Lifestyle Medicine on Trial: Nicola Guess Challenges Dietary Dogma with Nicola Guess

In this episode of Sound Living, host Dr. Mike Banna welcomes registered dietitian Nicola Guess to explore the complex role of carbohydrates in lifestyle medicine. Drawing from her extensive experience with type 2 diabetes, Nicola emphasizes the need for nuanced dietary guidelines, challenging common misconceptions about carbohydrate reduction's impact on glycemia.

They go on to talk about the risk of oversimplification in lifestyle narratives like veganism and low-carb diets, and address the polarised views within nutritional discourse.

Guest:

Dr Nicola Guess RD MPH PhD (https://substack.com/@drguess)

Episode Transcript

Mike: Hello and welcome to this episode of Sound Living, the BSLM podcast. (00:28):
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Mike: I am very happy today to be welcoming Nicola Guess to the podcast. (00:32):
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Mike: Nicola is somebody who I have followed for a very long time and have learned (00:38):
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Mike: an awful lot from about nutrition, nutritional science and carbohydrates. (00:42):
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Mike: So I would love to welcome her to this podcast. (00:47):
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Mike: Nicola, for those of the listeners who don't know who you are, (00:51):
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Mike: can you give us a little bit of background on yourself? (00:55):
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Nicola: Sure. I'm a dietitian. I've basically always worked as a diabetes dietitian, primarily in type 2. (00:58):
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Nicola: And then I moved into research and I did that because I didn't think there was (01:04):
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Nicola: much evidence for me to use with my patients. (01:08):
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Nicola: So about 15 years ago, I started on a research career. (01:10):
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Nicola: And ever since, I've combined clinical work with clinical research. (01:14):
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Nicola: And it's really been in the area of type 2 diabetes prevention, (01:19):
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Nicola: management, and a bit on blood pressure, NAFLD, and other cardiometabolic diseases. (01:22):
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Mike: Amazing and i i know that um you know (01:27):
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Mike: diet and nutrition are a huge topic in the lifestyle medicine space and (01:29):
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Mike: particularly when it comes to um (01:33):
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Mike: to the subject of carbs i think that it divides opinion quite significantly (01:36):
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Mike: so i'd love to delve into a little bit of that with you um one of the main reasons (01:40):
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Mike: that we that we invited you on onto the podcast um was was off the back of a (01:45):
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Mike: post that you made about lifestyle medicine on instagram um i think probably quite a while ago now, (01:50):
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Mike: which I found absolutely fascinating because I think. (01:55):
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Mike: As somebody who wants to promote lifestyle medicine and as somebody who is part (02:00):
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Mike: of an organization that promotes lifestyle medicine, (02:06):
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Mike: I'm absolutely fascinated to learn and understand more about the reputation (02:08):
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Mike: that the topic has among other people, (02:13):
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Mike: both members of the public, other professionals, and those who may or may not (02:15):
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Mike: be as passionate about the topic as I might be myself. (02:19):
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Mike: And it's always interesting to see how it gets interpreted, reinterpreted, (02:23):
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Mike: misinterpreted, And, you know, (02:28):
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Mike: both by those who promote it and those who who hear about it as well. (02:31):
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Mike: So we will delve into that into that post a little bit later in the podcast, (02:36):
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Mike: which I'm very excited to talk about. (02:41):
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Mike: And but to start with, can you give me like a lowdown about carbs? (02:43):
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Mike: Because I think that one of the things that I I struggled to get my head around (02:48):
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Mike: is I feel like there's a lot of evangelism about carbohydrates and about generally, (02:53):
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Mike: you know, about diets generally. (02:58):
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Mike: In the world and in the world of lifestyle medicine. (03:00):
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Mike: And I feel like a lot of the time we're told that specific diets do this and (03:02):
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Mike: are magic for this and have all of this evidence behind them. (03:07):
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Mike: And it's so hard to sort the wheat from the chaff. (03:10):
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Mike: And, you know, I've been to talks that you've done about carbs and it's really (03:13):
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Mike: helped me understand a little bit about it. (03:16):
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Mike: Talk us through a little bit of the work that you've done just to give us a (03:21):
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Mike: bit of a background to start with? (03:24):
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Mike: Because I think that really gives us an idea of your level of expertise on carbohydrates, (03:26):
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Mike: and then we'll delve into the science. (03:31):
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Nicola: Sure. I mean, I can probably start and introduce my research in a way, (03:35):
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Nicola: and the reason I did it was because of what's been done before. (03:40):
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Nicola: And in my view, that data was difficult to interpret. (03:42):
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Nicola: So historically, with nutritional science, when we do controlled trials, (03:45):
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Nicola: we do randomized controlled trials, they have nearly always been free living. (03:50):
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Nicola: So effectively, you have two groups, you randomized one group to low carb advice (03:54):
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Nicola: and another to a control diet that might be high carb, it might be just do what you were always doing. (03:58):
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Nicola: And the problem with free living studies is it's very, very hard to get people (04:03):
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Nicola: to stick to your dietary prescription. (04:08):
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Nicola: Because of course, this isn't the real world where you want to personalize it. (04:10):
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Nicola: If you want to test, does carbohydrate modification per se influence glycemia, (04:14):
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Nicola: you want your carbohydrate ideally to be the only thing that doesn't change. (04:19):
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Nicola: And there are a couple of problems there. One, it's really difficult to do that (04:23):
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Nicola: in a free living study, because what we know from looking at data is the average (04:27):
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Nicola: person, they might start out low carb, but carb will creep back into the diet (04:31):
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Nicola: because it's typically that's the diets people have had, that's what they'll continue doing. (04:34):
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Nicola: So that's one thing. The other thing is in nutrition, you can't just change one macronutrient. (04:38):
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Nicola: Because if you're reducing carbohydrate. (04:45):
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Nicola: You're either reducing calories and that's a confounding factor. (04:48):
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Nicola: But if you want to keep calories constant to reduce carb, you've got to increase protein. (04:50):
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Nicola: So then you've changed two variables. So let's say you see glucose go down. (04:55):
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Nicola: Is it because you reduced your carbohydrate or did you increase your protein? (04:59):
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Nicola: So those are just two issues in some of the studies that have been done that (05:03):
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Nicola: just make it so difficult to draw any interpretations. (05:07):
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Nicola: And I actually recently wrote a piece on my blog about (05:10):
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Nicola: is a study looking at advising people (05:13):
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Nicola: to cut carbs to understand the effect on glycemia or (05:17):
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Nicola: does cutting carbs affect glycemia because the (05:20):
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Nicola: two are quite different things and so the kind of (05:23):
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Nicola: research I've wanted to do is to get a definitive answer for does cutting carbs (05:25):
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Nicola: obviously with some nuance that we'll come to independent of weight loss independent (05:31):
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Nicola: of other things hoping that we know that people stick to the diet influence (05:35):
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Nicola: glycemia so we want basically want to get it a bit more controlled. (05:39):
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Nicola: So just to give you an example, and I mentioned protein specifically because (05:43):
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Nicola: there's lots of data that's manipulated protein, (05:48):
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Nicola: kept other things the same, and you can see protein increases insulin acutely (05:52):
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Nicola: and lowers glucose in healthy people or people with and without type 2 diabetes. (05:56):
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Nicola: So whenever I've looked at low-carb studies, I carefully look at, (06:01):
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Nicola: well, what was the protein? (06:04):
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Nicola: And for me, the studies that show the best effect on glycemia have an increase in protein. (06:06):
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Nicola: And so what I did is I designed a study where we kept protein constant. (06:12):
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Nicola: So we kept it at the regular amount, but we manipulated carbohydrate alone. (06:16):
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Nicola: And what we also did is we kept weight constant. (06:21):
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Nicola: And the idea about that was doing kind of controlled research to understand (06:24):
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Nicola: if you don't increase protein and you don't lose weight, does manipulating carbohydrate (06:28):
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Nicola: influence glycemia? And we did that in type 2 diabetes. (06:32):
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Nicola: And within the doses that we tested we did not see an effect on modest manipulation (06:36):
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Nicola: of carbohydrate alone on glycemia. (06:41):
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Mike: That's very interesting so so. (06:44):
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Nicola: Yeah so. (06:47):
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Mike: Then do we conclude from that that the main effect of that comes from when we (06:47):
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Mike: when we lower carbs we lower calories and we lose weight is that. (06:53):
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Nicola: This is where nutrition is always so complicated and i think this is a great (06:57):
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Nicola: example of why what does low (07:01):
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Nicola: do is almost so vague as to be a pointless question because we assume a lot (07:03):
