The Dr. Hyman Show - What Causes A Fatty Liver And How To Fix It

Episode Date: August 21, 2023

This episode is brought to you by Rupa University, Mitopure, Levels, and Super Simple Protein.  Fatty liver is a dangerous yet misunderstood disease that is growing more and more common, and its effects are numerous. Fatty liver happens when fat replaces your liver cells and thereby compromises its important functions, thus increasing inflammation in the body. Surprisingly, it is not fat that causes a fatty liver, but sugar and starch. In today’s episode, I talk with Dr. Elizabeth Boham, Dr. Robert Lustig, and Shawn Stevenson about the importance of our liver and how to support it. Dr. Elizabeth Boham is a physician and nutritionist who practices Functional Medicine at The UltraWellness Center in Lenox, MA. Through her practice and lecturing she has helped thousands of people achieve their goals of optimum health and wellness. She witnesses the power of nutrition every day in her practice and is committed to training other physicians to utilize nutrition in healing. Dr. Robert Lustig is a neuroendocrinologist with expertise in metabolism, obesity, and nutrition. He’s the Emeritus Professor of Pediatrics in the Division of Endocrinology and a member of the Institute for Health Policy Studies at UCSF. He is also one of the leaders of the current “anti-sugar” movement that is changing the food industry, in part through his game-changing books. Shawn Stevenson is the author of the international bestselling book Sleep Smarter and creator of The Model Health Show, featured as the number one health podcast in the US, with millions of listener downloads each year. A graduate of the University of Missouri–St. Louis, Shawn studied business, biology, and nutritional science and went on to found Advanced Integrative Health Alliance, a company that provides wellness services for individuals and organizations worldwide. This episode is brought to you by Rupa University, Mitopure, Levels, and Super Simple Protein.  If you’re a healthcare provider who wants to learn more about Functional Medicine testing, go to rupauniversity.com to sign up for a free live class or a boot camp! Support the growth of new, healthy mitochondria and get 10% off of Mitopure. Head to timelinenutrition.com/drhyman and use code DRHYMAN10 at checkout. Right now, Levels is offering an additional two free months of their annual membership. Head over to levels.link/HYMAN to learn more. You can get 10% off Super Simple Grassfed Protein with the code protein10 at drhyman.com/protein. Full-length episodes (and corresponding links) of these interviews can be found here: Dr. Elizabeth Boham Dr. Mark Hyman  Dr. Robert Lustig Shawn Stevenson

Coming up on this episode of The Doctor's Pharmacy. About 90 million people in the U.S. have fatty liver disease. It's increasing worldwide, the amount of fatty liver we are seeing. If you're a healthcare provider practicing functional medicine, you know how hard it can be to keep up to date with all the specialty lab tests that are available to you. Well, I have a solution for you. Rupert University. Over 20,000 practitioners go through Rupert University courses each year to learn from industry experts about specialty tests like GI map, Dutch complete, organic acids, and many others. And the best part

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Over 90 million Americans have fatty liver disease, which is when your liver cells turn to fat cells and the liver can't do the job it's meant to do. When left unchecked and untreated, this condition can lead to reduced detoxification function, insulin resistance, and more. Non-alcoholic fatty liver is preventable and can be improved using diet, supplements, and herbs. In today's episode, we feature four conversations from the doctor's pharmacy about why the liver is so important in our modern lifestyle filled with toxins. Dr. Hyman speaks with Dr. Elizabeth Boehm about the purpose of the liver. She shares a related case study and they discuss what to eat to support the liver. He also speaks with Dr. Robert Lustig about how to test for fatty liver and its role in insulin

resistance. And finally, Dr. Hyman talks to Shawn Stevenson about how inflammation damages the liver. Let's jump in. Fatty liver is when the liver cells, the cells in your liver, are replaced with fat cells. So fatty liver just means that some of the cells in your liver have been replaced with fat cells. And so there's fat deposited within your liver. Why do we care? Because then that means your liver can't work as well because it doesn't have all those liver cells doing the job that the liver does, right? So the liver really helps our body detoxify, metabolize chemicals from the environment, metabolize our own hormones, metabolize and get rid of toxins. And so we definitely don't want to have an under-functioning

liver, that's for sure. And the prevalence of fatty liver disease is really, really high. And unfortunately, it's increasing. But about 90 million people in the US have fatty liver disease. And so it's increasing in this country, it's increasing worldwide, the amount of fatty liver we are seeing. So Liz, tell me more about a patient that we've had. Because I think, you know, sometimes patient stories are really helpful and instructive

and give us a sense of how we do things differently at the El Gervando Center here in Massachusetts and Lennox. And what younox and what you found and what you were able to sort of help him with and how it all worked. Yeah. So I had a 50-year-old gentleman who came in to see me and he was told by his primary doctor that his liver function tests, his ALT and AST were mildly elevated. And so he came in because he was frustrated with his weight. He wanted to lose some weight. He was about 25 pounds overweight. And he just mentioned to me that his doctor had said his liver function tests were a little elevated and that they were going to

be rechecking them in a few months. And, we really got a good detailed history from him and we got a sense of what he was, what his diet was like and, um, and, and, you know, what his, what his alcohol consumption was like, because, you know, that's one of the first things, of course we think about with, you know, fatty liver or, or these elevated liver function tests is we're like, okay, how much alcohol is this person consuming? And what was interesting to me about him was, you know, he was pretty moderate in his alcohol consumption. He was having about two glasses of wine a night. And so not for a man, you know, that kind of almost falls within what's considered moderation. So I was, you know, he was not a binge drinker. He was not overusing alcohol from the,

