transcript

Speaker 1:
[00:00] Coming up on today's show.

Speaker 2:
[00:01] Do you want pleasure now? Do you want something far better in the future? So if you want pleasure now, eat the trifle, eat the cake. But if you want a better future, well, you got to work towards that. Let's put a lot more energy into thinking about a healthy species specific diet. So if you had a human being in a zoo, what would you feed them to keep them maximally well? Isn't it what we should all eat? What we're seeing at the moment is a gigantic experiment. And many of us are eating the wrong foods. And I'm seeing the consequences in every clinic I do. 150 grams of boiled rice, what is that equivalent to in terms of teaspoons of sugar? And the answer is about 10. The banana is about the same as six teaspoons of sugar on the glycemic load. Bananas are sugar sticks, very little fiber. You wouldn't believe the number of overweight people that eat bananas for the potassium, which is some sort of nonsense put out by the banana growers, I dare say. I can sprint with my grandchildren. I can play and roll around. That's life. Eating cakes alone, that's not life at all. Go for a little bit of pain now and a better future. You'll be glad you did because I certainly am.

Speaker 1:
[01:11] Dr. Unwin, what would you say is the most important thing about type 2 diabetes people aren't being told?

Speaker 2:
[01:18] Oh, that's great. The most important thing is that how it all turns out for most of you and for myself depends upon my lifestyle mainly. And so that again, for most of my patients with type 2 diabetes, and I have type 2 diabetes, every meal is both an opportunity or it could be a threat. So you have a sort of choice really on a daily basis of what you eat, because for most of us, that's what affects blood sugar. And it's blood sugar over time that cumulatively affects what's going to happen in terms of your health. So this can be a great message of hope. And that's what gets me up in the morning and what sends me to my clinic. I've just come out of clinic today. And in every clinic, I am seeing the most amazing cases. I've seen some this afternoon, that people are choosing to try and avoid lifelong medication and use lifestyle instead. And then they feel empowered and often healthier and more cheerful. It's a great journey, a great journey. I think the other thing I'd like to say is about type 2 diabetes prevention. Because treating is one thing, but I believe that most people have type 2 diabetes because they didn't know the risk they were running with how they were eating. And that's exactly how I developed type 2 diabetes. I had no idea that my diet was causing it. And if you know that, well, then the question is, could we prevent it? And given that so many millions of people around the world suffer with this, and it affects all cause mortality, and well, it isn't just about mortality, is it? It's about health span. So if we could prevent this, how wonderful would that be? Maybe people don't have to have it in the first place. Wouldn't that be exciting? And you're probably going to explore that. And this is some of the work we've done in our practice, where we're preventing diabetes now. All of it is very exciting work, really.

Speaker 1:
[04:15] You mentioned early on the fact that you are type 2 diabetic. You also mentioned the hope piece. I want to make a connection there, because somebody's saying they're still type 2 diabetic in a way that kind of kills the hope. So I want to understand what you mean by that and what the reversal potential is.

Speaker 2:
[04:37] If we go back to when... So I'm 67 now, but when I was 55, my experience as a primary care physician was that type 2 diabetes was a chronic, deteriorating condition. And that's exactly what I'd seen for 25 years. So people would start, and we'd put them on metformin, and then I'd use glycozide, and this drug and that drug, and then eventually we'd finale with insulin. And meanwhile, they'd get heavier and heavier, and their health would deteriorate. And that was really how I saw diabetes, type 2 diabetes, as a chronic, deteriorating condition. But contrast that with what I now believe, is that for around 50% of all the patients that I treat with type 2 diabetes, they're achieving drug-free remission of diabetes, so that what that means is they're not using any medication, and they have a blood sugar that's not in the diabetic range. So that's for me is hope, because relatively, that's a much better position to be in for me, so that my drug-free type 2 diabetes remission has now lasted since about 2013. That's 13 years I haven't taken tablets, and if anything, my health is now significantly better in so many ways than it was in 2013. So that for me is a great message of hope that you could be older. So I am older, but my health is so much better, and the health of a great many of my patients. And it's also, it's loads of hope in different ways, isn't it? It's hope for clinicians, because I became a doctor many years ago. In 1986, in a practice where I still am now, just north of Liverpool on the west coast of the UK, it's raining heavily, of course. And I became a doctor thinking I wanted to do primary care, because I wanted to be a larger fish in a small pool with the idea that I could help my community, and I would know who my community was. Fast forward 25 years and I was a disappointed man, because although I had become very fond of my patients, I didn't feel that I was making the difference in the community that I had hoped, and that my experience of medicine, I wasn't quite sure why, but I was disappointed with myself really, and disappointed with my career. With a very vague, I didn't really know why that was, and I thought I also didn't feel very energetic and a bit depressed, a bit anxious. And so you see now, here I am, so much older, having done, I loved this afternoon. I had such a happy, an experience of being a doctor, full of hope, meeting amazing people who have changed their lives. And that's great fun. So there's some more hope for you, hope for patients and hope for clinicians. Because most of, I'm the oldest practicing GP in a hundred miles radius of this room. Because all my friends, they've all, most of them retired 10 years ago or more. Because their experience of being a doctor was unhappy, full of stress and anxiety. And what a shame that is, because isn't being a doctor an amazing thing? Doesn't it offer wonderful potential? And yet most of my colleagues did not find the potential. So hope and more hope. It's a powerful thing, is hope. We can change the world.

Speaker 1:
[08:59] Well, the reason I honed in on that is just the tense you used, where you referred to yourself as type 2 diabetic, even how far you've come along the journey. So that leads me to further dig in to try and understand metabolically, because of your past, do you see yourself as different than somebody that's been metabolically healthy all along?

Speaker 2:
[09:23] Yes, I do. That brings up a couple of interesting points. So the first thing is, everybody loves the idea of reversing diabetes. And sometimes we do, and probably Prof Roy Taylor, a friend of mine from New Castle University, is a world expert on this, where sometimes you actually improve insulin sensitivity to a point where you can eat carbohydrates again and not put up your blood sugar. But I would say for most people, what you're doing is remission. And I call it remission, because I need that constant reminder that ice cream and biscuits and bread and rice are finished from my point of view. And that in my case, I damaged my own metabolism. I know how I did it, literally mouthful by mouthful over many years. So my metabolism is aged. I think type 2 diabetes, insulin resistance, is not to do with age particularly. But I do think there's a concept of metabolic age, and that I have some consequences of the dietary choices through quite a long life, and I'm stuck with them. But I'm not sorry for myself. I'm in remission. I'm using drugs. I'm physically very fit, incredibly active. So why would I moan? I am a little restricted in my diet. The key thing is I enjoy the food I eat. I look forward to meals and then I'm full. So the deal for me, yes, I can't eat Christmas cake, and trifle is a thing of these things. But hey, somebody of 67, I can sprint, I can run. I'm fit, and my brain works well. I think that's another most important point. So there are, just to be scrupulously kind of clear, some people reduce, they improve their insulin sensitivity. They also improve their pancreas, its ability to produce insulin. And there are people who literally cure their diabetes and then can, in a moderate way, eat carbs again. But I haven't met many of those. And I think it gives false hope, because then you just start doing what you did before. And when you think of the number of us that are actually junk food addicts, the thing an addict loves to hear is that, you know, cigarettes are fine, wine is fine, and chips and burgers are all fine. And so a note of caution for me. And that's how I run my practice, really, with the idea that this is remission, hooray. But be careful, you've eaten yourself into this thing once, and you might eat your way into it again. Which brings me to, I'll shut up in a minute, just brings me to a point. I've got 21 patients who've had drug-free remission more than once. So what's happened is they did a great job, well done. And then they go on an all-inclusive holiday. It's somebody's birthday, it's this, that, and the other, there's always an excuse. And carb creep slithers its way in. And then, oh, we're out of remission. And then I have to start all over again. But that's okay. Some of my patients have been in remission three times over 13 years, where, you know, and I think a lot of the listeners will have, they'll have experienced this. The cookie jar is calling to you. And friends say, go on, just have one, and then you do. And then before you know where you are, you're back where you started. So I like the idea of remission. I think we need reminding that we are safer than we were before, but that doesn't mean we can take it for granted.

Speaker 1:
[13:58] When it comes to these patients with carb creep, and they've had multiple remissions, what do you notice is different psychologically or behavior wise for those people?

Speaker 2:
[14:10] Great point. For many years, I called it carb creep, but I think what I was doing was trivializing something far more sinister. When you have intelligent people who know that what they are doing, what they are eating is damaging their health, you have to say, well, isn't this a bit like alcohol for alcoholics? Isn't it a bit like cigarettes for those addicted to nicotine? And of course, this is the life's work really of my very clever wife, Dr. Jennifer Unwin, who's a world expert on junk food addiction. And gradually, over the years, I've come to the conclusion that what we have here, and it's very, very common, is intelligent people doing stupid stuff. And they know that it's stupid stuff. And that is not carb creep, it's something far more sinister. And if Jen was here, she'd be pointing out that 14% of the adult population is probably an ultra-processed food addict now. And in truth, I'm dealing with junk food addiction in every single clinic I do, where I'm asking people, how are the cravings? How are you doing? Because if you don't help people with maintenance, you've wasted all that effort that it was to get remission in the beginning.