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Nicola: of nutritional research does and people do generally that there is always a (07:08):
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Nicola: linear relationship say between carbohydrate and glycemia and why would that (07:12):
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Nicola: necessarily be the case so for example I don't think modifying carbohydrate between let's say, (07:17):
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Nicola: 60 grams a day and 150 grams a day. (07:23):
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Nicola: I'm just kind of pulling these figures out of thin air, but roughly around that. (07:28):
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Nicola: Manipulating carbohydrate within that level does not over time influence glucose (07:31):
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Nicola: because the body adapts. (07:36):
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Nicola: But if you go low enough carb, even without weight loss, if you go low enough (07:38):
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Nicola: carb, you'll get generation of ketones. (07:43):
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Nicola: And that does seem to, independent of weight loss, lower glucose. (07:45):
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Nicola: And there's actually some data showing exogenous ketones acutely in type 2 diabetes (07:50):
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Nicola: and over time lower glucose so you take all of that together and it does look (07:54):
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Nicola: like if you go keto and you probably don't need to lose weight you can lower (07:59):
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Nicola: glucose by how much i don't think we know yet but so that's the kind of nuance i'm talking about so, (08:03):
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Nicola: is it just due to weight i'm not sure i think protein and ketones are modulators (08:08):
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Nicola: um and probably some of the effect in most of the studies and. (08:13):
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Mike: Is that um is that specific to diabetes or do we are we talking about like reasonably (08:18):
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Mike: significant fluctuations in glucose in non-diabetic people as well. (08:25):
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Nicola: Um so the keto the studies in ketones i've seen were in type 2 diabetes okay um, (08:30):
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Nicola: And with low carb, weight neutral, yeah, I think if you go, whether in people (08:37):
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Nicola: with diabetes and without, (08:45):
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Nicola: yes, it looks like going low enough carb does lower glucose significantly without (08:48):
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Nicola: or independent of weight loss. (08:53):
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Mike: And because I suppose that this sort of leads me to explore, (08:55):
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Mike: because again, there's so much stuff around this, because most of the time that (08:59):
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Mike: you see information about things (09:02):
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Mike: like low carb diets or keto diets on the internet is either by people who. (09:03):
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Mike: Are um vicious advocates for them (09:07):
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Mike: who are kind of you know quoting evidence that may or may (09:10):
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Mike: not exist or people who are viciously against (09:13):
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Mike: them who are you know who who are um who (09:16):
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Mike: are you know just refuting evidence and and (09:20):
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Mike: it is difficult as a consumer and even as a you (09:23):
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Mike: know as a health professional i think a lot of the time to try and to try (09:26):
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Mike: and differentiate between those things um and (09:29):
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Mike: a lot of people recently seem to be (09:32):
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Mike: talking in a in a similar vein about things like artificial sweeteners (09:35):
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Mike: as well sort of the idea that artificial sweeteners (09:38):
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Mike: have a significant effect on glucose spikes and (09:42):
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Mike: therefore um cause things like insulin (09:45):
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Mike: resistance and make you more likely to develop conditions like (09:48):
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Mike: diabetes um and i'm (09:51):
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Mike: keen to explore that because I love a (09:54):
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Mike: diet coke as much as most people do um and (09:57):
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Mike: I've always I suppose it myself kind of (10:00):
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Mike: advocated for it in the sense that you know if you're if (10:03):
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Mike: you're considering trying to trying to moderate your calories I found that things (10:06):
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Mike: like you know diet coke and um stuff with artificial sweeteners in it can be (10:10):
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Mike: a really really useful tool in that arsenal and trying to facilitate lifestyle (10:15):
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Mike: change yeah um so I'm keen to explore you know what is the data behind that (10:18):
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Mike: where where should we be pitching that? (10:23):
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Nicola: I mean, here is a really good example of when considering effect size is something (10:26):
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Nicola: that should be front and center. (10:34):
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Nicola: Because a lot of studies, you know, they might have statistical significance, (10:35):
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Nicola: and they might look in a large enough sample size to find even a small difference (10:41):
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Nicola: and it will come up statistically. (10:45):
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Nicola: And that might be under controlled conditions. (10:47):
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Nicola: So you see a signal coming through maybe maybe (10:50):
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Nicola: the artificial sweeteners do something now even with that said now this isn't (10:53):
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Nicola: my area and i certainly haven't read all of the studies out there on this but (10:58):
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Nicola: the ones i have seen they either don't show an effect or in my view it's kind (11:01):
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Nicola: of a bit of data manipulation to get a sexy paper and even where there is a (11:05):
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Nicola: an effect that we see it's very very small. (11:10):
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Nicola: Whereas the example you gave and and (11:14):
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Nicola: there's never going to be a perfect diet that works for everyone so (11:17):
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Nicola: it's about looking at tools as you've described and for (11:20):
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Nicola: a certain proportion of people simply switching to (11:23):
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Nicola: a full fat coke as we call it you know what i mean i said that on an (11:26):
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Nicola: american podcast and they were like what are you talking full fat coke (11:29):
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Nicola: i was like oh you know regular coke like if someone's (11:32):
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Nicola: having let's say three cans of regular coke a day switching to diet coke is (11:35):
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Nicola: boom it's going to save you calories and that's a really powerful tool and so (11:40):
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Nicola: if you lose enough weight and let's say your insulin sensitivity making this (11:43):
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Nicola: figure out but let's say it reduces by 25% and the artificial sweeteners in it, let's say, (11:47):
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Nicola: increase your insulin resistance by 1%, well, you've got a net win there. (11:53):
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Nicola: And it's that context that's missed. I mean, would you advise someone that having (11:58):
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Nicola: a diet Coke is good for you? (12:02):
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Nicola: I don't think you'd go that far. But does it do anything that we can probably (12:04):
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Nicola: reasonably measure taking into account a bunch of other lifestyle factors? I doubt it. (12:07):
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Mike: I think that's the key, isn't it? And I think that a lot (12:13):
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Mike: of the time people often get caught (12:16):
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Mike: up in this kind of appeal to nature kind of logical fallacy where they think (12:19):
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Mike: that everything has to be natural and i think like yeah in an ideal world or (12:23):
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Mike: in an ideal lifestyle you might say yeah drink plenty of water and let all of (12:29):
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Mike: your fluids that you drink be water that would be great but i think if you're talking about i. (12:32):
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Nicola: Like vodka and diet coke so. (12:37):
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Mike: Well exactly and. (12:38):
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Nicola: It's fun and it makes my life fun so don't care about. (12:39):
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Mike: I think that's the key is it's about balancing you know what works for you between (12:42):
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Mike: enjoying life and finding a lifestyle that works for you and you know, (12:47):
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Mike: I know how long I would last if I was only drinking water and I wasn't allowed to have, you know, (12:50):
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Mike: squashes or Diet Cokes or anything like that. (12:56):
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Mike: I know how long I'd last trying to stick to that. And I think that that's the (12:59):
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Mike: key is making lifestyle change sustainable, (13:03):
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Mike: while like by accepting that there will always be imperfections in somebody's (13:07):
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Mike: diet and actually trying to manage, you know, whether those have any significant effects. (13:11):
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Mike: And like, you know, know like you're saying i haven't really seen any (13:16):
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Mike: well demonstrated arguments to say that (13:19):
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Mike: people should be cutting out diet coke i definitely agree (13:22):
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Mike: that there's a huge argument for saying that if somebody is drinking only water (13:25):
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Mike: you shouldn't advise them to drink diet coke like you know right but i think (13:30):
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Mike: that there's a huge difference and i think actually i remember this this coming (13:34):
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Mike: up as a discussion a few years ago at a um lifestyle medicine event oh you remember. (13:37):
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Nicola: My answer i was not feeling well that day and i gave i gave a really um abrupt (13:43):
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Nicola: answer which which i think was correct but i i. (13:48):
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Mike: Was very firm. (13:51):
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Nicola: And and you know why i did let me just sorry to interrupt you it was because (13:52):
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Nicola: that person was not asking me a question they were telling me that it was unnatural (13:55):
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Nicola: and why would you advocate for. (14:01):
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Mike: Something unnatural. (14:03):
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Nicola: And like you've just said i mean like for example i've had patients who drink. (14:04):
