Peter Attia MD314 ‒ Rethinking nutrition science: obesity treatment, GLP-1 agonists, protein, & better research
EVERY SPOKEN WORD
105 min read · 21,417 words- 0:00 – 1:59
Intro
- DADavid Allison
And I think there's a lot of fear now among people who want community intervention, public health intervention, who say, "I don't want our solution to obesity be let everybody get obese or let two-thirds of the population get obese and then we'll give them surgery or drugs for the rest of their life. Um, it's too expensive. It's not my ethos," you know, et cetera, et cetera. Um, and I think they're worried that people like me who say, "Look at the efficacy data. We need to think about this more," are implying that we should shut down all the other stuff. And at least for me personally, that answer's absolutely not true. But I think we need sub-paradigm shifts within paradigms. And what I mean by that is I don't think the paradigm shift of saying, "Don't ever think about nutrition anymore, only think about drugs and surgery," is warranted. I don't think the paradigm shift of saying, "Don't ever think about behavior, community intervention, family intervention," is warranted. "Don't ever think about public health or policy," that's not warrant. I don't agree with those at all. What I do think we need to do is to say within the paradigms of behavior, community, family, policy, let's be honest. Let's look at Carolyn Sommerbell's data and others and say, "There is no compelling evidence that any of this has had a meaningful impact." You can cherry pick here and there. You can say this policy led to differences in how much of that food was purchased in this context. Even if that's true, and sometimes those are a little shaky, those conclusions, say did it lower obesity rates? And those have never been shown.
- PAPeter Attia
[upbeat music] Hey, everyone, welcome to The Drive podcast. I'm your host, Peter Attia. David, good to see you once again.
- 1:59 – 7:27
The complex relationship between nutrition, body weight, and body composition
- DADavid Allison
Good to see you, my friend.
- PAPeter Attia
Um, lots to talk about today. Uh, the, the world of, uh, nutrition and, uh, health, uh, are, are, are always in the, in the spotlight. Um, in particular, um, around a class of drugs, um, that no listener to this podcast will be a stranger to, uh, called GLP-1 agonists. Um, so I wanna spend some time talking about those, but I think before doing so, I wanna just maybe go back and talk a little bit about what we know and maybe don't know about the relationship between nutrition and obesity.
- DADavid Allison
Sure.
- PAPeter Attia
Which sounds like it should be obvious. So, um, tell us what you think is actually known about the relationship between food and body composition.
- DADavid Allison
So I like the way you phrased the question in using the word body-- or the phrase body composition as opposed to just obesity or weight. They're obviously three different things. Obesity implies a threshold. You're too much. Uh, there's a judgment about, uh, the quanti- or the, the effects of the excess. Um, then there's body composition, w- the tissue. How much is fat? How much is lean? Where is the fat and lean? What is the fat composed of? What is the lean composed of? And then there's just weight, which is just, you know, your, your mass on this planet. And those three things are highly related but not identical. What we know indisputably, and even people who sort of rail against something they call the energy balance model, which you and I have discussed, whether it's really a model is unclear. It's really more of a constraint. Um, it's really a restatement of the first law of thermodynamics, which is the law of conservation, [lip smacks] that matter and energy can neither be created nor destroyed, but only converted. It is a constraint by which all other descriptions of what happens with weight and mass and food intake and energy intake and energy expenditure must operate. It's not a description or an explanation of what happens. It just says if you prescribe, uh, if you describe any proposed explanation of what happens, it's got to follow that first law of thermodynamics in order to make sense. And that first law of thermodynamics in, in the field of nutrition obesity often gets stated as something like changes in energy storage equal changes in energy intake minus changes in energy output, or delta energy stores equals delta energy in minus delta energy out. Food intake can affect those things. Alternatively, you could say that energy intake is one of those things, so it, it gets back to that descriptive thing. Now one of the questions becomes how does all the other aspects of food besides the mere energy content of it affect the amount of weight one gains or loses, the body composition, the tissues, where they're dis- where the mass is distributed, what types of tissues it's in, composition of those tissues, and then of course whether or not one exceeds some threshold. There's every reason to believe that many, many aspects of food, from the marketing and pricing of it, which then can influence the intake of it and other things as well, to the taste, the smell, the timing, uh, what you eat it with, what it's combined with, phytochemicals in it, micronutrients, macronutrients, all can affect energy expenditure, subsequent energy intake, um, or nutrient partitioning, which is what we-- a fancy phrase for where you stick the energy that you store in the body. Do you stick it into fat or muscle or bone or visceral fat or subcutaneous fat, et cetera? So all those things can come into play. Now, what do we really know? The truth is I think what we know is modest, and partly that's because it seems to me to be very specific. That is we can do a study, and even when it's honestly done and well done and honestly reported, and we find that in this species with this delivery of this composition in this way, this thing happens. And then when you look in a different species or a slightly different food, you get different results. So there's many, many studies saying, "Well, we got this with pea protein and casein, but not whey," or, "We got it with whey, but not casein," or, uh, "We got it when we fed it two hours before the test meal, but not one hour before," or, "We got it in men, but not in women." This makes me think we're talking often about subtle effects that may not be that clinically reliable and meaningful. And so the really big effect seems to be how many calories do you eat. But all these other aspects of food may then influence how many calories you eat, either of that food or in subsequent occasions, and those can seem to have big ef- big effects, but we're still sort of, I think, trying to suss those out.
- 7:27 – 18:18
The slow progress in addressing obesity and public health despite substantial effort and investment
- PAPeter Attia
Do you ever spend time interacting with physicists or chemists, biochemists, um, who sit on the sidelines and sort of look at the field of human energetics and sort of wonder to themselves, "Why is there so much noise, and why is there so little understanding?" Um, and I don't think anybody is standing around blaming the scientists and saying, "Well, you know, in physics we have great scientists. In chemistry, we have great scientists. In human energetics, they must be subpar, and that's why they don't know anything." I don't, I don't... I can't imagine there's anybody that thinks that. What do you think it is at the meta level that explains the obvious, uh, but important observation that our knowledge in this space is woefully deficient relative to the, um, effort that has been put into elucidating truth? W- why, why... I- I- I-- Yeah, and just to restate that more poignantly, for how hard the field of science has worked to try to get at the questions we're going to discuss today, why do we know very little relative to the same amounts of effort that have gone into physical sciences, for example?
- DADavid Allison
I think there are many reasons. Some are perceptual and, and some are actual. Um, some of the perceptual is do we really know that much less, and we, we can argue about it. Um, I think there's still questions in physics where we say, "Gee, we really don't know that exactly how is it that relativity and, and quantum, uh, physics are, are compatible," or, "Is dark matter real?" Or what have you. I think there are questions there.
- PAPeter Attia
Though I would sort of just interject for a second, David, and say another way to think of it would be if you look at the amazing progress that has been made that has been enabled by the knowledge of physics and chemistry, right? If you just consider what's happened in the last 100 years-
- DADavid Allison
Mm-hmm
- PAPeter Attia
... in terms of what we've been able to do, you know, just look at computing power, look at, you know, semiconductors, look at airplanes. I mean, look at technology that has been enabled by engineering, physics, chemistry. Um, we're, we're multiple logs of advancement.
- DADavid Allison
Mm-hmm.
- PAPeter Attia
The same cannot be said of, um, what we're talking about now, right?
- DADavid Allison
Mm-hmm.
- PAPeter Attia
Our understanding of obesity 100 years ago versus our understanding of obesity today, while maybe greater, hasn't actually translated into a multiple log improvement in the outcome of interest, which in this case might be a reduction of obesity, just as it might be in, you know, uh, the, uh, the interest on the other side, which would be computing power.
- DADavid Allison
Right. Yeah, and again, I, I think that's only half true. Um, I think we don't give ourselves certain credit for certain things. In physics, there's not a lot of discussion in, in modern times of the power of Newton's universal law of gravitation. That was a pretty big deal and a pretty big accomplishment, but we don't talk about it a lot 'cause we f- it's been figured out a long time ago, and we take it for granted that we know that now. Um, in-
- PAPeter Attia
But do we even have the equivalent in energetics?
- DADavid Allison
Yeah, I think we do. Um, simple ex- some simple examples, both at the practical level. Uh, in this country and in most industrialized countries, there's very little food shortage. Um, that's a big deal. It is a big deal that we know that alcohol contains calories. We take that for granted, but Wilbur Atwater, who's the person who stated that, was vilified for it at that time by the temperance movement.
- PAPeter Attia
Hmm.
- DADavid Allison
And, um, because they wanted to say, uh, and he himself was a teetotaler, by the way, that alcohol had no calories. Uh, excuse me, that alcohol had no, um, nutritional value.
- PAPeter Attia
Hmm.
- DADavid Allison
And he said, "No, it does. It has seven kilocalories per gram."
- PAPeter Attia
Hmm.
- DADavid Allison
And so that's an example. Folate supplementation, which has radically reduced spina bifida. Um, uh, iodized salt. Uh, micronutrient deficiencies being maybe not eradicated in this country, but radically reduced due, among other things, to supplementation. Uh, greater food safety. So we've made a lot of practical progress.
- PAPeter Attia
Hmm.
- DADavid Allison
Um, we've feeding a number of people through nutrition and agriculture that, uh, you- Back all the way to Malthus, but even more, you know, recently in the 1970s when we were told there was going to be a population explosion that would threaten our ability as a species to survive.
- PAPeter Attia
But isn't that really more about agriculture than nutrition science?
- DADavid Allison
It's, it's agriculture, it's food science.
- PAPeter Attia
Yeah.
- DADavid Allison
But some of the nutrition science is more the micronutrients.
- PAPeter Attia
Hm.
- DADavid Allison
Um, all the way back to eliminating scurvy through the work of James Lind and figuring out eventually that it was vitamin C. They first thought it was just citrus in general.
- PAPeter Attia
Mm-hmm.
