The Diabetes Status Quo is Unacceptable! Dr. Koutnik Speaks Out

I was essentially about 2 days away from me not being here with you speaking, Nick.

What is type 1 diabetes?

For the rest of your life, you will be injecting the most powerful, potentially fatal hormone. 99% of patients will never have normal metabolic health again and will live 11 to 18 years shorter.

You achieved an A1C average over a decade of 5.5%, which isn't even in the pre-diabetic range, which fewer than 1%.

And I'm doing the exact opposite. I work with the American Diabetes Association, the leading body, and the president is sitting right in front of me.

You are in the 1%. Hello everyone, today we have our second guest on the interview series that I'm starting on this channel. Now I want to introduce Dr. Andrew Kutnick. He's an award-winning scientist who I can personally attest is committed to producing and communicating research on the treatment and management of type 1 diabetes. He's a really interesting guy. Beyond his impressive track record, doing research with institutes like Harvard, Johns Hopkins, NASA, the Department of Defense. He has an additional resume line, which some of you might be aware of, but I think it's really important and makes him a leading expert in the area of type 1 diabetes and human performance. And that is he lives with type 1 diabetes himself. And I can attest based on my experience with Andrew, friends, and myself, a scientist-patient blend is a potent mix. But not only is he a patient, he's also the first author and subject of a very well-received medical case report on himself that was published with NIH funding. We're going to get into all of that in this interview in part 1 and part 2. I'm very excited to welcome my colleague and friend, Dr. Andrew Kutnick, to the channel. Welcome, Andrew.

Hey, I appreciate it, Nick. It's really cool. We've talked over the years about everything you've done on the educational front. It's really cool to be here to to be along on this, this podcast series.

So awesome. Thanks for coming. So in part 1 of the interview, I really want to focus on your personal journey. I'm very eager to pick your brain about the bigger picture with respect to type 1 diabetes. And there's going to be some spicy stuff, I know, which we'll get to in part 2. But I believe there's so much to be learned from the personal side, especially when the patient themselves is an academic, an expert on the subject. So I think we can derive something very useful for that. So I'm going to start with us just talking about your personal journey. Can you start by just telling my audience in your own words more about you and why you're passionate about what you're passionate about?

Yeah, absolutely. You, you bring up a topic of passion, Belinda, with science. I, I feel like that was, has been honestly one of the most important things for me in my life journey, both as a scientist, but also as someone living with a chronic irreversible metabolic disease for essentially two decades. I was, You know, it's interesting, when I get asked this question, it, it changes almost every time how I, I look at it because life and your perspectives change over time. But if you dial back 2 decades ago, I was, I still remember sitting in the hospital bed, actually I was in the ICU. So intensive care unit for, for those in your audience who aren't familiar, that's, that's the kind of more severe cases when you're past the emergency room and you're put into critical care. I was in there for over a week and my blood sugar was 6 times normal. So imagine you have these, these tiny blood vessels, but you have 6 times the amount of, of this molecule called glucose that, you know, you could, you know, almost see your blood turning to sludge in essence. And I was essentially about 2 days away from potentially not being here with you speaking, Nick. And I was actually on a family trip in Washington, DC and hoping to have fun, but instead got a diagnosis that essentially changed the rest of my life. And I, and I believe turned what could have been an absolute devastating disease to what I believe is one of the best opportunities I've ever had. So I, I, it, it has been an incredible journey and, and I'm sure we'll dive into more of the nuance on that along the way.

Thank you. That's, it's very riveting and obviously something that resonates with me. I just wanna make an observation. This is tangential to where, where I was planning on going right next, but you know, the metabolic health space broadly, I have this impression, and I want to see if you agree, that it is built on the backs of human suffering, be it you, be it me, be it like the Buzuki family and Matt's mental health. There's not the economic landscape and incentive structures to have like business models built around metabolic health. So the way I see the field advancing in different niches, say yours, like type 1 diabetes, it's because you suffered and then became motivated to make this your life's passion, which I see like a pro and a con to that. The pro is it makes the metabolic health movement immensely resilient. The con is obviously that people have to suffer in order to get metabolic health in the spotlight. What are your thoughts on that?

