How To Use Diet And Lifestyle To Lower Blood Pressure

Coming up on this episode of the Doctor's Pharmacy.

High blood pressure is an inflammatory disease and we treat it like a plumbing problem. Hey everyone, it's Dr. Mark. One of the most important tools I have for helping my patients optimize their health is testing. And that is why I love what Rupa Health is doing. Functional medicine testing can require placing orders with lots of different labs and it can kind of get really complicated for doctors and their patients to easily access results and keep track of everything. But Rupa Health has totally streamlined that process. Looking at hormones, organic acids, nutrient levels, inflammatory factors, gut bacteria, and so many other internal variables can help us find the most effective path to health and healing. I'm really excited about that now and I can finally take advantage of these tests without the hassle and the confusion of going through so many multiple labs. Rupa Health is the place for functional medicine practitioners to access more than 2,000 specialty lab tests from over 20 labs like Dutch, Vibrant America, Genova, Great Plains and more. It's 90% faster, letting you simplify the process of getting you the functional tests that you need and giving you more time to focus on your patients. This is really a much needed option in the functional medicine space and it means better service for you and your patients. You can check it out with a free live demo, with a Q&A or create an account at RupaHealth.com that's R-U-P-A-Health.com During these winter months, people are always asking me how to support their immune systems. I like to try to help them reframe immune health to understand that it's not always about making the immune system work harder. It's helping it be smarter. And that means giving our bodies the right ingredients for the immune cells to work effectively and understand when they're up against a real threat. And this is where proper nutrition comes in. But since our food quality is not what it used to be, it's helpful to have a little extra insurance. I discovered this propolis immune support throat spray from Beekeepers Naturals. Beekeepers Naturals uses a potent natural ingredient called propolis in their throat spray that can act as a protective lining for the beehive, keeping out foreign invaders and germs. And it can do that for us too. Propolis contains multiple compounds that are essential to immune health like vitamin C, zinc, iron, magnesium and B vitamins. It's the perfect travel friendly way to get that additional extra nutritional insurance to feel more resilient all year long. They also have the spray for kids as well. Right now, Beekeeper's Naturals is giving my community an exclusive offer. Just go to beekeepersnaturals.com forward slash Hyman and enter the code Hyman to get 25% off your first order. That's Beekeeper's Naturals, B-E-E-K-E-P-E-R-S-Naturals, N-A-T-U-R-A-L-S.com slash Hyman.

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Week'S episode of the Doctor's Pharmacy. Hi, this is Lauren Vien, one of the producers of the Doctor's Pharmacy podcast. Our standard American diet, high in sugar and refined carbohydrates, is causing an inflammatory cascade in our bodies that leads to many unwanted conditions, including high blood pressure or hypertension. High blood pressure, a leading cause of mortality, is a silent killer that we often don't know we have until it is too late. In today's episode, we feature three conversations from the Doctor's Pharmacy on why we need to look beyond our salt intake when it comes to treating high blood pressure. Dr. Hyman speaks with Dr. George Papamichael on the functional medicine approach to treating high blood pressure, with Dr. James DiNicolantonio on why salt is not the cause of high blood pressure, and with Dr. Casey Means on metabolic syndrome and why.

High blood pressure can be one of.

The key signs that someone has insulin resistance.

Let's jump in.

1 billion people have high blood pressure.

Yeah, 25%. And by 2025, they think it's gonna be closer to almost 30% of the world adult population. And it's also considered one of the leading causes of mortality to mankind. So it's a big deal. And in our country, it's about 75 million Americans that have hypertension. That's one in three. and an additional one in three have what we call pre-hypertensive condition. They're like pre-high blood pressure. Yeah, pre-high blood pressure. So the way it's staged, you can, there's a category that's pre-hypertensive.

Well, it was interesting, George, is like we constantly change the goalposts. So when I graduated from medical school, the blood pressure we wanted was anything under 140 over 90. Then it was 120 over 80. Now we're down to like 115 over 75 as being normal, right? why are we changing the bullet post constantly?

That's interesting, that's interesting, and quite honestly, I'm not sure why we changed the bullet post.

Why we changed it, Georgia, is this reason. Because we keep doing the research, this finding that even at lower blood pressures, people are experiencing the consequences of high blood pressure, right? So what are the consequences of high blood pressure? Why should we care if our blood pressure's high?

'Cause it's a silent killer, we call it. that's the key. It's a silent killer. You don't know you have it. People won't know they have it. And what it causes, it's one of the leading causes of heart disease that's considered like heart attacks, congestive heart failure, arrhythmias, which is abnormal, the way, the abnormal electrical activity in your heart that can lead to critical events.

So big cause of all kinds of heart disease.

Yeah, heart disease, it causes end stage renal disease. Kidney failure. Kidney failure and stroke, you know. Stroke. And then stroke creates a great deal.

Of mortality and morbidity for adult population.

Even blindness. Yep. Right. Hypertension.

Microvascular disease and blindness. Can lead to dementia because of its effects on the vascular system in the brain. Yeah. And also affects things lower down, right?

