Episode 12: Always Hungry? A Conversation with David Ludwig, MD PhD

What you’ll learn in David’s podcast:

1. The failure of low fat, low calories
2. We’re dynamic biological systems: When you cut back on calories, the body fights back
3. Obesity-excess fat in storage, but a state of starvation to the rest of the body, cutting back on calories always worsens this phenomenon
4. Insulin: the most potent anabolic hormone, the ultimate “fat cell fertilizer”
5. Insulin directs incoming calories to be stored as fat in adipocytes
6. If you don’t have diabetes, the quickest way to adjust your insulin levels is based on the amount of processed carbs consumed
7. The quickest way to unlock excess fat in storage is through a rich, high-fat diet followed by the addition of whole-kernel high-fiber grains as tolerated by the individual
8. The gut microbiome and metabolic health
9. Pesticides, herbicides and food additives and GI health
10. Restoring sanity to our food environment- a grass roots movement

Podcast sponsored by Genova Diagnostics

Headquartered in Asheville, N.C., Genova Diagnostics is a global clinical laboratory, pioneering a systems approach that supports healthcare providers in the personalized treatment and prevention of chronic disease.

Podcast Series sponsored by Designs for Health

Designs for Health’s extensive line of nutritional products are created after extensive product research. Go to Designs for Health to learn more!

Kara Fitzgerald: Hi, everybody. Welcome to New Frontiers in Functional Medicine. I’m Dr. Kara Fitzgerald. Today, I have the pleasure of speaking with David Ludwig. As you know, David is the author of “Always Hungry” published on January 5 of this year and is now a New York Times best-seller, so we’re going to dive into that in just a moment, but let me tell you a little bit about his background. Dr. Ludwig is a practicing endocrinologist and researcher at Boston’s Children’s Hospital, professor of pediatrics at Harvard Medical School and professor of nutrition at Harvard School of Public Health. He’s founding director of the Optimal Weight for Life program at Boston Children’s Hospital, one of the oldest and largest family-based weight management programs. He also directs the New Balance Foundation Obesity Prevention Center.

Described as an obesity warrior by Time Magazine, he’s been featured in the New York Times, the Boston Globe, USA Today, and he’s been on NPR, ABC, NBC, CBS, CNN, and other networks. Dr. Ludwig, welcome to the program.

David Ludwig: Thank you, Dr. Fitzgerald.

Kara Fitzgerald: Yep.

David Ludwig: Great to be with you today.

Kara Fitzgerald: Oh, you know, I’ve enjoyed reading your book. You’ve synthesized of really high level of complexity into something I think anyone can understand. I appreciate you really … You’ve used a superscript to cite lots of research, which makes it easy for me to go and look at the studies that you’re looking at, and one of the fun anecdotes in the beginning of the book is your own process of looking at the research and that shaping you. In fact, I think you say something, and correct me if I’m misstating, is that you actually found it beneficial that your medical training was so limited in nutrition training because that gave you sort of a tabula rasa, I guess, an open mind to go in there and just look at the research. Tell me about that.

David Ludwig: Right. Yes, well, I had no bad habits to break. You know, as we know for worse but also in my case, is in some ways for better, there’s very little nutrition education in medical school, historically. I’m not sure that has changed much since I finished my training a few decades ago. The irony is that most cases of chronic disease are related to lifestyle and diet, and yet we study overwhelmingly drug and surgical treatments and neglect the origins of these diseases. I know you in your practice in functional medicine takes a very different approach to this.

I finished medical school and my training with very little background in nutrition and got involved in basic research in the bench looking at genes and biological factors that affect body weight in rodents. At the same time, I was setting up a clinic at my hospital, a weight management clinic, and using the same old paradigm of calories in, calories out, which seemed to neglect the fascinating biological factors that we were studying in the laboratory and were presumed to be critical in affecting body weight. In the laboratory, it was about biology. In the clinic, we neglected that and assumed this was all willpower, and that was a disconnect that I struggled with for quite a while until I began to understand a new way of thinking about food, food based on its effects on our hormones, metabolism, literally the expression of our genes, that opened up an entirely new approach to weight management that was free of the calorie in, calorie out prism through which we have been focused so long.