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Mike: A liter and a half of coke a day exactly and. (14:08):
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Nicola: Switching to water you know maybe there's some people that could do that but (14:12):
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Nicola: for someone who can switch. (14:15):
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Mike: To coke zero. (14:16):
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Nicola: You know huge huge. (14:16):
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Mike: Impact exactly so to just provide some context for for the (14:18):
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Mike: listeners we were at a lifestyle medicine event (14:21):
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Mike: and actually um nicola set a few (14:24):
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Mike: case studies for us to discuss and the the case (14:27):
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Mike: studies were basically people and it was a (14:29):
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Mike: description of different people's lifestyles and what were (14:32):
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Mike: you know a couple of name a couple of things that you could do to have (14:35):
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Mike: the biggest impact on that person's lifestyle and one of the people was somebody (14:39):
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Mike: who was um i think it was you know working shifts perhaps i think as a as a (14:43):
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Mike: lorry driver or something like that could only really get their food from service (14:47):
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Mike: stations and um drank however many liters of of coke a day for example. (14:51):
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Mike: And one of the suggestions of how to improve that person's lifestyle was (14:58):
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Mike: to switch to diet coke because it's an easy ish (15:01):
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Mike: transition it's not you know overextending that (15:04):
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Mike: person to be making a huge change of their lifestyle it's it you know it goes (15:07):
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Mike: with the bslm hashtag one change approach it's making small sustainable changes (15:10):
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Mike: to people's lifestyle which actually help you know that are that are um things (15:16):
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Mike: that they can stick to um without trying to you know trying to change the world in one fell swoop. (15:19):
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Mike: And one of the people in the audience was quite horrified at the idea that we (15:25):
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Mike: at a lifestyle event could be advocating for somebody to be drinking unnatural things like Diet Coke. (15:30):
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Mike: And I do think that it is a great source of misunderstanding in the lifestyle (15:37):
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Mike: medicine world that there has to be this sort of almost moralistic adherence (15:41):
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Mike: to this idea of the perfect diet. (15:47):
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Mike: And I think that it's very easy to get caught up in that if perhaps that's always (15:50):
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Mike: the world that you've lived in or that you've managed to live in that world yourself. (15:56):
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Mike: And I think that sometimes it can be very difficult to appreciate how difficult (16:00):
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Mike: it is for people who might have three or four decades under their belt of living (16:04):
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Mike: a certain way to try and change their lifestyle. (16:08):
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Mike: And actually, we should be reducing the friction rather than creating it when (16:11):
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Mike: we're trying to help people make those changes. (16:16):
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Nicola: And I think it's also putting your values on someone else. (16:19):
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Nicola: Just because you think your body is a temple and you treat it that way. (16:23):
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Nicola: And for some people, you know, that's wonderful if they eat clean, whatever that means. (16:26):
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Nicola: But for other people, it's not such a big deal. Like they want to be healthy, (16:30):
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Nicola: but they don't need or want to be perfect. And it's about meeting someone where they're at. (16:33):
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Nicola: But I would just add, I think there's another reason why you hear these things (16:38):
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Nicola: like about artificial sweeteners. (16:42):
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Nicola: There is this eating according to nature and going back to our roots. (16:43):
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Nicola: But I also think it's a lack of experience with research. (16:48):
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Nicola: And it's really over extrapolating from (16:51):
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Nicola: one bit of research and having been in the field for (16:54):
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Nicola: a long time the one thing that i'm learning and i've (16:57):
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Nicola: still got a lot to learn but certainly when i speak to people (17:00):
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Nicola: who've been you know professors in the field for 25 years it's context (17:03):
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Nicola: it's knowing where to put one randomized (17:06):
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Nicola: control trial or one short nature medicine (17:09):
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Nicola: whatever paper exciting paper in the microbiome where to put that into context (17:13):
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Nicola: taking everything else into account and you can see these people when they get (17:17):
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Nicola: overexcited about one new sexy paper and and that's what they use to define (17:21):
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Nicola: the advice that they give and that's just I don't think that's helpful no. (17:26):
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Mike: And where do you think that that comes from like why do we why do we do that (17:30):
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Mike: is it because we're after the you know we're after the secret so we're just (17:34):
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Mike: we're excited by these sexy papers and we just want to find something to. (17:38):
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Nicola: Tell people. (17:41):
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Mike: That we think is going to fix everything. (17:41):
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Nicola: I mean I think it's partly that. I mean, I do think, you know, (17:43):
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Nicola: when I've spoken to people who, I can't think of a better way to describe this, (17:48):
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Nicola: who kind of come across a little bit crazy about nutrition, and I try and explore (17:52):
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Nicola: why they think all these things that they do. (17:56):
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Nicola: And I think a lot of it is, like, for example, the gut microbiome. (17:58):
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Nicola: Okay, you know, I'm just going to name names. (18:02):
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Nicola: Tim Spector thinks that dietary advice has failed because we haven't been eating (18:04):
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Nicola: according to our gut microbiome. (18:08):
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Nicola: And that, I think, does come from frustration that regular guidelines have failed (18:11):
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Nicola: because people think the guidelines have failed. (18:17):
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Nicola: I mean, they haven't helped because they haven't changed our environments. (18:20):
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Nicola: And that, for me, primarily the problem. (18:23):
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Nicola: And so I do understand, and if I'm trying to be empathetic, people look at the (18:25):
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Nicola: health of the UK today and indeed around the world. (18:31):
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Nicola: They look at the guidelines and they say, well, the guidelines must be wrong (18:33):
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Nicola: because they're not helping. (18:37):
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Nicola: Therefore, it must be the microbiome. it must be the artificial sweeteners it (18:39):
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Nicola: must be the additives and you know if you're if you're being nice about it it's (18:43):
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Nicola: people looking for a solution and i think it's not sexy to say, (18:46):
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Nicola: eat in a way that can manage a healthy weight do enough physical activity don't (18:52):
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Nicola: drink too much and don't smoke that's basically what we know with a lot of confidence anyway so. (18:57):
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Mike: I guess if you weren't being nice what would you say. (19:01):
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Nicola: Oh i mean i i mean i i guess what i'm interested I don't mean to. (19:03):
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Mike: Obviously I always want to be nice I think it's important to be kind and to (19:12):
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Mike: be empathetic but I think what I'm very keen to explore. (19:15):
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Nicola: If I'm being real yeah I would I mean. (19:18):
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Mike: What I want to do is I want the listeners to go away with an (19:20):
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Mike: idea of what they should be believing and what (19:23):
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Mike: they should be questioning I think that that's that's really (19:26):
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Mike: important here is that actually I think that there is (19:29):
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Mike: a lot of a lot of people who are very very emphatic in (19:32):
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Mike: how they describe evidence and in how they describe um you know what we should (19:35):
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Mike: be doing um and it's really hard as a you know as a medical professional who (19:40):
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Mike: is not trained in nutritional science who's not a dietician it's hard when people (19:46):
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Mike: tell you with it from a place of authority what you should be doing. (19:50):
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Nicola: Here's my keeping it real answer i think people like the attention they like being a guru, (19:53):
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Nicola: um you could see it during the pandemic when people (20:01):
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Nicola: who were previously being terrible in science (20:04):
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Nicola: with regard to nutrition and not understanding the methods or anything and they (20:07):
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Nicola: all moved to covid and they had lots of wrong opinions i'm sure about covid (20:11):
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Nicola: and their follow account just exploded and then they did it more and more and (20:14):
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Nicola: i think that's probably some behavioral psychology that i couldn't begin to (20:19):
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Nicola: understand but i think people people like the attention. (20:23):
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Nicola: They like, oh, Dr. So-and-so or whoever, what do you think about this? (20:26):
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Nicola: And you see it with, okay, I don't mean you because you're actually a doctor, (20:30):
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Nicola: but you see it with the podcasters. (20:34):
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Nicola: And, you know, I see some of these dudes who've never seen a patient in their lives. (20:37):
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Nicola: They've never run a clinical trial in their lives. And they get these gurus (20:40):
