Dr. Paul Mason - 'Treating Metabolic Syndrome'

this talk that I'm about to give was going to be about good health and what good health is and the more observant of you looking at this picture here will have figured out the problem already for this chat with metabolic syndrome so that we soft drink bottle sitting there would possibly be a problem so we're not talking about good health I thought well what is good health it's the absence of bad stuff it means you're not overweight you don't have high blood pressure you don't have high levels there triglycerides in your blood the level of HDL that good protective LDL is high or it ought be high and you don't have elevated blood sugar levels so in essence this is good healthy so absence of what we call metabolic syndrome metabolic syndrome to a doctor has five features if you have three of those five I will diagnose you with metabolic syndrome that includes if you have weight around your abdomen if you're fasting glucose is over five point six if your blood pressure is over 135 and 85 if your triglycerides are over one point five if your HDL is less than one if you take three of those boxes you have metabolic syndrome now the interesting thing is that each one of those problems is caused by resistance to insulin every one and you'll notice that LDL doesn't form part of that definition that's because we know just looking at LDL level per se it's not that good so we're going to take a bit of a tour and have a look at each of those five features and have a look at how insulin parlays into those this is a DEXA scan of one of my patients and what you can note is that there's this yellow here this is fat this is an pattern of abdominal obesity this is the bad stuff this is the stuff that's associated with risk of heart disease and we also know very clearly that as your level of insulin there's a strong correlation with increased body weight so insulin is implicated in obesity so how does it actually causes obesity so we know that it does make the fat cells bigger but let's have another look at that mechanism here so this is a slide that you've seen already today but we're just for the sake of completeness run through it again so if you want to make that fat cell bigger you have to stuff more in and the things that you want to put in if we that was the goal would be a triglyceride here and glucose because when the glucose and fatty acids from the triglycerides are inside the cell they combine to form the storage form of fat which is called a triglyceride now this driver's robe molecule is too big to diffuse across the cell membrane it's not going anywhere so for it to be made small enough so that the fatty acids can cross over this membrane here we need to cleave it and that's where something called lipoprotein lipase comes into its own and it's no coincidence that you give a little bit of insulin and the activity of this enzyme here increases substantially insulin also acts on this transporter here what we call the glute 4 transporter this is like a gate that glucose uses to get into the fat cell if you have an increase in your insulin level it opens the gate glucose goes in and the end result is that you've now stored fast and the fat cell is bigger now to add insult to injury if you want to burn the fat you have to repeat this process in Reverse where you first break this complex molecule down and you do that using something called hormone sensitive lipase what does insulin do to to action of this wipes it out so there's a triple effect there if you have elevated insulin levels very very clear that that elevated insulin leads to increased fat size so let's have a look at number two elevated blood pressure it's been clearly shown that elevated insulin levels correlate with increases in blood pressure so on this graph you can see here from the top line this is what happens if you give people insulin on the bottom one that's what happens if you don't so what you can see is a clear causative mechanism of insulin in increasing their blood pressure and this is something which we see every week in clinic once people start the low carb diet the insulin levels fall what happens we have to reduce their blood pressure medications that they're invariably on otherwise they feel dizzy it will overshoot so you control insulin levels you can absolutely can control blood pressure now this is the most well known mechanism that insulin resistance can cause change in blood pressure essentially if you end up with a fatty liver you damage your liver you increase the amount of uric acid that's produced and that uric acid inhibits the action of something called nitric oxide and the job of nitric oxide is to cause the blood vessels to relax that reduces your blood pressure now while this is the most well known mechanism it's not the most important model to understand the major cause of hypertension we have to understand a key concept and that's it fluid follows salt wherever it is in the body if you increase the amount of salt you have in the blood that will draw fluid to it we've all probably come across this in chemistry classes in school now insulin does a magnificent job at telling the kidneys to hold on to salt so having a look here this is a example of the structure of the kidneys so this is where the blood come passes through here in and out here and some of the fluid from the blood gets what we call filtered here and that fluid passes through this tube you'll all the way down here until eventually it passes out into the urine and what you can see here is that these four sites here insulin draws salt back out of that potential urine and pushes it back into the blood so in a state of excess insulin our bodies are doing everything they can to hold on to salt now this explains a couple of things so first of all essential hypertension that type of high blood pressure that your doctor said we don't know why you get it you just get it if you speak to the smart doctors their renal doctors they're the ones who understand this stuff they will tell you that high blood pressure essential hypertension is an insulin dependent state what does that mean you don't have high insulin levels you're probably not going to have high blood pressure and this also explains something else ever heard of the Kyoto flu back in the 70s used to be called the Atkins flu they didn't