The Functional Medicine Take On Diabetes

Hey everybody, it's Dr. Mark Hyman. Welcome back to the Fat Summit, part two, where we separate even more fat from fiction. And I'm here to introduce to you someone you probably already know really well now, Dr. Caryn Zinkus. Now when we decided to put together another Fat Summit, my team and I talked about having someone co-host the summit with me. And Caryn was the first person I thought of. I've known her for a few years, but it feels like I've known her my entire life. I mean, she's so knowledgeable about functional medicine. She's one of the only female board-certified orthopedic spine surgeons in the country. In fact, she's probably the only functional medicine orthopedic spine surgeon. And she uses a functional medicine approach to help her patients heal and get ready for surgery or to avoid surgery. She's one of the only surgeons who encourages people to choose alternative to surgery when they can. and she's the medical director of an amazing clinical center called the Crystal Spine Clinic and Wellness Center in Ohio. Now you probably remember from the first Fat Summit that Carrie suffered from an autoimmune disease called type 1 diabetes. Now she knows a lot about fat because of that. She knows a lot about diet and a lot about carbs and she probably didn't want to learn those lessons but she had to and we're going to benefit from that. So I'm so happy to have Carrie here with me, co-sting with us with me and welcome to the Fat Summit Part 2.

Thank you, Dr. Hyman.

So, you know, you've really been struck with this disease at a point in life which most people don't think you get this. This is what we call juvenile diabetes or, you know, kids diabetes. And you got nailed with this thing when you were in your- Late 30s. Late 30s. And so it's kind of been a wake up call for you in a way. You were always focused on functional medicine, nutrition, but this made it really personal. We've talked a lot about this and you've explained to me how you've been able to control your diabetes using very high fat diets. And in fact, your diabetes was so well controlled and your blood sugars were so low that the endocrinologist was going to kick you out of his practice for keeping your blood sugars so well controlled because he thought they were too low, right? Can that be possible?

Well, that wasn't me. That's friends of mine who had that happen.

Oh, I thought you said your endocrinologist was not happy with you.

No, they're not, yes, absolutely. That, you know, my A1C was too low, which is sort of ridiculous. But yes, I was, you know, just to go back history-wise, in my 20s, I was about 100 pounds heavier than I am right now, and sort of sorted through all that and lost that weight and was able to keep it off.

You were like a whole other person.

I was a whole other person. And so, you know, I was a practicing orthopedic spine surgeon, and I was actually out talking about how to optimize patients with diabetes and obesity who are-- Type 2 diabetes. Type 2 diabetes who are, you know, orthopedic patients about to have surgery or, you know, suffering from orthopedic related conditions. And I went for an executive physical. And before the physical was over, she called me back into the room and she said, there's something really unusual here. Your A1C is pretty elevated. And I was shocked. I said, that really can't be possible. I mean, I'm doing everything right. There were a few things, extra sleep that I could get, and stress reduction, and things like that. And I thought I had a few places that I could tweak my diet a little bit. So I did those things, and I wasn't really able to get it controlled. And so then I started looking at-- so originally I did a lot of.

The-- you- called me.

Then I called you. Right. And originally I was doing the things that are the more traditional-- you know, advice, which is a low-fat diet, very little meat, a lot of, you know, beans and lentils and things like that. And every time I would eat those things, my blood sugar would go through the roof. And it got to the point where...

So eating whole grains and beans, your blood sugars would just go crazy.

They would just go crazy. And so then I said, well, this is not making sense and I'm a scientist. And so if Eating carbohydrate in any form raises my blood sugar. It clearly requires insulin. And so I need to, and at this point they thought I was type 2 because it's fairly uncommon, although it's becoming much, much more common.

They call it LADA now, late onset adult diabetes.

Well, there's, yeah, autoimmune diabetes of adulthood and there's some different distinctions in that. But it effectively, you know, diabetes, there's two, Primary types, although there's some other subtypes. So there's really three primary types. There's type 1, which is where the pancreas doesn't produce insulin, as you know. And there's type 2, which is where the body becomes insulin resistant, and so can't utilize the sugar and you produce a ton of insulin. But then down the road, the pancreas gets tired and gets burned out, and you can have people become sort of type 1 type 2s, although for different reasons. Exactly. And then there's gestational diabetes and some of the less common types like MODY, which are a genetic type of diabetes. And so we still really weren't sure what type was going on. What I had. But it made sense to me that eating sugar was, and not even sugar, but even whole grains was a bad idea because my blood sugar would go up.

But basically the American Diabetes Association tells people to eat whole grains and beans.

Right, which is good.

To control their diabetes.

Right.

And what you're saying is you're type one and you really are super sensitive to any carbohydrate. Right. And probably type twos are too, I bet.

