The Dr. Hyman Show - Why High Starch And Sugar Diets Drive Insulin Resistance And Chronic Disease

Episode Date: December 5, 2022

This episode is brought to you by Rupa Health, Paleovalley, and Essentia.   The leading cause of inflammation is a poor diet—specifically one rich in addictive starches and refined sugars that keep us eating more than we need to because they don’t fill us up. This standard American diet (SAD) of refined flour and sugar is the gateway to insulin resistance, diabetes, and other metabolic issues, which cause rapid aging and chronic disease.   In today’s episode, I talk with Dhru Purohit, Gary Taubes, and Dr. Ronesh Sinha about why we need to ditch the high-starch diet if we want to improve our metabolism and reduce chronic disease.   Dhru Purohit is a podcast host, serial entrepreneur, and investor in the health and wellness industry. His podcast, The Dhru Purohit Podcast, is a top 50 global health podcast with over 30 million unique downloads. His interviews focus on the inner workings of the brain and the body and feature the brightest minds in wellness, medicine, and mindset.   ⁣Gary Taubes is an award-winning science and health journalist and cofounder and director of the Nutrition Science Initiative. He is the author of The Case Against Sugar, Why We Get Fat, Good Calories, Bad Calories, and The Case for Keto. Gary is a former staff writer for Discover and a correspondent for Science. He has written three cover articles on nutrition and health for The New York Times Magazine.   Dr. Ronesh Sinha, author of The South Asian Health Solution, is an internal medicine physician who runs a lifestyle clinic in Silicon Valley focused on reversing insulin resistance in ethnically diverse patients. He is also an expert in corporate wellness and serves as the Chief Medical Officer for Silicon Valley Employer Forum, where he serves as a global adviser to shape health benefits for over 55 major Silicon Valley companies.   This episode is brought to you by Rupa Health, Paleovalley, and Essentia.   Rupa Health is a place where Functional Medicine practitioners can access more than 2,000 specialty lab tests from over 20 labs like DUTCH, Vibrant America, Genova, and Great Plains. You can check out a free, live demo with a Q&A or create an account at RupaHealth.com.   Paleovalley is offering my listeners 15% off their entire first order. Just go to paleovalley.com/hyman to check out all their clean Paleo products and take advantage of this deal.   Right now you can get an extra $100 off your mattress purchase, on top of Essentia’s holiday sale, which will also take 25% OFF your mattress purchase. Go to myessentia.com/drmarkhyman to learn more.   Full-length episodes of these interviews can be found here: Dhru Purohit Gary Taubes Dr. Ronesh Sinha

Coming up on this episode of The Doctor's Pharmacy. When you have starch or sugar in the morning, whether it's a muffin, a bagel, oatmeal, french toast, pancakes, fruit smoothie, whatever people are eating, it's the worst thing you could do. Hey everyone, it's Dr. Mark. I know a lot of you out there are practitioners like me, helping patients heal using real food and functional medicine as your framework for getting to the root cause. What's critical to understanding what each individual person and body needs is testing, which is why I'm excited to tell you about Rupa Health. Looking at hormones, organic acids, nutrient levels, inflammatory factors, gut bacteria, and so many other internal variables

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I definitely recommend stocking up on the grass-fed beef sticks to keep in your house and your car and in your office. It's one of my favorite tricks to stocking up on the grass-fed beef sticks to keep in your house, in your car, and in your office. It's one of my favorite tricks to staying healthy while on the go. All right, now let's get back to this week's episode of The Doctor's Pharmacy. Hi, this is Lauren Fee and one of the producers of The Doctor's Pharmacy podcast. The average American eats over 130 pounds of flour per year in the form of breads, wraps, bagels, and muffins, just to name a few. In a highly processed inflammatory diet, starch can affect our bodies in many ways. It impacts our mitochondria, metabolism, immune system, and often leads to chronic disease.

In today's episode, we feature three conversations from the doctor's pharmacy on the benefits of reducing our starch intake. Dr. Hyman speaks with Drew Proitt on why a high starch and sugar diet is behind most chronic illness, with Gary Taubes on reducing insulin resistance, and with Dr. Ronesh Sinha on his work to reduce starch consumption in the South Asian population. Let's jump in. I think it's really clear that the most serious threat to longevity and aging is insulin resistance, which is this phenomena of the dysregulation of metabolism from eating too much starch and sugar. The average American eats 152 pounds of sugar, 130 pounds of flour, about a pound of sugar and flour a day per American.

