This episode #30 features John Madany, MD – A Montana family practice doctor with super insights for resolving modern chronic disease! In this episode we focus on the scourge of hyperinsulinemia, and the power of understanding root cause and how to resolve the issues effectively!
As always, you must know your disease level to know your risk
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FULL TRANSCRIPT (scroll down to bottom for Audio Podcast):
Ivor Cummins 00:00:42 Today we’re talking to John Madany MD of Dillon, Montana who runs a family practice and deploys a lot of personal knowledge around metabolic syndrome and insulin resistance and blood measurements to track that in order to help his patients be successful in resolving their metabolic disease. So, great to see you John here in Seattle this time.
John Madany 00:01:03 Yes. I appreciate being able to visit with you.
Ivor 00:01:07 That’s great. And we talked a couple of times before in San Diego. All was fascinating conversations – patient stories. But you, I suppose several years ago, kind of discovered insulin resistance and the importance of insulin and glucose and chronic disease. And did you do that through your own research or it came down from the medical bodies?
John 00:01:26 One of my colleagues had me read the book by Gary Taubes, “Good Calories, Bad Calories.” When I read that, it was an aha moment because it explained the futility of my work for about 20 years.
Ivor 00:01:42 Oh, they are strong words. I guess, not totally futile, but mostly applied the drove to the symptom kind of phenomena?
John 00:01:50 Right. When I say futility, I would be referring to helping people with metabolic illness instead of just treating with more and more medication to control the numbers. Now I knew how to start D-prescribing.
Ivor 00:02:04 Right. So you’re not only improving their health, but you’re doing it in parallel to removing medications, which is kind of… that’s just a fantastic combination, obviously.
John 00:02:13 Oh, yeah. It was very satisfying. I didn’t know there was a term D-prescribing, but having to overcome the inertia of pulling back medication was unique.That was very satisfying, because this was for patients that I’ve known for years. So it’s like now I’ve got an answer, how we can stop this endless progression of, “It’s a new year, it’s a new drug.”
Ivor 00:02:37 Right? And that’s reminiscent of Dr. David on one story in the UK where he was close to retirement, discovered what you discovered and suddenly realized he enjoyed his role, his vocation, his job, because now he could actually intervene, help people and D-PRESCRIBE medications for the first time in his career, a 40-year career.
John 00:02:58 Right. So I kind of say now I found the best retirement plan is enjoying your work.
Ivor 00:03:04 Yeah, that’s huge. If you can, yeah, make your hobby your job, you know, you’ll never work a day in your life.
John 00:03:10 Yeah.
Ivor 00:03:10 So I’m guessing you’ve fantastic patient stories and we get into some of those. But you see quite a lot of people even though America has enormous obesity issues, you’d see quite a lot of people who are TOFI; not so obese outside, appear healthy, and yet their blood markers clearly show you with your expertise, that they are really high risk just like an obese person.
John 00:03:31 Yeah, and come to think of it. I’m one of a severe TOFI in that I had fatty liver disease diagnosed by biopsies, the liver enzymes were that bad. And the response I got was, “Oh, you don’t have hepatitis C, B or hemochromatosis.” And I was like, “Okay.” And then over time, I’ve learned that it’s a fructose disease, which is easily explained by my habit of minimal alcohol consumption and vast amounts of fructose consumption from age five.
Ivor 00:04:10 Oh I see. You’ve had a lifetime, most of your life until a few years ago of eating high sugar diet.
John 00:04:16 Yeah. And I was also a very diligent, low fat diet-er. So this all changed. It was very life-changing. Personally, it helps me empathize with patients. But I don’t practice based on, you know, what I did for me necessarily; it’s the science of it.
Ivor 00:04:37 Right. It is completely science based and even though Gary Taubes book tipped you off to the enormity of insulin and glucose dynamics and their connection to chronic disease, you really then of course took that as a springboard to go and research yourself, I think, with your access to the medical literature?
