Insulin: The Culprit of Chronic Disease with Dr. Ben Bikman

Welcome to Y Health, a podcast brought to you by the BYU Public Health Department. I'm Dr. Cougar Hall, a professor here at Brigham Young University. Whether you are a student, parent, or BYU fan, this podcast will help you navigate the world of public health. Our podcast strives to help individuals receive accurate information regarding public health. So whether it's global or local, we will discuss how it pertains to you. Just kick back and relax as we talk about Y Health. Dr. Benjamin Bikman, it's just an absolute pleasure to have you on the podcast this morning. How are you doing?

Cougar, I'm doing well, brother. Good morning.

I really appreciate your time. You're about the busiest, hardworkingest guy that I know. I really appreciate you taking some time.

My pleasure. Yeah, glad to do it.

So with our podcast, I typically— the last question I ask guests is, what are you reading right now? And interestingly enough, I'm reading your book right now. So I thought we should just start with that. And I do want to give you a chance to talk about your book and about all the good things that you're doing right now. But in fact, over the weekend, I just for a second time went through Why We Get Sick. And I think I first listened almost a year ago. I do have to tell you, I absolutely love the narration of this book.

You know, there's times where I listen to the audio.

I actually, yeah, yeah, I, I, I often return audio to Audible. I'm like, oh, I can't listen to a book from this voice. I think 2 minutes in I was like, okay, this is the best narration I've ever heard.

There's a funny story behind this. Is there? So when this all happened, it was during lockdown and they had initially mentioned that I would be able to narrate it, and I was very eager to do it. It was kind of a dream come true, the idea of doing that. But all the recording studios were down, they were locked down, and so I couldn't do it. And so they sent me some samples of readers, some sample narrators, and listening to them, and the other, I think there were 3 or 4 options, the other options were all very, insulin resistance is the pandemic you've never heard of, very dramatic. And this guy was just so much more conversational, and I thought, I'm going with this guy. Oh yeah. And come to find out, he was an actor in a movie that you and I would have both seen when we were younger. Adventures in Babysitting.

Oh, really?

He's the, like, main boyfriend in it anyway. So he's— he was spectacular. But I'm glad you liked it. I liked his voice a lot, too.

Love the book. I love the content. And that's where we want to go here in just a moment. But man, the presentation on Audible. So get a hard copy. But my goodness, if you're an Audible person, if you like books on tape or whatever the term is, this is the best.

Yeah, he was great.

Terrific. Tell us about the book. First, give me your background, Ben, because you're a faculty member here in the Department of Life Sciences at BYU. Tell us a little bit about your department, your education, how you wound up in a place where you are the voice for insulin resistance in America right now.

Yeah, yeah, well, that's nice of you to say. Yes, so it might be interesting for people to even wonder why on earth someone would devote their career to studying insulin resistance, and we'll get into that, but the statistics are sobering and they certainly warrant experts, you know, people focusing on that. My, my career here is, is, has been a wonderful journey getting here. I started my undergraduate, my academic career started here I'm from a little town in Alberta, all those little LDS towns up there, born and raised, served a mission in the mid-'90s in Russia, came home, met a girl, she served her mission in the same mission I'd just come home from in Russia. And then we got married, we finished our undergraduates here at BYU. And then it was, as you know, the academic journey. It was Colorado, then North Carolina for PhD, and then Singapore, around the world for a postdoc. A fellowship with Duke Medical School. It's an interesting thing for me to look back because I don't know if it was divine direction. I really don't. I don't know whether it was divine direction or just fortunate stumbling, but I had, during my master's degree, came across a paper that described how fat cells, when they grow, start to secrete pro-inflammatory proteins commonly called cytokines. And that was the beginning of my interest in in the journey that I'm still on to this day, it was stumbling across this paper as a master's student, which detailed how fat cells promote inflammation and how it was the inflammation, and this was the focus of my PhD work and my postdoc, how inflammation causes insulin resistance.

I think most of us are well aware of the connection with insulin and insulin resistance to type 2 diabetes, what we used to call adult onset diabetes, which we can no longer afford to call it that, unfortunately.

No, not when you have 4-year-olds getting it. No.