- DADavid Allison
But it was, it was vitamin C. Um, to the folate, uh, and so forth. I think our notions, our understanding about LDL cholesterol, which again, you know more than I about it, but which is very important, um, and the i- the role of saturated fats and that, we're still learning more, but we do know some things about that. So I don't think we want to take for granted that we have learned a great deal. In obesity itself, until about, oh, I don't know, maybe five years ago or a little more, when I would give talks about this, I would say, "We actually have learned a lot, but it's just not all that clinically relevant, and what's clinically relevant is mostly truly in the clinic, not in the community and the population." So I said we've learned a lot about genetics, and that's true. We have log orders, I would argue, magnitude increase in our knowledge about the genetic underpinnings of obesity that we didn't have prior to 1980. But until recently, we've had moderate improvements in the clinic and virtually no improvements in the sort of public health community sort of domain.
- PAPeter Attia
I- if you allow me to be humored with an analogy, though, just 'cause I'm gonna keep pushing back on this a little bit. Um, [clears throat] when the Wright brothers first put an airplane into the sky-
- DADavid Allison
Mm-hmm
- 18:18 – 28:10
The very limited success of public health initiatives in curbing obesity
- DADavid Allison
coming.
- PAPeter Attia
So, um, there were a couple of recent Cochrane collaborations that came out discussing the success or lack thereof of public health initiatives around obesity. Do you want to say a little bit about those and maybe also talk a little bit about the history of why-- I mean, if I'm going to be blunt, if I'm going to extrapolate from what we've just said, one would say that public health efforts to curb obesity have been a failure, um, and the future of obesity management will be pharmacologic, not public health related. Is that a fair prediction?
- DADavid Allison
I think it's a very reasonable prediction. I'm not sure it's one I will share completely. I would share the first part, that public health efforts to affect obesity in a meaningful way have thus far been singularly unimpressive.
- PAPeter Attia
Mm-hmm.
- DADavid Allison
And we'll come back maybe a little bit to why and where that's going and where we should go with it. Um, I do think that in the, in the present and even more so in the not too distant future, clinical management, including surgery and pharmaceuticals evermore, will be ever more powerful, safe, effective, and utilized. I don't think they will ever become the complete solution, and I don't think that there's no solution in public health, but I think we've got to approach it differently. So let's go back in time a little bit. When I started my career sort of as a, uh, real professional, basically 1991, I come to New York, the New York Obesity Research Center at Columbia University and St. Luke's Roosevelt Hospital. It's the only federally or NIH-funded obesity research center, uh, at the time. It's the first. It's run by Xavier Pi-Sunyer, the legacy of Ted Van Itallie. Across the park, you've got Jules Hirsch, Rudy Leibel, and that group at Rockefeller. And it wasn't at the level of academic-- uh, excuse me, of public interest that it is now, the topic of obesity. What you had is these very interdisciplinary groups, physiologists, geneticists, physicians, psychologists, statisticians, nutrition scientists, et cetera, all working together on these problems. Many worked-- had been working together for decades. Very academic, but also clinical. And you had the powerhouses that were in that region. You had Mickey Stunkard over at UPenn. You had Marcy Greenwood and others at Vassar, uh, and so forth. And if a young person like me made some foolish statement in a seminar about some aspect of physiology or medicine that showed that given my training, I had no understanding of what the heck I was talking about, one more senior person would put me in my place, but in a very constructive way, and explain that I didn't know what I was talking about. And the statisticians would argue with the physiologists and so on. So you had a depth of knowledge and a real depth of expertise and an understanding. Then NHANES III data came out, and there was this sense of crisis and panic, public health.
- PAPeter Attia
That was what, '94?
- DADavid Allison
Uh, it started to come out in the early '90s, the midpoint of it, like '90, '91, uh, was, was just starting.
- PAPeter Attia
Tell folks what NHANES is-
- DADavid Allison
Oh, sorry
- PAPeter Attia
... and what the data showed.
- DADavid Allison
This is the National Health and Nutrition Examination Survey. It was at the time only done every few years. So first there was something earlier in the '60s called, uh, NFHS, I think, uh, National Health and, uh, something else. Then they, they developed the National Health and Nutrition Examination Survey. They did two of them, and then the third one was done, I think, between '88 and '93 maybe. So I think the midpoint data they released around '91, if my memory is right. And people started using the word epidemic, and they saw what looked like a jump. Whether there's a real jump or not around the late '80s or in the '80s is actually not so clear.
- PAPeter Attia
Mm.
- DADavid Allison
If you look at skin folds, you see less of a jump-
- PAPeter Attia
Mm
- DADavid Allison
... and you see the increase starting earlier. If you look just at BMI and you look at increase, it's been going up for hundreds of years. Uh, the, the data from the Nobel laureate Robert Fogel, uh, who won it in economics, he's since deceased, but he's a terrific, generous guy. And he collected all these old data on, you know, British naval cadets from the 18th century and, um, French cadets and Civil War soldiers and recaptured slaves during the Civil War and looked at these different groups. And you see that, uh, obesity levels and BMI have been increasing for centuries. But there clearly did seem to be an acceleration, and that caused a panic. And then you had probably the most powerful voice at the time in this domain was Kelly Brownell. Kelly had been a real devotee of Mickey Stunkard. He was one of Mickey Stunkard's protégés, um, and mentorees. And he was a behavioral psychologist, still is a behavioral psychologist, doing behavioral treatment. You know, as a grad student, I'd go to his lectures and learn the mechanics of how to do behavioral treatment, cognitive behavioral therapy for obesity.
- PAPeter Attia
Meaning CBT to help people eat less? Help people eat less, exercise more?
- DADavid Allison
Eat less, exercise more, and so on. And then he had a change in the, I guess this would have been the very late '80s, early '90s. He, uh, shortly thereafter switched to Yale. Uh, he got a MacArthur Prize, the so-called Genius Award, and he started to look at maybe concerns about the negative effects of obesity. And he was one of the most powerful, not the first, but one of the most powerful voices to start raising questions about the effects of yo-yo dieting or weight cycling, going up and down. Are we doing more harm than good? Are we just building false hopes up for people because obesity treatment is useless? And that started to change, and then he morphed into, "It's the environment." And he introduced, at least as far as I-- at least to me, the phrase toxic environment. We live in a toxic environment. "You can't drive down the street," he would say, "without encountering a fast food restaurant." And so this is the problem. We need to stop the individual treatment. He sort of abandoned his roots, and we need to go to the public health treatment. Many others were grasping that idea, inspired often by him, but others on their own, and the public health community rushed in. And the public health community-
- PAPeter Attia
And, and this was a community that was up until that point working on smoking or what, what types of, you know-
- DADavid Allison
Smoking, food safety
- PAPeter Attia
... leaded gasoline.
- DADavid Allison
All kinds of things-
- PAPeter Attia
Yep
- DADavid Allison
... like the sanitation-
- PAPeter Attia
Yep
- DADavid Allison
... uh, vaccination, so on. They rushed in, and I think there was a lot of sense of, "This is simple. People eat too much. They don't exercise enough. Eating less is good. Eating more, quote-unquote, healthy food is good." There's something about the, uh, some foods are considered healthy, some are not, and if you eat the healthy food-
- PAPeter Attia
Mm-hmm
- DADavid Allison
... something magical will happen. Um, more exercise, of course, without any real understanding of this, right? I've had public health people who said to me, one person wrote and said, "Well, I think if we got people to not walk with their iPhones, then they would walk a little faster, and then they would expend more energy while they're walking across campus, and that will help with weight loss. And what do you think?" And I thought, "Well, we're still gonna cover the same distance." There's a nonlinear relationship between walking speed and energy expenditure, and the amount of energy is trivial, and et cetera, et cetera, et cetera. And I just thought nobody who understands movement science and energetics and kinetics would make such a statement. But if you're a public health person and you just think, "I just need clever ways of getting people to behave the way I already know they should behave," then you come up with ideas like that. That's where if you're embedded in a group of people, that doesn't happen, right? That wouldn't have happened at the New York Obesity Research Center. If I had said that in 1991, I would've been immediately educated by senior people who had been thinking about this.
- PAPeter Attia
So in other words, the, the public health field wasn't really able to self-police, uh, ideas that were not grounded in science.
- DADavid Allison
That's right. One of the things that we're very proud of in our school, uh, School of Public Health in Indiana University Bloomington, is that we have a kinesiology department, as in exercise science, and we're only one of four schools in the United States, schools of public health, that have a named kinesiology department. Now, every school of public health studies physical activity, but being-- studying physical activity and being an expert in exercise science are two completely different things. We have actual experts in exercise science who understand this, who treat it as a science and take it seriously. We're very proud of that, and they do great work. [lip smack] So we got a lot of nonsense rushing in the field. We, we got a lot of things that never would've, in the beginning, you wouldn't have predicted to work. But people tried them 'cause they sounded good, they felt good, gave people a positive feeling, vending machines, farmer's markets, uh, walking trails, without really saying, "All right, let's really work this out. How many people are gonna do it? If they do it, how much effect will it have? Will they compensate by eating more or less or moving more or less later?" Those things weren't done, so we got a whole couple of decades of lousy, uninformative research.
- PAPeter Attia
But
- 28:10 – 34:52
The evolving landscape of obesity research: public health initiatives and the impact of pharmacological success
- PAPeter Attia
while the public health, uh, movement was taking hold, what happened to the guard, the old guard, so to speak, that you referred to having learned the, the, the, the, the sort of the physiology, uh, of, of obesity in the, uh, late '80s, early '90s? What, what was their response to this? Were they a part of the movement? Were they distinct from the movement?
