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Dr. Mark Hyman (4:14)

Into today's episode, I'd like to note that while I wish I could help everyone via my personal practice, there's simply not enough time for me to do this at scale. And that's why I've been busy building several passion projects to help you we better understand. Well you if you're looking for data about your biology, check out Function Health for real time lab insights. And if you're in need of deepening your knowledge around your health journey, well, check out my membership community Dr. Hyman Plus. And if you're looking for curated trusted supplements and health products for your health journey, Visit my website drhiman.com for my website store and a summary of my favorite and thoroughly tested products. Hey everyone, it's Dr. Mark here. Dysfunction in our metabolic health paves the road for chronic disease. And that's why it's so important to pay attention to insulin response. Did you know that you can influence your insulin response just by changing the order in which you eat your foods? Balancing your blood sugar doesn't have to be difficult or even unpleasant, and you'll start to notice the benefits right away. In today's episode, we feature three clips from the doctor's pharmacy about how to eat for optimal metabolic health. Jessie Inshallah shares her favorite blood sugar hacks and why a savory breakfast is better than a sweet one. Dr. Casey means talks about why metabolic health is important and how everyone reacts differently to foods. And finally, I talked with Ben Bickman about the three causes, causes of insulin resistance, the importance of fat. So let's jump right in.

Jessie Inshallah (5:34)

Number one hack that is incredibly easy that has fantastic evidence supporting it is eat your food in the right order. So, yes. So anybody listening? If you're about to have a meal, look in front of you. Let's say you have some chicken, some broccoli and some potatoes. If you eat the elements of this meal in a particular order, you can reduce the glucose spike of the meal by 75%. This means less weight gain, fewer cravings, etc. The right order is vegetables first, protein and fats second, and starches and sugars last. And so when we do this, when we eat our vegetables first during a meal, the fiber in the vegetables lands in our stomach, then in our upper intestine, coats the walls of our intestine with this viscous mesh. And then any starch or sugars you eat afterwards will be absorbed to a lesser extent in your bloodstream, therefore smaller glucose fat. But you're eating the exact same thing. And this is so cool. And so many people send me messages like, I just simply changed the order in which I ate my food. I didn't change what I Ate, and things started changing. For me, yeah, that's the number one.

Dr. Mark Hyman (6:50)

Really interesting. I often recommend people take something called PGX or polyglycoplex, which is a derivative of cognac root. Cognac is a Japanese tuber, like a root vegetable, that is made into noodles. It's actually used a lot in Japanese cooking, and it's very viscous, and it absorbs 50 times its weight in water. So if you take some of this powder beforehand or even the capsules, it basically acts like a sponge, absorbs all the water, and slows the absorption of everything. So you can do glucose doesn't spike.

Jessie Inshallah (7:19)

Very cool. I mean, this is really super powerful. Another one that people love is vinegar. I don't know if you know about this, Mark. It's like, tell us. It's incredible. So the hack is before your meals, take a tall glass of water like the one I'm holding now. So this is about, you know, twice the size of a regular glass, and pour into it one tablespoon of vinegar. It can be any type of vinegar. My favorite is apple cider vinegar, but, you know, white wine vinegar, rice vinegar also work and drink it up to 30 minutes before your meal. And in the studies, the scientists say that the effect of vinegar is almost the same as the effect of medication given to diabetics to reduce glucose spikes. Why does it work by just doing this? Because there's a molecule in vinegar called acetic acid, and acetic acid does two really cool things.

Dr. Mark Hyman (8:08)

One, well, that's actually what vinegar is. It's acetic acid. Right?

Jessie Inshallah (8:12)

Absolutely. Right, Absolutely. There's also water in vinegar, right? So it's. That's one of the molecules in vinegar. It's acetic acid. So it goes into your stomach and it talks to this enzyme called alpha amylase. And alpha amylase's job is to break down starch into glucose, and it tells that enzyme, hey, girly, please slow down your role. Slow your roll. And so that enzyme works slower. So the breakdown of starches into glucose happens slower. That's number one. So slower delivery of glucose into your bloodstream later on.

Dr. Mark Hyman (8:42)

Number six, you take the vinegar. The vinegar, you take it like a spoonful before you should dilute it in.

Jessie Inshallah (8:48)

Water just to be safe. Yeah, So a spoonful. In the studies, you can do one tablespoon. You can do two tablespoons. Personally, one tablespoon is what I use, because it's just two tablespoons starts being a lot of vinegar in your glass of water. So one tablespoon is what I like. And the second thing it does, which is incredible, is that it goes to your muscles and it says, hey, muscles, as soon as glucose gets into the bloodstream, soak it up, store it as glycogen in the muscles, don't let it float around. And so by these two mechanisms, by these two mechanisms, glucose is broken down at a slower rate in your stomach. And as soon as it arrives in the bloodstream, it gets soaked up. As a result, glucose spike reduced by up to 30%. And this matters because then you don't have the glucose crash, you don't have the cravings, you don't start that cravings rollercoaster that so many of us are on, yet you're eating the exact same food as before.