No, and as a recovering high school teacher, having teenagers, adolescents that are not just pre-diabetic but actually diabetic is just absolutely heartbreaking. But on every page of this book, I'm introduced to another— I'm like, oh, I didn't associate that with Alzheimer's. I didn't associate that with migraines, with skin conditions, with asthma. It's just remarkable. Love the section on reproductive health.

Yeah.

For both men and women.

That's right. Yeah, so that's something I feel very passionate about. Maybe before I get into that, let me just briefly pause and just explain what insulin resistance is.

Oh, thank you.

Because I've mentioned the sobering statistic that it's the most common disorder. In fact, the scope of it can't be overstated. Insulin resistance, or this kind of metabolic syndrome, which is— metabolic syndrome is the modern name for what used to be called the insulin resistance syndrome. A group out of the University of North Carolina, a couple years ago, they published a report concluding that 88% of US adults were considered metabolically unfit. In other words, in their words, literally, they're, quote, "An alarmingly low level of metabolic fitness in American adults." And they based that conclusion on the aspects of the metabolic syndrome, which is this kind of constellation or multifaceted disorder. Again, all of which are derivative of insulin resistance, which is why it used to be called the insulin resistance syndrome. But to just state that again, 88%, almost 9 in 10 of us US adults are insulin resistant. Now, it's very popular in the United States to think that the United States is the worst place in the world, and it is not. We know that even as sobering as insulin resistance statistics are here, we are not the worst. I have given talks about insulin resistance literally around the world. In fact, the worst places in the world with regards to metabolic health is the Middle East. And then other, even above the US, Mexico is even worse than the United States is. Some countries in Southeast Asia, like Singapore, where I did my fellowship, is worse statistically than the United States is. So this is not just an American problem. It is a global problem. And it is entirely a result of how we live our lives. And we can get into that more later, but maybe it'll flow from this conversation of what to do about it. But then, just to define it, insulin resistance is a coin with two sides. On one side of the coin is this phenomenon where the hormone insulin isn't working as well as it did before at some cells of the body. And I'm emphasizing that, that's italicized, at some cells of the body, because some of the body cells are responding to insulin as well as they ever did. And I'll, I'll put this in context in just a moment. But so that's the first side of the coin. When we turn that coin over, the other side is elevated insulin levels in the blood, what we would call hyperinsulinemia, but again, just chronically elevated insulin. Those two problems will always, always occur together. You cannot have one without the other. Now, to put these in context and why they both matter, let's mention infertility, because that's one of the more unexpected connections to insulin resistance. On one hand, we have polycystic ovary syndrome, which is the most common form of infertility in females. That is a disease of too much insulin. In her body, relative to what insulin levels should be, her insulin is too high. And among insulin's myriad effects is that it inhibits the conversion of testosterone into estrogens. It's a little-known fact that all estrogens were once testosterone in men and women. They're converted. It's converted from testosterone. Insulin inhibits that conversion. And so now you have her ovaries who are attempting to release a lot of estrogens to maintain a normal ovulatory cycle, and yet insulin is preventing the ovaries from doing that conversion. And thus, her testosterone levels are too high and her estrogen levels are relatively too low, and she fails to have a normal ovulatory cycle, and the result of that is polycystic ovary syndrome. In men, the most common form of infertility is erectile dysfunction. In this case, it's not a disease of the hyperinsulinemia per se, it's the insulin resistance. In normal situations, insulin is flowing through the blood vessels and it activates this process called vasodilation. In other words, expanding the blood vessels. That's necessary for normal erectile function. When the blood vessels start to become insulin resistant, now, despite insulin's efforts to try to induce this growth of the blood vessels and enhance blood flow, the blood vessels stay constricted, they don't dilate, and thus he has erectile dysfunction. So these two forms of infertility, one in the woman, which is itself a problem of the hyperinsulinemia, one in the man, which is itself a problem of the insulin resistance, but they're both in fact coming from the same root problem, which is insulin resistance. Again, which is the coin with two sides. That is insulin resistance. So with all of that in mind, you'd asked, and it's taken me a long time to get to it. No, you're great. What do we do about it? What's the solution to it? Well, I like to explain