John 00:04:53 Yeah. Being that I can go to the National Library of Medicine online PubMed and type in “insulin and a chronic disease” and it just tumbles out of the computer. It’s almost to the point where you don’t have to keep up. You can just do a new search. If you want to show somebody an example. Like I work with medical students and it’s like, “Hey, watch this. Insulin this, boom, here’s a paper. I’ve never read this before. But it’s slam dunk.”
Ivor 00:05:18 Yeah. In [Inaudible 00:05:19] papers on any… I used to say that years ago as well, I mean, putting Google insulin resistance or hyperinsulinemia on the chronic disease of your choice, modern disease, and you’re going to get a ton of hits.
John 00:05:31 And it’s physiologic. We’re not talking about correlation; we’re talking about mechanism.
Ivor 00:05:40 Yeah, and pretty much validated. Nothing is 100% proven in any field, but this is right up at the top.
John 00:05:48 And when you start implementing it, and you say, “I think that your edema in your legs is from high insulin and the insulin level drops and the ankles appear, what can you say? And now you’re on a less blood pressure medication using, you know, one sixth amount of insulin.” And it’s like, “Oh, we’re onto something here.”
Ivor 00:06:12 Yeah, John. And you mentioned earlier Actually, this morning when we’re chatting that, you know, people who come in with high or high-ish insulin, you nearly always now find another sign also. Rarely do you find high insulin isolated, you’ll see hypertension with it or you might see some central obesity, something else.
John 00:06:32 Exactly! I haven’t found somebody with high insulin that I didn’t suspect. I should say that I’ve been able to start with this work was no insulin levels, using Richard Bernstein’s book as a guide to what foods stimulate insulin and that’s what I kind of started with making up recommendations based on what foods don’t trigger insulin release. And then the technology is advanced, then comes the Dexcom, which I work for a month total myself. Now we have the FreeStyle Libre where I’m just prescribing that to anybody who will take one because it’s such an eye opener to see what foods do. The classic one now is skim milk and cornflakes. And it’ll drop your job, what it’s doing to your insulin. Then within our hospital, I’m very fortunate that our hospital has high tech equipment where we can get an insulin level within hours. So it can in a sense, get a stat insulin level, beta hydroxybutyrate, the ketone level, using the FreeStyle Libre. You can put that together and you can see so much that if the lab results came in different days, it’d be hard to put it together. But when a patient sitting in front of you with the results, all came in today, and we can talk about what you did yesterday, the scene is believing.
00:08:13 And I will say with the insulin levels that this is anecdotal, but I’m correlating insulin levels with coronary calcium scores. It’s like, “Oh, your insulin level’s up. What is your LAD coronary calcium score?” And it seems like there’s a relationship.
Ivor 00:08:31 Right. And actually in the literature, yeah, there are limited papers on the insulin. There are many papers on insulin on future heart disease and future diabetes, of course, but there’s relatively limited ones that have coronary calcium. So that’s really interesting, and I’m hearing more it’s very heartening. I obviously work on behalf of Irish Heart Disease Awareness and David Bobbett, and our main goal is to get information out on the calcification scan to save the middle risk, especially non obese, non smokers, give them a heads up. But to your point, I’m hearing more and more doctors coming back now all over the world at conferences, emails, all beginning to do calcification scans when they actually realize the huge value of them. So you’ve been…
PART 2 of 5:
John 00:09:14 … starting to do those and with the American Heart Association, putting it in their guidelines, that was a big, good thing for freedom so that I’m not too far away out from guideline. But the area where I’m looking at is I’ve had some people that had a shockingly high score and low insulin and it’s only recently I’m really making an effort to find out, “What more can I do for you to reduce your risk of coronary artery disease and lower your insulin?” Because even the standard calculator is in effect, insulin resistance calculator because it looks at blood pressure, HDL cholesterol, and diabetes, and you say, “Well, if I lower your insulin, it changes all the numbers in the American Heart calculator.” So it was really an insulin resistance calculator disguised. “But if you don’t have excess of insulin, insulin resistance now, what do I do for you?” And that’s my current study is, because I don’t want to do a test on someone and then say, “Oh, this is too bad,” and I have nothing to offer but a statin. Because I’m not going to hold back on the statin and but it’s like, “I know, you need more.”
