The Peter Attia Drive - #211 - AMA #36： Fruits & vegetables

00:00:00.000 Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast.

00:00:16.500 I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can

00:00:20.460 access the AMA episodes in full, along with a ton of other membership benefits we've created,

00:00:25.440 or you can learn more now by going to peteratiyahmd.com forward slash subscribe.

00:00:31.140 So without further delay, here's today's sneak peek of the ask me anything episode.

00:00:39.240 Welcome to ask me anything episode number 36. I'm once again joined by Nick Stenson. In today's

00:00:45.380 episode, we talk about all things fruits and vegetables. We compiled some of you may recall

00:00:50.900 a list of questions around this subject that came through the website, through social media,

00:00:55.580 and directly through the users. And we've tried to organize this podcast around the themes of those

00:01:01.900 questions because we literally received thousands of questions. Conversation basically goes as follows.

00:01:07.380 We look at the idea of fruits and vegetables being uniform, which of course they're not. So we talk

00:01:12.160 about how they're similar and how they're different in terms of many features of their nutritional value.

00:01:16.660 We think about specifically the fiber, sugar, and other nutrient content of fruits and vegetables

00:01:20.940 as ways to assess their relative value. We comment on the difference between eating them or drinking

00:01:26.680 them and how processing fruits and vegetables can change their properties. Talk about NAFLD and type 2

00:01:32.780 diabetes and ask the question of whether or not those specific diseases require a different nutrition

00:01:39.220 strategy when it comes to fruits and vegetables. We then get into some of the science around the good

00:01:43.480 and the bad of phytochemicals, which we get asked a lot about. Talk about organic versus non-organic

00:01:48.760 handling of food and if different preparation strategies can affect the nutrient value of fruits

00:01:53.080 and vegetables. We round out the discussion by talking about supplementing fruits and vegetables

00:01:56.980 through things like multivitamins or green powder. So if you're not a subscriber, you'll only be able

00:02:00.560 to listen to a sneak peek version of this episode, but you can learn more about our subscription via the

00:02:05.400 website. One last thing to note is that based on the timing of when we recorded this, we weren't able to do it

00:02:10.540 via video. So this will be an audio only episode, although the show notes will be very helpful

00:02:15.640 because that includes a number of charts and graphics that we use in the episode. So without

00:02:19.820 further delay, I hope you enjoy AMA number 36.

00:02:27.700 Peter, welcome to another AMA. How are you doing?

00:02:31.100 I'm doing well. We just spent the last 15 minutes talking about why season four of Drive to Survive was

00:02:37.000 not good. So I wish we could continue on that discussion, but I don't think anybody wants to

00:02:41.400 hear us talk about Formula One anymore. Yeah, it will be interesting to see. I mean,

00:02:45.140 on the positive front, we picked a topic for today that you're second most excited about

00:02:50.100 in terms of right after Formula One, which is nutrition and in particular fruits and vegetables.

00:02:55.700 So I'm sure the excitement we had in our little intro on Formula One will be carried over to this

00:03:01.300 one. What do you think? I think it's hilarious that most people listening to this don't appreciate

00:03:05.940 the sarcasm in your comment. That might be true. This one's not via video, so they can't see you

00:03:11.800 smirking and smiling over there. So they might think we're being dead serious. This is polar opposite

00:03:17.100 discussion. All things Formula One, all things fruits and vegetables. I think just to completely show my

00:03:23.260 hands to the audience, this is not a topic I'm particularly interested in diving into, but this is

00:03:30.220 as close to taking one for the team as I've ever done in my life. The only reason we are having

00:03:36.000 this discussion is because of you. You, meaning not you, Nick. You, the listeners. The subscribers

00:03:43.420 have asked so many questions on this topic that I simply can't avoid this any longer. If we're going

00:03:51.340 to be true to our principles of trying to answer questions people have, we have to do this. I spent a

00:03:57.420 little bit of time in therapy trying to understand why I don't want to talk about this, and that's

00:04:01.360 only slightly an exaggeration. I think here's what it comes down to. I think everybody kind of has this

00:04:06.820 narrative that fruits and vegetables are like, quote unquote, good. Fruits and vegetables are good.