It's poison. And it's poisoning our fat cells. It's poisoning our mitochondria. It's poisoning our liver. It's poisoning our brain. And it's leading to all the consequences and all the diseases that we think of as aging. So heart disease, cancer, diabetes, Alzheimer's, the big ones, those are all either caused by or highly influenced by this phenomena of insulin resistance. So how big of a problem is this? Well,

really clear from the data that one out of two Americans has diabetes or prediabetes, which is essentially a state of insulin resistance. But I think it's more than that because 75% of Americans are overweight. And a lot of people who are not overweight are what we call skinny fat. They look thin, but are actually fat on the inside or toffee, thin on the outside, fat on the inside, as opposed to tofu. And a study came out last year that just even shocked me, which was that 88% of Americans, almost nine out of 10 Americans, are metabolically unhealthy. And what is metabolically unhealthy mean? It means they have high blood sugar, high blood pressure, or abnormal cholesterol. All of those are caused by insulin resistance. So hacking insulin resistance and getting your blood sugar balanced and normal

is so key. That's why these new technologies of continuous glucose monitors are so helpful. They really should be looking at insulin though, because way before your sugar gets abnormal and you get a perfectly normal CGM monitoring, perfectly normal blood sugar, but your insulin could be going sky high and crashing and sky high. It just keeps your blood sugar even. If that insulin is going wacky like that, and if it's high, it's driving all these diseases. And I once heard a professor from Harvard who was

a preventative cardiologist, Dr. Jorge Plutsky, say in a lecture, if you could take a group of 100-year-old people who are very healthy and had no cardiovascular disease, they'd have one thing in common. I'm like, what's that? They would be insulin sensitive, meaning their bodies with very little insulin can keep their blood sugar normal, as opposed to needing tons of insulin to keep your blood sugar normal. So we've got a society where almost nine out of 10 Americans are on this accelerated path to aging and chronic illness. You know, flour and starchy foods and grains, if you're super metabolically healthy and fit and exercising a ton, you can tolerate more of them

because you'll burn them off. But for the average person, oatmeal for breakfast is a terrible idea. Cereal is even worse. I mean, cereal is 75% sugar. And we think of oatmeal, oh, it's got fiber and it lowers cholesterol and does all these great things.

It's a big snow job. When you look at the data, and there's one profound study done by my friend David Ludwig at Harvard, where he took a group of overweight young guys, kids, teenagers, and he gave them three different breakfasts, exactly the same calories. Oatmeal, steel cutouts, omelet. And then he locked them in a room, they measured their blood every hour, and they tracked everything, and they said, when you guys are hungry, push this button, we'll bring you more food.

So they can eat whatever they wanted. The oatmeal group not only had higher levels of insulin, cortisol, adrenaline, which is the stress hormone, so eating oatmeal literally was like being chased by a tiger in your body. Your body didn't know the difference. It actually made these kids hungrier, and they ate 81% more food than the omelet group. Remember, they ate the same calories of omelet, oatmeal, or stilcroats.

The stilcroats was better, but they still ate 50% more food than the omelet group. So when you have starch or sugar in the morning, whether it's a muffin, a bagel, oatmeal, French toast, pancakes, fruit smoothie, whatever people are eating, it's the worst thing you could do. You want to start your day with protein and fat. So I was starting my day with starch, which is the typical American breakfast. And often people might have orange juice along with it.

Oh, yeah, orange juice. So it's fruit juice. Yeah. And that on top of the oatmeal. Then sugar in their coffee or whatever. Sugar in the coffee. So basically having, as you say, dessert for breakfast. Pretty much.

The amount of sugar that they're having for breakfast is dessert for breakfast. Right. And it'll throw you on a metabolic rollercoaster for the rest of the day. Absolutely. Okay. So that was you. And that would be a lot more grains, a lot more beans, a lot more, um, what I thought were healthy breads. Um, so just pausing again, right there, a lot of people who, especially if they're familiar with the world of plant-based eating and maybe learning from some of the best practices from other cultures, they think that grains, beans, those things break that down and talk a little bit about that, because a lot of people do think that that's that healthy way to go. And it's not that it can't be healthy. Let's talk about how it maybe wasn't the healthiest the way you were doing it. low starch and sugar diet and we're very active like we all historically were when we were eating those foods over the last 10 000 years you know we probably do better but the modernization of our industrial agricultural system has produced starchy really starchy versions of these grains particularly like flour whole wheat right even whole wheat flour made from dwarf wheat is

a sugar bomb right it raises your blood sugar more than table sugar. So when you don't understand that the food that we're eating is a driver of this insulin problem we talked about with aging, we're never going to get through this. And so I'm very careful. Do I eat grains? Sure. Will I eat them every day as a staple? No. Do I have quinoa? Will I have black rice sometimes? Will I have a little white rice sometimes? Sure. But it's not something I eat them every day as a staple? No. Do I have quinoa? Will I have black rice sometimes? Will I have a little white rice sometimes? Sure. But it's not something I eat on a regular basis. It's not something that I think is dangerous if you're metabolically healthy. But for people who are metabolically unhealthy, it's bad. And we're talking about 88% of Americans. My blood sugar,

