wasn't low fat enough. Like if it was really low fat, you would have gotten the result that I know that you would have gotten. And conversely, you know, your low carb, that wasn't low carb. You're like, look at what they were eating. That's not, when I say low carb, I mean this, that's not what you did. And then sort of an ancillary critique could possibly be, well, how many genotypes did you test for, right?

50:21Three, like how many are there? Like you just picked the wrong ones. If you pick the right ones, you would have seen what you were expecting to see. There is another genotype paper that's coming out soon. So I know there'll be a delay from the time we have this conversation to when it comes out, but there'll be another genotype paper that shows genotype didn't work. But again, there's probably a million different genotype options here to pick from. And so you pick the one that makes the most sense. Another one, again, this is a time issue. I just got an email this morning from a postdoctoral research fellow who went back to our diet fits study and took the 10 % of the people who were the lowest fat and the lowest garb, got rid of the other 90 % and pitted them head to head.

51:07There's really no difference in that. So here we are like, I don't know, 50 minutes into this conversation. And I'm trying to sit in the chair of the listener thinking, well, all right, so far, what have I learned about what to do? You've learned to eat a good quality diet. So really what I'm after here in doing my studies is to show that it's not that there's disagreement here. If you put this in context and see that we had a good quality, low carb and a good quality, low fat, that's better than - You're gonna fare well. Yeah, and that's already, it goes also to this adherence and self-awareness issue which is, I would imagine if you pulled 100 ,000 average people and asked them what they eat, they would probably report that they're eating better than they actually are, right?

51:56And so we have these arguments around the margins, around low carb, low fat, et cetera, when in reality, the low hanging fruit and the real issue that we should be looking at is, what are the big areas on which there is just incredible consensus amongst the scientific community in terms of what we should be doing and what we shouldn't be doing. Yeah, and we just published a study on that from the American Heart Association, if we can go there, the dietary patterns paper. Yeah, yeah, because it's sort of like start here and if you can do that, then do this. So I'll start describing what the point of this scientific advisory was.

52:31It came out in April of 2023. The American Heart Association has regularly for 50 years updated their dietary guidelines. And the previous most recent update was 2006. and in 2021, they did it again. Didn't honestly change all that much, but they refined a few things and they spent a ton of time in this paper looking at all the literature that was available before 2006 and between 2006 and 2021. Here's all the data we have on who has a heart attack, myocardial infarction, stroke, any kind of cardiovascular disease. Here's 10 domains that cover a heart healthy diet. And those are sort of individual things about whole grains and veggies and beans and salt and saturated fat.

53:16And they said, here's the things to include or avoid. And then the public said, so what does that mean? Should I be vegan or should I be Mediterranean or should I be paleo? And I said, ah, you know what? We should do another paper on patterns. So instead of individual components, how many of these popular dietary patterns out there could be consistent with this set of domains? In other words, like the overlap in the Venn diagram between all of these different perspectives. And so I wanna focus on the overlap at first. So the 10 patterns we picked were the DASH diet, that's the dietary approaches to stop hypertension, Mediterranean, three types of vegetarians who had pesca, who had the ovo-lacto-vegetarian, we had vegan, sort of a higher fat vegan.

54:01We also had a really low fat vegan diet. We had a low carb, a low fat, a paleo and a keto. I hope that was 10 because we had 10 patterns. And we tried to match them up to the 10 domains. And we scored them from high to low and Dash and Mediterranean got the best score and paleo and keto got the worst score as you were matching these domains. And happy to go into some of those details if you want. But one of my takeaways that I thought was great was across all 10, they all said more vegetables, more whole foods, less added sugar, and less refined grain across all 10. Now this could be a trivial response if those are things we already did.

54:45Those are four of the biggest problems with the US diet. We don't eat many vegetables. We eat a lot of ultra processed food. We eat a crap ton of added sugar and a crap ton of refined grain. So for me, this is a kumbaya moment. Oh my God, all the patterns agree on 50 % of probably what plagues human health associated with diet. But why don't we all get together and work on that? That's no fun. Yes, it's not as the clickbait doesn't work, but we really all agree on those. And those are all big issues. The one extra one I'd love to add in there is beans. I actually think eating more beans is probably the biggest thing Americans could do to change their diet in a positive way.

55:30And there's so many kinds of beans, culturally appropriate, lots of unapologetically delicious dishes with lentils and chickpeas and kidney beans and refried beans. Oh my God. But you wouldn't get the paleo and keto in there, right? Cause they're super low carb and beans are full of carbs. So if you, after the four things I mentioned first that they all agree on, the next ones I would add would be beans. We kind of all agree on beans. That would come next, yeah. I mean, I like that way of looking at it, like this heat map sort of perspective that allows you to transcend all the labels and the tribalism and all of that and really just focus on, this is, I think you've characterized this as being like 50 % of the, but it's kind of like 90%, isn't it?

56:18I mean, it's really like if you do those four things and then maybe the fifth with the beans, like you're on the five yard line pretty much, right? And another way to appreciate, to acknowledge that, appreciate it is, I do think there are arguments for some of these low carb, low fat, high protein, individual things. For whom and when. At the margins. At the margins. After you've got the foundation right. So there'd be a lot less bickering if, yeah, I do all these things. And I actually prefer avocado to steel cut oats or something. I prefer this higher protein to this higher carb, whatever. Yeah, I think you could hedge your bets.

57:02And at that point, sort of biohack your own metabolism and come up with something that's a little better for you than the other thing. But can you please fix the first 50 or 90 %? Because we all agree on that and you're doing that wrong. Right, so this first tier of the heat map, less added sugar, less refined grains, way more starchy veg, more whole foods, less ultra processed foods. and then with the footnote around beans, but then there's a tier just below this, right? Okay, we've done that. Now, how do we get to the next level? And I would flip that one little thing. You said starchy veg. So the one things they all agree on is non-starchy veg.

57:37That's what I meant to say. Sorry about that. Broccoli, cauliflower, leafy greens, red bell peppers. But then you get to the avocado, the avocados, the nuts, the seeds, the olive oil, fruits. Are we gonna eat fish? Are we gonna eat eggs? It's like that kind of all falls into that next tier. Yeah, we've got beans with lectins. Oh my God. No, no, no. Please just take one moment. Like, let's go on a, like put a pin in what we're talking about and just explain this lectin thing quickly. Yeah, so, well, there's different things in plants. There's fibrous things there, you know, fiber is great for the microbiome.

58:14Plants are toxic. Fiber binds some things and sucks it out of you in your feces when it leaves. but really the fiber was awesome for your microbiome and it came with lots of the plant foods that generated the fiber had lots of nutrients. There's phytates, there's oxalates, there's lectins. There's a couple things that are less than 100 % perfect, but to avoid those would mean you'd be avoiding getting all the fabulous things that come with it. And in my sort of, you're talking about this core that has a second ring and my second ring is beans. Oh my God, with lectins. Fruits, oh my God, they have sugar.

58:53Nuts, oh my God, they have fat. Eggs, oh my God, they have cholesterol. Fish, oh my God, they have a face. You know, at that second level, the lectins don't matter. The sugar in fruits is fine. It's in the fruit matrix. The nuts have unsaturated fat. So that next tier of foods is pretty good. But it's at the margin after you deal with that thing in the middle. And let's assume we've now mastered this tier. Okay. What comes next? Where are we gonna, we're gonna go behind the velvet rope and put the cherry on top of the sundae. Yeah. So to be honest, Americans eat too much wheat. They eat too much grain.

59:34They even eat too much whole grain bread. So kind of cracks me up going from white flour to, oh, I used to buy Wonder Bread. Now I buy my local whole wheat bread or I buy my grocery store whole wheat bread. Well, if you look, some of the whole wheat grocery breads have 30 ingredients in them. So we're like at this ultra process thing where there's dyes and additives and emulsifiers. There's the whole wheat bread that has five ingredients. That's all you need for bread, right? I think you need some flour and water and yeast and sugar and salt, a little bit of sodium would make the bread. I actually make a kick-ass wheat berry salad.

1:00:13People say, what's a wheat berry? I say, that's the grain. that you make the flour out of. So instead of grinding it all to a powder and consuming it in bread, you can soak it and add all the things that I add to my wheat berry salad, which I'm happy to elaborate on if you ask me. But I'll start first with this fun thing about glycemic index. So glycemic index is how fast the glucose from the food you're eating ends up in your blood. And a shocking thing for people who read into this and look it up is that white flour bread and whole wheat bread have the same glycemic index. It's like, wait. Very high.

1:00:50High glycemic index is not good. I switched from white flour to whole wheat flour. Why wasn't that better? And the reason it wasn't better is because it was ground to a powder and most of the digestion was done. So the time it takes you to eat it and absorb it is really small. If you had used the whole grain, which is the wheat berry, it would have taken much longer for your enzymes to digest it and make the molecules small enough to absorb. So the wheat berry salad glycemic index is quite low because it takes a long time. So you were saying go to the next level of these concentric rings. So grains.

1:01:28So a funny thing that I learned from doing some studies related to protein and trying to figure out where our protein comes from is looking at the USDA's fabulous website of all the food we produce and what we eat. and under grains, it said, okay, grains include oats and barley and wheat and this other thing. But because Americans, 90 % of the grains that eat are wheat, we're simply using the value for wheat for this thing that we're analyzing. And I stopped for a moment. I said, really? Has all these grains out there and 90 % of what Americans eat is wheat? And most of that is bread, right? Pizza crust, donuts, you know, some kind of bread like things.

1:02:12So at that next level, I think is grains. So I've actually, I hosted a debate one time between a paleo person and a Mediterranean person and a middle of the road person. And I tried to force them to say, what do you agree on? I know you guys disagree on some things. What do you agree on? And the first thing I got them all to agree on that people didn't expect was grains. Even like the vegan person said, but yeah, if I was gonna get rid of anything next, it would be grains because so much of it is refined, even the whole grain bread. So I'll pause for a minute there to see what you thought of that.