Dr. Mark Hyman (9:40)

Amazing. So I want to help you have me break down. You mentioned a few things, but I would really like to have you break down what the symptoms are that most people are unaware of that are related to swings in blood sugar. Because it's not just high or low, it's these excursions up and down that often cause the most havoc. So kind of walk us through. You're the average person, you're kind of walking around not knowing what the hell is going on in your body and what kind of things might you experience if your blood sugar is out of whack?

Jessie Inshallah (10:14)

Absolutely. So the average person walks around and they feel all these symptoms. So they might feel really hungry even though they just ate 90 minutes ago, or it might be 4 in the afternoon and they walk by a bakery and they're like, oh my God, I need to eat three cookies right now. Or they might feel really tired right now. Or they might feel really tired at 11am and these are symptoms that often we tend to attribute to like, lack of willpower. And then there are the more long term symptoms, like acne starts developing on your face, you might get hormonal imbalances that lead to things like polycystic ovarian syndrome, worsening menopause symptoms, long term type 2 diabetes, and all of these things we tend to medicate, right? We're like symptom medication, boom. But actually these symptoms are your body telling you, hey, hello, there's actually glucose spikes happening in here. There's something you can change and heal from within. So in my community, the most common symptoms, as I mentioned, are fatigue, waking up, not feeling rested, feeling like you need to eat every 90 minutes, you need to snack constantly, and feeling this pull towards sweet foods, and then just having very unsteady energy and feeling tired after meals, feeling tired throughout the Day needing coffee to keep going.

Dr. Mark Hyman (11:30)

Yeah, I mean, those are really the common ones, but there's others. I remember a guy who came to see me who was having incredible panic attacks. And I said, well, tell me about your panic attacks and your anxiety. And of course, in medicine we typically attribute these to psychological causes. And we prescribe anxiety medication like Ativan or Valium. And I said, well, tell me what's going on. When do you get it? What happens? And so go into the details of the story. And it turned out, you know, he basically had this big belly and was severely insulin resistant. And he ate a very high starch sugar diet. And you know, he would have tons of carbs for breakfast, which is basically the American breakfast. The sugar for breakfast. I should, I think we should call it dessert, not breakfast for what most people are eating. Muffins, bagels, cereal, which is 75% sugar. Pancakes, waffles, French toast, muffins. You know, it's just, it's kind of a sugar lollapalooza. And he said, every afternoon I just, I just get overwhelming panic attacks. I start sweating, my heart's palpitating, I feel like I'm going to die. I can't breathe. The world's closing in on me. And I said, and what do you do? He says, well, I drink a can of coke and I feel better.

Jessie Inshallah (12:45)

So he was on roller coaster or.

Dr. Mark Hyman (12:47)

Glucose sugars were up and down. And I'm like, you are hypoglycemic. So even though your sugars can go high, they can go low. And I think what happens is there's an issue.

Jessie Inshallah (12:58)

It was mental health issues.

Dr. Mark Hyman (12:59)

Yeah. And it creates all these mental health issues. Depression, anxiety, palpitations, panic attacks. And then you mentioned a bunch of things that people aren't even aware of, like infertility or acne. I mean, most people don't think about that. Wrinkles, Wrinkles. Right, Wrinkles, aging, aging, dementia, heart disease, cancer, fatty liver disease, fatty liver, every pretty much age related disease. In fact, aging itself is often related to sugar issues and to lack of insulin sensitivity, which is what happens when you make, you know, a diet that is full of starch and sugar. You get these wild spikes in sugar, but then that causes a spike in insulin and then sugar crashes. Then you need more and more insulin just to keep the sugar balanced. And ultimately that causes a whole cascade of problems that we now know as the fundamental drivers of aging.

Jessie Inshallah (13:53)

Yes. And on the, on the topic of aging, one thing that really startled me that I discovered is that every time your glucose Levels spike. All the glucose that's rushing into your system, it's going to bump into other molecules and it's going to do this thing called glycation to the other molecules. And when a molecule is glycated, it's damaged. And glycation leads to us literally cooking from the inside like a piece of toast in the toaster. That's what happens. And then when we're fully cooked, we die. That's why we die. And so the more glucose spikes in your diet, the faster you age internally, but also externally because it leads to wrinkles. It's mind blowing. It really is.

Dr. Mark Hyman (14:31)

Yeah. It's true. I remember I was at this longevity conference, the Menla Institute, which is mental center, which is by Robert Thurman, who's a Buddhist scholar, and he had the Dalai Lama there and all these Tibetan scholars, but also Nobel Prize winners and scientists about longevity. And there was Lennon, Lenny Guate there from mit, who discovered sirtuins and the role of life extension by, by activating sirtuins with resveratrol and other compounds. And I said, you know, these master regulators like, of aging, how, how do they get regulated? What screws them up? How does it work? He says it's sugar. Sugar is the biggest problem that we have in terms of not allowing these longevity switches to work properly. And so we literally turn off the longevity switch. We, we should have rapidly accelerate aging when we over consume sugar and I would say starch as well. I mean that's just the same as sugar because you can eat a bagel or a sugar, it's the same thing.

