Why High Starch And Sugar Diets Drive Insulin Resistance And Chronic Disease

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

When you have starch your sugar in the morning, whether it's a muffin, a bagel, oatmeal, French toast, pancakes, fruit smoothie, whatever people are eating, it's the worst thing you could do. Hey everyone, it's Dr. Mark. I know a lot of you out there are practitioners like me helping patients heal using real food and functional medicine as your framework for getting to the root cause. What's critical to understanding what each individual person and body needs is testing, which is why I'm excited to tell you about Rupa Health. 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 optimize health and reverse disease. But up till now, that meant you are usually ordering tests for one patient from multiple labs. And I'm sure many of you can relate how time consuming this process was, and then it could all feel like a lot of work to keep track of. Now there's Rupa Health, a place for functional medicine practitioners to access more than 2, 000 specialty labs from over 20 labs like Dutch, vibrant America, Genova, Great Plains and more. Rupa Health helps provide a significantly better patient experience, and it's 90% faster, letting you simplify the entire process of getting the functional medicine lab tests you need and giving you more time to focus on patients. This is really a much needed option in functional medicine space and I'm so excited about it. It means better service for you and your patients. You can check it out and look at a free live demo with a Q&A or create an account at RupaHealth.com that's R-U-P-A-Health.com Now so many of my patients ask me how I manage to work multiple jobs, travel frequently and spend time with my family and still focus on my health. I know it can seem hard to eat well when you got a lot going on. but the trick is to never let yourself get into a food emergency and to stay stocked up with the right things to support your goals. So recently I discovered Paleo Valley Beef Sticks. I keep these beef sticks at home and at the office so I know that whenever I'm in a food emergency, I have a healthy and delicious option to keep me on track. It's no secret that I have high standards when it comes to what I put in my body and Paleo Valley Beef Sticks checks all the boxes. they're gluten-free, grain-free, dairy-free, soy-free, and non-GMO. Plus, they use 100% grass-fed and grass-finished beef, which not only adds to the flavorful taste, but it also means they're free of any harmful antibiotics or hormones that you'll find in most meat. With grass-fed beef, you'll get more nutrients than you would with beef fed with grains, things like higher levels of omega-3 fats that help reduce inflammation, and more B vitamins and other antioxidants to support your body's converting food into energy, and also more of the fat soluble vitamins that are beneficial for a healthy heart. Plus, instead of being processed with chemicals and other questionable ingredients, these beef sticks are naturally fermented, so you get gut friendly probiotics with every bite. How cool is that? Right now, Paleo Valley is offering my listeners 15% off your entire first order. Just go to paleovalley.com/hymen to check out all their clean paleo products and take advantage of this deal. That's paleovalley.com/hymen. I definitely recommend stocking up on the grass-fed beef sticks to keep in your house, in your car, and in your office. It's one of my favorite tricks to staying healthy while on the go. Alright, now let's get back to this week's episode of the Doctor's Pharmacy.

Hi, this is Lauren Pheasant, one of the producers of the Doctor's Pharmacy Podcast. The average American eats over 130 pounds of flour per year in the form of breads, wraps, bagels, and muffins, just to name a few. In a highly processed inflammatory diet, starch can affect our bodies in many ways. It impacts our mitochondria, metabolism, immune system, and often leads to chronic disease. In today's episode, we feature three conversations from the Doctor's Pharmacy on the benefits of reducing our starch intake. Dr. Hyman speaks with Drew Prosewitz on why a high starch and sugar diet is behind most chronic illness, with Gary Taubes on reducing insulin resistance, and with Dr. Ronesh Sinha on his work to reduce starch consumption in the South Asian population. Let's jump in.