1:02:53Because if it was, go ahead. Yeah, no, I mean, I would say that yes, of course, if you're eating the whole grain and even better, the sprouted version of the whole grain, you're eating a very nutritious food. It's difficult to find the whole grain and even more difficult to sprout it yourself or find it in sprouted form. So even, and because of the way packaging works, very often we think we're eating whole grains when we're not as to your point, right? So this has led to a valid criticism of grains for their high glycemic impact and the fact that they're sort of devoid of any nutritional value when they're in that refined form.

1:03:31So there's this vilification of grains that makes it very difficult to have the conversation around the appropriateness or the nutritional value of the whole grain, such that if you raise that to the paleo community or whatever other kind of dietary tribe, they will bristle at the idea that there is a place for incorporating healthy whole grains into your daily routine. And they could find data. They could pull up a study that said, look what happens to the people who eat grains. And what we really need is the study that said, okay, they had steel cut oats for breakfast and they had a barley soup and they had Christopher's kick-ass wheat berry salad for dinner.

1:04:10What happened to them? We don't have that study. The grains are wheat and it's mostly refined. And I can see why there's some adverse studies when we overdo that. And then kind of beyond these generalizations, that's when we get into the charting of undocumented terrain with respect to personalizing your nutrition, right? which is some of the kind of emergent work that you're doing, which I think is really interesting. And we'll hopefully in time account for some of these findings that you've discovered in your studies where different people are having different responses to these dietary protocols in a way that, to date, you've been struggling to account for.

1:04:56Yep. And we could do some microbiome stuff if you want, or we could wait till later. I want to wait till later for that because there are a couple other things I want to get into. I mean, there's so many studies. I don't know that we can go through all of them. I mean, you did this keto med trial in 2022. You know, I guess in a nutshell, like without going through the whole rigmarole of this, like it was kind of the same, right? Like, okay, like if you're doing this right, we're getting good results for both of these communities. What do we make of that? What are we supposed to do with that information?

1:05:27Quality of food maybe is of more paramount importance than how this macronutrient breakdown is being kind of applied to these two groups. I mean, in the wake of that, like again, it goes to generalizations and perhaps this personalized nutrition kind of piece. Yeah, and keto med, we're really hanging on everything we talked about so far. So I'm very frustrated with keto, this idea that no beans, no fruits, no grains. That's just contrary to every public health diet recommendation across the planet. No refined grain, no added sugars. That's also consistent with keto and all the rest. So we set up these two diets to be compared to one another where both groups ate as many vegetables as they could and absence of added sugar and refined grain.

1:06:17So those were matched. This is sort of the fun for me in designing a study is what do you match and what don't you match to make it realistic? So those were matched, but opposites on grains, beans, and fruit. So Mediterranean, yes, encouraging all those. Keto, no, don't have any of those. And my hypothesis was, if you get rid of the damn added sugar and refined grain, that is 90 % of the battle. And that's pretty much what happened in the study. And so without going into all the details, if you could follow those first three pieces of the advice, yes, vegetables, no added sugar, refined grain.

1:06:52Yes, your glycosylated hemoglobin would improve. Your blood sugar would be down. you'd be monitoring that. So on this study, LDL cholesterol went up on keto and down in Mediterranean. Triglycerides actually got better on keto. They got better on Mediterranean, but keto was even more better. Why would you get rid of beans and grains and fruits if you could include them? And that's what I was after. Like that's too restrictive. Why would you need to go to that level if you took care of 90 % of the problem first, you could still enjoy those. Interesting.

1:07:37I think on a psychological level for some people, regardless of how restrictive the protocol is, there's something easy or comforting about the fact that you can just say, these are off the table and you can eat these things. And so it makes that decision tree a little bit simpler. And even if it's challenging from a sustainability point of view, there's something about the simplicity of it that makes adherence perhaps easier or a little bit better. Have you found that? Yeah. And again, as you started out our conversation, yeah, this adherence to whatever the guideline is for a study is a huge component of this.

1:08:18I don't really wanna go into intermittent fasting, but I will bring it up just for the moment because I don't like intermittent fasting. There's no attention to the quality of the diet. It's just a time thing, but I understand why Americans like it. Let's see, should I eat now? Let me look at my watch. No. Should I eat now? Let me look at my watch. Yes. Oh, thank God. That is so clear. It's really, I agree that it's clear, but I know some people who eat a pretty crappy diet intermittently fasting in that long-term, that isn't gonna do it to eat crappy food in a narrow window. You're still gonna have to eat good food.

1:08:55It's not enough. So as somebody who's incredibly steeped in nutrition science, who intimately knows the details, the benefits, the pros, the cons of every single, you know, kind of protocol out there, popular protocol, keto, low carb, low fat, vegan, you know, et cetera. You have been personally, like eating a plant-based diet for a very long time. Since 83. So knowing what you know and seeing that people can do well on a Mediterranean diet, et cetera, like why have you decided to eat this way? Like there is an argument to be said for like, this is the guy who spends, who's devoted his entire life to looking at all this stuff.

1:09:37Here's what he's learned, but like, let's just eat what he, like why don't we just, let's just do what he does. So walk me through why you're plant-based or how that fits into you as a human, but also as a scientist. Yeah. And it really all started out with a girl I got dumped by in 1983 from Marina Del Rey in your neighborhood here. Okay. Yeah. Are you having a moment being back here? Yeah. Thinking about her? I drove past the area where I was on the beach where I got dumped. It's on the way from the airport, right? 40 years ago. Yeah. So that was kind of funny. So I did it for the girl. And then I was like, ah, wow, wow, this is personally aligned with my values more.

1:10:18I actually had never been hunting. I actually hated fishing. I thought that's pretty funny that I could be eating all this food and have it be inconsistent with my personal values. I'm liking this. Oh, I'm liking the people that I'm meeting. This is fun. I'm a pretty active person. I play multiple sports and I would never want my sports performance to be impaired by this or my physical activity level. I've never really been overweight. I certainly want to maintain a healthy weight, be active, be sharp. Yeah, it's supported that over the years. So 83 on, I went vegetarian. And then I teach a class at Stanford called Food and Society.

1:10:54And I've now been teaching it for 15 years. And this is a pediatrician named Tom Robinson and I who got into this years ago. And there's a background story that I'll spare you. It was actually all done to collect data from Stanford students. It was gonna be a one-year thing. And we decided for fun, it would be a food-related course, but we would never talk about health. We had a handshake and said, okay, in this class, it's gonna be called food and society. And we're gonna deal with animal rights and welfare, environment and climate change, human labor abuses in slaughterhouses and fast food restaurants.

1:11:28But let's not talk any metabolism or any health. And it was career changing for me to hear the students be very engaged in social justice issues. And most of them reported changing their diet in class. And we actually published a paper on this, but let's put the paper aside. One of the books we read was Jonathan Safran for Eating Animals and I went vegan. I was like, oh yeah, I've been having dairy all this time. Oh yeah, all the male cows go to veal slaughter and all the cows making milk go in this factory process and it sounds pretty horrible. Why am I supporting that since I'm not supporting the other things?

1:12:08So I can't remember exactly, I don't know, it's 10 or 15 years ago, but went vegan. And I would say my personal philosophy is you don't need to be vegan. I actually would, I prefer the term whole food plant-based. But part of the reason I keep doing it is I kind of feel a personal responsibility like, hey, I'm 64 and I'm pretty active. shouldn't I stay this way just so I can, hopefully I'll be 75 and then 85 and 95 and say, you could do this. Kind of like the Game Changers documentary. I don't think that documentary was saying you have to do this to be a good athlete. I hope the take home message was you could, you could do this and your athletic performance would not suffer.

1:12:51So I've done it. And this is actually what my book is getting at. So this book that's coming out that won't be called It Depends. each chapter in the book says, here's the metabolism that's going on and here's the reasons it might be good or bad for you if you wanna ask an answerable question about whether to avoid it or eat it. But I know for a lot of people, part of that answer to choose it or avoid it is ethical or is environmental or is human labor associated. So what if you actually don't believe in the metabolism or think the metabolism is important for you, but the ethics are or the environment is or the human labor is.

1:13:27And if you put all those together, they are all well aligned with a plant-based diet. If you add those three other factors, and not only is it well aligned, but I think for a lot of people, aligning with your personal values is more of a motivator to be able to sustain it than knowing the metabolism and the enzyme and the organ that it goes to. And it's the kind of thing where you see this food in front of you and you just say, okay, if it's a metabolic thing, I know I'm gonna die someday. I know I shouldn't have that, but today I will. And tomorrow I won't. But if you look at it and you say, oh, it's not just me.

1:14:06That choice is having a bigger impact. Okay, I guess I'm not gonna eat it. I'm gonna go with a whole food plant-based diet. And in that regard for the people who are headed toward vegan, but stop short, and they have eggs once in a while, and they have some fish once in a while. And I can't point to a health benefit that is for 100 % vegan versus 95. I don't think anybody's ever done that study. Yeah, but in other words, what you're saying is not only is it doable and healthy to eat this way, it's sustained you for a very long time, you're thriving and vital at your age and have every expectation of being able to continue to do the active things that you love doing.

1:14:45You're not sacrificing anything by living this way and you're able to sustain, maintain this way of life because it's tied to a bigger why. It's not just about like what I want and my blood markers or whatever my doctor told me, but there's an ethical responsibility or obligation, but just that deeper sense of like, can I be a little bit of a better person or is there a better choice that I could make right here that has a consequence that's beyond my selfish, you know, taste buds in this moment? Yeah. And that Jonathan Safran Boer's book was so inspirational for me there. There is one line, almost exactly what you said and I won't be able to quote it, but two friends go to a store and they both wanna order a hamburger and one has it because they wanna have the taste.