Ivor 00:10:33 Yeah. And you are, by doing calcifications scans,i mean, besides saving lives by highlighting the people truly at risk way better than the risk calculator, you also begin to get an insight into those less common scenarios. I mean, you find someone with a high score and they’re clearly got a high [Inaudible 00:10:50] home or they’re diabetic. It’s simple. The first steps besides medications is to start reducing their diabetes. But when you get a guy who has no apparent issue with insulin or hypoglycemia, then you’ve got to go deeper. And I think you mentioned you saw a podcast I did with Bill Blanchett, cardiologist?
John 00:11:11 Exactly. Yeah.
Ivor 00:11:11 Maybe talk about that.
John 00:11:13 What I did on my flight here is that I, on the plane, I took detailed notes on that, because so many of the things that Bill Blanchett mentioned are so safe. And I know we’ve talked a bit about maybe have to do a little more homework on it, but it’s like, I have some things to offer you that, maybe they’re not good population interventions. Like giving too many people aspirin, you’re going to end up with a complication somewhere along the way. But if you can focus on thing… basically, almost they fall in to the supplement category because they’re over the counter, but could help. And I won’t go into detail on that because that’s my study of the weekend. Is to say, “Now, I’ve more to offer and these are pretty benign if your risk is high.”
00:12:05 I will say with the coronary calcium score, when you see somebody in their 60s with a zero score and has the risk calculator said that they were high enough for us to be on meds, that does make your day because then you say, “Oh!” You made it in a sense, and we can follow you along, but it’s going to be, “We’re not going to worry about you.”
Ivor 00:12:29 Yeah. I got someone in their 60s, maybe 5, 6, 7 years recheck the score, possibly, but they’re in a safe place. But there are many more anecdotes coming out now. They’re not documented in the published literature, but I’m getting a lot of them, of 60 year olds and even late 60s, zero scores, no measurable disease, but they were all candidates, obviously for drugs, because age is the biggest risk factor.
John 00:12:54 Right.
Ivor 00:12:55 So we’re going to see a lot more of that. Probably the really crucial thing is to catch though the guy who are in their 40s or 50s, who have no apparent risk factors that are very significant or middle risk, they don’t look obese, they don’t smoke. But the calcification scam might throw at someone with a 200 a huge risk. And you’re also coming across some of those.
John 00:13:16 Right. So now I think I have more tools to work with. And it’s things that I’ve actually D-PRESCRIBE based on maybe misinformation where I’ve taken away a fish oil or a niacin in the wrong person. That’s what I’m studying. But I also have to say that I have a little concern about the coronary calcium scores that the data was based on a healthier population than the current population. So maybe we need to start checking sooner. And because we’re getting the younger cancers, younger diabetes, the amount of young men in particular, men and women that I meet in my half day a week in a walking clinic, it is so hard to not just say, “Stop! I’ve got to bring you into a primary care setting and treat your insulin resistance now.” Because it’s it’s so sad to see guys that are in their 30s that are not gaining three pounds a year but 20.
So anyway, thinking about the coronary calcium score earlier and to follow along, just call it like a mammogram type of a concept. It’ll come out [Inaudible 00:14:40] as we get more information about what to do for these people, what to tell them. Then you want to know because if you get test results that cooled me off a bit is if you don’t have a baseline, “Oh, what do I do? Your score is 250,” and I get email from my patient, “I saw my score, I feel sick.” And it’s like, “Oh!” But fortunately, one of the persons, they were diabetic and it’s like, “Well, you’re diabetic and you’re high insulin. You know that means you have plenty of reserve to just reverse the disease.”