I think it's really clear that the most serious threat to longevity and aging is insulin resistance, which is this phenomena of the dysregulation of our metabolism from eating too much starch and sugar. The average American eats 152 pounds of sugar, 130 pounds of flour, about a pound of sugar and flour a day per American. It's poison and it's poisoning our fat cells, it's poisoning our mitochondria, it's poisoning our liver, it's poisoning our brain, and it's leading to all the consequences and all the diseases that we think of as aging. so heart disease, cancer, diabetes, Alzheimer's, the big ones, those are all either caused by or highly influenced by this phenomena of insulin resistance. So how big of a problem is this? Well, really clear from the data that one out of two Americans has diabetes or prediabetes, which is essentially a state of insulin resistance. But I think it's more than that because 75% of Americans are overweight, And a lot of people who are not overweight are what we call skinny fat. They look thin but are actually fat on the inside, or TOFI, thin on the outside, fat on the inside, as opposed to TOFU. And a study came out last year that just even shocked me, which was that 88% of Americans, almost nine out of 10 Americans, are metabolically unhealthy. And what is metabolically unhealthy mean? It means they have high blood sugar, high blood pressure, or abnormal cholesterol. All of those are caused by insulin resistance. So hacking insulin resistance and getting your blood sugar balanced and normal is so key. That's why these new technologies of continuous glucose monitors are so helpful. They really should be looking at insulin though, because way before your sugar gets abnormal and you can have perfectly normal CGM monitoring, perfectly normal blood sugar, but your insulin could be going sky high and crashing and sky high. It just keeps your blood sugar even. if that insulin is going wacky like that and if it's high, it's driving all these diseases. And I once heard a professor from Harvard who was a preventive cardiologist, Dr. Jorge Pleskow say in a lecture, if you could take a group of 100-year-old people who are very healthy and had no cardiovascular disease, they'd have one thing in common. I'm like, what's that? They would be insulin sensitive, meaning their bodies with very little insulin can keep their blood sugar normal. as opposed to needing tons of insulin to keep your blood sugar normal. So we've got a society where almost nine out of 10 Americans are on this accelerated path to aging and chronic illness. Flour and starchy foods and grains, if you're super metabolically healthy and fit and exercising a ton, you can tolerate more of them because you'll burn them off. But for the average person, oatmeal for breakfast is a terrible idea. Cereal is even worse. I mean, cereal is 75% sugar. and we think of oh, it's got fiber and it lowers cholesterol and does all these great things. It's a big snow job. When you look at the data, and there's one profound study done by my friend David Ludwig at Harvard where he took a group of overweight young guys, kids, teenagers, and he gave them three different breakfasts, exactly the same calories. Oatmeal, steel cut oats, omelet. And then he locked them in a room, they measured their blood every hour, and they tracked everything, and they said, well, you guys are hungry, push this button, we'll bring you more food. So they can eat whatever they want. The oatmeal group not only had higher levels of insulin, cortisol, adrenaline, which is the stress hormone. So eating oatmeal literally was like being chased by a tiger in your body. Your body didn't know the difference. It actually made these kids hungrier and they ate 81% more food than the omelet group. Remember, they eat the same calories of oatmeal, oatmeal, or steel cuts. The steel cut oats, Oats was better, but it was, they still ate 50% more food than the Amla group. So when you have starch or sugar in the morning, whether it's a muffin, a bagel, oatmeal, French toast, pancakes, you know, fruit smoothie, whatever people are eating, it's the worst thing you could do. You wanna start your day with protein and fat. So I was starting my day with starch, which is the typical American breakfast.

And often people might have orange juice along with it. Oh, yeah, orange juice. So it's fruit juice and that on.

Top of the oat.

And sugar in the coffee or whatever. sugar in the coffee. So basically they're having, as you say, dessert for breakfast. The amount of sugar that they're having for breakfast is-- It's dessert for breakfast, right? And it'll throw you on a metabolic.

Roller coaster for the rest of the day. Absolutely. Okay, so that was you. And that would have eaten a lot.

More grains, a lot more beans, a lot more what I thought were healthy breads. So just pausing again right there. A lot of people who, especially if they're familiar with the world of plant-based eating and maybe learning from some of the best practices from other cultures, they think that grains, beans, those things are the foundation and actually might be the key to even reversing climate change, right? This is a lot of the topic that people hear. So help us break that down and talk a little bit about that because a lot of people do think that that's the healthy way to go. And it's not that it can't be healthy. Let's talk about how it maybe wasn't the healthiest the way you were doing it. Well, I think there's a couple of.

Things to parse there. One is, if we're eating ancient grains and ancient beans and we're having them in the context of an overall low starch and sugar diet, and we're very active like we all historically were when we were eating those foods over the last 10,000 years. You know, we probably do better. But the modernization of our industrial agricultural system has produced starchy, really starchy versions of these grains, particularly like flour, whole wheat, right? Even whole wheat flour made from dwarf wheat is a sugar bomb, right? It raises your blood sugar more than table sugar. so when, when you don't understand that the food that we're eating is a driver of this insulin problem we talked about with aging, we're never going to get through this. And so I, I'm very careful. Do I eat grains? Sure. Will I eat them every day as a staple?

No.