1:15:38The other one says that I really would like the taste, but it doesn't seem worth my preference for taste for all the consequences that this is gonna have. Mm-hmm. And are you like a self-experimenter where you're always testing your own blood and your markers and all that kind of stuff? Yeah, because I get to do these studies. You just do that to other people. Yeah, no, yeah, I get to look at my TMAO and my LDL and my small dense LDLs and my, yeah, all the other things. It's all good, I presume. Yeah, I'm pretty good. And I have a massive amount of heart disease in my family. My dad died after 10 cardiovascular procedures.

1:16:10My uncle died at 40 of a heart attack. And so, yeah, I'm at risk of tons of things. And I haven't had any cardiovascular procedures at 64 and I'm pretty active. So I can't prove that it's my diet, but I'd certainly rather take that chance. And to your point earlier, I'm not sacrificing anything. I really enjoy the food that I eat. If you look at Middle Eastern food, Latin American, African food. I mean, there's so many cultures, Asian food, so many cultures around the world that make fabulous tasting food. My new friends are chefs. I've sort of switched to hanging out and trying to do studies with chefs because they make unapologetically delicious food and a lot of it is plant-based.

1:16:54Yeah, I wanna get to that, but let's push that aside for a moment. There is, we were speaking a moment ago about revising dietary guidelines and how to think about what's traditionally known as the food pyramid or the plate or what have you. And I remember, wasn't that long ago, there was some ripples around those guidelines being impacted by the environmental considerations of the food that we're eating. And that caused quite a kerfuffle publicly, people didn't like that. But to your point that you just made, it seems like that should be a consideration. Like we all have a greater obligation to the whole beyond ourselves.

1:17:37and these decisions that we're making every single day do have a real world impact as much as we wanna avoid really connecting with that. And I think that's something that you've clearly spent a lot of time thinking about. I would suspect that you would be in favor of those considerations being built into the recommendation structure. I mean, how do you feel about that? I feel very strongly. And I had the opportunity to pursue this and write a paper on it called sort of maximizing the optimal amount of protein that would be good for human health and the planet. Yep. And I got an environmental scientist to work with me and a food industry person to work with me.

1:18:18So sort of a multidisciplinary group looking at this. And at the end of the day, the conclusion was, if you really understand the protein guidelines that are out there, people need less than they think. They're a little confused about how much they need and they think they need a lot and they need less. They also underestimate how much they get because they get a lot more protein than they think. They undervalue plant protein. They think it's missing amino acids and it isn't. They're all there. There's a subtle issue about limiting amino acids, but let's not go there for now. It's not a big deal.

1:18:51And it would be, we modeled this, how easy it would be to cut back 25 % protein and still meet and exceed your requirements. What if you took 25 % from animal and shifted it to plant? you would be fine. And here would be the impact on greenhouse gases and water and land use and other things like that. You would make a huge difference with that 25%, 25 % shift. And that was just modeling it. So you could go lower in protein and you could shift it all to plants and you'd have a bigger impact. But yeah, so I've been having fun writing that. And it actually had to do with working with these chefs because they were thinking about this idea of a protein flip, if you wanted me to go into that, because dietarily, it's a pretty fun idea.

1:19:37So a group called the Menus of Change that got started by Harvard and the Culinary Institute of America. And the background story for this is pretty fun. Chefs were getting trained at the Culinary Institute of America, going out and being in restaurants and the public just kept changing their mind, gluten-free, vegan, paleo, whatever the popular diet of the month was. And the educational institution was feeling a little bad for the students they were promoting into the real world saying, sorry, but you're gonna have to be reactive to however the public changes and said, maybe not. Maybe we could get in front of this.

1:20:11What if chefs, we start defining what the right things to do are and we could serve our own menus and be more proactive than reactive. Let's get a scientific advisory board, a business board and a chef board. And let's put these concentric circles together and let's see some nutritional truths that will never change that make business sense. that are culinarily delicious. And so let's find this intersection of unapologetically delicious food that's good for humans and good for the planet. And you can make money making it and selling it. And so they came up with the 24 principles of the menus of change.

1:20:48It's pretty easy to find. And the CIA is awesome at making graphics. They have fabulous infographics. So look for this iconic thing or there's publications on their 24 principles of the menus of change. but one of the interesting things after establishing this was, what practical food choices could we suggest that hit multiple principles at once? Like what would be the biggest bang for our buck? 24 sounds like a lot of principles. Do I do them one at a time? So at their second annual meeting, I remember them saying, ah, we have this idea called the protein flip. And it actually came from a previous request we had about the dessert flip.

1:21:28and some folks had hired them and said, we're getting a lot of flack for how many calories our desserts have. And this age of obesity, can you help us? And they said, yeah, the dessert flip instead of cheesecake with a raspberry on top, have a bowl of raspberries and a dollop of cheesecake on top. It'll be a flip. I didn't take away your cheesecake. I have a smaller portion of it and most of it is fruit. And they said, kind of thinking a protein flip idea could work here. So what if instead of meat being the center of the plate, plants were the center of the plate, but you didn't get rid of the meat.

1:21:59It could be a side dish or a condiment, or it could be two ounces of fish or chicken on top, but not six or 12 ounces in the middle. And then they freaked out a little and they said, oh, but wait, that protein thing. Oh my God, the American public's gonna freak out. They're gonna say, where are they gonna get their protein? Christopher, will you do, at our meeting, our second annual meeting, can you do protein 101? I said, yes. I've been teaching this at Stanford for years. I have like four hours of lecture materials. how much time can I have? They said, eight minutes. I said, eight? Oh my God.

1:22:33Okay, okay, eight. So I boiled it down to what I could and I finished and their mouths were wide open. They said, no shit. I said, no, this is the real thing. Plants have protein, they have enough. They have all the amino acids. They said, next year you can have 20 minutes. The year after that, they gave me an hour. The year after that, a sports convention invited me to give a two hour talk. And so that paper that I was just describing about maximizing human health and planetary health grabbed probably 50 talks I've now given on protein. I actually never did a controlled randomized trial on it.

1:23:08I was actually just looking at metabolism and food and amino acids and starting to hang out with chefs and environmental scientists who sort of putting this all together, much like the Lancet report did, the Eat Lancet report in 2019. And it's all there. It totally justifies this protein flip idea, which can be unapologetically delicious, but plant-based. You could leave the meat off if you wanna be all whole food plant-based or you could leave it on if that's an easier way for you to make this transition. And it would make a huge impact for human health and the health of the planet. Yeah, that's really beautifully articulated and such a worthy mission.

1:23:50But I think in thinking about protein, as much as the tribalism lives and breathes around low carb, low fat, keto, et cetera, there is a really kind of emotional resonance or persistence around this idea that somehow we're protein lacking and we should be eating more protein, not less. Plant protein is inferior. Yes, plants have all the amino acids, but something about bioavailability, blah, blah, blah. It's just not quite as good. And if you want to maintain your muscle mass, particularly as we age, and I'm getting up there as well, you need to be increasing your protein intake. So like walk me through, I mean, I don't have four hours, but I have more than eight minutes to devote to getting some clarity on this from your perspective.

1:24:46Yeah. And actually there's a meta-analysis by Stu Phillips' group, I'm blanking on the first author, and they recently updated it and I don't have the updated paper. Sort of the conclusion of this meta-analysis, looking at multiple studies about resistance training and either muscle mass or muscle strength was trying to show the optimal amount of protein that you need. And it was sort of getting at supplementation, like when do you need to supplement? And if you look at the conclusion of the paper, it says, once you get to 1.6 grams of protein per kilogram body weight, after that, you don't really need supplementation.

1:25:28It doesn't really matter. And so there's an important point here is that the recommended daily allowance of protein is 0.8 grams per kilogram body weight. So this 1.6 would be double the RDA. but I want to walk it back a little before that even. So when the nutrition community came up with this, the recommended daily allowance is a principle that holds for lots of different nutrients. And what you do is you find sort of the normal distribution of nutrient need and everybody needs slightly different number just depending on how big or active they are or whatever. And in the protein in particular, the average is called the estimated average requirement of protein, and it's 0.66 grams per kilogram body weight of protein.

1:26:17Why then is the RDA 0.8? And the whole idea here is if the average requirement is 0.66 and everyone got average, the upper half would be screwed. They wouldn't be getting enough. So in the field of nutrition for vitamins and minerals and protein, the RDA is two standard deviations higher than the average requirement. So this is just a simple principle. So think of this, answer this question. If everybody got exactly the RDA, how many people would exceed their requirement? And by definition and math, that's 97.5 % would exceed their requirement. Okay, so 0.8 grams per kilogram per day is intended to exceed the requirement of the American population eating their diet.

1:27:06If you look at NHANES data, that's the National Health and Nutrition Examination Survey, it states that Americans eat 1.2 to 1.5 grams protein per kilogram body weight. So if these muscle builders are trying to gain weight and they need 1.6 grams per kilogram body weight, that's kind of what the American public eats anyway. Already, yeah. But my point here is, so let me add a twist to this. if you're trying to gain muscle, if you're working out hard enough to gain muscle, don't you have to eat more calories than the American public? And as soon as you eat more calories, you surpassed. Yeah, you're automatically, no matter what, increasing your protein intake.

1:27:49Over that. And so the idea, and Stu Phillips, we had a conversation actually on Simon's podcast. It was billed as a debate that it was gonna be the Gardner Phillips debate and they were gonna go at it. and he really doesn't like that 0.8 grams per kilogram body weight. He thinks that's wrong. And I, if you wanted to get into that, I could say, I agree with some of his points of why it's wrong, but I think it's kind of moot because when people eat protein, they eat 20 % of their calories from protein, they eat 2 ,400 calories a day and they get 1.6 grams per kilogram anyway. And one of his - So the 0.8 isn't even anything to discuss because no one's eating that little.