For sure. I mean, I like the term glucose intolerance. You know, we talk about, when I'm talking with patients about it, I'll say it's sort of similar to if you're allergic to peanuts. You know, I say carbohydrate intolerance. Right. Yeah. Saying that, you know, go ahead and eat the peanuts and inject yourself with epinephrine.

Right.

And that's sort of the same thing that we do with diabetes is we say eat the carbohydrates and there are medications. I actually had an endocrinologist say to me, just eat a cookie.

Just eat a cookie.

Just eat a cookie. And so I didn't, so I shifted my diet and I said, you know what, I've got to get rid of these beans. I can still keep eating the vegetables, but in the absence of carbohydrates, so you know there's three basic macronutrients. There's protein, there's fat, and there's carbohydrate. if you're dropping one of them, one of the other ones has to come up. So I played with fat and protein, and protein gets a little bit tricky at times because the body will convert through gluconeogenesis, which takes protein and converts it into sugar in the body.

Too much protein gets converted into sugar.

Exactly, and so protein needs some insulin as well, but fat is sort of insulin neutral.

Yeah.

And so I significantly increased the amount of fat that I was eating, and.

What happened?

Moderated my protein and got rid of almost all carbohydrates. And for a while, at this point, we had determined that I was type 1 because my C-peptide was very, very low, which is classic of type 1. A marker of insulin. Right, a marker of how much insulin. So you're not really making insulin.

Not really making insulin. And I was able to- By the.

Way, people who have type 2 diabetes, they make too much insulin. It just doesn't work. Exactly. And so I was able to stay off of insulin for a period of time. because during what we call the honeymoon phase, but I was able to sort of prolong that because I wasn't stressing my pancreas because I wasn't eating carbohydrate. And then I got sick and got the flu, sort of the classic story. I got the flu and then my blood sugars, it got much more difficult to control after that.

It's really fascinating. Type 1 diabetics, when they get diagnosed, they're typically losing weight. They're hungry all the time. They will eat like 10,000 calories in a day and they are losing weight. So how could that be if you're like calories in, calories out, if it's all about energy balance, which is this dogma that the whole medical and nutritional establishment and our government teaches us, right? Which is you should just eat less and exercise more. What if you're eating 10,000 calories and losing weight?

How does that work? Well, and I was eating quite a few calories before I added insulin, and then I can tell you as soon.

As I added insulin, I added 10 pounds along with it. Yup, that's the other thing. We know that when When type 2 diabetics are uncontrolled and then doctors add insulin, the first thing happens, they gain weight. Insulin is a fat fertilizer. If you eat tons of calories, if you don't have any insulin, you can't gain weight.

Right, right. I mean the same thing happens with kids and with type 1. So in the absence of insulin, you don't store fat, you break fat down, which is why we produce ketones, because ketones are a marker of fat breakdown. And they can have a slightly different meaning in type 1 if they get too high.

We're gonna get into that.

We're gonna get into that. So you break down fat because your body doesn't have any ability to use any of the sugar that you're eating.

So what's also fascinating is when you look at, as we said, type 1 diabetics, if you don't have insulin, you can't gain weight. But if you're a type 2 diabetic, some of the studies now are looking at using ketogenic diets, to actually reduce the need for insulin or in fact reverse insulin. I mean we've seen people get off 100 units of insulin in a week by dramatically changing their diets. And I'm not sure if you saw this study but it came out just recently, it was in mice which still has to be proven but it showed that using ketogenic diets in mice they could reverse kidney failure. Yep. These are like little mice that are on dialysis, you know.

Right, right. Yeah, I think it was a 2011 study that showed that.

It just came out, I thought. Or maybe it was 2011, but it was like, I'm like, wow, if this is true, this is revolutionizing medicine. If you imagine, if you take all the people on dialysis, how much that's costing, how much suffering they have, and put them on these high-fat diets, and.

By the way, most people on dialysis.

Are there because they have diabetes.

Right, or hypertension, that's the other one. Which is caused by insulin resistance. Right, right. So yeah, I mean, there are more and more studies that are coming out that are showing that for Type 2s, low carbohydrate diets can significantly decrease people's blood sugars, decrease their A1C, and get them off of some of the medications that they're on. One of the controversial things is that there was a study that came out a number of years ago looking at tight control of diabetes, and they looked at using medicines for intensive control. And what they found was that there were actually more complications in those who had intensive control. until you actually went down and looked at it, and the people who had those increasing complications were the ones who had longer, higher blood sugars. And so people will often push back and say that a type 1 or type 2 diabetic can't have hemoglobin A1c, which is a marker of the amount of sugar that's sticking to the red blood cells, that they can't have it in a normal range because they're diabetic. and that's just ridiculous to me because I have an insulin resistance.