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Nicola: online. And it must feel so good. (20:44):
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Nicola: I mean, I really like it. It feels good when patients come to me and ask me (20:47):
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Nicola: things, when other healthcare professionals say, Nicola, could you come and give a talk? (20:50):
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Nicola: It does make you feel good. And I think that's addictive. (20:54):
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Nicola: And I think that's what's doing it. and it's very easy with social media to (20:57):
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Nicola: have crap opinions that sound plausible enough and if you're telling people (21:02):
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Nicola: what they want to believe all the better um and i think that just turns the (21:07):
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Nicola: circle you know round and round they get a book deal they get to be on television. (21:11):
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Mike: I mean i guess like because then the other side of of the argument as well is that if, (21:15):
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Mike: because i think i think for the most part the majority (21:20):
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Mike: of the advice that gets given by these people is i'm (21:23):
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Mike: not all of them there are some some some who give very terrible advice but even (21:27):
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Mike: the ones that don't necessarily seem to be completely supported by science are (21:32):
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Mike: often giving pretty reasonably healthy recommendations i guess what i'm interested to explore is what is, (21:36):
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Mike: you know how far should we be pushing no that's not (21:45):
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Mike: correct because it's not scientifically backed and it's not scientifically appropriate (21:48):
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Mike: there's not enough evidence and how much should we say well yeah it's relatively (21:51):
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Mike: reasonable advice to be giving people let's live and let live because I suppose (21:55):
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Mike: the danger is if they continue to do that extrapolation we are going to some (21:59):
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Mike: at some point end up in in a place where maybe the advice won't be so healthy. (22:03):
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Nicola: I mean this is honestly this is a philosophical question I don't think I'm clever (22:08):
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Nicola: enough to answer and it's been a long day so I'm not going to try but like I (22:13):
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Nicola: do think sometimes the evidence crowd do sometimes also go a bit over the top (22:17):
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Nicola: because sometimes we simply don't know things. (22:24):
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Nicola: And I think an example was, and I might have been talking to one of the guys (22:26):
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Nicola: from our lifestyle group when we used to get together. (22:30):
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Nicola: And I think it was about maybe like oily fish and the potential effect on something. (22:33):
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Nicola: Like, let's say it was non-rheumatoid arthritis, something like that. (22:37):
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Nicola: And she was kind of saying, well, what about recommending this? (22:42):
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Nicola: I mean, it's not going to be harmful, is it? (22:46):
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Nicola: And like, I think with something like that, the way you frame it, (22:48):
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Nicola: if we care about facts and we care about speaking as precisely as we can, (22:51):
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Nicola: or at least know to, then that's reasonable. (22:55):
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Nicola: So if you say, listen, we don't know that this works, but it's not going to do you any harm to try. (22:58):
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Nicola: There's some theoretical evidence that it might work. (23:03):
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Nicola: And a really good practical example of that has sort of been the non-celiac (23:06):
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Nicola: glucose insensitivity, where there seems to be more and more case studies. (23:10):
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Nicola: There does seem to be a convincing body of data now building (23:15):
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Nicola: that in some people and they aren't (23:18):
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Nicola: diagnosed with celiac but removal of gluten does have (23:21):
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Nicola: some biological improvements that can be measured even (23:24):
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Nicola: though we don't fully understand it and i think that's a great example so (23:28):
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Nicola: you know you could go back 10 years and say listen we don't know (23:31):
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Nicola: why this seems to work but i've noticed in lots of my patients (23:34):
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Nicola: they remove gluten from the diet they feel better instead of (23:37):
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Nicola: these gluten containing foods what about these and you're not doing any (23:40):
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Nicola: harm and i think it's the framing that's important you're (23:43):
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Nicola: not saying oh oily fish does x or (23:46):
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Nicola: because then that's where i think you get into trouble as you were saying because (23:49):
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Nicola: eventually if you say something that's with certainty to be you know pretending (23:53):
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Nicola: that it's true and it's not then i think we get ourselves in all sorts of difficulties (24:00):
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Nicola: because effectively we don't care about facts anymore. (24:04):
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Mike: I think i agree and i think that that my (24:07):
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Mike: concern about it particularly when it comes to food is food (24:10):
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Mike: is such an emotive subject it's something that we all have huge like emotional (24:13):
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Mike: links to whether it's because of nostalgia because of what we were raised on (24:18):
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Mike: what is a normal diet to our family um you know ethnically socially psychologically (24:22):
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Mike: there's so many facets of it and so it always seems to have, (24:27):
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Mike: this real, um, I think that like the language we use around food is so important. (24:33):
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Mike: And, you know, one of my major passions is not demonizing specific foods, (24:37):
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Mike: which is why I struggle so much with, with the idea of, of low carb diets and (24:42):
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Mike: keto diets and paleo diets, because that, you know, they're things that I've (24:46):
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Mike: struggled with in the past myself. (24:49):
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Mike: And so I think when you see people talking about, you know, like, (24:51):
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Mike: I think, you know, there's really reasonable evidence that tells us that we (24:54):
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Mike: should be avoiding processed food, right? (24:57):
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Mike: It's fair to say that, that processed food isn't ideal. But also a donut isn't (24:59):
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Mike: going to kill you at the same time. (25:04):
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Mike: So it's really hard trying to find that balance between, you know, (25:06):
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Mike: trying to promote healthy eating, trying to promote healthful eating, (25:10):
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Mike: while also trying to not demonize foods and not scare people away from foods. (25:13):
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Mike: But I think I find it very hard, like when you go, when you hear people talk (25:18):
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Mike: who are perhaps advocates for things like, you know. (25:23):
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Mike: Microbiome related eating or low carb or whatever, (25:26):
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Mike: talking about ultra processed foods as (25:29):
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Mike: as poisons and all of that kind of stuff is such emotive (25:32):
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Mike: language that gets used and it's such definitive language that (25:35):
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Mike: people use that I think that the risks (25:38):
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Mike: of you know of of making people (25:42):
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Mike: feel morally inferior because they like (25:45):
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Mike: toast just you know it it (25:48):
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Mike: really worries me because I think that it puts like (25:51):
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Mike: it puts so much pressure on people to fail like and (25:55):
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Mike: they think that they're failing when they when they're trying to eat healthy but (25:58):
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Mike: they had a piece of toast or they had a donut um and (26:00):
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Mike: i think that that's one of the biggest barriers that (26:03):
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Mike: we have in trying to help people change lifestyle is is stuff like that and (26:06):
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Mike: i think that's the thing that i have the biggest problem with and that's why (26:10):
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Mike: i get so you know pernickety about people try you know people using appropriate (26:13):
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Mike: language people like describing the science exactly like you say saying there (26:19):
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Mike: isn't evidence to back this up, (26:24):
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Mike: but it might be helpful. Why can't we just say that? (26:26):
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Nicola: Yeah, and I sort of feel this way about diets and weight loss. (26:29):
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Nicola: So I do think with a very specific macronutrient composition, (26:33):
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Nicola: you can manipulate glucose in people with type 2 diabetes, and that's the people (26:37):
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Nicola: it matters in because their glucose is high enough to be a problem. (26:43):
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Nicola: But when it comes to weight loss there's so (26:46):
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Nicola: many different ways to do it and this is the real challenge (26:49):
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Nicola: with using language because I think there is a (26:52):
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Nicola: group of people for whom actually avoiding (26:55):
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Nicola: certain foods or food groups is helpful people who. (26:58):
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Nicola: Are essentially rule-based and if you say to them just don't (27:02):
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Nicola: these are the these are the starches that you shouldn't have cut them out for (27:05):
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Nicola: them that works well as an option and it's almost it (27:08):
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Nicola: is almost maybe in their head they're doing this almost saying that's (27:12):
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Nicola: a no-go for me that's a bad food that's the one I need to (27:15):
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Nicola: avoid you know maybe the bad isn't the right word but but (27:18):
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Nicola: they have a stronger view towards certain foods it's very rule-based (27:20):
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Nicola: and rigid and the difficulty is that (27:24):