Yeah.

Like sexual function. Oh, yeah. Right. Oh, yeah.

Blood vessels get problematic in your sexual organs. You're not doing things normally. Microvascular disease in your, in your, in your, in the penis can definitely result in erectile dysfunction and that's not a good state, nobody likes that.

It also causes stiffening of the heart of your arteries and you get vascular problems in your legs and blood flow issues.

Peripheral artery disease is a major issue and particularly if you have diabetes then you have two things that you have to deal with, the diabetic changes that.

Create the peripheral vascular disease and also the hypertension. And you can get literally blood flow issues, you need amputations. So this is a serious problem.

Very serious.

And a billion people have it. In America, a lot of people have it.

Yeah.

Right?

Yeah.

50 to 75 million Americans.

Absolutely. And growing.

And how many people are actually like treated well? It's probably like 14 million out of those 50.

Yeah, it's- As we talked about that treatment is primarily medication. It's not always effective. It has lots of side effects. And there's so many other ways to treat hypertension, besides just using pharmaceutical agents.

And you know, we have determined that by treating people's blood pressure with medications that people do reduce their risk of these complications. So it's important to understand that if you have high blood pressure, you need to treat it. Absolutely. And whether it's with the things we're gonna talk about or medication, you can't let it go. And it's something you should do as a preventive strategy. You can go to the drugstore, they have blood pressure machines, you can stick your arm in or you can buy one for next to nothing in the drugstore, 29 bucks, and you can monitor your blood pressure. Now, part of the problem with diagnosing blood pressure is that it's often hard to know if you have high blood pressure because one, it fluctuates all day long. Two, just getting one blood pressure reading in the doctor's office may not really tell you what's going on. You might have white coat hypertension, meaning you get nervous and stressed, it goes up. I mean, when you exercise, your blood pressure goes up. When you're stressed, your blood pressure, What's your average blood pressure? So one of the diagnostics we do is a 24-hour blood pressure test, which I found really effective because you can see what is happening when they're sleeping, when they're active, when they're inactive, and you get a really good sense of what their pattern is day, night, and.

Average, and that'll tell you what your real risks are. Right. So doing 24-hour ambulatory monitoring is something that is really important to do, particularly if you have any concern that the readings you're getting in your office are inappropriate. And you mentioned white coat hypertension, and that is not uncommon. It actually is fairly common. And so we will oftentimes recommend ambulatory blood pressure readings.

And that gives us the clearest picture possible. Yeah, it's true. And sometimes you can just get a cuff at home and have people monitor their blood pressure out the day, and that'll help too. You know, I want to just dig into a little bit before we get talking about the difference with functional medicine and traditional medicine, right? Traditional medicine is you check your blood pressure, it's high, you get medication, you moderate. We call it essential hypertension. Now there are other causes of hypertension that we know of that are kidney diseases and other problems, but for the most part, people call it essential hypertension, which I joke and I say it means essentially we have no idea what's causing it, but we know that's not true. We know that's not true. So everything has a cause. Nothing is just random. If you have diabetes, it's not a random event. It's not like, oh, I I got a virus, something happened. Now we know some of the major causes of high blood pressure are never addressed. And the two biggest ones that I see treating patients is insulin resistance. Insulin resistance.

And sleep apnea.

And sleep apnea. So one of the biggest factors is insulin resistance, which is an epidemic in this country. We have one in two Americans who have pre-diabetes or type two diabetes. 75% are overweight, 42% are obese, and they all have some degree of trouble regulating their blood sugar, which just causes them to get belly fat. And that belly fat is such a big factor in driving all sorts of diseases, everything from high blood pressure to cancer, to heart disease, to diabetes, to dementia, to depression, and so on. But the insulin resistance drives inflammation. and it drives inflammation throughout the body because those belly fat cells aren't just sitting there holding up your pants, they're dynamic hormonal and immune organs. Your belly fat is an immune organ and it drives inflammation throughout your body that causes oxidative stress, which is really what causes rusting. So it's like your arteries and your pipes are rusting and stiffening called hardening the arteries. And that happens as a result of this inflammation and oxidative stress. And so insulin resistance is probably the biggest cause of that today in America and it's really driven by diet. So I think people don't understand how powerful that is.

Diet is very powerful and you know, I call it, you mentioned the adipose tissue we have around our waist, I call that the toxic waist dump of the body. And that fat just does have a metabolic effect that is toxic to the body. As you said, it creates the hardening of the arteries. which is one important cause of high blood pressure. Yeah, and the other big thing is.

Often misdiagnosed, and by the way, insulin resistance affects so many people, 90% are not diagnosed. So the way you diagnose it is you do a test for insulin and blood sugar, and it's the fast glucose tolerance test that we do, I do.

On almost every patient. Yeah, and this is the other test.

It'S a little more advanced where you take a sugar drink, basically drink the equivalent of two cokes, Check your blood sugar and insulin fasting and then every one and two hours after, but most doctors just check blood sugar, but that's.

A very late finding. You want to check insulin earlier.

