June 16, 2014

Understanding science

Success versus Failure: A stark juxtaposition

What does winning, and losing, look like when confronting public health issues?

Read Time 11 minutes

In April I was part of a panel at the Milken Global Conference, the title of which was something like, “Keys to a healthier and more prosperous society.”  The panel was moderated by Michael Milken, and it was great to meet him and his rock-star staff (especially Shawn Simmons, Paul Irving, and Nancy Ozeas). The other panel members were seasoned vets of the obesity discussion: Troy Brennan (Executive VP and Chief Medical Officer of CVS Caremark), Tom Frieden (Director of the CDC), Lynn Goldman (Dean of the School of Public Health at the Milken School of Public Health, at George Washington University), and Dean Ornish (president and founder of the Preventive Medicine Research Institute). I was the pauper in the group—no big credentials and zip-zero “panel” experience.

A few weeks before panel, we all jumped on a conference call and Michael set the stage for the discussion he wanted to moderate. He pulled no punches. “If you include the indirect cost—lost productivity, for example—the total cost of obesity and its related diseases is $1 trillion per year to our economy. This is unacceptable.”

Who could disagree? Hell, I usually only reference the direct cost of obesity and its related diseases—about $400 billion annually.  But whether we talk about the direct or indirect cost of these diseases, I’ve always found the human cost even greater—every day 4,000 Americans die from four diseases exacerbated by obesity and type 2 diabetes: heart disease, stroke, cancer, and Alzheimer’s disease. Now that is really un-effing-acceptable.

So, back to the panel. The idea of being on a panel kind of freaked me out, even more than the sheer terror and vulnerability of TEDMed. No control. The possible need to be defensive. Sound bites over substance.

I don’t enjoy debates. Nothing comes of them. Just greater and greater polarization. The “winner” isn’t even necessarily the one with the best “facts.” Gary Taubes shared this quote with me recently, which I find really insightful. Dallas Willard, a well-known ecumenical pastor and theologian, was often invited to debate the existence of God and other matters. These invitations included Richard Dawkins himself.  His response: “I don’t debate, but I am glad to enter into a joint inquiry. We will seek the truth together.” That’s the attitude I like.

In the end, I decided to just tell a few (in some cases provocative) stories. Why? Because it’s easy to present reams of data, yet so few people remember the point. (If you want to read an amazing paper on the importance of storytelling, check out this one by one of my former surgical mentors, Curt Tribble. You don’t need to care one iota about training cardiac surgeons to realize the gems in this piece.)

I realized going into this that I would be the contrarian in the group. I don’t claim to know all (or even many) of the answers, but I’m willing to bend over backwards in search of them. I realize folks (from readers of blogs to members of the audience at the Milken Global Conference) want facts, answers, prescriptions. I think we need to know more, first.

Below are the notes I made for myself in the days leading up to the panel. Basically, I wanted to tell a few stories, plus summarize it all (if given the chance). I didn’t actually “practice” this or even take notes up on stage (which I regretted when I realized everyone else was smart enough to bring notes), so if you decide to watch the actual video of the panel, you’ll note that I only vaguely followed what’s written below.

But in my mind, here’s how I thought about it. (I haven’t watched the video and I’ve pretty much forgotten anything I said, but I’m sure what’s written below is better than anything I said. I did send the video to two of the best speakers I know to get their feedback. Their feedback: could have been much better, but not the worst job ever. Lots of work to do for next time. Duly noted.)

How did I find myself interested in this problem?

My arrival at this place is really a coming together of two revelations. First, during my surgical residency at Johns Hopkins, not surprisingly, I was often dealing with the complications from diabetes and obesity in my patients. It slowly became obvious that all I was doing was slapping on the surgical equivalent of Band-Aids without ever addressing the underlying problem. I was treating symptoms and not the actual disease. When I would amputate the leg of a diabetic patient, which I had to do, regrettably, all too often, I knew that my patient was more than likely to be dead within five years anyway.

The second revelation was five years ago—September 8, 2009—to be exact. I remember it so clearly. My sport of choice was marathon swimming, and I followed what I believed to be the iconic healthy athlete’s diet. I had just completed an especially difficult swim into the current from Los Angeles to Catalina Island, becoming one of a dozen people to do that swim in both directions.  After more than 14 hours in the water, I got on the boat to begin the long ride back to Long Beach Harbor, and my wife looked at me, in my speedo, 40 pounds heavier than I am today, and said, “Honey, you’re a wonderful swimmer. But you need to work on being a bit less not thin.”

And not only was I, well, fat, despite all this maniacal exercise, but it turns out I was also pre-diabetic.

Her comment launched me into a series of nutritional self-experiments. I was already working out three to four hours a day, so the problem couldn’t be sedentary behavior. It had to be what I ate. Over the next year I manipulated my diet until I found what worked for me, which paradoxically didn’t involve eating less, just eating very different from the food pyramid. Along the way I became obsessed with reading the nutrition literature. What I learned was that the evidence supporting our dietary guidelines was ambiguous, at best, and occasionally contradictory. There was a real dearth of evidence to support what seemed like the obvious questions.

I realized then, that if the guidelines didn’t work for me and if I can’t figure this out, with my background as a doctor and someone who studies healthcare, maybe they don’t work for a lot of people. Maybe there are systemic problems here. Maybe these problems were at the root of the ongoing epidemics of obesity and diabetes. Lots of maybes…and not a whole lot of clear, solid, unequivocal answers.

Since then, I’ve made a personal and professional commitment to finding the answers. And if the studies don’t exist to give us unambiguous evidence, then raising the funds and enlisting the researchers necessary to do those studies.

What does success in public health look like?

When trying to understand complex problems, I like to start with success stories, identify patterns and work backwards—reverse engineering success. Consider the following graph.

It shows the death rate from AIDS in the United States between 1981 and 2010. The point of this graph isn’t subtle. Death from AIDS rose steadily and monotonically through the mid-90s and since then has declined steadily. Though people still die from AIDS, this still represents a success story in health policy and science. For those experiencing the personal tragedy of AIDS, this is salvation.