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Nicola: might work really well for some people but for others that's (27:27):
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Nicola: going to cause major problems and so this is (27:30):
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Nicola: why weight loss is so difficult because it's hard enough anyway and (27:33):
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Nicola: that I think it's it's better to present the options and (27:36):
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Nicola: be very honest about the data and where it sits so you can (27:40):
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Nicola: say for some people cutting out the starches (27:43):
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Nicola: and just having these rules to live by works really well for (27:46):
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Nicola: others not eating after 2 p.m works really (27:49):
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Nicola: well and i'm sure it does very antisocial or for other people they might skip (27:53):
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Nicola: breakfast and lunch um and for other people it's about the things we were talking (27:56):
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Nicola: about just finding ways to modify the diet to reduce energy intake over time (28:00):
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Nicola: in a way that that they enjoy and um they can sustain yeah. (28:04):
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Mike: Absolutely and it. (28:09):
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Nicola: There is no one perfect diet and it is it is it. (28:10):
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Mike: Is really difficult um so i suppose i'm going to move on from the low carb thing (28:13):
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Mike: i suppose i just wanted a final sort of what is the what is the tldr about the low carb diet. (28:18):
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Nicola: I mean, this is my genuine answer. I don't think there's any particular reason (28:29):
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Nicola: anyone should go on it unless they have... This is going to be so long, sorry. (28:34):
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Nicola: Okay, I'm going to give you my TLDR. Okay, so I don't think there's (28:40):
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Nicola: any reason for anyone without type 2 diabetes to go (28:44):
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Nicola: on it unless that's a dietary pattern that they happen to (28:46):
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Nicola: find helpful for weight loss or it gives them energy or helps the meat well (28:49):
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Nicola: in type 2 diabetes it can be useful but only if combined with increased protein (28:53):
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Nicola: a calorie deficit with weight loss or in a minor number of people who enjoy (28:59):
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Nicola: and can sustain this diet even keto can be effective. (29:05):
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Mike: That was a that was pretty good that was very brief. (29:07):
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Nicola: No that was i'm i thought that was really i'm happy with. (29:12):
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Mike: That and it it's because essentially you know like your your area your main (29:15):
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Mike: area of research is in is in carbohydrates isn't it. (29:19):
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Nicola: You know i mean it's not really it's really in type 2 diabetes and (29:23):
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Nicola: i think i like to think i'm sure lots of people do (29:26):
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Nicola: that i'm fairly unbiased and i'm sure (29:29):
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Nicola: lots of people listen to me and go no you're so biased it's unreal but i like (29:32):
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Nicola: to think i am and i like to think that what's been helpful is that i've been (29:36):
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Nicola: very promiscuous in my research i'm like you get people who just study the glycemic (29:40):
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Nicola: index and you get people who just study low carb and you get people who just (29:45):
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Nicola: study plant-based diets, (29:49):
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Nicola: whereas I'm interested in the effect of nutrition, all of it, on glycemia. (29:51):
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Nicola: And I think that helps me not become a little bit crazy because I'm just interested (29:56):
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Nicola: in how they affect these things. (30:01):
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Nicola: And you know what also helps is I'm not that into nutrition. (30:03):
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Nicola: Like I, what really concerns me, and I'm sure we'll come onto this when we start (30:06):
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Nicola: talking about lifestyle medicine, it's people that follow a diet. (30:09):
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Nicola: They've chosen the diet. (30:13):
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Nicola: The diet is a lifestyle and a religion to them. (30:14):
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Nicola: And that's an enormous bias. I think nutrition is utterly boring. (30:17):
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Nicola: I mean, it's fascinating in work and I love it in terms of its effects on biology (30:22):
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Nicola: and I love helping patients. (30:27):
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Nicola: I couldn't care less about nutrition. I think my diet's reasonable. (30:28):
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Nicola: I don't measure things. I don't follow any given dietary pattern. (30:32):
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Nicola: I haven't had the vegetarian phase. And then I went to low carb and then I measured (30:36):
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Nicola: my blood glucose using CGM and then switched to something else and then measured my triglycerides. (30:41):
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Nicola: I don't even know how much I weigh. I don't know. (30:46):
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Mike: What my cholesterol. (30:48):
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Nicola: Is like i i don't care about this stuff. (30:49):
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Mike: And i think that's that that is the common theme that we often see in (30:51):
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Mike: a lot of people and in my you know myself included is that you know (30:54):
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Mike: part of the reason i'm here talking to you is because i've had my own (30:57):
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Mike: experience of lifestyle change and therefore i have (30:59):
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Mike: become passionate about it and i suppose you know (31:02):
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Mike: i i have been through those you know been through lots (31:05):
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Mike: of those phases and and i like to think i've come out the end the other end (31:08):
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Mike: being fairly unbiased but actually it's probably reasonable to say that my biases (31:12):
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Mike: are kind of you know are against the immunization of food and all of that kind (31:16):
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Mike: of stuff so probably i'm you know i'm a bit more um you know biased than i would like to believe, (31:21):
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Mike: but at the same time i'm still i think that's the key is is you have to maintain (31:28):
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Mike: looking for the truth and i think if somebody is sitting you down and telling (31:33):
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Mike: you this thing that you believe is not in concordance with the current scientific evidence, (31:37):
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Mike: you do have to stop and take a seat and listen and figure out why, (31:45):
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Mike: because it is important. And I don't understand why... (31:50):
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Mike: Why we have so much like discord in the nutrition advice world although you (31:55):
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Mike: know some of the things that you've explained today do explain a little bit (32:02):
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Mike: about perhaps why that is. (32:05):
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Nicola: Yeah and i mean i also think there are other things too i mean we talked about (32:06):
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Nicola: the data on carbohydrates specifically but in general what's really hard about (32:11):
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Nicola: nutrition is the effect size so the actual magnitude of impact on any one food (32:15):
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Nicola: on anything is pretty small. (32:22):
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Nicola: The magnitude of impact on food groups on most things is actually pretty small. (32:24):
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Nicola: Compared to medications, compared to things that are specifically designed to (32:29):
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Nicola: have a supra-physiological impact, nutrition doesn't do much. (32:33):
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Nicola: And so that makes studies really hard to do, makes them very noisy, (32:37):
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Nicola: makes them very hard to interpret. (32:42):
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Nicola: And then that gives people freedom to interpret them whichever way they want to. (32:44):
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Nicola: There's also a very vast literature, so you can cherry pick very easily. (32:48):
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Nicola: There is nothing, there is no crazy diet that you cannot defend based on a study (32:53):
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Nicola: that you find in the literature. (32:57):
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Nicola: And all of this just means it's very confusing to come to any conclusions. (32:58):
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Nicola: And let me just finish by saying, I mean, I'm a dietician. I've worked in the field for a long time. (33:03):
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Nicola: I know very little, and certainly not enough to give a lecture, (33:08):
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Nicola: a good lecture about, on, for example, lipid metabolism. (33:12):
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Nicola: I don't know enough to give a lecture. (33:17):
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Mike: On sports. (33:19):
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Nicola: Nutrition because it's complicated to know it you've got to know the methods (33:20):
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Nicola: you've got to have read maybe not every study because that's that's not realistic (33:24):
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Nicola: but I like to think I've read and understood 90% of the diet literature on type (33:28):
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Nicola: 2 and that's taken me 15 years and I'll be honest I still find it quite confusing. (33:34):
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Mike: And that's so interesting to hear because we do often get oh so-and-so is really (33:37):
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Mike: good about like really good at nutrition ask them about this and that you know (33:41):
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Mike: it's like being good at medicine yeah yeah no absolutely um i think it's time (33:46):
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Mike: for us to move on to phase two of this podcast, (33:51):
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Mike: um which i am i've obviously (33:55):
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Mike: alluded to at the beginning of the podcast but part of (33:59):
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Mike: the reason i was i was keen to get nicola on to talk to (34:02):
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Mike: me today um is because of this this post that she (34:05):
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Mike: put on on instagram um like i said a while ago and it is about lifestyle medicine (34:08):
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Mike: in general and the reputation of lifestyle medicine and shall i read it out (34:15):
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Mike: shall i say what the what the post was is that okay they're about is it used (34:19):
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Mike: like shall i give a little bit of a synopsis yeah. (34:24):