Kara Fitzgerald: You know, I’m curious in your drill down into the literature over the years … I mean, you cite a 1924 JAMA paper in your book. Has all the research over the years been towards this calories in, calories out phenomena? Actually, you quote in that 1924 study that they realize it’s probably way more complex, but was anybody sort of getting a bigger idea around it, or has it always been attempting to push that one idea?

David Ludwig: Well, in that 1924 piece, it was an editorial by the editors of JAMA questioning the simplicity of the calorie in, calorie out model. You know, it sounds … Of course, this has been questioned intermittently through the years and largely dismissed, discredited, marginalized as nonsense, but nobody … You know, the approach that I take in my book or others who have questioned the value of thinking of all calories are alike, we’re not questioning the physics of it, the first law of thermodynamics that says energy can’t be created or stored; calories in minus calories out equals calories stored. Nobody’s questioning the physics of it. We’re just asking in which side of the equation do we actually have control.

The conventional way of thinking is that you just have to eat less and move more and you’ll take care of a problem, any kind of a weight problem over time. There are a few awkward soft spots to this way of thinking. The first is that if you can’t do it, it implies that there’s something the matter with you, that you lack willpower or discipline or maybe even have a character issue, so people, our society, largely for this reason, get stigmatized, discriminated against if they have a weight problem in ways that would be unacceptable for virtually any other medical problem. We seem to think that it’s people’s fault, that they could just will away the extra weight if they had discipline.

This disregards the fact that calorie reduction is an extraordinarily poor long-term strategy for weight loss. Very few people can do it. The ultimate irony is if conscious control over calories were so important, how did humans manage to avoid massive swings in our body weight before the very notion of the calorie was invented 100 years ago?

Kara Fitzgerald: Right, right, yeah. Thank you.

David Ludwig: What happens when we cut back on calories? Well, we’ve known this for essentially a century. Actually, everybody’s intuitively known this all along. When you cut back calories, it’s not like our body is an inert object. We’re not toaster ovens. We’re dynamic biological systems. When you cut back on calories, the body fights back. The first thing that happens is we get hungrier. People tend to overeat because they’re already hungry, so you cut back calories, and you make that worse. Hunger isn’t a passing feeling. It’s a primal biological signal that the body needs fuel. Very hard to ignore over the long term. You can do so have hours or maybe a few days or a while, but over the long term, very difficult to do.

If you actually do manage to ignore your hunger, then the body has other tricks, including slowing metabolism. Your metabolism slows down. That combination of slow metabolism and rising hunger creates a battle that very few people can win over the long term.

Kara Fitzgerald: You talk about the impact of just going on this direction, the stress response when you’re in the starvation phase and cortisol rises, adrenaline is released, and what happens then?

David Ludwig: Yeah, so we got to ask what’s the underlying driver of weight gain? Our genes aren’t changing, leading us to become programmed to be heavier and heavier every year for inherited reasons, so what’s going on? We tend to think of obesity as a state of excess, too many calories in the fat cells, but it’s really a state of starvation to the rest of the body. The fundamental problem is that fat cells have been triggered to hoard too many calories, so they suck up all these calorie-rich substances in the blood that come from the food we eat so there are too few for the rest of the body, and the brain does what it’s designed to do. When it doesn’t see enough fuel for its needs, it makes you hungry. It also activates other areas of the brain involved in craving and reward. Then it actually starts secreting stress hormones, which serve to recruit calories from lean tissue in ways that you don’t want to happen because that’s not good for your body composition or heart disease risk factors, and metabolism slows down.

If you just cut back calories, you make that situation worse. The fundamental problem is that fat cells on calorie storage overdrive. There aren’t enough in the blood stream, and you are cutting back calories. You’re putting yourself deeper into starvation. Yes, you can do it for a while; anybody can lose a few pounds, but what happens after weeks and months? It almost always comes back, unless you change what you eat.