Even doing a fasting insulin isn't gonna give you an answer. It'll help. But by the time your insulin goes up, fasting, it's already down the road pretty far, right? So I agree. And then we have this other issue, which is sleep apnea, which is so underdiagnosed.

Yeah, so sleep apnea, there are about 25 million Americans that have sleep apnea, it is underdiagnosed. It's not just a disease of people that are overweight, that's, you know, most people think about obstructive sleep apnea being related just being overweight, but you also can have upper respiratory anatomy and muscular relaxation that even if you're thin, you can have obstructive sleep apnea.

Yeah, you have a narrow palate, a small airway, you have sinus issues.

And when, right, and when you have sleep apnea, that means you're just not getting enough oxygen to your body, particularly your brain, also to your, you know, to all your blood vessels and your cortisol levels rise. And then you get into that whole cycle you talked about before, which is an inflammatory cycle, which is an oxidative stress cycle, which can lead to hardening of the arteries. And when you're not getting oxygen to those blood vessels, then they actually can't perform the work they need to do and create the energy they need to have. And so they can't contract and expand the way they should, and that can.

Result in high blood pressure.

Yeah.

And then it also drives insulin resistance. So if you have sleep apnea, it also causes you to be pre-diabetic.

Yeah, it causes independent of what you're eating.

Weight gain, weight gain, leads to insulin resistance, it leads to diabetes, which complicates everything. I mean, I had this guy who couldn't lose 50 pounds. He was a lawyer and he told me the story. He said, Look, I need to lose the weight. I don't know what to do. I'm trying to eat right. It's not working. I'm trying to exercise. I said, what was your life like? He said, well, I'm a lawyer and I work really hard and, you know, but every day I have to stand.

Up at my desk.

I can't, sit down, and this was before standing desk.

And I'm like, why?

He says, well, if I sit down, I fall asleep.

Right.

And I'm like, Gee, maybe you have sleep apnea. So if you're falling asleep at work, if you're falling asleep in front of the TV, if you feel tired during the day, if your wife says you're snoring, and now there's apps you can get that actually record your, on your phone, that record your snoring, so you can see, 'cause people don't believe it, I don't snore. I love that app. And then there's one called Sleep Cycle that I like. It's record your snoring. And it's something that is easy to treat. I mean, there's different methods, CPAP, but it is a treatable condition and the weight loss then will happen and you'll feel better. So that's really important. I just want to talk about a few other causes that I think are really important and worth noting because those are the two biggest ones, but there's a lot of other ones. People who are nutritionally deficient in certain things can cause high blood pressure. Like magnesium.

So, and magnesium, you know, studies show that, you know, there's a very large percentage of people in our country have low magnesium.

45% of people have low magnesium, which is- and you know, magnesium, it's not.

Magic, but, you know, when we replace magnesium in patients, we see amazing things happen. We see blood pressure come down. We see them being able to sleep better. We see muscle twitching and cramping go away. We see mood improve. Magnesium has a very important role in the body and certainly plays a big role in lowering blood pressure.

Yeah, but I call it the relaxation mineral. And, you know, it's funny how in medicine we have these blind spots, but when I was training in obstetrics and gynecology, I was a family doctor, I deliver lots of babies, there's this common condition that women get called preeclampsia, which is high blood pressure in pregnancy. And when they come in and their blood pressure is high, which can cause seizures, the treatment isn't high blood pressure pills because they don't tend to work. We give them intravenous magnesium to relax their blood vessels and save their life. So we serve, and it's just a strange thing to me, we don't think about it that way. The other thing that is important is omega-3 fats and fish oil because it helps relax your blood vessels, make them more pliable. But there's other causes that we also see, for example, environmental toxins. Heavy metals in particular, lead and mercury are really common, they're under diagnosed. And when you go in your high blood pressure visit, your doctor's not checking your mercury and lead levels, not even in your blood, and probably not on the most important test, which we do at the Ultra Wellness Center, which is a challenge test, where we give people a drug to pull out the metals, the chelator, and then we check their.

Urine and see how much dumps in there. And if they have high levels, that's often a big factor as well. And I think you're really hitting on all the things that I think about, and I tell people when they come to me and hypertension is part of what they want me to work with, I said, we're gonna get your hypertension better by not treating your hypertension. We're not gonna treat your hypertension. We're gonna treat everything else that's causing your hypertension. We're gonna find the sleep apnea, we're gonna find the nutritional deficiencies, we're gonna work on your stress levels, we're gonna help you lose weight. You know, when you lose weight, I mean, you actually are going to drop your blood pressure. I think the number is, per pound, I think for every two pounds you lose, you drop your blood pressure by a millimeter mercury. So if you lose 20 pounds, you can drop your blood pressure by close to 10-15 mmHg.

So, diet is so key. You know, we created a program called the 10-Day Reset, which you can find in getpharmacy.com, we put a thousand people through it, tracked their blood pressures. It was incredible. Their blood pressures dropped an average of 20 points. Yeah. No, in 10 days. Well, if you think about it, if.

You think about that most Americans are at least 25 pounds overweight or, you.

