Dr. Jeffry Gerber - 'The Metabolic Syndrome and other Nutritional Disorders'

[Music] [Music] well it's a pleasure to be back giving a presentation this year so uh this talk covers um an overview of low carb and how we nutrition and how we can use food as a tool to treat and prevent chronic disease so disclosures first some standard disclosures and really i have no conflicts of interest here are some non-standard disclosures and these are really important right at the bottom my dietary bias is low carb important to say so the objectives again we're going to have an overview of low carb nutrition we're going to look at some metabolic conditions we'll look at some chronic pathways and mechanisms for chronic disease and we'll look at clinical tools to best evaluate insulin resistance and cardiovascular disease and we'll compare standard uh diets versus low-carb diets and practical approaches will finish to the treatment and prevention so rather than bore you with statistics i think it's fair to say that we're dealing with a triple burden of disease and you know them well their obesity diabetes and heart disease and it's really fair to say that two-thirds of the adult population have at least one of these conditions now if we could cure or treat these conditions i'd be out of a job right but if we could find some common pathways that would help us direct treatment we'd be heading in the right direction and there is a common pathway and that's the metabolic syndrome and we'll talk a little bit about that now so the metabolic syndrome what we like to describe as the insulin resistance syndrome because it really defines the central mechanism was first described by jerry raven in 1988 and there were five criteria that he identified they include glucose intolerance hyperinsulinemia and what we refer to as atherogenic dyslipidemia which looks at the quality of the cholesterol the ratios small dense ldl and interestingly ldl cholesterol is not a criteria now really atherogenic dyslipidemia is really an indirect marker of hyperinsulinemia and glucose so that's important to keep in mind there's also elevated blood pressure and abdominal obesity and if you have these criteria why they're important is they're strongly associated with type 2 diabetes atherosclerosis heart disease stroke and now we understand that the metabolic syndrome or the insulin resistance syndrome is associated with many of the chronic diseases that we see in modern society now when i first learned about the insulin resistance some 25 years ago this made sense to me because it did indeed define a common pathway it also defined a dietary approach that is low carb and we'll talk more about that and then during the same era we we see the work of dr joseph kraft and he described hyperinsulinemia which is really a clinical method to best identify diabetes and pre-diabetes at its earliest stage and he referred to that as diabetes in situ and what he did was he administered 75 grams of dextrose and then he monitored patients over five hours measuring insulin and glucose and he did his uh research on sixteen thousand patients over the career and we can look at the findings so here we see what we describe as pattern one or eu insulinemia where there's a normal insulin response the insulin level doesn't go up more than 60 micron units and superimposed on top of this are the three patterns of hyperinsulinemia and you can see that insulin can go up over 200 micro units now what is not included here are the glucose curves but dr kraft identified that insulin will go up years before the glucose rises and that's important to understand now catherine croft in new zealand reanalyzed the craft data and she came up with a simple clinical tool and that is to measure the two hour insulin and if it's under 30 it's normal and if it's over 40 you have a problem that's what we do each and every day in our office so thanks to the work of dr kraft and raven and others we now understand the natural history of type 2 diabetes and we'll take a look at this here and we have a time line and you can see at year 0 you get your diagnosis of type 2 diabetes and this is an easy diagnosis your hemoglobin a1c is over 6.5 your fasting glucose is over 126 and your 2-hour glucose is over 200. i mean are you helping the patient at that point i don't think so so let's step back in time and see what happens 20 years before the diagnosis so again dr kraft identified hyperinsulinemia that can set in 20 years before the diagnosis and then we see insulin resistance on a cellular level 15 years before diagnosis and you can measure this with a homa ir or glucose clamp if you choose to measure insulin now again most primary care doctors don't even bother measuring insulin levels and then 10 years prior you are diagnosed with impaired glucose tolerance if you choose to do a two hour glucose and it's over 140 you might begin to see your glucose and your hemoglobin a1c start to rise and then perhaps five years before you get a diagnosis subclinical cardiovascular disease sets in and we have to talk about doing the right measurements in a couple minutes but you can see that there's a problem for years and you're sick for decades and you and your health care professional are often unaware that there's a problem and of course by the time you're type 2 diabetic you're an absolute mess and so the point here is that you have to think about doing the right measurements and having an early level of suspicion or you're not helping your patient so when it comes to the metabolic syndrome let's talk about the elephant in the room what is that elephant it's nutrition specifically low carb nutrition now you have to understand that dr reeven and dr kraft they weren't really interested in nutrition they just wanted to focus on their methods what did they know anyway dr reevan was an endocrinologist and dr kraft was a pathologist so they just basically went along with the standard mantra but it was actually later in their career that they realized that there was some value to low-carb diets and we think that they miss this golden opportunity to advance nutritional science but you know what now it's our turn so let's talk a little bit about diets and compare diets and so we'll look at standard diets and there's many definitions for it but we're going to call it the perfectly balanced healthy