 Welcome to the session on insulin signaling science and policy. My name is Dr. Eric Daniels. I actually am not a doctor. I'm not a nutritionist. I don't do anything except study policy, which is the part of the panel that I will be talking about in brief as well as the rest of the panel. Let me just do a brief introduction before we get started of our panelists, many of whom you probably already know for some of you in the audience. Immediately to my right is Dr. Richard Feynman, who is a professor of biochemistry at SUNY Downstate, which I just think of as Brooklyn. I don't know why they changed the name. And to his right is Dr. Eugene Fine, who is a professor of clinical nuclear medicine at the Albert Einstein College of Medicine. And following up on his right is Dr. Judy Wiley-Rossett, who is a professor of epidemiology and population health, as well as a professor in the Department of Endocrinology, also at the Albert Einstein College of Medicine. So today our topic is an attempt to address the issues that come together between the latest research in insulin and insulin signaling and some of the ideas that are coming out of the science and why that is seemingly out of step with policy, and hopefully we can perhaps address what might be done about that. So the format of today's session will be fairly simple. Each of the panelists, each of the three panelists to my right, will speak very briefly about some of the science in the cutting edge science and where the science has been and where it's gone. And then we will each, and I'll prompt them with a very brief question here. And then after that we'll have brief answers on some of the policy issues. And we're hoping, and as long as I'm doing my job as moderator, we will have lots of time for questions from the audience for the panel. So let me begin then with the first question. So several decades ago, the federal government undertook making specific nutritional recommendations and guidelines that encouraged high levels of carbohydrate intake and reduced fat and cholesterol. A conflict emerged at the time between the science and the desire for some federal policy. In 1977, when the McGovern Committee met and made its recommendations, scientists and doctors who were at these hearings objected and called for more research to be done. In particular, Dr. Robert Olson, many of you have probably seen the video of him, called, quote, for more research on the problem before we make recommendations to the American public. To which Senator George McGovern said, I would only argue that senators don't have the time or the luxury that a research scientist does waiting until every last shred of evidence is in. 35 years later, with literally thousands of studies and detailed research having been produced, the shreds of evidence seemingly are now a mass of evidence, unfortunately largely in contradiction to what the McGovern Committee has recommended. So the question for the panelists to begin is where does the science seem to be right now? What do we know about insulin and carbohydrate and fat consumption? And what are the cutting edge issues in research today? So we'll begin then with Dr. Richard Feynman. Thanks for being here. I think that the reason that the school is called Downstate, rather than Brooklyn, is so that the state legislature does not have to admit out loud that it's funding something in New York City. Focusing on where the science is on insulin signaling, the most obvious place to look I think is on diabetes, which is the most obvious manifestation of insulin signaling. And I think it's a relatively simple science because all we need to look at is epidemiology and three studies. First, the epidemiology. During the epidemic of obesity and diabetes, the increase in calories was due almost entirely to carbohydrate. What you're looking at here are the NHANES data on absolute energy. These are actual calories on the left side. So the percentages of fat went down, but for men the absolute amount of fat also went down. So the increase in calories was due to carbohydrate. One is an experiment from Gannon and Nuttle, and they have a low carbohydrate diet, and the key phrase is weight maintenance diet, and you can see much better glucose control, improved insulin control, and a reduction in hemoglobin A1c. This is a 20% carbohydrate. So glycemic control does not require weight loss. Everybody knows that weight loss will improve diabetes, but you don't need it, and it's pretty hard to lose weight. The second and third experiments refer to a low glycemic index diet, which Jenkins compared to a high cereal diet, and almost the same day, the same number of subjects and very similar experimental design. Eric Westman compared a real low carbohydrate diet with a low glycemic index diet, and the results are pretty clear. The red is Eric Westman's low carb diet, and the bottom line is that the low carbohydrate diet is better for just about everything. And the low glycemic index diet was better than a high cereal diet. So experiments two and three show you that a low carbohydrate diet is better for weight loss glycemic control, HDL, and triglycerides. The key point, though, is that not every question in science requires a long-term trial. Not everything is up for grabs. You don't have to try everything. In diabetes, you have a disease of carbohydrate intolerance, and these four studies bear out the principle. There's no long-term study that has contradicted any of the results. Similar results have been found at one year or depending which things you expect. Most of all, you've got to use more than statistics. You've got to use some common sense. There's nothing in the design of these experiments that says you won't keep getting the same results as long as you keep doing it. And related to that is the low carbohydrate diets have better adherence than anything else, sometimes better than adherence to drugs. So that's my take on this science. Thank you, Richard. And we'll now have Gene Fine. I'm going to try to keep this as simple as possible. Some will, of course, overlap with what Richard's saying, and forgive me if I appear to be reading some of this, because I'm trying to keep it into four minutes. But the first issue is that, where are we? Apparently I have the wrong controller. First is that insulin is the central regulator of both carbohydrate and fat metabolism. We need to remember that even though the food pyramid has been abandoned, most Americans still consume about 300 to 400 grams of carbohydrate. 