really know what was going on back then but we do now so we understand it's due to salt balance but it's this is the mechanism why if you something on a low carbohydrate diet your body will not hold on to that salt that it once was because your insulin levels have dropped so you'll end up with a temporary period of salt deficiency until your body can re adapt to that remember fluid follows salt you lower the salt level in your blood you lower your blood volume you lower your blood pressure you're probably going to feel dizzy and we know that amongst other things that dizziness is one of the key features of what we see in the keto flu now as an aside there's a lot of concern about salt and I just like to present this paper here so big paper published in the New England Journal of Medicine over a hundred thousand participants followed them up for almost four years and they mentioned how much salt was coming out in the urine versus your chance of dying something we call all cause mortality so this is the graph so what we can see here is running up the side here this is your chance of dying from any cause and on the bottom here this is how much salt you are excreting in your urine so we can assume that your salt intake must have been at least that much and what we see here is that the lowest level of mortality was somewhere between four and six grams of salt a day if you had less salt than that look what happens to your risk of all-cause mortality if you're got two to Seoul today that's about double the risk of dying from any cause so when we're talking about salt it's critically important especially if you're on a ketogenic diet because you have to understand ketogenic diet means low levels of insulin your body's not holding on to that salt so a lot of people will actually find that to avoid the symptoms that kiddo flu they actually need to increase their salt intake into the diet now let's move on to another of these features of the metabolic syndrome triglycerides now clearly all the epidemiological data out there says if you have a high level of triglycerides in your blood your risk of heart disease is increased and this graph here demonstrates their association with diabetes and by proxy insulin levels if you have high levels of insulin as seen in diabetes you have high levels of triglycerides now to understand why you have high levels their triglycerides we first of all have to understand that the liver can store glucose as glycogen but only up to a point a hundred grams after you flood the liver with sugar and it reaches its capacity it has nowhere to go it can't be stored so instead what happens is it starts this process called de novo lipogenesis de novo lipogenesis means you'll produce fat you'll produce triglycerides and this is a very elegant study where they said we're going to give people more carbohydrate than they can burn and we'll see what happens so on day two here you'll see that they burnt that much of the carbohydrate and they test they measured that through some fancy techniques and they turned this much carbohydrate into glycogen stores now what happened on the next day because their stores were quite full they probably burned a little bit of glycogen but there wasn't that much room so they burnt a bit they burn a bit more actually they stored a vinous glycogen but then they started to produce fat and as the days went on and you can imagine that this is happening everyday to people on this day an australian diet they're giving their bodies more carbohydrates than they need and this process lipogenesis making triglycerides is occurring you put in more carbs than you can and because you have insulin resistance that other tissues the sugar can't be taken up that effectively in them in the muscle anymore it has to go somewhere part of it goes here and it forms fat so if we have a look here this is a liver we make this fat de novo lipogenesis so what happens then it gets exported remember these V LDL particles from the last lecture they're holding triglycerides enters the circulation Bank you now have increased triglycerides in your circulation now having a look at HDL this relates to triglycerides we know HDL is good if you have high levels of HDL it is a very good indicator that your risk of heart disease is reduced now the problem is that we can see the triglycerides can be taken up by the HDL molecules and through various pathways if the HDL molecules take up too much progress all right it ends up leading to their breakdown their catabolism hence a reduction in HDL so the same mechanism that causes an increase in triglycerides also eventually leads to a reduction in your HDL level so finally we come to Step five of the metabolic syndrome elevated blood sugar level now again this is clearly related to insulin resistance so what we're seeing here is a graph across the lifespan theoretical demonstrating how insulin is becoming more and more resistant what this means is it doesn't work as well as it used to work so the compensatory response of the body is to release more insulin for the same effect and if we have a look at what happens as the insulin resistance is occurring this line here is fasting plasma glucose we can see that fasting plasma glucose increases now to appreciate how this resistant causes have to understand that the insulin is what actually draws the sugar out of the circulation and in a normal situation where insulin is working it does this quite nicely it goes into the liver plunk a bit into the muscle take a little bit into the fat sure and you're not left with an excess amount of sugar in the bloodstream but if insulin stops working as effectively you still take a bit of sugar up but not as much what you're left with is a large amount of sugar still residing within the blood vessels so I thought I'd now go back this is the features of metabolic syndrome and clearly they're all caused by insulin resistance so let's have a look at some modern research done about 33 years ago because we've got a really good practice in medicine of ignoring good studies and good science this study took ten diabetic Aborigines who all met the criteria for metabolic syndrome they lived in urban areas and they were recruited for a seven week trial where they went to live a traditional lifestyle eating a traditional diet and this was conducted in the Punta Shan