The analogy I would use is like edema. Edema is a state in which fluid leaks out of the blood vessels and can accumulate elsewhere in the body such as the legs. Someone with edema might have 20 extra pounds of water in their body, but oftentimes, they have insatiable, unquenchable thirst. Why? Because even though the body has too much water, it’s not where it needs to be in the blood stream to satisfy the needs of the tissues throughout the body, and so drinking more temporarily satisfies that thirst, but then the fluid just continues to leak into the tissues, and that’s the same thing that happens with obesity. We overeat to keep enough calories in the blood stream, but if they’re continuing to be sucked up excessively into fat cells, it’s a never-ending battle of hunger, overeating and weight gain, but if we treat that problem at its source, and this critically involves lowering levels of the hormone insulin, then the fat cells open up, calories flood back into the body, hunger decreases, metabolism speeds up. Then you begin to lose weight with your body’s cooperation, not with your body kicking and screaming.

Kara Fitzgerald: Moving over to insulin, so you’ve outlined beautifully the starvation effect. Now, let’s layer into that the idea that low fat is good, which has been around as you point out for about 40 years, and replacing this low fat is higher sugar, simple carbohydrate foods. Layer that into what’s happening metabolically.

David Ludwig: If you like the calorie balance model of weight control, you’ve got to love a low-fat diet because fat has more than twice the calories of the other major nutrients, carbohydrate and protein. Remember the first food guide pyramid in 1992? You know, all fats are at the top to be consumed sparingly, and a range of highly-processed carbohydrates were at the base, grain-based carbohydrates, up to 6-11 servings a day. Some people were actually suggesting sugar was fine to eat because it helped you dilute fat calories. This was a quote from review article. You dilute out your fat calories in your diet by eating more sugar.

We’ve created a low-fat diet in the US, which is based on these highly-processed carbohydrates, that either raise sugar directly or digest into sugar very, very quickly. White bread raises blood sugar actually faster than table sugar. Table sugar is half fructose. Now, fructose is, in large amounts, isn’t a good thing for the liver, but white bread is all glucose. You can digest it in minutes. Blood sugar surges; insulin surges. Insulin is the ultimate fat cell fertilizer. It’s the most potent anabolic hormone for fat cells there is. This is endocrinology 101. Someone with type I diabetes, a child coming in first diagnosed, will not have had enough insulin in the body, and they’ve invariably lost weight, no matter how much they’re eating, 5,000, 7,000, 10,000 calories. Give them the right amount of insulin, and their growth trajectory resumes a normal course. If you give them too much insulin, they’ll predictably gain weight. Start someone with type II diabetes on insulin, they gain weight.

This is absolutely fair. Now, if you don’t have diabetes, the quickest way to adjust your insulin levels is based on the amount of processed carbohydrates you consume. These highly-processed carbs, sugar and refined grains, potato products, raise insulin calorie-for-calorie more than any other food in existence. The insulin programs the incoming calories to get sucked up in fat, and it locks the fat closed. It’s like being in a kitchen where you have lots and lots of food, but it’s all locked away in the cupboard, so you get into the kitchen, you can’t get to it, and you’re hungry. That’s the situation.

The quickest way to reverse this, and the diet that we propose, we offer … We have a 3-phase program in the book … is a rich, high-fat diet, nuts and nut batters, full-fat dairy, rich sauces and spreads, savory proteins, but also not … dark chocolate, I should add, but also not a very low carbohydrate or ketogenic diet. There are a lot of natural carbohydrates just to slow digesting. This lowers insulin, calms chronic inflammation, and helps those fat cells open up, flood the body with calories, moving metabolism into weight loss mode.

Kara Fitzgerald: You do this fairly aggressively, so the Always Hungry protocol is, as you say, a 3-phase program, and you know, it’s really quite high fat at the outset, but relatively briefly.