Yours are lower than mine and I'm not diabetic.

There you go. I mean, and again, it has a lot to do with your diet. What's your diet? My last one was 4.9.

See, mine's 5.4. See?

There you go.

I must eat worse than you. Or maybe I should get more and more information from you on what to eat. It's amazing. I mean, there is almost nobody who has that kind of control period. I mean, I rarely see a hemoglobin A1C of 4.9 and it's probably because you're eating such a low carb diet, a high fat diet. And that also takes away your hunger, it gives you more energy, it makes your brain work better, your brain already work pretty good, but it's pretty impressive your brain. It's an amazing strategy which I think you're now actually beginning to study, right? You're working with David Ludwig from Harvard and David told me, by the way, he's a friend of ours. He told me if you had somebody drink 10,000 calories of olive oil a day, they wouldn't gain weight. And if that's all they ate, they wouldn't gain weight because you wouldn't make insulin when you eat fat. So you don't make insulin when you eat fat.

When you eat fat. And if I eat just fat, then I don't need to give myself any insulin. So that was my sort of first eye-opening experience with this is I would eat a breakfast of just fat. and if I had that, I could actually operate the entire day. My blood sugars are stable, and I didn't need to give myself any of the insulin that goes along with a meal. If I eat carbohydrate, I need to give myself insulin. And, you know, that's the really tricky part, and this is the thing that gets really frustrating, is, you know, the ADA says things like eat 30 grams of carbohydrates per meal or more, and the problem is, is, you know, I have an advanced degree and was a biochemist and I can't...

I have no idea what that is.

Look at an apple and say exactly how many grams of carbohydrates are in it to match it with insulin. And so it's this roller coaster that you're on and it's fairly miserable and you feel bad when you're too high, you feel bad when you're too low.

You know one thing people might be wondering about is like they go, wait a minute, carbohydrate, an essential nutrient. And actually, what we know is that there's essential fats, there's essential amino acids in protein, there's no such thing as an essential carbohydrate.

Like humans don't need carbohydrates to live. Yeah, and the brain can function just fine on ketones.

Which may be better. May be better. I mean, because we're now looking at that in Alzheimer's, and autism, and brain.

Cancer, and epilepsy, the brain actually does better on these ketones. And we do need some insulin to live. You know, if I don't have some, doses of insulin than our bodies don't function originally. So this is the interesting history of diabetes is originally before insulin was discovered by an orthopedic surgeon, by the way. Really? Yeah.

Banting, was it?

Yeah, it was an orthopedic surgeon. And so originally when it was, or an orthopedic specialist, I'm not sure that he was a surgeon, but prior to that, Joslin's diet and Allen's diet were all very low carbohydrate.

There were 70% fat.

Exactly. And they were able to maintain people for, granted it was not particularly long periods of time who were type 1 diabetics, but for a lot longer than what they would without, with having regular diet.

I mean it's so funny that the Joslin Diabetes Center is named after a guy who actually created a diet that was 70% fat to treat diabetics. Now there's a guy who's gonna be in the fat summit, Dr. Hamdy, Osama Hamdy from Harvard, who runs the obesity program there in the diabetes program. He's actually using high fat diets in his patients to treat and reverse type 2 diabetes.

Dr. Yeah, he does a phenomenal job of going through the history of how diabetes has been treated. And it's fascinating how we've swung. And it's sort of akin to what we've been talking about a lot in the Fat Summit with going from a low fat diet and recommendations to the pendulum swinging to there being benefit from a higher fat diet. And it's not always, I still play with it now. There's not one particular level that we've dialed into. That was one of the things that Amy Myers and I talked about earlier in our interviews was that it's not one size fits all. And so there are times during this where I tried upwards of 85% fat. and now I've sort of dialed it down right now. What seems to work really well for me is about 60% fat, 30% protein, and 10% carbohydrate.

10%. So what does that look like in a day for you?

You know, usually I'll have, right now I'm doing some sort of ground turkey for breakfast with a non-starchy vegetable. I actually like Yacon root, which is a prebiotic and it's crunchy and it's got a little bit of sweetness to it. And I give myself a small amount of insulin for that.

That's a treat.

You have a Yacon as your sugar. Exactly, exactly. And then for lunch I'll have some, you know, chicken with a whole, two cups of roasted vegetables. And then- so you can just pig out on the vegetables. I eat the non-starchy vegetables. I eat, you know, although I have to be careful with some things like brussels sprouts and things like that just to measure the carbohydrates in them because there are some carbohydrates that I do have to dose insulin for but it's so much easier to do now. So if I eat grapes or something like that, my blood sugar shoots up and then I'm chasing it down and it's trying to not go too low because there's that thing where insulin keeps us alive but too much can kill you.