Speaker 1:
[15:47] So when it comes to these people that are more apt to fall back into carbs, how different is the treatment you use with them?

Speaker 2:
[15:56] Well, so if the model, if our model is addiction, we can use this and think, well, as a clinician, how would I help somebody with alcohol? Or how would I help somebody addicted to cigarettes? And the key thing, of course, is that moderation does not work. It really does not work. And that advising people to moderate bread, or rice, or burgers, or ice cream, any of these things, if you're an addict, well, you'll have a little bit and then you have all the rest and more and more and more. And I was a bit like that. And I know many patients who, if they were to have, well, even a half slice of bread, and bread's a very common addiction. In my practice, it's all over because you just cannot control it anymore. And so, using the model of how we look at addiction normally, and then just moving that across, you're thinking, first of all, abstinence. Be clear. The first thing, of course, is honesty. The first thing is honesty. It isn't carb creep. Have you been here before? Many people say, yes, loads of times. I've lost weight, a white knuckle ride. I went on holiday and two months late, I put all the weight back on. It's a really common story. Be honest. Could this be ultra-processed food addiction? Could it? Would it fit your life experience? It's interesting, isn't it? Because I never found a single food addict for 25 years, not one. And do you know why? Because I never asked. One certain way to not find out is never ask. And a lot of that time, I was living with an ultra-processed food addict, my wife, and we never, it never occurred to us. But now, when I ask in clinic, you're somebody that's gained weight and lost it loads of times. Do you think you could be addicted to some foods? And you would be astonished at the number of people who say definitely. And then I said, you know which foods they are? Because it's very important to be specific about your problem food. And they will say, yes, it's French fries or it's, I don't know what you call crisps in Canada, but you've probably got to need those little things in chips. Oh, right. Fair enough. You know the thing. Anyway, so they be specific about what your problems are. Be specific. And then the next thing is, how has moderation worked for you so far? How's it going in the last 20 years? How's that going? And they say, well, you know, Christmas, oh my God. And I went on a cruise and oh dear, that was a disaster. So then you come to abstinence. And then on top of that, you need support. You need help. Most people can't do it alone. Most people would struggle. You need support. Also, what attitude do your family have? Because if they don't support you, you will fail because they'll say, go on. Your mother will just make you that cake or your sister will offer you this, that and the other. So you probably need to share your problem. If you believe you are addicted to junk food, you probably need to share this with some of the people who love you. And it may be helpful to ask, could you help me? Because I'm going to try abstinence. And I think I need help. And there's a lot more to it than that because any of these addictions are battled with on a daily basis for years. And Jen would tell you she's still, she's an addict in remission. And that fight goes on on a daily basis. So that's a little trot through ultra processed food addiction. It's not carb creep for many people. For some people, they can say, yep, you're right, I'm wrong. I'll knock that on the head. I'll cut it back to one slice of bread or whatever. And if it works for them, fabulous. If it doesn't work, they need to ask, why is this not working? Am I possibly addicted after all? And welcome to my world. That's how the clinic goes. Round we go.

Speaker 1:
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Speaker 2:
[23:39] I love that question. I think it's very important because I actually made it far worse. Do you know, when you love somebody, it's really hard to watch them doing something that harms them. So I would know that Jen was eating things she shouldn't, sometimes in secrecy. I would see her suddenly start baking traybakes for the children, and I'd know that actually she's going to eat it herself. I would also know that if she gained a lot of weight, she became unhappy and stressed. So as a sort of caveman husband, it seemed obvious that I needed to stop her from doing the traybakes, and that I needed to knock this on the head and say, kind of, stop it. What are you doing? Or I'd throw stuff in the bin, or when she wasn't there, I'd find her secret stashes and throw them all away, or I'd deal with it head on. But of course, that made her more secret. It also made her defensive. It caused us to have arguments, and nobody won. It really didn't help, but I did not understand, and neither did Jen actually, what was going on. But the minute you think about somebody with an alcohol problem, and the complexities and difficulties of that, and the problems of self-esteem, considerable. Because you, as an intelligent person, you keep doing stupid stuff. So it needs a lot of sensitivity, it needs gentle support, not aggressive support. And sometimes you have to say nothing. You have to just let it go if you can, because they're probably going to deal with it, and better to let them pick the time. And let them know that when they're ready, you're there, and you will support gently. But I was far too heavy-handed, but it was through love. So, you know, you live and learn.

Speaker 1:
[25:52] By the sounds of it, this addictive nature of foods is affecting a significant amount of people. Given that, when somebody comes to work with you, and they haven't tried quitting before, is abstinence the first step for everybody?

Speaker 2:
[26:08] For people with addiction.

Speaker 1:
[26:10] Well, I'm trying to decipher, if somebody comes to work with you, and you don't know if they're addicted, if they don't have that personality type, do we have to assume until we find out otherwise?

Speaker 2:
[26:19] I have a certainly a high index of suspicion. But if somebody feels that they're not an addict, they may well be telling me the truth. So you have to be like fair do's. We've got plenty of time. So we say, well, I would say, well, okay, cut it back and let's see how we go. And I have people who attain drug-free type 2 diabetes remission still on 150 grams of carbs a day. So there are some people that can do it. But equally, if you fail, then we need to look a little harder at this as to what really happened and honesty is the most important thing. And I try and encourage people to realize I'm not critical. Just tell me the truth and we'll work our way through it. And also, I'm a great believer in reframing failure. I don't like the idea of guilt and failure. It's pointless emotion. So nothing is as dead as what you did, Jesse, yesterday. Who cares? But maybe, maybe you could learn from yesterday. Maybe you could do Christmas differently or a holiday differently. So I'm always fascinated by success. What exactly did you do? But I'm also very curious and interested by failure. And the idea is being curious, not judgmental. I'm just curious with the idea of... So if Christmas was a disaster, and that's what they come in, oh God, Christmas was a disaster, and I put all the way. That's fair enough. But specifically, what would you do differently next Christmas to avoid? What could we learn? And I help clients tease apart specifically what they could do differently next Christmas, how they could plan for success. And in that way, we try and reframe failure as a possible learning opportunity. And who hasn't done stupid things? Who hasn't made errors? But some of the wiser ones learn from their errors, and it's a pretty good way to learn. But if you keep doing the same thing and you get the same results, well, do you know, maybe it's time to do something different.

Speaker 1:
[29:02] We're going to get to the protocol and what people can do if they're in that boat of continuing to struggle and say they've been trying to cut back on calories, move the body more following that classic advice that doesn't work, at least not long term. But I want to talk about the physiology first, because when it comes to type 2 diabetes, the last stop for this train is type 2 diabetes. But there's a whole lot of other problems happening along the journey. First of all, how can people know if there's changes with the physiology more early on, early signs? And then let's talk about what's happening under the hood.