1:28:31If you got that low, that would be an issue. But I actually have a textbook that I use. One of the quotes from the textbook is, assuming you're eating a reasonable variety of food in the diet, if you had no beef, no chicken, no fish, no egg, no cheese, it would be almost impossible not to get 0.8 grams per kilogram per day, just if you were getting enough food. So Stu Phillips' conclusion is 90 % of your muscle strength building maintenance is the workout. Less than 10 % is diet. And so you don't need protein supplementation. You don't even need that extra chicken breast. If you're eating enough food to support your workout, you'll most likely get it.

1:29:16I know this to be true for myself just based on personal experience when I was training my very hardest in my early and mid 40s, putting in just, I don't know, 20 hours a week, 25 hours a week at the peak. And at that time, seeing pretty rapid gains in my fitness and my endurance and having no issues whatsoever, building lean muscle mass. And my protein intake, which I was pretty closely monitoring, just was not excessive at all. Yeah. And it made me realize like there's so much misplaced emphasis or concern on this particular macronutrient. And if you're just randomly grazing, even predominantly on plant-based foods, nature has it rigged that you're gonna be taking care of.

1:30:07Had nature not had it rigged, maybe we wouldn't have made it. Like it's built in. Yes. It's a fail safe sort of, you know, eat it and forget it sort of thing. and yet this idea continues to really, you know, become an obsession for a lot of people. And there is a lot of discussion right now around what to do when we're aging. So does that change as you get into your mid 60s? Like, and you really have to worry about maintaining your muscle mass because that's such a primary factor in terms of longevity? Yeah, and so that's not an area of specialization for me. And so I haven't done any studies in that area, but, you know, when I talk to people about sarcopenia, muscle loss, issues like that.

1:30:51Yes, protein in the diet is an issue, but a bigger issue for sarcopenia is dentition, loneliness, depression, being in a facility, a retirement facility where the food doesn't taste. It's just not eating enough food. And so if you weren't eating enough food, yes, you should get a higher concentration of protein in the small amount of food that you're eating. But if you were physically and mentally active and out there and working out, you probably wouldn't need that much more protein. It's some of these other related issues to muscle loss as you age, having a more sedentary lifestyle. It's much more complex than not getting enough protein.

1:31:30I would be all in favor of saying yes, and this isn't true. So the US has not upgraded the RDA for older adults. It's still 0.8 grams per kilogram. People have said, make it 1.0 grams per kilogram body weight. I would be fine with that. if you did have access to a reasonable amount of variety in your diet, you'd easily surpass that. Right, interesting. If you're not, then you might not have access to that food. There might be, what if there's food insecurity, nutrition insecurity issues going on? What if you are lonely or depressed? What if you don't like the food that they're serving in the retirement community?

1:32:05What if you really are sedentary? There are a lot of issues to address there. Interesting, yeah. That makes a lot of sense. it's hard to talk about longevity in terms of specific variables like that, because there are so many things that come into play. And I think the community piece, the connection piece, the sense of purpose, the Ikigai and all of that probably is the most predominant. Like as you age, losing that sense of connection and purpose in your life leads to rapid decline, Probably more so than your protein intake. Yeah, it's one of the things like - For most people. Yeah, I think the protein issue could be relevant at the margin.

1:32:53There are a lot of other issues to address. Continuing this exploration of protein, another thing that there's a lot of energy around right now is the health implications of plant-based meat, these burger analogs, et cetera. These processed versions of meat products that have found their way into mainstream culture all the way to the fast food outlets such that now we are blessed with choice. We don't have to get a cheeseburger, we can get a Beyond Meat burger, we can get an Impossible Burger. But I think a lot of people are wondering, well, okay, it's not meat, but it's processed. There seems to be a fair amount of chemicals in these things or saturated fat.

1:33:41Like, is this really better for me than the regular burger? Is it worse? Are they the same? This question occurred to you. And you said, well, let's look into this and figure it out. So walk me through this swap meat trial that you did. Okay, and first I hope everybody will appreciate the acronym swap meat means study with appetizing plant food, a meat eating alternative trial. Oh, I didn't even know that. I just thought swap meat, of course, That's what, you know, it makes sense on its face. We're pretty happy with our acronym. So I hope you like that. Yeah, that's very cheeky. And what came to me was three full page ads in the New York Times from a meat supporting group saying, oh my God, don't eat these plant-based alternative meats.

1:34:27They're practically dog food. They're all ultra processed. Yes, maybe they're better for the environment, for these things that they're saving, but they are gonna be bad for your health because they have saturated fat from the coconut oil. They have high sodium and they're ultra processed. and Kevin Hall did a beautiful study on gaining weight with ultra processed foods. So you don't wanna gain weight, have high blood pressure, have high LDL cholesterol, don't eat them. And I thought, oh my God, this is my superpower. I know how to design studies looking at exactly those things. Me, me, me, call on me.

1:34:58Okay, so full acknowledgement here, Beyond Meat paid for this study. I am an industry shill for having taken the money. Would the NIH have given me money? Yeah, I don't think so. And it was a relevant question. And so I applied the most rigor I could, but I just wanna acknowledge that upfront. Let's ruminate in that subject just for a moment though, because I think it's important. Obviously, when you see a study that was paid for by a lobbying group and the results of that study favor the lobbying group's political perspective, you're gonna question it, right? Like when the dairy, when you see this study that says chocolate milk is the world's best recovery drink and you see that it was paid for by the dairy lobby.

1:35:46Well, I'm like, all right, well, really? Is that what's going on here? Likewise, it's low hanging fruit criticism for you to say, well, Beyond Meat paid for this. We'll get into the results, but the results were not unfavorable to Beyond Meat in this regard. So, you know, duh, right? So the truth being that it is more complicated than that in terms of how these studies are structured and where the firewalls are placed. And that applies to whether the dairy lobby paid for a study or Beyond Meat paid for a study. Yeah, so you should be skeptical, but you shouldn't dismiss it. So a lot of studies wouldn't get done if they didn't get paid for by the food industry.

1:36:24So you should take the time to look at it. And if you don't understand it, ask somebody to explain the pros and cons of the study design. And quite often the bias is blatant. and in our study, we took every opportunity possible to make this objective science and I stand by it to this day. So put it aside for now and talk about the study. Yeah, except to say also on top of that, cause I wanna be, I don't wanna come off biased either. Like, you know, I'm sure you would have preferred private funding or the NIH to have funded this. Yes. And so that's a broader conversation around how the whole ecosystem of securing funding for these studies operates, right?

1:37:04Like it's hard to get money to do these things and they are expensive. And on one level, you gotta take the money wherever you can get it, try to protect the protocols as best as you can. But there's also, I'm sure compromises that you had to make or I've seen your colleagues make because is doing the study better than not doing it? Because of the funding source, et cetera. Like, again, you know, it depends, right? Like it depends, applies to this as well. Yeah. Part of my, I actually had a big tutorial before I released the studies showing, here's the things I did to protect the objectivity of the science.

1:37:43So if you ever want to look for my tutorial on that, which was part of it, I will just say was six industry funded studies that I did that all failed. They were all null findings. I published all of them. So that's just part of my defense. I did the science, they didn't work. I published the null findings. Did they not want you to publish or just sometimes they say if it's negative, you can't publish, is that part of the - No, so Stanford won't let me take the money unless I get to publish whatever I find. So there's some very strict guidelines that Stanford doesn't want their name brand sacrificed in this.

1:38:15Yeah, no, I have to get to publish and they can't have any say over it, even if it's null. Right, all right, go forward. Going forward. So real fun in designing this study was what do we control for? What do we let run wild? What do we provide? What do we not provide? What's the comparison group? One of the first questions is what's the dose? So if we wanna do this, what's the dose? Should we say Beyond Burger once a week? No, that's not enough. Beyond Burger every day. I'm not even sure if that's enough. All you get is Beyond Burger or red meat. Okay, nobody's gonna do that because it is supposed to be for eight weeks each so we can see cardiometabolic risk factors to change.

1:38:57So here's one of these questions that you started in your original conversation. We decided two servings a day of red meat or Beyond Meat. Somebody could say, what about three? What about one and a half? Yes, we only did it with two. So I can only answer this with two. What proportion of your calories was that? It was a quarter of their calories. So three quarters of their calories, they were getting themselves on their own and they were responsible for it. And in the run up - Whatever they wanted. Whatever they wanted with the acceptance you said, that as part of this study, we're not gonna provide the rest of the food.

1:39:28We will deliver the Beyond Meat or the red meat, but the rest, like if let's just take a burger for a simple example, if you're, we really want you to have the whole grain bun and the arugula lettuce and the farmer's market tomato on there with organic ketchup. If you do that for one phase, it's a crossover. Everybody was doing both. You have to do it for the other phase too. If, and we don't want this, if you have a white bun and iceberg lettuce and high sugar ketchup or something on one phase, you have to have it on the other phase. So that the other 75 % is as close as possible between the two phases.

1:40:05And the only thing different is this 25 % of calories from two servings a day of Beyond Meat. And it wasn't just burgers. So Beyond Meat makes crumbles and they had a chicken at that point and they had sausages and they had patties. So we did that and think of this. So who could we choose for the red meat? Should we get crappy red meat so that they have a better chance of winning? No, we went to a San Francisco company that sourced totally from organic, regenerative farming, all the right words so that it was high quality and very expensive red meat that we were delivering. And in parallel, we would deliver the same proportion of burgers versus ground beef versus chicken versus sausage that they want.

1:40:49There's a little personalization there. or you got to choose whatever you wanted in the first phase and had to match that in the second phase. And then we looked at all the nutrients. So what do you get nutrient wise when you do this? And it turned out, yes, Beyond Meat, the coconut oil has saturated fat, but it was less than the saturated fat in the red meat. Yes, the Beyond Meat has sodium added to it And ground beef has no sodium, but you know what? The participants salted their un-sodium containing ground beef. And the sodium levels were identical on the two phases. Calorie-wise, they were totally matched on calories.