And then what's for dinner then?

You know, we do a lot of different things around the house. I have little kids, so I eat salmon, wild-caught salmon, a lot with another plate full of vegetables.

That's what you fed me when I.

Came over for dinner. Right, exactly. So in fact, I think it was the recipe out of the book.

Oh, yeah.

So, yeah, I mean, that's common. But for our family, we almost always have some sort of healthy animal sourced protein, and then a lot of vegetables, and the kids get to pick and choose from that. And we do let the kids have options where, you know, our house, we've got celiacs in the house, so we tend to be more gluten free with things.

So in terms of like fats that you eat, I mean, do you want to talk about like some of the things that are controversial, like vegetable oils? Because I think there's, you know, there's a paper published a couple weeks ago in JAMA where It showed that looking at total fat, there was really no link to death, right? It was an inverse relationship. The more carbs you ate, the more you died. The more fat you ate, the more you lived. But when they looked at the different kinds of fat, they showed that the ones who were eating the polyunsaturated fats, even the Omega-6s and the olive oil, did better than the ones eating saturated fat and Omega-3 fats. I mean, the saturated fat and trans fat. So, what do you think about all that research?

So, the first thing is that trans fats, I don't think there's any controversy at this point that trans fats are just toxic for our bodies. Our bodies can't handle them and we just need to get rid of them. I mean, I think that that's the jury's out on that one. But as far as, you know, the seed oils and the issue is our diets have become really, really high in omega-6. and very, very low in omega-3. And if we look at the pathways, and you know, a lot of this can be linked to some of the chronic pain that we're seeing as well. So omega-6 through the arachidonic acid pathway becomes, it's a pro-inflammatory type of a fat, whereas omega-3 is an anti-inflammatory type fat. And so the way I describe it to patients when I'm talking about is omega-6 is more like the gas on the car, and the Omega-3 is the brakes. And we have to have both. You can't drive a car without both of them. So if you're exposed to a virus, you need the inflammatory response, or if you get an injury, you need that inflammatory response. Like Goldilocks, you just want the right amount. You just want the right amount. And so what's interesting is things like aspirin. Aspirin, so the one enzyme that they both are impacted by is the cyclooxygenase-2 enzyme. and depending on which fat goes through that pathway, whether it becomes pro-inflammatory or anti-inflammatory. When you take aspirin, you actually acetylate that protein, and the other anti-inflammatories don't do this. And so aspirin, an acetylated COX-2 enzyme in the presence of omega-6 fat can have anti-inflammatory end products. And so this is one of the reasons where aspirin can play in and we're aspirin beneficial? For some people it can be beneficial, you know, and that's one of the tools that I use when I'm seeing a patient who is having pain is we want to turn down all the inflammation. So as an orthopedic surgeon, I'm basically a construction worker when I'm in the operating room. But when I'm seeing a patient in clinic, there's a lot of other things that we can do. And so most of my focus is how do we get rid of the inflammation? And then other things like balancing out the body.

So the study basically showed that we should all be eating more omega-6 fats. so like and that they were preventing disease and death. Because to me it was like it was an interesting study but it was also observational. Like it didn't really prove cause and effect. And there are other studies that show that are randomized controlled trials that actually it may not be so good for you. Like the Minnesota Coronary Experiment where they looked at 9,000 people and they gave half of them butter and half of them corn oil which is an omega-6 fat and the corn oil people did worse. They died more and they had lower cholesterol, but it actually didn't help them.

Yeah, and there's other studies looking at inflammation. So this one was in another mouse model, but they took mice and they simulated a spinal cord injury with the inflammation that happens around that. And they did this study where they had the mice run on balance beams and they counted the number of foot faults. So whenever a spinal cord is injured in the cervical spine, it creates something called myelopathy, and you get gait abnormalities.

Yeah.

Can'T keep their balance. And what they found is they gave high dose omega-3 and curcumin, which is an anti-inflammatory. So they did two things together. And what they found was that the mice that had the high dose omega-3 and the curcumin had many, many fewer foot faults than the mice that ate the regular mouse chow. So, you know, we don't have studies like that in humans, but, you know, from the pathways, we do know that the omega-3 fats have anti-inflammatory properties. So the tricky part really is, is how much omega-6 is appropriate in our diet.

I mean, should we have vegetable oil in our cover? Do we eat it? I mean, should we put soybean oil in a cover, corn oil, canola oil.

You know, safflower oil, sunflower oil, these oils.

So none of those are on my shelf. So those in your cover, like I.

Said, they're not in my cover.