Do I have quinoa? Will I have black rice sometimes? Will I have a little white rice sometimes? Sure. But it's not something I eat on a regular basis. It's not something that I, I think is, is dangerous if you're metabolically healthy. But for people who are metabolically unhealthy, it's bad. And we're talking about 88% of Americans. Like, you know, my blood sugar, my insulin's less than two. So I can, I'm okay, I can tolerate a little bit, but I also work out a lot and I exercise and I burn it off and I do a lot of other things to optimize my health. So in a perfect world, yes, you can tolerate more, but what I see often is very low levels of protein in vegans. I see I see this over and over and I wish it weren't true, but I have to believe what I'm seeing, which is people have low energy, they lose muscle mass, they have poor cognitive function, they get hormonal dysfunction, low sex drive, libido, infertility, nutritional deficiencies that are really widespread in the vegan community, omega-3, vitamin D, iron, zinc, and more are really common. And so we have to say, well, how do we create a diet that is inclusive of many different foods? but focus on the quality. So for example, if you make your pancakes with regular flour, bad news, right? If you make them with, like in the Pegan Diet book, there's a recipe for chai pancakes, which is delicious, but it's using almond flour and buckwheat flour. Now you can use regular buckwheat flour or you can even upgrade that to Himalayan Tartery Buckwheat, which is available through bigboldhealth.com It's an ancient grain, 3,500 years old, higher in protein, lowering starch and sugar, more magnesium, more zinc. And what's really amazing is that since it was grown in such harsh conditions, very low water levels, high altitude, cold temperatures, poor soils, it's really robust. And that robustness, that stress on that plant, forced that plant to make its own defense system. And that defense system is phytochemicals. So the plant doesn't make phytochemicals for us, it makes it for himself. and so those phytochemicals in the Himalayan buckwheat are more than almost any other plant on the planet. There's 132 phytochemicals. Some of them are not available anywhere else. They have age reversing properties. They have immune rejuvenating properties. And so having pancakes from that flower is okay. And will I do that from time to time? Sure. Do I do it every day? No. But yeah, I'll make Himalayan buckwheat pancakes for a Sunday brunch with berries and you know, don't pour too much maple syrup on it because that'll screw it up. But you can actually include the right grains. So, what should we be eating? Ancient grains. I mean, one of the things that I was just shocked at in Europe, in particular in Germany, they make this rye bread and these dense whole grain breads not made from flour but made from ancient grains. If you stood on it, it wouldn't dent the bread. And, the only way you can cut it is with an industrial meat slicer, like even a knife, can't cut through it. You need these from slicing ham and the deli. Use those to cut the bread. And it's just so rich and good for you. So, some of them against grains, it's just the grains that we eat in this culture are so highly processed, pulverized, high glycemic grains, corn, wheat, those are the main ones, and they're deadly in the form that we're eating them. So, I think that's a huge factor for people to understand. Hey, everybody, it's Dr. Mark Hyman here. As you know, I turned 63 this year. and I'm dedicated to making my remaining 60 years, maybe more than that, even better than my first. That's right. I plan to leave at least till 120 and live well. And a big part of achieving this goal for myself is focusing on good quality sleep. Sleep really is the foundation of wellness and happiness. But when you're sleeping on a so-so mattress, getting deep, restful sleep can be a difficult endeavor. So thankfully, my friends at Ascension have solved the problem of less than stellar mattresses. Their mattresses have the latest in sleep technology to help you achieve high quality deep sleep and REM sleep that you need to optimize future health and wellness. Packed with patented technology, Essentia Certified Organic Performance mattresses feature brand new organic foam formulas to help you experience truly rejuvenating sleep. 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And now, let's get back to this week's episode of the Doctor's Pharmacy. Macronutrients influence insulin differently. So carbohydrates stimulate insulin secretion, protein stimulates in a little bit, fat does not. So you could drink a liter of.

Olive oil and your insulin would not go up.

No, you will store that.

And you won't store it.

No, you will. That's the interesting thing. So it's sort of the one of.

The- if you don't eat carbs, you'll.

Store it or only when you eat it with protein. Well, you're still, you're gonna have to clear it out of your bloodstream. Anyway, you don't want it floating around in your bloodstream. It's going to be stored on some level, even with low levels of insulin, but then it's going to be mobilized. So you basically think of your fat stores as the wallet that you go to the ATM, you take money out of the ATM, that's the food you're eating, and you got to do something with it. So you put it in your wallet, but you got to be able to get it out of your wallet freely when you need it. And insulin doesn't let you get it out of your wallet.

So as long as you're eating a high starch sugar diet, you can't get the money, namely the fat, out of your wallet or namely your fat cells.

Yeah, it's, you know, what happened is, and there was a lot of discussion back then, that carbohydrates are turned into fat when you eat excess carbs and they're not really turned into fat. That's a difficult process for your body to do when it's energy expensive and it doesn't do it that much. But what your body does is make sure you burn the carbs and when insulin's elevated, that's what you're burning. So it's not only telling your fat tissue to store fat, it's telling your lean tissue your muscles and your organs to burn carbohydrates and not to burn fat. Yeah.

But doesn't a carbohydrate increase what we call lipogenesis, which is our own fat production factory? That's why we get fatty liver.

In the liver, well, but again, that could be sugar, the fructose and sugar dependence. So that's the case against sugar story.

We're gonna get to that soon.

So, in pretty well done controlled studies, the amount of what's called de novo lipogenesis, so making fat out of nothing from carbohydrates was very low unless you had sugar in the diet, which is one reason why sugar might be key to this process.

Because like 90 million Americans have fatty liver, it's one of the most prevalent diseases in it linked to heart disease, cancer, diabetes.

Yeah, and which right 20 years ago, liver failure. Nobody knew existed. If you were diagnosed fatty liver disease 20 years ago and you told your doctor you didn't drink alcohol, then your doctor would assume you were lying. And then it starts showing up in kids. And suddenly it's like, okay, these kids are probably not heavy drinkers.

Drinkers of soda.

Yeah.

I met at an obesity conference, a pediatric gastroenterologist, and I'm like, well, what are you doing here? He says, well, I focus on fatty liver disease in kids, and we're seeing it in three-year-olds and five-year-olds. And I'm like, wow, they're needing transplants.

