History of Diet Trends & Medical Advice in the US, Fat & Cholesterol, Seed Oils, Processed Food, Ketogenic Diet, Can We Trust Public Health Institutions? | Orrin Devinsky | #135

About the Guest: Dr. Orrin Devinsky is a neurologist and Professor at the New York University School of Medicine.

Episode Summary: Nick and Orrin Devinsky, MD discuss: dietary consumption trends in the US; processed vs. whole foods; vegetable oils & polyunsaturated fats; relationship between saturated fat, dietary cholesterol & heart disease; history of medicine in the US; obesity & diabetes; sugars, fructose, and metabolic health; ketogenic diet & ketosis; whether or not we can trust our public health institutions; and more.

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Full AI-generated transcript below. Beware of typos & mistranslations!

Orrin Devinsky 5:11

Yes, I'm a neurologist, I went to medical school, and then did training in neurology, and then subsequently subspecialty training in epilepsy. And I have directed the NYU Epilepsy Center for the past three decades or so. But I have a fair number of other interests from evolutionary biology to nutrition, which I think we'll be discussing here to the history of science, and many of them come together on this topic.

Nick Jikomes 5:35

Yeah, you.

We're gonna talk basically about one paper today and some related topics, but you have this paper come out not so long ago, called United States dietary trends since 1800. Subtitle is lack of association between saturated fatty acid consumption and non communicable communicable diseases. So, you know, very briefly, your neurologist, you've got all these other interests, but what actually got you to write a paper about this particular subject.

Orrin Devinsky 6:09

So it's interesting, I think, going back 12 or more years ago, I took a family vacation in Mexico. And a good friend of mine bought me a book by Gary Taubes called good calories, bad calories. It was a big paperback. And having lots of time on a chair on the ocean, I read it cover to cover and it kind of blew my mind. It just completely shocked me that I was reading about parts of history that I just assumed were black and white, factual that we're not and things I was taught in medical school, my medical training and career had been wrong. And actually, we read the book during that vacation and since then, have become friends with Gary. And that led me to a deep dive into nutrition and health. Yeah, I mean,

Nick Jikomes 6:58

in a vague way, you know, I've had, you know, somewhat of a similar experience. So, you know, my background, you know, my PhD is in neuroscience, but I actually worked in the department of diabetes, endocrinology and metabolism at the Beth, Beth Israel, Deaconess Medical Center in Boston. So you know, I spent a lot of time thinking about feeding and metabolism and stuff like that. But I had sort of no knowledge of the history of the dietary recommendations and how all of the things that I thought were just the cold, hard facts of medical nutrition that I grew up with, and that I was taught, you know, as I grew up, about what to eat, what not to eat, I had no idea what the history actually was. And we're gonna get into some of that. Just to sort of start to set the stage for some, folks, before we get into the trends of the things you analyze in this paper. I want to talk about a few different things, and put put some historical context here for people. So roughly speaking, when we think about things like the obesity epidemic, the rise and diabetes, roughly when did these things start to clearly rise in the United States? So

Orrin Devinsky 8:05

I would say Eliot Joslin, who founded the Harvard Diabetes Center, where you worked was America's preeminent diabetologist, at the turn of the 20th century, going from the late 1800s, into the early 1900s. And he actually observed an epidemic, as he referred to it, of diabetes in his little hometown of Oxford, Massachusetts, where all of a sudden, many people were developing adult onset. So it was called at the time diabetes. So I think the these have been slowly creeping, but exponential epidemics of obesity and diabetes, probably going back centuries. I think it began in the wealthy class of people. So if you go back to the Middle Ages, and you look at who, you know, the fat, the fat was a not uncommon eponym after King so and so the fat and the only people who could be fat in the Middle Ages, were royalty, because they were the only ones who could afford the processed foods that could make you fat. So

Nick Jikomes 9:10

it was an eponym was actually probably a marker of status because it was so hard to actually do

Orrin Devinsky 9:17

that. And I think people didn't even understand obesity. There's one terribly racist but informative line from a doctor you trail he was one of the English what they called colonial physicians in the 20th century. So I think going into like 1920 1930 He went from England to East Africa, worked mainly in Tanzania and Kenya, and was one of the early members of the East African Medical Association. And he writes it really kind of eerily that during World War Two in the mid early 40s. He says we knew how to fatten a chicken for the pot. But despite taking 1000s of x rays of Africans and tested

And we couldn't figure out how to fatten an African for battle. So here we are 1942 1943. Here's an English physician. In East Africa, this is a British colony, many able bodied, black young men who they would love to have sent in North Africa for the, you know, desert fight against the Germans. And they couldn't, because they were underweight. And they did not know how to fatten them. So traveled goes and goes back to England. And I think he spent some time in Philadelphia, he returns to East Africa in the 50s. And he shocked to see an epidemic of obesity and diabetes has taken over the land. Now, they don't know how to keep an African from from getting obese. So over a period of 20 years in this specific area of East Africa, they literally they didn't know how to have black individuals reached the body weight of the average Englishman, and then shortly afterwards, they couldn't keep them thin.