They're not.

You know, because of-- Olive oil. Olive oil. Right.

Coconut oil. Coconut oil.

Ghee, we use because of the butyrate.

Butter, but without the dairy part in it.

Right.

Right.

Yeah.

The dairy fat.

Exactly. Right. So those are the fats that we cook with in my house.

And I think, you know, that's what my kitchen looks like. And I think when I read the literature, think about it, you know, when we look at the way we used to consume fats, it was butter, lard, tallow.

Right.

Right. olive oil, we'd have some nuts and seeds.

Right.

But that was it. We didn't have refined vegetables. I mean, we've had a thousand percent increase in a thousand fold increase in our consumption of soybean oil. It's now 10% of our calories. Right. Which we never had before. And it doesn't seem to make sense from an evolutionary point of view. It doesn't pass the sniff test for me. And when you look at the data from these guys like Hibbeln, they found that the high levels of these omega Six fats were linked to more homicide, suicide, violence, as well as all kinds of other chronic diseases and mortality. So I think there's a big split in the scientific community of those who think that omega-6 fats are the cat's meow and we should all be drinking them and having them all day long and others who think that the data doesn't support that. And I'm sort of concerned about it. And I think just from an evolutionary point of view, I'm not a big fan of eating a lot of omega-6s except in food. If you have nuts, if you have seeds, eat sunflowers, eat soybeans, eat corn, but don't eat the oils that are extracted from them.

Right, and again the extraction process for a lot of those seed oils is fairly intensive in order to get those out, so there are other byproducts that can be a factor in that as well. Whereas the more the other oils that we're talking about, it's a much more straight forward process.

Yeah, there's solvents, there's hexane, there's deodorizers, chemical processes that they go through that it's not exactly a very...

I mean, even coconut oil, you can get refined coconut oil, and that's something that's not on my shelf either at my house, because, you know, sort of the less processed it is is something that I'm more interested in.

Yeah, you know, it's interesting. I was talking to Dr. Hiblen, I don't think I told you about this, but he told me that the cholesterol that you have, you know, inside of the cholesterol are the fats, right, that you eat. Right. So, saturated fat makes your cholesterol very stable and not likely to be oxidized. Whereas the omega-6 fats, the linoleic acid, gets inside the cholesterol and becomes unstable. It's more likely to get rancid, which is actually what causes heart attacks. It's called ox-lams, oxidized linoleic acid metabolites. And this is a real thing, and most people don't know about it. So we think all the As long as the LDL is lowered when you drink omega-6 oils, that's a good thing.

Not necessarily, right? Yeah, I mean, this is again, not scientifically based, but my grandmother lived to be three weeks shy of 100 and she ate butter and lard. I mean, she cooked pies, but she.

Made them with lard. Well, it's interesting, a lot of people say, oh, well, we've eaten more fat and we've eaten more meat, and that's why we're all sick. But when you look at the data, and I looked at the data from the USDA, from the records of what Americans are eating, our butter consumption, our lard consumption, our egg consumption, our red meat consumption has gone down dramatically in the last 100 years, because everything is bad for you.

Chicken, I think, went up.

Chicken went up, which is, by the way, full of omega-6 fats, because they eat grains, which have these, and seeds, which have these omega-6 oils. They're not eating grubs running around the field. And also, The increase in the oils we're eating is vegetable oil. It's not butter. So, yeah, the reason I think we're sicker and fatter is partly because we're eating more of the wrong foods and not the right foods. I mean, did you see that article, Is Butter Back? Did you see that recently?

I did, I did.

Yeah, it was like a review of nine studies, 600,000 people. It was like 6.5 million people years, and they looked for correlations between people who ate butter and people who had disease. And they found that those who had the butter, there was no increase in heart disease, and there was an inverse relationship with diabetes. So people literally who had butter in their diet had lower levels of diabetes.

Well, and some of that may be from the butyrate that's in butter and the way that it it interacts with the microbiome.

Well, now you're talking about language. I like poop.

Right. So normally, if we eat a diet that's high in fiber, the healthy bacteria in the GI tract, as you know, will make butyrate and butyrate, higher levels of butyrate for many different reasons. There's several different reasons why it works. One is acting directly at the mitochondrial level, in addition to at the GI membrane wall level, improves metabolic syndrome, or improves a patient's metabolic status, impacts their insulin sensitivity. So, there are some studies where they've supplemented with butyrate and have seen some of the similar responses. And some of these have been in animal studies and they're starting to look at it in human studies. But part of the reason why butter may be for some people a benefit is because of the butyrate that's in it. In my patient population, because I sort of see, I have some selection bias, obviously, but I see people with significant pain and a lot of it's chronic pain. I have to get the casein and whey out because people tend to be sensitive to it.