my insulin is less than two. So I can, I'm okay. I can tolerate a little bit, but I also work out a lot and I exercise and I burn it off and I do a lot of other things to optimize my health. So in a perfect world, yes, you can tolerate more. But what I see often is very low levels of protein in vegans. I see, I see this over and over and I wish it weren't true, but I, but't true, but I have to believe what I'm seeing, which is people have low energy, they lose muscle mass, they have poor cognitive function, they get hormonal dysfunction, low sex drive, libido, infertility, nutritional deficiencies that are really widespread in the vegan community, omega-3, vitamin D, iron, zinc,

and more are really common. And so we have to say, well, how do we create a diet that is inclusive of many different foods, but focus on the quality? So for example, if you make your pancakes with regular flour, bad news, right? If you make them with, like in the Pagan Diet book, there's a recipe for chai pancakes, which is delicious, but it's using almond flour and buckwheat flour. Now, you can use regular buckwheat flour, or you can even upgrade that to Himalayan tartary buckwheat, which is available through bigboldhealth.com. It's an ancient grain, 3,500 years old, higher in protein, lower in starch and sugar, more magnesium, more zinc. And what's really amazing is that since it was grown in such harsh conditions, you know, very low water levels, high altitude, cold temperatures, you know, poor soils, it's really robust. And that robustness,

that stress on that plant forced that plant to make its own defense system. And that defense system is phytochemicals. So the plant doesn't make phytochemicals for us. It makes it for himself. And so those phytochemicals in the Himalayan buckwheat are more than almost any other plant on the planet. There's 132 phytochemicals. Some of them are not available anywhere else. They have age-reversing properties.

They have immune rejuvenating properties. And so having pancakes from that flower is okay. And will I do that from time to time? Sure. Do I do it every day? No. But yeah, I'll make Himalayan buckwheat pancakes for a Sunday brunch with berries and don't pour too much maple syrup on it because that'll screw it up. But you can actually include the right grains. So what should we be eating? Ancient grains. I mean, one of the things that I'm just shocked at in Europe, in Germany, they make this rye bread and these dense whole grain breads, not made from flour, but made from ancient grains,

that if you stood on it, it wouldn't dent the bread. And the only way you can cut it is with an industrial meat slicer. Like even a knife can't cut through it. You need these from slicing ham in the deli. Use those to cut the bread. And it's just so rich and good for you. So it's not that I'm against grains. It's just the grains that we eat in this culture are so highly processed, pulverized, high glycemic grains, corn, wheat. Those are the main ones. And they're deadly in the form that we're eating them. So I think that's a huge factor for people to understand.

Hey everybody, it's Dr. Mark Hyman here. As you know, I turned 63 this year and I'm dedicated to making my remaining 60 years, maybe more than that, even better than my first. That's right, I plan to leave at least till 120 and live well. And a big part of achieving this goal for myself is focusing on good quality sleep. Sleep really is the foundation of wellness and happiness, but when you're sleeping on a so-so mattress, getting deep, restful sleep can be a difficult endeavor. So thankfully, my friends at Essentia have solved the problem of less than stellar mattresses. Their mattresses have the latest in sleep technology to help you achieve quality deep sleep and REM sleep that you need to optimize your health and wellness. Packed with patented technology, Essentia certified organic performance mattresses feature brand new organic foam formulas to help you experience truly rejuvenating sleep.

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Just use the code HYMAN at the checkout to get this great deal. Learn more at myessentia.com forward slash Dr. Mark Hyman. That's M-Y-E-S-S-E-N-T-I-A.com forward slash D-R Mark Hyman. And now let's get back to this week's episode of The Doctor's Pharmacy. Macronutrients influence insulin differently. So carbohydrates stimulate insulin secretion protein stimulates in a little bit fat does not and you could drink a liter of olive oil and your insulin would not go up no you will store that and you won't store it no you will that's the

interesting thing so it's sort of the one of the if you don't eat carbs you'll store it or only when you eat it with well you'll still you're going to have to clear it out of your bloodstream anyway you don't want it floating around in your bloodstream yeah that said it's going to be stored on some level even without with low levels of insulin but then it's going to be mobilized yeah so you basically you think of your fat stores as like the wallet that you go to the atm you take money out of the atm that's the food you're eating and you got to do something with it, so you put it in your wallet. But you've got to be able to get it out of your wallet freely when you need it.

And insulin doesn't let you get it out of your wallet. So as long as you're eating a high-starred sugar diet, you can't get the money, namely the fat, out of your wallet, or namely your fat cells. What happened is, and there was a lot of discussion back then, that carbohydrates are turned into fat when you eat excess carbs. And they're not really turned into fat. That's a difficult process for your body to do when it's energy expensive and it doesn't do it that much. But what your body does is make sure you burn the carbs. And when insulin's

elevated, that's what you're burning. So it's not only telling your fat tissue to store fat, it's telling your lean tissue, your muscles, and your organs to burn carbohydrates and not to burn fat. Yeah. But doesn't a carbohydrate increase what we call lipogenesis, which is our own fat production factory? That's why we get fatty liver and in the liver well and but again that could be sugar the fructose and sugar dependence so that's the case against sugar story we're gonna get to that soon so um in pretty well done controlled studies the amount of what's called the novel lipogenesis so making fat out of nothing from carbohydrates was very low, unless you had sugar in the diet, which is one reason why sugar might be key to this process.