90% or more of these carbohydrates are simple sugars or starches that digest sugars. And the final pathway of these sugars turns out to be glucose in our blood and in our cells. Second, it's glucose, not fat, which is the principle stimulus for insulin secretion. So it's called hydrate in the diet that's driving insulin secretion. And then insulin turns around and it pushes glucose and fatty acids into our lipid cells to form stored fat in the form of triglycerides. Furthermore, just to add insult to injury, insulin inhibits the breakdown of fat. So to summarize, we're now in a position to summarize all of this and to recognize that insulin is what makes us fat, driving glucose and fatty acids into fat cells, stimulating fat synthesis, and it keeps us fat, inhibiting the breakdown of stored fat. I should mention that the commonplace wisdom, you are what you eat, it's very catchy, it's very convenient, it's also wrong. Our biochemistry just doesn't work that way. We have to understand that drinking a glass of pure fat drives no hormone comparable to insulin. We can't identify a single hormone comparable to insulin that has that role. Remember, cows get fat eating carbohydrates, tigers stay lean, eating protein and fat, and humans are omnivores, which means who knows what they do. And the only way to know what they do is to find out what they do, and I just told you. So, growing scientific evidence supports reducing the excessive insulin secretion that high-carb diets have produced in the population. Just to sort of take that into a little bit more detail, it's becoming increasingly apparent that the low-fat paradigm and food pyramid have resulted in an epidemic of obesity, type 2 diabetes, and lipid disorders, all consistent with the result of excess insulin secretion on overdrive due to excess dietary carbohydrate. It may turn out that this is overly simplistic to associate all the diseases of civilization with insulin, but at present it's certainly not unreasonable to examine whether reduction of insulin secretion ought to be a public health dietary priority based on the best available science. There's nothing about this that's new either. Human biochemistry certainly hasn't changed in thousands of years, and even the description of what we know about our biochemistry hasn't changed in at least the 40 years since I've been in medical school and certainly longer. It's possible that dietary steps to reduce overall insulin secretion may reduce the incidence of coronary artery disease, stroke, kidney disease, diseases of the eye and retina, obesity, degenerative joint disease, hypertension, as well as the observed increased risk for cancers, which now exceeds the risks due to smoking from obesity and hyperinsulinemia. So from a scientific point of view, the evidence continues to accumulate that reducing the effects of insulin signaling would possibly be of enormous public health benefit. Thanks. Thank you. And now Judith Wiley-Rawson. Thank you. I'm going to be going through, we are focusing on a series of questions in both parts of this and I'm going to be highlighting some of the questions that were approached by the American Diabetes Association and coming up with its recommendations. Where's the science right now? Recent research has provided insights about the intricate functions of fat tissue in relation to insulin resistance and its comorbidity. So that's been a heavy focus and Dr. Fine talked a little bit about some mechanism in place to this. What do we know about insulin and carbohydrate and fat consumption? Weight loss and modifying the amount and type of carbohydrate can reduce circulating insulin levels. Reducing total calories also has been associated and increasing physical activity has been associated with reducing insulin resistance. What are the cutting edge issues? My own personal view is the epigenetic research and the effects of nutritional and DNA methylation will hold great promise. And I think that there's been a lot of discussion in terms of looking at historic diets and the paleo diet in relation to evolution. And I think that epigenetics is going to be very helpful in that area. But it's at its infancy right now. This slide is actually an examination from one way of looking at the evolution and basically before the ice age basically the diet was potentially a fairly high carbohydrate. And with the coming of the ice age there may have been a breakdown and this is actually probably greatly simplified. But there may have been a group that had a higher carbohydrate. It was a lower glycemic index in one area where there was less impact of the ice age and in another area where there was greater, lower availability of fruits and vegetables then there would have been more consumption of beef as a logical and the availability of nuts were probably higher in the area that had the higher vegetable. And that we do know that there are at least 100 different genes involved in diabetes and about 150 genes involved in obesity so that it's not the gene. We used to look for the thrifty genotype. Now we're looking at what combination of genes. And then we basically have the westerization of diet and that was thought to be the availability of taking the Pima Indian population putting on reservations, giving them a high fat, high carbohydrate diet with lard, a lot of processed grains and a lot of cheese and making them very sedentary unlike their counterparts in Mexico who were very physically active consuming legumes, nuts and vegetables and fruits. And then there was the higher carbohydrate diet with a higher glycemic index and the European population