David Ludwig: Right, so for 2 weeks, we bring fat up to 50%. Now, that’s again, not an Atkins diet, but it’s a lush, rich, high-fat diet. All those fats help you displace the processed carbohydrates without missing them. There’s research, including from our group, to suggest that you can quite literally turn off the brain craving centers in as little as one meal. May I tell you about one of the studies we did?

Kara Fitzgerald: Yeah, absolutely.

David Ludwig: We published this in the American Journal of Clinical Nutrition 2013. We took 12 young men who have high body weight and gave them, in a cross-over fashion, 2 milkshakes, one on one day, another on the other day, randomized order. The milkshakes actually have the same protein, fat, carbohydrate, calories, the same sweetness, which was adjusted experimentally. One had fast-acting carbohydrate, corn syrup, and the other had slow-digesting carbohydrate in the form of uncooked corn starch, so that’s less processed. It takes longer to digest. We found that, as expected, the blood sugar and insulin shot up after the fast-acting carbohydrate milkshake. 4 hours later, blood sugar was crashing and people reported feeling hungrier. At that time, we did brain scans with something called functional MRI. We saw that one area of the brain had lit up in every single participant. I’ve never seen this consistent a result in nutrition research; usually, you get a few people going in the opposite direction. In this case, everybody did, so we had astronomical statistical power to look at this.

That area was called the nucleus accumbens, which is, for those of your listeners like me who aren’t neuroanatomists, the nucleus accumbens is the center of the striatal dopamine pleasure and reward system. It’s considered ground-zero for the classic addictions of cocaine, heroin, alcoholism, raising a provocative idea that these highly-processed foods are high-jacking the brain’s reward system and producing something akin to food addiction. It also suggested one meal, the slow-acting milkshake, turned off that craving center. The reason that you can turn it off so quickly is that simply when the calories that you eat from foods stay around in the bloodstream longer, when they don’t get sucked up into the fat cells so quickly, the brain says, “I like it.” The brain says, “You know what? I’ve got enough to run metabolism,” and so it says, “I can relax,” and it turns off hunger; it turns off cravings.

Kara Fitzgerald: Yeah, it’s fascin-

David Ludwig: We started out with this rich, high-fat diet and then, to help jump-start weight loss, it helps to lower insulin, chronic inflation; it helps these fat cells open up. Then we transition after 2 weeks to phase 2, which adds back whole-kernel grains. Now, for people who … You don’t have to eat the grains if … Some people don’t like to do that and will do best with relatively lower carbohydrate. Some people can tolerate it. Let’s face it, there’s a lot of tasty grain products out there, and some people can do really well on whole-kernel, high-fiber, even especially some of these ancestral grains, so there are plenty of gluten-free alternatives. We add back a touch of sugar so you get to have a sweet dessert once in a while, but you stay in phase 2, which is still quite high-fat until your weight comes down to its new lower set point.

Then you enter phase 3 where we allow people to experiment with some of the more processed carbs according to their body’s ability to handle it. If you can tolerate it, and some people, especially after eating well for a few months, have the ability to do that, then enjoy yourself. We want to ask people for the minimum of deprivation to provide the maximum of benefit. If your body can handle it, then go ahead and have a pastry when you’re traveling in Paris. Have linguine in Italy, or at a birthday party at home, have some cake and ice cream. Many people will find that they do best with little to none of those. We have symptom trackers and charts to help you find your tipping point. If you’re one of those people, especially people with like pre-diabetes or other significant metabolic compromise, they’re going to do best with really little to none of that. You’ll see it in your symptoms, and you’ll realize the benefits of feeling good, being in control of cravings and in control of your weight, are so much greater than the fleeting pleasure of the processed carbs.

Kara Fitzgerald: Now, since there’ll be clinicians listening here, I mean, are there labs you would recommend looking at? You talk about insulin sensitivity, leptin, thyroid function, cortisol, and so forth. Anything in our support of our patients doing this program you would suggest?