Nick Jikomes 11:02

So so we've got, you know, now now we live in a world where, you know, we literally talked about the obesity epidemic. And, you know, we're gonna get into some of some of the potential factors that influence that. The other thing I want to talk about, for historical context purposes, is something called the Diet Heart hypothesis. And before I even knew this, as as the name and the person behind it, and some of the history here, you know, I can remember growing up, so I was born in the late 80s. So I grew up in the 90s and early 2000s. And came of age, it was common knowledge at school, from physicians from adults, it you know, in all parts of my life, don't eat too much saturated fat, don't eat too much cholesterol, don't eat things like red meat, you know, too much. Because these are the things that cause heart disease, that, you know, until I was, you know, young adults, at least, that seemed like cold, hard facts of medical knowledge, like we knew. Yeah, yep. So where did this where did that those ideas come from? When did they start and at the time they were formulated, How strong was the evidence.

Orrin Devinsky 12:18

So the evidence is never been good. We are left with a relic. So unfortunately, the American Heart Association probably represents the most diehard advocate. And I think it would be wonderful if they would go back and do a deep dive over the history, which we'll touch on here. So I think the man who brought us the Diet Heart hypothesis was a scientist Ancel Keys. He is a remarkable man. So I think one thing I personally don't love is that there are either the Ancel key fanatics who just treat him as if he was God. And there are the Hanse, Ancel, keys, devil, that he's the one who messed up all of American medicine. And I don't give him credit for either of those things. I think he was a very brilliant card working remarkable individual, who made some enormous mistakes. And as most people do, put the force of his power behind his personal views, and advocated them and really confused, I think, opinion in science and I can get, I think there's one, one or a couple moments where the we've just got it wrong as a nation, and I'll see if I can just start. So the story of Ancel Keys, and it's been told before, there's a video at the University of Minnesota where he spent most of his academic career that highlights his career. And he was the person who invented the key rations of World War Two, they had actually asked him because he'd studied altitude medicine in South America in the Andes to help design meals for pilots. And as he said, this kind of crazy, he knew nothing about nutrition at the time, he'd studied oxygen concentrations when you're up high in altitude. So he devised some, you know, simple meals that could be stored for long periods. And they turned out to be pretty high in sugar. He was funded by the sugar foundation early on in the 40s. And these became known as the K rations or keys rations, and they were used by many, many G eyes throughout World War Two. And they traveled well, they preserved well, and the soldiers who were relatively happy with them. So he became somewhat famous for that. Then towards the end of World War Two is as the United States and the allies were preparing for hopefully victory, but also the recognition that there was going to be terrible food shortages all throughout Europe that, you know, many of the greeneries had been destroyed, and that there was, you know, going to be poverty and many countries that like Italy that were battered by the war, that they were thinking about how How do they how do they figure out the health of nutrition. And so Ancel Keys was funded by the government to do what was still probably the largest study of semi starvation ever done. He did this on conscientious objectors in at the University of Minnesota. And they gave him very low calorie diets, they hit a mark like five miles a day. And he documented all the changes, which had been documented before and documented subsequently, but a large two volume book, the biology of human starvation, and it showed their sex drives diminished, they became ravenous, they would fight each other over crumbs. It just what happens to young healthy men when they don't eat enough calories and enough food. So in that process, he wrote this two volume set and again, became very well respected internationally, because it was probably the best contribution to the study of the science of human starvation. So because of that, he got appointed in the late 40s, to the United Nations Food and Agricultural Organization Committee, and went there and got a, I think, a Fulbright or one of those scholarships to be in Oxford for a couple years. And while he was in Oxford, there was a ration on heat, fuel. He and his wife Margaret were freezing even though they came from Minnesota. They were freezing in Oxford. And he had heard from a colleague, a cardiologist or medical doctor in Naples, that whereas the rest of the world in Europe seems to be having a heart disease epidemic. People in Naples, we're not getting heart disease. So Ancel Keys and his wife, Margaret, who actually did the cholesterol measurements, decided to take a trip, and they took their car, and they literally drove across Europe and went down to Naples. And he went to a rotary club dinner. And there he had an epiphany. He was watching the wealthy businessmen of the Rotary Club, eat their roast beef and desserts. And recognize that the poor people in town were eating simple bread with vegetables. And when his wife measured their cholesterol, the wealthy Rotary Club members who are eating the beef and the end of the deserts had very high cholesterol, and the poor Labor's had very low cholesterol. And in his mind, it was the fat, a light bulb lid off that the big difference between these wealthy guys eating roast beef and dessert was the fact that they were eating, and that the poor people were eating the simple food that was just carbohydrates and vegetables, and essentially very, very, very little fat. And that was one way to interpret the data. And it was not an unreasonable way to do it. The problem is, he completely ignored the role of processed carbohydrates, sugar, white flour, that also distinguish those two groups of individuals. And I would say distinguished almost all groups of individuals who do and do not have obesity in the world or populations. But I think, if I can, so he took this, and he created a hypothesis back in 1952 53, called the Diet Heart hypothesis. And his first seminal paper was in the Mount Sinai Hospital journal in 1953. And that's where he really proposed the Diet Heart hypothesis. And the idea was, was really simple. He showed correlations if you picked, and he did this selectively six or so countries that have high rates of fat consumption. They also turned out to be the countries that have high rates of heart disease now, later criticized terribly for this because there were probably 22 countries with data available. And he chose the six that fit perfectly into this relationship. You could have chose another six that showed the opposite correlation, where the more fat they ate, the less heart disease they got. But he chose quite wisely to support his hypothesis. And again, this is 53 Before Data Selection was quite as big a deal in science as it is today. But I think the critical piece of data, which I'm going to talk about here, I don't think it's really ever made it into the Gary Taubes and, and other books of that genre is that he quotes and there's a looking at the paper right now it's table 14. And he gets data from a woman. I think her name was Elizabeth Flippered, from the USDA, on the percentage of total calories that are fat in the US diet. So just to do another caveat. The data from 1910 and 1920 and 1930 are terrible. We just don't have good data. Keep in mind and 1920, half of America lived on farms, or within five miles. So the USDA was not good at tracking. If you ate a piece of pig from the guy who's your next door neighbor. They can't track that degree they could track if it went to a big meat processing plant. In Chicago, but not if it came from the former mile away. The bottom line is between 1910 When the average American 830 2% fat in their diet in 1950, when the average American 840 2.2% of fat in their diet. And so he said, look what's happened from 1910 to 1950, our fat consumption has gone up 25%. And there's been an explosion of heart disease. What's going on in the arteries of these people who have died from heart attacks, they've got fat, they've got cholesterol. So in his mind, I think the pieces just fell in so perfectly to this little jigsaw puzzle. What no one goes back and does is look at flippers data, or, more importantly, what Ancel Keys found. And what he says is from the statistics and the USDA, it's clear, the biggest contributor to the fats in the American diet are fats and oils, excluding butter, which are nearly 46, and a half percent of the total meats, poultry and fish combined to make a poor second at 22%. And it is I'm quoting Ancel Keys, any attempt to reduce the total fat intake must then begin with cooking fats and oils. So that's what he said back in 53. The problem was, they then started doing feeding studies. And it turned out, giving people cholesterol didn't raise their cholesterol much, it did a little bit, still a little bit, giving them polyunsaturated fats, the canola oils, which is rapeseed oil, or other oils, like that, also barely budged the needle on cholesterol. And they found out during the mid 1950s, the only thing that really raised total cholesterol, were saturated fats. So he's pivoted from this early position where it was total fats. And that's caused heart disease. And indeed, the only thing that changed the American diet, were oils and fats, not butter, not Lord, as I discussed in the paper, but cooking oils, that was the explosion of the 20th century in the American diet for fats. And that's what was associated with the rise in heart disease.