Man, Nick, you didn't only nail it, but there's, there's deep layers to this. So I could not agree more. Number one, Uh, but you imagine you wake up every single day. I've had a lot of, um, future medical students, uh, medical doctors, scientists who I've been lucky enough to work with, uh, been under in our research lab, uh, for 10+ years. And they always ask me like, what, what should I do for my career? I'm thinking about doing this. And I'm like, I think you should wake up and do something you love every single day because you will do that better than anyone else will in your own special way. And I feel that that when it comes to patient advocacy, particularly on the, as you mentioned, the metabolic front, there's just not as much funding or resources that have been placed into these areas, historically speaking. And so as a result, when you're a patient and you're trying to understand, how do I do better? How do I wake up and, and not just survive this disease but thrive with this disease? And unfortunately, particularly in my case, uh, in type 1 diabetes, If you're looking at standard of care, 99% of patients will never have normal metabolic health again and will live 11 to 18 years shorter. So if you want to accept those outcomes, you can go the traditional path. But I refuse to accept those outcomes. I think most patients also refuse to accept those outcomes. There's, there's always a better way. We may not know it at the time. We may not know how to do it, but there's got to be a better way. And I, that, that breeds extreme passion. You know, there was a report that came out and 2017 in a journal called Pediatrics about nutrition. And that article, uh, from your institute at Harvard was the most shared New York Times article in 2018. So keep in mind that this patient group— this is— when you think of diabetes, you think, you know, type 2 diabetes, you know, this big behemoth. But type 1 is the smaller sector of the diabetes population. And you know, 5 to 10% of total population. And, and despite that, despite it being a smaller community, was the most shared New York Times article in 2018. And it illustrates just how powerful the, the motivation and power is behind people who actually deal with disease, suffer from disease, and want to do something about it. And when they find that life passion and they go after it, it's really hard to stop those people. Actually, Nick, you're an illustration of that. Seeing what you've done over the last 2 years is Unbelievable. Like, absolutely unbelievable. Major credit to you. And I know you've been through a similar journey.

Yeah, thanks. I, I want to double-click on something and then actually move it into the for-later file, which you alluded to. I guess the way I'd frame it— I've never framed it like this before— but the difference between evidence-based medicine— I'm going to put that in quotes for now— and what actually works best. I want people to just kind of muddle on that. Maybe in the background of the mind, we'll come back to it. But I realize we haven't actually defined define type 1 diabetes. So I have like a series of 3 questions for you. What is type 1 diabetes? How old were you and how did you react when you were first diagnosed? So I guess that's 3 questions.

Okay, so, uh, what is type 1 diabetes? It is a disease of insulin deficiency. So the best way to describe it is to give it as antagonistic to type 2 diabetes, which is a disease of, uh, insulin surplus or and as a result, insulin resistance, whereas type 1 diabetes is actually the opposite but has extreme overlap to type 2 diabetes. So what happens, or at least to the best of our understanding at this stage, is that the body has some type of autoimmune reaction to what they call the pancreatic beta cells, these small but extremely powerful cells that essentially are, I would argue, the, the rulers of your metabolism. They house the most powerful hormone in all of metabolism,, I would contend, which is insulin. And what happens is when your body, due to some autoimmune reaction, whether it be a viral trigger, uh, some type of, of list of risks that we are trying to still understand, interacting with genetics through genetic expression ultimately cause people to, to build an immune response to those key cells. You lose those cells over time and eventually you lose the autonomous control over your blood sugar. You, you essentially, for most patients, will go to zero or essentially neglectable levels of insulin production. And that means that for the rest of your life as a patient, you will be injecting the most powerful, potentially fatal hormone called insulin to regulate and control your blood sugar. I often describe this as a thermostat. So as blood sugar goes up, the thermostat detects that elevation and immediately starts controlling it back into range. Uh, so if your blood sugar goes high, your body immediately releases insulin into the hepatic circle vein, uh, hepatic circulation, goes to the liver, and then starts, uh, bringing down blood sugar into normal range. If your blood sugar goes low, your body stops the release of insulin, and that stoppage of insulin causes this cascade of changes in physiologic hormones, uh, neuroendocrine molecules, and ultimately keeps what is one of the most essential nutrients in the blood, in glucose, into an extremely tight range. In type 1 diabetes, when you lose that autonomous control, you are manually running the show. So imagine you have your phone and it does calls for you, it does scheduling for you, it— you text. Imagine if you had to go into the back end of your phone and code for all these different processes. Every time you go in to make a phone call, you have to set up code, uh, you know, 40 lines of code to process just one single phone call. In essence, that's what you're doing with your metabolism when you lose that control. And so that, in essence, is type 1 diabetes. I was diagnosed, and I believe this is your second question, is what happened upon my diagnosis and age. I was on a family trip to Washington, D.C. between my junior and senior year of high school. So at a very key moment of my life, very impressionable at least, I was on a family trip and we were getting on the airplane at 17 years old. Well, 16 going on 17, so not quite 17. I was pretty close to my 17th birthday. And I got extremely sick. I— my stomach started to irritate me. I drank Sprite and Gatorade thinking that the sugar was going to calm my stomach down. Obviously, this was very, very counterintuitive, or it seemed intuitive, but actually ended up being terrible for what was happening. And then 2 days later, I ended up in the hospital in Washington, D.C. So I was at a very— it was in junior, between my junior and senior year of high school at 17 years old. And essentially immediately changed the entire trajectory of my life.