but they may have been less sensitive but any population can become vulnerable but there is also, we're starting to study the healthy obese or metabolically healthy obese which is an intriguing population and then there are also the lean metabolically unhealthy and what the difference of the combinations of genes in those two groups and that may yield some valuable insights for the future. But we do have an obesity epidemic and we're moving toward a diabetes epidemic and basically this is just a simplistic diagram of what happens in that obesity is affected by both energy intake and physical activity and we create local insulin resistance and we have an excess of triglycerides being formed and they are first deposited probably in muscle tissue then there's a related inflammation then there's a spillover into the liver and there's been relatively little discussion of fatty liver at the conference but I think that's an area of great concern in terms of long-term health risks for people with diabetes and for children as we see an increase in the obesity epidemic in children. And this is just a projection of diabetes from Africa we're going to see the greatest percentage increase because it's starting from a low level by 2025 it'll still be low but we look at the western Pacific on the far side and we see incredibly high prevalence and India and China are both very worried about how they're going to handle the treatment of kidney disease related to diabetes and that brings me to the Diabetes Association conclusion in terms of looking at obesity as a risk for type 2 diabetes and basically the evidence level is considered high that a low fat, better training or a low carbohydrate diet can be effective for 2 years and this is an area where Dr. Feynman is going to raise an objection but an E level evidence is that low carbohydrate diets need monitoring of renal function and protein intake and those who have nephropathy so if you have end organ damage there would be a reasonable monitor protein intake and I think there's been universal agreement that if somebody is on hypoglycemic medications either insulin or sulfone areas that you need to monitor the glucose I think where the controversy comes up is monitoring lipids and we maybe need a caveat saying that high carbohydrate diets need to have triglycerides monitored and maybe that's where he should put his energy rather than fighting the whole statement and physical activity and behavior modification are important parts of weight reduction and that's level evidence B the largest trial of weight control in type 2 diabetes will be finished in 2014 it's the look ahead trial it uses a low fat diet in combination with physical activity and there has been about an 11% weight loss and we will find out what the impact that has been in about another year and a half thank you so we move now from the science which is the sort of very quick version of the science to the policy and the prompt that we've come up with for this part of the session is as follows one of the biggest challenges as we've seen from some of the research to our health and our health policy has been the rates of increasing degenerative disease brought about in part from faulty dietary recommendations there's no doubt that the surge in some of these pathologies were not just accidental that there are very coordinated timing between when some of the policies were adopted and the increasing rates which never increased before at that level so along with the recommendations a whole system of policy has developed to go along with simple dietary recommendations nutritional funding, government research agricultural subsidies, policies that encourage certain selection bias in the medical literature special interest in Washington, et cetera the question then is change how do we make that change and why is it so difficult so given that researchers in the fields have sifted and winnowed through the evidence and are now trying or arriving at different nutritional and dietary recommendations the question is where can we go to improve should the goal simply be a new set of recommendations that advise people more specifically on the cutting edge of science or is there a better way can uniform policy solutions one policy solution across the board give us the path to better health or is the ancestral health movement better to avoid such policies and work as it does right now from the grassroots up so to answer this question we'll proceed through the panel once again Richard Feynman Okay, I'm going to discuss my take on what the problem is and what the potential solutions are let me start with the answer tell you what the solution is and this just appeared on Metscape it says there's a new government commission to streamline diabetes care two U.S. centers introduced an act to ensure a thorough review and quotes Alan Garver the endocrinology society saying doing nothing or even doing more of the same will not reverse the arc of worsening diabetes prevalence and complications so what can you do well you should talk to your elected officials all you guys out there encourage the creation of the Diabetes Commission and tell them that they need to hear from all of the sides particularly paleo side low carbohydrate side and they've got a fun meaningful research research where all of the people are involved and all the sides agree that it's a real study the look ahead trial was started by people who were looking ahead in their direction but not in my direction let me say that this is serious your elected officials your senator will meet with you or at least their aides will meet with you because that's their job and they're interested they obviously have numerous other inputs but they are seriously interested in the problem possibly because they're on statins if you can drag that in may help so here's the problem is that we actually know a lot but there's a kind of disconnect between the science and the society this is from the food navigator which is a house organ of the food industry and it says a growing body of research