00:04:11.240 Everybody should eat their fruits and vegetables. Have your five to six servings a day. It's all really

00:04:14.060 good, good, good, good, good. Okay. But the reality of it is we don't really know that much.

00:04:18.480 It's true on average, and certainly all of the epidemiology would suggest that that is

00:04:25.300 correct. People who eat more fruits and vegetables are healthier than people who don't. And as you'll

00:04:30.760 see as we get into this discussion, I think there's plenty of evidence to suggest that that's the case.

00:04:36.920 But if you really get into the details of this stuff, I think there's far less that's known than

00:04:43.020 is represented as true. And I actually think that's a broader concept that applies to nutrition in

00:04:49.160 general, which also speaks to why of all the chapters I'm struggling with in trying to wrap up

00:04:58.380 in my book, the nutrition chapter is the one that is hands down posing the greatest difficulty.

00:05:04.600 It's not because I don't have anything to say. It's because there's less to say definitively

00:05:11.540 than I would have said 10 years ago or five years ago. And beyond a couple of really obvious

00:05:18.480 things, too much food is bad. Too little food is bad. Too little protein is bad. Certain micronutrients

00:05:27.320 are essential. Certain things are toxic. The obvious things like avoid E. coli in your food.

00:05:34.180 It starts to go from really clear absolute knowledge to probable knowledge very quickly, quicker than it

00:05:43.400 does with sleep, with exercise, and even with pharmaceuticals. And yet it's the one area where

00:05:49.920 I think people speak about things in more absolute terms than they do in anything else outside of maybe

00:05:55.500 their religion and their politics. Why do you think that is? I mean, I know you've spent a lot of time

00:06:00.340 thinking about this and looking at it. And my immediate thought goes to the podcast we did with

00:06:05.520 David Allison. And David talked about how if you worked on a pancreas and you're at a dinner party,

00:06:11.200 it's hard to talk about that because unless someone else works on the pancreas, they're not going to

00:06:15.580 know the details. But with nutrition, it's everyone eats every day. It's in their face every day. You know

00:06:21.040 what works for you. First question would be, why do you think that is? The second question is,

00:06:25.640 is it because people are trying to speak in absolutes because what works for them might genuinely

00:06:31.720 work for them, but it's not guaranteed to be widespread across a variety of people?

00:06:37.960 I think what you said, if David came up with that example, I don't remember that about the pancreas.

00:06:41.900 That's really funny. But I think there's an absolute truth to that, Rich, is we all have expertise in

00:06:48.400 nutrition, albeit not necessarily scientific, not necessarily broadly applicable, not necessarily

00:06:55.340 nuanced. But there's no one on this planet who doesn't have expertise of some sort with this

00:07:01.640 thing because we all do it every single day. Not everybody exercises every day. Most of us aren't

00:07:07.560 conscious when we sleep, but we're conscious and we make deliberate choices when we eat every single

00:07:13.320 day. And so, yeah, I think we generally have a sense of this works for me, this doesn't work for me.

00:07:18.700 I think there's also a very significant cultural and social component to this thing as well. So I think

00:07:24.040 that's where the tribalism comes from around nutrition. I think on the flip side, it's very difficult

00:07:30.840 to acquire reliable knowledge in this space. And I think there are some really good scientists

00:07:38.460 working on the mechanistic side of nutrition. There's people who are really under very tightly

00:07:44.420 controlled conditions, elucidating some of the most interesting knowledge with respect to energy

00:07:51.560 balance, with respect to appetite, with respect to fuel partitioning, food reward, all of these things.

00:07:57.940 I think these things are very interesting. The problem is they're nearly impossible to do this

00:08:03.780 type of work in large sample sizes over long durations. And you need large sample sizes and long durations

00:08:10.780 to infer hard outcomes that we care about, which are prevalence of disease or incidence of disease

00:08:19.620 and ultimately mortality. And so, therefore, to get insights on those topics, you have to rely, almost without

00:08:27.960 exception, on epidemiology. That's not entirely true. There are some reasonably well-done, large clinical trials,

00:08:36.560 but they require thousands of people and many, many years. And that means your interventions had better be

00:08:42.480 very, very, very simple if you're going to achieve compliance over that period of time. So all of this

00:08:47.660 is to say, nutrition is very hard. And when we rely on epidemiology, we're struggling to necessarily get

00:08:58.280 it right in areas where the hazard ratios end up being quite small. I won't get into all of that now

00:09:03.800 because we've talked about that so much. But when you get hazard ratios like 1.19,

00:09:09.180 it's very difficult to know that you've captured and removed all of the biases that fed into that.