And you, so for those who don't know, it sounds like you were in diabetic ketoacidosis, which is life-threatening. I wanna clarify that. Can you explain what diabetic ketoacidosis is, what's going on and why it could actually kill you?

Yeah. So, and this is important to the conversation of metabolism and ketones in general. I'm sure many in your audience have heard of that. Ketones got a very bad rap in the context of type 1 diabetes because they were what were analyzed and determined to be life-threatening to patients with type 1. So why is that, and what actually happens? Well, in patients with type 1 diabetes, or before they know they're even a patient yet and they're clearly on their way very rapidly to becoming one, the autoimmune attack starts to rapidly deplete insulin production in the body. And as a result, when it gets low enough, the body starts to shift just like when you go on a ketogenic diet or you fast and you lower your insulin, that low insulin level is the metabolic, quote unquote, switch to switch from glucose to fat metabolism in the body. Now, that elevation of fat metabolism is occurring because of this extremely low insulin level. Well, in type 1 diabetes, it isn't just low insulin, it is near to complete absence of insulin. And as a result, ketone— not only fat production goes up, but so does ketone production. Why does that matter? Well, ketone production, or ketones themselves when they're produced, hold what these call hydrogen ions. Hydrogen ions contribute to what they call pH, or acid levels. As more hydrogen ions are produced alongside ketones, ketones release the hydrogen ion within the blood, and you start building up higher and higher levels of acid in the blood. Well, normally if you go on a ketogenic diet or you fast, you have bicarbonate levels that would buffer that capacity. And because you have enough insulin on board, even when you fast, you have insulin being released at even small levels. It controls those ketone levels into a tight range or in a, in a controlled range. In type 1 diabetes, the absence or complete absence of insulin prevents any level of control of those levels. And as a result, you continue to rise at an exponential rate. So it's not actually the ketone levels that are damaging in diabetic ketoacidosis. It's the hydrogen ions that accompany the production of ketones that are uncontrolled because of their rapid nature that ultimately cause the devastating nature of what we call DKA, which is life-threatening within 1 to 3 days.

So just to clarify, people who don't have type 1 diabetes, they can't get into these dangerous ketone levels. This is like an order of magnitude above what you could achieve through nutritional ketosis. And just to, to double-click on the confusion around this, you shared with me a really nice review article that was actually done by a colleague of ours, David Ludwig of Boston Children's Hospital, and it went over the history of ketogenic diets. And one of the things that you alluded to that it pointed out was typically, or historically, diabetes was diagnosed by like you're peeing out sugar because there's so much sugar in your body. But you would also pee out ketones if you go into diabetic ketoacidosis. So often ketones were seen as a sign of this life-threatening condition, and this led to a bias towards— it's always most important to reduce ketone levels if ketones are elevated, rather than trying to reduce glucose to a healthy range. And, you know, historically that makes sense, especially when they were just kind of looking at a positive or negative in the urine. But it is astonishing the degree to which that tendency has held on. I can actually share a personal anecdote. When I was in the ICU at Oxford with inflammatory bowel disease, you know, at this point I was transitioning to a ketogenic diet or like there would be points in time where I'm trying ketogenic diet and I would be in ketosis therapeutically and they just wanna push sugar water. Like not just normal saline, but like they give me sugar in an IV because they were so scared. And I'm like, I don't have type 1 diabetes. Like I'm not eating carbs, this is physiologically natural. And I had to like, you know, against medical advice, refuse being infused with sugar water because it was just, you were positive for ketones, therefore we give you sugar. So anyway, just a side anecdote, but I, I wanna move on. You were presumably recommended, you're now 16, 17, a ADA, American Diabetes Association plan for your type 1 diabetes, correct?