diet just to point out the fallacies and what the conventions are so there's your perfectly healthy balanced diet so a third of the energy comes from each macronutrient fat protein and carbohydrate that must be right why it's mathematically precise there you go so some of the conventions all calories are alike and therefore the food quality is absolutely unimportant and this is based on the first law of thermodynamics that just simply defines what a calorie is and it seems that your health and weight seem to be determined by this positive or negative energy balance what we call calories in and calories out and it emphasizes the law of physics versus the law of physiology i don't think i like that some more conventions we should reduce total fat and saturated fat in our diet why should we do that for weight loss because we all know that fat calories are that that fat energy is caloric dense nine k cals per gram versus protein and carb which is 4k cows so to create a negative energy balance the convention says you simply reduce energy dense fat in your diet okay here's another convenient convention that if we reduce saturated fat in the diet it's going to reduce our risk of cardiovascular disease because we want to get rid of that saturated fat clogging uh artery substance in our uh in our diet right that's a convention and that cholesterol is somehow this dangerous substance and when it reaches a certain concentration it smashes its way into the blood vessel wall and causes disease it's just too simplistic and what's the solution they tell us to replace saturated fat with carbs and polyunsaturated fatty acids just as canola corn and soy and now what we understand is that is a disaster in terms of metabolic syndrome and metabolic disease it's the opposite of what we're trying to do and we blame the patient in this convention yes we have lack of willpower it's your fault rather than empowering our patients to make change that's what the convention tells us so what do we get serving up disease for over a half a century we need a better solution we need a different approach and this is where we want to now discuss that all calories are not at like at least in the in the in the body how it metabolizes energy and so how do we know that all calories are not alike so here we have the combustion chamber the bomb calorimeter which simply defines the first law of thermodynamics you put some uh energy substance a macronutrient in there and you you light it on fire and it gives off temperature and you can determine how many calories are released but that's not what happens quite in the body in the body we're looking at cellular respiration and we measure that in a metabolic chamber so you can put a person in there and exercise them you can give them different types of diets and then you measure things such as oxygen temperature water content co2 aerobic threshold oxidative potential vo2 max and lo and behold under different circumstances the energy is processed differently but guess what in both situations a calorie in equals a calorie out but that's not what's interesting it's the processing of the energy and so we'll take a look at this and rather than call it calories in calories out let's call it energy in and energy out and again the body has this wonderful ability to process energy it can partition energy meaning it can make a decision whether we should store energy that we just consumed or whether we should immediately use that energy it also has the ability to use the stored energy or not and then when you think about energy out all the metabolic processes that are going on and the fact that it actually takes energy to process energy and then very common in biologic systems we see feedback so the system is self-regulating and examples are satiety and hormones so a little bit more on this i think it's fair to say that metabolism is complex there's many hormones and biochemical pathways to consider and insulin is of particular interest we think of it as the fat storage hormone or an anabolic hormone that stores the energy but more important insulin regulates energy what we refer to as energy homeostasis so it decides what the body does with the energy and this is basic physiology that insulin is most sensitive to dietary carbohydrates now let's consider what happens when metabolic disease sets in in these energy pathways so again most agree that carbs and easily digestible processed food drives appetite but it gets worse during the state of metabolic disease we see hormonal dysregulation and we also see energy overload and you can see that the hormones and the energy and the calories all play into this now let's dive into metabolic disease a little bit further and we'll talk about insulin resistance and specifics and it really represents a state of hormonal dysregulation and i like to describe this through the insulin resistance cycle so let's walk through this so we start in the upper left we eat food let's say we overeat a little bit the body has this natural ability to store extra energy in glycogen which is a very small gas tank it fills up rapidly and also in healthy subcutaneous adipose tissue so let's say we continue to eat a little bit more so now our healthy subcutaneous adipose tissue will start to fill up and it continues to fill up we continue to eat and at some point the healthy adipose tissue becomes dysfunctional and it says you know what we've taken in enough energy we don't want any more energy and it begins to develop insulin resistance at a cellular level in the fat cells but the pancreas and the liver guess what they say wait a minute we still have this energy coming in we need to put it put it somewhere so we're gonna we're gonna up regulate insulin de novo lipogenesis will continue to pump out fat and and it gets stored right into the fat cells and the fat cells are are again trying to push back they're now becoming uh inflamed dysregulated more and more insulin resistance as we come around the curve we see hormonal dysregulation it drives appetite and what do we do we eat more food so that's the cycle and the two end game results here are that we gain fat we become overweight and the fat energy is literally trapped in the fat cells because of these high insulin levels it can't even get out and secondly it drives our appetite now you have to understand that