Because 90 million Americans have fatty liver. It's one of the most prevalent diseases, and it linked to heart disease, cancer, diabetes. Yeah, which 20 years ago, nobody knew existed. If you were diagnosed with fatty liver disease 20 years ago and you told your doctor you didn't drink alcohol, the doctor would assume you were lying. And then it starts showing up in kids.

And suddenly it's like, okay, these kids are probably not heavy drinkers. Oh, drinkers of soda. I met at an obesity conference a pediatric gastroenterologist and i'm like what are you doing here he says well i focus on fatty liver disease in kids and we're seeing it in three-year-olds and five-year-olds and i'm like wow they're needing transplants as they get a little older and i'm like wow yeah you know so and then then huge pharmaceutical effort to you to come up with a drug that you can give those kids for the rest of their lives. That's a great market.

Or you could maybe just prevent it by cutting out the sugar. The sugar is a bit, yeah. Which can help reverse that, yeah. Yeah, so anyway, that's the gist of the science is you elevate insulin, you store fat. If you want to get rid of the fat, you have to drop insulin. So how do you do that? That's the good calories and bad calories.

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

Okay, well, you jumped in there a couple of times with this fructose thing, and you said we didn't really even have it until the 70s, and then probably in the 80s, and now it's a big portion of our sugar consumption well so how is that different and why should we be worried about fructose okay so we actually there was a there's always been a lot of sugar and not always since the 18 19th century sugar intake goes from five pounds per capita per year at the beginning of the 19th century that's like coca-cola's worth of sugar once a week yeah to 90 pounds by the end of by 1900 and and 100 pounds by 1920 and then it stays relatively stable because when people are consuming a lot of sugar they're

getting tend to get fat so it tends to be self-limiting. And then the 1980s, it shoots up again because we start blaming everything on fat and high fructose corn syrup comes into the- At the same time. Yeah, so high fructose corn syrup, sugar, and this is where, this is what Elliot Jocelyn didn't know. This was the,

just, you know, very specified, siloed knowledge basis. So a physician who's not a biochemist might have taken biochemistry courses and become a physician, but you're not a biochemist. Right, it's basically biochemistry. I went back and looked at my first-year med school biochemistry text, but it's all there. Yeah, it's all there. It's all there. I'm like, okay.

So sugar, sucrose, the white powder, is a molecule, glucose bonded to a molecule. Half and half. Yeah, they're both carbs. They're both simple. Well, sugar is a simple carb. The fructose is the sweetest of all the carbohydrates. So any sweet substance naturally occurring is going to have, except mother's milk, is going to have fructose in it. The fructose, glucose is metabolized by virtually every cell in the body,

so it gets into your bloodstream. You secrete insulin in response to it. You know, we talk about high GI foods. They're foods that break down into glucose quickly. The fructose is metabolized not by every cell in your body, but it goes through your small intestine and into the liver. And in high doses, it's converted into fat in the liver.

So the way I think about it now is our livers evolved to see the fructose and fruit so very small amount of fructose in fruit a month or two a year yeah and bound up in the fruit so with all the fiber in the fruit so you would get you know a small amount of the substance it would take a long time to digest it and then it would have to make it through the portal system the portal system it may or may not do it there was a paper that came out this summer that says that low doses at least in rats fructose is not going to make it through the small intestine um then as we increase our sugar consumption and worse in that turn and once we start drinking sugary beverages in huge doses so the the soft drink industry begins in the 1870s and 1880s with

pepsi and well dr pep or coke colon pepsi in that order um the uh now you're suddenly you're drinking this stuff and you're drinking it between meals and 50% of the calories are fructose and there's no fiber to slow down the digestion and you're getting massive amounts compared to what we would have gotten historically. It was also high fructose, which is more than the glucose. The high fructose corn syrup is high. It was called high fructose because there were lower fructose corn syrups

that had been developed over the years. But it's 55% up to 75% fructose in some of these drinks. True, and may or may not make a difference. I just don't know. But the liquid sugars are compared to, so you're getting them between meals. You're getting sugar from basically breakfast through dessert.