Jessie Inshallah (15:30)

Yeah. And so we're, we end up in this situation where we know it's bad for us and we know we need to avoid glucose spikes, but often people can be a bit lost as to where to begin. Does it mean I should never eat starch and sugar again? That feels very draconian for most people. And so what I've developed are these 10 principles. These food principles allow you to keep your glucose levels steady without giving up all the foods you love. Because personally, Mark, I need a chocolate cake for my birthday. I'm not going to have a Brussels sprouts, low carb, no sugar cake. Like I need chocolate cake. This is a non negotiable part. You're a better human than I am. But like, I love sugar. And so when I first discovered the world of glucose, my fasting glucose levels was 95. I was 23 years old and that was high. And through my hacks I've lowered it to 79 without giving up all the stuff I love.

Dr. Mark Hyman (16:24)

And that's two hacks. So we've got the timing of when you eat what you eat when. Right. Vegetables, protein, and starch, and then the vinegar before you eat. What else?

Jessie Inshallah (16:33)

So if anybody is still having a sweet breakfast, this is a very important hack. Have a sweet.

Dr. Mark Hyman (16:38)

Of course, nobody listening to this podcast ever eats a sweet breakfast because they've been listening to this podcast and they know that we should not have dessert for breakfast. But just in case you haven't heard many of the podcasts, just in case.

Jessie Inshallah (16:49)

This is the first podcast you listen to. Have a Savory breakfast. So in the studies, what they've done is they've taken two groups of people and they've given them two breakfasts, One of two breakfasts, same number of calories. We know calories don't count, but still, it's important to mention this. One group had a breakfast that spiked their glucose levels. The other group had a breakfast that kept their glucose levels steady. What happened was in the group that had the spiky breakfast, they got hungry again after two hours, whereas the group that had the steady glucose breakfast didn't get hungry for five hours. So the curve, yeah, of course, the curve of your breakfast really determines how you're going to feel for the rest of the day and whether you're going to feel in control and connected to your body or whether walking by that bakery is going to give you an irresistible urge to buy all the cookies like it used to be. For me. I used to have a Nutella crepe for breakfast every morning growing up, mark. And by 10:30, I was starving.

Dr. Mark Hyman (17:48)

I mean, Nutella crepe, yeah, that. That'll do it.

Jessie Inshallah (17:52)

But I'm recovered now. I'm recovered. And if I really want Nutella crepe, what I do is I have it after lunch or dinner as a dessert, and I have some vinegar before. So that's another hack. You know, if you want something, put.

Dr. Mark Hyman (18:04)

Vinegar on your cookies. Is that. Is that the thing?

Jessie Inshallah (18:07)

Yeah, just pour vinegar. My friends love me when I come to parties. No, it's. It's so it's having a, you know, the vinegar in the water before you eat, the sweet thing, having the sweet thing after a meal, and also then using your muscles for 10 minutes. So your muscles are really your biggest ally in reducing your glucose spikes. And so what I recommend, it's another hack. After your meals, use your muscles for 10 minutes. Top favorites include dancing to your three favorite songs really loud in your living room, going for a walk with your dog, doing the dishes, the laundry, whatever. Use your muscles. That way you'll curb the spike and you'll feel better.

Dr. Mark Hyman (18:48)

That's a really important point. I think people don't realize this, but the data is so compelling on what you're saying, which is if you just take a walk after dinner for 15, 20 minutes, half an hour, you will see a dramatic change in your metabolism and your blood sugar.

Jessie Inshallah (19:01)

Absolutely. Absolutely. It's really incredible. And this works particularly well to combat the post meal sleepiness that a lot of us feel. If you just use your muscles afterwards, you have all this energy again because you're not experiencing such a big crash. And if you can't go outside and you're just home and you're watching, for example, a TV show after dinner or a movie, people can get really creative. So you could do like you could hold a plank in front of your couch while you're watching the movie. You could get some kettlebells and do some bicep curls. Whatever works, whatever floats your boat. But that'll really help your body deal with the glucose. Coming through.

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Jessie Inshallah (22:19)

I'll give you one more then the rest are in my book Glucose Revolution. One more is putting clothes on your carbs. So what do I mean? Do not let your clothes on your carbs. Don't let.

Dr. Mark Hyman (22:32)

No naked carbs.

Jessie Inshallah (22:33)

No naked carbs. No naked carbs. So I need.

Dr. Mark Hyman (22:37)

What's a naked carb?