So why did it happen? Well, first, the cause of the disease was correctly identified—the HIV virus—in the mid-80s; and second, by the mid-90s highly active anti-retroviral therapy, or HAART therapy, was able to effectively treat the virus and prevent progression to AIDS.

Again, two things happened: the cause of the disease was correctly identified, and an effective treatment was developed by an enlightened healthcare profession.

This is what success looks like.  Now, let’s compare this story to that of obesity and diabetes.

Do we have this situation under control? The case study of “failure”

Let’s take a look at this figure. It shows the prevalence of diabetes in the United States over the last hundred-plus years. (Thanks to Gary Taubes who dug up these stats while researching his upcoming book.)

In the early 1900s the leading figures in medicine, Sir William Osler at Johns Hopkins and Elliot Joslin at Mass General, did exhaustive analyses of the number of patients with diabetes based on hospital records and census data. As you can see, diabetes was exceedingly rare in the 19th century—somewhere between about 3 and 500 cases per 100,000, depending on the analysis.

By 1970, around the time I was born, that number was up to 2,000 cases per 100,000, and between 1970 and today—at a growth rate of nearly 4% per year—that number has risen to more than 8,000 cases of diabetes per 100,000.

Worse yet, type 2 diabetes is now spreading into demographics previously naïve to the disease, particularly children. I don’t think any of us in this room today would argue that we have this situation under control. So where are we failing? Many of you understand the world of business. If this were a business, we’d be asking a lot of questions at this point, or we would be out of business. Like any business, we have two possibilities. We either look at our business plan (the basic premise for how we’re going to succeed) or the implementation of that plan (the way we operate on a day-to-day basis).  When confronted with a runaway epidemic like this, we have to address the same two basic issues:

Either we understand the underlying cause of this disease and we have a good plan in place, but few individuals have the willpower or wherewithal to avoid the disease—whatever it is…In other words we’re not executing the plan.

Or, we don’t understand the disease in the first place and we’re giving the wrong advice. In other words, we don’t have the right business plan.

In this latter scenario, the failure is not one of personal responsibility, but of our assumptions about the cause of this disease. And these two scenarios have very different implications.

I am not certain which of these is more likely correct, but I do know the risk of ignoring the latter in favor of the former is not a choice we can make any more as a society.

So, maybe the question we should be asking is whether we are right about the environmental triggers of this disease—the underlying cause. Is it as simple as gluttony and sloth and a food industry that overwhelms us with highly-palatable, energy-dense foods, or is there something specific about the quality of the food we’re consuming that triggers these disorders? If we don’t answer this question about what is it in our environment that’s causing this disease correctly, just like we were able to answer it in the mid-80s with HIV’s role in AIDS, we can’t effectively treat the disease. Instead we’re stuck putting on Band-Aids.

Here’s another way to think about it: imagine this panel was on a new crisis in aviation. Planes are constantly crashing—falling out of the sky—and killing 4,000 people a day (just like obesity-related diseases are killing 4,000 Americans a day.) And you’re a pilot and you tell me that surely we understand the principles of flight. Right. Sure, we might suspect user error to be part of the problem. (Maybe the pilots aren’t flapping the wings hard enough!) But, maybe a better idea would be to go back to the drawing board to make sure we really understood this whole aerodynamics thing and we didn’t miss something important?

That’s how we think we have to look at this problem: 4,000 people in this country are effectively falling out of the sky every single day—dying—and we’re saying we’ve got it all figured out, and people just need to adhere better to our advice. I’m not confident that that’s the solution. Nor should you be.

Is there a policy-based solution to this problem?

Surely policy changes will play a necessary role in restoring our health. But it may be less about ‘how?’ and more about ‘when?’  I’d like to refer to this slide showing per capita cigarette consumption in the U.S. from 1900 until today—the number of cigarettes consumed is shown in grey with death rate from lung cancer superimposed in red.

Smoking and lung cancer

This is another success story. People in this room contributed to that success. The little colored triangles on the grey line are major milestones in science (red), market forces (green), and policy (blue). This is a great example of what one might call the “critical confluence”—scientific elucidation, policy action, market response, and behavioral shift—all coming together to save lives.

But, as in all things in life, algebra included, the order of events matters!

Which came first then? In the case of smoking and lung cancer, it was unambiguous scientific clarity, which in this case happened in the 1940s and 50s and resulted in the 1964 Surgeon General’s report. This information was absolutely necessary to drive the policy action, the market response, and the behavioral shift that followed. Without the knowledge that lung cancer is caused by smoking, no amount of policy or market response would have led to the necessary behavioral shift and so a meaningful reduction in lung cancer incidence.

When we consider the current situation with obesity and diabetes, we may still be missing the equivalent of the scientific clarity linking unambiguously the environmental trigger (smoking) that provided the obvious method of prevention (smoking cessation). And, again, if we think we do have that information, we have to ask why we’ve thus far failed to meaningfully prevent and successfully impact these disorders.

If the death rate from AIDS was still skyrocketing, I think we’d all agree we would either call into question our faith in HAART, or even the premise that HIV causes AIDS, if not both. Yet, in the face of skyrocketing obesity and diabetes, we play the who’s-on-first game all day long pointing fingers at people and industry.

Until we clearly identify the dietary triggers of obesity and diabetes, policies to shift behavior may be misguided and premature, despite their best intentions. Despite our best intentions.

I’m arguing that the policies so far may have been just that. Premature. And based on incomplete or faulty information. In other words, we may have the wrong business plan, but we blame our execution of the plan on our failure.

Parting shot

Today, we’re talking about a problem that touches, directly or indirectly, every single person in this room. It’s a topic that can be confusing and at times polarizing. We can’t lose sight of the big picture, which is easy to do when we just look at this problem through the lens of personal responsibility or will power. Remember, I used to think that “If people just learned to eat ‘right,’ (whatever that is), exercise and control themselves and their diet, everyone would be fine.”  Today I reject that logic and the hubris that fostered it.

