Carnivore Diet for Inflammatory Bowel Disease: New Source of Hope? With Nick Norwitz, PhD

Nick: 
And quite honestly, I think a carnivore ketogenic diet probably has, this is me now speculating, but the most potential for inflammatory bowel disease in that particular use case. It might sound heretical to say because people don’t like carnivore, but for IBD, it just makes physiologic sense and people are already having success.

Bret: 
Welcome to the Metabolic Mind Podcast. I’m your host, Dr. Bret Scher. Metabolic Mind is a non-profit initiative of Baszucki Group where we’re providing information about the intersection of metabolic health and mental health and metabolic therapies, such as nutritional ketosis as therapies for mental illness.

Thank you for joining us. Although our podcast is for informational purposes only and we aren’t giving medical advice, we hope you will learn from our content and it will help facilitate discussions with your healthcare providers to see if you could benefit from exploring the connection between metabolic and mental health.

PhD researcher and fourth year medical student, Nick Norwitz joins me to discuss a new case series he just published about 10 individuals treating their refractory inflammatory bowel disease with a carnivore diet. And at the same time, this case series is both incredibly controversial and incredibly hopeful and promising.

So, how is that juxtaposition there? And what does it mean about how we interpret studies and red meat and dietary tribalism and so forth? So, let’s hear from Nick.

Well, Nick Norwitz, welcome back to Metabolic Mind. Thanks for joining me again. 

Nick: 
Thanks for having me, Bret. 

Bret: 
Yeah, so we just heard from you about the lean mass hyper-responder paper. And you’ve been very busy because in addition to that paper, you also recently published in Frontiers in Nutrition a 10-person case series of people using an animal-based diet to essentially put their inflammatory bowel disease into remission.

So, first of all, congratulations for being incredibly prolific as a medical student, which is probably not easy to do. But again, I encourage people to go back and listen to our talk about the lean mass hyper-responder paper.

But again, this paper coming from a perspective that’s against the common paradigm and the common teaching. So, give us the background of how you came to this sort of, this paper and these 10 individuals, and why you specifically chose an animal-based diet for treating inflammatory bowel disease.

Nick: 
The title was the paper was specifically focused on carnivore diets for inflammatory bowel disease. And I’ll acknowledge my biases and tendencies for wanting to publish on this topic of inflammatory bowel diseases upfront, which some people may know, but it’s worth reinforcing that I found a ketogenic diet to treat my inflammatory bowel disease.

That was over five years ago. I was very skeptical. I was very desperate, and I was trying lots of different things. And I ended up trying a ketogenic diet, and it absolutely changed my life. It brought me out of ICU-level care to the point where I could re-engage in life, academics, finish my PhD, go on to medical school, and really just be like a living, breathing human being, where I was like the shell of a human beforehand.

Sounds dramatic, but it’s true. So, I want to acknowledge that upfront. One, to reveal my motivations. And if people want to use that as data, that I have some sort of bias, feel free. I’m not trying to be opaque about that fact. But inflammatory bowel disease, which I just want to distinguish because it gets confused a lot from irritable bowel syndrome,  irritable bowel syndrome.

A lot of people have IBD, ulcerative colitis and Crohn’s. You are like, for ulcerative colitis, you have ulcers that are opening in your colon. You’re having bloody diarrhea 20 times a day. You like, it really can overturn your entire life. It is a really terrible condition for which there are very limited treatment options.

There are some first line options, which don’t tend to be very effective. You can go up to immunomodulators and biologics, which have a lot of side effects and still aren’t that effective. Where some people end up with getting surgeries, parts of their colon or even entire colon in parts of the small intestine removed because disease gets so severe.

So, this is a life crippling set of conditions for which patients are incredibly desperate and willing to try anything. That was the place I was in. Thankfully, I didn’t lose my colon. But it’s a suffering and underserved population. And just high level for a sec, setting aside any particular diet, you’d think, okay, inflammatory bowel disease, it makes sense if diet were effective in treating inflammation in the bowels.