1:41:36So very similar between the two. Fiber beyond meat was more fiber. It was more of certain antioxidants. and so we sort of have a whole higher in carb. Protein was the same actually, protein was virtually identical because of the way they make their products. So we put these head to head in a nutrient context to show the relevant nutrients for LDL cholesterol and blood pressure and TMAO trimethylamine oxide. This thing that gets generated when you have red meat, this emerging new risk factor, et cetera. And at the end of the day, and we can go back if you need. In this crossover study with everybody doing both phases on the Beyond Meat, their LDL went down, their weight went down, their TMAO went down and their blood pressure stayed the same on both phases.

1:42:30So if you go back to that New York Times front page article that said, oh my God, this is gonna kill you because the LDL cholesterol goes up. No, it went down. Your weight is gonna go up because of the Kevin Hall study. Nope, actually went down a little, not up. Your blood pressure is gonna skyrocket. Nope, stayed the same. It was the same amount of sodium. And TMAO is sort of emerging new thing. It's not a typical clinical thing. That went down too. So nothing got better on red meat than beyond meat. And beyond meat had three things that got better than red meat. And as soon as I finished, people said, so this is what you want people to eat, not lentils?

1:43:04I said, no, that's not the question. The question was instead of red meat. I didn't say instead of lentils. I've been trying to get people to eat lentils and chickpeas forever. And a lot of people won't do it. They're still eating their red meat, but they might have Beyond or Impossible rather than red meat. What would happen? That's the question we asked. Right, it was very limited to that one comparison. Yeah. A couple interesting thoughts on that. So just so we're clear, each population did eight weeks of each, right? Yeah, not each population, the population did both, 36 individuals. Right, eight weeks of Beyond Meat and then organic beef and then another - In the opposite orders.

1:43:52Okay, so, but all of them did meat first and then Beyond Meat or some of them did the other way around, right? Randomly assigned to order. Okay, so half and half. Yeah. And one interesting insight was that people who did the, correct me if I'm wrong, People who did the plant-based eight weeks first didn't bump their TMAO when they went to the meet as much. Yeah, and this is kind of inside baseball, but it's pretty fun for me. So I'm happy to talk about it. It's pretty fun. Okay, quick one step back before I say that. So you can do two kinds of studies in an intervention. You can do parallel where everybody only does A or only does B, or you can do crossover where everybody does both.

1:44:38and people like the crossover because they want to compare for themselves how they did in both phases. A problem comes up if whatever you did on the first phase influences the second phase. Hence washout periods. It's a statistical problem. But even with a washout, so washouts are quite problematic because it's hard to decide should it be a day or a week or a month. Explain what that is for people that don't know what a washout is. So the washout would be you finish part A and let's say there were changes. it would be best if the changes went back to how they were in the beginning when they were randomized.

1:45:12So you have to know how much time it would take for everybody to get back. And you have them go back to their usual diet for, as I said, a day or a week or four weeks. And our primary outcome in this study, according to clinicaltrials.gov, was this TMAO, trimethylamine oxide. And there aren't really any data on how long it would take to go, if it changes how long it would take to go back. and we chose not to do a washout. My feeling is the phases were eight weeks long. The main comparison is week eight versus week eight. Whatever kind of thing was going on would be washed out anyway by eight weeks.

1:45:51And so I'm only gonna compare the end. We can go back to that if you want, but this study had no washout. You did one for eight weeks and you switched the other one and we got an unexpected result, which may have been due to the lack of washout, which for me was pretty fun. so let's start with the group that got animal first so when they got meat first their tmao went up now interestingly you couldn't be vegetarian to be in the study because we didn't think vegetarians be willing to eat red meat you had to be a meat eater if you were already a meat eater why did their tmao go up well looking back they were really eating one serving a day of red meat so when we moved them to two servings a day of red meat that was higher right tmao went up on average, it didn't actually go up in everybody, but it went up enough to be statistically significant.

1:46:41And then when they switched to the plant-based meat within two weeks, it dropped and it stayed down for the next six in that group. So I have a beautiful graphic of showing that and it's very clean. And then switch to the group that got plant meat first. So these were meat eaters, their TMAO level wasn't very high to begin with. It went down a bit, certainly didn't go up. and after eight weeks they switched to meat and we expected the TMAO to shoot up and it didn't. It didn't really go up at all. So partly this is not what we expected and super fun to think about. Geekily from science, it's like crap.

1:47:21There was a carryover effect. Something that happened in phase one for plant first didn't jive with what happened in the ones who got animal first. Oh my God. Now there's sort of a problem for me collapsing the two orders and treating them like they are identical. It was actually still statistically significant, even when you match them and it didn't happen in one order, the overall was still statistically significant. But what I thought was really fun was going to the literature saying, oh my God, how did this happen? And what looks like it was the explanation, we actually have some stool samples being analyzed right now to see if this is it, is on the plant-based diet, they change their microbiome and generating TMAO relies on a conversion of these two molecules in meat, carnitine and choline in the gut from the microbiome.

1:48:11And so if eight weeks of being vegan modified their internal milieu, their microbiome, so they no longer were supporting the microbes that converted to TMAO meant they were kind of protected in the second phase. So as much as it It was annoying for me to explain in the study what went on. It was also kind of this personalized nutrition, cool thing like, oh my God, they did this thing first and they didn't have the same response as the other folks. This is another hint that the microbiome is important. Right. For our health. This very interesting alliance that you now have with the Sonnenbergs and the work that you're doing.

1:48:50Yes. I used to call myself a feeder and a bleeder because of all my studies with cholesterol and TMAO and insulin and glucose. and now I'm a feeder and bleeder and pooper. Yeah, it's all about the poop now, right? I get poop from everyone, which I initially assumed, okay, this is so icky, no one will do this. Everyone is willing to give their poop. Like I never get through discussing the whole study and then mention the poop and they say, oh, you had me until now, but if you want poop, I'm out. It doesn't happen. People are fascinated to learn about their microbiome and they're willing to do it.

1:49:23And I have all the shit in the freezer to prove it. It is amazing how much poop we have in the freezer. People wanna know, it's a really fun topic. And it's so emergent, it's exciting because it's new and technology has sort of progressed to the point where you're able to extract information that wouldn't have been possible not that long ago, which makes it like this new frontier. And Stanford's working on a smart toilet, so it'll collect it. Oh, wow. Indirectly after you use the toilet, there's like a butt imprint. so it knows who sat on the toilet or there's a finger imprint on the thing when you flush.

1:50:01In the privacy landscape of like, now even my toilet has to know what's happening all the time. I'm imagining the powers that be over at Zoey thinking, we could come up with some use cases for the personalized toilet and capturing these samples and doing what we do with them. It is a really fun new field. Wow. So, just to kind of put a button on the whole swap meet thing, I'm interested in the follow-up study that you did where you basically took this and applied it to athletes with a tweak, not Stanford varsity athletes, but like really active athletic students at Stanford, sort of in maybe in some part in response to game changers, like how does this swap meet thing work for people who are concerned about how fast they can run or how much they can lift in the gym.

1:50:55I mean, again, given this is a protein issue and so many athletes are obsessed with how much protein they get. Most of my studies have been in older adults with cardiometabolic risk factors and they involve blood and poop. But a pretty simple thing is strength and performance. So I had a master's student who really liked this first idea and she was a runner. And she said, what ideas can you come up with for an honors thesis for me, I said, God, I've been really wanting to work with athletes, especially now that I've got into protein and all this bias that you need protein. What if we replicated swap meat among athletes and added that arm that people complained to me about, added the vegan arm?

1:51:36And so now we'll have omnivore versus vegan and vegan plus two servings of plant meat a day. And you nailed this right. So actually, this is during the pandemic. It had been designed to be done in dining halls with undergrads, but they were all gone and the dining halls were closed. She still needed an honors thesis. And so we advertised among grad students who interestingly stayed on campus to do their research. They didn't have to go to so many classes. So they were allowed to stay. And we advertised for only recreational lifters and runners. Because? So we didn't want a training effect. We didn't want while you're on this diet, we have to figure out what the training effect is being on.

1:52:18We want you to be running at your best right now, lifting at your best right now. And if you switched your diet, would that improve your performance or impair your performance or nothing? And our hypothesis was nothing, it wouldn't change it. Why not, I know the answer to this, but why not just go to the varsity athletes, go to the pool, go to the track, go to the basketball stadium? The coaches won't let me touch their teams. and interestingly, I've been approached once in a while by a coach who says, oh, I hear we have a nutrition professor on campus. So what do you think about this? I said, well, the literature is limited, but this, but if on off season, I could mess with your players.

1:52:56Nope, thank you anyway, goodbye. And I kind of get it. They paid all this, I don't know, they put a lot of effort into their varsity teams. But in their off season, okay, nevermind. That has never gone very far. But having closed that door, I actually think that in terms of generalizability, I like this recreational athlete thing. How many folks are out there that they care about their performance because they've been running for or lifting for their personal health for years and they intend to keep doing it for years. And they might've considered changing their diet, but thinking, well, I don't want performance to suffer.

1:53:35I'm not competing. I'm not going in some event, but I still like how fast I run and how much I lift. Yeah, it's much more relatable and applicable. Yeah. I mean, we can look at the Olympic athlete, but the reality is most people like to your point, is this gonna make me weaker? Am I gonna be slower and more sluggish if I eat this way? Am I somehow impairing my physical capabilities by not eating this and eating this instead? Yeah. And so there are some limitations of the study because it was only 22 people. it was only four weeks. It was a crossover again. So everybody did all three phases, which really makes recruitment easier because they were curious that you could tell the people who signed up were like, I've thought about this before, but I never was really - A reason and a structure.

1:54:23Yeah, if there's a study and I'm not only gonna learn what happens to me, but happens to others like me who are trying this, I would be interested in this. And the bottom line is the running and the strength training did not change among the three four-week arms over time. And it was really - Irrespective of group. These three groups basically result on parity. And very importantly, vegans got less protein. Plant protein was in the Beyond Burger or the plant-based meats were in the middle and omnivores had the highest protein. The omnivores had the lowest carb and the lowest fiber, the plant-based meat in the middle, and the vegans had the highest fiber and the highest carbs.