Ivor 00:15:18 Yeah, as shown by Vert? [Inaudible 00:15:19] in many other studies, we know now how to attack it. The people who don’t have apparent diabetes, of course, then, as you mentioned, and it’s something you’re going to be digging into more, there’s a whole range of other potential causes, like vitamin mineral deficiencies or heavy metal contamination. So it is a challenge for the medical profession, actually, that the calcium scored are not so familiar with, but as it gets used more and more, and with the 2018 AHA guidelines, we’re going to see this, we’re going to start finding all the people at high risk and some of them will not have an obvious driver for their calcification. But that’s okay, because, you know, we can’t hold off from using the best tool to identity the at risk and try and save them just because it may throw up some awkward questions. Those awkward questions are going to create huge learning. It’s going to be amazing, actually.
John 00:16:12 Yes. And even with the thought of how important dental health is to coronary artery disease. As a primary care doctor, you at least have intuited that poor dental health is correlated with poor general health. And there there’s a lot of correlation causation issue. But I’ve had some patients, their health did improve when they got all their teeth out, which is sad, but they were just, you know, portals of entry.
Ivor 00:16:43 Yeah. There are many places in the human body where you have an interface with the world, with the non self, with potential injurious agents. And of course, the gut is a huge one. If you have leaky gut you bring in foreign proteins, cause autoimmune and heart disease can be accelerated. But yeah, that’s another interface; your gums.
00:17:04 Interestingly Bill, I know mentioned that one and I agree, John that I always wondered how much is correlation with bad diet that gives you gum disease and how much is actual causal? And I think it’s both but you can address both together.
John 00:17:19 Right. And there are sometimes we have to acknowledge that the correlation causation isn’t really essential because there’s an immediate benefit of keeping your dental health. It’s just a part of sense of well being. And that’s something that I’ll just think of right now is that when I got the wheat out of my diet, I think because I don’t know if it would be all the sugar starch, canker sores went away. Well, that’s such a nice thing to not have.
Ivo 00:17:52 Yeah.
John 00:17:52 And then it had been plagued me my whole life.
Ivor 00:17:55 Yeah. I’ve heard so many stories from people now. It’s a deluge at this stage to be quite honest, and a lot of them come my way, were completely unexpected issues like acne or psoriasis or skin conditions or joint aches or mental fog or tiredness did myriad modern chronic ailments. It depends on the individual person, their individual physiology and how they’re affected by bad food, but fixing bad food can have this enormous population affect, beneficial effect.
John 00:18:28 Yeah. The amount of anecdotes of good things that have happened when I was just focusing on, “I wish you didn’t take as many blood pressure medications or medications for diabetes or cholesterol,” and then the good ripple effect of that, which I don’t promise to people, but I surely enjoy hearing the new good. Like mental well being, I haven’t prescribed it for psychiatric alone, but it should… to quote one of my patients, “I’m different,” you know, “that sinks in.”
Ivor 00:19:07 Yeah. Some part of it is when people lose weight and they feel great about that. But to be honest, that’s the small part. That’s the direct neurological effect I think and you’re right, it can’t be promised but it just happens in a huge proportion of cases. And people are always commenting on this. On the more extreme and now there are some amazing stories coming out and they’re true, they’re not stories, but they’re not published in the literature. One guy had bipolar for 20 years of meds and not being able to work and he went ultra low carb keto, and was off meds within weeks, and that’s a year ago, and he’s back working. Now, we got to be careful with any equals wounds? [Inaudible 00:19:47], but the sheer volume of stories like that are very gratifying. This is really helping people.
John 00:19:55 And I’d say somewhat tongue in cheek that there’s some folks, they should sign a consent form, saying, “I might have to go back to…” “I might return to the workforce.” And it’s like, “I’m sorry, I didn’t warn you that something might change.” I’ve seen people where they say, “I’m never going to be off disability,” and then over time, they’re looking for work.
Ivor 00:20:21 They actually feel like if they want to.
John 00:20:22 Yeah.
Ivor 00:20:23 It’s like, when you go from a bad diet to a good diet, you not only begin to lose weight as one example and lower your risk for cardiovascular and other disease of course, but you also begin to get more energy feel better. Ironically, that actually encourages you to do more exercise. You feel like doing more so you get a double whammy.