And yet, often what people and patients get told is, there isn’t good data that diet can treat inflammatory bowel disease. There are some diet-specific carbohydrate, low FODMAP that some clinicians throw out there because it might help with symptoms a little bit. But often the message is diet isn’t really a major lever you can pull to put your disease into remission.

And that brings up the idea of absence of evidence is an evidence of absence. And the fact of the matter is, highly intense quote, extreme diets have not been trialed rigorously for inflammatory bowel disease. We can talk about why that might be. It’s a little deep discussion, but the fact of the matter, it hasn’t been trialed. And yet, in that landscape, there are many people like me who are changing their lives with diet.

And so, we have to ask the question, could this be effective? And if so, what might be really effective? And my colleagues and I saw the opportunity to write a case series on a carnivore diet, a carnivore ketogenic diet for inflammatory bowel disease. Just because this is a matter of practicality. You could even say, with respect to what we had access to. But like it or hate it, the carnivore diet movement, it’s accelerating.

It’s popular, and people are very vocal. Some might even say evangelical, but they’re very vocal about their successes. So, there just happened to be a lot of people talking about their successes. And when you have that, clinical narratives, you could say, combined with what is really good biological plausibility for why this won’t work.

So, we know ketone levels are inversely-related to IBD activity. In humans, we know that already. We know ketones are anti-inflammatory, that they can feed the stem cell niche in the gut. We even know that fiber elimination, now speaking to carnivore, not just ketogenic diets, but can be therapeutic in Crohn’s disease.

Fiber-free liquid diets are often used for pediatric refractory Crohn’s disease, refractory pediatric Crohn’s disease. They’re just not generally used that often because of poor palatability, but they can be effective in 60 to 85% of, I think, treatment resistant cases. So, it’s effective. That mechanism might have to do with changes in microbiome metabolism as a patho-bio mucispirillum.

We can get into that if you want. But bottom line, lots of people having experimental success, biological plausibility. What we set out to do is tell the story of a set of patients. We capped it at 10, although we had many more that we could have taken, and present their clinical narratives and as much depth as we could in order to provoke discussion about this possibility and inspire future trials so we could get to the point, hopefully, where we actually do prescribe in a quote, evidence-based manner, diets for inflammatory bowel disease.

And quite honestly, I think a carnivore ketogenic diet probably has, this is me now speculating, but the most potential for inflammatory bowel disease in that particular use case. It might sound heretical to say because people don’t like carnivore, but for IBD, it just makes physiologic sense, and people are already having success.

Bret: 
Yeah, there’s so much there. And I’m glad you went into the mechanisms because I think that is important, or the potential mechanisms, I should say, because it’s not like this is just coming out of the blue, out of thin air. But there is that sort of background hypothesis of why this would work and people wanting to share their experience.

But one thing I want to get to, and we’re, we’ll get into a lot more, was the mental health side of what you found. Because here at Metabolic Mind, we talk a lot about mental health, obviously. And when we talk about inflammatory bowel disease, the focus is on the bowel. But how it affects your life is going to dramatically affect your mental health.

So, in this 10-patient case series, what kind of reports did you get about how the improvement after starting a carnivore diet helped their mental health and their outlook in general? 

Nick: 
You could say that your mind is who you are. It is your humanity, your life. Bottom line, a fair description of the human and the mind.

And people were literally saying that the time before they started the diet and their present day on the diet life were like two separate lifetimes. That they felt like different human beings. Mentally, I think, that speaks to their mental health because inflammatory bowel disease is such a life-overhauling condition that, if you’ve been dealing with it for long enough, you really forget what life can be like, and you become a whole different person.

Maybe just a shell of a person. I know I was, and you lose hope or you can lose hope. Recovering that, I can’t tell you how uplifting that is. The nice thing about the case series is we actually had the opportunity for all 10 to include quotes from the patients, and actually compiled them in a substack, which I can send you in like, I just like bullet point of the ten so you can hear them talk about their own experiences.