00:09:16.700 The work that the people you were talking about, what they're doing, do you think in the short term

00:09:22.160 we'll be able to have more concrete answers? Or is this one thing where you think, just given all the

00:09:27.620 limitations, it might be a long time before we have a lot of concrete, really solid insight on this?

00:09:35.000 There are certain people I like to have on the podcast, and at least at the time of this recording,

00:09:39.000 I haven't had them on yet, although I think we will. I mean, Kevin Hall, I think, is really doing

00:09:42.960 some super interesting work. And I know Kevin well, right? I've known Kevin for over 10 years,

00:09:48.260 and I've worked very closely with him in a previous project. And I think Kevin is, I think,

00:09:53.840 one of the most thoughtful people on the subject of energy balance. And I think that's the type of

00:09:58.820 work that can be studied over shorter periods of time. I mean, those are areas where you can get

00:10:04.380 answers to questions in months. You don't need years to get answers. You can get them in months.

00:10:09.160 Now, maybe you'll get different answers in years, but you're getting pretty interesting answers in

00:10:13.620 months, and you don't need thousands of people. You can actually do these in tens of people,

00:10:18.740 provided you're using very precise instrumentation. People like Kevin,

00:10:23.840 Rudy Leibel, Eric Ravison. I have somewhat of a bias because I've worked with them,

00:10:28.360 and I know them, and I think they're good thinkers. They're able to answer those types of questions,

00:10:32.720 but they can't answer the questions that we're about to talk about today. They can't answer the

00:10:38.280 questions that are still vexing me, like, are omega-6 polyunsaturated fats inherently healthy or

00:10:46.340 harmful? This is a very vexing question, and I'm sitting here trying to write about it in a book,

00:10:51.240 and I don't know what to say because I've seen pretty compelling evidence. For example,

00:10:57.480 looking at the initially unpublished data from the Minnesota coronary experiment that completed in

00:11:04.620 1973, didn't get published in its first rendition until 1989, and then wasn't reexamined and republished

00:11:10.720 until, I don't know, something like 2013. If you look at those data, you could make a very compelling

00:11:15.440 case that omega-6 polyunsaturated fats as substituted for saturated fats could actually

00:11:20.760 be viewed as harmful. But then you look at a whole bunch of other data, and you think, no,

00:11:26.080 any harm associated with those fats is purely due to the confounders of what they track with.

00:11:34.660 The seed oils that show up in low-quality foods and junk foods, it's not the seed oil that's the

00:11:41.600 problem. It's the junk food that's the problem. So that's just another example of, I think,

00:11:45.880 questions that have profound importance. I'm not really clear at this point if I have a sense of

00:11:51.080 what the answers are. I mean, we could skip answering these questions and just do a What

00:11:56.360 Grinds My Gears episode with Peter Atiyah for the next hour, if that would be more entertaining for

00:12:01.480 people. On that train of thought, just to give people a background, what we did is we receive a lot

00:12:07.400 of questions on nutrition, fruits, and vegetables. So we compiled them. And then a few months ago,

00:12:13.740 it feels like you went to Twitter and Instagram and also said, hey, we're thinking about doing a

00:12:17.800 podcast on this. What questions do you have? And there was just hundreds and hundreds and hundreds

00:12:22.380 of questions that came through, which kind of made us realize, okay, there's interest here and we should

00:12:27.080 probably try and work through these. So what we're going to do is we're going to go through these

00:12:32.620 questions, but do you want to set the tone a little bit, which is one, we're not going to give

00:12:38.440 clear cut guidelines on what people should and shouldn't eat. It is variable depending on your

00:12:45.320 metabolic health diet, what you're already eating. But the hope is the information we give you here,

00:12:51.660 you'll be able to apply it to your life to help you understand this subject better and ultimately

00:12:57.340 have better nutrition, whatever that means for you.