Jessie Inshallah (22:38)

Aha. So a naked carb is sugar or starch that you're eating on its own naked. You just eat it naked and it lands naked and it creates a big glucose spike. So to put clothes on your cards, what you do is anytime you eat something sweet or something starchy, you make sure to put some protein, fat or fiber on it. You put some clothes on that. So example, I'm going to take the chocolate cake example. I put Greek yogurt on it if I ever want it in the middle of the day. If you want a piece of sourdough bread, put some avocado on it, put some butter on it. If you ever want to eat some rice, have some eggs with it, some smoked salmon, some greens that you saute.

Dr. Mark Hyman (23:22)

That's brilliant. I think. I think the, the idea that we need to not be eating any of this stuff in a way that spikes our blood sugar is key. And what we're learning and what you learned through measuring your Blood sugar for years and tracking everything is how different foods affect you. What is the biology of what's happening when your blood sugar is out of control? What happens to your microbiome, to your immune system, to your brain, to your hormones? Take us through what actually happens in the body when you are eating the average American diet.

Blinds.com (23:53)

Yeah, so there's sort of four things that I think are kind of worth focusing on. There's the direct effects of high blood sugar. So you eat something and your blood sugar spikes. And then there's biological effects of that. And then there is a fourth thing, which is the long term stuff. So in terms of those short term things, like you drink a Coke and your blood sugar goes up from 75 milligrams per deciliter to 150 milligrams per deciliter. That blood sugar spike can cause glycation, it can cause oxidative stress.

Dr. Mark Hyman (24:22)

Wait, wait, what is glycation?

Blinds.com (24:24)

So glycation is the process where sugar just sticks to things in your body. It's actually just like sugar molecules sticking to things like fats and proteins and DNA. And that can cause dysfunction. It can cause those cellular parts to be dysfunctional. And so that's an issue. We don't want that. It can generate inflammation immediately too, this huge surge of sugar, unusual for the body. It's like, what is going on? Why is this big change, this sort of homeostatic shift happening? We don't want that. And then it can cause oxidative stress, which is sort of this reaction where your body's producing metabolic byproducts that are reactive and can be damaging to the cells. So these unpaired electrons that go around and want to bind with things. It's resting. Exactly. So big glucose spike, you can have immediate effects on oxytostation and inflammation. And then the fourth thing is this thing that's happening both immediately, but also really has cumulative effects, which is the insulin surge. So when you have that big glucose spike, your pancreas is releasing all this insulin to help you soak up the glucose out of the bloodstream into the cells so it can be processed and bring the glucose back down. And what can happen there in the short term is that if you've got a big spike, so that big up and down, the insulin can actually sometimes overshoot. It can actually do too good a job in soaking up all that glucose. And you can have what's called reactive hypoglycemia, which colloquially is known as the post meal crash. So if you've had lunch and then after lunch, feel tired, and you want to have that second cup of coffee at 1pm and maybe you feel a little bit more anxious. That might just be the fact that your blood sugar has gone up, you've released all this insulin. The insulin's kind of overshot, you've crashed down, and now you're in this dip and the body's trying to get back into balance. And that. That roller coaster that creates a secondary.

Dr. Mark Hyman (26:20)

Cascade of hunger hormones.

Blinds.com (26:22)

Cravings. Cravings, exactly. And so that's happening in the short term. And then that insulin process, going back to what we were talking about before, can over time, lead to that insulin resistance, where the cells see that huge surge in insulin so frequently that they actually say, we can't keep doing this. You know, this is too much insulin, and we get numb to it, and that's insulin resistance. And then what happens is your insulin levels, they start creeping up because your body's trying to overcompensate for that block by producing more. And then that leads to so many of the downstream conditions that, you know, we've been talking about when you've got this high insulin. One of the secondary effects of that. Let's just. We can talk about obesity. You know, insulin is a signal to the body that glucose is around for energy. And it's also a signal to the body that because there's so much glucose around, we don't need to use fat for energy. Glucose and fat are the two main ways that we produce energy in the body. And when that insulin's high, it blocks us from tapping into fat burning. It says to the body, nope, you don't need to tap into fat burning. We've got a bunch of glucose around. And so this is relevant to anyone who is trying to lose weight or who has the excess belly fat, because that insulin is a real block on helping us achieve those goals. And so for us to tap into our copious fats stores in our body, we need the insulin to be lower. So by getting off that glucose rollercoaster, by eating foods that keep us more flat and stable throughout the day, which is what we want for optimal health, both in the short term and the long term, we give our body a break from producing that insulin. And that can have a real significant impact on our ability to lose weight, to kind of get rid of that belly fat, to tap into this alternate metabolic fuel source, and to generate what we call metabolic flexibility, which is this ability of the body to flip between using glucose when it's around and using fat when it's not around. And that state of being able to do both is a really healthy state. It's adaptive. But the average American, with the vast majority of our calories coming from ultra processed foods, and I believe more than 70% of processed foods in the US have refined sugar in them. And we've been told of course, to eat six small meals a day. You are on as an American, this up and down glucose roller coaster all day. And so you're really never giving your body this time in a low insulin state. So you really do have to be quite aware and think differently. I mean, the reality is as an American adult, you're on a treadmill towards being overweight and chronic disease. And unless you are doing something different, you will end up sick. And that's, that's where having a little more awareness I think can be helpful 100%.