these mechanisms don't happen just in adipose tissue and i also forgot to mention that the healthy adipose tissue becomes dysfunctional and the energy actually pours into ectopic locations such as visceral fat and organ fat so that's all part of what is going on here but we see hormonal dysregulation and metabolic disease on a cellular level throughout the body and that's why we refer to this as metabolic mayhem the biochemistry is disrupted everywhere and we it leads to inflammation and oxidative stress and hopefully our other speakers will get into this a little bit further because this is just an introductory talk so this is where low-carb high-fat diets come in to address insulin resistance and metabolic disease and let's talk about the conventions so here's a typical low-carb high-fat ketogenic diet again the macronutrients 70 of calories come from fat and yes that can include saturated fat 20 protein and 10 carbohydrate now we could use any diagram here any pie chart as long as it wasn't the perfectly balanced diet just to make the point that the calories are processed differently so here are the conventions macronutrients are processed differently yes carbs are fattening and inflammatory why because carbs drive insulin we learned this back in medical school the problem is the heart associations got involved and told us to simply focus on everything possible to lower our ldl cholesterol and that would make us healthy wrong and carbs trigger appetite especially when we see these fluctuations in insulin in our body and that we have to understand that saturated fat by itself is not the cbd villain it is a metabolic damaging process to both the lipoprotein the cholesterol and the arteries that we're dealing with and that the seed oils the canola corn and soy again very unstable in the blood because of the molecular structure when you compare that to monounsaturated fat that the body actually finds to be quite stable and so we believe that the default diet should be a low carb diet when you're type 2 diabetic even a type 1 diabetic and i'm happy to report that in january of this year the american diabetes association again recognized low carb diets as a good approach isn't that great in fact this the ceo of the ada just went public and stated that she's treating her type 2 diabetes which is with a strict low-carb diet and she got off insulin that's that's an endgame story to me so that's awesome so what happens when you go on a low carb diet and you're you're diabetic for instance so this is a picture of a dam and it really represents dysfunctional adipose tissue where the energy like the water is literally trapped we have high insulin levels energy's trickling in energy can't trickle out so what do you do with an individual like this you put them on a low carb diet less than 40 grams of carbohydrate 70 grams fat like we discussed and it's it's a rapid response insulin levels drop the patient begins to feel uh energetic they lose weight all these wonderful things happen because we open up these insulin floodgates and again that energy is now available the fat stores are oxidized free fatty acids throughout the body and we metabolize that energy it's low carb to the rescue and there's a metabolic for advantage for diabetics when you understand the mechanisms and this supposedly high calorie diet defies thermodynamics well no it's not defying thermodynamics you're just not accounting for the energy and the hormones properly in your equations david ludwig showed that and as most of you know eating less is often spontaneous and eating less frequently as well and there's a psychological advantage because you're focusing on satiety rather than deprivation so maybe in this description calories don't matter well imagine this if you have a type 2 diabetic that needs to lose 40 pounds you put them on a low carb diet they lose the 40 pounds now hopefully their appetite will be controlled but i tell you if they continue to eat the same way as when they started they're going to hit a plateau and their weight is going to come back up so yes the calories and the quantity of food are important hormones and calories both we need to think about so shift gears on heart disease again we're dealing with a metabolic condition just like everything else we've been talking about it's damage again to the lipo protein the cholesterol and the blood vessel wall and you address this through insulin resistance and the quality of the cholesterol it really has very little to do with the quantity and these proper measurements help you to predict predict risk now i hope you i convinced you that there's strong relationship between diabetes and heart disease and we see that in the literature but when it comes to clinical medicine not so fast and unfortunately in 2020 we see this all the time so we have patients that come in that are diabetic they don't realize that they have heart disease and then we have they don't realize they have subclinical heart disease and on the other side we have heart patients that don't understand or recognize that they have some form of diabetes or pre-diabetes and even worse their clinician is clueless so why the disconnect well welcome to the framingham distraction yes that's framingham massachusetts where back in the 1940s they studied the population for decades to see which one had heart attacks and which ones didn't and they they identified factors that we now know as risk factors and they are bad cholesterol smoking hypertension and yes diabetes but the diabetes risk was always underplayed the significance of it but anyway since the original framingham work they've come with come up with guidelines tools and risk calculators all with a central theme to lower cholesterol and therein lies the problem because it doesn't properly address diabetes it doesn't measure glucose properly it doesn't measure insulin at all and it doesn't address metabolic syndrome again this approach misses the mark but i'm happy to say in 2018 i kid you not this is the first year that the cholesterol guidelines have now included the metabolic syndrome i had to read that six times i could not believe the metabolic syndrome was not included there it is and we'll talk about um heart screening that that is now included in the guidelines in a couple minutes so the bottom line for our dear health professionals