That's accurate. Yeah. Everyone is given, when you're diagnosed, the essential tools to survive, which is how do you measure insulin, how do you bolus for carbohydrates, a technique called carbohydrate counting. And then you're, you're, once you show a degree of competency to walk out into the real world, and the second you eat, you have to inject at every single meal for the rest of your life. That is when they release you and you're kind of on, on your own to survive.

How did that work for you?

Well, I remember walking out of the hospital— actually, Nick, I was in Washington, D.C., and I was lucky because there was actually some really amazing hospitals there. And we took the shuttle to back to the hotel. And I remember it was 2 weeks. I was actually in the hospital for 2 weeks, in the ICU for 1 week, in the main hospital for another week. And we leave. And of course, you have a blood glucose meter, you got a finger stick, and then you're also given syringes and you're given vials of what I know are insulin, but no one else knows that. And so I'm going to breakfast for the first time in the hotel, uh, you know, at the bottom of the hotel that we were staying at the time, and I look at the menu and I'm just immediately hit with overwhelming depression because I now realize Well, number one, I don't know everything that's on this menu. There's different food items, some sound good, some don't sound good, but I don't actually know how they're going to affect my metabolism. And in type 1 diabetes, you must become an expert on your own metabolism, whether you like it or not, particularly in nutrition. And I looked at it and I didn't know what to do, like, what do I eat here? And so I couldn't even order what I wanted. I had to order what I thought I understood. And so that gave me some insight as to, okay, I think I know how many carbs in an apple because they told me this in the hospital. And they told me that I need an estimated amount of this hormone, which by the way could kill me if I get the dose wrong. And I'm going to have to inject it at this meal. And by the way, I'm going to have to pull that syringe out in front of everyone with a vial and inject it because that's the only way I'm going to survive for the rest of my life and don't go right back to the hospital I just came from. And so it's, it, it was an overwhelming experience. Uh, the second I realized how important or how honestly impactful this was going to be on my daily experience. They estimate, although I don't know how accurate these numbers are, that you'd make about 180 to 300 additional health-related decisions in type 1 diabetes per day. And it's because you're constantly on, you're constantly, there's no days off with this disease. There's no meals off with this disease. If you do take a meal off or a few days off, you're, you're in deep trouble. So it, it was, it was pretty overwhelming, Nick, walking outta that hospital and, and realizing what this actually meant for me.

Yeah, it's, it's crazy. I mean, you're a 16-year-old kid and just to like emphasize how complex this is, it's not just a matter of like, oh, I have memorized a banana has 25 grams of carbs. It's like, well, that's the standard banana. Is this banana smaller or bigger? Cuz there'll be a twofold difference. Have I exercised recently? You know, what is this meal timing with respect to other meal times? It's so complicated. It's not like a static set of rules. It's an ever-changing set of rules. And you just have to build in these mental heuristics and calculus as a kid. You're 16. And then that also interacts with all the social complicating factors. It, it's really sobering.

Yeah.

So how long did you stay to that, that ADA-recommended diet? How was your blood sugar control? And then what eventually got you to try something different?