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Nicola: Go no you can read them i think. (34:27):
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Mike: Okay i think they're quite spot on and funny so um, (34:28):
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Mike: And again, to just give a little bit of context about this, it is, (34:33):
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Mike: I think, very, very important to listen to criticism and to listen to things (34:37):
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Mike: that aren't necessarily in support of everything that we might feel. (34:43):
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Mike: And so, you know, I know it's very easy to, I guess, have a knee-jerk reaction (34:49):
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Mike: if somebody seems like they're disagreeing with you. (34:55):
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Mike: But I think that the conversations in which you might disagree with people are (34:57):
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Mike: probably the most valuable conversations that we can have. (35:00):
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Mike: Um, so let's have that conversation and, uh, and explore it. (35:03):
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Mike: So the first slide is, it says, any healthcare professional interested in learning (35:06):
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Mike: about nutrition, be wary of the words lifestyle medicine in any conference or course. (35:10):
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Mike: There's a 45% chance it's a conference held by vegans who've already decided (35:15):
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Mike: 100% plant-based is the best. (35:19):
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Mike: There's a 45% chance it's a conference held by the low carb crowd who've already (35:22):
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Mike: decided carbs are the worst. (35:26):
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Mike: There's like a 10 chance it might be (35:28):
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Mike: legit save yourself the attendance fee i will (35:30):
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Mike: demonstrate how each of these courses will meet their aims at convincing (35:33):
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Mike: you to consume the best diet ever which is definitely vegan or keto one is cherry-picked (35:36):
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Mike: observational data vegans any observational data showing meat consumption is (35:42):
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Mike: associated with increased mortality keto pure of course and then there's a rude (35:46):
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Mike: word epidemiological epidemiological study number two claim the Mediterranean diet as their own. (35:51):
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Mike: Vegans, it's a 95% vegan diet, guys. (35:56):
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Mike: Keto, it's high in unprocessed animal products like meat, fish, (35:59):
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Mike: or poultry. It's basically paleo. (36:02):
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Mike: Three, they'll both point out the deficiencies of the other diet. (36:04):
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Mike: Vegans, where do they get their fiber from? Just awful. (36:07):
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Mike: Keto, who wants to be deficient in B12 and N3? Lol. (36:10):
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Mike: They'll both invoke the evidence. Vegans will say, this is an evidence-based (36:14):
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Mike: approach based on science. (36:18):
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Mike: Ketos will say, this is an evidence-based approach based on science. (36:20):
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Mike: Five, they'll both point out the other side misrepresents the data. (36:24):
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Mike: Also, lol at the controversial section which gets people debating. (36:28):
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Mike: Vegans, be wary of eating fish. (36:33):
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Mike: Keto, don't forget fruit, raises insulin. (36:35):
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Mike: So save yourself the money. If you want to learn about nutritional science and (36:38):
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Mike: what a fair representation of what's currently known and unknown, (36:41):
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Mike: check the list of speakers. (36:45):
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Mike: If they all promote the same diet, avoid. (36:47):
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Mike: So, I mean, it's a really, I think, actually reasonable post to make to talk (36:50):
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Mike: about, you know, what we should be looking at in this lifestyle medicine world. (36:57):
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Mike: And I think that the problem that we have, and I'm going to ask you what the (37:03):
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Mike: problem that we have is in a second, but I definitely feel that there's a lot (37:08):
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Mike: of muddying of the waters and a lot of a want to, you know, (37:11):
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Mike: put on events and talk about nutrition. (37:16):
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Mike: And we should be being more discerning about where we're getting the information (37:19):
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Mike: from but i'm going to pose this question to you and this doesn't have to be (37:24):
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Mike: a tldr this can be as lengthy as you like what is the problem with lifestyle medicine. (37:28):
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Nicola: I mean i think the major (37:33):
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Nicola: problem is lifestyle medicine is a really innocuous sensible (37:36):
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Nicola: phrase that you think yeah why would anyone argue about (37:41):
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Nicola: lifestyle medicine it's about doing what (37:44):
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Nicola: we can with our lifestyles to keep ourselves (37:47):
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Nicola: as healthy as possible so that we hopefully we (37:50):
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Nicola: don't need medicine I mean it sounds reasonable but it's it's (37:53):
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Nicola: a term that hides many sins and you (37:56):
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Nicola: can hide behind it and actually the reason why I wrote that post and what led (37:59):
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Nicola: to it was I mean I've been invited to present at lifestyle conferences and because (38:02):
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Nicola: I think I'm I don't sit in any camp and but maybe different communities have (38:07):
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Nicola: thought I did sit in a camp because I did one post one once about, you know, (38:13):
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Nicola: plant-based diets and another that the low-carb crowd saw when I was talking (38:18):
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Nicola: good things about low-carb. So I've been invited to both. (38:22):
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Nicola: And they call themselves lifestyle medicine. Oh, it's a lifestyle conference (38:26):
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Nicola: or a metabolic, you know, metabolic medicine conference or something. (38:30):
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Nicola: And it's basically, I went on one, it was just vegan. (38:33):
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Nicola: And I remember sitting there listening to the talks and there was one where (38:37):
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Nicola: they were talking about PrediMed. (38:41):
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Nicola: And they were basically saying, clearly, the benefits of PrediMed are because (38:43):
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Nicola: it's the plant-based aspects of it. (38:47):
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Nicola: And they had the PrediMed score, like the Mediterranean diet score that the (38:49):
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Nicola: investigators has used to see how compliant people were to the diet. (38:54):
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Nicola: So basically, like, if you had a minimal amount of red meat a day, (38:57):
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Nicola: certain amount of olive oil, blah, blah, blah, you were doing the Mediterranean, (39:01):
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Nicola: therefore the PrediMed diet. (39:05):
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Nicola: And the investigators or the presenters had left off fish, right? (39:06):
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Nicola: And it's just, it's an outrageous misrepresentation of the data to make your (39:11):
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Nicola: point, because you are just there to convince people to eat a vegan diet. (39:16):
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Nicola: This is not about teaching people evidence. (39:22):
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Nicola: And the people that presented this data were credentialed enough to know better. (39:24):
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Nicola: So it wasn't a, oh, oops, I didn't notice that. (39:30):
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Nicola: They knew what they were doing. And every single one of the presentations was like this. (39:33):
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Nicola: I mean, I know the literature for type 2 diabetes, and it was presenting on (39:37):
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Nicola: plant-based diets and type 2 and why are you ignoring the (39:40):
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Nicola: rest of the literature so that irritated me and then I'd go (39:43):
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Nicola: to a low carb conference and they would manipulate the data in (39:46):
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Nicola: exactly the same way and you could just literally (39:49):
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Nicola: you could play each conference side by side but just swap out plant-based for (39:52):
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Nicola: keto and it would be the same conference and so that led me to write the post (39:57):
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Nicola: is that they were hiding behind this lifestyle thing and it was basically a (40:02):
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Nicola: very dodgy scientific conference that was convincing people to eat a certain way. (40:06):
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Nicola: And I will say this, for me, I think the vegan crowd are a bit more devious. (40:12):
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Nicola: I mean, I can see through when people are talking rubbish, but based on the (40:19):
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Nicola: vegan conferences I've been to, they are very good at manipulating the data. (40:23):
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Nicola: The low-carb crowd are crazy. I mean, (40:28):
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Nicola: you just see presentations and you think, how does anyone believe this (40:32):
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Nicola: but they are way more evangelistic about it (40:35):
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Nicola: and i actually think if you look at a lot of the low-carb denver (40:38):
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Nicola: low-carb brisbane or whatever that you know they're all over the place it reminds (40:41):
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Nicola: me of hillsong church like the the you go there to talk about low carb for the (40:45):
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Nicola: entire weekend and how wonderful low carb is and how low carbs changed your (40:52):
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Nicola: life i mean that's what these conferences are like it's the only people that attend. (40:55):
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Nicola: Um are there because they already know low carbs great and they just want to (41:00):
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Nicola: listen to talks to reaffirm their belief and their understanding that yes it's the greatest diet um, (41:04):
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Nicola: It's kind of addictive. I mean, people like crowds, they like belonging. (41:11):
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Nicola: And that's what I think a lot of these conferences are too. I mean, (41:16):
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Nicola: most of the speakers are the same. (41:19):
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Nicola: I mean, look at low carb Denver compared to low carb Seattle, (41:21):
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Nicola: if there is one compared to low carb down under. (41:24):