In the business world we know that the wrong strategy, no matter how well implemented, gives us little chance of success. Similarly, the right strategy, if poorly executed, often fails. What we need is the right strategy first and then the right execution second. At the moment, it’s hard to argue that we’re not failing with at least one of these two tasks. The question is which one.

Much of the discussion around this topic focuses on the execution; little attention is paid to the strategy or underlying insights that form the basis of the intervention.

Just 40 years ago the prevalence of obesity in this country was about one-third of what it is today, and that of diabetes about one-fifth. Is this all because Americans have become too gluttonous and slothful and the food industry figured out how to make food cheap and addictive enough? That they simply are too lazy and stubborn to do what we’ve been telling them to do—eat a little less, exercise a little more—for fifty years. Maybe. And I trust many good minds are already working on solutions to address that hypothesis.

However, what if the problem isn’t about non-compliance but about the nature of the advice we’re passing along. Maybe it’s our failure in that we have a simple idea about what causes these diseases, and like many simple ideas—paraphrasing Mencken here—it just happens to be wrong. It’s hard to fathom that two out of three Americans are simply too lazy to be active and too stubborn to eat healthy, despite losing their lives and their loved ones to the negative sequelae of these diseases.  I find that hard to believe.

So, what if the problem is that our dietary advice is wrong in the first place? And incorrect dietary advice has resulted in an eating environment where the default for most people is a diet that causes obesity and diabetes?

If HIV or lung cancer were still spiraling out of control—as they were thirty and fifty years ago before the causes were unambiguously identified—the great minds in this country and the world would be leading investigative teams of scientists to figure out what we may have missed in our understanding of the cause of these diseases. We would not be complacent, perhaps because it would be harder to blame these diseases on the victims and their lack of will power. When we fail completely to prevent two devastating disorders for half a century, isn’t it time to investigate what we might have missed—what is it about these disease states that we do not understand? If nothing else, shouldn’t we hedge against the possibility—however slim you think the odds are—that we’re not as smart as we think we are. Those of us who are here today because of our business acumen know the importance of hedges in business. Isn’t it time we did that with obesity and diabetes?

Photo by PICSELI on Unsplash

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  1. Finally managed to scrape time together to make it through the video. Peter, you are a Saint and have the patience of a champion.

    Apologies in advance, this is going to be a bit of a rant……

    I commend the work the Milken Institute is doing but although they may be non-partisan, I think the common prejudice amongst many of the group was plain for all to see. How the hell you managed to get on that panel I will never know but well done!

    I hear your points on questioning what such debates achieve but I have to admit it was very entertaining if equally frustrating. Re the comments you made on your own performance, you are evidently self-critical (a man after my own) but although I felt you started slower than you could have (possibly 75%-80% Peter Attia), I felt you finished with aplomb.

    Frustration: You are extremely nuanced and devote limitless energy to the critical details. Lynn Goldman’s retort to your middle presentation made me growl internally. This is how I saw it.
    Lynn: We know it all. We have the answers (by implication, people are dumb/self destructive). Here’s how we implement them better i.e. more of the same (and probably the same results).

    Amongst the ‘here’s what healthy behaviour we need to promote’ slides I spotted a slide showing people how they could transition from the unhealthy to ‘healthy’ breakfast cereals. Isn’t amazing how deeply marketing penetrates? If you removed the heart healthy marketing claims from the bottom of the picture, what actual nutritional difference is there across the cereal spectrum?

    I am astounded that so many clever people, with access to and awareness of the same information to you are so closed minded. Did Dean Ornish really quote a mouse study basically saying that low fat = lower risk of heart disease? Forget the risk factors (in humans) he says, concentrate on the actual plaque accumulation (in mice!!!!)
    Although I thought Dean hit on a lot of important points (stress, reduce refined carbs etc.) I really think he suffers from thinking he knows more than he does. He plainly thinks high animal protein diets are dangerous but what type of animal protein are we talking about, what quality and what confounding corollary behaviours are packaged in with this high protein consumption?

    One of the speakers made a great analogy about a questionnaire Daniel Kahneman apparently carried out asking students why they smoked (they apparently had faith in the medical system’s ability to develop treatment to save them from lung cancer before it was too late). This faith in the system extends to diet and if we continue telling people we have all the answers and to live (& die) by the food pyramid/plate, they will believe us.

    I can’t accept the argument that the main reason for the obesity epidemic is that people make irrational decisions or somehow reach for toxic foods to self-medicate other stressors (though I am not ignoring this completely). If for arguments sake, we carried out 10,000 close to perfect studies and they all vilified carbs, are you telling me that if people knew they could eat as much butter/cheese/ as they liked with minimal damage and in fact this could help them lose weight/improve health, they would not do it? It’s all about the information.

    I thought your closing section, with the analogy to smoking, was a brilliantly crafted argument (and really a knock-out blow). I watched the film Rocky at the weekend at an outdoor cinema with a few friends and the crowd’s reaction when he ran up the Philadelphia Museum steps was similar to how I felt when I watched that part (I am sad possibly I know). I know it should but it never fails to amaze me how difficult it can be to progress science.

    Well done for sticking in there Peter, Haggler (grit) and Feynman (belief in science) would be proud 🙂 ?

    Ps Thanks for the Haggler, Hearns recommendation & unbelievable coffee recipe. I feel like I owe you something.

    • JJ, you owe me nothing for the recs. You’re very thoughtful response and commentary are more than enough. I appreciate your thoughts greatly.

    • I used a Youtube to mp3 converter and also looked at the slides, but I did not see any of the reactions that might have been on thevideo. That being said:

      It is becoming clear that Ornish is the new Keys. He must be aware that mentioning questionable mice studies was grasping for straws. And following it up with a strawman criticism of a LCHP diet, which was as disingenuous as one can get with a leading LCHF researcher on the panel. As stated above, it must have been very hard to hold your tongue.