has suggested that replacing fat with carbohydrates is going to increase the risk of heart disease but people keep looking for low fat foods and it's not up to the industry to sell people what they can't sell it's up to us to change the guidelines so the question is, is there a state diet and the USDA has put out their state diet let me give you a take on this from Obama who says not many Americans would feel comfortable the government monitoring what we eat well of course that's not true all kinds of people seem to be comfortable with all kinds of recommendations or attempted interventions not all of us are comfortable with that I previously mentioned that we had provided a critique of the USDA guidelines the editor of the journal wanted to know in brief what our problem was I said that they make drastic very detailed recommendations in the face of contradictory evidence so he said well make that the title of your review so we did publish a review in the face of contradictory evidence the USDA has not responded to that and we were the nearest amateurs in headlines the New York Post came up with Feds Food Pog and it's not just the USDA we have governments that we haven't elected like the American Diabetes Association and I'm very grateful to Dr. Wiley Rosette for actually willing to take on her critics unlike the USDA who just couldn't make it this says diabetes risk may not go up from a low fat diet what? who said that it could go up from a low fat diet so this is a remarkable redefining of reality or something I don't know what the Reuters take on this was that the low fat diet craze led some doctors to worry that Americans would instead start eating too many carbohydrates a new study suggests the low fat craze is that what it was? is that what it is? we're just getting mixed messages so this is one of the guidelines that Dr. Wiley Rosette mentioned and they did a systematic review the problem is that their system didn't include what I consider to be what I gave you as an example is one of the four main backbones of scientific evidence on diabetes that wasn't in that systematic review of macronutrients they did have another review the argument was they had picked an arbitrary number of subjects but in fact without going into detail they did it wrong but here's the real thing which Dr. Wiley Rosette mentioned for patients on low carb diets monitor lipid profiles now I've described this as devious I'm not suggesting that the authors are devious this is a devious statement what it's trying to say is low carbohydrate diets will give you cardiovascular disease because that's been a mantra of the establishment for 40 years and if they think that they should come out and say it but they don't say that and the level of evidence is in my view only characteristic in medicine most scientists don't know about these level E I think means is the lowest level of evidence information was on a piece of it was in a newspaper that somebody found on the subway on the way to the knee in fact it doesn't increase the risk of cardiovascular disease if anything it lowers it all of the markers that we have HDL LDL triglycerides total cholesterol these all are improved we tried to offer a different point of view with 24 authors who are head of endocrinology centers the diabetes care was not interested so there's the solution and I think we have to give it a try it's not easy to write even a short email to your senator and it takes a lot of messing around to figure out how to write a letter to anybody else's senator but I think we know that there's a problem and I think this is the way to get at it I generally feel sort of pretty helpless when it comes to the idea of understanding how to influence policy so what I'm really going to talk about is really just an anecdote of my experience with what the effects of policy have been in a very narrow example I know several endocrinologists that treat diabetics and several of them have told me that they treat diabetics with calorie restricted low fat diets and they also treat them with carb restricted diets they say because both work and I guess if the patient actually does stay calorie restricted it will work so they say but they have more trouble keeping the patients on the low carb diets so this is kind of an amalgam of the conversations that I've had with these endocrinologists and the question then came up to me I said well how do you keep your patients on the low fat diet I said do you refer them to a dietician and they say oh yeah I refer them to a dietician I said do you do that for your low carb diets patients and they say oh no there aren't any dieticians trained on low carb diets so somehow that might have something to do with why they can't stay on the low carb diet there's nobody reminding them what to do telling them as a book go figure it out for yourself and I say well do you monitor them he says well I don't have time so this is the effect of policy and I think until policy is actually able to change what dieticians learn what they're able to affect in their patients and how they're able to help them this is what we're going to continue to see so I'd agree if we can somehow influence our elected representatives in some way and tell them to look at all sides of this issue we'll do better thanks again I started with the this one time it's four questions and where can we go to improve and I actually had the experience last week or a week and a half ago of being asked to testify on the sugar restricted beverage policy it was being considered by the Board of Health and the borough president for Brooklyn not the Bronx testified that he didn't want anybody telling him what to do and that while he put his whole borough production diet they volunteered to do that and he didn't want the city of New York or the mayor in particular to tell him what to do and then the teamsters came out and testified it was going to affect their profits and the soda beverage companies actually I testified for the heart association and my position was it was worth piloting but we needed to evaluate