Know, so let's say it's better than medication results.

Exactly. If you get them to drop that 25 pounds, they're going to drop their.

Blood pressure by, you know, near 15 millimeters of mercury. Yeah. So, so we have, we have insulin resistance, sleep apnea, low magnesium, low omega-3 fats, which about 90 of Americans have. you have heavy metals, environmental toxins, and we now are learning that the gut microbiota, the microbiome in the gut, if it's altered through our bad processed diet and all the nasty drugs we take, it actually causes inflammation throughout the body that drives high blood pressure. Anything that causes inflammation or oxidative stress will cause high blood pressure. And the thing that struck me as I, and this is stuff that's in the traditional medical literature, is that High blood pressure is an inflammatory disease. And we treat it like a plumbing problem.

We do. And going back to the nutritional piece, a little potassium can be another reason why you can have high blood pressure. And that speaks to where do you get potassium, you get it from green leafy vegetables. So having a vegetable-based diet is very, very important.

I love my green smoothie in the morning.

Absolutely. Yeah, more kale. more kale.

Yeah. So, this is very important. I think people also think about salt. So, people think high blood pressure is salt. But, what's the deal with salt and high blood pressure? Is it something we should worry about?

Is it as big a deal as we thought? It's not something everybody needs to worry about. There's more pop, there's certain populations that are gonna have to be more salt sensitive than others. And so, we can actually do genetic tests and we do them here at the Ultra Wellness Center that lets us know if you have those genes that make you more sensitive salt more likely to have high blood pressure. So we do need to be concerned about it in certain populations and limit it. Salt actually, it's the salt we add to our food that is the problem because it's processed, all the natural nutrients are taken out of it. It can be iodized and iodine can cause problems. So it's not the salt that we.

Personally add in our kitchen. It's the salt that's added in factories to process food.

Yeah, exactly.

If we allow huge amounts of intake of salt, because how do they make junk ingredients taste edible? Salt, fat, sugar, and sugar and processed fats, right?

Yeah, so we know that. But if you get really good salt, sea salt that you've purchased that actually has nutrients in it, that can be valuable to you.

Minerals and so forth, yeah.

Exactly.

So these are some of the common causes we see, and they're often things that aren't looked at. Hey everyone, it's Dr. Mark. Now something I get more and more excited about every year is personalized medicine. Now when I began practicing functional medicine over 20 years ago, it was clear to me we have to look at how unique each body is. Now with technology advancing in amazing ways, we can truly take that concept to the next level. Like one of the tools that I recently discovered that can help us all do this from home is InsideTracker. Founded in 2009 by top scientists in aging, genetics, and biometric data from MIT, Tufts, and Harvard, InsideTracker is a personalized health and wellness platform like no other. It's purpose built to help you live a longer, more productive life. Their cutting edge technology analyzes your blood, DNA, your lifestyle to give you highly personalized recommendations. Then using the app, you can track your progress every day. InsideTracker tells you what to do and why, so your health goals are clear and actionable and most importantly based on exactly what your body needs. and now you can connect InsideTracker with your Apple Watch to unlock deeper, more precise insights into your health. With real-time exercise, resting heart rate, and sleep data synced with your InsideTracker plan, you can truly wear your health on your sleeve. My team took InsideTracker for a spin and really loved it. They discovered some important things about their health that led them to stop procrastinating when it comes to certain parts of their health, like, for example, finally taking a vitamin D supplement after seeing they were deficient. or eating more iron-rich foods due to low ferritin and hemoglobin, and making an effort to embrace stress reduction techniques after seeing high cortisol levels. Now, health is not black and white. Your wellness plan shouldn't be either. If you're curious about getting your own health program dialed in to your unique needs, I highly recommend checking out Inside Tracker. Right now, they're offering my community 20% off at insideTracker.com/DrHyman. I N S I D E T R A C K E R dot com slash Dr. Hyman. That's me, Dr. Hyman. And you'll see the discount code in your cart. Now let's get back to this week's episode of the Doctor's Pharmacy. The thing we often hear about, let's just sort of talk about some of these chronic age-related diseases is, you know, high blood pressure is an issue. And we're taught that we should not be eating salt or having too much salt because it can cause high blood pressure. And yet, you challenge that whole hypothesis. We've had you talking about this before, I think on an Instagram Live or a podcast. And you wrote this book called Salt Fix, which challenges our notion of salt being the enemy and the evil that we thought it is. Although it is for some people, can you kind of break down in just sort of a short nugget, what is the right thinking about salt and where have we gone wrong and how do we fix it?

If you eliminate refined carbs and sugar, you make sure you're getting enough magnesium, you make sure you're getting enough potassium, only 1% of the population would probably actually have a significant rise in blood pressure with a normal salt intake. In other words, it's not the salt. The problem is the sugar and the refined carbs that are causing you to over retain salt. It's really not a problem for most people if they fix those three underlying causes. And that's sort of what I discussed in the mineral fix and the salt fix.

The three causes of being again, of.

Over retaining salt would be insulin resistance, low potassium, low magnesium intake.