- DADavid Allison
I think it was a mix, uh, as with any, you know, thing with many people in politics and money and careers and dominance and egos. All kinds of interesting things happened. So some of the real strong behavioral people rushed in, did good science in the sense of things that were rigorous, but, um, maybe not always well-conceived that they were likely to be impactful. Um, but there was grant money to be had, and people went after it and still do, and so be it. What we've learned-
- PAPeter Attia
So was, so was this also just driven by funding? Was there a change in funding priority and this-
- DADavid Allison
There's a lot more funding for obesity. Still not as much as many people, including me, would like. Not as much as perhaps there could've or should've been, but definitely big increases. There was the Robert Wood Johnson Foundation, which didn't put a huge amount of money in, but put money in, whether it was intentionally or not, in a very strategic way, meaning they put in, relative to what NIH or pharma put in, they put in a small amount of money, but it sounded like a big amount of money. It had millions. They made a lot of noise about it very successfully. They got a lot of careers started. They drew a lot of people into the field around public health, around community intervention, around diversity issues, and that's all to the good. It's great. What I think often happened is the amount of money they were dangling in, again, relative to NIH, was small, and so many people would rush in, get started that way, but then they'd go to NIH and get bigger studies. So it did catalyze a lot of activity, and that's good. What we've learned, you know, you can make a, you can make different arguments about it. The very famous story with, uh, Edison, where his backers come to him and, whether it's a true story or not, I don't know, but say, "All this time and money and you still have nothing to show for your efforts toward making a light bulb?" And he said, "No, I now know 1,000 ways not to make a light bulb." Um- These two new papers you referred to earlier were from Summer Bell. She was the, the senior author, not the first author. Um, they're just out in the last week. I just put up a LinkedIn post on them about three days or so ago. What they do is one is in children five to 12, I think. The other is in adolescents. And they do systematic reviews, very thorough, very objective meta-analyses according to the Cochrane method. And what they find is that for both groups, there is no compelling evidence of what you would call a consistent, reliable, long-term clinically or public health meaningful effect on preventing obesity in either children or adolescents. I included a lot of adjectives in there, and those are important. Most important one is probably preventing. I didn't say treating, I said preventing. That doesn't mean that treatment of obesity in children doesn't have any efficacy. The second thing is these are community kind of diet exercise interventions.
- PAPeter Attia
By the way, how do we, um, how easily do we distinguish between prevention and treatment? Obviously, conceptually it's trivial. Uh, you know, prevention is reducing the number of new cases. Treatment would be reversal of. But can you give a sense of what reversal of obesity rates look like?
- DADavid Allison
With public health stuff, I think it's, I don't want to say it's zero because you just always have some spontaneous reversal.
- PAPeter Attia
But you, you said a moment ago that this article focused on the prevention side-
- DADavid Allison
Correct
- PAPeter Attia
... not the treatment side.
- DADavid Allison
Correct.
- PAPeter Attia
Was the implication of that, that the, that public health treatment has been successful, but prevention has not?
- DADavid Allison
No, no, no. I'm sorry.
- PAPeter Attia
I see. Okay.
- DADavid Allison
Clinical treatment, I think there's some evidence for success, more so in adults, um, but some evidence for success.
- PAPeter Attia
Does clinical treatment include drugs and surgery?
- DADavid Allison
Can include, but it doesn't have to.
- PAPeter Attia
Okay.
- DADavid Allison
So, um, you know the idea of somebody coming to the clinic, they go to see, let's say a Len Epstein at Buffalo, and they go to his clinic and he puts them in a study or what have you for weight loss. I would call that a clinical intervention as opposed to Len Epstein saying, "I've got an idea. I'm going to go out to the public schools and set these programs up."
- PAPeter Attia
Yeah.
- DADavid Allison
Um, "And we'll try to get everybody to be less obese and see if we prevent obesity." Those, that's how I distinguish those things. And Len, by the way, is he's one of the sharpest cats around and, um, he's a very good skeptic and a very good commenter on what we really know and don't know in that domain. But what Summer Bell shows basically is not only is there no compelling evidence for effects, but the, there's reasonably compelling evidence that given the methods we've used today, the effects are either zero or trivial. And so I think that's really important because I hear tremendous defensiveness now among people who are not practitioners of pharmaceuticals or favorable toward pharmaceuticals so much in, because of the great success of some of the drugs, especially the GLP-1 agonist related drugs. In the same way as in the mid-'90s, I heard tremendous defensiveness from the behavioral psychology community and others about genetics 'cause they weren't going to do genetics, and the Rudi Leibel's of the world and, and the Claude Bouchard's of the world were talking it up and it was going to be big, and they were starting to feel threatened and often didn't know much genetics, but would try to somehow minimize the role. And I think there's a lot of fear now among people who want community intervention, public health intervention, who say, "I don't want our solution to obesity be let everybody get obese or let two-thirds of the population get obese and then we'll give them surgery or drugs for the rest of their life. Um, it's too expensive. It's not my ethos," you know, et cetera, et cetera. Um, and I think they're worried that people like me who say, "Look at the efficacy data. We need to think about this more," are implying that we should shut down all the other stuff. And at least for me personally, that answer's absolutely not true.
- 34:52 – 44:42
Rethinking obesity solutions: the need for a paradigm shift
- DADavid Allison
But I think we need sub-paradigm shifts within paradigms. And what I mean by that is I don't think the paradigm shift of saying, "Don't ever think about nutrition anymore. Only think about drugs and surgery," is warranted. I don't think the paradigm shift of saying, "Don't ever think about behavior, community intervention, family intervention," is warranted. "Don't ever think about public health or policy." That's not warrant. I don't agree with those at all. What I do think we need to do is to say within the paradigms of behavior, community, family, policy, let's be honest. Let's look at Carolyn Summer Bell's data and others and say, "There is no compelling evidence that any of this has had a meaningful impact." You can cherry pick here and there. You can say this policy led to differences in how much of that food was purchased in this context. Even if that's true, and sometimes those are a little shaky, those conclusions, say did it lower obesity rates? And those have never been shown, right? None of these taxation, none of the policies.
- PAPeter Attia
So h-how do we, how do we do that? I, I agree with you, by the way. And my own personal... Because I think everybody has to have a personal sort of bias if they're being honest. My personal bias is that so many of these public health ideas on the surface just make a ton of sense. Like I, I, I, I can, I can, I can simultaneously hold true the follow, uh, you know, the following truths, right? Uh, which is on the one hand, I can completely see why it was logical in the, uh, early to mid-'90s to say, "We have to change the food environment."
- DADavid Allison
Mm-hmm.
- PAPeter Attia
Again, like, you know, Richard Thaler's work, right, another Nobel laureate-
- DADavid Allison
Mm-hmm
- PAPeter Attia
... um, would suggest that that's the answer. You fix the environment. You make the default environment better, and people will opt into good choices. By the way, the default environment used to allow people to eat in a way that was clearly ad libitum and obesity rates were not what they were. So something about the environment 200 years ago or 100 years ago or even 50 years ago was significantly different from the environment today. It's not that our genes changed, right? Nobody would argue there's been such a genetic drift that the reason that obesity rates are two-thirds as opposed to 10% is due to a change in our species. An environmental trigger or set of triggers seems more likely, and therefore public health solutions towards those seem very logical. So we can hold that truth here, and then we have to be brutally honest with your assessment as well, the same as Caroline's assessment, which is this has been an abject failure. I mean, if at the end of the day you're only measuring the outcome of interest, it hasn't changed. So there, you know, we can say whatever we want, but the outcome of interest hasn't changed. Either people smoke less or they smoke more or they smoke the same, and it-- that's the only metric that matters if smoking cessation is what you're after. It's not do we collect more tax revenue? Are the commercials more or less favorable? Uh, do people s- you know, it's smoke less in restaurants versus not in restaurants. No. We care if people as a society smoke less or smoke more. Um, so given that, how do we still say, and I'm not saying I disagree with this, because again, my bias is there should be solutions in public health. But how do we know after thirty years and billions of dollars with no effect that we should stay within the paradigm of public health solutions and just abandon all of the ones we have when we don't really have a sense of why they failed?
- DADavid Allison
Right. So we definitely don't wanna only rely on public health solutions. I would strongly oppose that. I agree with you that there is a superficial sensibility to the public health arguments that were made for the various things tried, and it was reasonable to try them. But I say superficial sensibil- sens- uh, sensitivity or sensibleness because everything that's true makes sense as once we understand it. If we're wrong about something, then it didn't make sense. We just didn't understand that it didn't make sense at the time. Some of that is assumptions, and it goes back to that public health thing. I had a wonderful lunch with the most generous, interesting person, Daniel Kahneman, who won the Nobel Prize a few years ago.
- PAPeter Attia
Who recently passed away.
- DADavid Allison
Right, before he died. And he and his wife were, uh, gracious enough to allow myself and Michelle Cardel, who now works at WW, was a former student, um, with the group I led, uh, to take them to lunch. And we talk about obesity a little bit, and he's this great behavioral economist. And he says to me, without artifice, he says, "Well, I think this nudge stuff is really good. And, you know, so you could put things on the menu, and that would make people eat less." And I say, "Well, that's a good idea, and some things like that are being tried and have been tried." And I said, "But the big thing is compensation. Yes, you can get a person to eat a little less in this context, but then if they go home for dinner and they just eat more at dinner," goes away. And he looks at me without artifice, and he says, "Hold it a second. So you're telling me that there might be mechanisms in people that lead them to adjust for-
- PAPeter Attia
A previous behavior
- DADavid Allison
... reduced calories?"
- PAPeter Attia
Yep.
- DADavid Allison
And I said, "Yeah." And this was a revelation. He said, "You've opened my eyes." And as an economist, he didn't think about this. He's great with math, and he's great with creative study designs, but this was again someone-
- PAPeter Attia
But yeah, he doesn't understand physiology
- DADavid Allison
... rushing in.
- PAPeter Attia
Of course.
- DADavid Allison
So I think that was a big part. A lot of things didn't make sense because they didn't take into account compensation and many other factors. They didn't take into account magnitude of effect, uh, and so forth. The second thing is the data themselves. People, uh, published a nice thing about, uh, a, a meta-analysis of nudge type stuff in PNAS, Proceedings of the National Academy of Sciences, a couple years ago. Someone else just went in and redid it and said, "If you adjust for, um, publication bias, it doesn't look like there's much holding up there." So often we're presented with evidence, and we may wanna come back to this when we talk about some other things like especially protein intake. We're presented with statements as though we confidently know these, and yet when you really start to open the hood and peel things back, you say, "Hey, there's not a lot of there there on the data." So the data that nudge works is actually shaky.
- PAPeter Attia
Mm-hmm.