As they get a little older. And I'm like, wow. So, and then, huge pharmaceutical effort to come up with a drug that you can give those kids for the rest of their lives.

That's a great market.

Or you could maybe just cut out the sugar by the day. Cut out the sugar by the day.

Give them more tea oil, which can help reverse that.

Yeah, so anyway, that's the gist of the science is you elevate insulin, you store fat. You want to get rid of the fat, you have to drop insulin.

So how do you do that?

That's the good calories, the bad calories. What are the bad calories? So the good calories by this paradigm, and it's very much a paradigm, are fat, healthy fats, and we could discuss what those are and what aren't. bad calories are going to be carbohydrates, the more refined and fructose rich, the bad calories, the more they're going to work to elevate insulin and keep fat locked away. And that's it's simple.

Okay, well you jumped in there a couple of times with this fructose thing and you said we didn't really even have it until the 70s and then probably in the 80s and now it's a big portion of our sugar consumption. So how is that different and why should we be worried about fructose?

Okay, so we actually, there was a, there's always been a lot of sugar and not always since the 18, 19th century sugar intake goes from five pounds per capita per year at the beginning of the 19th century. That's like Coca-Cola's worth of sugar once a week.

Yeah.

To 90 pounds by the end of, by 1900 and, and 100 pounds by 1920. And then it stays relatively stable because when people consuming a lot of sugar, they tend to get fat, so it tends to be self-limiting. And then the 1980s, it shoots up again because we start blaming everything on fat and high fructose corn syrup comes into the- At the same time. Yeah, so high fructose corn syrup sugar, and this is what Elliot J. Osbourn didn't know, this was the- It's just, you know, very specified siloed knowledge basis. So, a physician who's not a biochemist might have taken biochemistry courses.

Right.

Become a physician, but you're not a biochemist. Right.

It's basically biochemistry. Yeah. So, I booked it back and looked in my first year med school biochemistry.

Text, but it's all there. Yeah, it's all there. I'm like, okay. So, sugar sucrose, the white powder, you know, is a molecule glucose bonded to a molecule fructose. Half and half. Yeah, they're both carbs, they're both simple, well sugar is a simple carb, the fructose is the sweetest of all the carbohydrates, so any sweet substance naturally occurring is going to have, except mother's milk, is going to have fructose in it. The fructose, glucose is metabolized by virtually every cell in the body, so it gets into your bloodstream, you secrete insulin in response to it, you know, they talk about high GI foods, they're foods that break down into glucose quickly. The fructose is metabolized not by every cell in your body, but it goes through the small intestine and into the liver and in high doses it's converted into fat in the liver. So the way I think about it now is our livers evolved to see the fructose and fruit. So a very small amount of fructose in fruit, a month or two a year, and bound up in the fruit, so with all the fiber in the fruit, so you would get a small amount of the substance. It would take a long time to digest it, and then they wouldn't have to make it through the portal system. The portal system, it may or may not do it. There was a paper that came out this summer that says at low dose, fructose, at least in rats, fructose is not going to make it through the small intestine. Then as we increase our sugar consumption and worsen that turn, once we start drinking sugary beverages in huge doses, so the soft drink industry begins in the 1870s and 1880s with Pepsi and, well, Dr. Pepper, Coca-Cola and Pepsi in that order. Now you're suddenly drinking this stuff and you're drinking it between meals and 50% of the calories are fructose and there's no fiber to slow down the digestion. And you're getting massive amounts compared to.

What we would have gotten from the high fructose.

Well, the high fructose corn syrup is high, it was called high fructose because there were lower fructose corn syrups that had been developed over the years.

But it's 55% up to 75% fructose in some of these drinks.

True, and may or may not make a difference. I just don't know. But the liquid sugars are a problem compared to... So you're getting them between meals, you're getting sugar from basically breakfast through dessert.

So, like drinking alcohol on an empty stomach, you get the buzz faster.

You get the buzz and you get it all day long. And that's all your liver is doing all day long is basically processing fructose at doses that's never been designed, never evolved to see before. Like any machine, It's asked to do a job it wasn't designed to do. It doesn't pour it. And then making it do it year in and year out, constantly. Like remember, a little bit of fructose dribbled into the liver over the course of a couple of months. Summer, yes.

Binge on some fruit. Okay, fine. It's just the daily and repetitive doses that are the problem.

Breakfast, lunch and dinner. Breakfast, lunch and dinner. And in between. Because remember, we're drinking the Coca-Colas, not just at our meals, but between meals. And then, like I said, the 1980s with the low-fat dogma, or the 1960s with sugary cereals come in. They start coming in late 1940s and by the 1960s, it's, you know, there's an entire industry from the cereal companies to Madison Avenue, to TV shows that we grew up loving. Rocky and Bullwinkle was created to sell cereal, sugary cereals.

It's true, right? I mean, even Fred Flintstone was promoting cigarettes back in the day.

And was it Froot Loops? Fruity pebbles.

We didn't take good like a cigarette should. Fruity pebbles, right.

It's, it's, yeah.