what the impact was because there could be unintended consequences so again I think we need to consider a very toxic environment that we live in and I'm going to focus pretty heavily on the sugar sweetened beverages should the goal be a simply a new set of guidelines or should we scrap guidelines together and we need to consider the government's role in agriculture and food supply the development of the dietary guidelines is because the government is already involved in food the government has agricultural problems they subsidize certain crops they don't subsidize other crops and the school lunch program which started in 1946 was because ironically so many soldiers in World War II were undernourished of course what they did is through calories at them and so that the the government commission was partially to try to help rectify that they did probably go too far one direction but we need these sort of corrections that we need to develop do we need a uniform policy I think we need dynamic policies with an evaluation feedback loop and I'm a big advocate for using a systems dynamic approach or simulation modeling in which you get all sides in and you look at it because then you don't have opinion weighing it you can keep putting other things of the model saying if we make assumption X this is what happens so we make assumption Y this is what happens and I think it actually helps in keeping us all more objective and keeping our biases and our emotions reduced and the fourth question should the ancestral health movement avoid policy work and work for the grassroots work efforts need to involve collaborations and cooperation to consider policies that maximize benefit and reduce negative consequences and I think that looking at where there can be partnerships advertising of candy and sodas to children is one of my pet peeves and this is showing the price of food and as you see the upper line is fresh fruits and vegetables they have increased most dramatically carbonated beverages have not changed in their price fats and oils and sugars and sweets have increased slightly but fresh fruits and vegetables is where the most dramatic increase in price has occurred and that may also apply to lean meats and some things but this is showing the prevalence of type 2 diabetes between 1933 and 1997 with the increase in per capita consumption of corn syrup I don't need to explain this to you it's pretty evident the little solid dots are the increase in consumption and the vertical bars are diabetes and that trend has continued this actually is looking at corn price supports and the increase in corn syrup consumption has occurred in about 1957 and whole grains whether you think we should be having more or less whole grains has went down in that same time period and the commodity price support is basically that we support Sargam, Barley, Rye, Oats in corn production outside of the commercial corn area with a 70% parity and it's been projected that farmers may actually make more money in the drought this year because they're being paid what the parity price would be and another unintended consequence is our corn production in NAFTA has driven the Mexican corn producers out of business so they're not having local corn they're now having imported American corn so there are a lot of unintended consequences for things that are not even seemingly agricultural policies and this is a slide looking at the effect of and you could choose any legumes protein based food based on this is soybeans and this is the relative production in terms of meat I live downwind from a hog farm as a child it is not pleasant and I'm focusing on not sustainable agriculture I'm focusing on farm factories and I've lived downwind from chicken farms as well and basically the land use water requirements fossil fuel requirements phosphate rock and emissions there are countless unintended consequences in terms of the environment when we try to produce meat rapidly and the last slide is actually from the dietary guidelines focusing on these concentric circles I think we need to have this setup not in concentric circles but circles that intersect with each other and to really look at what the potential effects of policy are thank you so now that we're at the policy part and we don't have to worry about me speaking out of turn on science that I don't actually understand or at least only grasp from what I learned I'm going to close the panel and then we'll open it up for questions and as I mentioned at the beginning I am historian and economist so I don't do the medical policy but building off of what Judy has said what I wanted to focus on was one the rather disappointing fact that we can learn from history and then two to end perhaps on a more positive note the disappointing fact is when we look at this as historians and economists and political scientists look at the problem of agricultural subsidies at government recommendations we have to look at the long picture where did these policies come from why did they come about and then obviously what some of the unintended consequences are but when you look at the policies as they exist today one of the biggest problems that is difficult for people to understand is how in the world something like 800,000 farmers can extract somewhere between 10 to 30 billion dollars a year from the American taxpayer every year why are they getting such a high rate of subsidy and yet have such a small minute fraction of representation in the overall population this costs of course all of us money not only in the form of higher food prices and subsidy prices corn literally is triply subsidized they subsidize the growing of the corn they subsidize the marketing of the corn and they subsidize the sale of the corn when those price supports don't match they have ethanol programs to pull the corn in as well as the sugar market and the question ultimately comes down to actually something that was talked about on the first day on the panel about the seeds of our discontent panel and the problem is as the public choice school would explain