Speaker 2:
[29:41] Good idea. I think you'd have one of the first things to say is that, so I'm working in the British National Health Service with 10-minute appointments and many restrictions upon me. For instance, I can't measure insulin at all under any circumstances. I'm not allowed. So we're working a little bit blind. I dare say in Canada, where you are, you can probably measure insulin, but that would help, wouldn't it? So let's now just get to the model that I use with my patients. A lot of this is thanks to my good friend, Professor Roy Taylor. We've cooperated together over a very successful paper in BMJ Nutrition. So you can read about this, our 2023 paper. So what's going on? Right. So let's begin with the hormone insulin. And this is how I discuss this with patients. If a high blood sugar is damaging, and it is, so we know in fact that if you have a high blood sugar within six hours, you've damaged the non-stick lining of your arteries, the glycocalyx, within six hours, a spike of glucose is dangerous. So nature or God or whoever has designed us really well to be protected from spikes of high blood sugar. And that protection is complex, but the most important part of it is insulin. Insulin is brilliant at getting rid of spikes of blood sugar. And then the next question is, oh, that's interesting. So it puts down blood sugar. Where does the sugar go? Because questions are more powerful. Asking things is more powerful than telling people things. So where does that sugar go? Well, I love, I think his Jason Fung, you must know wonderful, wonderful Jason Fung. He would, yeah, I'm sure you do. Well, he's done some lovely work on this and written some very good books. And one of them is the idea. Think of insulin as pushing sugar out of the bloodstream and inside cells where it can do a lot less damage. Bit like a nuclear dump. So the sugar goes in the cell and what happens to it? Well, a lot of it is turned into fat. And so this relates to all sorts of things. And this can be how you develop a bigger belly. You start getting fatter tummy. Fat is building up inside your liver. And in fact, we know now that a third of everybody in the developed world has got fatty liver. We know that. There's some really good papers on that, a third. Then you've got a problem, because fatty liver interferes with the good work of insulin, so that insulin doesn't work as well, and you become insulin resistant. It's the first thing. And if we think this through, you still have that imperative to reduce blood sugar, but your insulin isn't working as well. So what does the body have to do? Produce more insulin. And that is hyperinsulinemia. So you then have two problems. One is insulin resistance, and the other is high levels of insulin. And there are some conditions which in part are caused by hyperinsulinemia. And I happen to believe essential hypertension is one of them, where insulin interferes with how you get rid of sodium at the kidneys. I've written a paper on that with Professor Brady, a professor of cardiology at Glasgow University. So, you have that. You have insulin resistance and hyperinsulinemia. For years, probably, getting gradually worse. But then there's another unfortunate thing working against you, because fat is building up in the pancreas also, the organ struggling to produce all that insulin. And eventually, what you have is a breakdown of homeostasis, where you cannot produce enough insulin to regulate your blood sugar. And at that point, blood sugar starts going up. But actually, probably for 10 years before then, you've had a problem that you didn't know about. Roy Taylor calls it the long silent scream from the liver, which he's trying to tell clinicians, think about abnormal liver function, think about fatty liver, because it's a call to do something different. So then you come to, well, what might you notice in, which was the other part of your question, what might somebody notice? Well, of course, if your waistline's getting bigger, if your belly's getting bigger, it's quite likely your insulin isn't working as well. It isn't necessarily, but it's quite likely. And then also if you're insulin resistant, you have a problem with energy. So you may not, you may feel, this is what happened to me for certain, that I lacked energy and drive. I had another problem as well, which was concentrating. I had brain fog, I couldn't think clearly. I didn't realize that until I was sorted out, because then suddenly I thought I haven't thought as well as this for years. So these are all things that you could notice, tiredness, a big belly, and maybe a brain fog. What your physician might notice is I specifically talk about to raise triglyceride because the fat that is produced in the liver by all that excess sugar under the influence of insulin is triglyceride. And again, I used to ignore high triglyceride levels because statins don't help them very much and I didn't really know what it meant. Well, actually a high triglyceride level arguably is a far more important cause of cardiovascular disease than a raised cholesterol of any type. And so I'm interested in, I'm watching people's belly, I'm watching the triglyceride HDL ratio, I'm watching blood pressure. And of course, all of these are part of the metabolic syndrome. Part of the metabolic syndrome. Type 2 diabetes is a reasonably late player. And you've got a problem years before then. It's interesting, what we've discovered in our own work is that progressively, the more damaged you are in terms of your metabolism, the harder it is to solve. So if I take, yes, if I take 100 people with prediabetes, so these are people who still have quite a lot of control of their blood sugar, and it's beginning to slip. Well, if they go low carb, 93% of them will end up with absolutely normal blood sugar, 93%. And none of them will develop type 2 diabetes, not one, over a period of years. Okay, if I leave you alone and wait until you've developed type 2 diabetes, and then I try low carb, which is the diet we'll end up talking about. If I try low carb in the first year after diagnosis, 73 out of the 100 will end up getting drug-free remission. If I leave it or if you leave it for five years, I'm getting about 51%. So you see, the longer you leave this, the more metabolically damaged you are. And the harder it is to solve. So really, it makes a lot of sense to swim back upstream. Particularly, I don't know, if you were thinking about your children, I don't know whether you've got any children, but if you had children and if you loved them, well, wouldn't it make more sense to start a bit earlier rather than waiting as I did? Really, wouldn't, shouldn't we be thinking about prevention? What about our children? What about what happens to them? Because we know in my own practice. So as a young man back in 1986, I never ever saw anybody with type 2 diabetes under, let's say 55 and most of them were over 70. We even had a different name for it in those days. It was called maturity onset diabetes. I never saw it. And now regularly, I've seen people this afternoon in their 20s. That's a new disease. It's very sinister. And think about this also. The damage that diabetes does to your arteries is a function of time. So the younger you are, the greater the potential for harm. So maybe if somebody's over 80, they could maybe enjoy a bit more carbohydrate and let it drift a bit, possibly. Although I don't even quite care for people over 80 even. Maybe 90. If you're 90, you could perhaps leave it. But a younger person, I'm trying really hard. Really, really hard. I hope that's answered your question, actually.

Speaker 1:
[40:20] That's great. And I think it's important to caveat what you said there about seeing more type 2 diabetes and seeing it younger, because somebody listening may be saying to themselves, okay, you're a diabetes expert. More people are going to come see you. But you run an NHS practice, where you're working with people in your proximity. So it is actually a valid marker of the change.

Speaker 2:
[40:44] Oh, yes. So again, let's just explain that. So I'm a National Health Service GP. We are allocated our patients according to where they live. And both I and the patients have no choice in this matter. Only death. Only my death or theirs allows us to escape each other. So we've got 10,000 patients in a geographical area. And they're fixed, they're our patients. And again, I happen to know that when I started in my practice, I audited a month after I came into the practice and there were 56 people with type 2 diabetes. We've now got about 600. So that's a tenfold increase. And that kind of epidemic is actually a pandemic. And it's reflected all over the world. Steadily, there are more people with diabetes and they are younger. And also they're getting fatter, they're heavier. Many of the young people I deal with, although they very often weigh around 120 kilos, something like that, they're very heavy people. So there you go.

Speaker 1:
[41:56] One thing I want to highlight that you brought up are these underlying changes that happen before type 2 diabetes. Because if we just say type 2 diabetes, people listening may go, okay, I'm not there right now. I don't worry about this. It's not me. But I want to highlight the fact that there's vascular damage, high blood pressure, adipose tissue accumulating, potential connections to cancer, neurodegeneration, mental issues. This could go on and on. And that's why this is so important and beyond to me, this diagnosis of type 2 diabetes.

Speaker 2:
[42:35] Great point.

Speaker 1:
[42:35] Because the major problems are happening 10, 15 years potentially before that.

Speaker 2:
[42:41] Are you confident? So it's a bit like death. Let's talk about death for a minute. So really, here we are, we're worrying about heart attacks and strokes, cardiovascular disease. And as you correctly said, insulin resistance is linked to eight forms of cancer, particularly breast. And we're seeing increases in colorectal cancer because of this. So most people would rather not die. And most people would rather avoid cancer, and they'd rather avoid cardiovascular disease and strokes. So really, it's most people, isn't it? Isn't it? You know, a third of deaths are cancer and a third of cardiovascular disease. So it's kind of two-thirds of all the deaths. And what if, what if you could live longer? Or particularly, a moment on cancer. We obsess about improving cancer treatment. But we know that eight forms of cancer, there's a strong association with cancer and central obesity. Shouldn't we be obsessed equally with prevention of cancer? Because if you had, like me, spent 40 years caring for people, and when you tell them they've got cancer, it's almost like their life is over. They're living from that moment on in fear, real fear because, well, it may have gone away, but will it come back? What's that pain in my back? Is it a secondary? I'm coughing a bit, you know, what's that? So it's a sentence. It's a cruel sentence. And so really, I'm quite interested in the idea of prevention. And wouldn't that, if we only spent, think about all the money spent on cancer research, which is good, it's good. But have we really had value out of all that research? Which is another point, I think, of Jason Fung's, isn't it? And what if we put some, let's put a lot more energy into thinking about a healthy species-specific diet. So if you had a human being in a zoo, and you wanted to look after your pet human being, what would you feed them to keep them maximally well? And isn't that what our children should be having? And isn't it what we should all eat? Because if you keep somebody in a zoo, and you give them the wrong diet, well, there are problems, aren't there? And I believe what we're seeing at the moment is a gigantic experiment, a huge experiment with us all in there. And many of us are eating the wrong foods, and I'm seeing the consequences in every clinic I do. And if you care for people, that's a bit sad really.