1:55:06And you can see similar things for saturated fat and cholesterol. I mean, if this wasn't a match, like I'm not matching protein and cholesterol and saturated fat, if I'm just having the meat plant-based versus omnivore and plus plant-based meat alternatives, everything went in the direction that you would think. Many of the nutrients were different. And what I think Aubrey Roberts did very nicely in this was look at some of the sports guidelines out there showing that even with fewer carbs, the weight lifters were getting enough carbs. And even with less protein, the vegans were getting enough protein.

1:55:46And this idea that you have to maximize these things is a little unnecessary. If you're eating a healthy mixed diet, you're getting enough carbs and enough protein. Interesting. And we should point out that that study was not funded by Beyond Meat. Yeah, actually that was almost a nothing. So we just, Aubrey did all the work on this. And because the outcomes were a composite score of a lap pull down, a bench press and a leg press, that doesn't cost anything. And the runner's performance was a 12 minute timed run. That doesn't cost anything. So Aubrey did all the work. And I'm happy to say that we had 24 grad students sign up and 22 did everything, which is pretty good for a dropout rate.

1:56:29Yeah, but the Stanford students, they're good students. They know how to like follow directions. Yeah, they were really fun to work with and they were really interesting to talk with about these results. And yeah, it was a blast working with them. The study that I think a lot of people would like to see performed is the plant-based versus carnivore. experiment. So, walk me through where your head is at with this and why or why not that would be a good idea and how it could even conceivably be structured. Yeah. So, on paper, that sounds fascinating. There's actually quite a few fascinating things in nutrition that could be done.

1:57:12And you can start, you could start looking at mechanisms. you could start looking at observational epidemiology, who is a vegan, who is a carnivore. At the end of the day, we've had a bunch of examples in nutrition, beta carotene being one, vitamin E being another one. Outside of nutrition, hormone replacement therapy being another, where all the mechanisms and the observational data pointed one direction so clearly that it seemed almost unethical to do a randomized control trial. But if you really want to know cause and effect, you have to do that at the end. In other words, saying everything that you know about nutrition over the many decades that you've been looking at this, you can't in good conscience corral a population of people and compel them to eat only meat for however long.

1:58:00Yeah, so that - Period of time. Yeah, if you took all the existing data, you couldn't definitively say, this is this, you'd want the randomized control trial, but what most, if I want your listeners to feel my pain. So for whatever question you ask, I have to recruit them. I have to say, I have funding. I'm gonna run a study. You have to do this or that. And my students will often say, yeah, I'll sign up for that. I say, do you realize what the comparison group is? Because like, if it's the coffee study, you have to agree to drink coffee for the next 10 years or not. You have to be fine with avoiding all coffee or never giving up coffee.

1:58:38If it's an alcohol study, you'd have to agree to drink all the time or never drink. But let's go for carnivore versus vegan. Who would be willing for some duration of time longer than a day, longer than a week, longer than a month to be meaningful? This would have to be quite a while. Let's say at least six months or a year. Sure, I'd be happy either way. I'd be happy going vegan or happy going carnivore. You can't possibly talk me into trying to recruit for that study. Is there any wisdom though in doing it for 30 days or 60 days? Like, do you think you could extrapolate enough actionable, helpful information from a shorter truncated period of time?

1:59:27You could, but then you'd have to say, we need a follow-up to study to see if they can sustain these. And the thing for me is having done the A to Z study, which was Atkins versus Ornish, which are both quite extreme for 12 months. even at three months, which is of all the time points we had three months was the peak of enthusiasm for them. They weren't doing Atkins and Ornish at three months. At six, they were doing it less. At 12, many had gone astray. And so if you would say, yeah, I'm going to do a one month study and I'm going to see what happens to these cardiometabolic risk factors or weight or other things in a short amount of time.

2:00:05I mean, Kevin Hall could do this, did this. He did, well, not carnivore, but he did a keto versus very low fat vegan and showed fascinating changes in two weeks on both groups in terms of energy intake, in terms of body composition. But you really need more people than the number he gets to do in his studies and you need longer amounts of time. You could, you could do it, you could report on it. And I if they continue the diet and if they can't, how much help is this study providing? Yeah, yeah, yeah. What is your perspective on that diet and some of the information that's being spread around the internet regarding LDL, regarding cholesterol, regarding the importance or lack thereof of fiber in the diet, like there's a lot of people who are experimenting with this diet, many of which are claiming it to be transformational in terms of how they feel, their weight, their energy levels, et cetera.

2:01:17I'm sure you've seen this and have spent some time thinking about this. Yeah, and I think there is a subset of people that have done this long-term. There's also a subset of vegans who have done this long-term. I have a hard time getting people to stay vegan in the general population, but I know there's people who've done it for a long, long time. For the carnivores, yeah, it's so restrictive. I would want to see it for longer. Shorter term, as a nutrition scientist, you can't get all the nutrients out of meat. You can't. And fiber, all of us think fiber is one of the nutrients of note that people aren't getting enough of already.

2:01:58And this is clearly far less, there's no fiber in meat. I don't know, I guess you could take fiber supplements, but that would be, I'm not ready for fiber supplements yet. There are so many nutrients that you need to get from a varied diet, a varied diet that we all evolved on forever, had all the food that was available. Actually, I remember a nice YouTube video of there isn't a paleo diet. There's probably eight paleo diets, depending on what part of the world you evolved in. And it was whatever was fresh and seasonal because there wasn't a food industry around. But to focus on one food group alone, yeah, after all my years of training, there's no way I could support that.

2:02:40It doesn't have all the nutrients. What do you say to the person who says, all this stuff about elevated LDL is misunderstood. If you're on the carnivore diet and you're experiencing that, you have nothing to worry about. Yeah, so I mean, my actually, I come from the Stanford Prevention Research Center, which is a division of the Department of Medicine. And my division chief is a cardiologist and he sees these people in his cardiology clinic and it worries him and he's concerned. Yeah, he has people, yes, I know my LDL is sky high and it's no problem because I read this here and he says, nope, that is wrong.

2:03:18I really need to put you on a stat and I'd really rather have you change your diet. Oh, but the small dense LDL versus the large puffy LDL. The whole particle size thing. Particle size thing. I actually, my first major paper was on LDL particle size. So I've actually known about this since 1996. One of my studies that had to do with a Stanford group I was working with helped to establish small dense LDL as an independent risk factor for cardiovascular disease. And there is something there, but it's one of these at the margin things. Yeah, the particle size matters, but a sky high LDL isn't diminished by the fact that maybe they're larger and fluffier particles.

2:03:59So one of the things that people in clinical world are moving towards is an ApoB. ApoB count is the number of particles out there. And when ApoB goes up, it's probably more powerful than LDL cholesterol, the number of particles you have. And on a carnivore diet or a ketogenic diet, it's up. With that saturated fat, it's up. and clinically from everything I know, it's not good for you. You can't dismiss this with particle size. ApoB being the new kind of more accurate, more definitive way to assess your cardiovascular disease risk. And so it's because, so LDL stands for low density lipoprotein cholesterol.

2:04:42And this is a goofy story if you'll allow me 30 seconds. If you go back 60 years, instead of a centrifuge, somebody used an ultra centrifuge and spun it like 24 ,000 revolutions per second, per minute for 24 hours in a blood sample. And it would really make particles in the blood sample separate. And that's why it's called low density lipoprotein, high density lipoprotein cholesterol. There's a very low density. There's an intermediate density. After this ultra centrifugation, And it split based on, who cares what the hell the density is? Oh, it was just a very practical thing. And then what they found was, oh, these are all related to this family of things called lipoproteins, which carry fat, but on their outside surface, there are little balls that go through your blood that have cholesterol and protein and phospholipids on the outside of the particle.

2:05:36And some of the proteins, one is called apolipoprotein B. there's actually a B48 and a B100 and there's an ApoE and there's an ApoC, but let's not go there. The ApoB tends to be a really good reflection of the actual number of the particles that are these lipoproteins circulating in the blood. And so rather than worry about how fluffy or puffy or smaller dense they are, one is just LDL happens to basically just have this ApoB100. So why don't we just look at the ApoB? Right, and it's like a proxy for - This is probably better than LDL cholesterol itself is the number of, and so when people say, oh, statistically, I have the LDL cholesterol, the HDL cholesterol, I have the triglyceride, and I have the ApoB and the ApoC and the ApoE.

2:06:23Huh, ApoB looks like a better mathematical predictor of who gets heart disease and who doesn't, even better than LDL cholesterol. So it's sort of come down to if you have that assay and it's not a standard clinical measure, that might even be better. And so on a carnivore diet, the APOB is way up. The LDL is up. Clinicians, I feel like are only at the beginning of actually even advising this test. So if people are listening and they're concerned about their cardiac health, I would suggest that you specifically ask for that marker when you do your next blood test. And I'd specifically ask for insulin.

2:07:00So here's another twist along those same lines. So in the community of metabolism, Yes, we know that blood sugar is a really important marker, but people who are pre-diabetic tend to be insulin resistant, which could mean that your glucose levels are actually still being maintained at a non-diabetic level at the expense of very high insulin. Insulin is not a standard clinical measure. And it's amazing how much we all understand that an insulin spike is really important. If you got to blood pressure or blood glucose or LDL, HDL cholesterol, There are national standardization programs. So if you had your blood measured at any clinic, you'd be reasonably comfortable knowing that they're probably very replicable across labs, not for insulin.