- DADavid Allison
Um, so that, that's the second problem. And the third is we seem to be unwilling to really learn from our mistakes. That is, well, I shouldn't say mistakes. Unwilling to learn from the outcomes of our studies. That is, unwilling to say, "We tried the school-based thing, and it didn't get a big effect. We tried it again. Fair enough. Let's try it a second ti-- Let's try it a third time." At a certain point, we say, "Enough." So if someone were to come to me, and I've been saying this for twenty years now, but I'll say it even more strongly today. Uh, if someone were to come to me and say, "We, we've got this opportunity to invest in these big school-based, community-based, public health-oriented trials to reduce obesity levels in children or adults, and we have the money available, and we want to do good. Should we do it?" And I would say, "Show me how this proposed idea is radically different than what's been done for the last thirty years." And then let's talk. And if it's not radically different, why are we wasting our time and money on that? So I think we really need radically different public health paradigm. We need to stay in the public health paradigm, but within the paradigm, we need a sub-paradigm shift to say nutrition education, modest physical activity, build a little bit of a facility to allow people a little more activity. These have been tried. They don't work. They don't have big meaningful effects. Let's try something completely different, and it's worth a try. That's what I think we need within the paradigms of public health policy and so on, radically different proposals.
- PAPeter Attia
Now, if you were czar of the universe and the ultimate resource allocator, what percentage of resources would you put into a new and different form of public health, i.e., radically different approaches, and what percent would you put into medical treatments for, such as surgery and drugs?
- DADavid Allison
So first, I find it very entertaining to think about being the czar of anything since my grandparents spent a lot of time successfully escaping the czars. Um, but, uh, it's interesting that what I would say is probably a little more in the near term on the clinical treatment because I think we can make more rapid gains in that while we need some slower, longer term assessment of the others. But also I would amp up the, the non-pharmaceutical, non-clinical, non-surgery a little bit, the funding from the government, because I think a lot of that funding for those other things will come from industry. So, you know, if you look at a budget of a Pfizer or a Lilly or a Novo Nordisk and what they put towards certain areas, and then you look at what NIH can put toward those areas, we're not talking about NIH being this overwhelming big dog.
- PAPeter Attia
Yep.
- DADavid Allison
And in fact, when you combine the pharmaceuticals on certain areas, they may be much bigger than NIH.
- PAPeter Attia
They would, they would presumably
- 44:42 – 56:18
Understanding environmental triggers and embracing a balanced approach to addressing obesity that includes both pharmacological treatments and realistic lifestyle changes
- PAPeter Attia
exceed, yeah. A-a-again, there's still something here that just philosophically doesn't sit well with me, not morally, so I want to be clear.
- DADavid Allison
Mm-hmm.
- PAPeter Attia
Um, I don't have a moral issue with the remarkable success of the drug class that is now probably going to be the first thing that bends the arc of this. I don't know when the next check-in will be, the next NHANES check-in, but it, it seems-
- DADavid Allison
Now it's annual.
- PAPeter Attia
Yeah. So it seems likely that very soon, if not already, we're going to see for the first time in five decades obesity rates going down. I hope we do. So, but, but the reason that I'm still a little troubled is that from a public health perspective, we don't have the answer to the question, what was the, what was the or what were the environmental triggers? I mean, we think we know the answer, but every time we try an intervention against those things, it doesn't work, which makes us call into question what the answer is. So clearly we did not get obese because of a GLP-1 shortage that is now being ameliorated with GLP-1 drugs, right?
- DADavid Allison
Sure.
- PAPeter Attia
So clearly we have something that was causing the problem, again, multifaceted likely, and then you have a totally different hack to work around the problem, which is why you're saying, I think what you're saying, which is we need to do both of these things. We still have to get back to this. But if you had to speculate, what is it about the world in the early part of the 21st century that makes, um, makes obesity and by extension type 2 diabetes a problem that it wasn't, uh, again, the year I was born? You know, it just was... You know, it's literally a log fold difference in type 2 diabetes, a log fold.
- DADavid Allison
Mm-hmm.
- PAPeter Attia
That's, that's hard to imagine in, in 50 years.
- DADavid Allison
I think there's multiple closely related factors. Um, I think one is the food supply and its availability itself. I think the second is kind of lagged intergenerational effects. Um, just for fun, I'm gonna, uh, try to rebut you on the genetics point, uh, but only, only, uh, pedantically.
- PAPeter Attia
Mm.
- DADavid Allison
Uh, I think that we have seen genetic changes that-
- PAPeter Attia
Epigenetic changes or genetic changes?
- DADavid Allison
Both. But certainly I'm going to put more direct knowledge, my, my direct knowledge and confidence on the genetic as opposed to the epigenetic changes. Um, and this is assortative mating, differential mating. Are the-- do these fully account for the obesity epidemic? No, of course not. Am I trying to say that they are the biggest influences? No, of course not. But I do think it's important to push back and say these are factors and they come in through migration, through differential fertility, uh, and through assortative mating. We've written papers about all these and as have others. If you look in things like Framingham, you see that people in certain BMI ranges have more children than people in other BMI ranges. And some will say, "But obese people have fertility problems." You see, we're not asking about how good you are in theory at producing offspring. We're asking how many offspring you produce. And so if richer, thinner people use more birth control and have fewer offspring, then... and there are some genes for thinness, you're gonna reduce their prevalence and vice versa. So through migration, uh, differential fertility, and then the other is assortative mating, which doesn't change allele frequencies, but changes gene frequencies, which you get like mates with like.
- PAPeter Attia
But if you had to... A-again, all of those things make sense.
- DADavid Allison
Yeah, I just wanted to dispute that.
- PAPeter Attia
They, they strike me as somewhat marginal though. What do you-- what fraction of the increase-
- DADavid Allison
Yeah. So I had to be a professor for a minute and get the pedantic points out.
- PAPeter Attia
Fair. Okay.
- DADavid Allison
All right. So now that's, that's out. I think that it is Largely, but not exclusively, um, the increased availability of a greater variety of foods, of highly palatable foods, of foods that are relatively modest in cost, foods that are easy to acquire, the, uh, control of ambient temperature, which makes it easier to overeat foods. You don't want to overeat a lot if there's no air conditioning and you live in Austin, Texas, and it's 110 degrees out, right? But if there's air conditioning, the buffet's okay. Uh, and then I think there are some intergenerational lagged effects that we, or at least I, don't fully understand. If you look at the Danish data, Torkild Sorensen and others have written about this, they for over 100 years conscripted, if that's the right word, every 18-year-old healthy male into the Danish army. Um, and they have not only heights and weights of each one naked, kind of weirdly, they have photographs of each of them naked. Um, and what you see in these, these BMI levels is you'll see a period where it's flat for a little bit, approximately, then you'll see a steep acceleration or steep increase, and then it'll flatten out again a little bit, and then you'll see a steep slope. And this happened, this has happened in three or more cycles, I think. I don't think anybody exactly understands why. Um, Diana Thomas' mathematical model, she's a professor at, uh, West Point, studies obesity, her mathematical models predict some of that. I don't fully understand how that works, but we might ask her. Um, it does suggest to me even culturally or behaviorally there could be some lags whereby the weight of your parents or grandparents is affecting you.
- PAPeter Attia
Socially or genetically?
- DADavid Allison
Both, right? So the oocyte that formed you was formed in your grandmother.
- PAPeter Attia
Mm-hmm.
- DADavid Allison
So potentially through epigenetic things you've mentioned-
- PAPeter Attia
Mm-hmm
- DADavid Allison
... or others, that could be affecting you. Then there's the cultural part. You know, and I, I think about it. When I was a kid and we went out to dinner with my dad, and we weren't poor, but we weren't rich. We were decidedly, you know, middle cla-- lower middle class creeping up. Um, if we went out and we wanted or at the local Italian restaurant or something order shrimp, you had to ask Dad about that. The chicken parm you could order without asking. Shrimp you had to ask, because shrimp was expensive. You can get shrimp by the bucket now at the local buffet for next to nothing. So I'm prepared to eat a lot more shrimp than my dad ever would have thought of ordering or sitting down because of our changing economic times and so on. Now, my kids think nothing about ordering dinner in from DoorDash every night. Where I still think even though I could afford to do it, as well as my kids could, because they're spending my money [chuckles] some of the time, which is great, I'm glad they're doing it. Um, but I think, "Oh, that just seems excessive to me. You know, it seems too indulgent." So I think there may be sort of levels at which one ratchets culturally as well as physiologically or anatomically. So I think all of these things can be in play. I also think we need to change some of the attitudes, and th- this is speculative on my part and I have no proof that this is true. But I think one of the bad things that the nutrition field has done, including, um, very much the public health community, which talks about the, I, I used it earlier, I said the healthy foods that have magical effects. But I also think the, the, the low carb advocates and zealots who came up through the late nineties and still exist at present and have very powerful voices, and yet others still. I think there's the sense that there's a right way to eat. Nobody agrees on what the right way is, but there is an underlying supposition that there is a right way to eat, and if you just ate that right way, then you would maintain the weight you want to maintain and the fat level you want to maintain without ever feeling lack of satiety or dissatisfaction or what have you. You and I were talking about our personal diets.
- PAPeter Attia
Yeah, but, but what's interesting about that is that's actually philosophically not that different from a drug approach. In other words, if you constructed a lot of parallel universes, it's certainly possible that if you put everybody on a perfectly adherent version of diet X, Y, and Z on each of those parallel planets, you would eradicate obesity. And by the way, one of those planets you might say, "Well, we're also going to put everybody on tirzepatide."
- DADavid Allison
Mm-hmm.
- PAPeter Attia
And so, so you now have multiple different dietary treatments when perfectly adhered to that will dramatically improve obesity. One of those will be just a drug.
- DADavid Allison
Mm-hmm.
- 56:18 – 1:08:01
The need for higher standards in obesity research
- DADavid Allison
let's, let's go back to something you were asking though about evidence earlier. And I do wanna make a point about this, that we also need to increase the quality of the evidence and the standards we hold. We spend too much of our research budget on lousy evidence. So in the childhood obesity field, my, my group, for example, often will write letters to the editor. We just, another paper was retracted last week because we found statistical errors in it. And if you think about it, this was a randomized controlled trial of a, some treatment for obesity related or-
- PAPeter Attia
Behavioral?