Dr. Mark Hyman (29:08)

And all the things you mentioned earlier, people don't relate to this. They don't relate to blood sugar. They get. Diabetes is related to blood sugar. But what about cancer and Alzheimer's and depression and heart disease and so many other issues? Infertility, gout. You mentioned sexual dysfunction, acne, I mean, just whatever. It's just unbelievable how much of our modern ailments and how many of those ailments are driven by this single process. And you don't have to treat all these diseases separately. If you dealt with that, then these other things would get better.

Dr. Casey Means (29:43)

There are three primary causes of insulin resistance. And by primary I mean that literally I can cause insulin resistance in isolated cells in laboratory rodent and in humans with all three of these, and that is elevated insulin itself, elevated stress hormones and elevated inflammatory proteins or cytokines. All three of those things are considered primary in my definition because you can just make insulin resistance happen at the cell, in the rodents and in humans, all three biomedical models. But as you were kind of alluding to, if we were to tell someone, all right here, but there are others, like you said, like noxious toxins that can accumulate in fat cells and alter fat cell growth. Absolutely, that is relevant. So I'm not suggesting that there aren't others. There are, but I kind of put these ones as the kind of holy trinity or the unholy trinity of insulin resistance. But we would tell someone, control your stress, and they would say, well, great, doc, how am I going to do that? You know, it's a little difficult. Stress is one of those difficult things to truly wrap your head around. But even still, you'd mentioned like meditation and quiet. I wholly agree with that. But even still, it's a little difficult to fully manage stress. Same with inflammation. We would say lower your inflammation and say, well, how do I do that? You know, we'd have to find out what's the, what are the stimuli that are inducing that increase in that immune level. But if we say, control your insulin. Easy, easy. That is a lever we can grab with both hands and immediately start to pull down. Just through time restricted eating and intermittent fasting. And by just managing macronutrients and altering that ratio, focusing more on the foods that have the lower effect on insulin, like fat and protein, and controlling the starchiest of the carbohydrates or the most sugary. Now, neither you nor I are declaring war on carbohydrates. And I'd hate for someone to leave this talk, leave this discussion, thinking we are. We're not. You know, neither of us is advocating a carnivore diet, but we are certainly. My view is don't get your carbohydrates from bags and boxes with barcodes. Yeah, good. I love alliteration, so I'm glad you appreciate it.

Dr. Mark Hyman (31:53)

Bags and boxes and barcodes. All right, good.

Dr. Casey Means (31:55)

Yep. But that's where people get it wrong, right? They're thinking, I need to. They have a box of crackers or a bag of chips or a box of cereal. No, go eat fruits and vegetables. Eat them. I'm an advocate of fruits and vegetables. Eat them, but don't drink them and don't get them in processed foods. Bags, boxes.

Dr. Mark Hyman (32:13)

Barbara, my joke is I always say carbohydrates are the single most important food for health and longevity. Right. And what I mean by that is that plants are carbohydrates. Broccoli is a carbohydrate. You know, asparagus is a carbohydrate. Those are the ones you want to eat, not the ones that come from a factory or, or from, you know, some processed ingredients that you mentioned.

Dr. Casey Means (32:37)

Bags and boxes, barcodes.

Dr. Mark Hyman (32:39)

What I, I'd like to sort of go into now is an understanding of some of the challenges and controversies around fat. I wrote a book called Eat Fat, Get Thin where we talked about this. But, you know, there's still a sense that your cholesterol is a big problem, that saturated fat is the devil, and that we should not be eating it. Butter cream, coconut oil, animal food, saturated fat. Talk to us about the biology of what happens when we increase fat and why, why it doesn't work in the same way we think. And also, if you can speak to the heterogeneity in the population because there's subsets of people who do great with high saturated fat diets and those who don't. And I'm just going to give you a quick scenario of that and then you can kind of riff on how we start to think about it. I had a woman who was about late 40s woman who was struggling with her weight inflamed, trying to do good. She exercised, she ate pretty healthy. She wasn't off the rails with her eating. Her triglycerides were 3, 400, her cholesterol was 300. Her HDL was like 30. I mean, which is terrible numbers, you know, which is classic of prediabetes insulin resistance. And I said, look, you know, you've tried a lot of things. Let's just try a ketogenic diet and see what happens. You know, no harm, no foul. She did it and it was remarkable. Her. Her. Not only did she lose 20 pounds like that, but her levels of inflammation came down. Her triglycerides dropped 2, 300 points. Her HDL went up 30 points, which you never see. Her total cholesterol dropped 100 points by eating butter and coconut oil. And yet another, another guy was a very thin, fit, mid-50s guy who was a really aggressive bicycle rider. He rode 30, 50 miles a day, and he decided he wanted to try it for performance reasons, not to lose weight. And his numbers went completely the opposite. He got very high levels of cholesterol, very high levels of small particles. Just, it was just remarkable to see the difference. And it sort of woke me up to the fact that there isn't a one size fits all regards to this. So with that framework, take us down understanding of, you know, if we are going to be reducing our carbohydrates, starchy, sugary carbohydrates, and we're going to be increasing our fats. How do we do that? And what's the role of saturated fat? And should we be worried and how does it work?