from the criteria we were talking about earlier. But I think the amount of alcohol he was consuming in connection with his diet, and probably his genetics and many other things like his microbiome that we've spoken about, you know, that all together was really impacting these liver functions for him. And so, you know, we noticed with his diet, it was, you know, not rich enough in vegetables, that's for sure. And, you know, really, that was probably the biggest thing I would say with his diet, it was just, you know, devoid of a lot of vegetables. And you were talking about some of the things supplements we use for helping the liver. One of the things we think a lot about is sulforaphane, which comes from your cruciferous vegetables that helps and encourages the production of glutathione in the body. And so one of the things we really work down with him

is making sure he got some cruciferous vegetables every day, broccoli, cauliflower, cabbage, kale, Brussels sprouts, you know, really to help support, support, uh, the, uh, liver and help it heal. Essentially. Um, we also had him take a break from alcohol. You know, we said, you know, let's just pull away alcohol for a period of time, really help that liver calm down and give it some time to heal. And as I was mentioning earlier, we really can see the liver function tests go down pretty quickly for some patients. We can see if somebody did have fatty liver, you can watch it improve within a few weeks of cleaning up the diet and decreasing alcohol intake. So it can be, especially if it's not too far progressed, we can see changes pretty darn quickly.

And so with him, we really focused on cruciferous vegetables, lots of the sulfurous vegetables like onions and garlic. We gave him turmeric. We gave him dandelion root to help his liver and gallbladder work better. Lots of green leafy vegetables. We made sure he was eating enough protein. We know that protein is really important for the detoxification process in the body. We need to be eating enough protein to do that. And so we made sure he was getting enough and, you know, foods that were rich in fiber, divine toxins, things like the beans and legumes and nuts and seeds, ground flaxseed.

And I did, I gave him some N-acetylcysteine, some NAC. I gave him some liposomal glutathione and milk thistle. We put him on a really good multi that had methylated B vitamins in it. I gave him a little bit of an extra methylated B vitamin and really focused on those nutrient dense foods so that he wasn't wasting his calories because he was 25 pounds overweight and we needed to cut back on that weight. So we really needed to pull away those foods that were not nutrient dense. So things that are just people are eating way too much of that are getting into our, our, our diet that are not giving us all of the nutrients the body needs

to work properly. Yeah. So incredible. So incredible. So I feel like we, you know, we, we see this so prevalently, it's so misdiagnosed or underdiagnosed. It's such a huge impact on your long-term risk factors for all sorts of chronic illnesses from heart disease to cancer to diabetes and more. And it's something that traditional medicine doesn't really deal with very well. And you might've been told your liver function tests are elevated or don't worry about them or they're not that bad or whatever, we'll watch it. That is just not a good idea. And I don't think we are equipped in our traditional training with understanding how to actually figure out what to do for these patients with abnormal liver function tests.

And I certainly was never trained. But the beautiful thing about functional medicine is that we have a way of evaluating the liver differently. We have a different diagnostic test we use. We have different therapy options. And we see tremendous improvements in liver function and quality of health. And it's not just about the liver. It's like when you treat what's going on with your patient, it's like everything gets better. His hormones get better. His liver gets better. He loses weight. His sex drive improves, you know, like everything gets better. Blood pressure goes down. And all of a sudden you've got a person who's instead of going on a trajectory towards increased risk of disease and death to actually having a more vibrant, healthy life. So it's super encouraging when you see these kinds of patients because they're really relatively

easy to diagnose and treat, and yet traditional care just doesn't cut it for the most part. Yeah. I mean, within four months on the plan, his liver functions came down to totally normal. You know, after he lost 10 of those pounds. And then within a few more months, he lost another 10 pounds. And his fasting insulin came down to normal. His liver function tests, his markers of inflammation in the body improved. And then eventually, I've been seeing him for a while. So at this point, he does have one or two glasses of wine a few days a week. Like he does drink some alcohol at this point. Um, he never, as I said, he never had a problem with alcohol abuse or alcohol overuse disorder. Um, it just was, he was drinking too much

for his body. And so at this point in time, he's having a little bit of alcohol and doing, doing okay with that. And it's not causing a bump in those liver function tests or some problem with his weight or insulin resistance anymore. So he did really well. So why is fatty liver a problem? I mean, so my liver is a little fatty. Who cares? Why is it an issue for people?

Why do we care to fix it? Other than the fact that you can get cirrhosis and die from liver failure. That's not a common thing. Other than the fact that you can get cirrhosis and die from liver failure. That's not a common thing. Other than that. But that's a late stage thing. The other problems are not late stage and they happen to a lot of people and they're unrecognized as related to fatty liver. Right. I mean, they can happen quickly. Fatty liver can develop quickly. They know that within two weeks of heavy drinking, having one and a half to two ounces of hard alcohol every day for two weeks, you can start to see signs of fatty liver, which is that it can develop very quickly. What's great to also understand within a lot of this research is

that it can resolve quickly. So when somebody has fatty liver because of alcohol and you take them off of alcohol, that you can see resolution of fatty liver within four to six weeks. So it can progress, unfortunately, quickly if we're not taking care of ourselves. And then it also regresses when we start to make some shifts. And as you were mentioning, we're seeing this huge rise in fatty liver, not only because of alcohol, but because of how high blood sugar, high levels of insulin, toxins like glyphosate and all the other toxins you mentioned, medications that people are taking, all are putting stress on our liver and making it so then our liver can't do what it needs to do

to detoxify. So it becomes this vicious cycle of we're inundated with toxins that are impacting our liver, but then the liver can't work as well. And so then we can't get rid of the toxins that we're inundated with. So it becomes a vicious cycle of having issues with our detoxification system in our body. And as we've spoken about before, the liver is such a critical organ within the body's natural ability to detoxify and handle all the toxins we're exposed to. Maybe we weren't put together to handle all of these toxins, unfortunately, that we're exposed to, but we do have this ability to handle toxins and we want to take care of our body so we can handle the toxins that we are exposed to. And so it's really important that we take care of our liver. And so what is considered, you know, what's considered normal for alcohol intake, you know,