- DADavid Allison
Uh, I think so. And, and we find it in diet behavior, et cetera. Not usually drugs. Um, and what we, we see is, you know, if you think about a randomized controlled trial, at the low end, a randomized controlled trial is usually over $100,000 to conduct. At the high end, it's tens of millions. Um, the ones we're looking at that often we find these mistakes in, in many cases are retracted, especially in childhood obesity, are probably in the multiple hundreds of thousands of dollars, occasionally millions. And then you think, "That's all wasted if they misanalyzed and misreported the data and got the wrong answer." So we kind of feel like we're rescuing those dollars in some sense by getting the wrong answers out and the right answers in. So we think it's an important service. Um, but I think we need to hold our field's feet to the fire much more strongly on doing research that answers new questions, that answers questions well, that honestly reports the data, makes the data publicly available.
- PAPeter Attia
Do, do you think that that problem, which I'm quite aware of, of course, is, um, disproportionately present in this field? Or, um, do you feel that it's, uh, both acknowledged and demonstrated at the same frequency in all fields of medicine? Um, do you, do you feel that, you know, this is, we, we have a, we have a brighter spotlight on it here thanks to certain individuals? Y- how, how do you think this stacks up?
- DADavid Allison
All of the above. Uh, and so what we know is that there are many anecdotal statements by leading thinkers like Stuart Ritchie as one, just one example, uh, Gary Taubes, our mutual friend, uh, who say nutrition is singularly bad. And there are some of these old wonderfully colorful statements. Johnny Ioannidis said, "We need to accept that nutrition epidemiology is a dead science and bury the corpse." That's a quotation, right? So that, that's, those are opinions. Those are not bits of data. If we go further and we look at the Pew Charitable Trusts-
- PAPeter Attia
But, but hang on. That's, I mean, you, you... I mean, one could agree with that on some pretty objective facts.
- DADavid Allison
Sure.
- PAPeter Attia
But the question I'm asking is more on the challenges of experimental research that you're talking about-
- DADavid Allison
Absolutely
- PAPeter Attia
... where real dollars are being thrown at experiments that are being done incorrectly or being analyzed incorrectly, um, or where the questions that are being asked are incremental, useless, uninteresting, and unlikely to add meaningfully to the fund of knowledge. Like, let's even, let's just forget about nutritional epidemiology. Um, but I, but I wanna talk about this other, what seems to be more distressing problem-
- DADavid Allison
Mm-hmm
- PAPeter Attia
... um, based on both the dollars that go into it, but also I think the confusion that it sows and the noise that it creates.
- DADavid Allison
Right. So it's clearly created that confusion noise, and that's what the Pew Charitable Trusts have shown, that in surveys, now we're talking data, in surveys of representative samples of American population, people trust nutrition experts, clinicians, purveyors of knowledge more than they trust nutrition scientists, and they trust nutrition science less than they trust other forms of science. So that's a fact. We do have a trust problem in nutrition science. Now let's go to the last stage, which is, is our research really better or worse? Harder to pin that one down. There's not enough concrete strong comparisons to other areas. We're trying to start some in our group. Uh, but there was a recent paper that came out in economics. Now, there's no... It's not a one-to-one comparison, but in an economic journal looking at reproducibility. Reproducibility and replicability are not quite the same. Reproducibility is can I get your original data, run exactly the same analysis you said you ran, and get exactly the same result If I can, I've reproduced your research. Doesn't mean your result was right.
- PAPeter Attia
Yep.
- DADavid Allison
Maybe you ran the wrong analysis, but at least I could do what you said you did. And we do that in nutrition and obesity, and we find, uh, we don't have exact numbers. It's not a random sample of papers, but we find what seems to be a not infrequent errors, irreproducibility, or what we call, um, verification problem, meaning we could reproduce your result, but it was wrong. Um, it was wrong 'cause you ran the wrong analysis. We ran the right analysis, get a different conclusion.
- PAPeter Attia
And you might do how many of these a year?
- DADavid Allison
More than a dozen.
- PAPeter Attia
And of the dozen you run a year, how many turn out to be not reproducible or not verifiable?
- DADavid Allison
I would say probably, again, these are all approximations, maybe half, but keep in mind, we're not randomly sampling.
- PAPeter Attia
Understood. What's the criteria upon which you select besides size of study?
- DADavid Allison
It's usually one of two things. It's interestingness or it's something doesn't look quite right. So if it's something doesn't look quite right-
- PAPeter Attia
Your pretest probability is higher
- DADavid Allison
... then we, we take a closer look at it more often. Or if it's just very interesting, we say, "That's really interesting, and it was published in Nature, and that could be, you know, paradigm changing."
- PAPeter Attia
I, I'd be curious, when you have enough data, to know if you just look, if you take out the "that looks fishy" sample and just said, "Hey, when we looked at the this is interesting," if half of those are coming up, uh, uh, unverifiable, uh, that's a crisis.
- DADavid Allison
Yeah, and I, I would say we should do it. I hope there's, there's a funder out there listening who will want to fund it. And NIH, as you might imagine, may not be always so keen on-
- PAPeter Attia
[laughs]
- DADavid Allison
... on answering, uh, having us answer this question, and it's hard to, to get that through. But, um, yeah, we'd like to do that and, and hope we can do some more. We're doing little spot checks in the area. My sense is even within obesity, if you look at pharmaceutically done randomized controlled trials, you know, and I'm not trying to say that people at pharmaceutical companies or pharmaceutical companies somehow morally superior or not. They're people. They're just responding to their environment as well, but their environment is a very strong regulatory authority called FDA that holds their feet to the fire and so on.
- PAPeter Attia
Do you think that's the reason that drug studies tend to be very rarely found, uh, to require retraction?
- DADavid Allison
In modern times, yes. In modern times, I mean, if somebody said to me, "Do you trust, uh, randomized controlled trials coming out of the pharmaceutical industry more or less than academia?" Infinitely more from the pharmaceutical industry.
- PAPeter Attia
Yeah. Think about that for a moment. Let's just reflect. That's a, that's a big statement that I, I, I agree with you, but I think it's not, it's not intuitive to the average person listening to us.
- 1:08:01 – 1:18:08
The rapid success of GLP-1 receptor agonists for weight loss: a discussion on the societal impact and controversy of their growing usage
- PAPeter Attia
let's, let's pivot now and kind of talk about, um, the current state of obesity, which, um, uh, is, is, is really seeing a success it's, it's never seen. Um, and it's been a relatively short period of time. I think three years ago, very few people knew what semaglutide was, um, or even Ozempic, which is the trade name given to the diabetes version of that drug. Whereas today, I, I, I can't imagine too many people haven't heard the words Ozempic, um, or some of its derivatives. But l-- I think Ozempic might be one of the most recognized, um, of these drugs. So again, it's pretty remarkable. Um-
- DADavid Allison
Mm-hmm.
- PAPeter Attia
It's also worth noting that these are not new drugs, right? I mean, semaglutide and tirzepatide are newer drugs, but they've been around for a while, at least semaglutide has. And-
- DADavid Allison
Liraglutide.
- PAPeter Attia
Liraglutide and others have been around for decade, you know, at least a decade. Um, and they've successfully treated people with type 2 diabetes, and like all things, or as is often the case, you sort of notice something in treating one subset of patients-
- DADavid Allison
Mm-hmm
- PAPeter Attia
... that gives you an insight into treating another. And so basically, as people with type 2 diabetes were treated with this class of drug, you notice that it wasn't just improving their diabetes, they were also losing weight, and that led to what became a set of dedicated experiments to test the efficacy of these drugs in non-diabetic obese patients, and the rest is history. Talk a little bit about what you, what you think is socially and psychologically happening at the moment. It-- W-why? Why are people so interested in this drug?
- DADavid Allison
Yeah. I think it's, it's fascinating. I think people are interested for the obvious reason, and the obvious reason is lots of people want to lose weight, and lots of people wanna help other people lose weight. And for the first time in, in history, um, as you've noted, we have drugs that are now powerfully effective and appear to be reasonably safe. We've had drugs that were powerfully effective before but would kill you, and we've had drugs that were reasonably safe before but at best modestly efficacious. We now have ones that are powerfully effective and appear safe, reasonably safe. Safety is a social judgment, right? Not a factual determination. Risk is a factual determination. Safety is a social judgment. And so it invites all kinds of interesting speculations, um, about cause. What is the role of GLP-1 in causing obesity? And is there a role? Just because it-- things involving GLP-1 treat it doesn't mean it's involving the cause. Um, what's the, um, effect on stigma? If we can treat it, does that reduce stigma in the same way that Viagra changed many things around erectile dysfunction? Uh, and interestingly, you know, I sort of didn't predict the full cultural impact of that, which shows you it's hard to predict these things. People didn't predict what Viagra was for. It was being used for something else. They noticed erections as a side effect, and then they started working on it. And in the early '90s when I went and visited one of my buddies who's a biostatistician at Pfizer, and that individual told me they were working on this new thing and explained what it was to me. I laughed at it and I said, "Why are you wasting your time on something so ridiculous and unimportant? Why don't you do some important research?" Shows you what I know. Um, so I think here we're, we're learning that, again, that we get surprised in science. We're seeing a moral panic. This is subjective on my part, but this is something I'm noticing. A lot of old arguments that had kind of gone semi-dormant, at least in the academic community, um, over the years of, "Well, if you give people a drug for obesity, it doesn't teach them anything, and therefore, when you stop the drug, the weight just comes back." And this was said as a criticism, as opposed to saying, "Well, who said it had to teach them anything? Who said that was the goal?" And for many drugs, anti-seizure medications if you have seizures, antihypertensives, anti-diabetes drugs, um, et cetera, you're gonna take those for the rest of your life if you're in the right class for that. We don't say, "But the person with schizophrenia shouldn't get the drug because if we stop giving it to them, the schizophrenia symptoms come back." Say, "No, schizo- schizophrenia's a serious disease. We need to give it to them." With obesity, this has come up again. It sort of seemed to be put down a few, that idea, a few years back, and now I'm seeing, I'm hearing it again, this kind of moralistic judgment about that. We're also hearing the moralistic judgments come about motivation. It's okay if you're motivated for health. It's not okay to get the drug if you're motivated for something other than health, which implies that assuming we have the same health issues, I mean, the person would equally benefit from their health. We make a moral judgment about your motivation, but there is no evidence that I know of that people who are motivated for health to lose weight do better than people who are motivated for cosmetic or any ego, business, any other reasons. So I think we need to get over some of that moral panic. Once we get past the safety, the cost, and the availability issues, and I don't want to trivialize those, the safety, the cost, and the availability issues are big issues. The safety issue is really-- And, and in that sense, I'm defining safety in the sense that sometimes the FDA defines it, which is safety involves risk, and risk involves uncertainty as opposed to being risk involving known factor, right? Now, I don't just mean the probability that you get this. I mean the fact that we don't know what happens if you take it for forty years. Um, so there is some safety issue, some open questions. No one's taken it for forty years, so we don't know what happens if you take it for forty years. Right now, it's very expensive. Our country is divided on how healthcare should be paid for. There's a lot of different opinions. Um, and also there's an availability problem. But let's just fast-forward to a time when we say we've, we've learned the safety.