Dr. Casey Means (35:04)

Yeah, yeah, the great question. So my postdoctoral work really was seminal in that it scrutinized the degree to which fatty acids themselves can contribute to insulin resistance. And this is a conversation that I'm passionate about because so many people start beating this drum of saturated fats and use it as evidence against animal products, because animal products do contain saturated fats. Invariably. Now they're never completely saturated fat, and that's important. There's a mix of saturated, mono and polyunsaturated fats. And now what?

Dr. Mark Hyman (35:40)

These, by the way, all saturated fats aren't the same. There's like 10 or 12 different saturated fats. So they're not like, oh, my gosh.

Dr. Casey Means (35:46)

Yeah, yeah, yeah. Oh, there's, there's, there's dozens of them. Yeah, that's right. Yes. I'm a huge advocate of a full spectrum of fats, namely of saturated fats, even long chain, which we get a lot of medium chain and then short chain. But putting that to the side. When you incubate a cell, if you have a cell culture, whether it is muscle cells, liver cells, neurons, fat cells, and if you incubate those fat cells with palmitic acid, which is the prevalent saturated fat in the human body, certainly in circulation, palmitate, or the 16 carbon saturated fat. When you incubate cells with palmitate or stearic acid, even 18, 18 carbons, they will become insulin resistant. You treat them with the fats, then you put on some insulin a little later and then measure. Then you take all the cells and measure what insulin did and it is compromised. That doesn't happen when you incubate the cells with monounsaturated or polyunsaturated fats. It will not cause direct cellular insulin resistance. So I've done these studies myself. Maybe the most cited study of mine I've ever done was this exactly. Series of studies. So. And the same thing happens in rodents. When you infuse the rodent with fat, when you're infusing it directly iv, the saturated fat will cause insulin resistance, but the monounsaturated, like olive oil, for example, doesn't. So there is a direct effect of saturated fats at the cell to cause insulin resistance. And this is all once you actually get into the cell itself, it's because of how these fats will induce the accumulation of another molecule called ceramides. And if anyone has ever heard ceramides in the audience, they might be thinking of it as like in lotions or shampoos and stuff, but it is a slightly different version of it. But saturated fats will induce the accumulation of these molecules called ceramides, within a cell. And then ceramides will directly prevent insulin, the insulin biochemical pathway, from doing its job. It directly antagonizes what insulin is trying to do. So that's the actual where the rubber meets the road. Molecular mediator. So now to zoom back out to the level of the whole body. Some people look at those studies, even possibly my own, and will use that as evidence against saturated fat. And they will say, see, saturated fat causes insulin resistance, but it doesn't work when you actually go to the whole body and look at the consumption of fat. This is the paradox is the vast majority, overwhelming majority of saturated fat in our blood is palmitate, but it's not from the diet. It comes from the liver. The liver is the primary source of saturated fats that are circulating in the blood, that when we eat saturated fats, they're packaged into the chylomicron, and there can be some depositing of that throughout the body, but it goes to the liver. And then the liver will repackage all that fat, and almost always the saturated fats will have two things happen to them. They get elongated by two carbons. So you'll take that 16 carbon palmitate, which is the most prevalent saturated fat. We take that 16 carbon, we make it into an 18 carbon, and then we desaturate it. There are these two steps. And so we end up taking the palmitate in the diet and turning it into oleic acid, or the primary fat, olive oil. And that is the primary fat that is stored in every single person's fat cells. So 18 months.

Dr. Mark Hyman (39:12)

So basically, your liver makes olive oil?

Dr. Casey Means (39:15)

No, no, no. So the fat cells turn it into olive oil, but the liver makes palmitate. Yeah, yeah. So when we eat saturated fats, the body will turn it into olive oil, basically. But when the liver is making fat, it makes saturated fats. And so this is why you can take someone and put them on a ketogenic diet. Low carb, high fat, and they could be eating three times more saturated fat than they were before than the other group, than the low fat, high carb group, three times more saturated fat. And yet the actual composition of fatty acids in their lipoproteins in their blood is much less saturated. So the actual amount of saturated fat circulating in their blood is much lower than it is if someone is eating a diet that is spiking their insulin, because most of the saturated fat in the blood, which is what's coming to the cells throughout the body, the phenomenon that I mentioned a moment ago, most of that saturated fat is coming from the liver, and the liver makes saturated fat when insulin is up. This is a process called lipogenesis and palmitate.

Dr. Mark Hyman (40:20)

Lipogenesis, Yep.