David Ludwig: You know, there’s different levels of assessment which are going to be relevant for at different practices and different patients. A dietitian seeing a patient won’t necessarily being ordering laboratories themselves, but if you’re a physician and especially if a patient seems to have elevated risk factors, then there are some standard work-ups to be done for metabolic assessment. In addition, we can, and I can mention a few, but one can also think about adding on some other laboratories to look specifically for insulin resistance and chronic inflammation.

You know, a standard work-up would involve like an assessment of diabetes risks, so hemoglobin A1C is an easy one, and just as good as doing an oral glucose tolerance test in many situations. One thing you don’t get is, of interest, is insulin 30 minutes into an oral glucose tolerance test. That shows whether you’re a high insulin-secreter, and those people seem to be very sensitive to processed carbohydrate. That’s more of a specialty interest right now. Hemoglobin A1C, maybe a fasting blood sugar, of course a fasting lipid panel is helpful. The classic risk factor was LDL, and that’s why everybody worried so much about saturated fat. Saturated fat raises LDL, but those tend to be bigger, fluffier particles that are a little less atherogenic, and saturated fat also raises HDL, so the total ratio remains relatively unchanged. Triglycerides in addition, or one can do a full LDL particle size panel. That’s a more elaborate test and for specialized circumstances, people with higher risk. Then I oftentimes get an ALT as a marker of fatty liver. It’s not a perfect one, but if it’s significantly elevated, that can be of particular concern.

Oh, in terms of insulin levels themselves, you can just get a fasting insulin, which is a good marker of insulin resistance, and then CRP, which is a marker of chronic inflammation, C-reactive protein, if you want to. In special circumstances, you can assess for thyroid. I mean, there’s many places that I’m sure your team or your various specialists will go based on the clinical indications.

Kara Fitzgerald: Right. Thank you. Okay, I think that those are tests that everybody’s familiar with and are good investigations to make. Do you concern yourself with looking at ketones specifically when you’re doing maybe the phase 1 of this? Is this something that you’ve investigated in your research at all?

David Ludwig: Yes, we’ve investigated, and this is not a ketogenic diet, both because even in phase 1 with 25% carbohydrate, that’s really enough … We intentionally designed it to provide enough so people weren’t dipping in and out of ketosis, and I’ll tell you why we designed it that way in a moment, but also the 25% protein. Protein is gluconeogenic, so with the combination of … With only 50% fat, people will not become ketotic unless there’s an unusual situation, they’re extremely physically active or they’re intentionally restricting calories, which we ask people not to do.

There is a lot of interest in ketogenic diets now, and perhaps especially for type II diabetes, the famous exercise physiologist Tim Noakes from South Africa had recommended a low-fat diet for many years. He was running marathons and developed type II diabetes himself. Then he became interested in low carbohydrate and ketogenic diets, got on one himself. Basically his diabetes is in total remission. He speaks of this publicly. He wrote a letter of apology, saying, “I’m sorry to the world for recommending a low-fat diet for so many years.”

In type II diabetes, I think the ketogenic diet has a lot of interest. It really needs to be tested. Of course, this diet’s been used for decades. It shows remarkable effects in epilepsy in children. Some children who have intractable epilepsy get cured on a ketogenic diet. That said, it’s an arduous regimen. It requires a lot of focused intention. It can be difficult to come in and out.

When you’re not ketogenic, your brain is dependent on glucose. As you transition into a ketogenic diet, the brain shifts from a primary dependence on glucose to ketones. Ketones are a great fuel for the brain. They come directly from fat, and you’ve got an unlimited amount of it in your body, in effect, the fact, enough to fuel ketones for weeks or months in some cases. Glucose is stored in limited amounts in the body, so there’s a lot of interest in why that could be beneficial, but going in and out of it, the body has to transition. That can be a rocky transition for people, so we want to stay away from skirting the edge. That edge would be if you were, say, eating 15% protein and 15 or 20% carbohydrate. You’d be kind of going in and out, and people may not feel good at that, so we really backed off from that degree of restriction.

