Good Energy: The Surprising Connection Between Metabolism and Limitless Health

Introduction

Good Energy begins with a manifesto about the causes of poor health in the modern world, and the flaws in how we approach healthcare in the American medical system, wrapped in a touching story about the authors’ mother’s health problems. It argues that we don’t recognize the root cause of ill health until it’s causing disease, then we treat the disease rather than the root cause. The book then offers a suite of diet and lifestyle advice intended to solve the problem. 

We decided to review this book because it’s particularly important at this time in US history. The book’s main author, Casey Means, MD, is the current nominee for US surgeon general, the nation’s chief public health spokesperson. The book’s second author, Calley Means, is a health entrepreneur and social media firebrand who is an advisor of Robert F. Kennedy, secretary of the US Department of Health and Human Services. As such, they hold considerable influence over government public health policy. Both authors are part of the “Make America Healthy Again” movement led by Kennedy, which is often at odds with the public health and medical communities.

Scientific Accuracy

We reviewed three representative claims in Good Energy: 

1. Poor metabolic health is the cause of cardiovascular disease.
2. Poor metabolic health is the cause of depression.
3. Eating added sugar contributes to poor metabolic health.

We chose the first claim because the book argues that “bad energy” (poor metabolic health) causes cardiovascular disease, and cardiovascular disease is the leading cause of death in the US and globally. We chose the second claim because we wanted to evaluate the book’s claims about mental health, and depression is a common and highly researched mental health condition. We chose the third claim because refined added sugar is the first item listed under “bad energy foods” on page 170, and the same page argues that it may be the “worst offender” that leads to “bad energy”.

It wasn’t always clear to us how the book defines “good/bad energy”. On page xii, it says “Good Energy is also known as metabolic health”. That’s the definition we use in this review, because it’s the most explicit definition we found in the book. At times it seemed like the book was implying that “good energy” means mitochondrial function. Mitochondrial function isn’t quite the same as metabolic health, and although differences in mitochondrial function are correlated with many common diseases, the evidence that it causes them isn’t very strong in most cases. 

What is metabolic health? It typically refers to how the body distributes and uses energy sources. A person who is in good metabolic health has healthy levels of sugar (glucose) and fat (triglycerides) in the blood without requiring medication, and high sensitivity to the energy-regulating hormone insulin. A person who is not in good metabolic health has high levels of sugar and/or fat in the blood, may have the metabolic syndrome, type 2 diabetes or prediabetes, and has low insulin sensitivity.

Good Energy received an average scientific accuracy score of 3 out of 4 (75%), which means it’s moderately well supported by evidence overall.

The first claim, that poor metabolic health is the cause of cardiovascular disease, received a score of 3 out of 4. That means it’s moderately well supported by current evidence. Metabolic health is a major factor in cardiovascular disease risk, which is why people who have the metabolic syndrome (poor metabolic health) have 2.4 times higher risk of cardiovascular events than people in better metabolic health. That said, the risk that comes from some cardiovascular risk factors like LDL-cholesterol and Lp(a) is partially or entirely independent of metabolic health, so “bad energy” can’t explain everything.

The second claim, that poor metabolic health is the cause of depression, received a score of 2 out of 4. That means it’s weakly supported by current evidence. Obesity and the metabolic syndrome (a cluster of features indicating poor metabolic health) are associated with a higher risk of depression, but causality probably goes in both directions. In other words, obesity contributes to depression but depression also contributes to obesity. Also, these associations are dwarfed by the effects of other factors not mentioned in Good Energy, like stressful life events and genetics.

The third claim, that eating added sugar contributes to poor metabolic health, received a score of 4 out of 4. That means it’s strongly supported by current evidence. Added sugar tends to worsen metabolic health, and studies suggest this is mostly because it encourages us to eat/drink more calories than we need. We think Good Energy overstates the case against sugar, but it does clearly acknowledge that other factors in the diet and lifestyle are also important, so we didn’t lower its score for that.

Good Energy had many chances to say that the causes of disease are often complex and not fully understood, and metabolic health is important but not the only cause of disease, low energy, and low mood. But it generally glossed over this complexity and uncertainty, and confidently stuck to the story that nearly all physical and mental health problems are caused by poor metabolic health. This simplistic theory of health is why it fell short of a higher scientific accuracy score. 