- PAPeter Attia
And by the way, say, say a little bit more about the availability problem. I mean, uh, I only realize it because you see compounding pharmacies now making semaglutide and tirzepatide, which when I first saw that, I couldn't understand how they were doing that legally because, uh, that's, that's pretty clearly not within the statute of what a compounding pharmacy can do. A compounding pharmacy can't make an existing FDA-approved drug. They have to make a variation of that drug. For example, they have to change the delivery mechanism if they make something topical that would only be available orally or something of that nature. Unless, and one of the exceptions to the rule is if the FDA-approved drug can't be, uh, produced in sufficient quantities, then a compounding pharmacy can create the exact same drug that is available through the FDA label. So presumably, that is happening. Do we have a sense of why it's happening? Uh, what is the manufacturing bottleneck? Obviously, demand is outstripping supply, but that-- the, the, the question is why is supply not able to meet demand? And then secondly, do you have any insight into whether the quality control at the compounding pharmacy level, it matches that of Lilly or, uh, Novo Nordisk?
- DADavid Allison
So with respect to the first part, why is there an availability problem? I don't know the technical mechanics of it, but my understanding is that the technical process by which these drugs are produced is different than some other drugs, and the technical process is a slow one.
- PAPeter Attia
Hmm.
- DADavid Allison
And so until they ramp up more and more production sites, they just can't do it fast enough. But they are ramping up more and more production sites. Um, so that's good. Um, Novo just bought, bought Catalon, which happens to have a plant i, in my backyard in Bloomington, Indiana, so we'll probably see more of that ramping up. Um, we, uh-- The second thing is about the compounding pharmacies. So when I first heard about it, and I'm, I'm far from an expert in compounding pharmacies or the legal aspects, but I too was skeptical, is this okay? What is the quality control? And, you know, is this a kind of shady thing? And I started to hear a lot of reports about this and described as though it was a very shady endeavor. And again, that moralizing came in again. Then I've talked to some other people who are experts in it, uh, and who are using these, and I've said-- Now admittedly, again, this is their business, so they have a motivation. But they have said, "Well, when we do it," and they've described, and I said, "Tell me your process. Who do you use? How do you do it? What quality control?" And then they've gone through, say, "For this compounding pharmacy that I use, we use it in this way, this degree of quality control." And I say, "Wow, that sounds to me," again, I, I'm not physic-- have not physically inspected the plants. I'm not an expert in it. "But it sounds to me like some very rigorous quality control." So I don't think we should be dismissive of the concerns around compounding pharmacies, but I also don't think we want to paint everybody with the same brush. The question becomes, as with anything, is show me your data, show me your evidence on your quality control, your procedures, and if they're good, they're good, and let's use them. Let's get over the moral panic.
- PAPeter Attia
Yeah, I, I don't know that I
- 1:18:08 – 1:31:48
The ethical and practical considerations of obesity drugs: risks, benefits, and motivations for usage
- PAPeter Attia
think of that as a moral panic. I think the bigger moral panic is the-- is less about the source of the drug, but the use of the drug.
- DADavid Allison
Right.
- PAPeter Attia
And, and so you, you, you, you brought up an interesting distinction, um, which is you-- let's take two people with obesity. Actually, let me take that back. Let's take an individual who is medically obese, um, and let's take an individual who is-- Uh, and by the way, metabolically unhealthy, right? So that's the key point I want to get at here. So this is a person whose health is compromised by their weight, um, both from an orthopedic perspective and metabolically. And then let's take another individual who's overweight, but if you're looking at them objectively, you don't see the metabolic signs of overweight. They're not suffering, um, physical and orthopedic issues associated with it. So both of these people, let's just assume, have a desire to lose weight, one of them to primarily ameliorate the medical conditions, uh, and also the-
- DADavid Allison
Mm-hmm
- PAPeter Attia
... aesthetic conditions, and then the, the, the, the latter person just for the aesthetic conversions, right? Um, okay. We, we probably look at those people differently. When I say we, I mean society.
- DADavid Allison
Mm-hmm.
- PAPeter Attia
Might make a different moral judgment on those two.
- DADavid Allison
That's right.
- PAPeter Attia
You're arguing that's a false dichotomy.
- DADavid Allison
I think it's, it's a, it's a legitimate dichotomy to see the situations as distinct situations, but not necessarily implying distinct recommendations coming from those. Let's, let's refine it to a two by two.
- PAPeter Attia
Hmm.
- DADavid Allison
We've got people as, let's just say four individuals come to you, and we're gonna say that you're the objective all-knowing agent. And-
- PAPeter Attia
Meaning I determine who g- goes on the drug?
- DADavid Allison
No.
- PAPeter Attia
Oh.
- DADavid Allison
You determine their state of being.
- PAPeter Attia
Got it.
- DADavid Allison
Right? Half of the people are objectively at medical physical risk because of obesity and would be objectively medically helped by losing weight on this drug. Half of the people are not at objectively medical increased risk and would not be predicted to have a medical, a major medical benefit. Within that, each of those groups-
- PAPeter Attia
Yep
- DADavid Allison
... half of them think they have a medical problem, regardless of whether you objectively determine they do-
- PAPeter Attia
Mm-hmm
- DADavid Allison
... and think they would benefit, and half of them aren't interested in that. They're wanna do it for cosmetics, income, o- other opportunities, et cetera, stigma reduction, quality of life. And the question is how should those four groups be treated?
- PAPeter Attia
Hmm.
- DADavid Allison
Now, it seems to me from an obvious point of view, if we're concerned about expense and the expense is borne by society, not the individual coming, or if there's shortages and we're gonna take it away from someone who's genuinely medically needed, then going to the non-medically needy people is questionable. But if we get over those problems, if the person says, "I can afford to pay it for it myself," and the availability is there, and we think there's no big safety problem, or even if there's some safety problem, but we've told them-
- PAPeter Attia
Yeah
- DADavid Allison
... it's fully consented, take the libertarian view, it's their choice it seems to me.
- PAPeter Attia
Yeah. And I, it's hard to imagine any reasonable person could argue with that position.
- DADavid Allison
Well, one of the big statements that got in some news was a, a, a very reputable, um, entity, major player in mainstream medicine, who has an interest in actually promoting this, and a, a three sort of s- step statement was made. Step one is the drugs were intended and designed and studied for this use, meaning treatment of medically needy people. Second, the drugs were approved for that use. Third, therefore, they should only be used for that.
- PAPeter Attia
Right.
- DADavid Allison
And the third part is a moral judgment-
- 1:31:48 – 1:39:31
The use of GLP-1 agonists by athletes as performance enhancers
- PAPeter Attia
let's consider one more zinger on this topic. You are now in charge of both WADA and USADA.
- DADavid Allison
Okay.
- PAPeter Attia
Right? So World Anti-Doping and US Anti-Doping-
- DADavid Allison
Ah, thank you for defining those for me
- PAPeter Attia
... agencies. You have an obvious and clear hard line against drugs that improve performance, so a, an athlete cannot take testosterone or growth hormone or EPO or anything that boosts performance. Now, if you think about it, a lot of sports have their performance improved when the athlete is lighter. Weight management is a big part of many sports. Cyclists, runners, gymnasts. If you think about it-
- DADavid Allison
Rowers
- PAPeter Attia
... rowers, any sport that is cardiac output versus body weight, those athletes, and I used to be one of them, you are relent-- you are just as focused on weight management as you are cardiac output. Should these drugs be banned by WADA and USADA? Are they indeed performance-enhancing drugs?
- DADavid Allison
Great question. I hadn't thought about that until you asked it. Great question, because it introduces a whole different set of interests. Prior, we were talking mainly about the individual person's taking the drug's interest and a little bit about the provider's interest, you, a little bit about society costs, FDA, so on. Here, you've introduced a fourth party, and that party is the sport, um, all the spectators, the people who own it, the other participants. The sport has rules, and sport is very different than some other things where there's an arbitrariness to it, right? Why does the baseball bat have to be this long and not that long? Why does the tennis racket have to be within these dimensions?
- PAPeter Attia
Well, that part's arbitrary, but what's not arbitrary is we want it to be equal. We want everybody to have the same chance. So in other words-
- DADavid Allison
Mm-hmm
- PAPeter Attia
... we don't spend too much time worrying about the length or weight of the baseball bat. We worry far more that you didn't screw into yours and put cork in there and change the weight of it. That's the thing we care about, is fairness.