Nick Jikomes 22:20

But because he was fixated on this cholesterol levels that made him go, Okay, well, it's got to be the saturated fat here. Correct. He

Orrin Devinsky 22:29

pivoted from the early mid 50s, to the late 50s. And then he took over the American Heart Association nutrition committee, and got this to become national policy. I

Nick Jikomes 22:39

see. So So part of the trajectory here is, I don't want to I don't want to spend too much time on Ancel Keys. Everyone's everyone talks about him. But smart guy motivated guy probably like being right, probably thought he was right. And he wasn't it wasn't, you know, like this was coming out of nowhere. It was based on what he was seeing. But he was also good at getting into positions like, you know, being the chair of committees at the AMA. And that was probably a key factor in why his ideas were able to spread through institutions and radiate outwards. So, so effectively,

Orrin Devinsky 23:11

correct. Yeah, even like when Eisenhower his heart disease, heart attack. White who is the head cardiologist at Harvard became Eisenhower's cardiologist and, and he got to write a large piece of the New York Times on the front page. And Ancel Keys was the only scientist he calls out and did so several times in that article. So keys, you know, was a very influential figure. Having said that, white towards the end of his career and days, wrote a long biography and barely mentions Ancel Keys. So you know, Keyes was one of those people who could ingratiate himself, but he may not have remained on everybody's most popular list. Okay,

Nick Jikomes 23:51

so just so it's top of mind for listeners, in plain language. What was the Diet Heart hypothesis that he formulated,

Orrin Devinsky 24:00

the Diet Heart hypothesis morphed over time, but it began with the idea from this 1953 paper, that heart disease is caused by too much cholesterol in your blood, it congeals in the arteries, and causes heart attacks. That's essentially the hypothesis and that the most important factor determining cholesterol levels is diet. In 1953, as I just said, he thought it was all fats that caused cholesterol buildup in heart disease. By the late 1950s, when the feeding studies had clearly shown that the only fat that really raised cholesterol was saturated fat. He pivoted to that. And although saturated fats the only fat that also raises HDL what's known as the good cholesterol, He ha ignore that. That's like, talk about it.