So it's frightening. So, the case against sugar is your next big tome. It was, I thought, incredibly well researched, really historical, and sort of caught us up to date on why we have this sugar glut and actually what it's doing to us. Tell us more about this sort of case against sugar and should we be having any sugar and is it- Most of that's okay.

So there are two issues here. There always are multiple issues. When in talking about the case against sugar, I'm implying that there's a crime that's been committed and that sugar is. So the question is what's the crime? Yeah. So the crime is obesity and diabetes epidemics worldwide. Recently, described by the director general of the World Health Organization as slow motion disasters, although in some places there's nothing slow about it. Yeah. So these epidemics occur whenever a population transitions from whatever its native diet is to a Western diet. So it doesn't matter what the native diet was. It could be Southeast Asia where it's mostly carbohydrates, a lot of rice and wheat, could be Inuit diet where it's seal meat and whale meat and caribou. It could be a pastoral Maasai diet, warrior diet in Kenya where it's the blood, meat and milk from the cattle. It could be a Native American diet that's primarily carnivorous or a Native American diet that's primarily agricultural. add a Western diet and lifestyle, you get obesity, diabetes, and like I said, some populations like in the famous Pima Native American tribe in Arizona, diabetes appears in the course of a decade, just explodes in this population.

80% of them have diabetes by the time they're 30.

So, the question is what are you adding? It's not the native, it's not the baseline diet. and it's probably simple because you add it to anything, any baseline diet, you get obesity and diabetes. And conventional wisdom is so, I mean Michael Pollan talks about this in In Defense of Food, in a book that I disagree with almost entirely. But we're working from the same observation, which is, what is it that causes this disease of Western diet?

He says don't eat food like substances.

Which is processed foods. So one answer is processed foods. And a lot of people like that. It's a simple answer. We don't have to be wrong about the saturated fat thing. So it's an interesting issue because in the US when we focused on saturated fat, it's because researchers like Ancel Keys and other researchers were asking, Rimmer, the question determines the answer. So the question is, why do we have such high levels of heart disease in the US? We live in the US, what we see, is massive amounts of heart disease, what's causing that? We'll do studies to try and figure that out.

And the answer we come up with is saturated fat. Which wasn't based on cause and effect.

Just a bunch of patterns in the data that turned out to be wrong. Yeah, we've done clinical trials. So British researchers, they have the British Empire, they're all over the world, right? Missionary colonial hospitals all over the British and the remains of the British Empire are asking a different question. Why is it that we have obesity and diabetes epidemics appearing in all these different populations all over the world? And they're coming to the conclusion that it's refined grains and sugars. The only caveat with that is that the same thing happens to populations that are already eating refined grains. Southeast Asia, right?

Although they're also working in the rice paddies 12 hours a day.

And that's one possibility.

So if you want to exercise 12 hours a day, it's fine to eat more carbohydrates.

Quite possibly, quite possibly. So that's one, and that's the first time I heard this story from an epidemiologist at Harvard who is Chinese. And his answer to this question, because I asked him, what about China? They're eating, it was, they're peasants, they're out in the fields all day long, so it mitigates, ameliorates the problem. although it clearly doesn't, because there are people who are working all day long who still get obese. Actually one of the first observations of interest here in the Pima back in 1902. So the Pima had been through 30 years of famine. Horrible, devastating famine. And towards the end of this period, a Harvard anthropologist comes to live with the Pima and study the Pima. He actually had tuberculosis, so he wanted to go to Arizona in an effort to to cure the tuberculosis, which didn't work. But he spent six months, nine months with the Pima and writes a seminal book about it, and he takes a photo of a Native American Pima. He points out that they have a high level of obesity in the tribe, particularly in the older population, particularly in the women. There's a photo in the tribe of a woman he calls Fat Louisa, who's clearly obese. And he asks us, it's sort of, the interesting thing is the older population, they had lived through the famine. 30 years of famine is 30 years of calorie restricted diet, right? And it's very high carb and low fat. And the question is, why are these people fat anyway? And then of course you start looking what's happened. They're on a reservation. They've been introduced to Western foods.

The commodities.

They've been to commodities, which are at the time was mostly white flour, some powdered sugar, some lard. Lard. So anyway, the simple way to answer this question is you say it's food-like substances, it's processed food in general. Now you don't have to think more deeply about it. So you want to know what causes yellow fever, malaria, you blame it on miasma, bad air from swamps. This was the miasma theory of disease, which was like, 'cause the people who lived in low-lying areas and cities and coastal areas tended to get these diseases, and the rich people lived on hills. so they'd be away from the bad air and the bad water and they wouldn't. And you could, you know, avoid the disease with the miasma theory, but it didn't tell you what was causing it. They were mosquito-borne illnesses, that they were viral. And once you know it's a mosquito-borne illness, you can save the poor people too. Sure.

The ones who can't afford to move away from the water.

Yeah.

So they were- Then you spray them.

All with DDT and they get- yeah, or you could spray DDT. So yeah, this is a refined Processed food thing is to me like a miasma theory. It's great, but it doesn't, you know, there is an agent here. It may be multiple agents, may be physical inactivities involved, may be...