Yeah, yeah.

Yeah, so-- I think that's true.

So ghee is good. I remember when I reviewed that study from my book, There was a lot of very controversial studies that looked at 72 studies. It was, I think, 600,000 people, 19 countries, and some of them were plasma fat levels. So they actually looked at the blood of people and they measured the fatty acids and the kind of fats that were in their blood. And what was fascinating, when I looked at the graph and I saw what was sort of mapping out, there's not just one thing that's called saturated fat. There are many kinds. The kind in coconut is different than the kind in butter that's different than the kind in meat. different than the kind and whatever.

And for all of these, even Omega-6s, there are different Omega-6s, there are different Omega-3s, it's not simple and straightforward.

Exactly, right, that's why I wrote a book. But what was fascinating was that when you look at the graph, the only ones that seemed to show benefit were the ones that, most of the saturated fats were neutral, but the ones that showed benefit were the dairy fats, like basically butter.

Right, well there was just a recent study that came out that showed that increased level of dairy fat in the blood was associated with fewer medical problems effectively.

Yeah, no, this was like I think the diabetes study. It was 3,000 people, 15 years, and they looked at blood levels of basically butter, and the ones who had the highest levels of butter in their blood had a 40 to 50% reduction in type 2 diabetes. Which is borne out in this other study. So it's very fascinating to me how that works, and I think that we don't exactly know the mechanisms, but We did one of the interviews with Dr. Ron Krauss and he's a very humble guy. He basically is one of the pioneers in breaking down this stereotype of saturated fat being the bad guy. And you use ghee in your diet, right?

I do. I use ghee. We cook with ghee. And I think that there are some definite benefits to ghee. We're not, from my standpoint, I do think there are some people who have to be careful with saturated fat. but I think in the absence of sugars, saturated fat for a lot of people can be neutral. So, you know, and that's where looking at how your body responds to things, I mean, that's sort of what I do with myself and what I do with patients is we try something and then we measure blood levels and we see where if we're moving in the right direction and then we do something simple and say, how do you feel?

Right.

Right. Because that's your first indicator that things are either working well or not working well.

It's how people feel.

It's how people feel because when you get them sort of on the right track, they'll feel better. And, you know, I can tell you, I mean, I was vegan for a very long time and, you know, and was low-fat vegan. And I struggled with keeping weight off.

So, you were gaining weight.

I was gaining weight. My hair was falling out. My, you know, menstrual cycles were all messed up. Like, it wasn't good. I was trying to run, you know, I was running fat and bald in the middle.

Yeah, yeah.

And I was running.

I was screwed up.

Exactly. Not something you want to be. And I was running a lot and the whole calories in, calories out. So I had to keep running more and more and more to keep my weight stable. And it wasn't until ultimately I added more fats back in my diet.

So that's amazing. Did you hear about that recent ruling in Italy where they had passed a law that parents, if they put their kids on a vegan diet before three years old, they would put them in jail for two years.

Oh wow, no, I hadn't heard that.

What do you think about that?

I mean, here's the thing.

Because these kids were coming in malnourished and they're deficient in iron and vitamin.

D and zinc and omega-3 fats and... I mean, here's the thing. I think that we can be healthy on a variety of diets. The issue is, you know, vegan can.

Mean a lot of different things. Chips and Coke.

Exactly, chips and Coke, right? And, you know, I know a lot of vegans who don't actually eat many vegetables.

Yeah.

So, you know, it's very different if you're eating a vegan diet that's avocados and coconut butter and coconut oil and nuts and seeds as opposed to, you know, carrots plain by themselves and, you know, potatoes and all of those things that even the beans, I mean beans get tricky for some people. Again, the beans, people get- that's interesting when you told me how you eat.

Beans, you eat beans with fruit. And then my blood sugar goes high, yeah. Which we all think is healthy, it really has a big impact on your blood sugar.

For sure, I mean it's got, at the end of the day the amount of carbohydrate that is in it, whether it's absorbed slowly or over a long period of time, as a type 1, I have to cover that with insulin. So as a type 2, if it's covered slowly over time, they may not see the spike because of phase 1 versus phase 2 insulin release, and they can keep up, but it's still needing to be matched with insulin.

Yeah, that's true. I remember I gave a talk at your daughter's school, and there was a woman who got up and she said, you know, I'm diabetic. I had a heart attack. and I went on Dr. Esselstyn's program, which is very low-fat vegan diet, like no nuts, no avocados, no olive oil, nothing. And she says, I got another heart attack and I can't keep my blood sugar in control.