Kara Fitzgerald: You know, I was going to ask you, and that makes sense, and I appreciate your explanation around that. The protein is a little bit on the lower side in your program. When you move into the final phase, it’s actually at 20%, and you just mentioned that protein is gluconeogenic. Any comments on that, just keeping the protein a little bit lower?

David Ludwig: Actually, phase 1 and 2, the protein is-

Kara Fitzgerald: 25.

David Ludwig: … substantially higher than prevailing consumption levels; it’s 25%. Prevailing levels are about 15-18% in the US population. We increase the protein during phases 1 and 2 because people will be naturally eating less, not through calorie restriction but because they’re more satiated, and they’re eating overall less, so increasing the proportion of protein makes sure that there’s enough grams of protein during the weight loss phase, and that has metabolic advantages. It causes glucagon secretion, which helps balance insulin. Then, as your weight drops back to its new lower level, you’ll increase your calorie intake because you’re no longer living off of stored fat that you’re burning. As your total calorie and food intake goes up, you wind up eating the same amount of protein, but its proportion decreases a little bit.

Now, there are some diets that go even higher in protein, like the Atkins diet, goes up to 30%. I think that’s, in most cases, I think that’s more than necessary. Sometimes it’s hard to get all that … It really involves eating a lot of meat; there’s no other good way to get that amount of protein in than eating a lot of meat, which has its own issues, which we can discuss. Protein in high amounts is very anabolic. It causes insulin secretion. It can itself over-stimulate the fat cells. We think that the sweet spot is around 20, 25%, but that will vary from person to person.

Kara Fitzgerald: Okay, yeah, that’s … Thank you. You know, another thing that you’re emphasizing in your book is lifestyle, adequate sleep, some movement, which I think you kind of turn the volume up on over time, and a focus on stress relief. I mean, these are all incredibly important. Comments on how they’ll impact?

David Ludwig: Yeah, well, in one sense, it’s kind of like, to your listeners, it’s going to be just intuitively obvious, but just to walk through it a little bit, the fat cells are influenced by many, many factors. Insulin is the granddaddy of them all, but sleep deprivation and stress also produce … You know, we oftentimes think, “Well, if you’re just too sleepy, you’re going to be making poor decisions, you’ll be eating too much, you’ll not be able to exert control,” and there may be some truth to that, but sleep depression and stress act on a much more fundamental biological level by increasing counter-regulatory hormones and destabilizing circadian rhythms in ways that program fat cells for calorie storage.

Stress, of course we think of cortisol. Cortisol is related to prednisone, which is oftentimes used as an anti-inflammatory for auto-immune diseases, but too much Prednisone, we know what that causes, Cushing’s syndrome, in which there is a build-up of fat around the mid-section, visceral adiposity, the highest risk, and a breakdown of lean tissue, so that’s the worst possible state to be in. We want to make sure that cortisol and the stress hormones are not working against us and undermining the benefits of a good diet. We focus on a variety of practical techniques for stress reduction and talk about creating a sleep sanctuary to make sure that …

You know, so many of us are over-stimulated; we’re on electronics all the time, and I’m just as guilty as anybody, especially with the roll-out of my book, which takes a lot of time on social media and the like. That can work against us because it gets into a vicious cycle of stress and then not sleeping well, which leads to other poorly-adaptive changes. You know, we may depend upon caffeine too much, alcohol too much, and so just some attention to consciously, mindfully winding down at the end of the day, creating a bedroom that is supportive of good-quality sleep and reserving the bedroom just for sleep. We say the 3 things rest, reading, and romance. That’s what we reserve the bedroom for. Start that turn-down around 8:00 at night, ideally.