Dr. Casey Means (40:22)

Lipogenesis, yep. And insulin is what turns that on. And that's the paradox here, really, to put a kind of point.

Dr. Mark Hyman (40:28)

Turns on insulin.

Dr. Casey Means (40:29)

Starchy, refined carbs.

Dr. Mark Hyman (40:31)

Yeah, yes. Sugar and starch. Right. Okay, well, let me just recap more. What you're saying is that if you eat saturated fat in your diet from animal protein or dairy or Coconut oil, it gets turned into olive oil in your fat cell.

Dr. Casey Means (40:49)

That's right.

Dr. Mark Hyman (40:49)

If you actually eat sugar and starch, it turns on the fat production factory in your liver to make saturated fat.

Dr. Casey Means (40:58)

That's right.

Dr. Mark Hyman (41:00)

It's saturated fat that's coming from eating sugar. People don't get this connection. They think, oh, sugar is sugar. How does it turn to fat? But there's a mechanism by which these sugars cause the production of saturated fat in your blood, which is what's causing a lot of the problem.

Dr. Casey Means (41:18)

And it's a one, two punch. Absolutely. It ends up being a one, two punch where these starchy sugary carbs will both act as the skeleton. You know, the liver will take those carbons and rearrange them to create a saturated fat. And at the same time, the starchy sugary carbs are increasing insulin, which is what's driving the signal. That's the signal to tell the liver to do that in the first place. Because the liver will not make fat out of carbs unless insulin is elevated. It is antithetical. It is impossible for the liver to do because like every cell in the body, insulin tells the liver what to do with the energy that it has available. And when insulin is up, one of the things it wants the liver to do is turn the carbs into, turn the glucose, those carbons into fat. And the only fat the liver is making and packaging and releasing is palmitate, that saturated fat.

Dr. Mark Hyman (42:10)

That's incredible. So I want to drill down a little bit into the take homes and I sort of want to recap a little bit. And then I want to ask you what we can do to fix this, because it seems to me that what you're saying is that this whole host of chronic diseases is driven by or affected by this phenomena of insulin resistance. And it's the biggest scourge causing 88% of Americans to have poor metabolic health.

Dr. Casey Means (42:42)

Second is in 90% of people and 90% of people with COVID to have it so bad they have to go to the hospital.

Dr. Mark Hyman (42:48)

That's right. That's right. And the second thing is that we, we understand that the way in which insulin resistance is controlled is through primarily diet. And I want to go through a few of the other factors too, but primarily diet. And it's primarily the starch in our sugar, which is enormous in this country. It's 60, 70% of our diet. It's usually in the form of flour and hidden sugars in our diet or added sugars. About 152 pounds of sugar and 133 pounds of flour recently, according to USDA data. You know, that's almost a pound a day of sugar and flour per person per day. It's staggering. It's staggering. Which our human biology never, never was exposed to. Right. We see 22 teaspoons a year. If we found some berries or honey. Now it's 22 teaspoons per day for the average adult and about 35 for a kid. And three, that by changing the quality of our diet, in other words, reducing starchy refined carbs and increasing good fats or maybe even saturated fat, we can actually stop this process which is underlying everything that goes wrong with us at least aging. And that there's some heterogeneity in the population. But we need to figure out, one, how to diagnose it. I want to talk about that. Two, then how to treat it. Because if we understand this is the problem, you know, one, what, what do people listening need to do to find out if they have this problem? Let's start there.

Dr. Casey Means (44:20)

Yeah, yeah. Well, I.

Dr. Mark Hyman (44:21)

Aside from the mirror jiggle test. The jiggle test, yeah.

Dr. Casey Means (44:24)

Yeah, yeah. Well, I will. I will try not to be too redundant to what you said, but I would say anyone who has any potential, get your insulin measured. And you'd mentioned some wonderful metrics. I've always said below six. I think you said below five. I think that's a brilliant way to do it. Now, at the same time, insulin, like every hormone, has a bit of a rhythm to it. There's a diurnal or circadian rhythm. So it's possible someone would go get their insulin checked and maybe it's 12 or 13 or so. And you and I both would say, oh, that's a little high, we need to be a little worried. But it's possible the person has measured it at a peak and that in reality, give it an hour or two later and it would have gone down to five. It's possible. So I think it is important to note that there are other things, like challenging it in a dynamic glucose test, like you'd mentioned, that is absolute gold standard. Alternatively, another metric you mentioned is looking at lipids, because insulin controls the production of fats and the regulation of lipoproteins in the body, because lipoproteins are energetic molecules. And so look at the triglyceride to HDL ratio. And if a person has a triglyceride to HDL ratio and it's above 1.5, that's strong evidence that they're insulin resistant. Now, that Ratio doesn't hold across all ethnicities, it starts to get a little loose, you know, from Caucasians to Asians to African Americans or so. But nevertheless, that ratio of 1.5 is generally going to be a pretty good indicator that if you're lower than that, if your triglyceride HDL ratio is lower, that's a good sign that you're insulin sensitive. The good old fashioned waist to hip ratio or the waist to height ratio, if you measure your waist like the biggest part around your belly, and if you multiply that by two, if that number is higher than your height, that's a very, very good indicator that you have metabolic syndrome or insulin resistance, to be more precise. If your waist circumference times 2 is less than your height, that's a good sign that you're generally doing okay. And then one other metric among many is what's on the skin. And there are two things people can look for on their skin which are it's almost proof positive of insulin resistance. The first one is skin tags. Those are these little kind of mushroom like or columns, little stalks of skin. They're not like a flat kind of round mold. They just sort of jut right up and they're small. I bet everyone already knows what I'm talking about. People can get them in their armpits or around their neck if they have a fat fold around their neck. So those are skin tags. And at the same, in the same place, especially around the neck or the armpits, anywhere where skin is rubbing, they can start to develop something called acanthosis nigricans or these patches of skin that are a little darker pigment and they have a kind of altered texture, kind of this velvety kind of texture to it. But that's another one. So the skin, I kind of joke the skin is the window to the metabolic soul just because like every part of the body, it responds to insulin. And so we start to see these little hints of it.