Expand the scientific accuracy scoring section below for more detailed discussion, supporting quotes, and citations.

Scoring for Scientific Accuracy

Reference Accuracy

Good Energy received a reference accuracy score of 3.1 out of 4 (78%),* meaning its references support its claims moderately well on average.

In most cases, the book accurately represents the references it cites, and the references strongly support the passage in the book. In cases where a reference got a lower score, it was either because the book represented the reference inaccurately, or the book represented the reference accurately but the reference itself wasn’t convincing.

One example of the former is that Good Energy cites a paper to support this statement: “compared to one hundred years ago, we are consuming astronomically more sugar…” (p. xiv). However, the paper itself reports that added sugar intake in the US today is similar to one hundred years ago (figure 10).

In some sections, the book relies heavily on information from Mark Hyman, MD, and Robert Lustig, MD. Dr. Hyman’s books The Pegan Diet and Eat Fat Get Thin didn’t fare very well in our scoring, with overall scores of 59% and 48%. Dr. Lustig’s book Metabolical also didn’t fare very well, earning an overall score of 55%. Despite partially relying on information from these authors, Good Energy has significantly higher reference accuracy.

The references for Good Energy aren’t found in the book itself. Instead, they’re found in a file on Dr. Means’s website. We prefer references in the book itself because that makes it easier to fact-check the book’s claims and access can never be withdrawn, but we were able to access the references without any difficulty so we didn’t lower the book’s score for it.

*We used a true random number generator to choose a chapter, then a reference from that chapter. We repeated that ten times, and evaluated how well each reference supports the associated claim in the book.

Scoring for Reference Accuracy

Healthfulness

Good Energy received a healthfulness score of 3.3 out of 4 (83%), meaning we think its advice is quite healthy overall. We think following the program would improve physical and mental health in most people. That said, the book fell short of a perfect score because the program is too demanding for most people to stick with long-term. The book also overpromises on results.

The book recommends an intensive diet and lifestyle overhaul that includes a whole-food-based diet free of added sugars and refined grains, lots of physical activity, sleep guidelines, meditation, cold and heat exposure, using a high-end water filter, and swapping out personal care products. The book recommends eating organic foods at a minimum, but ideally “regeneratively grown” foods that meet an even higher standard of farming practices. The advice is conveyed in 25 “Good Energy habits”.

Many of these habits are evidence-based and should improve physical and mental health. For example:

• The diet excludes highly processed foods, which helps with weight management, and probably also metabolic health and cardiovascular health (although the evidence for the last two isn’t currently strong). 
• The diet is high in protein and fiber, which probably help with weight management and cardiovascular health, though the evidence isn’t strong for all of those outcomes.
• Aerobic exercise, walking, and resistance training improve metabolic and cardiovascular health and may help with weight management (the 2018 Physical Activity Guidelines Advisory Committee Scientific Report for US HHS reviews the evidence).
• Meditation can probably improve mental health, with moderate-size benefits for anxiety and depression in the average trial, but most of the studies were at high risk of bias so it’s hard to be sure.

That said, some of the advice is probably unnecessary and may make the Good Energy program harder to follow. For example, eating organic foods does reduce the amount of pesticides we eat, but pesticide exposure from conventional foods is usually within safe limits, and there isn’t convincing evidence that eating organic foods has a positive impact on health.

The book makes sky-high promises about how effective its advice is, implying that it can prevent or cure virtually any common disease and make people feel “incredible” (front flap). These claims go far beyond the evidence, oversimplifying diseases and mental states that have multiple causes, often aren’t fully understood, and may not be completely avoidable no matter what we do.

The reason the book lost healthfulness points is that we think few people will stick to its demanding advice in the long run. Tallying up the time a person would need to do all 25 “Good Energy habits”, we estimate they would take 10-20 hours per week. It would also be expensive to eat only organic or “regeneratively grown” foods, buy a high-end water filter, and follow the other advice in the book.

For more detail, expand the healthfulness scoring section below.

Scoring for Healthfulness

Most unusual claim

Good Energy contains a few surprising claims, but we think this one is especially important to the book’s argument that the American medical system isn’t serving our health very well: “In fact, if you pull out deaths from the top eight infectious diseases (which were decreased by antibiotics) from historical data, life expectancy rates haven’t improved much in the past 120 years…” (p. 71).