Then lastly, physical activity has oftentimes been advocated to burn off calories, but you really don’t burn off that many short of marathon levels. You can spend 20 grueling minutes on a treadmill and replace them in a few seconds with a handful of raisins. What physical activity does is improve insulin sensitivity and lower chronic inflation, so this synergizes with diet. We focus on enjoyable physical activities. We want people to be having fun again. The prototype of it for our book is the [Italian 00:33:32]; it’s the Italian walk that people take after dinner in Italy, where you’re not wearing Spandex and a pedometer. You eat dinner, hopefully a delicious, low glycemic, higher fat meal, and then you go out. You go for a stroll, you see other people, and you get the last few rays of light before turning in. You tune up your metabolism at a time when your body’s absorbing these calories. That’s where we have people start. If they’re engaged in a fitness program, we actually ask them to cut back a bit during the first 2 weeks as their body transitions out of this high-insulin state.

Kara Fitzgerald: Thank you for that explanation. Nicely stated. I only have a few more questions, so you can take care of yourself as well. I know it’s been quite a tour that you’re on. Gut microbiome and metabolism. Of course, lots of research coming down the pike, and those of us in functional medicine often measure the gut microbiome. Lots of us are doing stool analysis and really paying attention to optimizing it through diet and lifestyle, and you know, we know that it’s going to influence both the foods that we crave, inflammation, and you know the research around metabolism. Comments on that?

David Ludwig: Well, no question that our internal garden is of critical importance to us, and we do focus in the book on the 3 Ps, prebiotics, probiotics, and polyphenols. The prebiotics are the poorly-digestible plant substances like fiber that serve as growth for the microbes in our gut. Probiotics are the microbes themselves that we can get from a supplement, but traditionally, we’ve gotten them from fermented foods and other environmental sources. Our family and my 7-year-old, at home, we eat naturally-fermented foods everyday, kimchee, sauerkraut, and you can get … Yogurt is a great source of probiotics, so you don’t necessarily have to be taking probiotic pills. We’re just at the dawn of this new revolution. We don’t even know whether the probiotics put into pills are the right ones.

I think, I don’t have anything against supplementation, but again, there has been a way that humans, throughout our history, in virtually every culture around the world, has gotten probiotics, and that’s through naturally-fermented foods. I don’t mean like, you can’t just get like a kosher pickle from the deli because that is typically not fermented. They add acid to give it that fermented taste, but actual, traditionally-fermented foods that you can get. Or, even better, make yourself. How great to ferment foods at home, to pickle them at home.

Then the last part of it is the polyphenols. These are the plant-like substances. Oftentimes, they give plants their color and their flavor. One classic example is curcumin from the herb turmeric, which serve as herbicides in our internal garden, but kind of the organic herbicide, inhibit the growth of deleterious microbes and allow the beneficial microbes to take over, so again, prebiotics, probiotics, and polyphenols are the key to cultivating a healthy internal garden, and that we know plays a critical role in weight maintenance and chronic disease reduction.

Kara Fitzgerald: What about, you know, going back to herbicides, not natural herbicides, but you know, what about pesticides, herbicides, and the myriad toxins that we’re exposed to and their impact on altering our metabolism?

David Ludwig: Right. Well, and it’s not just the things that get into our bodies unintentionally; there are things that are put into foods intentionally, including emulsifiers. A range of things like lecithin and carrageenan … There are a variety of names for them, food additives which seem to … They can have all sorts of negative effects on our gut microbiome and elsewhere. In terms of the emulsifiers and the like, they may actually disrupt the tight junctions that link gut cells together, creating the syndrome of leaky gut in which microbial products from the gut or incompletely-digested antigens, food, leak across and chronically overstimulate the immune system, leading to a range of symptoms, chronic diseases, and the like.