for, for men, it's less than 10 drinks a week. And for women, it's less than five drinks a week. And so we know that that problems with the liver can occur when we're drinking too much. So we see problems when people are binge drinking or consuming more than 14 drinks a week for men or more than seven drinks a week for women. So I think it's important we also talk to our patients about what is moderation with alcohol? How do we take care of our liver, both from all aspects of nutrition and lifestyle? So there was also an interesting study came out recently looking at cancer. of our liver, both from all aspects of nutrition and lifestyle. So there was also an interesting study came out recently looking at cancer and alcohol and showing that there's a dramatic increased prevalence of cancer, even a little bit of alcohol may actually increase the risk of cancer. So it's not just fatty liver, but it was a Japanese study with 63,000 adults where they

looked at people who are drinking alcohol, and it was a concern. But that aside, besides just the overload on your liver, besides just the stress on your liver's ability to deal with all the normal toxins we have to deal with, what happens when you have a fatty liver is it drives inflammation in the body. And it's linked to heart disease, to cancer, to diabetes, to diabetes, to even dementia, and all sorts of things that we don't think necessarily related to a fatty liver. So fatty liver is sort of an early warning sign and clue that there's something wrong in your body and it's causing a risk, an increased, dramatically increased risk of all these other problems. With that said, how do we know if we have fatty liver?

You know, one of the first ways we find out is with general blood work. So if you do a metabolic panel, comprehensive metabolic, a panel on a patient, and we look at these markers like the AST and the ALT, and if they're elevated, either high end of normal or elevated above the normal range, you know, that's something we really have to be thinking about is, is this, is this fatty liver? Is this, should we go on and do an ultrasound of the liver to see if we are seeing some fat deposition in the liver? And so that's one of the, the ways we start to see it most frequently with our patients. Yeah, absolutely. And so there's other tests you can use, which I've had personally,

just because I've started biohacking, kind of like to check everything. But you can do an MRI and look at liver fat. And it should be less than 2%. And many people have very, very high liver fat. I thankfully have less than 2%. You can also, they're actually also doing fiber scans, which look at the fibrous content, the fiber, sorry, the, the scar tissue from the fatty liver, and they

can use ultrasound scans. And those are good for measuring the degree that you can do liver biopsies. And I think, you know, what we see is, is really in functional medicine, a roadmap for healing the liver in ways that just doesn't exist with a traditional medicine or conventional medicine. So talk about what are the ways that, you know, in addition to the testing we talked about, we'll look at insulin resistance, we'll look at the particle size, we'll look at inflammation, we'll look at a lot of things that traditional doctor wouldn't look at. What are the beginning things we do from a dietary lifestyle and supplement perspective to reverse fatty liver? I mean, one of the first things we do, right, is of course we get a good detailed history from our patients and try to get a sense of what's going on for them, get an understanding of their timeline

of their health. And that can help us find out what may be driving health problems in that person. So if there is concerns about fatty liver, you want to get a sense of what their toxic load has been in their lifetime. What is their weight? What is their nutrition? What are they eating? And what is their microbiome like? And so we can really evaluate all of that and get a sense of how best to help this patient, that individual patient improve. Because we know that for some people, it may be more focusing on toxic load. For somebody else, it may be focusing more on alcohol intake. For somebody else, it may be more they're eating way too many carbohydrates, refined sugars, soda, coffee drinks, muffins, and not exercising enough and that whole metabolic syndrome process. So we want to really

help focus the treatment plan on that individual patient. And I think that's what's so special about functional medicine is it's really looking for that underlying root cause for that underlying patient so that they can reach their optimal health. And we know that problems with the liver and fatty liver impact our immune system and how well we fight off infections. It impacts how we can digest food, metabolize food. It impacts our nutritional state in our body. So there's so many reasons why we really want to look deeper. Absolutely. And I think in addition to the dietary stuff and getting rid of the environmental toxins that we can, sort of decreasing our overall toxic load. And we've talked about this in other podcasts, like the Environmental Working Group's Guide to How to

Reduce Your Exposure to Toxins in Food and Household Cleaning Products and Personal Care Products. But there's also a lot we can do from a dietary perspective to upregulate those pathways in the liver that boost glutathione, all the brassica family, the onions and garlic, all the spices that we can use, and even herbs that can be very helpful, like milk thistle and others to help improve the liver function. And then there's a whole bunch of nutrients that the liver needs to function.

And in fact, you and I were both trained in traditional medicine and we worked in the emergency rooms and, you know, people come with a total overdose. We give them this quote drug called mucamist, right? Which is actually N-acetylcysteine. It's a supplement you can get over the counter. And what it does is it boosts glutathione and helps the liver to regenerate glutathione, which is what's depleted often with fatty liver and internal liver damage from overdose. And so there's a lot of things you can do to boost glutathione. You can take glutathione, you can take initial cysteine, lipoic acid, milk thistle, curcumin.

We use a lot of herbs. We use also the B vitamins, zinc, selenium, amino acids. And we do a lot of things to help the liver heal. And what's amazing is when you use this cocktail of substances, things like milk, thisyl, lipoic acid, N-acetylcysteine, glutathione, and so forth, livers will come back. And it's striking to see the drop in liver function tests, the improvement in fatty liver content. And I encourage people to really think about, one, checking to see if they have it. Two, thinking about how to actually upregulate your lifestyle so that you can protect your liver. Hey, everyone. Dr. Mark here.