      He gave a tepid “while I support the research that Peter is doing”, he then went into a typical and presumptive “the science is settled” stance for the rest of the talk. These are high school debating tactics, but they work surprisingly well even today (and especially in politics, whether nutritional or otherwise)..

      Repeating others’ criticisms of Ornish’s research, there were many confounding factors, the sample was small, there was no statistical power, and my personal pet peeve – it has never been independently replicated in the 15 years since publication (AFAIK).

      With the caveat that he has produced some positive changes in some areas in his patients, and I am sure that there are some people who benefit more from LFHC than LCHF, I don’t understand how he continues justify his arrogance.

  2. It is amazing how much of modern medicine is still the same wretched Greek science that Western society has been following for thousands of years. “A balanced diet” is not unlike the balance of the four humours redux.. Medicine by analogy: eat fat and you get fat. The appeal to “common sense” in eat less/exercise more. The Greeks didn’t experiment, but rather thought about a problem and used analogy to arrive at a solution. We mock blood-letting and emetics, but we (i.e., the modern age) are not so far from it, it seems. Next we will be returning to the theory of the Wandering Womb (you have to read it to believe it!) to explain all things wrong with the female body. Nutritional science has become a kind of religion, in which people believe what they want to believe, ignoring or deriding evidence, because it points in the contrary direction. Whatever happened to the scientific method? It is held only by the minority, it seems, like you and Gary Taubes.

    I get angry because after years of stable (though a bit heavy) weight and tons of exercise, I dutifully followed my doctor’s advise to eat less fat, and I gained 35 pounds. Low carb has taken 10 off, but I sit here in solid ketosis, on a seemingly endless plateau, despairing of ever losing the rest. Thank you, modern medicine.

  3. Hi Peter. Very interesting blog again, right on the heels of the last one, and related in some ways.

    I find the quote you mention by Dallas Willard – “I don’t debate, but I am glad to enter into a joint inquiry. We will seek the truth together” to be a fine goal, one which suggests honourable pursuit of what is right. Unfortunately, I think it is misplaced in the present situation, that is, in the context of the panel “debate” which you attended. Not all were interested in finding the truth.

    You say “I realize folks (from readers of blogs to members of the audience at the Milken Global Conference) want facts, answers, prescriptions…”. This is probably true for the audience and the majority of those who take an interest in this subject. However, I believe it is not true for the majority of the panel members nor is it true for those in policy making processes in government, academia, and big business involved in producing carbohydrates for human consumption.

    Logical and persuasive arguments such as those you used to highlight the AIDS success story are nice, but they will not help much. The cigarette debacle ended well but how long it took! Look at how much push back came from the tobacco industry which for decades resisted any change in legislation to discourage smoking. Every legal avenue (even illegal ones) were tried to scuttle government interference. The reason it took so long was because cigarettes did not kill you fast enough. When the results of actions are clear and indisputable, things move quickly. The nutrition problem is similar and even slower.
    Unfortunately, most people do not understand science or the scientific method. They do not understand the need to constantly question our beliefs (hypotheses) if there is even a small amount of evidence which puts them in doubt. Since most people do not have knowledge of science to guide them, they default to those trusted professionals in the medical profession to be honest and right, and to tell them what to do. How many times have you heard someone say “ My doctor said that …….” . Now. as a non-medical doctor, try to convince this person that perhaps their doctor is misinformed. Not going to happen. Then there is the media which provides all the information the average person really needs. Why question such reports when they are coming from highly recognized sources in academia?

    The main problem is that this whole process of developing the “correct” nutritional advice for the country has been politically and financially driven by business interests who stand to either make or lose a lot. Science is not going to win the war. Good science will not stand in the way. We have already seen examples of science being marginalized and ignored if it did not support the status quo. Remember the case of Helicobacter pylori. The establishment ridiculed this notion that a bacteria was responsible for stomach ulcers. It finally took the good doctor to infect himself and cure himself to make an impact and win some support for his discovery. That is what I call drastic action.

    This was not a debate in which rationallity or good science prevails. There already exists tons of credible evidence which at least should make a true seeker of truth question the validity of the nutritional advice which we are given by the government, and which is supported by the professional medical institutions. There is no sign that these institutions are looking for the “truth”, but there are all kinds of signs that they are “in bed” with those who stand to lose a lot of cash if the truth gets out. We will not win this war any time soon if we cannot get the majority of the population to question the conventional wisdom. So how will this happen? As I already surmised, the vast majority do not understand science and simply trust their medical advisors, the majority of whom are plain ignorant on the subject of nutrition. This is very troubling, and I don’t have a neat solution. What I do believe, however, it that it will not happen by being polite and a “team player” (as I am sure you are) with those who are part of the problem. I think it will take dramatic and drastic action (such as publically calling some folks liars and idiots perhaps, or publically trashing someone’s research if appropriate). The media has been part of the problem, but now media is much more diversified. We need to enlist the media’s help in sensationalizing the process of ridiculing the conventional wisdom, just as those who have ridiculed good research in the past. It will take some serious leadership skill to move the population in the right direction, not through science, but through down and dirty persuasion of the traditional kind – appeal to the basic instincts of people – long life, good health, and good sex. We need to be on the offensive.

    Rational scientific arguments are fine for the vast majority of the scientific community. Unfortunately, too many of the leaders of these communities have been corrupted with money and advancement issues. It will take to long to reverse this situation. Drastic and politically visible action which garners media interest is required to shake up the status quo. If I sound like someone who believes in conspiracy theories, well I do in this case.

    I join the others who applaud you for being such a fine advocate of this cause. This is a tough battle and it needs tough people, and I believe you are a very tough guy.

    • Agree with a great deal of what you’ve suggested/proposed. How can people like you help? For organizations like NuSI to succeed, funding exceptional and rigorous science is necessary but not sufficient for change. We need an “irate and vocal minority” to set brush fires for change.
      I’d like to better understand what that looks like over the next decade. This will not be a simple petition or campaign contribution. No bumper stickers here.