it there is a distributed cost to these programs that is that we all pay for them we pay a very small amount but there is a very very concentrated benefit the farm lobby as it's called has very very powerful interest and can affect this policy and as was noted in some of the panels yesterday only very recently have people become aware of the annual or regular re-up of the farm bill typically this just passes and agricultural senators and representatives support the policies that support them but again the question is how can such a small number of people affect such a major major policy that has all of these spillover effects well the reason is that this concentrated benefit gets them much much more bang for their buck than it does the rest of us if we all could coordinate a popular grassroots movement to try to overturn the farm bill right to convince if we wrote to all of our senators if we wrote to all of our representatives to try and convince them to not pass the next farm bill to end agricultural subsidies which would be a great policy it's likely that the cost of doing so for all of us in time and in resources would far exceed what the cost is in at least nominal terms to the average person if you're only paying five ten fifteen dollars more for your food every year but you would have to pay five hundred dollars and say forty hours of your work in order to overturn that it's very simple to see that the person might choose simply to have the bad policy at a lower cost and it's not the farm lobby alone the farm lobby has has favors that are done or at least it has allies in urban areas in the form of the subsidization of food programs and SNAP and with the food stamps programs it has allies in the education lobby with the school lunch program there are interlocking problems here and if one just stops to consider where many of these policies come from it's really daunting to think that we can end them or even start to reform them just consider the subsidization of sugar which I know Lustig is talking about in the other room I appreciate all of you coming here to listen to us sugar has been officially subsidized to the tune of some billion two to three billion dollars a year to the American consumer has been subsidized since eighteen sixteen this is not a new policy these are these are very very old rooted policies so the question that I want to ask in terms of the where do we go from here that's that's a very daunting reality to face there are numerous numerous policies that are interlocked into the cause of some of these problems but my recommendation is the following I don't have specific recommendations about which committees you can write to and which policies you can try to change but I have a recommendation about how you can make those arguments because I think that there is one overriding fact that we the ancestral health movement can take advantage of and that is that we can have the moral high ground we need to argue for the idea that the government shouldn't be dictating these policies to us that freedom is the better argument what we need is to remind people that what they put in their bodies is as fundamental a choice as their reproductive freedom as their religious freedom as their freedom of speech it is fundamental to who we are to who we become and to the health consequences that we have and that people should have that kind of freedom we need to make the case that markets can solve these problems what rob wolf was talking about that people can actually figure these things out and that we can work toward better policy in a sense in a distributed grassroots way that people will see the evidence of better solutions and adopt them voluntarily much more readily than they will by adopting them as a matter of government influence or government policy what we need to do in a sense is to advocate like we have a separation of church and state to have a separation of science and nutrition and state and that I think will ultimately be the moral high ground that we can take to win this argument in the popular mind to remind people that it's their freedom to make these dietary choices to figure these things out for themselves with of course a healthy dose of non-government influence non-biased science so that we can have a debate and so that we can figure these things out so that's my recommendation in terms of what we can or how we can argue I think many of you know that the what we can argue of course will emerge from the science will emerge from the researchers that are at this conference and many also from the grassroots people that are figuring things out for themselves but we have to remember to keep that moral high ground that we're advocating for something that's in people's interest, freedom so I will end there so that as moderator I can say that I did my job and had time for questions so if there are questions for the panel please come up to the microphones and we have I think we started a little bit late so we have perhaps not quite as much time as I had hoped but some time for questions this is quite an informative session as far as I could see the topics are quite broad and complicated policy and science issues have always been integral to the nature of the nation I think the science from my perspective with respect to insulin and food choices and this thing I think the science is pretty solid I think that case has been made very clearly at this I'm very impressed the first time I've been to this ancestral health symposium I think they're on target the word has is getting out gradually the policy issues are always going to be problematic because there's big huge amounts of money associated with these particular policy changes the pharmaceutical industries, the healthcare industry to embrace the concepts of the ancestral health symposium could have massive financial repercussions throughout the nation there will be gainers and there will be losers so the question is how can everyone be somewhat of a winner the science is solid the reason why we don't move forward is we have merchants