It's like drinking alcohol on an empty stomach, you get the buzz faster. You get the buzz and you get it all day long. And that's all your liver is doing all day long is basically processing fructose at doses. It's never been designed, never evolved to see before. Like any machine that's asked to do a job. It wasn't designed to do. It does it poorly and then making it do it year in and year out constantly like remember a little bit of fructose dribbled into the liver over the course of a couple of months summer you binge on some fruit okay fine it's just

the daily and repetitive doses that are the problem breakfast lunch and dinner breakfast lunch and dinner and in between. Yeah. Because remember, we're drinking the Coca-Colas not just at our meals, but between meals. And then, like you said, the 1980s with the low-fat dogma, or the 1960s with sugary cereals come in. They start coming in late 1940s, and by the 1960s, there's an entire industry from the cereal companies to madison avenue tv

shows that we grew up loving you know rocky and bullwinkle was created to sell cereal sugary cereals it's true right i mean even fred flintstone was uh promoting cigarettes back in the day and was it fruit loops fruity Winston takes good like a cigarette should, right? So fruity pebbles, right. It's, it's, yeah. So it's frightening. So the case against sugar is your next big tome. It was, I thought, incredibly well-researched, really historical and sort of caught us up to date

on why we have this sugar glut and actually what it's doing to us so tell us more about this sort of case against sugar and should we be having any sugar and is it well so that's okay so there are two issues here as there always are multiple issues that when in talking about the case against sugar i'm implying that there's a crime that's been committed and that sugar is so the question is what's the crime yeah so the question is, what's the crime? Yeah. So the crime is obesity and diabetes epidemics worldwide.

Recently described by the director general of the World Health Organization, slow motion disasters, although in some places there's no- A little bit fast. Slow about it. Yeah. A little bit fast, yeah. So these epidemics occur whenever a population transitions from whatever its native diet is to a Western diet. So it doesn't matter what the native diet was. It could be Southeast Asia where it's mostly carbohydrates, a lot of rice and wheat.

It could be Inuit diet where it's seal meat and whale meat and caribou. 70% fat. seal meat and whale meat and caribou it could be a you know a pastoral messiah diet warrior diet and in kenya where it's you know the blood meat and milk from the cattle it could be a native american diet that's primarily carnivorous or a native american diet that's primarily agricultural right um add a Western diet and lifestyle, you get obesity, diabetes. And like I said, some populations, like in the famous Pima Native American tribe in Arizona,

the diabetes appears in the course of a decade, just explodes in this population. 80% now. In the 1960s, yeah. Diabetes by the time they're 30. So the question is, what are you adding? It's not the native, it's not the baseline diet. And it's probably simple because you add it to anything,

any baseline diet, you get obesity and diabetes. And the conventional wisdom is so, I mean, Michael Pollan talks about this in In Defense of Food in a book that I disagree with almost entirely. But we're working from the same observation, which is, what is it that causes this disease of Western diet? He says, don't eat food like substances, which is processed food. Well, so one answer is processed foods.

And a lot of people like that. It's a simple answer. We don't have to be wrong about the saturated fat thing. So it's an interesting issue because in the U.S., when we focused on saturated fat, it's because researchers like Ansel Keys and other researchers were asking, remember, the question determines the answer. So the question is, why do we have such high levels of heart disease in the U.S.?

We live in the U.S. What we see is massive amounts of heart disease. What's causing that? We'll do studies to try and figure that out. And the answer, we come up with the saturated fat. Which wasn't based on cause and effect, just a bunch of patterns in the data that turned out to be wrong. Yeah, it's poorly done clinical trials.

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

Although they're also working in the rice paddies 12 hours a day. And that's one possibility. If you want to exercise 12 hours a day, it's fine to eat more carbohydrates. Quite possibly. And that's the first time I heard this story from an epidemiologist at Harvard who is Chinese. And his answer to this question, because I asked him, what about China?

They're eating. It was their peasants. They're out in the fields all day long. So it mitigates, ameliorates the problem. Although clearly doesn't. Because there are people who are working all day long who still get obese. I actually, one of the first observations of interest here

in the Pima back in 1902. So the Pima had been through 30 years of famine, horrible, devastating famine. And towards the end of this period, a Harvard anthropologist comes to live with the Pima and study the Pima. He actually had tuberculosis, so he wanted to go to Arizona in an effort to cure the tuberculosis, which didn't work.

But he spent six months, nine months with the Pima, and he writes a seminal book about it. He takes a photo of a Native American Pima. He points out that they have a high level of obesity in the tribe, particularly in the older population, particularly in the women. There's a photo in the tribe of a woman he calls Fat Louise who's clearly obese. And he asks us, it's sort of the interesting thing is the older population, they had lived through the famine.

Thirty years of famine is thirty years of calorie-restricted diet, right? And it's very high carb and low fat. And the question is, why are these people fat anyway? And then of course you start looking at what's happened. They're on a reservation. They've been introduced to Western foods. They've been to commodities, which are at the time was mostly white flour, some powdered sugar, some lard. So anyway, the simple way to answer this question is just say it's food-like substances.

It's processed food in general. Now you don't have to think more deeply about it. So you want to know what causes yellow fever, malaria. You blame it on miasma, bad air from swamps. This was the miasma theory of disease, which was like because the people who lived in low-lying areas in cities and coastal areas tended to get these diseases, and the rich people lived on hills, so they'd be away from the bad air and the bad water, and they wouldn't.

You could avoid the disease with the miasma theory, but it didn't tell you what was causing it, that they were mosquito-borne illnesses, that they were viral. Once you know it's a mosquito-borne illness, you can save the poor people too. Sure. The ones who can't afford to move away from the water.