      So what does the movement look like?

    • Personally I think that the movement looks exactly like what you’re creating: Fomenting distrust of doctors and health experts and fomenting trust of science and experimentation.

    • It would have to have a goal first – x amount of people with x amount of knowledge and/or doing xyz. If Nusi has a brief for organizing people for science or health, you might be able to do it through that. For online activism it would require more robust forums to create communities. Look to how Jimmy livin la vida and others organized communities for specific targets – low carb, paleo, etc and look for specific health goals among their communities. You see much further than that, you might want to have 1000 people with ability to comprehend 50% of a research paper or ability to parse statistical values, you might have those people crowdsourcing reviews of science papers, which are worth looking at which not etc. Since Denise Minger is self taught, she might have some ideas on how to get people to teach themselves. Lots of others ways to go about this with more thought.

  4. We are bombarded with advertisements for cheap high carbohydrate/sugar foods presented through targeted ad campaigns and marketing strategies designed to convince us that certain foods are highly desirable and even “healthy.” Large corporations fund “studies” and even the government presents a food pyramid that includes massive amounts or sugar. I recently noticed a wheat cereal company marketing a “protein” breakfast cereal that of course is packed with carbohydrates so they see the trends and develop a very sophisticated strategy to fool the public into thinking they are eating something healthy. In other words, the truth has been buried behind a massive misinformation campaign and a lot of junk science. Many in the medical profession are complicit or ignorant so there is no authority figure or consensus for the ordinary citizen (most of us are “followers” as you noted in another post) to find the truth.

    Trying to discuss the “facts” in such an environment is very difficult but I think it might be necessary to “debate” or confront the corporate machine and misinformation in order to change minds on a large scale. I do see a sort of slow turn in progress, hence the protein cereals and “low carb” breads etc., so I think the science may be winning out on some level. However David is trying to bring down Goliath and it is going to take a while to dismantle years of misinformation about diet and health.

    Best wishes,


    • That is a really good question Peter. My thought is that NuSI is on exactly the right track. Serious people with the science to back up their conclusions. I would not engage on a Madison Avenue level, no TV commercials, no charismatic doctors with talk shows, no bumper stickers, just serious people talking clearly to the media about the science.

      Maybe more important than the media because of the scope of their influence are the trade organizations, the AMA, the American Heart Association, etc. and the medical schools. First, I think all physicians should be required to learn about the biochemistry of nutrition in medical school through a non-dogmatic course emphasizing the best new science . Courses and textbooks on the cutting edge of the field should be part of such a program and need to be written. Second, the professionals themselves must engage in the debate with their fellows in these trade associations to try and change the paradigm.

      I am just throwing out ideas here as I am no expert. I hope we will reach a tipping point eventually. I see this happening with statins for example. My guess is that in a decade or less the medical profession will be forced to to admit that they recommended and prescribed this drug too broadly and thus caused more harm than good. Many of these doctors simply did what their associations recommend for patients so perhaps they are a significant lever to effective change.

      At least for me the movement looks like Taubes, Attia and others who have put themselves and their careers on the line to try and bring about the kinds of changes that in time will increase health and decrease health costs on a large scale. I will be very interested to see where this goes and who wins the war for public health.

  5. RE: HIV/AIDS (off topic but VERY important)
    I consider you a brilliant person. I have you as having more in common with Mullis and Duesberg than with the Ornishes of this world. Haha!
    Check this out:: https://www.niaid.nih.gov/topics/hivaids/understanding/howhivcausesaids/pages/hivcausesaids.aspx
    The articles presented as “evidence” in my view are as good as all the trash presented in the nutrtion science universe. The discussion (see link above) even states this “fact”: “Chimpanzees experimentally infected with HIV have developed severe immunosuppression and AIDS” If you notice NO REFERENCE is provided.
    Compare that statement with this: https://www.dailymail.co.uk/news/article-2034439/Lab-chimps-freed-caged-fior-30-years-injected-HIV.html
    Something’s off…
    Also, just like statins may prevent a second heart attack in certain populations (unrelated to lowering cholesterol levels), HAART is believed to stabilize certain parameters due to its ANTI INFLAMMATORY effects.
    Watch the documentary “House of Numbers”. All the top players of the AIDS field were interviewed (on both sides of the debate). It’s a great starting point. Will put some healthy questions in your mind just like Gary Taubes’ book did for the diet debate.

  6. Regarding what to do to tackle Goliath (a good anolgy btw), we absolutely have to have the media involved. After one’s own family physician, most folks listen to the radio commentaries by nutritionists and read the newpaper columns on health and diet. When these sources offer “bad” advice (not supported by good science and research studies), they need to be taken to task in possibly an arrogant way, no mincing of words. The question then is how to make this happen. In fact it is already happening on a whole bunch of good web sites, hosted by well qualified and credible bloggers. The problem is only one of exposure. Note enough of the general public read these blogs. So, what if Nusi or a similar organization (I am thinking here of something like Thincs, the network of cholesterol sceptics) would start a web site devoted to bashing the conventional wisdom, using facebook, twitter, and written communications to news media after some crappy study is published in their pages. This organization’s main purpose would be to attack all public and psuedo-public (such as medical journals) publications and news releases which require debunking. Such an organization would have to be staffed by full time employees who devote their time and energy to meeting this goal. Such an organization would have to be associated with a number of prominent medical professionals (much like NUSI) who would also write articles and critiques and provide the element of high credibility. I suspect that we already know many names who might be wiling to associate themselves with it, but I confess that this part might be a bit trickey. The existence of such an organization would have to be publicized in the media and its mission would have to become well known to the general public, hence substantial funding would be requried. I suspect a lot of the general public would be interested to follow the editorial comments of such an onganization, because people like to read about controversy and discention. Attacking the traditional advice of your government makes for very interesting reading and listening, especially when the subject matter is about your own health and well being. So I believe that it is doable. If I were a medical professional with good credentials, I would certainly try to form such an organization, so I suspect there must be others with the appopriate credentials who think similarly and are not afraid of the political and professional repercussions, and there certainly will be many.