Speaker 1:
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Speaker 2:
[47:34] Well, I was senior partner of this 10,000 patient practice with that we've got about probably got 10 doctors working in there and three nurses. It's a big thing to run. And the government advises us on guidelines. And a good doctor will tend to follow the guidelines. And that's what I did until that was eat a little and often. It's healthy whole grains. A basis, you know, the start your carbs are a third of your meal, all of those. The first thing I noticed that didn't go well was the idea of weight loss. So people would ask how they could lose weight. And I'd say eat less and move more and more fiber and more water and all this kind of thing. And the great majority of those people failed. Failed, failed. They might lose weight initially, but then they nearly all failed. And the tragedy is I blamed those patients to a point where I got really fed up with people with overweight as a problem. And in fact, diabetes, and our senior partner was the boss. So I just snapped that out of my portfolio and gave it to a junior partner. Because I was so fed up with these patients, they never got any better and didn't lose weight. And that is a shocking admission. Because what I know absolutely to be true now is that the common denominator in all those failures was me. And my advice, and to blame the patients for what I now believe to be very, very poor advice, is shocking. And I'm guilty to this day for years of nonsense that I peddled. But then again, in my defense, I was a tired doctor doing my best. And the guidelines said very clearly that it should be low fat and so on and so forth, which your listeners know very well. So that was the backdrop. And blaming the patients, isn't that shocking? Still think about that now. And of course, many of them are still my patients now. So we can kind of laugh about it. And yeah. And then of course, my own health deteriorated over the time and I became a bit depressed and a bit anxious. And really what most doctors do is they start dreaming of retirement, don't they? And playing golf and doing other things. And I planned for my escape. I planned for my escape. And by this time, I'm about 55. And this bit will be boring for people who have heard me on podcasts before. So I really apologize. But maybe some of you are new. Maybe you are. So yes, two women changed my life. One of them was a highly intelligent and aggressive patient who wasn't taking her metformin. And we get paid according to people taking their metformin, which is the commonest drug for type two diabetes. And so it was routine that when people weren't taking their metformin, they'd get a letter from me inviting them to come and chat to me about this. And of course, basically, I'm just going to tell you off and wave a shroud at you. And this woman was, and still is, a remarkable woman. So she knew, you know, she marches in and she says, you think you're going to tell me off, don't you, about the metformin? Well, I've got a surprise for you, Dr. Unwin, because I've got a bone to pick with you. You know, when you do my blood test, you will discover that my blood sugar is now normal. As you can see, I've lost three stone in weight. And I've discovered that you were drugging me quite unnecessarily. You gave me metformin for years. You never once told me that bread was sugar, that rice was sugar and that potatoes were sugar. And if I'd only known that, I could have been saved, the embarrassment of the diarrhea, that your drugs caused me. And it was pretty obvious she'd come in to complain, and that was utterly justified. And that I needed to listen and listen good and listen fast because you need to be careful of powerful women that feel that. And she, I've said this many times, but it's true. She said, this is school boy biology. That starch is sugar. So I have to wonder whether you're even medically qualified, Dr. Unwin. She's really threw the gauntlet down with that. And horribly, it was true. And we did the blood test, and she was right, of course, she was in remission. And she was one of 40,000 people online teaching each other how to cut the carbs. And when I went online, I was really upset because those people were being ridiculed by GPs like me for their hard work and success. And they were being told, you'll die, you know, your cholesterol go sky high and you'll die. And I thought this is a terrible injustice, an awful injustice. Then we have to speedily move in the second powerful woman who obviously is my wife. And she read a book by a really clever doctor, Dr. John Briffer, who wrote a best seller on Beat the Diet Trap in about 2011 or 2012. And she read this book and she kept saying, David, you have to read this, this insulin resistance thing. I didn't know what she was on about, but she made me read the book. And then it was amazing. And the rest is history really, because we decided to, I tried it, Jen tried it, we both improved. And then we started working in the practice. And there was initial real resistance to this. And I faced resistance everywhere. So this was in 2013, where I would be heckled in doctor's meetings. I'd be shouted down. I got hate mail for what I was doing. It was very, very mysterious. Cause I was thinking, well, this is so odd, cause everybody's loads better. And it felt as if colleagues would prefer that I use drugs and not diet. And I thought, that's weird. But it's all changed since then. Anyway, there you are. So it sort of changed. And then my health improved. And there is nothing like seeing it yourself to know that it's true. And once you've seen it yourself, nobody can argue me out of this because I know it to be true for myself. And I've seen it with so many patients. So we went from guidelines, wishy-washy guidelines in inverted commas, to seeing unbelievable changes in patients. Changes of a magnitude that I had never seen with drugs. I mean, really big changes. The first ones, actually, it wasn't diabetes. The first things I saw was improvements in liver function. So I got patients who got really poor liver function for years. And I thought most of them drank. They didn't. It was non-alcoholic fatty liver. And I wrote a paper on this, and their fatty liver improved by about 35 percent, or the gamma-GT levels, which is a marker of liver function. But what was crazy was, those improvements in liver function happened in weeks, weeks. So the blood results were coming in in the morning. I could not believe what I was seeing. Case after case of these improved liver function, improved triglycerides again. And then later, a few months later, the improvements in hemoglobin A1c, the average sugariness of the blood. And I, you know, the first case of remission, the other was the lady. And then there was another one, and another, and another. And now I've seen drug free remission. I think we're up to 157 or maybe 158. I've seen somebody today that I think is probably number 158. So yeah, the blood results, really amazing. And bear in mind, I'd sat there for decades. So I'm not easily amazed and astonished and galvanized into action.

Speaker 1:
[56:53] That is amazing. And I want to talk about diet early days and then any pivots for you and the patients you've made along the way.

Speaker 2:
[57:01] Yeah, that's a good thought, isn't it? Because I am learning. So what have I changed? Interestingly, the, I mean, the low carb diet that we began with is mainly the same. So if anybody wants to look at the diet sheet, nothing I do is copyrighted, nothing. So anybody can steal anything off me. And the diet sheet will either be in the papers I publish, or far easier ways, just go to a British charity, which I helped set up, the Public Health Collaboration, and look under in that on the website, we store a lot of useful information and the diet sheet is there for anybody to steal. But yeah, let's talk about, so there you could go and look at the diet sheet. I think, yeah, what's changed? I think I've simplified it a bit. Oh, I don't bother with calories much, or portion control very much, and just help people understand the diet, or eat the diet sheet. And then if it doesn't work, we have to ask why, and then we get down into the nitty gritty. For many people, I'm saying, really, base your meals on protein. What have you got in the fridge? What protein is acceptable to you? What can you afford, and what would you enjoy? And then add a bit of green veg, and some healthy fats. And that's kind of, but then again, it needs refining. Constantly needs refining, because what you find is that Jen and I don't have the same diet ourselves. So it's very important to help the client refine and find out what their best diet is, because it's not the same from person to person. So how do they get feedback? How do they know whether something's good or bad for them? And I think that's some of the refining that's taken place. And a major part, of course, is continuous glucose monitoring. This is speeding me up. Oh, my gosh. So I'm going to tell you about a case that I saw this afternoon now, and this person has consented to share this. So this is a 38-year-old man. And do you deal in hemoglobin A1C in percentage or in millimoles per mole?

Speaker 1:
[59:38] I'm the same as UK and Canada.

Speaker 2:
[59:41] Millimoles per mole.

Speaker 1:
[59:42] Right.

Speaker 2:
[59:43] That's millimoles per mole. Right. So this young man came to me three weeks ago with a hemoglobin A1C, the average sugariness of his diet, sky high despite his medication. So the result was 94, which is very, very high. And in percentage terms, for any American listeners, it'll be something like 12 or 13 percent. And he was symptomatic, of course, because that means you're weeing all the time. So I broke the guidelines and I prescribed him a continuous glucose monitor along with the diet sheet so that he could see, is it working? What does your blood sugar look like 24-7? And he came back a week later with an absolutely normal blood sugar on the trace. Normal, day after day, normal, normal, normal. So I said to him, this is amazing. How do you feel? And he goes, fabulous. I haven't felt this well in years. And then I said, I see you're having some very low blood sugars. I think we need to stop your drugs. So last week, I stopped half his medication. And he comes in today. And his blood sugar is normal, day after day after day. And I've stopped the other half of his medication in three weeks. In three weeks. This is a modern miracle because I know he's safe, because he's got a continuous glucose monitor on. And he's a clever person too, actually. And of course, I have to judge risk. Don't try this at home, folks, along the line, you know. Chat with your prescriber. I am the prescriber for this person. But it gives you the idea I couldn't have done that. So within three weeks, I've got somebody now. And not everybody can do this. But he has. I've got somebody with his blood sugar 100% in range, 100% in range. And that is amazing. And it made him and I, we were just laughing. It's so, you know, this is medicine as I love to do it. Amazing case. So that's a big difference. I've got loads, actually. This will go on for a bit. Magnesium. I've learned a lot about magnesium over time. It supports insulin sensitivity. Can be great for constipation as well. In which case, I'd use magnesium citrate. So most of my patients, I'm, you know, modern diets are now deficient in magnesium because of modern farming. It doesn't look after the soil. And so most of the food is magnesium deficient now. So magnesium, that's the thing to add. I know far more now that many of my patients, when they go low-carb, will need more salt because of the work, the paper with Professor Brady that I was talking about earlier on, that you start weeing out salt normally when your insulin levels recover. So quite a lot of, so I'm better at avoiding what people call as keto flu, by ensuring that people have enough fluids and being open to the idea of more salt in the diet. And magnesium, I've learned that. I've learned that your blood pressure may be going to improve dramatically. So I nearly fainted loads of times at the beginning because I used to have high blood pressure. I discovered when I stood up at my desk, I was so dizzy I had to hang on to the desk. It was completely new experience. And it wasn't till I checked my blood pressure, I discovered I had low blood pressure and had low blood pressure for a decade. And you see the lowering of the insulin, meant I was weeing out the salt. And so I ever since then have needed more dietary salt and my blood pressure has been fine ever since. And then you have to add, there's a lot of... Yeah, here's an important point. At least 50% of behavior change is not due to information. Because if it was just like information, I could give you the diet sheet and walk away. You wouldn't need me, would you? If it was due to information, nobody would smoke cigarettes ever again, because you never met anybody who didn't know that cigarette smoking causes cancer. So behavior change is far more interesting than just supplying information. And a sensitivity and an interest in psychology is really important in behavior change. And I'm so lucky because I'm married to a very clever psychologist, and we've worked together for many years now. And things like hope, collaborative working with patients, like what are you hoping for? What are your goals? Not mine. What are your goals? Very important. And then, you know, why does continuous glucose monitors work so well? Well, it's because you're getting feedback hard on the behavior. So if you cheat, then you'll see that spike in 30 minutes' time. Whereas the human globe in A1C is an average over three months. Can anybody remember what they ate three months ago? I am the foggiest. So you see hope, collaborative working, and feedback. But there's feedback in many forms. So it, you know, why don't you notice when you are your best self? You're thinking better, you feel optimistic, you're sleeping well. Why did that happen? What did you do that day? Could you do more of it? How did exercise, you know? Probably, Jesse, I would imagine in your own journey, you've got into the habit of noticing what works for you.