Right, no. I mean, it's, and that was, you know, my experience, but I have that with patients. That's one of the things, the first thing that I do when I see a patient who has metabolic syndrome Pre-diabetes. Pre-diabetes or, you know, I kind of lump all those metabolic syndromes. Type 2 diabetes is on the spectrum of metabolic syndrome. And so the first thing that I do is we talk about, okay, let's get the carbohydrate out for a period of time. And, you know, when you get the carbohydrate out and you keep the protein relatively stable, then the only thing you can do is increase fat. And a lot of people are really sort of fearful of that. I mean, I know for me it was a big deal because I was scared that I was, you know, I sort of have this little thing like, There's this hundred extra pounds that could come back on me like that. And so there was a fear of what happens if I start eating all this fat? And it was fine. Right. And you know, yeah. And I mean, I'm afraid.

People are so afraid.

It's true. I mean, people are afraid of avocados.

It's crazy. No, I was.

I mean, it was- that's fattening.

That would be on my no foods.

Nuts, they're fattening.

Nuts are fattening because there's all this fat in them. It's such a paradigm shift for people, right?

Well, and I think the guy who just won the Tour de France is a low-carb, higher-fat diet.

Well, let's talk about that, because you're an athlete. And I think what's fascinating to me is, for years we were trained, have that big bowl of pasta before a race, carb load. And then you need carbohydrates for energy and fuel. I remember I rode my bike from Boston to New York. and all I did was eat PowerBars, which are like pure sugar the whole way.

I lived on them.

I mean, they're so bad.

Right, because they're low fat.

Yeah, low fat, high sugar. Can be quick energy. So what is the deal with people who want to be athletes and they think they need carbs to do high performance athletics? What's the story with that?

So Jeff Voloch has done a ton of excellent work in this area. He's in Columbus right now at Ohio State. so he's really looked at a lot of this. But most of the science that- Dr.

He wrote a book about the art of low carbohydrate performance.

Performance, yep, and it's a great book. I really encourage people to consider to go out and get that book if they're looking at doing this. But ultimately our body can become keto adapted to where our muscles and our brain can use fats for fuel. And so our body stores sugars, but we store a very limited number of sugars that we can utilize.

About 2500 calories.

Exactly. So when you're doing an endurance type sport, like a marathon or an Ironman or something like that, you get to a point, we called it bonking, where you're out and you were just done. You couldn't, you know, you had utilized your glycogen stores and you were finished. And every athlete who has experienced that knows what I'm talking about.

Bonking.

Bonking. When your body, when you exercise on fat, when your body is, when the mechanisms are in place for your body to utilize those fats, the amount of carbohydrate that you need for that goes down dramatically. So it sort of reserves that. And you have this almost unlimited source depending on how much body fat you have.

I have 2500 calories of carbs in your body stored, but you might have tens of thousands of calories of fat.

Right, I mean it's really hard to burn through all of that in the period of what you can do in a day. Right? Even with some of these endurance sports. And you do have to, you know, eat some carbohydrate. I mean, I can tell you the thing that happens with me that's interesting is my body has gotten so efficient at burning fat when I exercise that if I do a high intensity, my blood sugar will go up and I'll actually, my body just, you know, unless I give myself insulin, it's not utilizing it. So adrenaline causes then release of sugar. and without insulin to match it, it doesn't get utilized. But I'm out running and feeling just fine because my body is functioning on fat. It's actually not using the sugar. Right. So, you know, I don't need to give myself extra insulin, although, you know, then I need, if there has been a spike from an adrenaline release, then I do need to usually cover that with a little bit of insulin at the end. So.

So, what, tell me about this study with the type 1 diabetics. What are you hoping to find?

So, Dr. Richard Bernstein is an endocrinologist who's a type 1 diabetic himself. We're actually interviewing him as part of the Fat Summit coming up. And he has been a strong proponent of a low carbohydrate diet for type 1 diabetics for a long time. And that's the way he's managed his diabetes. He's in his 80s now. Amazing. And has no complications related to type 1 diabetes. And he was diagnosed as a small child. And so, you know, we get deeper into his story. But a whole group, so he's written a book called the Diabetes Solution, Dr. Bernstein's Diabetes Solution. And there's a whole group of people who, parents of children and adults with type 1 diabetes, either they had it as a child or they were diagnosed as an adult, who've read his book, who've sort of come together in this Facebook community. And so, you know, David and I looked at this and we said there's this whole group that we can study because there's this fear about type 1 diabetics being on a diet that produces ketones.

Dr. Yeah, right. Dr. Because that's what diabetics can diet.