2:07:44So we've never had an insulin standardization program. So it's not a standard clinical measure. So if they're gonna ask about their APOB, ask about your insulin too, because there actually is some movement afoot to make insulin a standard clinical measure. That's interesting. Yeah, I hadn't even thought about that. As somebody who's played around with CGMs and the like, you're thinking about your blood glucose level, but that's only relevant in proportion to how much insulin you're putting out. And if you are putting out too much insulin and your curve looks healthy, you're not really seeing the whole picture potentially.

2:08:23In one of the studies we did, we had 60 people in a pilot project and they had to be non-diabetic. So their glucose had to be under control. and we did this, that oral glucose tolerance test where you get the 75 grams of glucose and you measure blood at zero, 30 minutes, 60 and 120. And I plotted all the insulin curves and for the best person versus the worst person, the worst person had 40 times the insulin production of the first one. They were both non-diabetic. Wow. So that person who had 40 times as much probably got diabetes within the next year, but wouldn't know. But wouldn't know. And even if that person had a CGM.

2:09:02Wouldn't know. It would look fine. Maybe not fine, but it wouldn't look like, ah, I'm not too much out of range. Yeah, I'm not out of range here. I'm okay. But it was at the expense of their pancreas was cranking out insulin to keep it there. And there's some point when you exhaust the pancreas ability. Right, right, right. You could know that ahead of time if insulin was a standard clinical measure. And it's not. Ask your doctor that too. Why is there no standardization of that? Don't know. You have to ask the endocrinological society. And I do think there's a movement afoot to make it a standardized measure.

2:09:35It's easy for me to get as a research method, but here's a fun thing. So when I, in all our studies, we hand our results back and insulin is one of the ones we have to say, this is not a standard clinical measure. You can bring this to your doctor if you want. We can't tell you anything about it because we don't have a standardized cutoff for high or low. You were higher or lower than the rest of the people in the study, but this is for research purposes only. And the lab that does this for us won't give it to us unless we put that disclaimer on the report. The we are not clinicians disclaimer.

2:10:08That this is a research value. This is not a clinical value. Interesting. Wow. After all these years, I'm actually kind of stunned that that hasn't happened yet. Huh. Is that like a cover your ass litigation thing? Yeah, well, I don't know about the lip. I think, yeah, because we don't have this, it's just they've been doing it for 20 years with me and they'd keep, but since they've been doing it for 20 years, hasn't somebody stepped up and said, why don't we just, we have a lipid national standardization program. We have a glucose national standardization program. Why don't we have, and you know what you have to do for this is every year your lab gets an anonymous blood sample or two or 10 and you have to analyze it and report back and it has to be in the range that got done in a standardized lab.

2:10:58And if it's outside, they have you check your equipment, maybe your reagents are out of date or something, but there's some monitoring of how comparable they are to the rest of the country. Yeah, yeah. Why don't you just do that with insulin? How hard could that be? It's not an expensive assay. It's a radio immunoassay that's quite standard. I feel like that should get dealt with immediately given the incredible rise in prediabetes, insulin resistance, type two, like the curve on that is insane. This is something that's impacting so many people and is going to continue to only accelerate. And this is an important thing to have wrapped around, your heads and where everybody is with it.

2:11:40And that's easier than a microbiome standardization or an inflammatory standardization. Oh my God, if we're not have insulin, how the hell are we gonna get the inflammatory number or the microbiome number? Can we at least have insulin? Right. Right. Before I let you go, I do wanna spend a few minutes on this idea of stealth nutrition, which is this really cool thing that you've pioneered that I think is interesting in the context of what we were speaking about earlier, like what are the most important things to look at? We can have fun on the margin cases over here, but when we look at the big issues that we can all agree upon in terms of what we should eat and should be avoiding, stealth nutrition kind of plays into that same philosophy in terms of what are we really doing here in terms of moving the needle and getting people to eat better?

2:12:29And where should we be focusing our time and our energy? Yeah, and this all came about because of this class that I was teaching where we agreed never to talk about health, only to talk about animal rights and welfare, environmental concerns, and human labor issues. and it was career changing for me to see how engaged the Stanford students were in those issues saying, they'd come early to class, they'd be talking about, they'd stay after class, they'd be saying, I sent this book to my parents, I'm trying to get my brother to change. My roommate doesn't want to talk to me anymore because every time I come back from this class, I'm talking about this thing and they're annoyed that I'm so obsessed with this thing.

2:13:06It's like, that never happened when I talked about how cool cholesterol metabolism is. This is really fascinating And a clarification I want to point out is stealth nutrition is not about being deceitful. I think for a lot of people who first hear this term from me, they say, oh, it's cauliflower rice. It's not real rice. And you fake them out by like sticking broccoli into this thing, but didn't tell them. No, it's not deceit at all. The stealth part is just, hey, I'd like to talk about metabolism and health. Oh, you're not interested. Okay. Animal rights and welfare. Oh, don't you pet your dog?

2:13:41And don't you love cows and pigs? and I'm still not getting a reaction. The environment, how about land use, water use, greenhouse? Oh, I'm seeing you perk up. Okay, so I had this other tool in my tool chest. So you're interested in the environment. Can I tell you from a protein perspective, the impact of animal foods versus plant foods and now I've got you engaged and if it wasn't that, maybe it was human labor issues in slaughterhouses where the immigrants are poorly treated and those are the only ones working in the slaughterhouse and terrible other people won't volunteer for that and it's very abusive system and we should slow down the speed of the slaughterhouse and we should take better care of the work.

2:14:18For some people that gets their attention. So what I learned in this class was of all the one hour lectures I can get, give on insulin or antioxidants or microbiome or whatever. If it doesn't change your diet, if I had these other things in my tool chest and I brought them in, if they choose to follow animal rights and welfare or climate change or human labor abuses, they would be eating the way I wanted them to the first time. It's sort of, they arrive - Discovering what's animating that person and using that enthusiasm as a Trojan horse to bring in this stuff about nutrition. And it's aligned.

2:14:56It's actually surprisingly, when you see what they're doing after they hear about these issues, they're eating more plant foods, they're eating less fast food, they're eating less meat, they're cooking more on their own, they're going to the farmer's market, they're eating fresh food, They're eating less ultra processed food. And it's just getting at them another way and just finding what are their hot buttons to motivate them to make a change and sustain it. And the last one there is deliciousness where we're sort of working with chefs now. We're doing this protein flip, getting to eat more plants and say, unapologetically delicious is a very important term to me because it reminds me, I don't know how much it resonates with everybody else, but it came from Greg Drescher at the Culinary Institute of America.

2:15:39And as soon as he said, I thought, you're right, I have been apologizing. I know how metabolism works. And I've been saying, I know you want to have the steak or the cookie. I have some cardboard for you. The cardboard is going to lower your cholesterol. And my face scrunches up and I say, I'm sorry that you're giving up on taste to have cardboard. And Greg Drescher looked at me and said, why are you apologizing? Why don't you say that this is kick-ass global fusion of flavors, this plant-based mouth-watering, relentlessly delicious dish that we have created by putting Moroccan spices on this heritage grain, topped in seared vegetables or this, so that you're salivating listening to, and you're not apologizing anymore.

2:16:23You're saying this is, the taste is amazing. So we've been leading with taste, which is not that hard to do working with chefs and having health and the environment in the back pocket and a couple of other issues. And so I think of it as stealth nutrition, not deceit, just recognizing how many values a person brings to the table when they're thinking, do I choose A or B? I think of it as seamless nutrition. Okay. Taking like removing that negative kind of connotation altogether, the seamlessness part being the connection between the animating force within an individual and the better food choice, but also deploying those chefs in the right way to move the most number of people.

2:17:14In other words, by employing them at institutions that are serving lots of people three times a day, because for many people, students and in our workforce, that's where they're getting their food. And if you can elevate the quality of food that's being offered at those institutions, you're making a much bigger dent than trying to convince people one-on-one or that they should. It's like, it's that blue zones idea of you have to make the healthier choice that the one that's within arm's reach and the more convenient choice. And if you can go step beyond that, we actually have to grow and raise different food to be able to do that.

2:17:52If institutions start ordering that food, a farmer would be inclined to change. You really want me to change my crop? I need to make a living. I'm not sure if there would be a demand. Oh my God, the universities are asking for this. The work sites are asking for this. The institutional food settings are asking for this change. I can see the demand. I'm gonna change what I'm growing and respond that way. And the more that's available and the chefs offer it to the students and the work site folks, and they respond positively, the more they'll order it again. Right, but you're making it sound a lot easier than I'm sure that it is.

2:18:25When you start talking about school lunch and hospital, food service, I mean, there's massive corporations, bureaucracies, lobbying efforts. Like this is a, you know, there's a lot of people who've tried to solve this problem and have walked away, you know, sort of, browbeaten here. So there's a second class I teach now called healthy and sustainable food systems. And in that class, I bring in a speaker from a hospital, from a university, from Google for a work site, from a food bank, from a K to 12 school food service director. And when the students sign up for the class, they think this is all theoretical.

2:18:58and the people I bring in have made those changes in their orders. And the students are blown away like, this isn't theoretical. You actually, you changed what you order. You don't offer that anymore. You focus on that. You emphasize, why did you do that? And it's working. So I would say there is movement in that direction in institutional food, which is why I want everybody to hug a chef because part of this is bringing the chefs in as partners in this movement because taste is so important here and taking advantage of their skillset to help move this forward. They've been fabulous partners for me.

2:19:34They're my most intriguing new partners in research is bringing in a chef. Yeah, that's cool. And I know you've done a bunch of stuff with Google. Yeah. In that regard too. Super fun. Interesting, yeah. Final thing. And I ask this question frequently with people of your credentials and caliber, which is if you woke up tomorrow morning in a parallel universe and found yourself to be the surgeon general of the United States, what is first order of business? Like how are you tackling the problems that we face from a nutrition perspective? And what are the changes regulatory, policy-wise, legislative, just or otherwise that you would be interested in pushing forward?