    The existence of all the blogs on the web devoted to this subject is a good start, but these blogs wil never achieve the results which most of us would like to see in any time soon. What we need is powerful people who are well connected and with access to substatial funding and who truly want to do the right thing.

  7. Open up multi-front battles, used by other winning causes successfully, to defeat the forty-plus years alliance of government, big business, academia and media that has thrived from SAD paradigm. To protect their own self-interests, the SAD alliance will crush any dissent.

    Short-term (such as Greenpeace)
    1. At conferences and PR events, such as Milken conferences, confront the authorities’ personal conflict of interests. Point out the lack of proof, fallacies and collateral damages of SAD. Shame and stigmatize the SAD promoters and experts.
    2. Publicize the debate, via mainstream and new media to the general public that the current dogma is faulty.
    3. Organize, promote and publicize the benefits of keto.
    1. Deploy legal strategies to tie up current regulations promoting SAD.
    2. Defund SAD researchers.
    3. Instant war-room rapid responses and detailed rebukes to flawed pro-SAD studies.
    4. Coordinate an alliance of anti-SAD groups (government, big business, academia) for actions.
    Long-term (anti-tobacco)
    1. PACs to promote keto.
    2. Fund research for legitimate clinical experiments.
    3. Usurp establishments (AHA, ADA, medical societies, gov agencies) from within their power structure, similar to how Ancel Keys drove his agenda once he became a director of AHA.
    4. Coordinate and organize disparate keto entities’ actions to define plans, actions to achieve goals.

    • Agree with some, but not my question. My question was not “what is the strategy to do X, Y, Z?” My question is more about the role of folks who aren’t stupid enough to give up their day jobs, but still want to help a movement change the face of nutrition and human health? In other words, what should the readers of this blog and folks like them, with “normal” lives, be doing?

    • > In other words, what should the readers
      > of this blog and folks like them, with
      > “normal” lives, be doing?

      * Be an example. Make sure that what you are doing nutritionally actually works. Be able to explain why you’re doing what you’re doing.

      * Share but don’t preach.

      * Keep in mind that we don’t yet know what the ideal diet is for everyone (and it’s apt to be a set of diets matched to a long list of variables). What we are certain of is that the USDA MyPlateOfMetabolicSyndrome is a disaster for anyone.

      * Join the health committee where you work, or find out who’s on it and kibitiz from the sidelines. I’m the token SAD dissenter on mine.

      * Donate to nusi.org or just shop through it’s amazonsmile link (Peter smiles).

      * Sign the “Attia for Surgeon General” petition (Peter frowns).

      All seriousness aside, there probably is some maximum rate at which the culture can convert to what is likely to be a set of diets featuring lower carb, higher fat, lower n6 fat, no grains, no soy, favoring organic, favoring grass-fed/finished meats, avoiding GMO and it’s entourage, etc.

      I frankly did not expect to see that Time “Eat Butter” cover this soon.

      It’s going to take some time for the food industry to respond to radical changes in what people eat. I work in ag machinery. I eat almost nothing that our equipment plants. That’s a sobering situation.

    • Hi Peter,
      I think we, laypeople, can’t provoke big changes in the way other people think about health and nutrition:
      1) Everybody thinks they are doing the right thing. And when we say that almost all the public health institutions in the world are wrong, they think we are talking nonsense. “How could that be?” It is incredible.
      2) We are neither medical doctors nor registered dietitians. Why should people listen to us? They won’t. They don’t.

      In my experience only my family and close friends are open to new ideas: they know how fat I was one year ago, they can see me now and they know I am no moron. They know “first-hand” this way of eating works. AFAIK only my wife, my parents and a friend (he is a T2D) have changed their diets because of my success.

  8. My mistake, I misunderstood your question. I suppose the answer to that is to become informed, to engage in the debate, to experiment on themselves and find what works, and to support those individuals and organizations that promote a reasonable approach to nutrition. I suspect real change will happen from the top down not the bottom up but as voices are heard the marketplace will respond so there is value in speaking up.

    Mostly the individual should take responsibility for his own nutrition and become informed enough to make sound decisions. Correcting the rest of the world is an incremental process that will eventually tip toward significant change when the marketplace realizes it makes economic sense because enough people have “put their money where there mouth is.”.

  9. Peter, re what we readers could be doing to help this movement, I think that the working masses who just read the blogs and write comments would be able to so on a site which would be well publicized and therefore hopefully read by the masses. Its mission (provide credible information regarding science and health and debunk the bad advice offered by conventional wisdom) should be, and hopefully would be, interesting to follow by anyone who has doubts about his or her health status and what his or her medical practionner is advising as corrective action. The usual fare which is currently offered on so many blogs would now appear on a site which is read by a lot of people. These readers and commentors should also write to their political representatives and ask pointed questions refering of course to the (counter) information on the blog. Big business lobbies are only successful if they have the govenmental policy makers on their side. We need to rock the boat and create mass concern about our health so that these policy makers realize that to stay elected they need to respond. Creating a national health scare might be good, especially if the masses realize that it is not their fault that they are in bad health.

    All this may be wishful thinking, but I do believe that competing clinical studies will not make enough of a difference. Loud and abundent bombardment of the authorites in the NIH,AMA,congressmen, senators, etc. might provided a bigger bang. This can only happen if there is a well oiled machine in place which can drive public policy changes. We, the masses, can only provide the science and the anectotal evidence to support it. Even anectodal evidence cannot be ignored if there is enough of it.

  10. For the big pic strategies to fight against the SAD alliance, I leave that to the pros, such as yourself. As for myself and family, we eat keto primarily and abstain from junk and carb rich food. To make this into a movement, be an influencer and share , without being obnoxious, knowledge with our families and friends, one person at a time. The most important thing parents can do is to have their kids bring their own food to school, instead of eating federal mandated low-fat-high-carb fare served at the public school system. Educate our own kids. Get them to correlate the obesity epidemic in shoppers and what the items in the grocery cart. They must have the knowledge base and courage to stand aside from the herd, dismissing the SAD propaganda. We may not be able to change the older generations; but we have a chance to try to save the next.