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featuring my super simple protein made with really clean ingredients and also minimal ingredients from grass-fed beef protein. Right now I'm offering the doctor's pharmacy listeners 10% off. All you have to do is go to drhyman.com forward slash protein and use the code protein10. That's drhyman.com forward slash protein and use the code protein 10. That's one and a zero. We all need to learn how to love our livers. They do a lot of work for us. They clean our blood. They keep us healthy.

And when they don't work, we get sick. And people think that, you know, unless you have liver failure, it's fine, which is not true. The liver needs a lot of support to do its work. And I know this personally because I had mercury poisoning and I had to take care of my liver if I wanted to get better. The liver requires a lot of support to do its job of detoxification. And also, unfortunately, we are in a sea of toxins. So what is the worst toxin now affecting the liver? You might say pesticides, you might say industrial chemicals, you might say heavy metals, and you'd be wrong. The biggest problem affecting the liver is sugar. It's the number one cause of liver disease

today in America. In fact, it's the number one cause of liver transplants. Drew, I don't know if I ever told you this story, but I went to a conference on childhood obesity. It was maybe eight years ago. And there was a doctor there who was chatting with in the hall. I'm like, hey, what do you do? He says, well, I'm a pediatric gastroenterological surgeon. I'm like, what are you doing here? He said, oh, well, we do liver transplants. I'm like, what do you mean? Liver transplants for what? He said, when I was seeing teenagers with cirrhosis of the liver from fatty liver,

from eating sugar and soda. And I'm like, you're kidding. This is just horrific. We see kids as little as five years old with what we call non-alcoholic steatohepatosis and fatty, which basically means fatty liver. And eventually ends up with scarring the liver and cirrhosis. We think it's alcoholism.

It's not. It's sugar and starch. So this is the biggest driver of a toxic liver. So the first thing you need to take care of your liver is really dramatically cut down or cut out starch and sugar. Obviously, alcohol is a problem. You next want to make sure you're avoiding as many toxins as possible. So get rid of the toxins in your food.

Obviously, processed food for sure, additives, preservatives, but also pesticides and chemicals in food. I am on the board of the Environmental Working Group, and it's important to check which vegetables you're eating that are contaminated. For example, strawberries, which I love. The worst, I would never eat a non-organic strawberry. It's number one on the Environmental Working Group's list of most contaminated fruits and vegetables. You can Google it, ewg.org. You can find the dirty dozen list, stay away from those. And then there's a clean 15. So if you don't eat organic avocados or bananas, it's okay, right?

Save some money there. But for sure, if you're having celery, if you're having nectarines, if you're having strawberries, you do not want to eat those if they're not organic. Next is clean up your house. You know, your house is one of the biggest sources of toxins, both indoor air pollution from off-gassing of VOCs and chemicals, whether it's paint or furniture, carpets. I mean, there's so much plastics and chemicals out there. So try to use natural materials in your house.

And also household cleaning products are, and if you don't, if you can't make sure you redo everything in your house, get an air filter and clean your air with a HEPA filter. We use one called Air Doctor, which is really great. Next, I would say you want to make sure you are using household cleaning products that are not making you sick. I mean, think about it. When you read these products, if ingested, go immediately to the hospital. You don't want those in your house. So the Environmental Working Group has, what do they say, household cleaning products, skincare products. They have a wonderful database called Skin Deep, where you can see what are you putting on your face? Your lipstick has got lead in it? Well, don't use it. If your topical creams have parabens and plastics in them, don't use it.

You're absorbing it. If you wouldn't eat it, you shouldn't put it on your skin. And next, you want to make sure, obviously, the fish and the meat you're eating has low mercury and toxins, and there's, again, guides on the EWG.org. So it's a great resource to lower your exposures. The next thing I would do is make sure you're eating foods that upregulate all your detox pathways. So the most important categories of foods are the brassica or cruciferous vegetable family, which is broccoli, collards, kale, cabbage, Brussels sprouts, that whole family, and the garlic and onions and family. And so I would eat those on a regular basis. For tonight, I'm having broccolini with garlic. So I do it pretty much every day. I make sure I have these foods. Next, you can actually start to do kind of more fancy stuff.

You can have green juices, celery juice, watercress juice, cilantro juice. I had a guy who had heavy metals and he just juiced cilantro and had a cup of cilantro juice every day. And cilantro is a great detoxifier that helped his liver flush out the metals and he got rid of his metals. You also want to eat herbs and spices like rosemary, curcumin, which like turmeric, which for curries, you want to make sure you have things like rosemary, lemon peel. We throw away lemon peel, but if you get organic lemons, you can kind of, I like to kind of grate the lemon peel and put it in salads. It's great with like my kale, pine nuts, lemon peel, lemon juice, olive oil, salt and pepper. It's delicious. That's why I like summer because we grow fresh kale. It's really good with the fresh kale. And then once you've kind of upgraded your diet, include all the phytochemicals, and I'm literally

just like touching the surface. There's whole books written about this. I just got picked from Ikaria, which is in Greece, one of the blue zones. And every morning, and all day actually, they had this stuff called wild sage tea. And I'm like, wow, what is this stuff? Why do they live to be 100 years old? Why do they have the longest lived population in the world? I'm like, does it have anything to do with the tea? Well, I think it does. Because when I looked up the tea and the phytochemical content, it was full of something called epigallactic catechins, which are these incredible compounds that are detoxifying, that are anti-inflammatory, that help your immune system, that activate longevity switches. In fact, there's some theory that, and in fact, there's data on this, that these catechins in green tea

and also in this wild sage tea upregulate glutathione and help your body detoxify, which is the main detoxifier. Then after you've done all that, obviously exercise is important. Making sure your gut's healthy is important. Making sure you're sweating. I call it the three P's, pee, poop, and perspire. You want to make sure you're flushing your system. Lots of water, lots of sweating, saunas.