2:20:21Yep. Well, everything we've talked about today, but a focus on beans. Beans are so undervalued and underappreciated. So thinking about all the things that we talk about in eating better, one of the things that often gets left out is people with food insecurity or nutrition insecurity. Like who has the resources for this food? How can it be culturally appropriate? There are so many kinds of beans. We got lentils, we got dolls, pulses, chickpeas, hummus. Think of how many amazing bean-based dishes there are and how inexpensive dried beans are. And all you got to do is soak them overnight or even canned beans are pretty expensive.

2:21:02Super nutritious, high fiber, the highest of any kind of plant food of protein. So if you are trying to displace some of those animal-based foods, beans are the obvious answer. And it is embarrassing how few beans Americans eat compared to the rest of the world and the other food groups. So if I were to do anything, I do want to focus on what we said in the beginning, more vegetables, more whole foods, less added sugar, less refined grains. But almost separate than that, beans. There's a woman named Liz Carlyle who wrote an amazing book called The Lentil Underground. And it is a really fun thing about Trader Joe's partnering with the lentil farmers and finding a way to package lentils that was sort of just consumer friendly.

2:21:44And it elevated lentil farmers, at least for a while. I don't know where it is today. and it was one of these structural issues of, oh wow, lentils actually cook more quickly than the other beans. They're quite versatile. So I mean, among the bean family, lentils would be a great example, but how easy is it to make hummus at home? My kid, I had some raw veggies at the table and my kid said, I would eat these if there was any hummus, but there isn't. And I got up from the dinner table and I got my food processor out. I had hummus on the table in three minutes. I chucked in garbanzos and olive oil and some tahini that I had there and some lemon and some, what is it?

2:22:26Pepper. Cumin? No, not, well, some cumin. Anyway, it was super fast. I just blended it up and kid ate the vegetables with the hummus and it was super delicious. So yeah, if I was czar for the day. You'd be the bean guy. You're the bean surgeon general. I think I would be the bean surgeon general because it's so versatile and everything we talked about. The lentil thing with Trader Joe's, is that part of like, cause they offer, they're the only place I've been where you can buy cooked lentils in like a shrink wrapped thing. They're already cooked. And I buy those all the time cause they make for a great snack.

2:23:00You just crack them open into a bowl and put some whatever hot sauce on it or just eat them the way that they are. And it's super cheap. And Trader Joe's has done a marvelous job of making things convenient and relatively inexpensive. So that model, if we could build on that model of making some very simple foods more accessible. Yeah, and even sort of like chopping and freezing the veggies. So a bunch of people think, oh, frozen vegetables, I want fresh. Frozen veggies are pretty good. If you imagine all the miles the fresh stuff had to travel and how much - They lock in the nutrients. Lost there was versus, no, I froze it on site.

2:23:37It's more shelf stable now, although you do have to have refrigeration. Yeah, I would try to take advantage of just some things like that, that everyone could enjoy. And you've done sort of partial prep. So that, cause people also fear inconvenience in the U.S. And so it needs to be low cost, tasty and convenient. And I think there's a lot of room for movement there. So you got this book that you're working on. It's coming out when? Sometime next year? Sometime next year. Yeah. Yeah. And beyond that, what are you working on right now or what's got you excited? What is the study that you wanna be performing or that you wanna see put into action?

2:24:17Yeah, so if it's okay, the two that are most exciting right now is one with pregnant women and the microbiome. So we're getting for second and third trimester, moms are getting randomly assigned to have more fiber or more fermented food or both or neither. So there's four arms, 130 pregnant women and we monitor their microbiome during pregnancy. And then we wait for the birth. and one month in, we measure the kid's microbiome and that's our main outcome. But we continue to follow the kid for years after that. And we're trying to learn how the mom could optimize her maternal microbiome in a way that she passes it off to her kid.

2:24:55So what is the lasting effect of that over time in the child? And well, how does - How persistent? So we've got these dietary changes, but we're also facing gestational diabetes, C-section versus vaginal birth, breastfeeding versus not, not what foods they wean their kids on. So we're trying to sort of open the door on this transmission of optimizing maternal microbiome that gets to the kid. Cause what we find is whatever you got from your mom, a lot of that sticks with you forever. So that one's pretty fun. Is that with the Sonnenbergs? Yeah. So we've got 120 women now. We just need 10 more women.

2:25:28We already have 70 babies born. So that one's super fun. The other most more interesting one is along the lines of one of this last things about food security. So in the fall of 2022, the White House had a conference, first one of this magnitude in 56 years, on hunger, nutrition, and health. And in that, American Heart Association and the Rockefeller Institute pledged$250 million to address food as medicine, or food as medicine, depending on which way you want to call it. The idea being, insurers pay a lot of money for covering drugs. would it be worthwhile for insurers to cover meals? And there's actually, so food working as men, they're covering meals like they would cover a drug for somebody with diabetes or heart disease or cancer or something.

2:26:18So there are a bunch of small short-term studies out there that aren't very appropriate for proving this concept would work. So American Heart and Rockefeller say, okay, how about$250 million over years? Let's design this thing. let's take people with food insecurity who classify as having food insecurity and have these conditions and see if we can do, there's a couple of things. You can do what's called medically tailored meals or medically tailored groceries or produce prescriptions. There's a couple of different ways you could do it. How could we help these people eat a better diet and not go on drugs and prevent disease?

2:26:54And could we get insurers to cover this? Isn't there a cost benefit to that? So to me, that is a long overdue issue that we could be helping with. That would be a massive watershed breakthrough. Yeah. Just to burst the seal on insurance coverage of food. The broken healthcare system, which is really not a healthcare system. It's a sick care system. It's only focused on people who are already sick. You need to dial it back and prevent it. And diet is such a huge under appreciated, underutilized factor for preventing disease. I think that's a great place to stop it for today. We didn't even get into much of the microbiome stuff in detail, but that gives me an excuse to get you back here.

2:27:38Okay. To talk about all the fascinating emergent work that's happening there, as well as these advances in the world of personalized nutrition. I know you're on the scientific advisory board of Zoe. Yeah. Zoe being the personalized nutrition company that was co-founded by Tim Spector, founded, who was recently a guest here. And of course, Dr. B, Will Bulsiewicz, who's been on the show a couple of times. So I think there's a lot of really interesting things that that company is doing and the caliber of individuals who are involved with it, I think is pretty interesting and compelling. So I look forward to learning more about what's coming out of that meeting of the minds and all of this microbiome stuff as well.

2:28:20Yeah, very excited. And super happy that you're promoting this kind of thing because the field is moving and I think you're really helping people stay on top of it. Yeah, well, thanks for coming and sharing today. That was really eye-opening and fantastic and it only scratches the surface. So yes, lots more to talk about. So I appreciate you. Please keep doing all the work that you're doing. If there's anything I can do to help you, please reach out. And in the meantime, if people wanna connect with you beyond this conversation, where do you typically direct them? You've got a Twitter and all that kind of stuff, but is there somewhere?

2:28:56I'll put links in the show notes to all the studies that we talked about, et cetera. Yep, so we have a lot of our studies and a bunch of videos that you can get to. So our website, you can go to just nutrition.stanford.edu. It'll actually send you somewhere else, but that's easier to remember, nutrition.stanford.edu. Just past studies, current studies. We've held a whole series of food summits on campus. We have tons of videos about food summits where we've brought people in from all seven schools in Stanford to give us their take on food. And you did this camp. Are you still doing the camp? So this is that 12th or 13th year of farm camp where I get Stanford undergrads to be counselors on an 11 acre organic farm on the grounds of a middle school in Sunnyvale, California.

2:29:42It had been a high school, demographics changed and they went to a middle school where they didn't need the baseball, football or soccer field. they converted it into an 11 acre organic farm and we have a camp and the kids come and it's lunchtime. We say, what should we have for lunch? Should we slaughter some animals? No, there's no animals around. Let's pick veggies. And then we say, oh, what should you eat raw veggies? No, let's cook them. And we have stoves and we have pots and pans and we hand kids knives and they say, wow, my mom and dad don't give me knives to cut things up and my mom and dad doesn't let me play with fire and they saute veggies and they pick fresh herbs.

2:30:21And it's a stealth nutrition way of just, the stealth part is just, let's get them engaged in tending them, harvesting them, chopping them, seasoning them. And oh, how about that? They wanna eat it after you did all that work. You told me about a kid who was pre-med at Stanford, who was on the track to becoming a plastic surgeon. and he, as a result of this experience, course corrected. Was he a counselor or did he go to the other summit? He was a counselor. He was a counselor at the camp. Yeah, he came and he loved it so much. He wasn't supposed to. So I hope that person isn't listening, but he would stay overnight and sleep on the farm.

2:31:00It like changed his life and he became a farmer instead of a physician. It's amazing. And he's been going around the country working in different farms, was a wrestler, wanted a BMW, not anymore. He plays guitar at the farm and grows great food. You turned him into a hippie. Yep, pretty fun. Awesome. All right, well, thank you, my friend. Come back again soon. I appreciate you. I'd love to. Thanks for having me. That was a really fun conversation. Peace, plants. Peace out.

2:31:38That's it for today. Thank you for listening. I truly hope you enjoyed the conversation. To learn more about today's guest, including links and resources related to everything discussed today, visit the episode page at richroll.com, where you can find the entire podcast archive, as well as podcast merch, my books, Finding Ultra, Voicing Change in the Plant Power Way, as well as the Plant Power meal planner at meals.richroll.com. If you'd like to support the podcast, the easiest and most impactful thing you can do is to subscribe to the show on Apple Podcasts, on Spotify, and on YouTube and leave a review and or comment.

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2:33:00Portraits by Davey Greenberg, graphic and social media assets courtesy of Daniel Solis, as well as Dan Drake. Thank you, Georgia Whaley, for copywriting and website management. And of course, our theme music was created by Tyler Pyatt, Trapper Pyatt, and Harry Mathis. Appreciate the love. Love the support. See you back here soon. Peace. Plants. Namaste.

2:33:39guitar solo