Speaker 1:
[65:58] For sure. I'm always testing things and-

Speaker 2:
[66:01] Yeah, yeah. And in that way, you're individualizing, you're testing hypotheses, and then you're individualizing what you do. And of course, over time, as circumstances change and, I don't know, life events, stress comes with people die, babies are born, all of these things, actually, your diet may need to change. And if, if patients are truly to be robust, it's better if they can do this for themselves and that they don't need me, because I don't last forever. It'd be better if you knew how to care for yourself. And I expect that's your journey, isn't it, Jesse?

Speaker 1:
[66:41] Well, the thing about our world is people taking advice from the different leaders in the natural health world are forced to test, because no two people are saying it the exact same way.

Speaker 2:
[66:53] Yeah.

Speaker 1:
[66:54] So given that, you can take all this different information from different experts, and you're forced to try different things and see how they work with your biology.

Speaker 2:
[67:04] And that would be my advice. Don't just trust me and do it. Measure something of, you know, what are the variables you're interested in? How will you measure them? How will you know how this is going? And then if you drift off for a bit, you've got more of an idea what to do or what works for you. And that's happened back to your original question. Well, yes, I've been doing this since 2013. So of course I've noticed things and I've learned stuff. And that's how, in a way, the whole ultra-process food addiction came on. I called it carb-creep for years. And then I thought, actually, I saw one guy had two toes amputated for this. I'd sorted out his diabetes. Then he ate food that he knew did him harm. And then half his foot comes off. That is not carb-creep. Something far more sinister because he ate stuff and ended up with really terrible surgery and the wound healed very, very slowly. And then you've got to think, what can you do about that? And then when I, I'm constantly wanting better results, I've become very competitive really, and excited. And I like to throw down the gauntlet, so people are sometimes critical of what I do, which is great. So I would say, you go out there and beat me in your own practice. Let's get some data and see how you do. And if somebody gets better data than me, well, I've probably got something to learn from them. But yeah, that's about all of it really. There'll be other things as well, but you could probably read one of the papers. Because when I write a paper, I try in the method to help other people who wanted to do this, know what's in the secret source. Because it isn't the David Unwin diet that makes me a fortune. I'm an NHS GP paid for what I do, so steal it and beat me.

Speaker 1:
[69:10] Well, coming back to that NHS part, we talked about it before and you just brought it up again. That's going to mean a lot of different types of patients are going to be coming to you.

Speaker 2:
[69:21] Oh yeah.

Speaker 1:
[69:22] Patients that are used to conventional doctors who are going to write that prescription for things like metformin insulin. So let's talk about a hypothetical patient, somebody metabolically deranged, overweight, coming to see you. How do you propose this different style of treatment to them? And then again, let's walk through the early stages of what that looks like.

Speaker 2:
[69:50] This happens in all sorts of different ways, but a common one would be somebody who comes in because their blood work is poor, hemoglobin A1C is up. So we're at a choice point. So I'm saying to them, okay, from the blood tests, it's pretty certain you've got type 2 diabetes, and high blood sugar over time is damaging for your health. So we need to sort this out. We've actually got two approaches and you can help me decide which one. The element of choice is really important, really important. So you've got to help me. We're going to work together to work out. I could start metformin right today. I'm going to be honest with you though, there's a third 30 percent chance of diarrhea with that one, but it may not happen and we could try it and see. Or if we could work out where the sugar was coming from in your diet and you ate less of it, maybe you'll never need medication. Also, you might lose weight and improve your blood pressure. Which would you prefer? I'm giving you choice. The idea of choice is powerful. I've started you thinking because if I just tell you, then you become a passive recipient of my expertise. If I involve you in the process and ask you questions, which would you prefer? What do you think you're eating that might be putting up your blood sugar? Questions like that. How do you feel about lifelong medication? Questions like that. It starts you thinking. And one of the great joys of this approach is patient activation, by which I mean, you start off with patients very passive. They just take their tablets. And what I've got now is partners thinking, working with me. And it's a fabulous way to practice medicine. And one of the things I'd say, if you tell people what to do too early, they say, I can't live without bread. That tells me something. That tells me that I didn't motivate you enough. If you're telling me I can't live without bread, because if you understood properly where you are in the world, and the risks there and the possible benefits, you'll give up bread. Unless you're a really serious bread addict, in which case that needs addressing too. But that comment, I couldn't give up bread, I can't live without bread. Maybe you can't live with bread. You know? So that you can see the psychological subtleties of dealing with fellow human beings. And it's to do with hope and choice and treating them as intelligent equals. What I have, I suppose, I have expertise in a very general way, but that person has expertise in themselves. And you shouldn't throw out their expertise, likely, because you may have a very powerful ally, as I find in that young man, that 38-year-old. I've got a very, I sort of got into his strengths, and then he's sorted himself out within weeks. So this is the art of medicine. There's the science of medicine, but there's the art of medicine, too, to do with hope, to do with psychology, and it's endlessly fascinating.

Speaker 1:
[73:40] Over the years, you give your patients this choice, Metformin or this new diet and lifestyle.

Speaker 2:
[73:46] Yes.

Speaker 1:
[73:47] How many times have they picked the Metformin?

Speaker 2:
[73:51] Never. Not one, not a single patient has said, give me the drugs when I do it in that way. Not one. Isn't that amazing? And of course, if you carry on doing that, you start making substantial drug-budget savings because people don't, they don't like, another one is insulin for type 2 diabetes. Who's gonna choose insulin? Because that's really hard on your life. And so what's happening now is I'm receiving referrals from the whole of the practice. So instead of sending them to an endocrinologist, I get all of the hardest patients that the nurses and the doctors can't sort out because I've trained them all. And these are people with much sicker people. But I mean, it's really motivating. So then I'm saying, well, how we're at a choice point. You know, we got to do something because you're really ill. Maybe it's insulin or maybe not. And if you could think about changing your diet, maybe you don't have to have insulin and maybe you could have much better health. Now that they're really interested in that. So the answer is nobody's chosen metformin. I had one patient only who knew herself to be a chocolate addict. And she said, I know I cannot give up chocolate, Dr. Unwin, I can't do it. And you know, I'll have to take the consequences. So that was one incredible, honest person actually who knew herself to be a chocolate addict. And really was. But that's the only one I remember. And you know, I'm seeing them kind of all the time.

Speaker 1:
[75:36] You mentioned the fact that the diet, the protocol is all available online. But let's go over it in a general sense. Somebody decides on the diet lifestyle. It's their first visit with you. Again, hypothetical patient, overweight, they have metabolic dysfunction. How do you ease them into the diet and lifestyle?

Speaker 2:
[75:57] Right.

Speaker 1:
[75:58] And then does it change over time?

Speaker 2:
[76:00] It does change, yeah. So the first thing really is again, the question, your blood sugar is very high. Do you know what you are eating? That puts your blood sugar up, because if they know already, then that saves a bunch of time. So and then if you do know, could you eat a far more protein, less of the starchy carbs? And bear in mind, I've already explained about insulin. That discussion has already happened about insulin, insulin resistance, fatty liver, and the danger of high blood sugar. That discussion happened already. Do you know what's putting up your blood sugar? And if you do, how would sometimes I'm saying, what do you think you could do? And they might say, I suppose I need to give up bread. Yes. What are you gonna eat instead? I don't really know. Well, I'm saying how about more eggs? How about more protein? Of course, the advice you give, again, why general practice is such fun is every person is so different. So I'm having to factor in your education, the job you do, your background. Because the way I explain it would depend, are you 90 years old or are you a teenager or what are you? And it varies greatly. And that's why family practice is a skill. Because you wouldn't get the same chat with me, hardly twice running. Because I'm watching your eyes very closely while I'm talking and I can tell you're paying attention or you're drifting off. I mean, one interesting concept is, so some people will say, well, the idea of I couldn't possibly live without bread. Maybe you're not scared enough. Do you see? Maybe I need to be a bit honest, because your hemoglobin A1c is sky high. And you know, at that point, you're losing a third of your life expectancy. So some people are glib and say, it doesn't really, I don't care. Ah, they do actually. They do. So some people need scaring. And part of my skill is to know how to do that. Other people need reassurance because they're too frightened already. So they need more hope. So a frightened person, and I see a lot of those who's worried. I'm saying, you know, the great thing is, you could very quickly get this under control and you could feel so much better. So do you see the subtlety? I'm looking at you and I'm thinking, do you need a bit of scaring? Are you a bit arrogant? Are you a bit sort of over my dead and bleeding body while I do what you want, Dr. Ramin? Or are you actually a bit scared? And what I do depends on what I see in your eyes. And one of the skills of general practice is to read people very, very quickly, because I've only got 10 minutes, and what happens? But that's why it's not boring, because it's not, I am not a talking leaflet. What happens, the psychology, or another thing, you know, is the family that you're in. So I have to know what motivates you. Have you got kids? Because men with children really, really care about their children, and they don't want to be ill. So what are the levers of change? So you might not even care about yourself, but being a dad, you want to be an active dad. You do not want to be a liability. Or maybe you have to earn a living. Maybe you seriously need to earn a living. The idea of going off sick is not acceptable, because you've got to pay the rent. So the I know, I try and find out what matters to you and who you love. So that very often I like... Another question is, who does the shopping? Who's cooking in your family? Can we meet? You know, who is this person? Do you want to bring them in? And then I've got an ally, then there's a team. And you know, people who love each other will facilitate change. And also I learn a lot by watching the husband or the wife. I'm watching them too. Sometimes they're new. But the person is a food addict, so they tried. So it's endlessly fascinating. And I'm giving you a confusing answer because people are confusing. And what motivates each of us is different. Some people are very excited by, you know, maybe I could wear fashionable clothes. They're very, they, they, it's quite common to avoid mirrors altogether because you can't bear looking at yourself in the mirror. Well, maybe we could improve that. Maybe you could wear fashionable clothing. For some people, they're frightened. Commonly, they're frightened because they're breathless. That's really common. They can't bend over. They can't climb stairs because they're so heavy. And being breathless scares them. So, we offer the hope of, do you know what, we might be able to help that. A lot of breathing occurs at the diaphragm. And a big belly splints the diaphragm. So, you can't shift it. If we could move some of that fat, you'd breathe better. Common related things, sleep apnea. Terribly common, terribly common. And a very long waiting list in the National Health Service. And you stop breathing in the night and then the wife's scared because she can hear you've stopped breathing. It responds very well to low carb. So, I think I'm spending a far more time on your psychology and hope and motivation because the leaflet, you could read that and learn and then I'm going to see how you do. I need to see you again, what we're going to measure. If you do well, you don't need a lot more chat from me. If you don't do well, I have to dig in deeper. And at that point, I might ask you to photograph everything you eat for a few days on your phone. And then I get to see what you're doing. And then I'm over time learning and trying to come up with better hypotheses that more closely fit what is the individual in front of me. It's gone a bit detailed that, but that's how interesting it is. And you can see that it makes medicine seem really like a puzzle, doesn't it? I'm a detective and a magician. And, but it's worthwhile. And none of this did I do for 25 years, the first 25 years. If only I'd started younger. But hey, you know, I'm doing it.