I mean, I did hot yoga. I was just in New York. I love hot yoga. Kind was just in New York. I do, I love hot yoga, kind of flush your system out, moves your lymphatic circulation. All that's great for detox. And then lastly, you want to kind of beef up your supplement measurement. So a good multivitamin. The reason, and the reason is, oh, before I go to the supplements, I just want to kind of loop back to the food. You know, a lot of people don't realize how important amino acids are from protein. So protein is so important for detoxification because a lot of the pathways,

and I'm not going to bore you with all the fancy chemical names, but a lot of the pathways in the liver to get rid of toxins require amino acids. So you have to have a good complement of amino acids. And if you're just eating plant foods, you might not get those. So important to make sure you're getting enough of the right amino acids. And then supplements. So what should you be taking? A good multi is important, but then there's a number of ones that are really key. Methylation, B12, folate, B6, very critical. Zinc, very critical. Selenium, important for the liver detoxification and boosting glutathione. Magnesium. So you want to make sure you have adequate levels of these nutrients. Then there's all the herbs like milk thistle and other compounds that can really be helpful,

curcumin, artichoke. There's a lot of these compounds, ellagic acid and pomegranate. So there's all these things that we can use as part of our diet to upregulate these pathways that are phytochemicals. And then there's the supercharged ones like glutathione-boosting supplements like N-acetyllcysteine which works so well the government wants to ban it which makes me laugh you know anything works too good they want to turn it into a drug I'm like no it's just like it's just a supplement and then lipoic acid also is very important and then there's a host of other things but those are those are the main things I focus on and I and I I've learned to incorporate

these it sounds like a lot but I learned to incorporate these into my life every day. This morning, I had a green juice. I make sure I took a sauna today. I have one in my house, a steam. I'm having broccolini and garlic tonight for dinner. I'm taking my supplements with N-acetylcysteine, lipoic acid, and my methylating supplements. So I just work it into my life. It sounds like a lot, but once you kind of learn how your body works, you kind of just do it automatically. I want to talk about how we diagnose insulin resistance and you have in your book a way to self-diagnose because it's really important because your doctors are missing 90% of it. They don't get taught how to diagnose it. They don't, because there's no simple drug for it. So if there's no drug for it, why test for it? Right. And, and you just talked about a few major things that are a little bit confusing.

One is you can be metabolically normal obese, meaning you're overweight, but metabolically normal. And I think that's a small number of people. You can be metabolically obese and normal weight like the people from India and China. They can be on their BMI, their body mass index normal, but they're still diabetic. Right. Right. And that's dangerous. In fact, I've seen some studies that that may be more dangerous than being overweight and metabolically unhealthy. And then there's the and then there's the obviously the overweight, the metabolically obese and obese, obese patients. So there's these different categories. Some of it's genetic.

Some of it's, you know, has a lot of variations. But you kind of can't know until you test. So explain to us how we can understand what's going on in our bodies. How do we test for this phenomenon that's driving all these diseases for which we're taking so many medications that aren't really working? They're just managing the disease and they're not actually treating the problem. They're treating the symptoms. Totally. The problem, of course, is that your doctor has access to all of this and you don't.

And you need to and they need to, but they don't understand it, which, you know, maybe you can teach your doctor what to do. How would that be? All you audience out there. Okay. All right. Sometimes doctors are a little, you know, shall we say provincial and they don't necessarily, you know, listen to their patients, but they really should. If they listen to their patients, they'd be much better doctors. All right. Number one, you look at your waist. Now, your waist is a conglomeration of many things, but primarily visceral fat and liver fat. That's what determines your waist circumference. If you are a male and your waist is 40 inches or greater, the chances are you have visceral and or liver fat. And that probably means you have insulin resistance and you have mitochondrial dysfunction.

If you are a female and your waist is 35 inches or greater, same thing. Now, that's the cheap way. Unfortunately, it's sensitive, but not specific. So there are other things that can, you know, cause you problems as well, like ascites and other things, but, you know, we're not going to- Pregnancy. Pregnancy. Yeah, pregnancy. Thank you. Yes. Okay. So, which of course is insulin resistance also, you know, but that's for another day. Then you start getting into the lab tests. Okay. What lab tests do you need to get? The most important lab test for determining insulin resistance is a fasting insulin.

Now, doctors don't draw fasting insulins. I think it's the single most important lab test to draw, but they don't draw it. Why don't they draw it? Because the American Diabetes Association told them not to draw it. Now, why is it that I'm saying that this is the most important test that you have to run? And the Diabetes Association is saying, don't bother. How come we are so completely diametrically opposite? The answer is because I'm right, they're wrong. Now here's why. I agree. Actually, by the way, I've been measuring this test for 30 years. Me too. And it's just astounding to me how important it is and how nobody tests for it who's in the conventional medicine. That's right right so here's why the ada says don't

draw it two reasons and they're both wrong and specious number one they say well lab tests around the country for fasting insulin are not standardized yeah now that is true that is true i don't argue that and the reason is because cheap tests, cheap insulin tests do not distinguish between the insulin molecule and its precursor, the pro-insulin molecule. Now, pro-insulin is a pro-hormone, meaning it's before you get the active hormone. It's bigger. And the pancreas, the beta cells in the pancreas make this thing called pro-insulin. And then there's an enzyme that cleaves the C-peptide piece off, and then you release the insulin. Now, when you're sick, when you're insulin resistant, your pancreas doesn't

have time. Okay. And that may actually even be a problem that you have a problem with that enzyme. And that enzyme is called PC1 or prohormone convertase one. Now you may, if you're sick, release both, you may release both pro-insulin and insulin. And so pro-insulin gets picked up in the insulin assay. So indeed, insulin assays around the country are not standardized. So the American Diabetes Association is right about that. But so what? If it's high, you got a problem. Okay.