Okay, so this seems so easy to fix. You get magnesium, you get potassium, which we get from vegetables and plant foods, right? And you cut out the starch and sugar. And, you know, as a doctor, it was interesting when I tell people to cut out starch and sugar, what happens is the body starts to dump huge amounts of salt. And you get all kinds of, quote, side effects from going on a low carbohydrate diet. including, you know, feeling achy, tired, wiped out. And it's like essentially having electrolyte depletion. And the reason that you're doing that is not because your body's doing something wrong, it's because before you were having so much sugar and starch, your body was holding onto all this salt and so it dumps fluid and salt, which is a good thing. But you have to make sure you get adequate salt while you're doing that, because if you don't, you're going to feel like crap. And so it's really important for people who do switch their diets to understand that you can. And the same thing happens with the keto flu, you know, this whole idea that the keto flu, go keto and you kind of carbohydrates, you get sick like the flu, but that's because of the mineral depletion from the dumping of the salt, from the lower levels of insulin in the blood, which is after you cut out the starch and sugar. So it's really, it's a really important idea. But there are, but there are people who are salt sensitive and have salt sensitive hypertension, right?

The African-American community has more of that. Is that, is that fair to say? It's fair, yeah, they do have more, but typically it's because their dietary potassium, magnesium is very low and they eat high amounts. find carbs and sugars. And what's interesting, you give those people metformin and you help fix their insulin resistance and you actually fix most of their salt sensitivity. So in in the mineral fix and the salt fix especially, we cover a couple of those clinical studies. You give salt sensitive people metformin or you put them on a lifestyle better diet and you fix their insulin resistance. They're no longer salt sensitive. So really one of the best measures.

Of insulin resistance is if you're salt sensitive. interesting.

Interesting.

So, yeah, I see, you know, a lot of my patients, as soon as they change their diet, boom, their blood pressure comes down and it's, they have to start peeling off the medications because their blood pressure drops too low. So it's sort of paradoxical to think that actually, maybe it's not the salt, it's a lack of potassium and magnesium, which are rampant deficiencies. And potassium, you know, comes from mostly plant food. So you say, oh, eat a banana for potassium, but it's, if you just make a big vegetable broth or, you know, make a good soup, even like seaweed, I like to put seaweed in the soup that helps to get a lot of potassium and extra minerals. So that's really important.

Seaweed's a great source of minerals, isn't it? Yeah, no, it absolutely is. And that's a good point that just being a little bit low in potassium can cause you to over retain salt. And so again, it's this balance. You need to make sure typically what I do, I probably get four grams of potassium per day and four grams of sodium. And I don't have high blood pressure and it dramatically improves my performance.

Most people don't really utilize salt correctly. Before you go on, just the average recommendation is like two grams or less for salt, right? It's two and a half. So, you're saying you eat twice the amount of salt that our current experts are recommending, but you also eat a lot of potassium and it seems to balance out.

Exactly. So, the typical American is only consuming maybe two and a half grams of potassium and that's the problem. If they bump that up to about four grams, then most of those individuals wouldn't have an issue with a normal salt intake. I mean, I've published numerous papers on why we recommend such a low intake of salt and it's strictly based on blood pressure. But they never look at the other surrogate markers that are actually worsened on a low salt diet. So for example, you may have a slightly lower blood pressure, but that's not necessarily good. I can dehydrate you and tell you to only drink two ounces of water per day and lower your blood pressure. So to think that that one surrogate marker is the most important is really just narrow focused. But if you look at the harms like stress hormones, aldosterone, renin, angiotensin II, those artery-stiffening hormones, they all increase with a low salt diet. If you go below three grams of sodium per day, all those stress hormones increase.

Yeah, I mean, historically, we're all picking. Yeah, I mean, that's great. It's really helpful. I mean, historically, as hunter-gatherers, we probably had 10 to 1, I mean, sorry, you know, 1 to 1 sodium, potassium. Now we often have 10 to 1. sodium to potassium. And that's coming probably primarily from processed food. I always say it's not the salt or sugar you add to your food. It's the sugar salt that's added by corporations that's hidden in your food. It's the problem. And the amount, I mean, you probably wouldn't be able to tolerate that much salt if you just put it on your food, but when it's sort of buried in tasteless, you know, refined ingredients.

It kind of makes it all taste good, but it's actually killing you.

Right.

Well, I mean, getting a normal salt intake is actually one of the best ways to reduce sugar Cravings because one of the mechanisms, the survival mechanisms that we had, that you can see this in animals. When they're depleted, how do they know to go to a salt that can actually eat salts? Like, how do they actually do that? Right? It's because the reward center in the brain is actually hyperactivated. So that's what happens in humans as well. If you don't get enough salt, your reward center is hyperactivated and you get more of a dopamine response to things like sugar, Adderall, or any type of addictive substance.

And so low salt can literally drive sugar addiction. I think it's really important to define this poor metabolic health. There's really three biomarkers that are looked at, right? And it was blood sugar, blood pressure, and cholesterol.

Right, exactly.