Speaker 1:
[83:05] I love that approach. It makes a lot of sense. But underneath that, when you get in, and you really leverage that why, and that motivation out of that person, is the diet very similar when you find that unique way in?

Speaker 2:
[83:24] That's good. Let me think about.

Speaker 1:
[83:28] Because at the end of the day, we're gonna have to lower the carbs. We need to find out how we're gonna motivate you. We're gonna find out your why. But in the end, you gotta bring these down.

Speaker 2:
[83:38] It's very interesting. So we run one of our ways to do this and make it affordable is to run group consultation. So we do 30 at a time. And my wife and I have done that from the very beginning. So there was a meeting last night. And what's really interesting when you get these people all together, they are actually eating in quite a similar way. So they are leading with protein. Mainly they're eating more protein and there is the protein in the green veg is going on. And over time, what's very interesting too, is they learn to go, they tend to go lower carb. And quite a few of them go keto over time because they find, well, I'm just a bit, I'm better when I do that. And so although I say it's highly individual, not many people can eat bread. Not many people end up eating potatoes. They give them up because they cause spikes and they're problematic. Another thing that can be problematic are sort of miracle keto foods full of sweetness because then they get fat. So many of them end up producing food themselves, leading on protein, adding in green veg. If you came last night, that's the kind of, or if you saw the photos that I see, because they photographed what they eat, that I'm seeing a lot of very tasty meals leading with protein, loads of green veg and a bit of fat. But then there are exceptions. Yeah, it's variable, but not as variable as you might think. Good point.

Speaker 1:
[85:23] And what about fruit? I find a lot of times when it comes to whole fruit, a lot of the experts are saying, okay, you can include that in moderation. It has fiber. But modern fruit, most, if not all, has been hybridized and is super high in sugar. Things like bananas, oranges. Are these things you're having people take out right away?

Speaker 2:
[85:50] Right. Now we need to come to my teaspoon of sugar equivalents, because there is something there for the listeners to understand. So right at the beginning, bear in mind these 10-minute appointments. I've got a hell of a lot of information to get across in that time, and I had to find faster ways to do it. I became very interested in the glycemic load and the glycemic index. These give an idea of the sugariness of the carbohydrates that are in our food. But the result comes out in grams for the glycemic load, grams of glucose, and my patients don't know what 25 grams of glucose looks like. They don't cook with glucose, so they have no experience of it at all. So I had an actual idea. And it's, could we possibly look at the maths of the glycemic load in a way that patients do understand? Could we redo the maths in terms of teaspoons of sugar? Because my patients really do understand teaspoons of sugar. And I found an international expert on the glycemic load, Dr. Jeffrey Leavesy. And he said my idea of the way of doing the calculations was correct, in his opinion. And he helped me, and he calculated out the glycemic load of different portions of 800 foods, and we published it. But that means you can then do an infographic where you can say, well, so 150 grams of boiled rice, what is that equivalent to in terms of teaspoons of sugar? And the answer is about 10. So whether you have 10 teaspoons of sugar, or you have a bowl of rice, it's about the same. And then your particular point about fruit, well, a banana is about the same as six teaspoons of sugar on the glycemic load. Now raspberries and berries are far less sugaring. So there's a spectrum of sugaringness, and it's to do with photosynthesis and sunlight and carbon dioxide. So photosynthesis turns carbon dioxide into sugar. And the more sun you've got, the sugary. So this is why oranges, all tropical fruits, they're all too sugary for somebody like me. Even an apple, I could only eat a quarter of an apple without it putting my blood sugar up significantly. But I can eat a small handful of raspberries or strawberries, particularly if it's in double cream. And so these infographics, of course, are on the Public Health Collaboration website. There are seven of them. They've now been translated into 35 languages and downloaded multiple of millions of times around the world. So they're there, all seven of them, probably in any language a listener wants, because volunteers have come to me and said they're so good, I'll translate into Russian or Mandarin or whatever. And there are these infographics on fruit. But in general, avoid fruit that has a lot of sunshine and you're left with berries very much in moderation. And then the question is, are you going to eat a kilo of raspberries or can you manage a small handful? So that's my take on fruit. And I particularly get cross about bananas, which I get a lot of flag about. But you wouldn't believe the number of overweight people that eat bananas for the potassium, which is some sort of nonsense put out by the banana growers, I dare say. But yeah, bananas are sugar sticks, very little fiber. And you make it worse with all the tropical fruits, far worse if you juice them. That's a real sugar bomb, a glass of Florida orange juice. If you have to, I couldn't possibly have even a quarter of a glass full of orange juice without it doubling my blood sugar.

Speaker 1:
[90:11] I think it's important we're going here because for a lot of people who are having ultra processed foods, going to fruit or starchy veg would be heading in the right direction. But I want to make sure people get success with this. And if they're just swapping that out and having expectations, like you talked about today, these fruits are better, but they're not going to necessarily get you there.

Speaker 2:
[90:39] Exactly.

Speaker 1:
[90:40] Yeah.

Speaker 2:
[90:40] So no, I think for me, the emphasis is on green veg, above ground green veg, healthy fats, whatever we mean by healthy fats, and protein, lots of protein. And I particularly say, there's no evidence against eggs anymore. That's all fallen completely to bits about 2016. It's 10 years out of date. The eggs are, you know, the idea of dietary cholesterol makes any difference to anything, dietary cholesterol is, I don't believe makes much difference. So that's it, yeah. Protein, green veg, and some healthy fats. Fruit, be careful. Be careful, and also even nuts. And because bear in mind, peanuts are not nuts. A peanut is a legume, grows under the ground, not on a tree. And for some people salty peanuts are obesity right there in the bag because they can't moderate them. Cashew nuts are another problem because they're quite carby, and some people really can't control those. So I'd say with nuts, don't have them salted because you probably eat too many. And they should be tree nuts like almonds or walnuts, or possibly pecans. And of course, if you're not sure, you should buy yourself a continuous glucose monitor and find out, and then you'd soon know, does this food. We should be able to eat nutrient-dense food that you enjoy, that you can afford, that doesn't put up your blood sugar. Because that's the whole, that's what we're talking about, isn't it? Eat nutrient-dense food. You need your vitamins, your minerals, but eat food that doesn't put up your blood sugar. And I can eat, for instance, I could eat maybe a curry made with a chicken butter curry with roasted sprouts. I've done it. I've got the results. It doesn't lift my blood sugar a tiny bit. So I can have a great big plate of very, very tasty curry with roasted sprouts. I'm happy at the end of that, my blood sugar hasn't shifted a tiny bit. That's nutrient density, really, without the consequences for my blood sugar.

Speaker 1:
[93:05] Do you find early on in the journey, somebody with a CGM having say that curry would have a more exaggerated sugar spike than someone like you who has done this for a long time and healed the body?