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Nicola: They're the same speakers with the same talk every year. (41:27):
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Nicola: There's no new information. And yet people go to keep listening to, (41:31):
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Nicola: you know, the one truth. It's very religious. (41:35):
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Mike: And why do you think, like, why does that develop? Because I suppose that, (41:38):
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Mike: again, I want to sort of almost play devil's advocate in this scenario and say, well, (41:41):
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Mike: surely the reason that these people are becoming evangelical about this diet (41:46):
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Mike: is because they feel so strongly that it is so beneficial. (41:52):
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Mike: Like I guess there are there are people who have you know a financial gain perhaps (41:56):
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Mike: in it but there are those people are few and far between why is there such a (42:00):
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Mike: strong community of those people that believe that like where does that come from. (42:05):
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Nicola: You know that's I'm really glad you asked that that is a really good point and (42:10):
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Nicola: I do think particularly for people that have struggled with their weight, (42:13):
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Nicola: and found diet that works for them and I will say anecdotally in my practice (42:17):
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Nicola: the people that have lost weight and kept it off almost seemingly effortlessly (42:22):
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Nicola: have been the low-carb crowd. (42:26):
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Nicola: And I can absolutely understand that after years of struggling and very possibly (42:29):
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Nicola: being told by healthcare professionals and the scientific community, (42:34):
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Nicola: low-carb doesn't work, you're crazy, what are you doing? You're going to give (42:38):
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Nicola: yourself a heart attack. (42:40):
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Nicola: And it actually really does work for them, improves all of their cardiometabolic risk factors. (42:42):
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Nicola: You know, that's a really good point, I can believe and understand why they (42:46):
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Nicola: would become evangelical about it. (42:50):
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Nicola: That doesn't excuse scientists, in my view, promoting this view. (42:52):
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Nicola: You know why I don't like it, and this maybe is on me? Because that's easy to do. (42:59):
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Nicola: It's easy to preach to the converted. Whereas I think what scientists should be doing is... (43:06):
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Nicola: Maybe educating sounds too high horse, but just helping people to understand (43:13):
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Nicola: as much as possible and certainly not intentionally misleading them to make people like you. (43:18):
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Mike: It is a fascinating topic. And I suppose from the, you know, (43:25):
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Mike: from the plant-based perspective, (43:29):
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Mike: there are so many ethical considerations as well with the plant-based diet that (43:30):
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Mike: I think that the waters can often again get muddied between the, you know, (43:33):
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Mike: the nutritional science between the benefits of the vegan diet and the the wish (43:37):
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Mike: to adhere to that diet from a you know from an ethical or even a planetary health aspect. (43:43):
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Nicola: 100 and i and again you're you're a very empathetic nice person it definitely (43:47):
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Nicola: can see that that you have such a love for animals and like you say all of these (43:52):
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Nicola: ethical concerns that that just compels you to want to get people to stop eating (43:56):
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Nicola: animal products in whatever way you can do that yeah. (44:01):
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Mike: And i guess it it all comes back down to kind of the you know know, (44:04):
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Mike: the honesty side of things. (44:08):
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Mike: But I think, I think that what's really difficult, and again, (44:10):
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Mike: I sort of speak from my own experience on this, is I think when you're in the (44:12):
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Mike: midst of that, like, so I, and I've told the story on this podcast before, (44:16):
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Mike: so I don't want to go into it too much, but I, (44:21):
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Mike: my own experience when I did paleo and I lost weight faster on paleo and more (44:24):
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Mike: effectively perhaps on paleo than with any other diet I did. (44:30):
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Mike: And, you know, in hindsight, that was because it was so boring. (44:33):
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Mike: I couldn't be bothered to eat any of the food. (44:36):
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Mike: But at the time I was like, wow, this is the best thing since sliced bread. (44:39):
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Mike: This is the best thing I've done. I'm eating so healthily. I'm getting so many nutrients. (44:43):
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Mike: I'm so happy. Everything is wonderful. (44:47):
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Mike: And I was happy because I was losing weight. And that's what I wanted to do. (44:50):
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Mike: And so I kind of, you know, my own confounding variables were just out of control. (44:53):
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Mike: And, you know, I was convinced that by cutting out wheat, sugar, (44:58):
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Mike: and dairy, these, you know, this was why I was losing weight. (45:03):
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Mike: It wasn't about calories. It was about that. I know scientifically that that's not the case. (45:06):
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Mike: I'm pretty sure I knew scientifically that that wasn't the case at the time (45:10):
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Mike: as well, but I managed to almost brainwash myself, even as a scientist. (45:13):
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Mike: So I suppose I've got, i have got a fair amount of um again i guess empathy (45:17):
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Mike: for for people who who get sort of sucked into this situation because i've done (45:23):
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Mike: it myself like i absolutely advocated for the you know for the paleo diet and (45:28):
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Mike: for um you know for cutting out wheat sugar and dairy for people that (45:32):
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Mike: wanted to to lose weight and actually in hindsight those things were causing (45:37):
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Mike: potentially significant damage to my relationship with food and i didn't see (45:42):
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Mike: it at the time because i had tunnel vision. (45:46):
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Mike: And I think if those of us who do consider ourselves scientists and well-educated (45:48):
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Mike: are still at risk of behaving like that, then I guess what's the hope for everybody (45:53):
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Mike: else who doesn't even have that scientific background or scientific education? (45:58):
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Mike: And so it is something that really worries me about this whole world because (46:03):
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Mike: we are so riddled with our own biases that it does make it very difficult. And I think that, (46:09):
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Mike: Unless you fight very hard against those biases, it's really hard to counteract them. (46:16):
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Nicola: Yeah, it is. And like I say, I mean, this is one of the benefits from working (46:25):
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Nicola: with people who disagree with you. (46:29):
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Mike: Exactly. (46:31):
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Nicola: And actually, now there is a good thing. I mean, lots of journals now when they're (46:32):
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Nicola: asking for review articles, and I know this because I've just been asked to (46:36):
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Nicola: write one, is they want groups of people who have slightly differing views. (46:40):
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Nicola: And you don't want to get into this you know you always have (46:45):
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Nicola: those manufactured debates on like network news particularly (46:47):
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Nicola: in the u.s where it's like hey let's and it's ostensibly a (46:50):
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Nicola: serious debate but actually you get the person furthest to (46:53):
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Nicola: the right and the furthest to the left and they're looking for fireworks and (46:56):
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Nicola: to me that's unhelpful because both of them are wrong in their own ways and (46:59):
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Nicola: they're never going to meet anywhere whereas if you get people who and this (47:03):
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Nicola: is probably true for lots of nutrition you agree on 80 percent of it and it's (47:07):
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Nicola: just the minor things to tease out and you do learn to recognize when you're (47:11):
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Nicola: in the field for a while who cares about what's, (47:15):
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Nicola: actually true who cares about actually understanding this and getting to the (47:19):
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Nicola: answer and then you have people who've already decided for complex psychological (47:23):
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Nicola: reasons and then I think maybe the minority of those that are there for the (47:28):
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Nicola: book deals and selling supplements online and so forth. (47:32):
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Mike: Yeah, no, that's fair enough. So I suppose my question to you is that, you know, (47:36):
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Mike: the BSLM as an organization, if we want to change this world, (47:40):
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Mike: if we want to move things forward and be the providers of that positive information and help to achieve, (47:45):
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Mike: you know, the mission statement of the BSLM, you know, (47:52):
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Mike: while also maintaining that adherence to science and that adherence to to facts (47:57):
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Mike: um and you know nutritional correctness what should what should we or they be doing. (48:02):
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Nicola: I mean one thing i think is really helpful i think maybe (48:09):
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Nicola: the best event that i've or certainly (48:12):
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Nicola: one of the best but it's the best that i can remember was the one that was it (48:14):
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Nicola: john organized and me yeah and but i didn't know you then i think i met you (48:20):
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Nicola: afterwards and we had a well Our first discussion was on protein bars, (48:26):
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Nicola: a shared love of protein bars. (48:30):
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Nicola: But the reason I remember that one, if I'm remembering the right one, (48:32):
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Nicola: I was there to speak about diabetes. (48:35):
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Nicola: And that's my specialism. And like I said, I've been in this field a long time. (48:37):