So 88% of Americans have a problem with one or more of those. And the cause of all of those poor metabolic health markers is blood sugar.

Dysregulation and insulin resistance.

Yeah.

And so, So, what happens is, you know, we have these 30 trillion cells and every single one, trillions, needs energy to function. We need to convert food to energy, an energy form that we can use in our cells, namely ATP, for our cells to function. And when that process isn't going properly, the metabolism, when that conversion is not working properly, we don't produce energy properly in cells. And what happens when you have energy, you get cellular dysfunction. When you have cellular dysfunction, you get tissue dysfunction. Tissue dysfunction leads to organ dysfunction, and organ dysfunction is symptoms. That's what it is. And so this is why metabolic dysfunction underlies so many of these seemingly disparate symptoms we're dealing with today, so many of which you've talked about in so much of your work. But, you know, metabolic dysfunction, this problem with producing energy in the body is underlying some of the big heavy hitters, big killers in the US, obviously heart disease, diabetes, Alzheimer's dementia, cancer, chronic liver disease, chronic kidney disease, depression, but all these other things that people don't even realize, depression, brain fog, infertility, erectile dysfunction, chronic pain, gout. There's so many of these that we don't really relate, when in fact a lot of these are just this energy deficit, this problem creating energy and processing energy showing up in different cell types. But that core physiology is really the same. So what the main issue is is that our lifestyle and what we're eating and what we're doing and how we're living is hijacking that process, that food to energy process by one of the big, big key players is the amount of sugar that we're eating in our diet. You know, the average American these days eats 152 pounds of refined sugar per year. 100, 200 years ago, we were probably eating around one pound of refined sugar per year. That's 152 times the amount of substrate that these poor little cells have to process. They break down. They just say no. And what that looks like is insulin resistance. As I'm sure many of you listeners know, when we eat carbohydrates and sugar, the body releases insulin, a hormone to help you take that sugar out of the bloodstream into the cells so that it can be used for these metabolic processes. but when that's happening in all the time, day after day, huge spikes in blood sugar, the cells become resistant to this insulin. There's so much insulin being poured out, the cells are like, we cannot process all of this. This is too much and the cells block it. So now you've got this issue where you've got tons of this glucose substrate, you've got all this insulin being poured out, trying to force more glucose into the cells, the whole machinery essentially gets gummed up. And that's really the root of metabolic dysfunction. You've got poor energy production in the cells. So by day after day, learning what is spiking our blood sugar and then learning how to optimize that, keep the blood sugar down, figure out what foods are affecting you, you essentially let the body rest a little bit. If you can keep the glucose down day after day by learning what's affecting you, you can keep the insulin down. And then the cells start to perk up again to that signal and say, okay, we can do this. This factory can run a little bit better. That's what Levels is helping people do, is really to learn how different foods and these products that we may be told are healthy are actually affecting our blood sugar. With that information, it's the first time ever we've had a closed-loop biofeedback system about what we're putting in our body and what it's actually doing to our health. I believe that people should know what food is doing to their bodies. Right now, it's kind of a black box and it's a mystery and we have to trust food marketing, we have to trust the different nutritional ideologies. And there's a lot of conflicting information out there. It's a hugely confusing landscape. And I really do feel that objective data, like through a wearable device that's giving you this real-time biofeedback, can just cut through A lot of that marketing, a lot of those loud voices, a lot of the information from governing bodies that we know is not actually helping us achieve our goals. You can just see, this works for me, this doesn't, and then improve your metabolism with that information.