But it turns out your conclusions were.

That it was sugar. Yeah, so I conclude it. Sugar is the simplest possible explanation and the obvious explanation.

And for two reasons... Flour, because we.

Also seen a spike in flour consumption, right? Well, you do, but so here's the issue. Again, because remember we got all those Southeast Asians. I had your buddy David Ludwig and I argue about this about once a year. And I say, I'm not willing to ignore two billion possible black swans to my flower theory on the basis that they're out there in the field. They're not all out. So even in Southeast Asia, you see an increase. So obesity and diabetes are now manifesting themselves. And these are always low sugar consumers. So to me, it's a simpler hypothesis. And there are two So we have the fatty liver link, but there's also a link with insulin. So type 2 diabetes is a sort of insulin resistance fundamentally. And one of the arguments I make in my books and David makes and others and has now been embraced is that, and actually Rosalyn Yalow and Solomon Berson suggested in 1965, is that the root from health to obesity and diabetes doesn't go health and leanness, obesity, diabetes, it goes health and leanness, insulin resistance and hyperinsulinemia to obesity and type 2 diabetes.

Yeah, absolutely. And as a doctor seeing patients and testing all this stuff for 30 years, I would completely agree.

Yeah, and a significant amount of evidence, laboratory research and animal evidence in the 50s, 60s, 70s and 80s implicated fat accumulation in the liver. in insulin resistance. And once we start talking fat accumulation, the liver, if I'm an investigator, I'm gonna start wondering about sugar, the fructose. And there's a link between insulin resistance and fatty liver disease. Again, these aren't the same problem. It's all the same problem. It's all the same problem. But the liver, the livers role in all this, tends to implicate something unique to hepatic metabolism of something. And fructose is just the prime suspect. In the case of, you know, South Asians, a lot of the cultural preferences.

Are for vegetarianism, where there's a high amount of starch, high amount of rice, high amount of bread, high amount of sugar.

Yeah.

How do you, how do you navigate that? Because I, I had a patient just, it was really hard to help her because all, like, what could I have her do? It was trying to approach shakes, nuts that, and it was just She really, it was very resistant to it. And, I know I could have fixed.

Her overnight, but she really struggled. Absolutely. So, that's a big cultural part of it. And, you're right. So, the early work that I did, I highlighted that most South Asians are actually not true vegetarians. They're granitarians or they're carbetarians, right? Because the proportion of vegetables that they're consuming is- Carbohydrates. Carbohydrates, right? Because if you basically use a general term vegetarian for all people that don't eat meat and fish, you miss all the nuances, right? If you look at a typical Western vegetarian diet, a healthy form of that versus a traditional Indian vegetarian diet, there's tremendous differences in that. So just to give you a quantitative approach, if you were to quantify it, and again, I think you and I both share one thing is we like to personalize diets for different individuals. So, you know, look for not right for everyone. But definitely, if you take a population, and again, if we're thinking of the fact that we've got less horsepower in our engine genetically, and carbs are a high energy fuel source, we're overwhelming that engine on a regular basis. If you want to get quantitative about it, a lot of my patients, for example, they'll thrive if they can bring their carb intake down to 100 grams per carb per day. But my typical South Asians and East Asians, they're consuming 400 to 500 plus grams of carb. And I tell them the carb itself is maybe benign if it's rices and starches. If you were Michael Phelps or if you were an Olympic level athlete with a V12 engine under your hood, but you've got more like a minivan or a lawnmower engine. We can't flood it with that sort of carbohydrate. Exactly. We don't have that sort of horsepower. We can build that up and we'll talk about that later, but we just don't have that. So, one paradigm that I use to.

Really- so, what you're saying is genetically or is mitochondrial function genetically less in South Asians?

I will tell you this. So, it's a combination. Genetics is a part of it. But then the lifestyle is key. So when we talk about this car vehicle, I tell people the prototyping and designing happens with the parents, right? So even before conception happens, if mom and dad are both insulin resistant and they're sedentary, what happens is they're already insulin resistant and that's going to get transmitted into pregnancy. And that's why in a lot of parts of India and even the US, South Asians have 40 to 50% gestational diabetes. They're already hyperinsulinemic and they're transferring that to the placenta. And the sad thing is you mentioned skinny fat when you look at the South Asian fetus or the newborn, they're already skinny fat. They've got less basically muscle mass and a tiny little pot belly. So they're already a version, a mini me version of what they're going to be later on in adulthood. So that's a big problem. That design happens early on. So part of it's genetics, but the other part is a lifestyle before and during pregnancy. So a lot of the health education I've done out for tech companies in the community is how do you design a healthier pregnancy? Because I'll tell you one thing that really makes this engine much worse. so VO2 max, which is a marker for mitochondrial performance, that's something the parents can influence. So I tell parents that if you're planning to get pregnant, you got to get fit for this pregnancy. Both of you need to be physically fit. But most South Asians are so sedentary that they come into this pregnancy unfit and they're going to have basically an offspring that's going to have a low VO2 max and a low horsepower engine. But my patients that take this to heart, their kids don't have that. Their mitochondria is stronger. It can withstand a little bit more carbohydrate load, but this cultural epigenetic intergenerational issue is really causing that engine to be really much less capacity. So, that's a big problem.