it's the insulin stupid and we're dealing with a metabolic disease it's not simply about bad cholesterol and if we focus simply on ldl cholesterol like the authorities have told us we're going to miss many at risk and we like to say if it weren't for ldl cholesterol everyone be on a low carb diet that's crazy and this is really the message that i like this is not about pumping people full about full of medication it's about diet and lifestyle and that's what this whole conference is devoted to so cardiovascular imaging wouldn't it be great if we had a tool we could look inside to the blood vessels and see the damage itself and determine risk based on that well we have such a tool it's coronary coronary artery calcium score again we look inside and we can determine risk now it's different than a blood marker a blood marker is just associated risk factor versus the calcium score that is seeing the disease process itself itself and the imaging actually provides us with historical data important to understand versus the blood test which kind of tells you the current status so i think they're both important to look at and we use this test to track progress and again motivate our patients now again the 2018 guidelines have finally included the calcium score they're using it as a really a tool to make decisions rather than a preventive tool but we think it's good because it is fitting in with the 2018 guidelines and hopefully more healthcare professionals will use it as a tool so here's your calcium score it's a cat scan of the heart it uses a little bit of radiation maybe more a little more than a mammogram and it's a 3d image and it takes pictures of the heart we have just one slice here and it sees calcium in the tiny little coronary arteries and you add up the calcium you get a score so the individual on the left circled in the green is the left anterior descending artery there's a zero score and you can compare that to the individual on the right where the led or the widow maker is circled in the red and that person has a lot of calcium in the white so it's a zero score on the left maybe a 400 or greater maybe a thousand on the right side and so based on this you can determine that the guy or the individual on the right may have a 20x increased risk of having a heart attack so again you're just using this visualization to determine risk it's much better than a um a blood marker itself and there's there's so many nuances to this but hopefully you'll hear more about this in the conference so almost finished clinical assessment important to realize i've been talking about insulin but it's not always insulin resistance so you have to measure the insulin status and consider that in the individual patient that'll help to guide you in terms of treatment so here we have two individuals that are actually insulin sensitive on the other side of the spectrum in the upper left we have this slim insulin sensitive person who guess what that's the healthy person and you know we hate that individual because nothing seems to bother them at least you can measure it at a certain point and see what changes and then the individual on the right is insulin sensitive but overweight and we see a lot of women that fit into this category and i tell you if you put them on a low carb high fat diet they might lose a little bit of weight they might not lose any weight but it plateaus or the weight comes up and they're often frustrated and so with these individuals the approach is different we're again trying to find ways to control appetite so these people eat less and the macronutrient mix will be different for an individual like that and on the bottom we have your insulin resistant individuals again this represents two thirds of the adult population the individual on the left is the slim insulin resistant what we refer to as tofi thin on the outside are fat on the inside so these patients become diabetic without gaining much weight and we see asian population fit into this category and then the typical what i call american overweight type 2 diabetic so again important to understand the insulin status clinical evaluation early level of suspicion for metabolic disease and we have to do the right tests we can do simple body fat waste to height anthropomorphic measurements standard testing such as a fasting glucose hemoglobin a1c standard lipids advanced lipids but we're looking for metabolic disease then we can do some more nuanced tests such as insulin homa ir c-peptide hscrp and what we like to do is the two-hour glucose challenge with insulin which is something we've done for 20 years in our office and we think it's an important test for people to consider and then cardiovascular imaging so here's how we treat our patients this is how we address a healthier lifestyle we want to limit processed foods sugar grains seed oils processed food we wanted them to eat real food that's slowly digested in the body we use alliteration from from ben bickman to say that we control our carbohydrates we prioritize our protein and we fill with fat and the macronutrient mix again will vary if it's working right it will control appetite about some common themes low-carb mediterranean nobody knows what a mediterranean diet is anyway but it just sounds healthy so we'll throw that in but i think a diet that is meat vegetables and natural fats make a lot of sense supplements for some we want to address sleep and stress and sunlight movement and activity we're not trying to create a negative energy balance it's just there's uh great psychologic and physiologic benefits and and more more and most importantly is to empower our patients to make change patient education and support and so this is our last slide that brings us back to the beginning and the point is that food can be powerful like medicine i'm not the first guy to say that we have the father of modern medicine hippocrates who said it long ago but i think it's fair to say that we weren't listening until now thank you [Music] you

Channel: Low Carb Down Under

Views: 55,728

Keywords: Low Carb Down Undert, LCDU, www.lowcarbdownunder.com.au, Low Carb Denver 2020, #LowCarbDenver, #LCD2020, Metabolic Syndrome, Insulin Resistance, Seed Oils, Processed Food, Obesity, Kraft Insulin Assay, Blood Glucose

Id: 7zZpbnKa6lU

Length: 31min 29sec (1889 seconds)

Published: Sat Dec 05 2020