  11. I think a grass roots movement is beginning to create a stir. I see more and more papers touting the evils of sugar and carbohydrates.  This is do to your contribution Peter. You need to do exactly what you have been. You are are providing a well crafted pathway through education. 

    Peter, you have taught us what the problem is. You have provided us with evidence to back up what you say. Then you have shown us how to interpret it for ourselves, how to recognize the fallacy from the logical in the conclusions of the research. You have provided us with the tools we need to talk to our physicians in ways they will respect our opinion.

    You have offered the counter argument and not only shown us the bad interpretation but have given us the tools to find it for our selves.

    This is a passionate debate that incites emotional (and irrational) responses from I’ll-informed naysayers whose only tools for debating are to scream and yell thinking that those who yell loudest are right.

    I am an educated lay person (who has earned my masters in other than science). I see more talking (by myself and others) taking place, some quietly, some not so quietly. I can now talk intelligently about low carb because of you and this blog. 

     I notice two things, the quiet agreers are nodding and joining the conversation and people are beginning to listen (of course Dr. Oz being lambasted before the Senate helped. Sorry, couldn’t help that one).

     I  agree, the “squeaky wheel does get the oil” but, we need more refutation of the bad science not only by organizations like NuSci, but by researchers, without agendas, who loudly speak up and say, Hey, wait a minute that argument  doesn’t make  sense for these reasons.

    We need to keep talking, with the tools you have provided us, sometimes loudly, sometimes quietly (and perhaps with a big stick?).

  12. What’s wrong with bumper stickers? We need memes to combat “Artery-clogging saturated fat.” Keto is King. LoFat -> Fat. LowCarb for Diabetes. Sugar kills. A calorie is not a calorie. Carb/Insulin/Fat. Fat is the new carb. If the controversy won’t fit into a bumper sticker, it won’t fit into people’s attention span.

  13. 2:25 into the panel video: “More than 50% of all economic growth in the last 200 years” has come from public health and medical research? I really doubt that. It’s hard to take someone seriously when they start with unscientific BS like that.

  14. You are my hero, Dr. Attia. Not only because of the tireless effort you make to truly help people, but for your ability to stay calm and thoughtful during that discussion! I have to admit I got quite angry with a couple of those panelists! But as I reflected on the massive success (this is not an overstatement) I’ve had in the 5 weeks since discovering your blog (through your wonderful TED Talk!), it just made me sad. You truly have your work cut out for you.

    The fact that these health professionals still tout the conventional wisdom despite all evidence to the contrary is just plain depressing. It would’ve been a better discussion if they would have shown the maps charting the increase in obesity in the US at the beginning of the discussion instead of the end. It would take an unrivaled set of cajones to make some of the assertions the panelists were making in light of that information!

    All I can say is thank goodness for NuSI. It’s crystal clear that if we want any meaningful scientific studies done on this topic we’re going to have to do it (and fund it) ourselves!

    • Well, yes, we definitely have our work cut out for us. I try not to reflect on that often, otherwise I’d stop tomorrow and do something different.

    • It certainly wasn’t my intention to discourage. Let me add a little perspective to my frustration. I’ve been dieting by the conventional wisdom for over 30 years. Not only was I unsuccessful, but I was worse for it in ways that go well and far beyond a number on a scale. I won’t take up space and time with personal specifics. Suffice to say that I completely related to your personal journey (x 100!)

      The majority of the focus tends to be on physical wellbeing, but as someone who has lived over half my life as an obese woman I feel there is a significant need factor in emotional and socioeconomic wellbeing, too. Perhaps I took things too personally, but all I could think listening to this discussion was how people will take what they are saying as hard fact and use it to justify judging, shaming, humiliating, underestimating, undervaluing and underpaying a rather sizeable group of individuals.

      However, what I was really trying to accomplish in my post was to get the folks who value your efforts as much as I do to donate to NuSI. Perhaps I was too subtle. I can’t imagine the effort it takes to prepare for these types of discussions and to maintain this blog (heavy on real information with very clear explanations of complex ideas) and you’re not even trying to sell me supplements, powders, or books. There are no advertisements. There’s not even a donation button. Top that with heading a non profit and I have to wonder when you sleep! But here’s what got me. All this effort has the potential to benefit me far more than it will you, yet you are making most of the sacrifice (I’m sure you aren’t making the salary you would as a Surgeon!). It is truly the least I can do to forgo a few lattes!

  15. Well, how about starting with a citizen and health professional lobbying effort to have a government funded review of current medical research that determines once and for all what a healthy diet is comprised of? Different nonprofit and public interest groups could work together to fund the lobbying effort.

    Once a healthy diet is determined, pressure the appropriate government agencies to change public policy to support the research. THEN the bumper stickers kick in! (the parallels with the tobacco industry are pretty amazing.)

    The “carb lobby” is going to fight it all tooth and nail b/c profits are involved! But we did manage to drastically reduce tobacco use in this country.

    It’s always interesting to me to walk through the grocery stores and see the aisles of carbs. Whole aisles devoted to energy bars, cereal, crackers, etc., many purported to be healthy! It’s going to take an effort to alter public perception, but it can be done.

    • I am also thinking along the lines of CW. We all need to start writing to our ELECTED government reps stating our case to the best of our ability. I believe that elected reps pay attention to such things when there is a significant volume of letters, whether email or otherwise.