That's huge. And, it's really, it reminds me a little bit of the Pima Indians who 100 years ago, 150 years ago were thin, were fit. Their diet was about 80% carbs, but it was like acorns and nuts and things like that. They grew. and there was no diabetes, there was no obesity. And now, you know, Pima are probably the second most obese population in the world after the Samoans and their life expectancy is 46, 80% get diabetes by the time you're 30. And we're seeing, you know, type two diabetes in three year olds in that population.

Incredible.

It is the opportunity.

I wanted to connect the Pima Indians to Indians because there's another characteristic we're seeing evolutionary that evolve in that. And that's the type of fat that South Asians and Pima Indians actually have. we have less of the brown adipose tissue. That brown adipose tissue, as you know, is the mitochondrially active fat tissue that can actually burn carbs and glucose. And Asians, populations that come from more equatorial regions, they have less brown adipose tissue. And that makes sense because if I'm out in the field, I'm out in the sun, and I'm toiling and I'm laboring, I don't want to generate extra heat, right? That's going to be a dehydrating factor. But as you take these individuals out of their equatorial climates and you put them in temperature-controlled rooms, and then all of a sudden you flood them with this diet, you see a huge impact from that. And honestly, that brown fat can, it can contribute 15 to 20% to your baseline resting metabolism.

So that's a major overlap that we're seeing. That's interesting.

So there's less brown fat in these populations. There's less brown fat. I've got brown skin, but I've got less brown fat.

Unfortunately, they don't correlate. So amazing. And the the, you know, the, the thing that just occurred to me, Rinesh, was that being South Asian and aging are very similar. And that as we age, the population loses muscle and becomes fat. And you marbleize your muscle looks like a rib eye instead of a filet mignon. And that's the source of poor metabolic Health, which means pre-diabetes diabetes, hypertension. heart disease, cancer, everything else. And it's a hundred percent fixable, preventable. You know, I actually, as I've gotten older, I've gotten more and more muscle because I realized that muscle is the neglected organ. Oh, so true. It is the key to health. And it's not just about looking like Arnold Schwarzenegger. It's really about creating metabolically healthy muscle, which is the main sink for your calories and for your food. and if that's not working efficiently, you're in trouble. And what happens also to these people is they have a low VO2 Max, which is basically the amount of oxygen you can burn per minute, which is the rate limiting step in your metabolism. So you can only burn as many calories per minute as you can breathe liters of oxygen or run leaders of oxygen per minute through your mitochondria. And the mitochondria in these people are impaired for a number of reasons. One, the diet itself impairs the mitochondria. Two, it sounds like genetically there's some issues there. And we know even in the PCG1 receptor, there's challenges genetically, even in first-degree relatives of type 2 diabetics. So, they may have 50% slower metabolism to start with. And I think this is a really prevalent condition in South Asians. And so, we see the aging phenomena the same as the phenomenon you're seeing. So, what we're saying here applies not just to South Asians, it applies to everybody. and there's a lot of people walking around who are skinny fat. They think, oh, I'm good. I can eat my sugar and I can eat this and that. I don't gain weight. Well, that's not the key metric.

It's really a much deeper metric. I love what you brought up. You know, that age related muscle loss, which we call sarcopenia, at a molecular level, I call it mytopenia, because if you lose muscles, you're losing mitochondria as well, too. And those engines, you lose horsepower, you're not going to be able to tolerate the carbohydrates. an adequate amount of that. And so one way I bargain with my patients, whether they're of Asian Indian descent or anything, is if you want to eat rice, you've got to sort of earn the right to eat that rice. You've got to squat for your rights, you've got to walk for your rice, you've got to do some physical activity to earn that. Because otherwise, if the minivan's sitting in the garage and it's not doing anything, your body's not going to tolerate that. And the beauty of that, and you know this Mark firsthand, is when you get people more aerobically active, more physically exercising, All of a sudden, they can handle a little bit more of the carbohydrates. The same rule that caused me to get insulin resistance now as a fuel source after I work out, it doesn't have the same impact. So, I think that gives our patients some hope that this is not a banned food like the fructose is and the other processed foods out there.

We can reintroduce it gently to the diet as you upgrade your metabolism. It's true. I mean, honestly, I love to eat, which is why I like to exercise. I like that you guys are true. But, I'm like, I go for a two-mile bike ride. I'm like, oh, great. I just, I went for a 50 mile bike ride the other day and burned 2,400 calories. I'm like, I can eat more food today.

Right, totally, totally.

So, you know, same way.

I don't have any willpower. Yeah, totally.

That's so great. So, Ranesh, your work is pretty remarkable in calling this out and talking about the cultural differences and health disparities. And that's why we often see health disparities in other populations like Native Americans, African-Americans, Hispanics, and of course in South Asia. So, you had this problem too, right? You developed metabolic syndrome and your triglycerides were high, your HDL was low. What were you living like? What was your diet and what was the story around that?