John 00:20:42 Yeah. That’s another thing. I work with a fair number of folks that are not even ambulatory with weight loss. They’re seriously ill. And to see how they can come back to life it’s really gratifying. With all the tools we have now it’s it’s amazing.
00:21:03 I had a gentleman who, he wore his continuous glucose monitor for the first two weeks, became non diabetic after 14 years. And then after the second two weeks he said, “Why do I need this?” And I had to respond. “You don’t need it because you’ve learned all there is to know. What can you do with a 90 something blood sugar day in day out?”
Ivor 00:21:29 And no spikes after…
John 00:21:30 No spikes and no meds.
Ivor 00:21:33 Yeah. That’s the holy grail really. But more and more people are achieving this through, to be honest, doctors like yourself who have become knowledgeable on what the main drivers are and know how to pull them back.
John 00:21:45 In my case, I’ve been wearing the CGM since last August, the FreeStyle Libre and the good thing about that is that it’s accessible if you wanted in a sense. Because the reader or receiver cost somewhere around $70, and the sensors that you wear are 40 to $70 for two weeks. So if your curiosity is there and you realize the potential health benefit, it can be very valuable. And I keep wearing mine because I learn new things all the time. And it took quite a while to realize that exercise raises your blood sugar, and then somebody that’s eating diet that doesn’t stimulate excessive insulin production. Your fluctuations are basically due to activity. And it can unmask things like sleep apnea, or stressors. You say, “Why is there so much fluctuation in blood sugar?” So I find that really valuable and to keep wearing it myself. And as I said when we were talking before, I have what I called Type 2 physiology because, the other day I ate some granola with sweetened yogurt at a conference and my blood sugar on the FreeStyle Libre read 210. And if I would have done a fingerstick, it might have been 180. But I have done the correlation; I wasn’t able to at that moment.
00:23:17 So you see all these things in yourself, then when your patients are calling you and showing you pictures of their readings, you start to understand why. And you realize the counter regulatory hormones are huge.
Ivor 00:23:32 Yeah, so you have got a rapid feedback now on bad things and also an insight and awareness into not bad things. Like you grow to understand that exercise or gearing up for an event can raise the blood glucose and that’s okay, that’s part of physiology.
John 00:23:48 Yeah.
Ivor 00:23:48 But most importantly, you can do the finger prick or the CGM, into your meter, and spot those problematic foods, and everyone has different problematic foods.
John 00:24:36 And that’s where we got to say hats off to Dr. Bernstein. He had made comments about colors of peppers. That was the only thing that I just dismissed. It turns out that eating colored peppers shows up on my CGM. And so it’s interesting thing.
Ivor 00:25:01 Yeah. You know what, you triggered a thought there. We recently did a documentary with the Irish football stars from the 90s; top guys, still in great shape now, very little obesity. And we got a lot of guys with calcium scan, huge score, needed immediate follow up, and their doctors thought they were fine. And they were not overweight; I mean muscular guys. But the interesting thing was they have the go now to use the meters because they’ve been informed by not necessarily by their own doctors, but they’re getting to grow and learn. And one guy was telling me, “When I eat beetroot, I like beetroot that’s kind of healthy, but when I beetroot I can go up to 180, 190.”
00:25:42 And this person is very driven because he’s got a high score, he knows you can intervene and stop it progressing. So there’s all the hope there to stop that event he might have got. And he’s also getting all this feedback as you describe it. He’s trying different foods. He has porridge and honey which he used to always eat, and he looks as mean and says, “Uh oh!” I mean much smaller portion is needed or maybe eat some eggs, healthy eggs.