Nick Jikomes 24:52

Yep. So don't hurt hypothesis. Basically, heart disease comes from your cholesterol levels being too high, your cholesterol levels being too high, widely believed to be Coming from saturated fat, therefore donate saturated fat to raise your cholesterol levels and then get heart disease. Exactly. In parallel to that, what is, you know, because we're going to talk about obesity as well. What is the inner energy balance hypothesis of obesity.

Orrin Devinsky 25:18

So the energy balance hypothesis, which was I was taught in medical school. You know, it's touted as being consistent with the laws of thermodynamics. And thermodynamics works beautifully. Well, for physics, biology is more complicated. So the energy balance hypothesis is that you know, you're an adult male, I'm making this up, but you weigh 175 pounds, your basal metabolic rate, if you just you know, sit in a chair and read a book all day and go to sleep, let's just say you burn, you know, 1500 calories, but you're not a couch potato, you walk a couple miles a day, you lift some weights, so you burn 2400 calories a day, you're an average man. And the energy balance says, if you have a basal metabolic rate of 1500, you burn 900 and exercise, then if you take into 2400 calories a day, you'll be weight neutral for the rest of your life. If you take in 20 450 calories a day, that 50 is just a teeny weeny bit, but multiply it by 365 days, times 10 years, and you'll gain 10 pounds or whatever that number comes out to over 10 years. That's the energy balance hypothesis. And I think it's mainly wrong, I think there's certainly shortage of truth thermodynamics is true. The problem is our bodies are not engines. They are metabolic engines, but they're much more complicated. The simplest example, it's almost comical is that the amount of calories in something like four and a half ounces of a ribeye steak, and four and a half ounces of diesel fuel, and four and a half ounces of gasoline, may all have the same calories. And for an engine that could burn all three, they are energetically identical. However, you will die. Of course, if we took the gasoline or diesel, we would be barfing or having diarrhea or probably both and get very sick and get no beneficial calories from it. Our engines don't burn gasoline, in the same way a gasoline car will die after a couple of miles on diesel. So you know, the idea that it's just calories is just way too simplistic. We have microbiomes that influence our metabolic rate. Not all of us are able to digest the same foods in the same way. But we also have these things called hormones that greatly influence where we put calories, how we put calories. And you know, examples are men and women, you know, men and women after puberty distribute calories very, very differently. Men have a greater muscle mass. Women have larger breasts and larger hips and obviously, reproductive reasons why those things happen. They're present in all human populations. But it's not that kids grow because they eat too much. It's well because hormones tell them to grow.

Nick Jikomes 28:12

Is it fair to say that the energy balance hypothesis is essentially just saying it's about calories in calories out? And a calorie is a calorie, but alternative hypotheses are saying, well, no, a calorie is not a calorie, your body uses different calories in different ways. Exactly.

Orrin Devinsky 28:28

And I think they're both true to some degree. I think, you know, many of my friends and I'm on their side that I think the energy balance hypothesis is way too simplistic for human beings or any animal quite frankly, by the same token, you know, if you eat junk food, or you eat healthy food, and you have 7000 calories a day, you're gonna probably gain weight. Even if you're eating, you know, broccoli and asparagus. It's going to be hard because it is just a crazy overload of of energy that your body can use. But it's simplistic. Yeah,

Nick Jikomes 29:01

so yeah, so So I don't think anyone's saying calories in calories out doesn't matter at all. It's just whether or not that is sufficient to explain.

Orrin Devinsky 29:09

It's not the primary driver, there's no way it's the primary driver, because as I said, go back to you trowel in Kenya 1942. They try that in the same way, find me an obese individual who hasn't tried to reduce their weight by reducing their calories. Find me one. You know, everyone tries it intuitively, you know, you go out to a wedding or it's summertime and you want to lose a few pounds. Everyone just intuitively says I'll eat less and I'll lose some weight. And it's just not that simple. Certainly not for obese people.

Nick Jikomes 29:43

So getting into the paper now, I mean, you know, roughly speaking, right when we carry when we think about some of these questions, diet, heart hypothesis questions and heart disease, obesity questions, metabolic health. One key piece of information to evaluate some of these ideas at least partially is just to Look at how the food supply and how food consumption changed. And you did that? Can you briefly just explain for people? What is this paper? Where did where did the data come from? And, you know, how did you look at it? How good is the data?