Well, to your original question on this, uh, the— when I left the hospital, I actually dealt with obesity as a kid. In adolescence, I had, I actually had on-paper obesity. I was, I was diagnosed with obesity. And, uh, it wasn't like I was, uh, big-boned as they would say. I was definitely obese, like adipose levels very high., and I struggled for years to lose weight, and I finally did lose weight. So I was familiar with, you know, nutrition and exercise impact on at least that. Uh, so, but pretty quickly I realized, you know, I need to flip the script on the situation. And so I just did what everyone said was healthy, you know, and the American Diabetes Association was recommending exactly what that was, which is when you think the average audience member, and your audience is probably way more, uh, advanced on these topics the most. But those who are not very advanced, when they think of health, they're thinking, oh, I'm going to have some potatoes, I'm going to have some fruit, I'm going to have some lean cuts of fish or meat with a salad or something along those lines. And that was very much in line with the ADA diet. But keep in mind that back in the 1970s, the ADA recommended high carbohydrate diets, just illustrating the— and I will quote that people with type 1 diabetes should eat the same diet as those people without type 1 diabetes. Now that we have insulin, you know, now that we have insulin, we should be able to do that. And so I followed that approach, and this was despite me having an extreme awareness of how I'd been more than most, because I had just went through years of changing my nutrition and exercise to try and lose weight, failing numerous times, finally being successful. So I, I had a lot of experience knowing it mattered. And also which foods had kind of estimated grams of carbohydrates. I also bought a weight scale. I was very motivated to do well because I had already seen how nutrition impacted the way I looked at a very impressionable time in my life in high school. So, okay, it's important, clearly. And so now with this disease where it's not just about superficials, obviously obesity affects health and metabolism as well. But now everything I do has another layer of impact. On a whole different level of depth and nuance on metabolism. And so I, I did that approach with a lot of forefront, more expertise than most people, despite not yet having the knowledge I do now. And I— let's put it this way. It's, it's a very hard journey, Nick, because a lot of times you described many things because your knowledge of all the things that change insulin sensitivity. But the truth is that you will go one day and inject the same amount of insulin for the same meal, the same Simonton, the next day will be totally different because of this nuance of metabolism, how complex it is. And most people, patients are told, hey, you're, you're not doing good. Like you come back and your glucose levels are high and you're like, oh, you're, you're not a compliant patient. And in reality, they're doing everything they're told except what they're told doesn't always work., and we have been told strategies that aren't necessarily inherently optimal without evidence that they should be recommended since the 1970s, actually since the 1920s. And that approach did not lead me to anywhere near normal control. In fact, if you, your audience is, wants to, they can just Google right now while listening to this hyperglycemia and hypoglycemia and just look at the symptoms. You know, if you go outside this tight, really tight range of glucose control, you start accumulating not just physical symptoms of fatigue, irritability, but mental symptoms, actually mental health symptoms, uh, lack of concentration, uh, anxiety, uh, uh, you know, fatigue, all these things that affect not only how you physically function but how you mentally function. And this is biological change. It isn't like, oh, you, you just need to change your mindset. No, like this is a biological induced change on your mental health status. And so it has— it had a profound impact. And I was still getting the ADA-recommended HbA1c, which is a measure of your 2 to 3 month average glucose control. I was still getting the target values within that ADA high carbohydrate approach, but it was—

what was your level specifically?

So I was averaging around 6.5 to 6.7 at this time. Okay. So percent HbA1c. But even despite that, it was very far from normal. You would experience sometimes daily symptoms of fatigue, irritability, lack of concentration because you just can Google type 1 diabetes continuous glucose monitor graph and just go to Google Images and you'll see how variable it is. And even at a 6.5 and 6.7, the lines are, are much like a roller coaster all the time. And the HbA1c is just an average. And so you're really dealing with extreme robust fluctuations in glucose. Most patients with type 1 diabetes range in glucose can be north of 200 to 300 milligrams per deciliter, whereas patients without type 1 diabetes, as a reference range, often have a standard deviation around an average glucose control of around 15 above and below the mean. So the difference here is tenfold more fluctuation in glucose, and it has a direct impact in how you feel.

So to summarize, you were an incredibly motivated educated and compliant patient with the guidelines you were given. I mean, you might have had a PhD at the time, but you obviously had the propensity to go on and you were, you know, trying your best. And regardless of that, while you were able to achieve what I think is pretty good levels for someone with type 1 diabetes, an A1C of like 6.5, 6.7 is, is good by, by general standards. That's still in the, you know, you still have diabetes. It's still not normal. And as you pointed out, the average blood sugar doesn't actually reflect the, you know, the patterns, the excursions. A lot of people aren't wearing CGMs. So by analogy, I hope this analogy doesn't offend anyone, but it just came to mind because I do see, like you mentioned, the overlap between, you know, whole body metabolism and mental health. If somebody has type 1 bipolar disorder and they have episodes of mania and then severe depression, you don't just say, well, their mood averages out to stable. So there's stuff going on here that somebody's gonna get upset at me, the analogy, but I actually think it's a fair one with what's going on with your metabolism.

So Nick, can I, can I touch on that for one second? Yeah. When you said, I hope I don't offend anyone, the, the truth is that that fluctuation in how you feel in the average, actually we see that mental health disorders go through the roof in type 1 diabetes post, not pre-diagnosis, post-diagnosis in a dose-dependent manner, often in association with the the how poor glucose control is. So hazard ratios for things like anxiety and depression are on average somewhere between 2 and 5, but you can see studies where hazard ratios— the risk is up to tenfold higher for virtually every major psychiatric disorder post-diagnosis in type 1 diabetes, often in association with glucose control. So poor glucose control, higher incidence and risk for, for psychiatric diagnosis. So your example while, you know, I think on point and obviously may, may throw some people for a loop, like, how are you comparing these two things? They're actually directly similar in an evidence-based way.