Virtually every chronic disease has been linked to at least, in theory, leaky gut syndrome. We need more research there. Those are a lot of food additives that are intentionally put there. In terms of the persistent organic pollutants, herbicides and pesticides and the like, or things that leech out from plastics, many of these are endocrine disruptors. They literally alter the functioning of our hormone system in ways that could plausibly overstimulate fat cells or cause all sorts of other problems. That’s why we use a whole foods-based diet, with the emphasis on plant foods. There are vegetarian options, but there’s options for meat-eaters as well, including full-fat dairy. We really want to make sure that people have a range of choices to meet their biology, their lifestyle, their ethics, and preferences, but by focusing on whole foods and tending to eat a little lower on the food chain, we can reduce exposures to many of these substances. Then use a water filter, and let’s all work together to try to create food policies that will favor the smaller farmer that’s less likely to use tremendous amounts of artificial chemicals in big monoculture. It’s so common with big, big agriculture. If we can restore some of the more traditional practices in agriculture, we can create a food environment that is really more supportive of all of us.

Kara Fitzgerald: That’s very nicely said. Thank you so much. You know, just in wrapping up, I know you’ve been involved in policy and really kind of helping to shape where we might be headed. Are you thinking about that now with this book and the research that you’re doing, how big picture we might be going forward in this country?

David Ludwig: Absolutely. You know, the first step is to bring healing into our own homes and to ourselves with the right food and the right stress reduction and care of ourselves. Once we’ve brought that healing to ourselves, we’ve reduced our chronic disease burden, and we’re feeling more energetic, that’s energy to then use banding together, hopefully in a grassroots campaign, to help detoxify our environment. We’ve heard of this term, the “toxic environment,” in which private profits and special interests have trumped public health. You know, they have inordinate political influence in Washington. They’re the ones who can give the $100,000 or million-dollar donations to politicians. Unfortunately, those politicians are beholden to the big food and big agriculture, and so create policies that don’t reflect the needs of the population.

The epilogue of my book and we felt very important to put that there … It’s a very short section at the end of the book, which offers a 10-point plan to, as I describe, restore sanity to our food environment. The last 2, among the other offerings, one is vote with a ballot because we can … Why haven’t we seen the candidates for president talk about food policy and chronic disease reduction? I think it’s an outrage that that’s been ignored, but we can, through our voting, demand that politicians respond to our interests and not special interests. You can also vote with the fork. Every time you buy food, you send a powerful message to the food industry. The food industry isn’t immoral. They’re just there to make a profit, and they’re just as happy to make a profit from healthy foods as unhealthy foods, and we can guide them to the healthy alternatives.

I should say that I do want to add that I’ve created a Facebook community with my wife. My wife did the recipes and meal plans in the book, and she oversaw our pilot. She’s a gourmet natural foods chef, so we together, about 2 weeks ago, created a Facebook community. It’s called the Official Always Hungry Book Community in Facebook, and we already have about 1,500 members in just 2 weeks for support. They’re sharing recipes and helping each other through the program, but that’s just the first step. We really hope to … I invite your listeners to join, and then I hope that we’ll transition over time into a grass roots community that can be of service to others and then also be demanding changes in our social environment to make the easy choice and the healthy choice.

Kara Fitzgerald: Dr. Ludwig, that’s, I think, a great place for us to end. It’s inspiring, and I appreciate the service that you’re doing and also just the years of careful research that you’ve been doing. I think the book that you have published will be very useful for many of us.

David Ludwig: No, thank you so much for your interest and your great questions. I know you’re doing great work, and I wish you much luck with it.

Kara Fitzgerald: Thank you. Okay.

David S. Ludwig, MD, PhD, is a practicing endocrinologist and researcher at Boston Children’s Hospital, Professor of Pediatrics at Harvard Medical School and Professor of Nutrition at Harvard School of Public Health. He is Founding Director of the Optimal Weight for Life (OWL) program at Boston Children’s Hospital, one of the oldest and largest family based weight management programs. He also directs the New Balance Foundation Obesity Prevention Center. Described as an “obesity warrior” by Time Magazine, he has been featured in the New York Times, Boston Globe and USA Today and on NPR, ABC, NBC, CBS, CNN and other networks. His new book ALWAYS HUNGRY? published on January 5 is a New York Times bestseller.

http://drdavidludwig.com/
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