Based on the evidence we reviewed, the claim is incorrect. It is true that the reduction in infectious disease deaths caused most of the 30-year gain in life expectancy in the US since 1900. However, the 9-year gain that happened since 1960 was mostly due to a reduction in deaths from non-infectious causes like heart attacks. We think a 9-year gain in life expectancy is large, contrary to the claim that “life expectancy rates haven’t improved much”. Additionally, much of the 9-year gain in life expectancy since 1960 has been due to medical advances.

In 1900, life expectancy in the US was about 49 years. Today, it’s about 79 years – a gain of about 30 years. See this chart for the data.

Much of that 30-year gain happened because we conquered deadly diseases like pneumonia/influenza, tuberculosis, diphtheria, pertussis, measles, typhoid, dysentery, and syphilis. This resulted from a combination of water treatment, sanitation (flush toilets), vaccines, antibiotics, and better hospital care for sick people. Antibiotics can’t be the main explanation because most of the decline happened before antibiotics came into use in the 1940s. 

Between 1900 and 1960, infectious disease deaths declined by about 92%, then plateaued (see figure 1 of this paper). The reduction in infectious disease deaths was basically done by 1960, with only small changes after that.

Yet we’ve gained 9 years of life expectancy since 1960. That can’t be explained by changes in infectious disease deaths. By 1960, non-infectious diseases like heart disease and cancer were the most common causes of death, as they are today. According to Cutler, Deaton, and Lleras-Muney, most of the gain in life expectancy since 1960 was due to a reduction in cardiovascular events like heart attacks and strokes. This shouldn’t be surprising, since cardiovascular deaths are the most common cause of death in the US, and they’ve declined by about two-thirds since 1970.

Most of that reduction in cardiovascular disease risk, Cutler, Deaton, and Lleras-Muney argue, was due to medical advances in the prevention and treatment of cardiovascular disease. A separate analysis concludes that about half the decline in coronary heart disease deaths between 1980 and 2000 was due to improved medical care. Some of the remaining gain in life expectancy came from better neonatal care – fewer newborns dying in hospitals. 

So it seems that the US medical system has in fact increased our life expectancy significantly over the last 120 years, via better care for infectious diseases, better prevention and treatment of cardiovascular disease, and better newborn care.

Other

The authors are very intense about optimizing health. While we aren’t judging anyone’s lifestyle choices, we think they may underestimate how hard it would be for the average person to follow their program, particularly people with families.

Here are a few examples from the book that illustrate this:

• At least one of the authors plans almost all of their social activities around “Good Energy habits”. Page 282: “When I have visitors, I plan almost every event to check off ‘Good Energy’ boxes, like taking a neighborhood walk or local hike, walking through a park or botanical garden, taking friends to try cold plunging in the ocean or a local body of water, doing breathwork together, going to a concert where we’ll be standing, streaming an online workout class on the TV and doing it together, mountain biking, paddleboarding, snow-shoeing, or going to a meditative sound bath together.”
• The book recommends complete avoidance of added sugar, refined grains, and seed oils (like canola oil), as if they were acute toxins. For example, one of the questions in the “Good Energy Baseline Quiz” on page 270 is “I am certain that I have consumed no high-fructose corn syrup in the last month”. If you had eaten a single sweetened yogurt in the last month, or maybe were unsure of whether you had eaten high-fructose corn syrup once, you would lose that point on the quiz.
• On page 204, the book recommends “intensive pet training or finding a new home for your pet” if it’s disrupting your sleep.
• In the healthfulness section, we estimate that following the book’s guidance would take about 10-20 hours per week, assuming you consolidate some activities. Expand the healthfulness scoring section for more detail.

Conclusion

Good Energy is based on a valid argument: poor metabolic health is a major cause of the diseases that plague us in the modern world. Yet it takes the argument too far, arguing that nearly all disease is caused by poor metabolic health, and improving metabolic health can prevent and cure nearly any disease. In some cases, like type 2 diabetes, this is mostly correct. In other cases, like cardiovascular disease and depression, we know the causes are more complex than that. In yet other cases, we simply don’t know enough to say whether poor metabolic health is the key driver. 

Despite that, the book scored fairly well in scientific accuracy and reference accuracy, and very well in healthfulness. While the book’s theory of disease is overzealous, its diet and lifestyle advice is mostly solid – if you can stick with it.

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