community about an hour's light plane flight north of Derby so what happened so short answer things got better this is a graph here showing their blood glucose level their fasting blood glucose level on average at the start of trial was eleven point six after seven weeks just seven weeks it went down to six point six their triglyceride level at the start was 4.0 - and after seven weeks it went down to one point one five huge reductions what about their body weight we saw a large reduction in their body weight a main reduction in their BMI went from twenty seven point two down to twenty four point five so you're probably wondering what is it in this traditional diet that led to these very impressive results well I did a bit of research and when I actually looked into the literature a bit deeper it appears that the indigenous population has always valued fat in the diet this here is a witchetty grub 67% fat and considered a delicacy so when I have looked at the data from this study and I plotted it and I compared it to the NHMRC recommended diet so this is a diet here that fits within their recommended macronutrient intake I compare it to a typical high-fat low-carbohydrate diet which I use for my patients and I think you can see that the diet used in this study is far far closer to a low carbohydrate diet it's almost opposite of the diet that's suitable and recommended by the NHMRC so I just want to try and present a view of the totality of evidence here so I'm going to present a series of meta-analysis now the way these studies work is that each line here represents an entire study and the results are it's called a forest plot and the results are shown here on the end and this point here represents the average results and the length of this line represents a narrow bar so this large dot down here represents an average of all the results so when we have a look at low-carb diets and weight loss across the board the science says they help you lose weight we apply this same methodology to looking at triglycerides again down the bottom they help you lose weight they help you lose stroke lower your triglycerides your HDL well look at these big increase in the good HDL what happens to blood pressure well blood pressure goes down and we know exactly why's that salt effect in the kidneys and finally we get a reduction in the blood glucose level as well as we can see from this point down here so we're now just going to take a little bit of a detour and have a look at what causes insulin resistance clearly it's not good clearly it's doing us a lot of harm so I'm going to also take you through a bit of a journey on some of the patient results that we've seen in the clinic over the last few years so the first point here is a visceral fat fat in the liver leads to insulin resistance and we've now started to figure out the pathway as hell this is retinol binding protein for you don't need to know the name but you do need to know that it correlates very well with body mass index correlates very well insulin index and it's been implicated as a causal mechanism of insulin resistance it's produced by fatty livers so here's what happens and this is grossly simplified but we might present the science at a conference in the future you have a high carbohydrate diet and in particular fructose is implicated here as most of you all know and that leads to fat accumulation the visceral fat and around the liver that then directly leads to an increase in this retinol binding protein for and through various mechanisms this is the molecule which actually contributes to insulin resistance now I think you can see the problem here because we know that insulin resistance leads to fat accumulation this is a rust and rather nasty cycle here and the only way to deal with it is to eliminate carbohydrates from the diet so I was always impressed in the clinic where not have people come in and not be morbidly / obese so sometimes be 130 hundred and forty hundred and fifty hundred and sixty kilograms and neither lose maybe ten percent of their body weight they'll still be grossly overweight but their blood tests looked very very good they look so much better than they were before and this is why this is a DEXA scan of that same patient you saw earlier you can see the fat around the viscera here a repeat scan six months later after only about nine percent weight loss and we can see the visceral fat is all but dissolved so the fat that you lose first on a ketogenic diet is the bad stuff this is magnificent so a very modest degree of weight loss is going to be beneficial for your health now if we actually have a look at this in another way I can assess liver health through blood tests which I do in my clinic so what you need to understand about liver cells is that they've got chemicals and constituents inside them that aren't really found anywhere else in the body in high levels and if you damage that liver cell it will release the contents into the circulation where we can detect it with a blood test and if we see certain chemicals that we know are particular to liver cells in the circulation that infers that there's a degree of damage happening to the liver so what we're having a look at here I won't you have a look at this bottom line on the line all the doctors in the audience know that alt relates to liver health look what happens before a low-carb diet and after a low-carb diet the liver gets healthier now this is probably one of the most important tests I do in the clinic and call it the glucose tolerance insulin response test what happens is that you have a blood test and following that you have a drink at half an hour are not shown here one hour and two hours we then repeat blood tests but rather than testing only glucose which is the standard test done we also measure your insulin level and this is really really important because the pattern of insulin the height of insulin is very predictive of your future health outcomes this was a really nice study published several years ago and the main finding from this study was that the peak insulin depending on whether occurred at 30 60 or 90 minutes was very predictive of your chance of developing diabetes over the next 11 years so in this first group you can see your chairs are becoming diabetic over 10 years not so bad what happens if you're a pattern for almost a 1m2 