Yeah. So the refined... Or then you spray them all with DDT. Yeah, or you could spray DDT. So yeah, this is a refined processed food thing is to me like a miasma theory. It's great, but it doesn't... There is an agent here.

It may be multiple agents maybe physical and activities involved maybe but it turns out your conclusions were that it was sugar yeah so i concluded sugar is the simplest possible explanation and the obvious explanation and uh for two reasons because we also seen a spike in flour consumption right well you do but so here's the issue again because remember we got those all those southeast asians i had your buddy david ludwig and i argue about this about once a year and i say i'm not willing to ignore two billion possible black swans to my flower theory on the basis that they're out there in the field they're not all out you know so even in southeast asian increase so obesity and diabetes are now manifesting themselves.

And these were always low sugar consumers. So to me, it's a simpler hypothesis. And there are two, so we have the fatty liver link, but there's also a link with insulin. So type two diabetes is sort of insulin resistance, fundamentally. And one of the arguments I make in my books and David makes and

others and has now been embraced is that that and actually rosalind yallow and solomon burson suggested 1965 is that the route from uh health to obesity and diabetes doesn't go you know health and leanness obesity diabetes it goes health and leanness, obesity, diabetes. It goes health and leanness, insulin resistance, and hyperinsulinemia to obesity and type 2 diabetes. Yeah, absolutely. As a doctor seeing patients and testing all this stuff for 30 years, I would completely agree. Yeah, and a significant amount of evidence,

laboratory research and animal evidence in the 50s, 60s, 70s, and 80s implicated fat accumulation in the 50s 60s 70s and 80s implicated fat accumulation the liver in insulin resistance and once we start talking fat accumulation the liver if i'm a investigator i'm going to start wondering about sugar because of the fructose yeah and there's a link between insulin resistance and fatty liver disease again these, these aren't perfect correlations. It's all the same problem. But the liver's role in all this tends to implicate something unique to hepatic metabolism of something. And fructose is just the prime suspect. In the case of South Asians, a lot of the cultural preferences are for vegetarianism

where there's a high amount of starch, high amount of rice, high amount of bread, high amount of sugar. How do you navigate that? Because I had a patient who just, it was really hard to help her because what could I have her do? And she tried protein shakes, nuts,

and it was just, she was very resistant to it. And I know I could have fixed her overnight, but she she really struggled absolutely so so that's a big cultural part of it and you're right so so the early work that i did i highlighted that most south asians are actually not true vegetarians they're granitarians or they're carbotarians right because the proportion of vegetables that they're consuming right because if you basically if you basically use a general term vegetarian for all people that don't eat meat and fish, you miss all the hard, not right for everyone, but definitely if you take a population, and again, if we're thinking of the fact that we've got less horsepower in our engine genetically and carbs are a high energy fuel source, we're overwhelming that engine on

a regular basis. If you want to get quantitative about it, a lot of my patients, for example, they'll thrive if they can bring their carb intake down to a hundred grams per carb per day. But my typical South Asians and East Asians, they're consuming 400 to 500 plus grams of carb. And I tell them the carb itself is maybe benign if it's rices and starches. If you were Michael Phelps, or if you were an Olympic level athlete with a V12 engine under your hood, but you've got more like a minivan or a lawnmower engine. We can't flood it with that sort of carbohydrate. Right. Exactly. We don't have that sort of horsepower. We can build that up and we'll talk about that later, but we just don't have that. So one paradigm that I use to really... So what you're saying is genetically, is mitochondrial function genetically less in South Asians? So I will tell you this. So it's a

combination. So genetics is a part of it, but then the lifestyle is key. So when we talk about this car vehicle, I tell people the prototyping and designing happens with the parents, right? So even before conception happens, if mom and dad are both insulin resistant and they're sedentary, what happens is they're already insulin resistant and they're sedentary, what happens is they're already insulin resistant and that's going to get transmitted into pregnancy. And that's why a lot of parts of India and even the US, South Asians have 40 to 50% gestational diabetes. They're already hyperinsulinic and they're transferring that to the placenta. And the sad thing is you mentioned skinny fat. When you look at the South Asian fetus or the newborn,

they're already skinny fat. They've got less basically muscle mass and a tiny little pot belly. So they're already a version, a mini me version of what they're going to be later on in adulthood. So that's a big problem. That design happens early on. So part of it's genetics, but the other part is a lifestyle before and during pregnancy. So a lot of the health education I've done out for tech companies in the community is how do you design a healthier pregnancy? Because I'll tell you one thing that really makes this engine much worse. So VO2 max, which is a marker for mitochondrial performance, that's something the parents can influence. So I tell parents that if you're planning to get pregnant, you got to get fit for this pregnancy.