Speaker 2:
[93:19] Not necessarily, no. Because if you've been low carb for a long time, your body is no longer used to dealing with carbohydrates and hardly ever produces much insulin. So some people like me get a worse response than before. But actually, if you carry on eating the carbs, it starts improving again. So what I don't know, because I'm not going to experiment, I'm so happy with my diet and how I am. I don't know to the extent that this is a physiological adaptation and that if I carried on eating more carbs, I'd be able to produce more insulin and it would improve. I remember one time I was playing about, so I got a lot of followers on Twitter. So please follow me on Twitter, people, X Low Carb GP on Twitter, very important. So I remember I spent a week eating all the foods I'm not supposed to eat. But what was interesting was by the end of the week, my responses were much improved. And I think that was just I was cranking up the insulin supply. And so my response to carbs is much better than it would have been years ago. But some of it is worse just because I'm not so used to, I'm keto to be honest. I've been in nutritional ketosis for years now because it suits my mental state very well. And gives me flexibility. I'm not hungry. I can fast if I need to fast. Because often you go places. You wouldn't believe I'm often invited as a speaker to a diabetes event. You'd starve to death in those events because they offer me sandwiches, which I cannot eat. I often say to them, there's nothing I can eat here that wouldn't protect my blood sugar. These would be big national diabetes events. And particularly if you've got CGM on, it's hilarious because I can offer to eat stuff. I'll say, I'll eat it and then I'll share with you all what's just happened. I mean, even a milky coffee, a latte will double my blood sugar. It'll put me up to 11 or 12 and has a consequence because I can't think straight. So I did that recently and had to delay driving back because I wasn't fit to drive because I'd had a milky coffee.

Speaker 1:
[95:50] It's interesting to think how metabolism changes over time. Somebody like you who has had lower insulin for a long period of time and then having carbs versus somebody coming to you as a new patient, body is full of glucose, insulin is running high. And this is why I asked that question. I'm just picturing them putting in more glucose to a body that's already saturated with that and insulin and the difference on the CGM. So just interesting to think of different metabolisms along this journey and how that would change.

Speaker 2:
[96:24] It does. Well, as I've explained, I'm better than I was, but my blood sugar will go up with quite small amounts of carbs, and I believe it's because I don't have much insulin. But I've noticed it will improve over time and that doesn't tempt me. Because I'm slightly addicted, I appreciate the sense of control, and I'm not about to give that up because it was hard won. And you go through periods of time feeling sorry for yourself. I'm so sorry for me because I can't eat Christmas cake. Well, I just needed to grow up, and I eat loads of delicious food, and I'm well and healthy, and I love playing with my grandchildren. So that matters. I enjoy playing with my grandchildren more than I do eating Christmas cake.

Speaker 1:
[97:16] Somebody who is brand new to this, they're prioritizing protein, some green veg. They want an objective number with the carbs. What number do you like them to bring that down to? And then are we talking total or net?

Speaker 2:
[97:33] Right. Well, I'm going to disagree with you now, because what this is about is where on the spectrum of carbohydrate eating are you? So you see, I've got patients who have achieved drug-free type 2 diabetes remission on 200 grams of carbs a day. So the idea of an absolute figure is ridiculous, because it depends where you started. So that same person began at 400 grams of carbs per day. So they dropped it down to 200, and that was enough for that person to achieve remission. You see, so I try and move people along the sugar spectrum to lower, and then we see how is it for you. Now, I've also, we had a dietician do a PhD in the practice, looking at the diets of the patients that do well. So the average person at Norwood Avenue who gets remission is having about 70 grams of carb a day. And it's simpler here, because we don't include fiber in this, so we just say grams of carb, because the labeling here would have fibers separate. So that's just 70 grams of digestible carbohydrate a day's average for my patients at Norwood Avenue. So most of them, that would tell you, are on less than 100 grams a day, most of them, and some a lot less, because many of them go keto. But there are exceptions, and if you start off very carby, there are patients who are still eating bread, but not many. Not many, partly because it's a really interesting piece of work that looked at people with type 2 diabetes. Food addiction is 600%, actually 670% more likely in people with type 2 diabetes. A lot, we once assessed the entire, everybody in the group, in the waiting room, because Jen, you'll have to have Jen on separately because this is her thing really. But we actually, she's got a thing called the, well, it's a model really of a questionnaire to try and discover who is an ultra processed food addict. Every single person in the room, every single one, without exception, when they did that thing, was an ultra processed food addict, everybody. So that's the danger of, you know, are you absolutely in control over the small amounts of bread? And if you are, well, I'm good, that's marvelous. And if you're not, time will tell. And then I help you then.

Speaker 1:
[100:27] I'd have to imagine for a lot of people, just getting started, having a specific number of carbs, whether it be 50, 75, would make it a lot easier, or even going keto or all the way to carnivore. So somebody coming to you, wanting that objective cutoff, what would you say?

Speaker 2:
[100:52] It depends. So some people like figures and some people don't. I think you're a person who clearly does. There are other patients who find that very confusing. And so for them, it's easier just not to eat bread, potatoes, and to eat the proats. So that's why I try and make it simple. For the people who want a figure, I'd say, well, start about 100 grams of carbs, and let's see how that feels for you. But it's just a start off point. The carnivore thing, well, very interesting. I've got patients who are carnivore, and they do very, very well. And then I've got others who go carnivore and then get bored with it, and can't stick it out. For me, it's helping you find how you're gonna do this, and how is it gonna be sustainable, and I need you to enjoy food, and you're probably part of a family, so that all has to go on. But yeah, I've got carnivore patients. Another thing that I do explain to patients is, then there's the whole thing of fasting, intermittent fasting, or indeed, you know, probably, you're better to eat your food earlier on in the day, and not later, because there's evidence of that. If you're thinking about fasting, I would say, well, go low carb first, so that you become a fat burner, because then it'll be so much easier for you. Trying fasting when you're not low carb, and the enzymes are not already in your liver is a problem. If like me, you're a fat burner, fasting is much, much easier. So the progression for me starts with, let's try low carb. Think about when you're eating the calories in the day. Can you have them earlier? What fits in? And you know, I've got patients who like one meal a day. They do very well. Two meals a day. Don't eat more than three times a day though. That's another point because that's a little stimulus to your insulin, all those meals. So cut out the snacking first. Try and eat no more than three times a day. Try and avoid any kind of snacking in the evening particularly. Be careful what we talk a lot about. Don't have too much milk because that's got loads of sugar in. And as I say, there are about 100 grams of carbs. And then let's meet again and see how it's going. And bring your questions. And also, of course, you and along with many of my patients are very clever. So why don't you look it up on these following websites? And then you'll come back with more questions. Or have you come across the Freshwell app? It's free.

Speaker 1:
[103:46] I've heard you talk about it, I believe.

Speaker 2:
[103:48] Yeah. Well, the Freshwell app is some younger doctors who took my work and turned it into an app. And it's free. See, it's free because like me, they want to help you not to make money. And also it's NHS approved, it's Kismet approved as a source of respectable information. So this is the Freshwell app. You can download it on your smartphone and it's full of recipes and advice and detail. So we just send a code to every patient with diabetes. You know, could you just look at the Freshwell app, see what you think about it, to all of them. Because information, if you're careful where you get it from, is easily there. And if people followed me on Twitter, they'd see there's a sort of community that we're part of, a community of, on the whole, very caring people doing their best. And so where you're going to get your information from is important. Freshwell app, good idea.

Speaker 1:
[104:58] I have heard you talk about it on another podcast.

Speaker 2:
[105:00] Yeah, yeah.

Speaker 1:
[105:01] Coming back to fasting, somebody wanting to use that as a tool to jumpstart what we're talking about today, or if they've been following the diet and lifestyle for a while, to have a breakthrough of a plateau. How do you feel about multiple day water-only fasts?

Speaker 2:
[105:20] I've done it. You know, so I experiment on my own body. Jen and I have both done it. And it's interesting the results were different. Jen lost a lot of weight, but it actually, it was bad for her in terms of food addiction and what happened afterwards. Because she became obsessed with fasting and losing more and more weight. And that actually, she overdid it in a way. It took on a life of its own. And she got to about eight days, I think the longest fast she did. And the results looked wonderful. But her reflection now is, for her, it's not such a good thing in terms of maintenance. For me, it's quite useful to maybe do a 24-hour one after a holiday. So it can be a reset. I find, particularly if my appetite is getting. So I think hunger is a really interesting signal. Clinically, I use it a lot. I say to people, are you hungry? Because if you're hungry on this diet, it's not right for you in some way. If you're hungry, that's odd. Maybe not enough protein, it may mean too many carbs still, but let's go into it. So on holiday, I ramp up, even though it's low carb, I eat more. Sometimes I get into the habit of eating more, my weight goes up a bit, and then I just do a 24-hour fast, and that knocks that on the head, and it's surprising how the appetite shrinks away. So for me, that's a reasonably successful strategy, and I use it occasionally, and it's there in the armory. I mean, as I'll be honest, as is going carnivore is another way. I've discovered now that actually instead of fasting altogether, I can just go a few days on basically beef or lamb. A couple of days on that, and my appetite drops behind again, and then I reintroduce the green veg and all the rest of it, and I've stopped the 24-hour fasts because it works just as well for me to go carnivore for a couple of days. And this is how I'd encourage everybody to experiment, see if it works, and that has worked for me. So I used to fast quite often, but then I wonder, autophagy, that's interesting. Maybe I'm gonna get cancer now because I'm not fasting and autophagy's not going on. I don't know. It's all work in hand. That's what I've discovered myself. Also, I've discovered be careful of dairy because it can ramp up where I'm starting to glug double cream down and butter on everything. And that can be another source of drift. Very important to be honest with yourself about what's really happening. And if I'm putting butter on everything, well, there are a lot of calories in butter. Or I love full fat yogurt and I can start eating whole cartons of that. And where's that gonna lead? So there we are.