And they basically don't understand that. And so that's specious issue number one. Specious issue number one. Specious issue number two. They say insulin levels don't correlate with obesity. That is also true. They correlate with metabolic health. Yes, and heart disease and cancer and dementia. Exactly.

And we just told you that there are thin, sick people. So they're not registering on the scale, but then they don't know that they're sick. Yeah. This is exactly why we need to be drawing fasting insulins

is to figure that out. Yeah. Fasting insulin. By the way, the other thing I do, I would just say, it's going to add my two cents because I've been doing this for a long time too. And I started measuring not just fasting insulin, but I measured a glucose tolerance test with insulin, almost on every patient who I thought even smelled that they could have had metabolic syndrome. And it was fascinating to see

the data on this you'd see people with like blood sugars that were perfect like i had this one woman like like a big apple her fasting blood sugar was like 90 after the 275 gram glucose which is like you know two coca-cola worth of sugar her blood sugar went to like 110 never even went into glucose intolerance but her fasting insulin was like 50 and it went to like 110, never even went into glucose intolerance. But her fasting insulin was like 50, and it went to like 200 at one in two hours. So I found that very helpful. And fasting insulin is probably the second stage. The first stage is a postprandial insulin that goes up, right?

Yes, exactly right. So, in fact, we did oral glucose tolerance tests with simultaneous insulin levels on kids, published this back in the early 2000s, where we, this is where we realized where we had these two problems. One's called insulin hypersecretion, and those kids are fat, but healthy. And this thing called insulin resistance, and those kids were fat and sick. And so even though they are both insulin problems, they are for different reasons and different things in our diet cause each of them. Insulin hypersecretion can be genetic. Insulin resistance usually is not, but it's very, very fat specific, and very much dietary, um, uh, fixable. So we learned quite a bit by doing that. I don't need to do that anymore. And I actually retired anyway, so I'm not seeing patients, but, um, but the point is I can figure out from the other lab tests, what's going on. So I don't have to exactly. Exactly. I, me too. It's a, I, it's actually, when I was in residency training, I had a, I had a pulmonologist who was one of my preceptors and

he, you know, he taught us to read x-rays and he goes, well, you know, this is this, this is that. And then he goes, and this is the Aunt Millie sign. I'm like, well, what do you mean? What's the Aunt Millie sign? Well, it walks like Aunt Millie. It talks like Aunt Millie. It looks like Aunt Millie. So it must be Aunt Millie. It's, it's, it's basically, if you look at the pattern, it's a pattern recognition. And if you look at the types of cholesterol, if you look at uric acid, if you look at, you know, all these other phenomena, hormones, you can tell so much about what's going on. So besides the insulin fasting level, what else should people be measuring besides their waste and their fasting insulin? Right. So the next thing down the list is their ALT,

alanine aminotransferase. Okay. Now the problem with ALT is not- It's a liver test. It's a liver test. It's a test that tests for fatty liver. Okay. It's again, sensitive, not specific, but the problem with ALT is not the test. The problem with ALT is the interpretation. Yeah. Now, in 1976, when I entered medical school, the upper limit for ALT was 25. Today, you look at the lab slip, it's 40. It's 50. Or 50.

Sometimes 50. Yeah. So same test, but now double the upper limit of normal. How'd that happen? The answer is because everyone has fatty liver disease. That's right. Okay. The entire curve shifted to the right. And the way the lab determines normality is they do a whole bunch of tests on, you know, 10,000 or a hundred thousand people. Okay. And they get the mean and they get two standard deviations and they draw a line at those and people, okay, and they get the mean and they get two standard deviations, and they draw a line at those and say, okay, that's the upper limit of normal. Well, if the

entire curve shifted, guess what? The upper limit shifts, but that doesn't mean it's normal. It just means that the patient didn't know they had a problem. Yeah, well, it's like if you were a Martian landing an American today, it would be normal to be overweight and obese because that's what Americans are. It doesn't mean it's optimal. That's right. And so, in fact, an ALT upper limit is 25. If you're African American, an ALT upper limit is 20. So if you see an ALT above that, you've got a problem.

And you don't necessarily know why. And your doctor's looking at it and saying well you know your alt is 30 you know it's below 40 or 50 you know then no problem and so your doctor's missing it yeah so that's that's the second test and those are cheap these are cheap tests these are cheap tests these are tests that are normally done on standard chem panels. The next test is uric acid, as David Perlmutter and Rick Johnson are espousing. Now, uric acid is the breakdown product of purines. So if you eat a lot of meat, you will get a higher uric acid. It's true. All right.

And of course, everybody with gout knows this. Benjamin Franklin knew this. Okay. He wrote an ode to his gout many years ago. But it turns out sugar also increases uric acid. Now, how can red meat cause increased uric acid and sugar increase uric acid? Red meat and sugar don't look alike. Well, in fact, in the liver, they do. And the reason is because they both cause an increase in ATP being converted to ADP, ATP adenosine triphosphate being converted to ADP adenosine diphosphate, which then goes down the breakdown pathway to uric acid. So uric acid is a proxy for both red meat and for sugar. In our society, it's actually a proxy for sugar. Now, uric acid is bad for two reasons. One,

it inhibits an enzyme in your blood vessels called endothelial nitric oxide synthase or ENOS. This is your endogenous blood pressure lowerer, keeps your blood pressure down. And so when your uric acid rises, your blood pressure rises. And it is the reason why sugar is more important for hypertension than salt is. And we actually look at the data. Yes. Thank God you're saying that. Salt restriction. Sugar restriction actually causes a bigger decline in blood pressure than salt restriction does. Yes. Thank God. I mean, I've seen this over and over that the cause of high blood pressure