that there are three primary causes of insulin resistance. Now, I'm emphasizing the word primary because I would say that there are other secondary causes. When I invoke the word primary, I have in my mind that these are the causes that I will explain in a moment have been proven in isolated cells. You know, like up in my lab, we're growing fat cells in little Petri dishes, for example. So in isolated cell cultures, which is a Petri dish, or in laboratory rodents, like in mice or rats, and in humans at the kind of peak of all experimental model and the peak of all life form. So all three of those commonly used biomedical models, we, we can cause insulin resistance in three different ways. The first one is stress. Now when I say stress, people are thinking of this big vague idea, but when I, when I say it, I mean increased levels of stress hormones because there is no stress in the body unless cortisol and/or adrenaline are elevated. Those are the stress hormones that are eliciting the stress response in all of its infamy. Those hormones, in addition to causing the stress response, like the increased sweating, the elevated heart rate, the increased blood glucose, they also directly antagonize insulin. So if I took, Cougar, you came to the lab and we injected a dose of cortisol, I could determine that you were insulin resistant in about 30 minutes, demonstrable insulin resistance, same with adrenaline. So stress is a cause of insulin resistance. The next one is one I'd mentioned at the beginning, which is inflammation. This has been a very strong area of research for me over the past 10, 15 years. Well, yeah, 15, 20 years actually. And it's really borne out consistently that when a cell has activated its immune pathways, which we would call inflammation, it starts to work against insulin. And thus the cell has become insulin resistant. So those are two causes. And then the third one is chronically elevated insulin. Now that one sounds a little strange. I'll come back to that one in a moment. But if we were imagining all of these things as 3 levers on the wall, and they're both turned on, all 3 of them are turned on, and we would say to someone, alright, here's the lever that is controlling your stress. Well, that is a hard lever to grasp. You know, if you and I were talking to some friends, and they tell me they're insulin resistant, and I say, well, your stress levels are too high. They say, "Well, great, Ben. How do I lower stress levels?" Well, it's not so easy. You know, that's a slippery lever, although I would say the low-hanging fruit is improving sleep habits. But even still, it's hard to control stress because there are so many things that push it up. On the next lever, as we go to the side, we would say, "Okay, here's the inflammation lever." "All right," someone would ask, "well, how do I control my inflammation?" Well, that's a hard answer. Because we don't know what might be happening in that person's body. Is there some autoimmunity that we don't know about? Is there some food sensitivity that we don't know about? It's difficult. And so once again, that's a slippery lever to really grasp and pull down. When we come to the last lever, the elevated insulin levels, that one we can firmly grasp with both hands and start pulling it down immediately. I have devoted more of my time in recent years to that lever because I think it has so much greater potential to elicit benefits. You know, as much as I had spent time studying inflammation and even stress hormones as causes of insulin resistance, as I was imagining how would I best propose that someone address insulin resistance, I had to come back to chronically elevated insulin. And people listening might be puzzled at what I'm saying if they're paying attention, because I just got done saying that elevated insulin levels are a feature of insulin resistance. And now I'm saying that they're also a primary, and I would say even the primary cause. Well, that's true, and it is reflective of a fundamental biological principle. Too much of something will recall— will cause a resistance to that something, a resistance. And this is— it's— I say it's a fundamental biological principle. I can say that in this kind of podcast. I can say it's also a spiritual principle. When the, when the soul is exposed to a noxious stimulus, it starts to try to become insensitized to that stimulus. And so the— whatever it is, we need more and more of it to elicit what used to be, you know, to elicit that comparable result, that, that response to it. Insulin is no exception. And so when the body is constantly flooded with insulin, it starts to become resistant to it, which feeds more insulin being produced, and it becomes a vicious cycle. But that then brings us, you know, finally getting to what can we do about it? And that was those clever little mnemonic sort of devices that I'd created, which was control carbohydrates. And that's the order I put it in: control carbohydrates, prioritize protein, and don't fear fat. I start with the control carbohydrate. To me, that is pillar number one. I think because we've gotten that one so wrong, and it is so— it is such a metabolic offense because carbohydrates are the food that will elicit the greatest spike in