Speaker 1:
[108:51] Earlier, you mentioned salt, you mentioned magnesium. Somebody embarking on this diet, any other supplements or supplement-like things such as salt, you'd suggest including?

Speaker 2:
[109:06] Obviously, vitamin D. Many of you know we live in England and it rains for months and months and months. So vitamin D and for my patients where we are, I'm saying you need to start a supplement, probably October through to March here. Probably Canada is about the same. Because I stopped measuring vitamin D because so many of my patients were always deficient in it. So vitamin D is one. And really, I'm still reviewing that. I worry about supplements because clearly, people selling supplements are making money. So, and I'm always thinking, well, the reason I'm saying supplement with magnesium is I know you're not gonna get that in your diet no matter how you try. But other things, if you're thinking of, for instance, zinc or something, well, could you look into, if you were thinking about that, could you look into what foods might contain it and have more of that? So, in my practice in the health service, the supplementing advice I give stops where I am certain. And I'm certain vitamin D, I'm certain magnesium and I'm certain for salt. There's many other things that might be, but I'm just not that sure. So I kind of make my mind up over time. Jen is far more pro supplement than I am. And she'd give you a different answer, as I noticed she takes quite a few. But there's always this, it's a bit like fish oils, isn't it? Where the results from supplementation weren't quite the same as eating fish. So you've hit upon an area there of uncertainty for me, and I'm still working on it. And at the moment, those are the supplements I recommend. Occasionally, Brazil nuts for selenium, but not to overdo them. Organic Brazil nuts, I'd say, are a good idea. And beyond that, I haven't really come across, you know, have I ever seen somebody with zinc deficiency that I've known about? And the answer is no, I haven't. Whereas vitamin D deficiency, yes, folic acid. Oh my goodness, loads of young people are deficient in folic acid. It's really common. Magnesium deficient, very, very common. So I simply, my expertise fades away on supplements with a little bit of suspicion about the capitalism aspect of selling supplements and saying, you feel wonderful if you take this supplement. And I got to be really careful as an NHS GP in that line and keep sort of super clean.

Speaker 1:
[112:02] Last nutrition question. When it comes to the green veg, you mentioned you'll periodically do carnivore.

Speaker 2:
[112:09] Yes.

Speaker 1:
[112:09] So you're not totally sold on that we need the veg all the time. Are you including that for certain nutrition benefits or just to be more social so you can include more foods? How do you look at that piece?

Speaker 2:
[112:24] I'm still looking at that. I'm a great fan of Paul Mason in Australia. Do you know what a fabulous guy? He says, this fiber thing is a bit overblown. It's certainly true to say it's very interesting to try carnivore and find out what happens to your bowels. The answer is actually, it's fine. I don't know that you have to have fiber. I do know that I enjoy green veg, and I get a bit bored on carnivore, and it doesn't seem to do me any harm. And then you've got to think about, well, what about vitamin C? Does that matter? I think it depends how much carbohydrate you have. And if you have less carbohydrate, you probably need less vitamin C. So why do I bother with the green veg? I think, I just, oh, here's the point. Here's the point, yeah. So when you're on loads of junk food, you no longer get any signals from your body as to what to do. You get no useful signals. But once you go low carb, you start getting signals of, wow, that steak was really special, or whatever it is. And I've noticed that I seem to get a craving for green veg and then really enjoy it. So that can't be wrong. It's not doing me any harm. I really enjoy it. And maybe there's a craving there. I'll give you an example of magnesium, because the magnesium story is really interesting. I'm going to shorten it for you, because that's quite a long chat. But I noticed for years and years, I really enjoyed a particular sparkling mineral water. Turns out it has a really high level of magnesium. And then I spoke to a professor of nutrition at Cambridge University. About, we were talking about magnesium and he said, of course, you do know that you can taste magnesium. You can taste magnesium. Humans can taste magnesium because it is so necessary to life, that you can taste which water has got magnesium in it and which hasn't. And I think that's true. I think that's true. So if I'm get a signal that I want, I could just fancy a crunchy salad. Well, why don't I have one? And I think let's be a bit flexible and also be honest about what we know and what we don't know. So I don't really know whether is carnivore safe long-term or it's probably okay. But I've got to be careful with my patients. And why don't I stick to what I do know, which is sugar is certain death, you know, bread, avoid that, avoid junk food linked to all cause mortality. And then there's all the fascinating small print stuff that you can work out for yourself and see what suits you. And yeah, I won't be too judgmental if it's working for you and you look well. It's probably all right.

Speaker 1:
[115:54] What was the brand of water?

Speaker 2:
[115:57] Pellegrino.

Speaker 1:
[115:58] I'm a fan.

Speaker 2:
[115:59] Pellegrino. Yeah, Pellegrino. And I used to think it was a ridiculous indulgence. It seemed like how pathetic that I have to have Pellegrino. And yet I did. And I thought, well, it's no good. I do enjoy it. I don't care why, but I do. And then I discovered it's got one of the higher. And then I managed to find some as a German. I forget its name now. The German Sparkling Water with even more in. And I love that a lot. Interestingly, your requirement for magnesium varies. So I do a thing called Keto Live every year in the Alps. And altitude stresses me considerably. And public speaking stresses me. My need for magnesium is treble when I'm at high altitude. And when I'm doing public speaking, it's treble. And without it, I'm cramping up badly. And now I've discovered to vary my magnesium supplementation depending on how stressed I am and what I'm doing. And altitude definitely is another factor. See, nutrition is endlessly interesting.

Speaker 1:
[117:09] I hear you, I love it.

Speaker 2:
[117:11] We don't know, there's loads we don't know, and that's quite fun really.

Speaker 1:
[117:15] How does movement fit into this? Somebody coming to see you, they've lowered the carbs, they want to do all they can do. How do you look at that?

Speaker 2:
[117:25] Movement, well, it's like this really. So with patience, I'm trying to work out what the low-hanging fruit is. How can we do this easily? So if you weigh 100 kilos, telling you to start going to the gym and moving around loads, it's just like punishing you unless you want to do it. But after you've gone low-carb, you've lost a bit of weight, have more energy, particularly if you're fat-burning, and adding in exercise at this point can really improve things still more. Because of course, muscles are endocrine active, so they do stuff. Also, it's a terrific sink for glucose. So I have a thing called the Dawn Phenomenon, which people with type 2 diabetes have. And I can soak that up wonderfully with 100 press ups, or a run. So I like exercising it, I love it, and I tend to exercise in the morning, because it deals with my Dawn Phenomenon. And so yeah, exercise. And of course, so exercise improves insulin sensitivity. So it's one of the levers I use with people who don't seem to be doing as well. I don't know why. I particularly like a bit of resistance training for older people to build muscle mass. So I explore that, because sarcopenia is a real problem for people. So increase the protein, but also are you doing squats? What sort of exercise might suit you? And particularly, it's funny, when they go low carb, they have this spare energy. So they're kind of more open to going walks or joining a gym. And having the energy it gives you is very important, because then you can follow through and do things. Whereas making people exercise doesn't always go as well, they just feel guilty because they don't. So in my practice, on the whole, we try diet first. But some of them do exercise and fabulous, well done. But a lot of the gym people there's more men for us to do that. So I exercise, I personally do it, I love running. I don't enjoy press ups and power squats as much, but I make myself do it. Because I'm 67 and I've got to hang on to those muscles.

Speaker 1:
[119:57] Somebody that's been with us now almost two hours, they're on the fence. They feel a little bit of motivation, but they need that nudge in the right direction to get going. What would you say to them?

Speaker 2:
[120:08] Yeah, I think it's how we began really. What if every meal you eat is a choice point? And what if your future health depends on how you eat? And which future are you going to pick? Because I know which future I would pick. And yes, it's also, do you want pleasure now? Or do you want something far better in the future? So if you want pleasure now, all right, eat the trifle, eat the cake. But if you want a better future, well, you got to work towards that. And I'm 67, I have eight grandchildren, all of whom I saw yesterday. I can sprint with my grandchildren, I can run with them, I can play and roll around. That's life. Eating cakes alone, that's not life at all. So I'd say to you, go for a little bit of pain now and a better future. And you'll be glad you did, because I certainly am.

Speaker 1:
[121:16] All right. Perfect way to wrap up. Thank you for that. Really enjoyed the conversation. We're going to link up your Twitter, the infographics, your website, everything in the show notes.

Speaker 2:
[121:27] Lovely.

Speaker 1:
[121:28] What was the last one, sorry?

Speaker 2:
[121:30] The Freshwell app. Put in a link for the Freshwell app.

Speaker 1:
[121:32] Yes, we'll put that in there as well.

Speaker 2:
[121:33] Before you do it, will you check that it's available in Canada and the United States? I think it is.

Speaker 1:
[121:39] Okay.

Speaker 2:
[121:39] Do check.

Speaker 1:
[121:40] Okay, if it is, it'll be included.

Speaker 2:
[121:42] That was fun. That time went very quickly for me anyway.

Speaker 1:
[121:47] Thank you, Doc. Me too.

Speaker 2:
[121:49] Bye bye now. Bye bye.

Speaker 1:
[121:51] Now that you're finished with the episode, head on over to jessichappus.com for detailed show notes, including links to everything we discussed. Thanks for listening and have a great day.