Orrin Devinsky 30:15

I think that data is as good as we could get it to be. As I said, as you go back in time, it gets really hard, because you go back to 1920 1930, a lot of the data was collected, I think, at the beginning of World War Two retrospectively. So it wasn't, I mean, the USA, DEA did collect some data, but it was dirty, rough, and you know, would not make scientific merit in today's world as being accurate data. So these are rough estimates. Certainly, we know that, you know, we can go back and look at diaries from places like African slaves in the south. And they, you know, they, we ate huge amounts of pork, and fried bread and things like that. So, you know, we have ideas about what they ate, but America ate a lot of meat. Keep in mind, we had millions and millions, you know, Native Americans had millions of bison, to hunt. And they did, you know, settlers ate bison, too. But in the northeast, you know, people ate steaks for breakfast. And meat was very available in the 1800s. Now, again, these going back to historical records, and who's writing these are often the wealthy people, not the poor people, poor Irish immigrants in 1910, ate a lot of bread and vegetables in New York, I believe. So a lot of it was socio economic. But even in the south, on plantations, in the slavery days, blacks were given pigs to own, the whites pretty much had cows and chickens. So, you know, people had access to meat, but we tried to get all the data we could all the USDA data, all of the published records that were out there, we went through all the papers that looked at dietary trends, tried to get all of their sources, I was fortunate to have several research, students helping me on the paper, and it took well over a year, and we went through many, many hundreds of sources. To compile the best data we could Is it far from perfect, but I think it's about as accurate as we can get.

Nick Jikomes 32:14

Yeah, I mean, it's like I got interested in this topic and related topics. And I just wanted to know, like how diets actually changed over time. And as I was, as I was, you know, digging around online, I started noticing these figures, that all kind of look the same in that same style. And I actually realized that you had sort of put a lot of the stuff in one place. So to give people an idea for some of the major trends here, I just want to go through some of the figures in the paper, and have you give us at least a bird's eye view, but just starting with total calories and macronutrients carbs, total carbs, total protein, total fats, what are the most salient ways that consumption of those things was changing throughout the 20th century?

Orrin Devinsky 32:57

I think overall, we we got better at processing food. So things for example, vegetable, what we call vegetable oils, but they're not vegetable oils, they are industrial process seeds. For mature oils are extracted under high pressure and temperature and things like that. So they're not natural products. So you know, one way to think about diet for me is, and not the first person to say, but if your great grand parent consumed it, then it probably was fairly healthy. But if it had to go through a factory in the Midwest to get to your plate, you should be suspicious of it. So what we call vegetable oils, or seed oils, which make up about 8% of the American diet. Now, they didn't exist prior to 1909 and Crisco. And when Crisco was first commercialized, it was, you know, an oil that was hydrogenated, so it was under pressure. Hydrogen was put in there, and it created a lot of trans fats, as we now know, which are another category of unhealthy foods that can accumulate. They're not natural. There are some trans fats in nature, but they're very, very tiny amounts. But they became a large part of the American diet of my diet. In my childhood, you went to a fast food, McDonald's or Burger King, you bought some, you know, Suzie Q's or Drake's cakes, they had, they all had were abundant and trans fats, and no one was keeping track of it. Obviously, that eventually came out and they've been greatly reduced in the American diet for people like myself in the 60s in my 60s, you know, in when I was 10 years old, 2030 trans fats were just a big part of the American diet. So though, that's one thing, we introduced all these unnatural fats. At the same time, natural fats like butter. Lord SUID, tallow, the cooking fats of our parents generations, have largely gone down 70 80% largely being replaced by vegetable oils? Is that good? You know, maybe good, maybe bad. I don't think we know these are complicated questions, but we do know, the butter. And Lord had a lot more saturated fats than the vegetable oils do. So in principle vegetable oils, we should have seen a dramatic reduction in heart disease if it was really the Lord and the butter that was driving it. But indeed, we saw a rise as vegetable oils displaced Lordan butter.

Nick Jikomes 35:26

Yeah, and you know, one of the one of the things I see here, you know, when I look at just the the trajectory of the supply of total calories, total carbs, total protein total fat, is it? Well, first proteins quite flat over time, protein consumption changed very little compared to the others. Certainly, by about 1970, you start seeing the steep rise in total calories. And that seems to be driven by a rise in both carbs and fats. But then, by about the turn of the millennium, about 2000, things actually start going down. And so that's interesting to me. So things did rise. And you know, obesity would have been rising around this time period 6070s 80s 90s. But then it continues rising, obesity does, and yet total calorie, total carbon total fat start actually going down somewhat after about 99 2000. Is that, is that accurate? That's correct,

Orrin Devinsky 36:17

is the best. And again, the more recent data, I think, is probably more accurate than the data from the 1830s or so. And I think it speaks to the fact that what creating the obesity now, it was what everyone's still, you know, the American Medical Association hardest. If you want to know how to lose weight, reduce your caloric intake, and that's what people will tell you. Unfortunately, it just doesn't work. As I said, most obese people have tried to reduce their calories and losing weight, it's just not that simple.