But I get emotional just thinking about it. I’ll speak to mine because I know it the best. Like when I was 21, sitting in like a pal care ward, the youngest person there by decades, not really thinking much about my future, completely withdrawn from my friends. Dating was like entirely off the table. You don’t want to have a girl over and then have bloody diarrhea.

It’s not very romantic. Probably like thinking about giving up my position at Harvard Med because I just couldn’t even cope with like kind of laissez-faire, free time in my PhD, let alone medical school, which is quite rigorous. Like I really didn’t feel like I had life at all to then recover all of that at once with dietary therapy.

Now I, to be clear, I actually am not a carnivore. Nor was I carnivore in transitioning. I was just on a ketogenic diet, just as a point. But to recover that, get back your life as an athlete, get back your life as an academic, get back your life as a son and brother and friend and boyfriend, and all these things.

I don’t really have the words to express what that means in terms of mental health. I think the only way to really understand that is to either live it or to see a loved one live it. Yeah, no, this wasn’t a mental health paper. But I think implicit in the results were that the people’s, the patient’s quality of life including their mental health, was revolutionized in a way they could never have imagined.

That was the sense I got in interviewing these patients. 

Bret: 
Yeah, and I think that is such an important answer because you can check the boxes of how many times did you have diarrhea today? How bloody were they? What were your symptoms score?

And that will get to the treatment, but it doesn’t get to the whole treatment, the whole effect. And what you just did really does, about giving your life back and your mental health back, which I think is so important. So, the other part though, about what these patients found that you reported in this case series was the term remission.

And I would like, I would think that remission of Crohn’s, ulcerative colitis can come with very expensive, very aggressive medications or could be considered with surgery. Although, you can argue whether remission includes taking out your colon, if that really fits the definition of remission.

But to have none of those and still achieve remission, I would think would be pretty revolutionary. So, tell us about, of these 10. How many use the term remission? 

Nick: 
I would say remission is a fair term. They were using the term cure. I mean that’s how a passionate people feel about this.

Reported we had people, everybody had at least five months of remission to over five years. And I’ll be clear, this wasn’t, you said, does it really count if you have your colon removed or have surgery? Like we had patients who had like ileostomies and were still having problems. You can have these like last line surgeries and be on these high dose biologic and still not have effective control.

And we had lots of patients like that. They had been through three, four biologics, had surgery, been struggling with this for decades and still could not achieve remission. And this diet was the only thing that could do it. So, I think this is very profound. The patient certainly did. We even had, and I would drop the video, my pinned comment right now is like an ileostomy nurse talk.

She said, I watched the video and read the paper, and it made me cry because of just how much patients suffer even after they’ve had surgeries and they have ileostomies. So, I do think with all the caveats that this is a case series and has all the limitations of a case series, there is a provocation here for a therapy that could be revolutionary.

And while the clinician to be in me, or the clinician-in-training to me needs to say, this can’t be recommended to standard of care because we don’t have an RCT, yada, yada, yada. The patient in me knows for a fact that when you’re in that place and you maybe had surgeries or been on biologic and you’re absolutely hopeless, any hope is really meaningful.

And honestly, like what do you have to lose other than your colon, in terms of trying something like this? And even in saying that, I know people are going to be put off by the idea of recommending a carnivore diet, which we can dig into a little bit. But I do want to emphasize the precision with which we’re speaking here.

People will hear carnivore diet or any diet, and I think that there’s a tendency to paint with broad brush strokes and assume I’m making a claim about this being the best diet for humanity or longevity or whatever. I’m not saying any of that. I’m saying specifically for patients suffering with inflammatory bowel disease, let’s even say treatment refractory inflammatory bowel disease, physiologically, this makes a lot of sense.