- DADavid Allison
Because that's the rule. But the rule, we even change the rules about the intrinsic things. So we change the rules about, in some places, we don't condition on age. In others, we have age brackets. Some boxing, we have weight brackets. Wrestling, we have weight brackets. We don't have height brackets in basketball. And it's interesting, some colleagues and I are trying to write a whole paper on, you know, mathematically, what is bias? What do we mean by that? And we use basketball as an analogy, and I use myself as the example and say, "If I try out and, and I don't do well for the basketball team because I'm short, I don't call that bias because intrinsic to the idea of basketball is these are the rules. We don't have springboards for shorter guys. Um, we could, but we don't. We don't have height classes, and so that's not biased." In contrast, if you ask me to try out to be a biostatistics professor, and the book is on the top shelf that you want me to lecture from, and there's no step stool, I would argue that's biased because you could have put a step stool there, and it's not intrinsic to biostatistics professor performance to be able to reach tall things. And so we need to look at the sport and say, "What do you want it to be?" And if somebody says, "I want it to be things where part of the sport is being able to maintain your weight, and so I don't want anybody to have a performance-enhancing drug," then to me, so be it. I could also alternatively turn around and say, um, "We just want you to be able to get the basket in the, in the hoop," or, "We just want you to be able to row the boat." And, you know, if you do it by having more money and hiring a better coach, and you do it by taking Ozempic, and you do it by, um, having good genes, all is fair. And I don't, I don't think there's a right answer there from the sport point of view. I think you, you just decide what is-
- PAPeter Attia
But given that the sport has already made several decisions, right? They've already said you can't take a drug that increases the number of red blood cells that you have.
- DADavid Allison
Mm-hmm.
- PAPeter Attia
That's EPO. You can't take a drug that increases the rate at which your muscles repair themselves after hard training. That would be testosterone, right? You can't, you know, and go on and on and on. You can't take a drug like a diuretic that takes body weight away from you. Um, I just wonder where-- This is a, this is not a philosophical question about drugs. It's a quest- it's a practical question-
- DADavid Allison
Yeah
- PAPeter Attia
... about this class of drugs whose efficacy is, as you said, profound, and its safety, at least in the short term, unquestionable. Um, you know, are we going to basically see at the Olympics this year in France, if they were drug testing for it, what fraction of athletes would be taking GLP-1 agonists of the sports where body weight, um, regulation is a key? I don't expect many shot putters-
- DADavid Allison
Fascinating
- PAPeter Attia
... to be taking it.
- DADavid Allison
No.
- PAPeter Attia
But I do wonder how many boxers and rowers and runners and cyclists will be taking it.
- DADavid Allison
Really interesting. We should do that study. Let's work on it.
- PAPeter Attia
[laughs]
- DADavid Allison
Um, but, uh, so I don't know the answer. Haven't heard about that before. I think your speculation is, is apt. I think that as a formalist, I would go and say, "Well, what is these groups that have said you can't take testosterone and this and this and that?" What's th- they probably put out some underlying principle that said, probably said, "You cannot take a drug that enhances performance unless you have a medical need." I, I don't know if they've said that, but if they have, then, then it could get really tricky.
- PAPeter Attia
[laughs]
- DADavid Allison
Because now you say, "Well, who defines the medical need?"
- PAPeter Attia
That's right.
- DADavid Allison
What about, you know, now is it fair if we take the person who's just below the threshold for needing it who says, "I don't get to take the drug," but the person who's just above the threshold who does? You have then also this idea of a fairness of disabilities issue. If I, if I have obesity and I p- particular- I've got a strong genetic predisposition to it and, um, I can't manage to be not obese without the drug, do I effectively have a disability? And is this now prejudicial or violation of, you know, Americans with Disabilities Act or something like that? Or, you know, different countries have different variants, but is there, is there a fairness issue? And again, I, I don't know that there's a right answer. I think these, these would be tough political and moral questions, but it's really particularly tough 'cause you bring in the interest of the sport. And then you're gonna get also... It's gonna reflect back when you get into the health interest of the individual, just as with many sports we might say it's in the interest of the team or the coach or the sport itself to have this person at greater risk. But of course, it's not in the interest of their situation. And yet we somehow accept that we allow people to play football even though there's concussion risk, and we allow people to box and many other things. Um, but i- are there some limits where we might say, "We're not comfortable with your putting yourself at risk, um, for this. We need to protect you as much as the sport."
- 1:39:31 – 1:55:19
Unanswered questions about protein intake and health
- PAPeter Attia
[laughs] All right, let's pivot to something a little bit easier to talk about. You've already alluded to protein.
- DADavid Allison
Mm-hmm.
- PAPeter Attia
Um, it's a, it's a huge interest of yours clinically, personally. Um, it's a topic I've addressed a number of times. Um, what do we know about protein and what do we, at least in your view, what do you, what do you think we think we know that we don't know?
- DADavid Allison
Okay. So you're as much or more of an expert on the physiology and biochemistry of it than, as I, but I will, um, venture a few things. So with respect to what we know, we know some very basic things. We know you can't live without protein, without consuming some protein. We know that the body is made, not totally, but heavily, of proteins. They're essential for functioning. We know that proteins are made up of amino acids. There are different amino acids that have different effects. Some amino acids can be synthesized in the body, some can't be. Um, I think you did a podcast with Luke Van Loon recently, which I found enormously educational and, um, so I refer [chuckles] people to that one, and he knows a lot more about protein than I do. And so I think we know that we need protein. We need a certain amount. Uh, we need certain amino acids, and we can get them from various foods or combinations. Uh, animal-based foods, we can pretty much get all the proteins we need from them. If we only eat plant-based foods, it's not impossible with the exception of maybe taurine, but whether we have to consume taurine or not... If you're a cat, you have to consume the taurine. But if you're a human, maybe not. Um-
- PAPeter Attia
You could drink Red Bull-
- DADavid Allison
There you go
- PAPeter Attia
... and still eat plant-based protein and you're fine.
- DADavid Allison
So then we get into are there known things about the amino acids in terms of long-term human health, and I, I think modest. So, you know, we see certain things about, uh, leucine being important for skeletal muscle growth, uh, anabo- anabolic effects. We see, um, some things about isoleucine in mice maybe not producing longevity. We see taurine, um, supplementation in mice and some other species appearing to prolong life in Vijay Yadav's work. We see methionine restriction in Rich Miller's work prolonging life. Methionine's related to taurine, so a lot of confusion. What will really prolong life in humans is unclear. Whether the same things that will prolong or shorten life in terms of macronutrient composition in mice will do the same thing in humans is unclear. And there are different outcomes. This is, again, part of why I railed against the idea of healthy foods, so-called, or unhealthy foods, so-called. Healthy for what? You might wanna be 10 pounds thinner. I might wanna be able to lift 10 more pounds on the bench press. That person wants to live 10 years longer. The three diets for those dif- things may be different. And so I think that after that, after the idea that we need some protein, we need some minimal amount, we need the amino acids, I think it gets shaky then. Some of the things that are said are-
- PAPeter Attia
In other words, minimums and maximums were not necessarily a part of what you just described with much certainty.
- DADavid Allison
Right. I think there's reasonable confidence, and you've been a, a great progenitor of this idea, that the, the old school recommendations for this much is enough were probably too low.
- PAPeter Attia
0.8, uh, grams per kilogram body weight is the RDA.
- DADavid Allison
Right. And I think many people think that's too low, that you can survive on. It's not that you can't survive, but can you thrive? And that, and that's sort of, I think, a big point of your book and, and other people's lives, you know, your book Outlive, which is, um Yes, we can think about treating diseases, we can think about preventing diseases, but neither of those are equivalent to optimizing our lives and our health. And, you know, different people have different ideas of optimal. Is optimal optimal comfort? Is it optimal lo- length? Is it optimal ability?
- PAPeter Attia
Performance. Yeah.
- DADavid Allison
Um, whatever it is, it doesn't seem that that's the level, the RDA-
- PAPeter Attia
Correct
- DADavid Allison
... 0.8 g/kg, uh, is the optimal level for health or longevity or anything else. So it's probably somewhat higher. Next question is: are there minimal thresholds at any sitting? So Don Layman and others have argued there are. Sometimes you hear 20 said, 20 grams, sometimes you have 30 said. So 20 to 30 grams in a particular sitting is the minimum to get anabolic. Is that true? When I, as a statistician, hear this, I'm like, "Really? A threshold in biology? You're telling me there's a step function and you know it?" Now, I don't really believe there's a step function, but maybe it's sigmoidal. Maybe it's sort of a little flat, and then it goes up steeply, and then it flattens out a little bit. And then I say, "How much sample size and how many different doses would you need to really get a fix on that and test whether it's there?" And then you look at the studies done, and you go, "You've got to be kidding me." We talked earlier about pharmaceutical company studies. Think about the numbers of people-
- PAPeter Attia
Mm-hmm
- DADavid Allison
... on which we tested COVID-19 vaccines. Think about the numbers of people we've tested statins and now GLP-1 agonists. Now think about the numbers of people used in randomized controlled trials from the nutrition community to look at protein needs. And not all of us need to take a statin. [laughs] A lot of us do. Not all of us need to take GLP-1 agonists. We've talked about that. All of us need to eat protein, and yet the quality of evidence and the quantity of evidence we have is tiny. It's dust compared to what we have on these pharmaceuticals. And so we really need to ramp this up. I would say I don't think that we really know that you don't get anabolic until you hit 20 or 30.
- PAPeter Attia
But, but again, just to be clear, I mean, the mechanisms that are described on those are based on small studies. Um, and, and they're really small by necessity just based on funding and complexity of doing these studies.
- DADavid Allison
Right.
- PAPeter Attia
I mean, these are amino acid labeled tracer studies, right? Where they give people various doses of protein, and they look at muscle protein synthesis, right?
- DADavid Allison
Right.
- PAPeter Attia
And, and so, um, a- again, I'm not, I'm not here to say that we shouldn't be doing bigger, better studies, but, um, the, some of the studies that have been aimed at elucidating this are quite rigorous in terms of their, their, their mechanistic insights. Um, and, and so I guess the question is, isn't it at least biologically plausible that there is a threshold? And I agree, it's very unlikely a step function. It's more likely a sigmoidal shaped curve, but it seems at least biologically plausible-
- DADavid Allison
Of course
- PAPeter Attia
... which doesn't make it right, that at low doses, you know, at 10 grams of amino acids, the liver itself might just prioritize gluconeogenesis, and there's a saturation point at which it says, "Oh, well, okay, we have excess nitrogen now. Let's go off and do this other thing."
- DADavid Allison
I think it's entirely plausible, but we talked many times about that.