Both of you need to be physically fit. But most South Asians are so sedentary that they come into this pregnancy unfit and they're going to have basically an offspring that's going to have a low VO2 max and a low horsepower engine. But my patients that take this to heart, their kids don't have that. Their mitochondria is stronger. It can withstand a little bit more carbohydrate load. But this cultural epigenetic intergenerational issue is really causing that engine to be really much less capacity. So that's a big problem. That's huge. And it's, it's a, it's a really, it's like, it reminds me a little bit of the

Pima Indians who, you know, a hundred years ago, 150 years ago were thin were fit, you know, their diet was about 80% carbs, but it was like acorns and nuts. And like, yeah, they grew and there was no diabetes. There was no obesity. And now, you know, Pima are probably the second most obese population in the world after the Samoans and their life expectancy is 46,

80% get diabetes by the time they're 30. And we're seeing, you know, type two diabetes in three-year-olds in that population. It's incredible. I wanted to connect the Pima Indians to Indians because there's another characteristic we're seeing evolutionary that evolve in that. And that's the type of fat that South Asians and Pima Indians actually have.

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

overlap that we're seeing that's interesting so there's less brown fat in these populations there's less brown skin but i've got less brown fat. Unfortunately, they don't correlate. Amazing. Amazing. And the thing that just occurred to me, Ganesh, was that being South Asian and aging are very similar and that as we age, the population loses muscle and becomes fat and you marbleize your muscle. It looks like a ribeye instead of a filet mignon. And that's the source of poor metabolic health, which means prediabetes, diabetes, hypertension,

heart disease, cancer, everything else. And it's 100% fixable, preventable. You know, I actually, as I've gotten older, I've gotten more and more muscle. Because I realized that muscle is the neglected organ. Oh, so true. It is the key to health. And it's not just about looking like Arnold Schwarzenegger. It's really about creating metabolically healthy muscle, which is the main sink for your calories and for your food. And if that's not working efficiently, you're in trouble.

And what happens also to these people is they have a low VO2 max, which is basically the amount of oxygen you can burn per minute, which is the rate limiting step in your metabolism. So you can only burn as many calories per minute as you can breathe liters of oxygen or run liters of oxygen per minute

through your mitochondria. And the mitochondria in these people are impaired for a number of reasons. One, the diet itself impairs the mitochondria. Two, it sounds like genetically there's some issues there. And we know even in the PCG1 receptor, there's challenges genetically, even in first-degree relatives of type two diabetics. So they may have 50% slower metabolism to start with. And I think this is a really prevalent condition in South Asians.

And so we see the aging phenomenon the same as the phenomenon you're seeing. So what we're saying here applies not just to South Asians, it applies to everybody. And there's a lot of people walking around who are skinny fat. They think, oh, I'm good. I can eat my sugar and I can eat this and that.

I don't gain weight. Well, that's not the key metric. It's really a much deeper metric. I love what you brought up. You know, that age-related muscle loss, which we call sarcopenia. At a molecular level, I call it mitopenia because if you lose muscles, you're losing mitochondria as well, too. And those engines, if you lose horsepower, you're not going to be able to tolerate the carbohydrates, you know, an adequate amount of that.

And so one way I bargain with my patients, whether they're of Asian Indian descent or anything, is if you want to eat rice, you've got to sort of earn the right to eat that rice. You've got to squat for your rights. You've got to walk for your rights. You've got to do some physical activity to earn that. Because otherwise, if the minivan's sitting in the garage and it's not doing anything, your body's not going to tolerate that. And the beauty of that, and you know this, Mark, firsthand,

is when you get people more aerobically active, more physically exercising, all of a sudden, they can handle a little bit more of the carbohydrates. The same way it caused me to get insulin resistance, now it's a fuel source after I work out. It doesn't have the same impact. So I think that gives our patients some hope that this is not a banned food like the fructose is and the other processed foods out there we can reintroduce it gently to the diet as you upgrade your metabolism it's true i i mean i honestly i love to eat which is why i like to exercise but like i like i'll go for a two-mile bike ride i'm like oh great i just i went for a 50-mile bike ride in the damper and 2400 calories i'm like yippee i for a two-mile bike ride. I'm like, oh, great. I just, I went for a 50-mile bike ride to the dam, burned 2,400 calories.

I'm like, yippee, I can eat more food today. Right. Totally. Totally. So, you know. I don't have any willpower. Yeah, totally. That's so great.

So, Ranish, your work is pretty remarkable in calling this out and talking about the cultural differences and health disparities. And that's why we often see health disparities in other populations like Native Americans, African-Americans, Hispanics, and of course in South Asians. So you had this problem too, right? You developed metabolic syndrome and your triglycerides were high, your HDL was low. What were you living like? What was your diet and what was the story around that? Yeah, you know, I've been a lifelong devotee of healthy practices. And even back then, when I started my practice in Silicon Valley,

I was following the standard dietary guidelines. I was exercising four or five days a week. But what I was doing was- Oh, wait, wait, that was the problem. You were following the standard dietary guidelines. That's exactly right. You nailed it right there, right? And my standard dietary breakfast was pretty starchy with a lot of fruits and oatmeal. I'd have a whole wheat bread sandwich for lunch. So it was a lot of those healthy carbs that were, you know, so-called healthy carbs that were really overwhelming my system. And then also my exercise was really a lot of HIIT training, a lot of high intensity interval training, and not really that steady, more long-grade sort of cardio.