Dr. Right, so ketoacidosis is something that kills diabetics, but so do, you know, really low blood sugars, hypoglycemia. And so, you know, one of the things that David was really interested in is showing that there's this group of type 1 diabetics who are managing it on a very low carbohydrate diet, and there are different insulin strategies for doing that, and that a lot of people can have normal blood sugars. And so... Perfectly normal. Perfect, yes. So, you know, we're looking at this whole group through a survey, and trying to, you know, to just demonstrate that this is something valid we're studying, and then from there, we can go on and do-- this is revolutionary, right? More randomized controlled trials. Yeah, because there's a lot of people who I know who have shown letters where their endocrinologist dismissed them from their practice, as we talked about earlier, because they were not feeding their child enough carbohydrates. Now the kids are growing, the kids are thriving.

Well, that's, you know, essentially that's what we're trying to do at Cleveland Clinic is just some research looking at how we can get type two diabetics off of insulin. And, you know, most physicians don't see that. They don't see that in three days or four days or a week. People can get off 50 or 100 units of insulin. It's just impossible. But we know it happens all the time. If you have bariatric surgery, you know, you can actually get off insulin within days. Right.

If you sort of cut out half your stomach.

Right. But that is a surgery. And there it affects the microbiome as well.

That's a drastic way to do that, but you can actually do same thing through food. Yeah, I mean, I see it in my own clinical practice as well. In fact, I'll warn patients, I'll say, you,'re gonna need to cut your insulin pretty quickly if you start to do this and really watch for, you know, if you're giving your low blood sugar. Low sugar. And here's how you treat low blood sugar.

That's true. I mean, we got a lot of concern from people and I actually was very clear in the book that this is so powerful that you have to make sure that you lower your medications with your doctor because if you don't, you can get really in trouble. Low blood sugar and low blood pressure can kill you. If it's a little high for a bit or a little elevated, it's not gonna kill you, right? So people are often surprised at how fast their blood sugar and blood pressure comes down when you change your diet. It doesn't take weeks, it takes days.

And we do it in surgical patients because we know, and the studies are coming out getting into the nuances of where the A1C is, that indicates a clear increase in surgical complications. But our goal is to have a good outcome with patients from surgery. And so when I see a patient whose A1C is above seven, we don't, unless they have something that's life-threatening right then, we work to optimize their blood sugar and get it below that prior to surgery. And I'll have endocrinologists call me and say, they're as good as they're gonna get. and they're not. And so, you know, I work with them and within days and so that's the other, you know, sort of fallacy is that you can't see an improvement in an A1C in a period as short as six weeks. Perfectly right. You can, and if you need to measure it, you can measure fructosamine to get, you know, a more finely tuned, you know, to see what's happening over the past few weeks. But you can get better results from surgery by optimizing patients by getting their blood sugars down.

No, it's true. I see it so much. I mean, just people have no idea. I mean, I had one guy who was very overweight. He was on diabetes medications, blood pressure medications. In six weeks, his triglycerides dropped from 300 and something to 65, like 300 points. His HDL went from 22 to 46, which you never see.

Right.

And, and his LDL and his total cholesterol from 200 to 150. and his blood sugar went from 7.3 hemoglobin A1C to 5.3, which is, I mean, in six weeks, it's dramatic. And literally he got off his medications, reversed his diabetes. It works so fast, right?

Yeah, no, absolutely. I mean, that's my experience with my patients as well. And, you know, we do monitor blood sugars carefully after surgery because the stress of surgery, cortisol, and sometimes patients get prednisone associated with surgery. bacteria like sugar. And we don't want patients to get post-surgical infections, so that's where we're really keeping blood sugars. And it drives me crazy when I come in and I see a patient with pancakes on their plate a morning or two after surgery. So, you know, hospital food, we got it. Hospital food, that's a whole separate discussion in and of itself.

It's true, yeah. No, we are still giving patients with heart disease these high carb diets, low fat high carb diets. I mean, it takes so long from the changes in science till actually they're implemented. So I think it's great that we're having this conversation. I'm so happy to have you here as part of the Fat Summit and Coach's Corner. It's been so much fun. And it's just great to be able to just get into this stuff with people and tell the story of what's happening, 'cause there's so much misinformation out there.

There is, and I think, you know, looking at why this hasn't changed, why is people are, you know, All of our medical education was based on eating fat is bad. Totally. And it's really ingrained and unless you're really paying attention to what's going on with the science, then it's a little bit frightening for some docs to start to recommend patients are eating their fat unless they have some personal experience with it or they've really been paying attention to what's going on with science. The science that's out there is confusing too with, you know, looking at the epidemiologic studies versus animal studies versus actual.

Human studies and the metabolic ward studies and those things. Cool, well thanks for coming, Carrie. Well thank you. Really appreciate it and thank you all for joining the Fad Summit.

We'll see you in the next session.