And so for this use case, let’s start talking about this use case. I’m not talking about heart disease. I’m not talking about animal welfare. I’m not talking about climate. I’m talking about for inflammatory bowel disease, I think it’s reasonable to propose the hypothesis that a carnivore diet could be highly efficacious and very clinically responsible in this patient series.

Actually, I’ll bring up a funny, one comment that’s come up again and again in, on social media is, aren’t you worried about colorectal cancer in me now? I think the data on that are a little bit shaky, but my go-to reply has been, okay, we’re talking about inflammatory bowel disease.

What’s the relative risk of red meat intake versus active colitis for CRC? I will tell you, active colitis is a much higher risk factor, and chronic inflammation is a higher risk factor for heart disease as well. So, in this series of patients, not just these 10, but this specific-use case, I don’t think it’s actually that extreme to propose that this could be a reasonable intervention that someday could be standard of care.

Bret: 
Yeah, that’s such a great perspective and important to point out, like you said, who these patients were. That they were refractory to so many different types of therapy. So, I would like to think that any clinician reading this would be able to say, wow, these patients were at their wits end.

They tried everything and they got their lives back. Hooray, right? This is amazing. And yet, and a lot of people have responded that way, to be fair. A lot of people have, but yet, there are some who have responded, this is irresponsible. You can’t promote this. A carnivore diet is dangerous. It was just a case series.

You can start talking about it when you’ve done a randomized controlled trial, and really lashed out rather than appreciating the benefit that these patients have seen. And to be fair, you recognize all this in your paper. So, I want to touch on that a little bit and get your perspective on how you feel when you read that. Look, at missing the point in a way you could say, or if you feel there’s some truth to that. So, give me your perspective there. 

Nick: 
Yeah, over time I’ve developed a rather thick skin on social media. I think you have to develop an equipoise around it. And so for people who are like, this is just a case series and it’s selection bias. I’m like, yeah, it’s kinda the definition of a case series. We talk about selection bias in the paper and, okay, so we’re on the same page now. Let’s move forward from that.

I think, what I would say broadly, is you need to evaluate literature based on the objective it’s trying to accomplish. What are the questions it’s trying to answer? What is it saying? What is it’s not? What is it not saying? And so I don’t really see it as a comeback, per se, to say this is just a case series. Show me when you have an RCT. All that says to me is the person doesn’t, the person commenting, including the clinicians commenting, don’t understand the practicalities of doing this kind of research. This is the reasonable first step.

Nobody was going to come and give me 3 million, 4 million, $5 million to do the RCT that I want to do. If somebody did, I would never have done this case series. It would’ve been a moot point. Now that this is out there and getting talked about, and yes, provoking emotions, then you get the eyeballs and you have the proof of principle that then allows you to do the randomized control trial.

So, I fully acknowledge this selection bias here. Duh. I would say that doesn’t detract from the fact that these are real humans being helped. And like you said, can’t we just say hooray for these people? Now, let’s figure out what about these people made them responders and pursue further research so that we can scale these 10 saved lives to hopefully hundreds and thousands, acknowledging all the caveats, the research for those who then are a little bit more aggressive.

And just say things like, this isn’t even research. I have a game. This is probably not showing me in good light to say, but I’m going to be honest here and authentic and tell you what I do. Because what I usually do is look up their profile and also look up their research background, and I’ve quantified this in anticipation of this question.

I’ve had 12 comments to that extent from people who say that they’re a doctor and that can mean different things for different people. None of them had published more than two papers ever, and they were like, bottom line is like they didn’t actually have research experience. And they were reacting reflexively, often with a background of if they say, hashtag vegan doctor, hashtag whole food, plant-based, hashtag like vegan lifestyle.

It just, it’s very transparent bias, and I’m not saying anything negative about vegan. It’s just like it, the optics here. So, speaking to them now, the optics for you, having that profile and that research background and coming out without really addressing the content, but just reflexively reacting negatively to a carnivore diet.