      I just finished reading “The Big FAT Surprise” by Nina Teicholz which I enjoyed immensely. Even though most of us were aware of the general picture about Keys and his cronies, Nina included a lot of information about other players and research of which I was unaware. Significantly, I was surprised that, according to NT, elected officials, who started to receive mail from their constituents about the nonsense that was going on, reacted and started to panic. This is what we need to make happen again. I can’t believe that the leaders in the diet-heart hypothesis and their many associates (including elected officials) are not aware of the ground swell of rebellion regarding the poor nutritional advice which became and still is public policy. I bet they are still counting on the fact that we are a small group of unorganized sh*t disturbers and they will prevail, at least for another 10 years. In this age of internet, speed of light, communications, I think they will lose. We need to help make this happen as fast as possible by bombarding our reps and the media with letters, facebook posts, tweets, whatever, protesting the stupidity that is being ignored by the establishment and the waste of money which is being spent on dead-end research. Where is the science in all of this? There isn’t any.

  16. One possible tactic for getting the word out

    The way in which news stories propagate across the most watched platforms (web, TV, radio, print) often times depend on an originating source with sufficient credibility for news editors in smaller newsrooms to be comfortable repeating the story with minimal incremental investment in time or resources. That is the nature of the news industry with constant demand for stories yet limited budgets for original content creation.

    For those intent on having their message heard given a viral news propagation environment such as we have, it is necessary to have each new message published or posted by a news outlet with sufficient credibility within the news-editor community such that the virus begins to multiply within and across news platforms (ie. go-viral).

    There are a few national outlets that could be targeted (AP, Time, CNN) and the tactics may be varied depending on the openness of a news outlet to counter or non-mainstream ideas (regular columnist, panel member, feature article, or editorial influence).

    Once Peter were to become a regular contributor to any of these credible source news organizations, there is created an instant viral multiplier effect which can be counted on to reach millions of people as multiple news outlets reproduce the storyline on thier platform. This would be a much more powerful for message propagation than the blogging model which tends to attract like-minded people with a strong interest in a topic.

  17. I just saw something online that I have never read about in detail in any of my voracious reading of low-carb books, blogs, etc. I would be grateful if you would address it briefly here.

    Maybe this isn’t totally relevant to your post, but since the topic is success vs. failure, I suppose any comment could be technically be responsive, provided it has to do with whether various theories re weight loss have any merit. 🙂

    Here is the issue. Most everything I’ve read from you, Taubes, Eades, etc., have focused on reducing carbs as the primary way of lowering insulin levels to control obesity. And it all made sense to me. But I just watched a YouTube video by a Dr. Jason Fung. He spoke about how various foods score on the insulinogenic index — and the levels do NOT always correlate with the glycemic index or carb load. Apparently some proteins cause a far greater insulin response on this index than do some carbs. I did some research online and found this to be true. (E.g., Per the always reliable Wikipedia, All Bran has a 40 percent lower score than beef!)

    Question: why shouldn’t we be focusing more on this index as opposed to carb grams if we want to lose weight, avoid metabolic syndrome, etc.?


    • Not sure. It’s more than just unit insulin response, it’s also the substrate being provided. Protein will primarily be used for muscle anabolism before GNG, but starch will first be used to replace glycogen, then DNL.

  18. Thanks much for your answer re the insulinogenic index. The fact that I can write to you and get a response within a few days says much about my thoughts on the question you posed here.

    I know your question is how to get the word out, and it is an important one, but just a few thoughts on the unstated assumption that it isn’t happening.

    The Internet is allowing it to occur organically in ways that were never possible before. Gary Taubes wrote GCBC in 2007 (just under 7 years ago) and WWGF fewer than 4 years ago. I’m not a doctor (unless you count being a Juris doctor ;-)) but it seems from my the ideas he wrote about are now largely considered (at worst) somewhat controversial and untested scientific theories, and (at best) obvious scientific truths that need more study.

    But when he first wrote “What if it’s all a big fat lie” in the NY Times magazine (12 years ago this month), the reception he received was that of a total lunatic. It was essentially the same as the one Atkins received 30 years before. I was struck by this a few weeks ago when I reread the article and then some reviews of it in the popular press.

    Thing has come so far, so quickly. And I have every hope that NuSI is going to continue this progress exponentially in the same manner that things have already been happening.

    You are a perfect example of this phenomenon. You are now posed to become one of the world’s most respected authorities on obesity and nutrient metabolism. But just five years ago, you were just some overweight (but fit) physician who never could have predicted where your life would quickly turn after your wife’s gentle comments on your physique got you thinking. If she had made those comments in 1985, you may still have been spinning your wheels trying to follow Pritikin or something else. The low-carb resources you found online have been seen by millions of others.

    For every Peter Attia, there are docs who are learning about these ideas and lay people who are too. They may not end up leading a 501(c)(3) that may change the world, but they are opinion leaders who are creating a critical mass of thought. I think of an acquaintance who trains people with Cross-Fit. He (and his colleagues) would never consider urging their clients to eat low fat muffins in the morning to stay fit.

    Before the Internet, these “new” ideas couldn’t be shared at 1/100th of the efficiency they can be now. Not only does the Internet give people the means to learn about and share ideas more quickly, but it also gives a voice to smart people (non-MD researchers) who can spread the word without fear of funding being cut off. Had the Internet been around from 1950 onward, I believe Yudkin would have won the debate against Keys. Keys could not have held a lofty, largely untouchable place from which he would spread untested theory as gospel. Nor could he have easily acted as a scientific bully to mock those who disagree with him without fear of being challenged by the masses (eg., opinion leaders who read about this stuff – docs and others – and then share their thoughts online).

    I think it is beyond reasonable debate that the progress that has been made in the past 5 years will be a fraction of what takes place between now and 2019. That is just the way things work when people learn about ideas. One person tells two, who each tell two, etc. Before long, people who read the “Big Fat Lie” article would view it as a mundane statement of the obvious and not the scientific equivalent of an argument that the world is flat.

    So just keep it up, Dr. Attia. You are changing the world more quickly than you can possibly imagine.

    • And PS – it appears the increased knowledge is already paying health dividends. Last I looked, childhood obesity rates are already starting to inch down. And I’m sure the reason is an emphasis on decreasing sugar from the diet.

    • Thank you, Norm. That is a great article discussing the notion that “insulin isn’t that important after all.”

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