is not necessarily salt, it's sugar. And when insulin resistance is driving the high blood pressure in the first place. Indeed. And insulin also prevents you from being able to excrete sodium. So the higher your insulin, the more sodium you hold onto at the kidney, which raises your blood pressure too. So by fixing the sugar, you're fixing the insulin resistance, you're fixing the uric acid, and you're lowering your blood pressure virtually overnight. Yeah, and that's why people who stop sugar and starch, like they just pee a lot because they lose the sodium because their insulin goes down and they start peeing a lot and lose a lot of fluid, which is water weight. But that actually is a good thing. That's a good thing. That's a good thing. We showed in our 43 children study that these kids' blood pressures went down by five points in just 10 days with no change in sodium.

Yeah, it's true. Yeah, it's true. So that's one reason why uric acid's important is because of the blood pressure thing. But the second reason uric acid is important is because uric acid blocks an enzyme that are in your mitochondria. Carnitine palmitoyltransferase 1, CPT1. This is an enzyme that regenerates the transporter carnitine. Carnitine is a transporter for fatty acids from the outside of the mitochondria

to the inside of the mitochondria so that they can be burned for energy. If you poison that enzyme, you don't regenerate the carnitine. You can't transport the fat into the mitochondria. Mitochondria become dysfunctional. And guess what? You have buildup of fat in your cells because you can't burn it. So uric acid is a bad guy in the story and sugar makes uric acid. So the problem with uric acid, just like the problem with ALT is the interpretation. If you look at the lab slip, it says seven is the upper limit of normal. Wrong. 5.5. Yeah, yeah.

Anything above 5.5, you got a problem. By the way, what should fasting insulin be? Because I think we didn't talk about the number there, but it's important because it's what your doctor is going to say is normal and you is normal if not two of the same thing. Agreed, agreed. Fasting the same thing. Agreed. Agreed. Fasting insulin should be less than 10. Optimally, if you're an exerciser and all, you might even get it less than five.

Mine's less than two. Well, you are a paragon of virtue, Mark. Because you practice what you eat. Well, no, I just don't eat a lot of sugaring and starch and exercise that's right that's right well mine's not as good my my last time i checked was 8.6 okay but it's below 10 um if your fasting insulin is above 15 that's a problem okay to be sure all right so fasting insulin alt uh uric acid. The next thing you want to check is your lipid panel. Now, the problem with your lipid panel is that everybody just looks at the LDL.

The LDL is the least important thing on that lipid panel. I'm not going to say it's not important, but it's the least important. What's more important is the triglycerides because the triglycerides are much, much more atherogenic than the LDL is. Which is amazing, right? Because our entire medical system, a trillion dollar pharmaceutical drug is focused on lowering LDL and not addressing triglycerides because you know why? There's no drug that really works to lower triglycerides. Because you know why? There's no drug that really works to lower triglycerides that well, except fish oil and maybe niacin, which is vitamin B3.

Right, exactly. The reason everybody focused on LDL is because we had a drug for it called statins. That's the reason, okay? Not because it was the really atherogenic particle, but rather because we had a medicine for it. Food is information. It's not just calories.

When you eat, and it's different than if you burn a calorie in the lab. If you burn a calorie in a lab, and 500 calories of soda and 500 calories of broccoli are exactly the same. They both release the same amount of energy, And that's defined as how much energy it takes to raise one liter of water, one degree centigrade. That's a calorie. And it's fine. When you eat them, it's very different because when you're eating the foods, they're going through all sorts of different mechanisms that change what happens. So they alter your microbiome, which changes your weight. You literally can swap out bugs from a thin mouse

to a fat mouse, and that fat mouse will lose weight because of the thin making microbiome, right? So you're feeding the microbiome, you're driving inflammation or cooling it off, which drives weight gain. You're regulating hormones like insulin, testosterone, estrogen by what you eat. You're regulating your mitochondria, which really about how much energy you burn. You're regulating all these various factors that are so critical for weight regulation, your brain chemistry, your hormones. You write all about this in Eat Smarter, which is why it's such a smarter book because you actually address these scientific issues that still are staggering to me that most traditional doctors, nutritionists, academicians, and nutrition societies, and the government all don't buy into. And it's really, honestly, I hate to say this,

but a lot of it has to do with the fact that the food industry wins by all calories being the same. Because then you can have 100-calorie soda or 100-calorie bunch of blueberries, and there's no difference. But that's just absurd. Even a fifth grader or a kindergarten kid would understand that, you know, 500 calories of soda and 500 calories of blueberries are pretty different when you eat them. And it's your fault. It's your fault. It's your fault. You're overweight, right? Because if you just ate less and exercise more, everything would be great. Manage those calories and you'll lose weight. And the entire paradigm is really skewed.

And I got to reiterate this because when you just mentioned the research in mice, for example, now we have paralleled research in humans. This is cutting edge data that is getting out to the world right now. And one of the fascinating studies, this was published in Cell. They was looking at they looked at what's happening's happening in mice depending upon their microbiome cascade, and they found that there's specific, I'm sorry, specific, I'm so excited, specific bacteria that is found in mice that actually reduced the amount of calories that they were absorbing from the food that they were eating. Now, you take that piece of data and marry that with the human data that we have now. And this was conducted at the Wiseman Institute of Science. And what they did was they were taking, this is well known right now, guys,

but I want everybody to get it today, that when folks, once our bodies start to venture into being overweight and obese, our microbiome changes massively. And now we know that there's a kind of a bacteria cascade that is associated with being overweight. All right. It's like a fingerprint. All right. It's a very unique kind of dynamic thing are all of our metabolism, but there is a very specific spectrum that you see when folks start to become obese. And what they did was they took these human fat bacteria associated with obesity and put them into lean mice. And then the mice inherently gained weight. Their insulin sensitivity went down and they gained body fat versus taking the bacteria from a healthy human subject and putting into the mice and the mice continue to stay lean.