You’re not pushing us down. You’re promoting us because the attack is just so weak, and obviously, knee jerk that I don’t really know what people think they’re accomplishing. I realize it might be cathartic for them, but like warning, you’re not a, you’re not like a speed bump. You’re a little bit of a springboard if you want to actually try to criticize the text.

Going beyond the limitations that we’ve already put out there, then let’s have a discussion about it. But the troll-y comments generally are the ones that are best for the algorithm and get the conversations going. They get the eyeballs on it to get the altmetric score up, to get attention to get funds for the research we want to do.

So, I’m telling the trolls that are helping us. If they want to keep helping us, go ahead. Bring it on. But for those who seriously want to platform nuance and have a conversation about what we’re saying, and especially what we’re not saying, i’m very happy to have those conversations. I have a lot of friends who are very pro-whole food, plant-based. And I can talk about the pros and cons of that versus carnivore diet. Again different contexts for different patients.

This doesn’t need to be tribal, but acknowledging the reality of social media, I’m not above capitalizing on pre-existing tribalism without, per se, contributing to it in order to get the resources I want to do research, I think will help people. 

Bret: 
Yeah, so if you believe whole food, plant-based is the right way to go, if you’re a clinician and a scientist, you still have to be open to other alternatives. And same if you believe carnivore is the right way to go. As a clinician and a scientist, you need to be open to alternatives. But this gets to another big topic of red meat. Just such a hot topic that red meat causes type 2 diabetes, red meat causes cancer, red meat causes heart disease.

These are beliefs that many in the medical field hold, which I would maintain are completely false and based on very weak evidence. And you recently made other posts, and evaluated other articles about this. There’s a lot to get into, but how is that concept of red meat causes these diseases been chipped away at recently or with on further more detailed analysis? Really doesn’t hold up. 

Nick: 
Yeah, I think it’s a little grandiose to even imagine I’m chipping away at it. Like we had, so this came as a trifecta. We had our little dinky case series come out right after a Nature Metabolism, which is a high-tier journal piece on heme iron in red meat and diabetes type 2 diabetes, and then a Lancet, a Lancet Journal article on a meta-analysis of 31 cohorts and red meat and diabetes.

Now, to be very clear, case series for Interior Nutrition, Nature Metabolism, and Lancet Publications, like in terms of perceived research hierarchy and academics, these things could not be like a more stark contrast. I’ll fully admit that. So, not trying to be like grandiose here with teeing them up as equals, per se. But again, it’s about what are the data and what are they claiming and what are the legitimate caveats?

So, when you go to these top-tier papers that are coming out in top-tier journals, you expect top-tier rigorous results. They weren’t, to be clear. They actually weren’t bad papers, but the way they get twisted and manipulated and into the idea that red meat causes diabetes. I would agree. I think it’s beyond, it’s very weak, and basically maybe a statistical quirk and a clinical nothing burger.

Let’s take them one by one. So, there was the one on heme iron intake and type 2 diabetes. You read the paper. Now, this is Nature Metabolism. One of my favorite journals, actually. I love that journal. I was a little disappointed to see this paper because it’s like, alright, high level, the effect size they observed, which is an association was very small or pretty small.

It was a hazardous ratio of 1.26, which is pretty small. By comparison, the risk ratio for BMI over 30 for type 2 diabetes is 4.44. In addition to that, the high heme iron group had lower physical activity, more obesity, higher BMI and more smoking. Now, you can do or try to do statistical adjustments for these.

I really don’t think, and you can ask statisticians like my friend, Professor Adrian Soto-Mota. He would also say, look, you can’t adjust away these things confidently. So, when you combine these big confounders with a small effect size and kind of questionable biological plausibility, I’m left at, I think this is massaging the data to tell a narrative that maybe really isn’t there.

Or let’s put it this way, I definitely do not think that heme iron reduction, including red meat reduction, is low hanging fruit for type 2 diabetes prevention. So, if you’re going to have a villain in this story, reduce the refined carbohydrates and the sugar and do whatever you need to reverse metabolic syndrome and get your weight to a healthy level.