Yeah, I mean, here's the thing, Casey, is that as doctors, we really don't learn about metabolics. We have nutritional biochemistry lessons and we study the Krebs cycle in first year medical school. and the joke among all the medical students is, you know, this is just a grunt class. Basically, you're gonna forget it as soon as you're finished. Just cram for the exam and don't worry about it. Turns out it's probably the most important class in medical school. And we don't understand metabolism as doctors, and we don't understand even blood sugar and insulin resistance. You know, 90% of the cases of pre-diabetes, which affects about one out of every two Americans, are not diagnosed because doctors don't know how to diagnose them. and they'll say, oh, your blood sugar is normal on your test. Well, what is normal? What is optimal? They'll say your A1C is great. You're fine. No problem. No problem. But after practicing this for decades, I have really learned that there are other ways to get the science of what's happening, which is sort of what you're really doing with levels, is you're giving people the opportunity to measure in real time what happens when their body ingests food and how that affects their particular blood sugar. Because everybody eating exactly the same food might have very profoundly different responses to that food. I can, you know, drink a can of Coke and my blood sugar and insulin might go to X and Y. Somebody else might go to, you know, A, B and A and B. And that's not something that you would inherently know. And the other thing that struck me was that the metrics, that we have are just really poor. And I think, you know, I was going to share a story of a patient which taught me so much about metabolic health. And this was a woman who had an enormous girth. She was just round around the middle, skinny arms and legs, just big circle around the middle. And clearly she was in poor metabolic health. Blood sugar was perfect. I measured her blood sugar. I said, well, maybe we should do a glucose tolerance test. Her A1C, which is the average blood sugar was 6. perfect. Like, that wasn't like, oh, it was a hundred. It was like 80, you know, fasting, which is really optimal. And I said, let's do a glucose tolerance test and measure your blood sugar. And we're gonna also measure insulin because most doctors, and this was, this was probably 25 years ago, most doctors just never measure insulin even today, 25 years later. But it probably, as we were discussing earlier, probably one of the most important tests. So her blood sugar after she took, like, the equivalent of two Coca-Colas. perfect, like never went over 110 even after drinking the equivalent of two Cokes. Her A1C was perfect. Her insulin, on the other hand, like normal should be about five or less. Hers was over 50 fasting, which should, which is super high. It's 10 times. And when she, she had the sugar drink, it went to 200 or 250, which you just almost never see. It should never go over 30. after a sugar drink. And I was like, wow, here's someone who, if she went to a regular doctor, would have a perfect test, even if they did a glucose tolerance test. And so, you know, the, the importance of really digging down to understand what's happening with your own body is so key. And that's what's so exciting to me about levels, is it gives people real-time access to data through a continuous glucose monitor. which is a really relatively non-invasive procedure where you track your blood sugar on your phone, super easy and fun and gives you so much insight. And, like, I was sharing a story before, I was using the Levels app and I had the device on my arm. And this friend of mine, we're having a meal in Martha's Vineyard last summer and it was a farm-to-table meal, but we got it brought in because it was COVID, we didn't go out, we had it delivered. and it was a huge amount of extremely healthy food. And it was so delicious that we ate an enormous amount. But even the idea that you could eat healthy and it still causes a problem, if you overeat, it's nothing that most people really understand. So, you know, I can eat all this healthy stuff, but actually our sugars, both of our sugars really, really spiked, even though we're both really metabolically healthy. So it's kind of a fasting lesson. And gee, you know, we don't really always know what's going on inside our.

Bodies until we start looking. I think that's absolutely right. And I think you bring up the great point about biochemical individuality when it comes to metabolic health and metabolism. What might affect you might affect me very, very differently. And I wonder, you know, with you and your friend at this dinner might have had actually eaten the same thing and had different responses, you know, and, and that is really an important piece. You know, there was a really fascinating paper that was published in the journal Cell about five years ago by the Weissman Institute, and it was called, personalized nutrition by prediction of glycemic responses.

This was based on the microbiome.

Yes, yes. They took 800 healthy people, so non-diabetic individuals, and they put continuous glucose monitors on them, these little devices that measure your glucose 24 hours a day in real time, send that information to your smartphone, and they give them standardized meals. So they said, you all are gonna eat an identical meal or identical cookie, and see what happens. And based on what we know about the glycemic index, which is this idea that each food has sort of an inherent property of how much it will raise your blood sugar, they actually found something very different. Wait, wait, wait, hang on.

So, what she's talking about, Casey's talking about, is that scientists have come up with this chart of if you eat a banana, it'll raise your blood sugar this much. If you eat an apple, it'll do this much. If you eat chicken, it's going to do this much. And what you're saying is that was.

All thrown out the window because it depended on what was going on in the microbiome. Right, exactly. They had some people who raised 10 points to a banana and others that 10 glucose points and others that went up 100 milligrams per deciliter. So what might be a really sort of okay metabolic choice for you might not actually be for me. And they actually found equal and opposite reactions between people. So person A could eat, have a huge spike to a banana and no spike to a cookie, and person B could actually have the exact opposite. So this is where I think testing can be really helpful because we sort of have this culture where there's loud voices in the nutrition space saying there's a one-size-fits-all diet, but I do think there's probably some more nuance to that. So that gets into the kind of the nitty-gritty of the biochemical individuality. And like you said in that study, the microbiome was a key determining factor of how people responded to those different foods differently, which was pretty fascinating.

So true. I had a patient once that taught me a lot also. I mean, most of the stuff I learned, I learned from my patients. You start looking at the biology and you start asking questions, start thinking and most of us as doctors honestly just are pretty arrogant. We got trained in this guild in which we were told that this is sacred knowledge that's true with a capital T, that anybody who questions it is a heretic. and is not, quote, evidence-based which is the sort of the way we crusade against people who have ideas different than us. And we, and, and, you know, we're, you know, we're basically, you know, often blind to the very things that are in front of us. You know, when a patient gets better or changes something, pay attention. So this guy had this diabetic regulation problem where his sugars are really volatile and brittle and it was tough to control. And we did get dramatic improvements by changing his diet and putting him on a super low glycemic diet, but it still wasn't great. And he kept complaining about his gut. So we started working on his gut. And at one time, I was saying, oh, I'm just having all this gas. And no, no, no. So why don't you just deal with your GI symptoms, just take some charcoal as a sort of an emergent you know, stop gap measure to help fix what was going on with him. And I next time I talked to him, he's like, that was a miracle. I said, what do you mean? He says, my sugar dropped 100 points when I took charcoal.

Right?

And I'm like, how did that happen?

Right?