Nick Jikomes 36:45

Another interesting thing here, you know, related to, you know, the change in the consumption patterns for specific foods like vegetable oils, like butter, lard, etc. is thinking about this in terms of the different fatty acids. So the three main categories here that people will have heard of saturated monounsaturated, polyunsaturated fats, how did those specific fats change relative to one another, over time, since, say, the mid 1900s.

Orrin Devinsky 37:11

I think saturated fats overall have been pretty stable. Heart again, hard to really know truly what they were consuming in 1910 1920. But as best we know, it's pretty stable. The big rise has come from the polyunsaturated fats, which are mainly the vegetable oils we were talking about. And then also the minor ones, saturated fats, which is a laic acid, things like that. And olive oil, which is a more natural product, and obviously has been consumed by Mediterranean populations, like the Greeks and the Italians most famously, and been associated with good health in those populations. But no population, no human population has consumed vegetable oils, historically. And,

Nick Jikomes 37:53

you know, again, for my entire life, for many people's entire lives, even to this day, like when I go to the supermarket, and I look at what are the things that have that heart healthy sticker on them. It's things that contain unsaturated fats and polyunsaturated fats. What Where did that come from? What why? Who considers those to be the healthy fats? And what is the evidence behind calling the unsaturated fats, the heart healthy ones.

Orrin Devinsky 38:22

So I'd say two streams of evidence supported one I've already discussed in the mid 1950s, they started doing very large scale feeding studies, they took young adults, you know, put them in a dormitory, counted everything they ate for a period of a month or so. And those who are given polyunsaturated fats like canola oil or things like that, they found that their cholesterol levels often went down a little bit by having high polyunsaturated fat diets. So in the simplistic view of high cholesterol causes heart disease causes death. Polyunsaturated fats can be associated with a reduction, especially if they replace saturated fats, then yes, total cholesterol will often drop. Now the HDL ratio to LDL may get worse, but the total cholesterol would typically go down and total LDL would typically go down. So that was kind of the simple story. And in public health. The goal of physicians and public health officers is to keep it simple for laypeople don't make it complicated. And they tried to suppress the whole concept of HDL and LDL for a long time saying people would get confused just talking about total cholesterol. So there were journals that wouldn't publish on HDL and LDL in the 60s and suppressed a lot of data on this. So that was one of the areas and the other is that there have been some studies in a limited number, where populations have been put on a quote unquote, medical Mediterranean style diet, where they did reduce saturated fats, they did increase Use polyunsaturated fat consumption. And some of those studies, a limited number have shown some reduction in heart disease. Now, that may not be the only thing that changed in the diet, very few of those people getting put on a Mediterranean diet were eating, you know, Hershey candy bars by the pound. So there are other changes that go with it.

Nick Jikomes 40:20

Yeah. And I also suspect that, you know, key thing, when we think about that body of work is, it's not enough just to think about unsaturated or polyunsaturated fats, for example, you have to go down to the level of individual fatty acids. So you know, the Mediterranean diet, if you were to look at, say, the Omega six to Omega three profile of that, versus a high vegetable oil diet that an American might be consuming, those are very different animals.

Orrin Devinsky 40:48

Absolutely. And again, you know, if you look at the Blue Zones, whether it's Okinawa, or Sardinia, you know, there are some common themes. Number one, people eat real food, the foods are very different, whether it's Costa Rica, or Japan, but they eat foods that comes from nearby, and it's minimally processed. And they move, and they have family relationships, you know, those are the three key things that are associated with good health and human populations. But I think as far as diet goes, for me, it's the Ultra Refined diet that Americans eat, that's killing them and causing obesity and diabetes.

Nick Jikomes 41:26

Yeah, I mean, another remarkable thing, when you realize it, it's, it's, it's, it's, it's, you know, arguably obvious until, until you just really look at it, you know, as I've thought about the diet stuff is, you know, to echo what you just said, if you look at, say, the anthropological literature on, you know, hunter gatherers in, you know, all over the world, people have radically different diets, some of them ultra high carb, some of them ultra high fat. And in all of these vastly different populations, they still have very, very low levels of chronic disease, obesity, things like this, including

Orrin Devinsky 42:01

kids. So I'll just though, for me, cancers, what my family has too much of, and I was shocked when I started going through this literature as well. I mean to two observations, one, which I think should be a foundation of medical school education. You know, when people like Albert Schweitzer went to West Africa in the 1920s, he started operating on large numbers of people and seeing many, many patients in his clinic on a five, six day a week basis. And he said, after being there a couple of years, I'm sure cancer exists somewhere in Africa. But if it does, I haven't seen it. Hundreds of colonial physicians made that observation in Australia, in China, in Japan, in South Africa, in East Africa, in West Africa, where Schweitzer was, cancer was a rare disease prior to industrialized process food, and indeed, the only animals on the planet that suffer from cancer really, are domesticated pets outside of that, and farm animals for what we feed them doesn't exist. like monkeys in captivity, they get put on an American heart association diet, they get obese, because it's a processed diet. And monkeys aren't fat in the real world.