And as a result of that, I started seeing my patients developing insulin resistance. I was giving them advice, but then I was getting insulin resistant too. So I'm like, okay, so this is not going to work out. How can I be a health leader if I'm developing the same conditions as my patients? And then that really caused me to dig deep into the literature. I had the benefit also of being mentored by Jerry Riven, who actually coined the term metabolic syndrome. Oh, really? Yeah. So I used to drop by his office in Stanford, and he really helped highlight this triglyceride HDL, this issue. And he was really such a pioneer.

He literally told me that sometimes he doesn't get invited to conferences because his metabolic syndrome criteria doesn't include LDL, right? He kind of nailed the triglyceride HGL insulin resistant axis. And so I took that learning and then really dug deep and then made changes in my body, which I basically translated to my patients. But that was eye-opening. That was over a decade ago. So when I saw that, I'm like, okay, standard dietary guidelines, the websites and resources I'm giving my patients are actually making them worse. They're making me worse as well. And that really kind of led me to really create the resources they need to really address this problem. That's amazing. You know, I had a lot of Indian patients in my practice and I see exactly what you see. And I often wanted to create a

cookbook that's like a high fat, low carbohydrate, vegetarian Indian cookbook that's like a high-fat, low-carbohydrate, vegetarian Indian cookbook. Oh, Mark, I would love it if you did that. People ask me to write a cookbook. I have no interest in that. So if you did that, I would love to promote that. Please put that in your book. You're allowed to do that. A friend of mine is an Indian woman.

She was going to get her mother to do it, but she never did. But it's challenging. So what do you tell your patients? Because, you know, if they're already kind of set up, you know, with a deficit because of genetics, then it's a little bit frustrating. How do you help them? So we do two things simultaneously. So, so the first thing I have a bit of a clever mnemonic that I use my, with my patients called carbs. So they can basically just identify the framework for the sources of their carbohydrates.

So the C in CARBS stands for chapatis, which are flat Indian bread. Okay. The A is aloo, which are starchy potatoes because most of the vegetables we're consuming are a lot of starchy potatoes and samosas. The R is rice. The B is beans and lentils.

And the S is sugar and sweets. So when they have that framework- I love that. What? It works perfectly. I love framework- I love that. What? It works perfectly. I love that. I love that. The bodies, oligopoly, I got it.

Yeah, I got it. Beans and sugar and sweets, right? So if you have that framework, and I'm not telling them they're going to eliminate all of those, but let's have just small portions of that with each of the meals. Maybe one meal is going to have a little bit of rice.

Maybe we'll have some lentils with that, but then where are protein sources coming from? Like, how do you really compose the meal so they're not like 100 to 150 grams per carb per meal, which is what I see in my vegetarians. But how do we mix proteins and healthy fats into it? And this is the hopeful part is a lot of the fats and oils and foods that we thought should be banned in the Indian diet. They're actually now becoming healthy, right? A lot of the paleo primal movements, they're using a lot of our traditional healthy fats.

So once you- You mean like coconut or ghee? Yeah, exactly. Coconut oil, ghee for people who tolerate it. So one trick I teach them, for example, is when you have starches that are not mixed with other ingredients, that's when the problem happens.

If you love rice, eat it more like biryani or fried rice style where you mix vegetables into it, nuts and seeds, healthy oils and fats. And you're going to see that's going to dampen the glycemic impact. A lot of people are making chapatis or flatbreads, but they're adding eggs to it like egg paratha or they might mix almond flour into the batter. So I teach them how to make higher protein flatbreads. Like chickpea flour, chickpea flour, almond flour. And you get full off having one or maybe two max,

and your glycemic stability is much better. So dilute out the effects of that starch by mixing the vegetable proteins and fats. And the Indian diet has plenty of those. So when they feel miserable about that, I really add that diversity. And they feel fuller. Their energy is better. And oh, by the way, their net carbon intake has gone down by 30, 40%. And then simultaneously, we do have to upgrade their physical activity levels and really work on the things you talked about. We got to make up for the loss of lean

body mass, muscle. We got to gently elevate that VO2 max. But I start with food first because immediately they start to feel better. And as you know, the numbers are magic, right? Within a month, we see triglycerides drop. And if they see that metric, we're very metrically motivated as a population. You see those numbers go down. You're like, okay, what do I do next to get the numbers even better than that? So that's one framework that I use. I hope you enjoyed today's episode. One of the best ways you can support this podcast is by leaving us a rating and review below. Until next time, thanks for tuning in. Hey everybody, it's Dr. Hyman. Thanks for tuning into The Doctor's Pharmacy.

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