It's not like the charcoal is not absorbing the sugar. What's happening is that in the, in the intestinal tract, he had a whole bunch of bad bugs that were producing endotoxins, which are these really nasty toxins that certain bacteria produce called lipopolysaccharides, they get absorbed over the gut, they activate the immune system. The immune system, and this is just old technical stuff, but it activates these things called cytokines, which then bind to receptors on the cell that cause insulin resistance. So basically these toxic bugs in his gut was causing his blood sugar to be all off. And fixing that fixed his blood sugar. So it's very complicated. I want to get into something with you that I think is really important for people to understand because we sort of we touched on metabolic health and poor metabolic health. But I wonder if you can take us through a story of like what actually are all the things that are happening? Because you create a list of conditions that are related to poor blood sugar. What is the biology of what's happening when your blood sugar is out of control? What happens to your microbiome, to your immune system, to your brain, to your hormones? Take us through what actually happens in.

The body when you are eating the average American diet.

Yeah.

So there's sort of four things that I think are worth focusing on. There's the direct effects of high blood sugar. So you eat something and your blood sugar spikes and then there's biological effects of that. And then there is a fourth thing, which is the long-term stuff. So in terms of those short-term things, like you drink a Coke and your blood sugar goes up from 75 milligrams per deciliter to 150 milligrams per deciliter, that blood sugar spike can cause glycAteion. It can cause oxidative stress. Wait, wait, wait. What is glycAteion? So glycAteion is the process where sugar just sticks to things in your body. It's actually just like sugar molecules sticking to things like fats and proteins and DNA, and that can cause dysfunction. It can cause those, you know, cellular parts to be dysfunctional. And so that's an issue. We don't want that. It can generate inflammation immediately, too. This huge surge of sugar is unusual for the body. It's like, what is going on? Why is this big change, this sort of homeostatic shift happening? We don't want that. And then it can cause oxidative stress, which is sort of this reaction where your body is producing metabolic byproducts that are reactive and can be damaging to the cells. So these unpaired electrons that go around and want to bind with things, it's resting. Exactly. big glucose spike, you can have immediate effects on oxidative stress, glycation, and inflammation. And then the fourth thing is this thing that's happening both immediately but also really has cumulative effects, which is the insulin surge. So when you have that big glucose spike, your pancreas is releasing all this insulin to help you soak up the glucose out of the bloodstream into the cells so it can be processed and bring the glucose back down. And what can happen there in the short term is that if you've got a big spike, so that big up and down, the insulin can actually sometimes overshoot. It can actually do too good a job in soaking up all that glucose and you can have what's called reactive hypoglycemia, which colloquially is known as the post-meal crash. So if you've had lunch and then after lunch feel tired and you want to have that second cup of coffee at 1:00 PM and maybe you feel a little bit more anxious, that might just be the fact that your blood sugar has gone up, you've released all this insulin, the insulin's kind of overshot, you've crashed down, and now you're in this dip and the body's trying to get back into balance.

And that roller coaster with that creates.

A secondary cascade of hunger hormones and cravings. Exactly. And so that's happening in the short term. And then that insulin process, going back to what we were talking about before, can over time lead to that insulin resistance where the cells see that huge surge in insulin, so frequently that they actually say, we can't keep doing this. This is too much insulin and we get numb to it. And that's insulin resistance. And then what happens is your insulin levels, they start creeping up because your body's trying to overcompensate for that block by producing more. And then that leads to so many of the downstream conditions that we've been talking about. When you've got this high insulin, one of the secondary effects of that Let's just, we can talk about obesity. You know, insulin is a signal to the body that glucose is around for energy. And it's also a signal to the body that because there's so much glucose around, we don't need to use fat for energy. Glucose and fat are the two main ways that we produce energy in the body. And when that insulin's high, it blocks us from tapping in to fat burning. It says to the body, nope, you don't need to tap into fat burning. We've got a bunch of glucose around. And so this is relevant to anyone who is trying to lose weight or who has the excess belly fat because that insulin is a real block on helping us achieve those goals. And so for us to tap into our copious fat stores in our body, we need the insulin to be lower. So by getting off that glucose roller coaster, by eating foods that keep us more flat and stable throughout the day, which is what we want for optimal health both in the short term and the long term, we give our body a break from producing that insulin, and that can have a real significant impact on our ability to lose weight, to get rid of that belly fat, to tap into this alternate metabolic fuel source, and to generate what we call metabolic flexibility, which is this ability of the body to flip between using glucose when it's around and using fat when it's not around. And that state of being able to do both is a really healthy state. It's adaptive, but the average American with the vast majority of our calories coming from ultra-processed foods, and I believe more than 70% of processed foods in the US have refined sugar in them, and we've been told, of course, to eat six small meals a day. You are on, as an American, this up and down glucose roller coaster all day. And so you're really never giving your body this time in a low insulin state. So you really do have to be quite aware and think differently. I mean, the reality is, as an American adult, you're on a treadmill towards being overweight and chronic disease. And unless you are doing something different, you will end up sick. And that's where having a little more awareness, I think, can be helpful.

100%.

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