of doubt whether you consider it as climate change insulin role in diabetes you know we remove the smoking we have people living longer and now they have diabetes they become a cash cow for the pharmaceutical industry you get 20 more years out of a diabetic than you would out of a smoke there is massive financial repercussions to the healthcare how do you change the policy so that we can have a healthy population and have the federal government feel good about it without the input from all of these other teamsters or whatever you want to it's very very complicated but I think it has it may arise as you said from a grassroots because I'm convinced the science is solid I don't think we need any more research more research just muddles the situation even more it's clear the question now is policy and how you go about it from the grassroots or from the top and that's where the challenge has to come well my suggestion was that your elected officials will listen to the grassroots and I think the problem is that there's very strong competing inputs from lobbies and official health agencies but if you don't fight with that if you don't try to get your input in you know you'll lose but it's worth the effort because my limited experience with my elected officials is that they understand the problem and they one in particular said give me one page of information that I can use if the question comes up now what he meant is that the question is not going to come up unless five other people come to him and the senator the other senator from that state says he had 20 guys in his office then they'll listen and they'll only listen because they understand the problem they are in sympathy with the science I think you raised a very interesting question about the interest that if you propose to the pharmaceutical industry to everyone that if overnight these subsidies were ended and the whole cycle really because it is a cycle it's a cycle from the subsidies for growing and then the health pathologies that develop and then the treatments for those pathologies and the whole system but there are literally billions of dollars of cost and if you project out what that's costing the government and what that's costing the American taxpayer in terms of it's a really vicious cycle we spend billions of dollars to enter into the system to create a certain situation which then costs us hundreds of billions of dollars we go from tens of billions of dollars in subsidies to ultimately hundreds of billions of dollars in health care costs as Rob Wolf put up on his slides the other day the increase in health costs has been primarily driven by the pathologies that have been talked about today and so the one thing that I would recommend and I know some people disagree with this but I don't think that taxing sugar or banning soda or doing these things is really ever going to be an effective way of doing that that's a very dangerous tool to be using it it's a knife that cuts both ways so to speak because as we've seen when the wrong science or when mistaken science or when policy rushes ahead of science takes that same tool it can have very deleterious consequences and so for us to simply say well but if we got the smart guys in the room to write the recommendations or to control what people ate we have to be that's a lot of trust that you're putting in the smart guys I think that advocating a reduction in cost for all of us ultimately because of that vicious cycle is the way that you can convince people that it's a win-win and even though certain companies or certain lobbies may lose out there are more of us than there are of them in population at least if not in bank role next question my background is in economics and public policy so I agree with a lot of what you said I'd also point out that there seems to be a persistent pastoral myth about how agriculture operates in this country and it seems to me that a big part of the problem is that the other side is kind of dominating the conversation in public so I'm wondering if you have any thoughts on how we can kind of fire back and kind of get our side out there I mean writing to your senators is a laudable goal but I don't think it's going to really change anything and I've got a poster in the hallway all right well terrific that is an interesting question how many of you in this room well maybe in this room probably there will be more people that would know and believe this but how many of you in this room know what the average demographic make up is of a farmer who gets subsidies sometimes in the media and sometimes there are exposés about this but many of the highest rates of subsidies for agricultural lobbies are paid to people who have zip codes that run between 10016 and 10021 that's New York area right in Manhattan even what are people in Manhattan being paid farm subsidies well they're of course landlords they own farms they're people being paid for farm subsidies who literally have not grown I mean everyone knows about the New Deal programs paying people not to grow on their land but they've actually had land that's been converted that can't be grown on it's not just line fallow for this season it's land that literally has been taken out of cultivation trees have been planted and people are being paid for not growing or for increasing production in other land in order to not grow on that land the problem is that these are not small American families right most of those 800,000 that I mentioned that are receiving farm subsidies are people that are receiving the farm subsidies large typically associated with the major agricultural businesses ADM cargo con agra etc this is not the mom and pop farm that that the kids are helping out you know by going and plowing the fields these are multi-thousand acre farms with satellite imaging of the water content of the crops etc etc so that they can help develop this in a sense this is this is what we have from this policy right that you encourage people to get these subsidies well they'll find more and more efficient ways of gaining these