insulin. So when someone goes and drinks a soda, a sugary soda pop— diet soda actually wouldn't do this— so sugar soda, they drink that and their insulin is going to skyrocket, and it's going to stay elevated for at least 2 hours and the more insulin resistant they get, it could be elevated for up to 4 hours. Wow. So a long time. And unfortunately, we've created this perfect storm. So someone wakes up in the morning, insulin has slowly been coming down all night, and now they've finally gotten low insulin levels right around the time they're waking up. And what do we do? Certainly here in the US, but it's also abroad, we wake up and we eat a bunch of starchy, sugary junk food. It's almost totally dessert all morning. So we eat this starchy, sugary junk and our insulin and our glucose levels skyrocket. Well, at about 2 hours in, insulin has kind of reached its peak. It's making its way down, and wouldn't you know it, now it's time for a mid-morning snack. And so we bump it up again. We bump it up again at lunch, and then a mid-afternoon snack, and then dinner, and then an evening snack. So the average individual is living literally every waking moment in a state of elevated insulin. Yeah. That is driving insulin resistance. And so my view is, all right, the first offender is these refined carbohydrates that we're eating, all this sugar we're dumping in everything we're drinking, or the starchy sugary bagel that we ate, or the starchy sugary cereal that we ate. It's— that is— and especially in the LDS culture, we justify poor eating habits oddly through the lens of the Word of Wisdom. I believe that many people will defend their unhealthy habits because they will tell themselves, well, at least it's not breaking the Word of Wisdom as they define it, as they have perceived it to be in their own mind. So control carbohydrates. In my view on it is don't get your carbohydrates from bags and boxes with barcodes. That's my simple statement on it. If it's fruits and vegetables, love it. Eat 'em, eat 'em. Don't drink 'em. But eat them the way God intended. If he wanted us to drink apples, that's— it would have— they would have come from a liquid form from the tree, you know. In our hubris, we've adjusted these things. And then the next rule is prioritize protein. It is essential that we eat enough protein, and the older we get, the more we need. Actually, this goes against what a lot of people think. We become less capable at turning dietary protein into the amino acids that get incorporated into muscle and bone. And so oddly, or in opposition to what many people think, we need more protein as we age. And the simple reality of protein, although it is not popular to say this, and we— I'll come back to this when we talk about the Word of Wisdom— um, animal protein is superior to plant protein, full stop. Now, people may have various reasons for wanting to eat one over the other, but it doesn't change the reality that animal protein is superior for humans to consume compared to any plant protein. And then the final rule is don't fear fat. And that was meant to be— it's kind of addressing your own, you know, sort of stated fear that you just can't shake, which is we have been raised thinking fat is the demon. And the reality is it is essential. We need it. It is deeply nutritious. It is very satiating. It helps us feel full. And my sentiment on it is don't be afraid of it, but don't have a love affair with it. Let fat come with the protein that you're prioritizing, because in nature there is literally no exception to this. And I don't use the term literally too liberally like kids do these days. There's literally no exception in nature. If it's a protein, it has come with fat. That's how we should eat it. When fat comes with protein, we digest the protein better and it is more anabolic at muscle. This has been proven in humans. Fat and protein is more muscle-growing, muscle-promoting than pure protein alone. So there's a reason they come together in nature. Once again, in our hubris, thinking we know more than God, we've pulled the two apart, and now people are just drinking pure whey protein shakes. And I would look at that and say, "Ah, that's great, you're prioritizing protein, but you're forgetting about the third rule, which is don't be afraid of the fat that came with that protein originally." And the beauty about protein and fats, not only are they essential, but they also have little to no effect on insulin. Well, for a guy like me who views metabolic health and even chronic disease through the lens of insulin, that's, that's a perfect conclusion then, because I need these foods, and yet, and they're going to be the best metabolically speaking. But then you can start to see how we got it so profoundly wrong with the Dietary Guidelines to Americans, where we have totally inverted this whole thing. And now the average individual is getting the vast majority of their calories from a macronutrient nutrient that they don't need. We're just wasting energetic space in the body. Let's focus on what we need and then let that— let the carbohydrate part of it just be the garnish, if you will. That's the cherry on top.

Thank you for listening. Stay tuned for part 2 of our discussion with Dr. Benjamin Bikman.