So, um, that's really interesting, but I do now want to pivot to your case report. Um, so a massive respect for, you know, publishing n=1 data, but your case report is tremendously comprehensive and goes basically over I mean, technically a 17-year time frame because it gave about a 7-year period, I believe, of when you were on the ADA-recommended diet and then 10 years, so 2013 to 2023, where you were on a ketogenic diet. And forgive me for giving the spoiler up front, but you achieved on the ketogenic diet an A1C average over a decade of 5.5%, which isn't even in the pre-diabetic range.. So you achieved normal glycemia, which fewer than 1%, I think this is the opening line of your paper, fewer than 1% of patients with type 1 diabetes achieve normal glycemic control, but you achieved it for a decade straight. Tell us about that statistic and just let's talk about your case report.

So the numbers, let's start with the numbers first. So in, in type 1 diabetes, and I think you laid that out brilliantly, Nick, is In type 1 diabetes, that data that less than 1% of patients achieve normal glycemic control, which is based on this HbA1c value, that's based on the best clinics, best diabetes clinics in the entire United States, over 30 of them, uh, that were clustered together to pull patient data. So the best clinics, the most knowledgeable physicians, the best resources, uh, and, and arguably the best funding, uh, inputs into these these systems, that's when we're seeing that the average was less than 1%. And that was also data that was also showing that over a decade-long period, despite advancements in medicinal and therapeutic technology, that glycemic control is actually— was deteriorating in our, in our community. And so when, when we think about type 1 diabetes and that impact, I just so happen to have stumbled across the ketogenic diet into diagnosis, actually for fitness reasons. I was big into exercise and I thought, oh man, it was being hyped up, of course, as you can appreciate, Nick, and your audience will, inappropriately, that it's this magic pill that all you do is that and you will never lose any muscle. It will just literally burn fat off instantly. And there's actually some degree of truth to this, by the way, but not to that magical degree, right? There's a lot more nuance in it. But that's why I got interested. I'm like, man, it could do all those amazing things. Let me try this for my performance-based goals. And so I actually happened to reach out to a professional athlete who had type 1 diabetes. Hmm.

And— Can you name who that was?

I can't, because I don't know if they want me to disclose this. Otherwise, I definitely would.

My audience would have come after me if I didn't ask.

Yeah, I always ask. You never know. Maybe there might— I might be able to. I don't want to ask them first because I don't want them to be— you never know how people feel about being tied to something.

I appreciate you keeping confidence.