Changing the bacteria in our bodies has a massive impact. And one of the other studies took a set of twins, all right? And all they did was they had them on the same calorie-reduced diet, but one of them had a microbiome associated with obesity and one had a microbiome associated with leanness on the same diet. And they're twins on the same diet. The one with the microbiome associated with obesity continued to gain weight while the other one didn't. So this is real stuff. So what do we do to fix this is where we really got to put our focus. I agree. And I think, you know, I just want

to sort of summarize a few key elements here that are worth underscoring. And then I want to talk about the three major things that cause problems when you want to try to lose fat. So if you eat ultra processed food, by the way, it's 60% of our calories. It's most of what Americans eat, all the starch, sugar, processed food, anything that's sort of made in a factory that's not from real ingredients. One, if you're eating it, even if it's the identical same calories as whole food, your metabolism is slower. That's what you just said. Two, in another study, they found that if you let people eat ultra-processed food compared to regular whole foods, they'll eat 500 calories more a day. So they'll eat more and they'll be hungrier. And three, it changes your microbiome in ways that increase bad bacteria that cause weight gain.

And of course, there's a lot of other things that drive inflammation, hormone, and appetite issues, which are really the things that really you talk about that are three major things when it comes to fat loss. So let's dig into those three things, inflammation, hormone dysfunction, and appetite problems, which is, you know, I mean, I had a doctor call me about one of his patients for advice. And he's just this guy really exercise a lot of time, you know, really focus on eating healthy, but he's just hungry all the time. And I'm like, well, it's probably because of what he's eating that's driving his brain chemistry and his immune system and all the mechanisms that drive hunger. So we

have to change that. And it's not that hard to do. Yeah. So tell us about those three things. Absolutely. And the thing that I really wanted to usher in and bring to the forefront, because it sounds the most like ghostly, it sounds like cast with a ghost, like it's not even a real thing is inflammation and how inflammation has an impact on your body composition. And the data exists, it's just that a lot of folks don't know about it. And the way that it really manifests when we're talking about inflammation is that it has this very detrimental impact on our organs that are related to our body's production and utilization of our fat loss-related hormones. So namely, let's take our liver, for example. Your liver is incredibly important in regulating your metabolism. You know, we're talking about

a relationship with how it manages insulin, even the production of fat takes place in your liver to the storing of glycogen can take place in your liver. You know, if your liver is if your body's overburdened by glucose, your liver can literally convert that into fat right there on the spot. And so if something is damaging your liver, it's going to inherently damage your endocrine system and your process of metabolism. So inflammation, and I've just kind of shared some of the data in the book, damaging your liver. And this is one of the most fast growing issues in our country is non-alcoholic fatty liver disease. This is really a kind of chronically inflamed

situation taking place in our liver. And also- How do we get fatty livers? Because I think people should know. We go to fancy restaurants and they give you foie gras, which is French for fatty liver. And how do they get the ducks to be like that? And how do they get us humans to have 90 million Americans with fatty liver? Everybody should know by now. Very simple. The fastest way to damage your liver and to create that fatty liver, by the way, it's called non-alcoholic fatty liver disease because we associate it with alcohol, but sugar. Sugar, absolutely. Sugar, starch, flour. It's, it's so bad. It's so bad. Particularly your liver has to take on the brunt of it because your liver is really, even the name live, live, it's responsible for so much. Every minute, it's filtering your entire blood supply.

It's so important. That's right. But to take this one step further, and I'll just drop this little nugget so we can move on to the other topics, but also the master regulator, often referred to, of course, I've even taught this in my conventional university setting, but your hypothalamus, right? Your hypothalamus is one of the major regulators and communicators with your thyroid, with your liver, with your adrenals, all the organs related to fat loss and fat storage, the governing kind of master gland is called the master gland is your hypothalamus. That's in your brain. Right. And now we've got data that this new term, neuroinflammation, inflammation specifically regarding the

function of your hypothalamus can damage what's happening with your metabolism. But nobody's talking about that in these cookie cutter diets that you need to address the inflammation in your brain in order for you to lose weight, right? So these are all, and the beautiful part is it's possible. It's not just possible, it's probable when you have the right information and we avoid the things that create the inflammation. And namely, you just mentioned sugar, but we go through a whole subset of the different things. Yeah, in functional medicine, we also look at, you know, food sensitivities and environmental toxins and the microbiome and all, there's so many things that drive inflammation. And if you're overweight, you're inflamed. And for those listening, you know, think, oh, you know,

I'm a few pounds overweight, a little extra belly fat, you know, maybe I need to lose 10, 20 pounds, or maybe you're over more overweight or obese. You should really pay attention to what Sean's saying, because right now during this COVID pandemic, what we're finding is those people who are overweight or obese or have even a little bit of extra fat are much more likely to get sick, much more likely to end up in the hospital, the ICU, and to die from COVID-19 because of poor metabolic health. And what's so beautiful about the body is that you think, oh my God, I've taken years and years to get here. Within a couple of weeks, you can change all of that. You might not lose all the weight in a couple of weeks, but you can change your inflammation markers, your hormones, your brain

chemistry, literally in a couple of weeks of changing your diet. 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. Hey everybody, it's Dr. Hyman. Thanks for tuning into The Doctor's Pharmacy. I hope you're loving this podcast. It's one of my favorite things to do and introducing you all the experts that I know and I love and that I've learned so much from.

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