Nick Jikomes 43:18

Do you think like if you had to, if you had to really, really boil this, maybe getting a little bit ahead of ourselves. But if you had to, like really boil this down for the average person, who doesn't have the time, or the inclination to think about metabolic details and different foods, and you know, different saturated fatty acids, and blah, blah, blah, blah, blah, is the sort of key dichotomy people should keep in mind when they're thinking about healthy eating simply processed versus non processed, I

Orrin Devinsky 43:48

believe so. And within the processed, I would just, you know, the big category of the culprits are sugar, white flour, white rice, and anything that comes packaged, I mean, if you're gonna buy something, throw out the microwave and nuke it and eat it and call it pizza, you're in big trouble. You're eating unhealthy food.

Nick Jikomes 44:09

So you mentioned meat consumption earlier. So for most of us history, you know, people live on or in close proximity, proximity to farms, meat consumption is pretty high. It's readily available, as you said, people were eating, you know, steak for breakfast commonly in the 1800s. One of the striking charts in this paper, too, is basically the change in the meat supply over time in the 20th and 21st centuries. So at a high level, you have a graph that shows red meat, versus poultry versus seafood, fish and shellfish. What are the main trends that we've seen there in the last, you know, several decades? So

Orrin Devinsky 44:48

I think the big, big big ones I mean, red meat has fluctuated a little bit. It goes down during all the world wars because soldiers get priority over the rations to the people at home, but apart from That red meat consumption has gone up and down a little bit, but it's been relatively stable. As best we can tell pork consumption probably down a bit, but cow meat probably up a little bit. So they balance the huge chain and fish and shellfish pretty constant over time, the remarkable change has been chickens. Chicken was kind of a luxury item, either you had a chicken coop nearby at a farm in the in the rural America. But otherwise it was it was kind of a luxury food and just wasn't consumed. It was a lot of work for a little bit of meat, so to speak, think about how much meat is on a cow, or a pig versus on a chicken. And so they were relatively expensive and kind of a luxury item like hens for the upper wealthy class. And then I think with industrial farming of animals, which we have now. And the promotion by the American Heart Association, that chicken meat was considered healthy while cow meat was considered unhealthy. There's been a dramatic rise in the consumption of dairy meat, dairy meat of chicken meat following, you know, really 1950 5560 When Ancel Keys came out with the diet, heart hypothesis, chicken consumption went through the roof.

Nick Jikomes 46:19

And so over time, for for much of the 1900s. Certainly by mid century, yeah, this, this line for poultry is just going up into the right, much more than for red meat and shellfish and fish, which are relatively stable over time. So the ratio of the meats we're consuming is very different by the time you get to the 2000s Compared to earlier in the 1900s. The other factor here that I just want to quickly ask you about that's not in the paper, but I think would have to be relevant here is not only our meat consumption patterns changing, but I imagine the macronutrient profile of the meat itself is changing as we scale up and do more things like factory farming, and we start feeding the animals in a different way. Is there anything worth talking about there?

Orrin Devinsky 47:06

Yes, certainly the one thing that has been well studied is that animals that are cows, for example, that are grass fed have a much healthier Omega three to six ratio than animals that are grain fed on corn. So you know, again, corn, corn fed animals, which is what a lot of our meat comes from, it's a better way to get fat in there. Because corn turns into fat much better than does grass. It's just, you know, the fructose in corn is great for making fat. Fructose is the most fat producing sugar on the planet for a mammal, including us. And so you know that dietary change has changed, not just the, you know, the cow we're eating now is not the cow our great grandparents ate, it's very different. It's got a different fatty acid profile, and, you know, is less healthy, unfortunately.

Nick Jikomes 47:59

And you've already mentioned that, you know, the vegetable or seed oils, they've become much more common over time, when you actually look at this graph, the added fats and oil availability. It's remarkable. You see, you know, the drop in butter, lard and in the animal fats started quite early in the 20th century. But then by the time you get the data in mid century, by the 60s with vegetable oils, when you look at this, it's going up into the right the entire time, basically, but it's going up strongly from mid 1900s, to late 1900s. But then at about the year 2000. It starts accelerating even more. And now it's you know, sort of Off The Charts today compared to these other things. What was actually driving this dramatic rise in vegetable oil, and we just get really good at agriculture.