chance of developing diabetes understanding your insulin profile is essential to understanding your health so let's have a look at real-world patience these are actual patient results so we can see here looking at the insulin we have a pic of insulin occurring at the one hour mark so we'll just ignore the glucose for a moment so what pattern of insulin is that that's a pattern three percent chance of progressing to diabetes over the next 11 years 15 percent what about this individual their insulin levels are not as high doesn't look as bad right but it's the duration and the timing and the peak which is also essential we can see here it's constantly going up there's no peak in the first two hours chance of progression to diabetes in the next 10 years or so about one in two so we can also get some other interesting insights from this type of testing in our patients so this patient came to me and they were caught in a pattern of cyclical eating so those of you who are now ketogenic think back to when you used to eat tabs come morning tea time you would hunt down a small child if you needed to to get something so why is that so something I see not infrequently in my patients is something called reactive hypoglycemia so you'd think that if you stuffed 75 grams of glucose into the circulation that your sugar should be high and should stay high but not in everybody in this individual you can see they overshot they released insulin and that insulin overcorrected the sugar that was put in throughout the two-hour mark they left with a blood glucose level of 1.1 in this situation you're going to feel lousy all the doctors in the audience are probably wondering what happened to this patient they find they did not die but at this point in time this patient was going to crave carbohydrates now you've seen bowl and a half a crunchy nut cornflakes coupler up and goes is the same as this blood test if you start off your day with that healthy breakfast for this individual that means they'll be caught on a cycle of reactive eating trying to restore their blood glucose levels back to normal so in this situation this is a revelation for this patient you stop putting that rubbish in at the side of the day your blood sugar levels stabilize and that's exactly what happened now one other point is that because we do the testing so depending on who you are we'll do the half now testing as well as a one hour testing but something we see not infrequently is an elevated one hour test or a half an hour blood sugar with a normal two hour test now a blood sugar of over eleven point one at any point time during this test is consistent with the diagnosis of diabetes so I suspect there's a lot of stuff even if we were only measuring glucose if we included the one hour marker into the standard test it would be a whole lot more diagnostic so we've talked about the insulin resistance that tends to develop over a long period of time and so what essentially happens this was very well covered by Doron is that over time insulin gradually rises to compensate for the resistance but there reaches a point where it can't compensate any longer and then your blood sugar starts to rise and then several years after that your insulin secretion reaches a peak now this is what is in common parlance known as pancreatic burnout now I'm going to tell you what causes this so you've all seen before in my previous lecture what happens when sugar attaches to proteins glycated them that leads to the formation of something called advanced glycosylated end-products that leads to swinging proteins and basically D functions it well this very process has been shown to happen in the cells of the pancreas that make insulin now I don't know if you think that's ironic or not but the sugar which the insulin is trying to control will actually kill the cells that release the insulin now one of the exciting things that we see though is that this process if you don't get to a too late he is partially reversible and I can actually test people's ability to secrete insulin I measure something called C peptide and what we're seeing is that we have been doing it for very long but the data looks relatively promising at the moment that we're starting to see a restoration of people's ability to secrete more insulin over time it's taking several months but it looks quite exciting at the moment so let's think about this chart of insulin resistance and compare it to patients we've actually seen in the clinic so these are actual patients which I've seen so here we see we're right down the left hand side healthy days blood Sugar's low insulin slow ten what happens now blood Sugar's low but you can see that insulin is now come up to 83 this is not diagnostic of anything this individual would go and have standard testing and be told they have nothing to worry about it's at this point that they might be told they have pre-diabetes because their blood sugar here has started to come up off the baseline but you can see here the insolence even higher and the final stage is now blood Sugar's eleven point four that's diagnostic of diabetes at two hours this patient would be told that they have diabetes but have look at the insulin the insulin is actually not that high this is demonstrating how the capacity of the pancreas to secrete insulin actually gets damaged when it's exposed to sustained elevated blood sugar levels and your insulin level will then drop so here's a good news we can fix this and you can fix it in a relatively short period of time this patient over about three months have a look at the one our level of insulin there big drop this patient again some quite reasonable drops even more weight loss this patient again some very impressive drops so we can actually reverse this insulin resistance we can test it we can prove it thank you

Channel: Low Carb Down Under

Views: 260,775

Rating: 4.9154105 out of 5

Keywords: Low Carb Down Under, www.lowcarbdownunder.com.au, LCDU, Low Carb Sydney 2017, #LowCarbSyd, Paul Mason, Metabolic Syndrome, LCHF, Low Carb High Fat, Ketogenic Diet, Low-Carbohydrate Diet, Physiotherapy, Low Carb Doctors, www.lowcarbdoctors.com.au

Id: KlHPmJTihBc

Length: 29min 4sec (1744 seconds)

Published: Tue Mar 27 2018

Reddit Comments

[u/RangerPretzel]

Just tried to post this, but you beat me to it. Really good watch. Highly recommended!