Yeah, they— I had reached out and I said at the time, actually, to be honest with you, Nick, I was so into fitness and being an obese kid younger that I was so focused on being bigger, stronger, faster than 18 years old. This is the impact that, you know, having obesity can have on you as a kid. I reach out to this professional athlete— is why I'm not saying their name— and said, hey, I'm thinking about taking steroids. I'm thinking about taking anabolic steroids with type 1 diabetes. I at least have the knowledge and awareness that I should not do this without some insight of what that would do to me. And also didn't have access to these tools anyways, so I was just kind of thinking in my mind, this might— okay, this, this will help me get me closer to my goals because if I'm obese and I I want to be as big and strong as fast as possible. That's the opposite of that. And I reached out to this, this person and they said, first off, they actually got on a phone call with me. A professional athlete got on a phone call with me and said, don't do that. Okay. Like, if you, even if you're going to do that, please wait like a decade. Like you don't do that now. And so I never ended up doing it. Thankfully, I'm very grateful to them. But then as we started communicating, I just, it was incessant with questions and They're like, okay, look, I can work with you, but I actually— we had to do it in this way, etc. I was like, okay, I don't care how I do this. They're like, okay, I'm going to teach you along the way. I'm like, what do you think about this diet? You know, I'm thinking about this diet. And they're like, oh, I've done that. You know, we're talking about a professional athlete over a decade ago, over— I mean, actually at this point, you know, 12, 13 years ago, was doing this diet. And they were doing it because it helped them get glycemic control and how impactful that actually is for people with type 1 diabetes around performance. And they're like, okay, this is how you do it. It was a very interesting approach. It isn't just lowering carbohydrates, you also have to match it with insulin. And so I— number one was dissuaded against making poor choices with my health around other exogenous tools besides insulin. You know, I need insulin to survive, but luckily I didn't take these other ones. And then they guided me on doing this approach. I walked into my doctor's office 3 months later, and at this time I didn't have a CGM, so I didn't know how my glycemic control looked every 24/7. I just knew at each finger stick, you know, 4 to 6 to 8 times a day, what the numbers were. And they would always be in this normal range, you know. If they weren't, they were very close to it. And I always— I felt better. And then I walk into the doctor's appointment, who happened to be the American Diabetes Association president at time. And I said, hey. He said— I actually walked in the room. He's an amazing man, one of the best doctors I've ever had. And he said, what are you doing? I said, what do you mean? He said, I've never seen an HbA1c like this in my office before. What are you doing? I perked up like, oh, I'm doing something special here. He's like, your HbA1c is 5.5. Which means that I'm going to have to now justify you still have type 1 diabetes so you can get medication. I haven't seen this before. He calls in the medical students in the office to hear it. And, you know, the residents who are trying to under, you know, do their, their training. And I said, look, I'm doing this low-carb diet and like I changed my insulin and this and this. And they're like, okay, interesting, you know? And from that day forward, I thought, okay, I'm doing something special here. But what I realized, especially with more awareness of tools and over time, that I was mitigating the primary risk factor for my disease that not only predicted the elevated risk of all-10 leading causes of death, but also predicts how long you will live. Not just, let's say, in the advanced Western world, I'm expected to be shortened in my life expectancy 11 to 18 years, at least on the average. And so now I had no idea at this point I was mitigating that to a hypothetical zero. I mean, you know, obviously we don't know, but much lower. And now I'm thinking, wow, not only did changing nutrition affect the way I looked, but now it changed these critical biomarkers of my overall health. And, and I'm doing I'm doing the exact opposite of what the American Diabetes Association, the leading body, and the president is sitting right in front of me. And I'm telling him I'm doing the exact opposite of everything the institute's told me. And I have something that's remarkable and unbelievable. So much so that he invited me to speak to the medical school, to every student that he had. And I, from that day forward, I didn't look back because not only was I doing something that was being praised at this time, this young impressionable age, but I felt completely different. How I felt in the gym changed. I was performing better. My— I was much more, uh, stable in how I felt. It was, it was unbelievable how transformative getting off these high and variable glucose levels are that less than 1% of patients will ever experience after they're diagnosed.

That's really amazing. We'll get into more of the metabolism in part 2, but I want to ask a few follow-up questions on your personal journey, which Let's just start with, you are in the 1%, less than 1%, and you've been there for over a decade. You know, you'd be called an outlier, but do you think glycemic control like yours is possible for every patient with diabetes?

100%. I think being told that less than 7% as an idealistic goal is absolutely failing patients if they don't realize that normal control, less than 5.7%, is readily obtainable. I think it is completely failing not just the patient, but also healthcare practitioners who often don't even realize this is an option. This is an option that is not a— some advanced medicinal therapy that just revolutionized care. It isn't some technology that took $100 million to develop. It is a switch in what you do once, twice, maybe, I don't know, a week when you go in the grocery store. That's what we're talking about here, is a swap in what you were eating to arguably what's arguably healthier, even for people who don't have type 1 diabetes. And so it, it can be that simple. And so in many ways, I think everyone should become aware that there are opportunities and options on the table that allow for what many people believe is, is unachievable, which is normal glycemic control. And we're actually working on this, and I won't go into details here, on, on illustrating that if you look historically, that what I'm saying here about myself and my personal journey, my case report over 10 years, isn't a one-off scenario. In fact, there's an abundance of evidence, uh, in, in nearly 50,000 patients with type 1 diabetes in all published studies, that what we're describing is readily achievable, Nick. Not a one-off. It actually illustrates that this may be one of the most reliable ways for someone to get what appears to be a moonshot of, of what is less than 1%. I believe the 99% can be in the 1%. And I also believe that all of them, including the patients and healthcare professionals, absolutely ethically should be given awareness that that's an option and the lack of that. Is a tragedy for patients and also healthcare practitioners, many of which from elite-level institutes in diabetes clinics have reached out to me asking me, how do I do this? Because patients are doing this at record levels and we have no tools or guidelines on how to do this.

That would be a good conclusion, but I have one or two more questions left. Um, one, I think I share, uh, your position as both a patient and scientist, and I think it's very easy to fall prey to confirmation bias or even just get typecast as an evangelical for an approach because it worked for you and it's what you have experience in. And so it's what you're going to speak to, obviously. So my question is, how do you balance personal experiences with being scientifically objective when evaluating new research?