Yeah, you know, I've been a lifelong devotee of healthy practices and even back then when I started my practice in Silicon Valley, I was following the standard dietary guidelines. I was exercising four or five days a week. But what I was doing was-- oh.

Wait, wait, that was a problem.

You were following the standard dietary guidelines. That's exactly right. You nailed it right there, right? And my standard dietary breakfast was pretty starchy with a lot of fruits and oatmeal. I'd have a whole wheat bread sandwich for lunch. So it was a lot of those healthy carbs that were so-called healthy carbs that really overwhelming my system. And then also my exercise was really a lot of HIIT training, a lot of high intensity interval training, and not really that steady, more long grade sort of cardio. as a result of that, I started seeing my patients developing insulin resistance. I was giving them advice, but then I was getting insulin resistant too. So I'm like, okay, so this is not going to work out. How can I be a health leader if I'm developing the same conditions as my patients? And then that really caused me to dig deep into the literature. I had the benefit also of being mentored by Jerry Reaven, who actually coined the term metabolic syndrome. Oh, really?

Yeah.

So, yeah, so I used to drop by his office in Stanford and he really helped highlight this triglyceride HDL, this issue. And he was really such a pioneer. He literally told me that sometimes he doesn't get invited to conferences because his metabolic syndrome criteria doesn't include LDL, right? He kind of nailed the triglyceride HDL insulin resistant axis. And so I took that learning and then really dug deep and then made changes in my body, which I basically translated to my patients. But but that was eye opening. That was over a decade ago. So when I saw that, I'm like, okay, standard diet, trade guidelines. the websites and resources I'm giving my patients are actually making them worse. They're making me worse as well. And, that really kind of led me to really create the resources they need to really address this problem.

That's amazing. You know, I had a lot of Indian patients in my practice and I see exactly what you see and I often wanted to create a cookbook that's like a high fat, low carbohydrate vegetarian.

Indian cookbook because oh, Mark, I would love it if you did that. People ask me to write a cookbook. I have no interest in that.

So if you did that, I would.

Love to promote that.

Please put that in your. You're long to do what? A friend of mine, an Indian woman, she was getting her mother to do it, but she never did. Right. But it's, it's, it's challenging. So what do you tell your patients? Because, you know, if they're already kind of set up, you know, with a deficit because of genetics and. It's a little bit frustrating.

How do you help them? So, we do two things simultaneously. So, the first thing, I have a bit of a clever mnemonic that I use with my patients called CARBS. So, they can basically just identify the framework for the sources of their carbohydrates. So, the C in CARBS stands for chapatis, which are flat Indian bread. Okay. The A is alu, which are starchy potatoes because most of the vegetables are consuming are a lot of starchy potatoes and samosas. The R is rice. the B is beans and lentils, and the S is sugar and sweets. So when they have that framework, I love that.

It works perfectly.

Rice, beans, and sugar sweets, right? So if you have that framework, and.

I'm not telling them they're going to eliminate all of those, but let's have just small portions of that with each of the meals. Maybe one meal is going to have a little bit of rice. Maybe we'll have some lentils with that. But then where are protein sources coming from? Like, how do you really composed a meal so they're not like 100 to 150 grams per carb per meal, which is what I see in my vegetarians, but how do we mix proteins and healthy fats into it? And this is the hopeful part, is a lot of the fats and oils and foods that we thought should be banned in the Indian diet, they're actually now becoming healthy, right? A lot of the paleo primal movements, they're using a lot of our traditional healthy fats. So once you- Dr. Like coconut oil, ghee for people who tolerate it. So one trick I teach them, for example, is when you have starches, that are not mixed with other ingredients, that's when the problem happens. If you love rice, eat it more like biryani or fried rice style, where you mix vegetables into it, nuts and seeds, healthy oils and fats, and you're gonna see that's gonna dampen the glycemic impact. A lot of people are making chapatis or flatbreads, but they're adding eggs to it, like egg paratha, or they might mix almond flour into the batter.

So I teach them how to make higher protein flatbreads.

Yeah, chickpea flour, chickpea flour, almond flour. And you get full off having one. or maybe two max and your glycemic stability is much better. So dilute out the effects of that starch by mixing the vegetable proteins and fats. And the Indian diet has plenty of those. So when they feel miserable about that, I really add that diversity and they feel fuller, their energy is better. And oh, by the way, their net carb intake has gone down by 30-40%. And then simultaneously we do have to upgrade their physical activity levels and really work on the things you talked about. We got to make up for the loss of lean, you know, body mass muscle. We got to gently elevate that VO2 max. But I start with food first because immediately they start to feel better. And as you know, the numbers are magic, right? Within a month, we see tricalcium phosphate drop. And if they see that metric, we're very metrically motivated as a population. You see those numbers go down. You're like, okay, what do I do.

Next to get the numbers even better than that? So that's one framework that I use. I hope you enjoyed today's episode. One of the best ways you can support this podcast is by leaving us a rating and review below. Until next time, thanks for tuning in.

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