00:13:00.740 Yeah. I think there's another point that I would add to that, which is, and this is true

00:13:06.640 of nutrition in general. Don't confuse the optimal diet for you in a state of health versus the optimal

00:13:15.000 diet for you in a state of sickness that's trying to restore your health. They aren't necessarily the

00:13:19.920 same thing. So I'll use just one example because it's germane to our topic. When we work with patients

00:13:25.860 who are metabolically healthy, I've never once restricted the amount of fruit they consume.

00:13:31.760 When I work with a patient who has type 2 diabetes and non-alcoholic fatty liver disease,

00:13:38.920 I will actually restrict how much fruit they consume. No, I'm not going to say they shouldn't

00:13:44.320 have any fruit, but if that's a person who's eating four bananas a day and watermelons and apples

00:13:51.720 and pears and peaches, I am going to say, actually, we're going to have a better chance

00:13:56.140 improving your metabolic health if we at least temporarily reduce the volume of that significantly

00:14:02.340 and reduce the burden of fructose on your liver. Because fructose and ethanol are, at least to my

00:14:10.420 reading of the literature, pretty uniquely poised to make a sick liver sicker. So again, does that mean

00:14:19.640 that that person's going to always be restricting fruit? No, not necessarily. Does that mean it's

00:14:24.320 the only way to do it? No. You could probably just completely restrict other calories and not

00:14:30.240 restrict fruit as much, and you might achieve the same benefits. But empirically, it seems easier

00:14:36.800 in those people to reduce fructose intake and to do so through fruits. There's multiple different

00:14:42.980 ways to think about this, but I think it is important for people to not extrapolate from the hill that

00:14:48.440 they're sitting on to the hill that anyone else is sitting on. How I eat today to preserve my health

00:14:54.560 is probably different from, not probably, it's unquestionably different from how I was eating

00:14:58.860 15 years ago when I was in the process of trying to improve my health from a place that was actually

00:15:04.420 below where it is today. Keep all of that in mind. Yeah. I think that's really good. And just for

00:15:10.580 everyone listening, do you mind just giving that quick definition of metabolic health again,

00:15:15.280 just so everyone is on the same page of what that is and what you mean by that?

00:15:20.400 Yeah. I mean, I think there's a lot of different ways you can define it. It's sort of like BMI can

00:15:25.080 be used to define overweight and obesity, and that's the way we do it. It's not really great. I think

00:15:30.420 body composition would be a better way to do it. Similarly, I think the quickest and easiest and

00:15:36.280 dirtiest way to define metabolic health is probably to use the criteria for metabolic syndrome.

00:15:41.440 So metabolic syndrome is basically defined in a somewhat binary fashion, which is you have three

00:15:48.240 or more of the five criteria or you don't. Those five criteria are truncal obesity, high blood

00:15:55.500 pressure, high fasting glucose, high fasting triglycerides, and low HDL cholesterol. And we'll

00:16:04.340 list in the show notes exactly what the criteria are. They differ slightly between men and women.

00:16:08.300 We don't look at that in our patients, truthfully, because we're not trying to make assessments at a

00:16:13.700 population-based level. So we're looking at many more factors beyond those things, looking at oral

00:16:19.240 glucose tolerance tests, looking at uric acid levels, homocysteine levels, looking at the entire lipid

00:16:27.720 profile, and then looking at functional testing. So looking at how the mitochondria perform in a zone two

00:16:33.680 test. So how much lactate is a person producing at rest? And then how much lactate do they produce

00:16:39.200 under increasing amounts of workload? And all of those things then factor into our assessment of

00:16:44.680 metabolic health. That sounds good. And it kind of fits well into the first question that we were going

00:16:49.820 to tackle here, which is someone reached out and said, fruits seem to exist on a spectrum. Many are high

00:16:56.020 in sugar and are calorically dense. Could you help break down the glycemic content of common fruits

00:17:02.840 and how this matters in determining best choices for different diet staples? I know this could vary

00:17:09.200 person to person in terms of determining the quote-unquote best choice, but I think just even

00:17:14.740 breaking down how to think about the sugar content, the various nutrients in fruits, how would you do that

00:17:21.820 with the patient? Thank you for listening to today's sneak peek AMA episode of The Drive. If you're

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The Peter Attia Drive - June 20, 2022

#211 - AMA #36： Fruits & vegetables—everything you need to know

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