This is an amazing question. Most interviewers don't even ask stuff like that. They're afraid to offend someone. This is critical because in science, when you are a patient, there is no way your patient experience doesn't influence how you think about things. But let's back up for a second and, and state that when someone is looking at a scientific publication, particularly those who may be looking at it as someone who's looking to optimize their health or their performance, it could be even an elite athlete who is like, man, I'm trying to fix this issue I'm having, what do I do? And they'll pull up the article, they'll probably read the abstract, look at the figures and try to deduce what's going on. But what most people are not appreciating in those figures is that the average is often what's reported. So let's say you had 100 people, Nick, and, you know, some people responded really well, some people responded not so good, but the average was, you know, this average response here, this line graph or this bar graph. And then we give clinical guidance information based on that line, that singular line. But at a patient level, you may fit well above that line or well below that line. What if you're the dot well at the very top or well at the very bottom? Um, you may follow that strategy and it doesn't work, and someone says, you— oh, oh, it's your fault because no, no, of course what you did should have worked for you, it didn't. And you say, well, no, like it, it clearly didn't. And I— you just keep trying and keep trying and think you're the person who's failed when in reality Science is often about providing the best objective way of determining how something works with the largest number of people possible so that we can inform what is happening on the average. But you also have to look at the nuance of how does that apply to me on a personal journey. Like, we wouldn't even care about science if it didn't have some type of application to our lived experience in some way. And so you have to filter these things for yourself when it comes to application. But to your question, how do you, how do you feel? How do you actually process that? Well, a lot of times when I look at science, I'll think, okay, what, how does this science apply to, let's say, optimal metabolism performance or the management of type 1 diabetes and outcomes? How does that apply to the average person with this disease? How does that information now relate back to what often is decades and decades of prior research? It's not just this one study revolutionized everything, and sometimes it does actually, But oftentimes we have to contextualize it. But I always go through a second layer process, which is how does this apply to me? Does, does this apply to me? Because I have found that processing that information through my lived experience has given me more insights into how does that research article have implications on metabolism. And so you think, okay, well, I'm, I'm a unique person. I'm a unique case. I might not know, I might not respond like other people do. When in reality we're all very, very similar, you know, much more similar, let's say, than a rat who shares an extreme high overlap to our genetic structure, or much more so than, you know, you know, plenty of other animals or species in the animal kingdom. Either way, so we're very, very similar. And so if I respond a particular way, it's possible that that has some insight into other people and how they respond. And so what I have found is that there's always a stepwise process of understanding how does this apply to the average person? How does this apply to me? If it does or doesn't, what insights can I gain from that? And then I also have to check myself, Nick, because if it didn't work for me, I'm going to think I'm extra skeptical of this because if it didn't apply to me, is that because I'm unique or is it because something about this may have different methodologies or different, uh, approaches that may guide me in, in, in actually picking apart the application of that at a deeper level. But you always have to check yourself because if something didn't apply to you, it may very well apply to many other people. And that's important because at the end of the day, I've always tried to approach science with a, a particular mindset that I think is critical, which is how do I help as many people as possible with this disease with the information I can gather here and how I can use that information to help them. But if there was a different ulterior motive, it may be a little harder to, to process that through a lens that is hopefully more unbiased and less filtered. And so there's no easy answer to this, Nick. We're all unique individuals that come with our own biases. And being a patient with lived experience every single day, absolutely. Frames how we think about things. So much so, Nick, that on almost every single presentation I've given over the last 5 to 6 years, in my disclosure section, I almost always say lived experience for X number of years with type 1 diabetes, because arguably that is the biggest disclosure I have and what's going to frame these presentations and how I think about them.

Well, that is a fantastic answer. I loved how you framed it with curiosity and asking the questions that you need to check yourself. And I don't think anybody can doubt the authenticity of your purpose. So thank you for part 1 of this conversation. I'm going to release this in 2 parts, so I'll ask you now, where can people find more information? And we'll link your socials in the video notes.

Yeah, I think the easiest place to go for most people if they're trying to just find everything that's out there, uh, that I'm trying to put out there for free to help patients is, uh, andrewkutnick.com. There's a place to sign up if you want stay connected on the various things that I'm doing, uh, to, to put resources out to help people. So you can go there, but I have, uh, a Twitter X account at @akutnik, Instagram and TikTok, uh, @andrewkutnikphd. So, uh, and also a YouTube channel with the same handle. So check all those out if you're interested.

Amazing. Thank you so much. And, uh, everybody should come back for part 2. Bye.