subsidies cracking that pastoral myth might be a way of convincing people that the farm bill you know if you actually look at who's receiving the benefit and remind people of that and remind people that it's not the small farmers right it's not drill salatin it's not the farmer that I drive to you know 30 minutes from my house it's major farms that don't have farm stores that don't sell their products to the American public if we can remind people that that's who is getting the benefit and it becomes a little bit easier to break through that myth I think actually there's a huge diabetic community out there that is self treating each other because what the doctors tell them to do low carb I mean low fat high carb is not working and I hang out on these diabetic forums and they're huge there's one that's got 200,000 members and what they're doing is giving them self advice on what to do it and of course the advice that works for almost all of them is low carb eating and they are coming away from their doctors not only ignoring what they're saying but laughing what they're being told because they know it doesn't work now these this is a huge group and it's growing bigger day by day and I just wonder academics should get involved in some of this grassroots movement in an educational mode I think that one of the things that's concerned to me that I've been here is that people make an assumption that the American Diabetes Association recommends one diet and it's a diet and it's been 25 years since my recommendation and I think that look for your allies and the statement that I showed that they basically look at a wide variety of macronutrient diets have been tested and there's been no recommendation to not follow a low carbohydrate diet so I think that rather than and I one of my concerns in terms of the Diabetes Association is that the recommendation is people start medication I think there are a lot of patients who develop diabetes who don't want to do that so I think that we need to look for your allies not to try to create enemies well let me speak to that because I suggested to Sue Kirkman who is a spokesman for ADA that they were much stronger on what they were against namely low carb diets than what they are for and she said yes that was a reasonable criticism you can't say it's okay to go on a low carb diet but get your lipids checked in other words it's okay to go on a low carb diet if you don't mind having a heart attack it's devious and you know we want to be polite here but it's bad it's wrong and you are the enemy and when I suggested to one of these diabetes groups that I thought that I thought that the nutritional board of the American Diabetes Association was compromising all of the good things that the organization was doing for people with diabetes I got a flood of people coming back saying they didn't do anything for me it's not just the critics it's the grassroots who are angry at the American Diabetes Association and I sent Sue Kirkman a statement from a woman who lost her eye following a high carb diet given to her by an ADA spokesperson this was a health provider diabetes educator and when she went on a low carb diet things got better the ADA is not facing the facts you know we want to be polite we want to be collegial but there's a large army of people out there with diabetes who see them as the enemy absolutely see them as the enemy and I think there's a problem and it is true that there's slow acceptance but the slow acceptance and the statements from the ADA have been way out of tune with the science and you know tell me that if you say it's okay but check your lipids not check your lipids for every diet but check your lipids tell me that isn't an intent to dissuade people from trying a low carb diet so as moderator maybe I can be the voice of moderation we are just increasingly running out of time so the people that have questions please if you'd like stay around so that you can ask the questions I'm sure the panelists would be happy to answer them but let me just as moderator I guess I'll take the privilege of having the last word let me just say two things as a try trying to moderate both of these solutions can work the ADA is not at least as far as I know I mean they may be behind step if Richard wants to agree with that or not but they will look at what people are telling them they're not just ensconced in an ivory tower handing down recommendations they do take account of these things and they do research so please advocate to them but also it's important you mentioned some of these forums where people talk to each other this just brings up a point because I want to get in a plug in the very last seconds here the case that many of you are probably familiar with of Steve Kuski in North Carolina had a blog that the state of North Carolina because he's not a licensed dietitian had been going after him please support other organizations that help people remain free to advocate such things so the Institute for Justice I have a lot of friends that work there it's a public interest law firm in Washington DC to represent him in his fight to be able to advocate the kinds of things that actually worked for him there are organizations that do this that are open to feedback and open to what people are telling them and will be more open if more people tell them but there's also the grassroots and that has to be protected and so when you advocate don't think that just writing your senators and representatives is the only solution don't think that just working from the grassroots is the only solution there are so many facets of this problem from school lunches to agricultural subsidies to dietary recommendations use your expertise use what you know to help fight this fight so that everyone ultimately can benefit so that there is a win-win situation because if we're all healthier and if we all save billions of dollars trillions really of dollars a year from making these changes we'll all be better off so thank you all for coming as I said if you have more questions please stick around thank you