- PAPeter Attia
Yeah. Lots of plausible things turn out to be wrong.
- DADavid Allison
Exactly. So we need to do the studies. The-- I'm not putting anybody down for these studies.
- PAPeter Attia
No, no, I get it. Yeah.
- DADavid Allison
Uh, some of them, you know, when I hear about what Don Layman's done and what, what Louke Van Loon has done and others, it is really impressive and rigorous. But as a statistician who's saying, "Do we know the answer?"
- 1:55:19 – 2:01:55
Future research needed to understand basic questions around protein intake
- PAPeter Attia
you know, the, the-- let's just assume that those studies don't exist, in fact. Um, or if they do, they're, they're very, very small and therefore probably not worth extrapolating to the ends of the universe on. What is the probability that such basic questions like this will be answered in the coming decade of nutrition science? What is the appetite, no pun intended, for this type of clinical investigation, especially in light of everything else we've spoken about, which is, hey, the name of the game in nutrition science now is pharmacology. It's not these sort of mundane questions about macronutrients?
- DADavid Allison
For obesity treatment and closely related things, diabetes treatment, prevention, I think you're right, the name of the game. Um, for other areas, I think there'll be more interest, so longevity promotion, and you'll get something like the Hevolution Foundation weighing in, which could conceivably do big studies. But even there, I mean, there, nothing's unlimited. Um, they may say, "Well, we're gonna focus a, a big trial that'll be definitive and really give the answer, but it's gonna give the answer only in this age group," or something like that. Um, I think NIH will, will fund some. I think industry will fund some. But NIH industry are likely to fund, in most cases, things that are small enough that we're not going to know the answer about every dose eaten at every period of time in every race, age, sex, and health status group. What we'll know is pocket answers. So I think what we could get, for example, is a study funded in which we very, very thoroughly looked at ordinary healthy adults, uh, over 60 years old who want to increase strength and muscle mass, and we'll look at protein intake, and we'll look at are there upper limits. I think that could conceivably be done, and we could probably nail that answer. But then you might come back and say, "Well, you've shown it's safe or unsafe for a 60-year-old. You haven't-- That doesn't mean it is for a 20-year-old." And we'll say, "Hmm, that's true." And you say, "Well, you showed it with casein whey but not with pea protein and, you know, whatever." That's true too.
- PAPeter Attia
So how compelling do you find the data that high protein diets reduce longevity? Uh, there are many proponents of this view out there, um, often, I suppose, within the plant-based community, although again, I don't think those are necessarily an overlap, although that just seems to be where I notice most of the lower protein is better, um, rhetoric. But, but h-how do you assess the strength of that claim?
- DADavid Allison
Very low. Um, I think it's gonna depend on species, and that's important because it leads to the extrapolation, uh, issue. If you're a butterfly, I think it probably does reduce lifespan, and I think a higher carbohydrate diet may increase lifespan more if you're a butterfly. If you're a mouse-
- PAPeter Attia
We, uh, and you know, we do have some butterfly listeners of this podcast. But I'll be honest with you, we've-- our efforts to increase butterfly listenership have largely been, uh, I would just say they've been less successful than I would've enjoyed.
- DADavid Allison
We'll, we'll keep working on that. But I think in humans, there's no compelling, in my view, no compelling evidence. I, I would even say there's some evidence and reasons to believe the contrary. Um, some of that's gonna be tied to wealth. Um, wealthier people eat more protein than less wealthy people, including within our country. So it's hard to tease all this apart, epidemiology. But if you look at the association studies, even there, I don't find it compelling. Then you can say, "Well, do you accept the association studies?" It's, eh, not all that much. Um, if you look at the mouse studies, um, I don't think-- I'm not sure there you see the full translation. Uh, but also, uh, I'm not sure they're all that compelling, that, um, low protein. So I think nothing that I know of would say to me there's very strong reason to believe, even if not definitive RCT, that higher protein will lead to less longevity. And if anything, I think there's more compelling reason the contrary. Now, my friend and, and a, an IU alumnus, Barry Sears, and, you know, talks about the zone diet. And the idea of the zone is that there's not too much on this end. You shouldn't be too high on this end. Don't be too low over here. There's a zone of things in the body and in diet that are right. You gotta find the right spot. And he very strongly believes that you want to upregulate AMPK to live longer, and you want to not upregulate mTOR too much to live longer. And I know you've talked about rapamycin, which, you know, sort of has effects that would go along with what he's saying. So he might argue from that point of view that too much protein would reduce longevity. And again, I can't say he's wrong. I think it may also depend on at which period of time. So what's good for you to, to do or eat early in life may not, to prolong life, may not be what's good for you later in life. Um, sometimes we call that antagonistic pleiotropy. And here we might say, and John Holloszy found this in rats. Now, I don't know if it holds up as one study, but found that exercise in rats reduced mortality rate in the first half of life, but it increased mortality rate in the second half of life. And so if we accept that as causal and, and valid and replicable, then maybe the same things might be true for protein. Might be good to eat more when you're younger and less when you're older, or less when you're younger and more when you're older. I don't know. But I think that we also need to think that longevity's only one factor. Um, we talked about this a little bit the other day and, you know, um, there's no right answer to this. But if somebody were to say to me, "Live this way and we-- our best guess is you'll die two years earlier. But until you die, you'll be stronger, you'll feel more energized, you'll look better." I'd say, "I'll make that trade." Now, someone else might say, "I won't make that trade." And who's to say who's right? You know?
- 2:01:55 – 2:06:55
David’s weekly newsletter: “Obesity and Energetics Offerings”
- PAPeter Attia
David, one last thing before we go. You, um, you, you serve as sort of the editor of a newsletter that comes out every Friday, Obesity and Energetics. I've Been a subscriber for I guess a decade, maybe a bit more, right? When did it start?
- DADavid Allison
It started kind of organically all the way back when I was just in grad school basically-
- PAPeter Attia
Okay
- DADavid Allison
... or getting out. And then there was no formal letter, didn't have the internet. I would hand my professors papers I had read and said, "Hey, maybe we could talk about this or something." Then I moved away, I would mail them, and then I mailed to a couple of people, and it kept going. And soon people started getting, asking to be adding to my list. Then it became electronic. Then it became a formal web thing. So now it goes out to, um, over 100,000 people worldwide. We don't charge anything for it. It's free. It's called Obesity and Energetics Offerings. We don't accept any commercial support for it. Uh, it contains usually about 100 or a few more links to mostly scientific papers, sometimes popular media articles commenting on things in virtually every category related to obesity, energy metabolism, nutrition.
- PAPeter Attia
Well, I'm, I'm a big proponent of it. My team all subscribes to it. Um, and, uh, it's one of the, it's, you know, it's, it's one of the not too many newsletters that I rely on. Uh, again, people ask me how do I stay up to date on things. Um, and the truth of it is I have to rely on other people doing a lot of the aggregation, and then I'll kind of go where my curiosity goes and sometimes go a bit deeper. But anyway, I just wanted to make a plug for people to subscribe to Obesity and Energetics Offerings. It's, it's great. Um, and, you know, one of the, one of the fun things that I think is great for people learning is one of the sections is always called, uh, headline versus study.
- DADavid Allison
Yes.
- PAPeter Attia
And I just think that's... If, if, if folks listening to us now are not going to read any of the subheadings there, just read that one, because it gives you a great sense of how misleading the traditional media can be. Um, not necessarily because they're nefarious. I don't think that's the case. I think it's, uh, scientific ignorance and a misalignment of incentives. Um, so one, they're simply not qualified. They don't have the scientific literacy to understand what a study shows. And secondly, they're really incentivized to get you to read a study and click through something e- and they have to come up with a headline that makes that appealing. And as you point out every week, there's a great example of one where the headline is patently false, uh, at worst, and at best, so misleading as to be useless. So what I think is valuable for folks is to get into the habit of checking that once a week and seeing, "Hey, that was a headline. I could see that headline. I could see how I'd get fallen, you know, I'd get duped for that. But oh, there's the study that really had..." You know, the headline could be something as outrageous as, "Women are so much more likely to, you know, outlive their partners if they have sex three times a week." And then you look at the study and it's about this rare species of fruit fly that sometimes mate with male fruit flies that die a little premature. Like, you know what I mean?
- DADavid Allison
Exactly.
- PAPeter Attia
It can be so ridiculous.
- DADavid Allison
Well, I really appreciate your pointing that out. And anybody can subscribe for free. Just type into Google Obesity and Energetics Offerings. You'll find it. If not, email me. And, and I hope Andrew Brown, who's a professor and a former mentoree of mine at University of Arkansas now, is listening. He took over handling that category, uh, a few years ago. He does a beautiful job with it. And so, um, he sets these things up and often finds these interesting things and, and even got to the point where others picked up on his use of the phrase "in mice" as kind of like a standard thing, which is just as often a way of saying, "Well, we found this in mice," and but the "in mice" is often left off-
- PAPeter Attia
Yeah
- DADavid Allison
... in the headline. So hat tip to Andrew Brown.
- PAPeter Attia
How many people are involved in curating that list each week?
- DADavid Allison
It's, uh, in any one week, it's about five people, uh, including me. Um, so there's me, there's an editor, then there's Andrew who, uh, cleans everything up, and then there's Colby Vorland who cleans everything up, and someone else who posts it.
- PAPeter Attia
That's a lot of work for five people.
- DADavid Allison
That's a lot of work. Um, but it rotates. So the editor rotates every week, but the rest of us, including me, are on.
- PAPeter Attia
Thank you for never asking me to be an editor on that. [laughs]
- DADavid Allison
[laughs] I hadn't thought about it until now, maybe I will.
- PAPeter Attia
[laughs] No.
- DADavid Allison
It is a lot of work.
- PAPeter Attia
Yeah.
- DADavid Allison
But it's fun. It's a labor of love.
- PAPeter Attia
Yeah. Well, David, thank you so much. This was, uh, this was a super fun discussion, and I know that folks are, uh, gonna get a kick out of it.
- DADavid Allison
Thank you, Peter. Great to be here with you. [outro music]
Episode duration: 2:06:55
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