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Nicola: I still think it's confusing. (48:41):
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Nicola: And then there was Irene who spoke about gut microbiome. (48:42):
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Mike: Gut health. (48:46):
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Nicola: It was gut disorders. (48:47):
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Mike: And she basically said, we don't know very much, didn't she? (48:48):
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Nicola: Yeah, and that's her area. And that everyone spoke about the thing they knew about. (48:50):
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Nicola: And that's, I think, how you get closest to the answer. (48:56):
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Nicola: Because until you've spent, I think, a decade in each of these fields, (49:00):
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Nicola: you simply cannot know enough to give the best, most accurate information that (49:04):
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Nicola: really, truly reflects the evidence that's out there. (49:10):
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Nicola: And like i said the all-important context of okay (49:12):
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Nicola: so a tiny study showed a r value (49:15):
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Nicola: of 0.74 between this gut microbiome or (49:19):
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Nicola: you know whatever like these things and you can put it into context of well (49:22):
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Nicola: what does the rest of the literature show so i think the best thing they could (49:25):
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Nicola: do is make sure if they're interested in these niche areas that they have someone (49:28):
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Nicola: who truly knows that field involved um because what i see is and i hate to say (49:32):
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Nicola: this but i i remember when i wrote that post someone was quite cross with me. (49:38):
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Nicola: And I think it might have been someone in your organisation. (49:43):
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Nicola: Can I say your organisation? Because then it's like... (49:45):
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Mike: Depends on how the podcast goes. It might not be my organisation for my... (49:48):
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Nicola: Okay. And someone from the organisation you're affiliated with didn't like my post. (49:52):
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Nicola: And she said, oh, but he or she, I can't remember, we try and do a good job, (49:59):
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Nicola: check out the website or something. They might have not asked me to check out the website, but I did. (50:03):
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Nicola: And there were just two articles that were exactly what we've been talking about. (50:07):
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Nicola: It was just wild extrapolation, probably something to do with the microbiome, (50:11):
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Nicola: something about inflammation, because that's another sexy sounding scientific (50:16):
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Nicola: word that we really don't understand what it all means. (50:19):
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Nicola: And I think I responded and said, this is the entire problem. (50:22):
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Nicola: There's lots that we know. We know there's food that's pretty crappy that people (50:26):
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Nicola: are eating a lot of just because that's the environment they live in and i know (50:32):
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Nicola: you don't like the word crappy food maybe if i can say when eaten more than (50:36):
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Nicola: twice a week it's probably quite crappy i don't know i'm. (50:41):
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Mike: Happy with the terms crappy food because i think it is also important to be (50:44):
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Mike: honest less healthful food. (50:48):
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Nicola: I mean maybe a better word is not healthful yeah um and so we know that there (50:49):
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Nicola: is a bunch of unhealth there's unhealthful food people are eating in large quantities (50:54):
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Nicola: because that's the that's the what their environment drives them to eat. (50:59):
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Nicola: And we know these things. (51:02):
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Nicola: And for me, that's what an organization like the British Society for Lifestyle (51:04):
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Nicola: Medicine should be writing about. (51:08):
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Nicola: Because lots of patients now will come and they'll have these really big, obvious red flags. (51:11):
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Nicola: You know, the idea, my goodness, that the average person in the UK struggles (51:17):
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Nicola: with obesity because of fruit, because of fructose. (51:22):
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Nicola: You know, like you see these things, oh, fructose is metabolized differently (51:25):
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Nicola: and it sounds clever and sexy. And what is it? (51:29):
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Nicola: No one's eating too much fruit. You know, they're not overweight because they've (51:32):
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Nicola: been eating too much fruit. (51:35):
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Nicola: And you get these silly things like tim (51:36):
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Nicola: spectra again thinks it's because we're not having enough sauerkraut it's (51:39):
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Nicola: because we're eating unhealthful foods in (51:43):
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Nicola: extraordinary amounts because it's advertised in (51:46):
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Nicola: our faces every second of the day and it's cheap and it's palatable and lots (51:49):
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Nicola: of us are stressed um all of these things and so for me the british society (51:54):
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Nicola: of lifestyle medicine would be better sticking to the stuff where there is pretty (51:59):
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Nicola: unequivocal evidence and that's lots of patients I'm sure you see. (52:02):
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Mike: Yeah, absolutely. I mean, it's unfortunately, I think there does have to be (52:08):
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Mike: an emphasis, not unfortunately, but there does have to be an emphasis on sticking to the basics. (52:12):
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Mike: And I think, yeah, we are always looking for, you know, for the sexy information, (52:17):
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Mike: the information that sounds exciting, the information that sounds new. (52:22):
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Mike: And I think there is a balance between, you know, wanting to explore newer information (52:26):
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Mike: and scientific advances and all of that kind of stuff and the understanding (52:30):
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Mike: that you know this information takes decades to flesh out like you say um. (52:36):
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Nicola: And we. (52:41):
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Mike: Didn't know anything about the gut microbiome or gut health at all maybe what (52:41):
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Mike: you know 10 years ago in in mainstream sort of health and fitness kind of discussions (52:45):
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Mike: and then now we know a tiny bit more than nothing but still not an awful lot. (52:50):
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Nicola: I agree but but my view is regardless of what that (52:55):
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Nicola: research shows i mean definitely we should pursue it it (52:58):
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Nicola: doesn't change the fact we barely move (53:01):
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Nicola: we're bipedal and we barely move and (53:05):
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Nicola: we eat about 200 calories of high (53:08):
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Nicola: sugar crappy processed snacks a (53:12):
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Nicola: day at a population level we drink (53:15):
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Nicola: way too much sugary you know we drink way too much sugar that's (53:17):
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Nicola: a good way of putting it and it's this kind of stuff to me that's unequivocal (53:20):
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Nicola: and i remember when i when i deliver stuff like gp training (53:24):
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Nicola: on nutrition i have this slide where it's (53:27):
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Nicola: like five things that are going to be applicable to (53:30):
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Nicola: probably 80 of your patients and it's thinking about do you need to snack when (53:33):
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Nicola: you get to that two three o'clock and whatever you're eating and we might discuss (53:37):
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Nicola: what that might be you know that's 200 calories a day it's probably not doing (53:41):
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Nicola: you much good are you eating then because you're hungry are you but do you feel (53:44):
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Nicola: biologically hungry do you eat because your mates in the office are, (53:48):
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Nicola: do you eat because you're bored because it's cake friday yeah i think that's (53:52):
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Nicola: the thing isn't it yeah And it's like that's, (53:56):
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Nicola: empty calories and it's little things like that that most of the (53:59):
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Nicola: population do um alcohol people some (54:02):
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Nicola: people get 20 if not more of their calories from alcohol that's a lot of your (54:05):
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Nicola: that's a lot of most gps practice you know they don't need to get into sauerkraut (54:10):
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Nicola: and buying an app for 750 pound and having their poo sample to give them personalized (54:14):
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Nicola: recommendations that was a sub tweet. (54:21):
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Mike: It sounded like a sub tweet i shall (54:24):
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Mike: investigate um nicola thank you (54:27):
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Mike: very much as always i think that the the thing that (54:30):
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Mike: i love about you and your work is that you know (54:33):
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Mike: like we've spoken about you're always very direct and honest (54:36):
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Mike: and you are always very open and always i (54:39):
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Mike: think very nutritionally agnostic as it (54:42):
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Mike: were so very science for science-based and unbiased (54:45):
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Mike: and i really appreciate that i really appreciate that that discussion um and (54:48):
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Mike: i think we can all learn a lot from that approach so thank you very much for (54:53):
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Mike: joining us today um if people wanted to um follow you get in touch with you (54:56):
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Mike: um or find you where would they go i've. (55:01):
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Nicola: Started writing a blog it's always going to be free so i'm never going to be (55:06):
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Nicola: one of those people that's like pay for my work i write it on the train so don't (55:10):
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Nicola: at me about typos um and there i try to expand on some of the things that we. (55:14):
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Mike: Talk about oh thank you very much for your time and uh thanks for joining us today. (55:18):
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Nicola: Thanks, Mike. Nice seeing you. (55:23):
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