And if that includes eating more red meat, that’s fine. With respect to type 2 diabetes outcomes, even if there is something here, and I’m not ruling out that possibility to be clear, I’m open to hypotheses. And I could come up with mechanisms, and they mentioned a few by which like, oh, too much heme iron could cause reactive oxygen species and oxidative stress and these different systems, yada, yada. So, it’s plausible, but the effect size is tiny, and there are major confounders. So, I don’t make much of it. The other paper, which was arguably the bigger newspaper, the one in The Lancet, was looking at the association between red meat intake and type 2 diabetes. So, directly red meat and type 2 diabetes.

And the inevitable thing was there was a stream of headlines from CNN and The New York Post and Healthline, whatever. Some are making causal claims about red meat increasing type 2 diabetes risk because it’s in The Lancet. And then also on social media, you have academics, like Eric Topol and others, who I have nothing against, but who were doing this thing I called abstract bombing, where they take the abstract or the title, and they like just bomb it to their hundreds of thousands of followers and then make a short claim in line with their pre-existing worldview and the title, maybe with a clip from the abstract. Which for something like this, I think, is doing a disservice because when you look at that paper, too, this one had even maybe larger limitations.

The effect size was tiny, even smaller. The hazards ratio for all 31 cohorts was 1.10. It was tiny, and this is 31 cohorts. There was a lot of cohort heterogeneity such that 21 of the 31 actually showed no effect. So, the majority showed no effect whatsoever. So, thinking about this like in almost an a priori way.

Imagine if you had to, imagine you wanted to show an association between red meat intake and type 2 diabetes. So, you ran analyses. And you ran it on one cohort, and there was no effect. You ran it on another cohort, there was no effect. You ran it on a third cohort, there’s a little effect. And then, all together, they balanced out to having a tiny little effect, and that was your result.

Like what do you make of that? Then on top of the fact that still again, there were confounders, I forget exactly what I think obesity was. Again, a confounder, you can look in my analysis for these, but there were big confounders. A lot of study heterogeneity and a tiny effect. You combine those and you’re left, I think, with really not much there. Not much to make any news out of.

And even in the discussion of that paper, they acknowledged there wasn’t really a clear underlying mechanism. They’re like, eh, it’s a little bit hazy. And I’m like, with all the resources spent on studying this topic, and quite honestly, the effort made to make red meat a scapegoat, you think you’d have something a little bit better in terms of a biological possibility statement.

So, you can combine those four things: tiny effect size, a lot of heterogeneity, most studies showing no effect, confounders and weak biological plausibility. And I’m just left with like, guys, who’s really thinking red meat causes type 2 diabetes right now? Like again, precision of the discussion.

We can actually talk separately about colorectal cancer or heart disease. Again, I think the data are a little bit shaky there. But I’ll say right now, where the news cycle is at speaking about these specific claims, I don’t think there’s much there. And we have to question the incentive structure that permits one, these papers to get published in top-tier journals.

And then two, the incentive structure of taking these top-tier journal research publications and then manifesting them in these absurd research headlines, like red meat increases your risk of diabetes by 15%, that then feedback to create a social psyche and a confirmation bias that then propagates or incentivizes more research to get into these top-tier journals somehow.

And it just cycles and cycles. Because, quite honestly, this is all built on incentive structure in friends of friends, and the fact that the peer review process is not a meritocracy, which any academic knows. That’s not a controversial statement.

So, it’s difficult because as these three papers come out, like I don’t fancy myself the red meat defender. Honestly, I prefer fish. I could be a pescatarian. I don’t really care. But the science is just the science. And I just see these papers come out and I find them, the conversations around them, disingenuous.

And so, I feel welcome to comment on it. And the shocking thing, maybe not the shocking thing, I put these criticisms out there on Twitter on my substack. I tag in people, like I mentioned, Eric Topol, Eric or other people, and I’m like, here are my criticisms. I’m not jumping up and down saying red meat is a superfood or anything.