Orrin Devinsky 48:48

So I think there are a few things, you know, the data from the early part of the century is horrid. And again, a lot of that was just really Crisco. So Crisco launched a big campaign, you know, which would promote themselves as clean. And one of the things that did change meat consumption patterns in America was Upton Sinclair's The Jungle. Written interestingly, as kind of a socialist book depicting the plight of these poor workers in these meatpacking plants who lose fingers and the fingers would end up in the, you know, the meat that goes to the housewives in Milwaukee or wherever. And as in the book became a best seller changed national policy. I think, you know, USDA was revamped at that point to do many more inspections of meatpacking plants. I think Roosevelt was president around that time. And Upton Sinclair said, I shot an arrow at America's heart, and I hit them in the stomach. And what he meant by that is, he wrote this, he wrote the jungle to say how bad the plight was of these American workers. He wanted to hit people in the heart of how much these working class people were suffering. But all he did was hit them in the gut that they were disgusted how was horrible there the meat supply was and what the conditions were that there was urine and feces. And, you know, it was just a disgusting people were you know, the sanitation conditions were horrific. Nowadays they're probably not perfect. But in those days 1909 The truth is in Chicago meatpacking plants, they were beyond horrible.

Nick Jikomes 50:23

And, you know, as we've said, we have this transition away from animal towards plant based fats driven a lot in large part by things like the vegetable oils and away from things like butter, lard, etc, you know that that graph is also dramatic, when you just look at, you have a graph of the availability of vegetable based versus animal based fats and added oils. And you know, by the 1950s, these, these two lines are diverging, and then it just gets really dramatic. And you know, today, it's like, you know, the vegetable oils are way up here. The animal fats are way, way below that. Can you talk a little bit more, so not only are we consuming more vegetable fats today than ever before more of them compared to the animal fats. But let's dig in a little bit more and explain for people how the fatty acid composition of these products differs. So can you give people just a basic one on one there?

Orrin Devinsky 51:15

Sure. So you know, as we've kind of mentioned here, at different times, there are three broad categories of fats. There are the saturated fats, which means there are no double bonds for those who remember their high school chemistry. And so they line up very straight. And they're solid at room temperature. Because they, they're there, they can line up and form not quite crystals, but they're much more solid structures. The unsaturated fats, whether they are mono unsaturated like olive oil, oleic acid, which has one double bond, or the polyunsaturated, poly means many, so there are many double bonds in canola oil or oils like that. Those are going to be liquids at room temperatures. And so one corollary of that, which is always nice to remember, if we talk about Native American Eskimos Inuit, who also can have extraordinarily high fat consumption, but have unremarkable as best we know heart disease prior to the introduction of processed foods. Although that data is not the best in the world, they were eating a lot of their fats came from marine animals. So if you think about it, if you're a marine animal, what's evolution going to do? It's going to put a whole lot more polyunsaturated fats in your, in your fat, as opposed to saturated fats, because if you're mostly saturated fat and your seal, or a whale, in the Arctic Circle, your fats are going to be frozen solid, as if they're polyunsaturated, they'll remain liquid in the cold weather. So much sea mammals by and large, who swim in very cold waters, even even in temperate regions tend to have very high ratios of polyunsaturated fats to fats. Very different than things like cows and pigs, pigs, we live in much warmer environments, they're going to have much higher saturated fat components. But I think people really get mixed up with the fats because pigs lard for example, you know, the classic saturated evil fat, you know, bacon fat is terrible for you. It turns out a lot of bacon fat, number one is mono unsaturated, and a lot of the saturated fat gets turned into our body into mono unsaturated fats. So they these things are not these dichotomous things where lard is evil, saturated fat. I don't think saturated fats evil to begin with, but it's just not that simple. They're all mixtures. There's no animal, whether it's a cow, or a seal, or a pig, who's fat doesn't have mixtures of all three types, saturated, mono unsaturated, and polyunsaturated. Certainly, when you get to the vegetable oils, they can be pure polyunsaturated, or things like olive oil, where it's a mix of a lot of Mono Unsaturated with some polyunsaturated, maybe with a drop of saturated, and then you get to the tropical oils like coconut oil. And those are going to have high amounts of saturated fats and against populations in Polynesia, who ate enormous amounts of saturated fats from coconut oil and things like that they had very low heart disease rates prior to the introduction of processed foods.

Nick Jikomes 54:39

Another dramatic change over time here is you've got a graph of caloric sweeteners. And you know, they all change in different ways, but probably the most dramatic change is the corn sweeteners, high fructose corn syrup, glucose dextrose, things like this. Can you summarize that for people

Orrin Devinsky 54:59

again, I think you know, as this really began with the industrial age in England, which is where the obesity diabetes epidemic began as well. But with industrialization, you know, we were able to power steam engines, we were also able to do large processing of sugar and flour and get it to a higher grade used to be molasses back in the 1800s. It was dark and, you know, much less pure than, than what we can get in our Dominos white sugar box today. So that's all industry,