Dr. Mark Hyman (47:25)

So that's really helpful. You know, I wrote, I wrote a little description of how to look at this in great detail called how to work with your doctor to get what you need. It's available on my website, Dr. Hyman.com, it's also available, I think online, you can just google it. And I go through all the diagnostic tests to help you identify the ways in which either you have insulin resistance or the consequences of it. And the things that I tend to recommend people do is like you said, a fasting insulin, super important. The best test is because the Fasting insulin elevation is really the second stage of the problem. The first stage is elevations of insulin after you consume a sugar drink. So that's a little bit of more of a pain in the ass test where you have to drink a sugar drink. It's equivalent of two Coca Colas, and then get your blood tested either 30 minutes after or, or one and two hours after, as well as fasting. That's really important. The lipid test you mentioned are super important. I'm going to just drill down a little bit on that because there's something called an NMR or a cardio IQ test from LabCorp Quest which look at not just the total numbers of like the weight of cholesterol, which is your milligrams per deciliter. It looks at the particle number and the particle size, which is really important. And so when you have insulin resistance, you have a perfectly normal cholesterol of 200 or 150. But your triglycerides may be 300. Your HDL is 30. You're like, oh, your cholesterol is fine. Your LDL is fine. It may not be because you may actually have really dangerous small particles. Also. We look at, you know, like, the triglyceride HDL ratio is very important. It's something not really paid attention to much by doctors, but it's more. More predictive than an LDL elevation. More predictive. The most predictive tests are, you know, triglyceride HDL ratio and total to HDL ratio. And the HDL ratio reflects the insulin resistance. So we've always been looking at it, but not in the right way. We also looked at inflammation, which can happen through a crp. We look at uric acid, which can be elevated, which David Perlmutter's book Drop Acid was all about. We look at liver function tests, which can be abnormal. We look at male hormones, sex hormones. We look at DHEA and sulfate in women to look at the effect of androgens being produced from the insulin resistance. So we look at a whole host of things and we can get a pretty good picture of where people are in that spectrum. But the most important, like you said, is looking at the insulin fasting or after glucose tolerance test. And you mentioned the waist to hip ratio. That's important. But, you know, when you look at the Data on the 88% of Americans who are metabolically unhealthy, only 75%. Only. Right. 75% of us are overweight three quarters. But like, what about that other, you know, like, you know, 8, whatever, 8% like probably about a quarter of people who are thin also have prediabetes. They're what we call skinny fat or thin on the outside, fat on the inside. They're metabolically obese, but normal weight. And that's just because they they may not gain weight, but they actually the metabolic consequence are all the same. So we start to look at all these factors and we get a pretty good sense of the problem. Thanks for listening today. If you love this podcast, please share it with your friends and family. Leave a comment on your own best practices on how you upgrade your health and subscribe wherever you get your podcasts and follow me on all social media channels at Dr. Markheimen and we'll see you next time on the Doctor's Pharmacy. I'm always getting questions about my favorite books, podcasts, gadgets, supplements, recipes, and lots more. And now you can have access to all of this information by signing up for my free Marks picks newsletter@drhyman.com Markspicks I promise I'll only email you once a week on Fridays, and I'll never share your email address or send you anything else besides my recommendations. These are the things that have helped me on my health journey and I hope they'll help you too. Again, that's drhiman.commarkspix thank you again and we'll see you next time on the Doctor's Pharmacy. This podcast is separate from my clinical practice at the Ultra Wellness center and my work at Cleveland Clinic and Function Health, where I'm the Chief Medical Officer. This podcast represents my opinions and my guest opinions, and neither myself nor the podcast endorsed the views or statements of my guests. This podcast is for educational purposes only. This podcast is not a substitute for professional care by a doctor or other qualified medical professional. 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