I’m like, just hear the criticisms of the literature. Do you want to engage into discussion about the criticisms and your perspectives on them? I’ve had zero, a flat zero, reply in any systematic way to my points. And if this is major news that academics want to get behind, then you should be able to address the criticisms and have an elevated discussion about the limitations of these data.

And maybe even we can have it at his broader conversation of the overall healthfulness of red meat? So, I welcome speaking with Eric or Simon Hill or Peter Attia. Actually, I saw Peter posted on it. I think his interpretation was similar to mine, although I didn’t actually, it was based on a reading his title. There, I’m a hypocrit.

But it’s, let’s just have a discussion about these things because i’m getting a little bit tired of the diet tribalism. And as much as I enjoy making mayhem and touching on provocative topics, it needs to be followed. Like the legit bait, thumbnail and title needs to be followed by a pretty authentic intellectual engagement.

And sometimes I have trouble finding people who are actually willing to step up and engage in those. 

Bret: 
Yeah, that’s such a thoughtful answer. And like you said, the timing of your case series with these two papers coming out is, in a way, is it really points out the difference in overall reaction, whether it’s from news media, from clinicians, from social media, whatever the case may be.

The complete difference in how critical you can be about the study, about the weaknesses, about the outcome, when it’s something that fits the common narrative or something that doesn’t fit the common narrative. And I think that’s been blatantly obvious, which shows that if you want to help explore something like a carnivore diet for treatment of certain medical conditions, there is an uphill battle because you’re fighting that bias and that difference in how people react.

I remember asking you this question about the lean mouse hyper-responder paper, but what do you hope is the result? You’ve published this 10-person case series. What do you hope people will walk away with? The researcher? The clinician? The individual to say how do I, what happens next? 

Nick: 
I would say one, can we just get on board being excited about people who are healing themselves?

I don’t care if it’s carnivore diet or a vegan diet. If a human being was suffering and they’re doing better, let’s just celebrate that. Let’s start there. And then getting to the scientific elements of it, is it ask yourself, is it a legitimate question to ask whether a ketogenic carnivore diet, given the biological plausibility I explained earlier in the clinical narratives we have building, could be effective treatment for specifically inflammatory bowel disease?

Making full effort to leave your biases at the door with respect to red meat and take another issues. And what I would say is for those really wanting to make an effort beyond just this case series but using it as a case in point, really try to hear when someone’s speaking to you. Or when you’re speaking, really try to hone in precisely on the topic at hand and notice when topics might be bleeding into each other through pre-existing biases and emotions.

Red meat is a great example because people feel so strongly about important topics, like climate change and animal welfare. And I realized that provokes emotions and that all these things should be part of a broader discussion. But we can’t really get to a good, broader discussion until we start with a precise discussions.

So, when a paper comes out like ours or like the ones with the red meat and type 2 diabetes, evaluate what is this piece of content saying? And is this in isolation a fair claim? And what are the limitations? Be that selection bias in our study, our case series, or tiny effect size combined with major confounders and study heterogeneity in the Nature Metabolism and Lancet papers.

There is no perfect study. We can be very forward about what the limitations are, what’s being claimed, what’s not. And then really do our best to steelman on the other side and just have authentic conversations so we can move this forward. And, hopefully, everybody wins, or at least everybody learns. 

Bret: 
Yeah, and I would just add to that move it forward in ways to study it more rigorously, and like you’ve proposed for carnivore for inflammatory bowel disease. But we need to have that same discussion about a more rigorous evaluation for red meat and type 2 diabetes and red meat in cancer and heart disease.

Those need to be studied much more rigorously as well. That’s my 2 cents there. But thank you so much for joining me. Thank you so much for your contribution to the literature and to, and for asking the questions. And celebrating people’s successes. And asking the question of how we can do this to help more people?

I think that’s so important. So thank you so much. 

Nick: 
Thank you so much, Bret. 

Bret: 
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