John 00:26:05 Yeah. Another interesting one on the CGM is seeing how (once it gets into the summer months) how leaving the dinner table more quickly to get to my garden has a beneficial effect. And that’s one of my things that I like to teach is that like from the… if you actually start in the garden, and you combine it with the healthy animal products, you know, it’s sort of a continuum. But even just having that, “I want to leave the dinner table to go pull some weeds,” can improve your butchers. Because you do eat a little less and calories. I never count calories and I’m a numbers guy but I’m allergic to the thought of counting a calorie but still volume matters. And if you just keep eating, you aren’t going to get all your weight loss goals. And so many people need weight off.
Ivor 00:27:04 Yeah. Primarily they need the metabolic health. I mean, even an insulin sensitive overweight person, that’s the big goal. But yet, in America particularly, but all around the world, we’ve got a huge challenge. But that thing about getting up actually, I remember there was a story, well historical fact, that the Romans I believe used to always as a policy, not fully understanding it, after meals would walk around the amphitheater or whatever. And they knew that right after a meal was a great time to walk it off. And of course, what they’re doing is they’re keeping their blood sugar lower after the influx from their meal. It’s great timing to do something after a meal, yeah. Not just for calories.
00:27:44 So any other patient’s stories? Of course for several years you’ve obviously got a lot of patients you’re helping at this stage.
John 00:27:50 One of my best patient’s stories was, I’ve a patient that has been my patient for 21 years. He’d be happy if I used his name, but there’s no need to. But, in a rural community, people, if they saw this, they could figure out who I might be talking about. I met him on an ambulance run in 1997 were, because of his obesity he couldn’t be brought to the hospital so the ambulance took me to his house. He was in a diabetic, almost coma from overdose of sulphonylurea. Brought him to the hospital, kept him on… he had to eat around the clock for a couple days to get the sulphonylurea out of his system. And he was a 350 pound gentlemen, already had charcot feet, the broken bones in the feet from diabetic neuropathy. This is in 1997.
00:28:49 Fast forward to 2017, so 20 years later, he comes in the hospital in heart failure and I had just learned about fasting, which I practiced on myself for a couple months, so the intermittent fasting. And so I thought, “Now I know what to do for this gentleman.” I talked to him about this the night after he was admitted. He didn’t eat another… he has almost been perfect keto since. He went to a nursing home, because he’s wheelchair bound, went to a nursing home for three weeks for rehab and the next week he started working there two days a week as the Activities Coordinator in his 70s. Here’s somebody coming out of disability of 20 years spontaneously. He is not technically diabetic. He is not on any diabetes medications, and he went from 410 to 240 some pounds in a wheelchair. And when your patients are excited because they have a narrower wheelchair and they can go through the doors easier, that is amazing.
00:30:01 The neat thing about this gentleman was laughed about the bad advice I gave him. The whole, “If you would eat whole wheat instead of white flour, you would get your metabolism together.” And we can laugh about it because I did tell my patients, I was wrong. When it comes to metabolic syndrome, if you don’t know about the insulin and all of that, it’s just hitting your head against the wall. And it was so funny because here’s the guy I’m preaching whole week to as I gained weight, and in front of him, I gained about 30 pounds while I was giving him over the four years that I worked with him; I left there and then came back and got him back as a patient much later.
00:30:47 So those are the things where it’s just like every month we have like a reunion. And it’s like I’m down a little bit more. And this is a year and a half into the weight loss and it’s still marching down in wheelchair.
Ivor 00:31:01 In a wheelchair, which of course means he’s very limited in exercise.
John 00:31:05 Yeah, but I have a bunch of patients where it’s like, “You’re in a wheelchair, lost 100 pounds.”
Ivor 00:31:13 And relatively older like at 60s and 70s.
John 00:31:16 Yeah.
Ivor 00:31:16 And still never too late.
John 00:31:18 Right.
Ivor 00:31:19 It kind of though it really epitomizes, or it brings to the forefront the incredible power of the correct dietary intervention. You know, the trials for DAWN and there was a lot of variability and they never did low enough carb and there are lots of other flaws and they claim that there’s not a huge difference, but we’ve myriad and equals ones.
John 00:31:40 “Oh, here’s a one meal a day.”
Ivor 00:31:42 Yeah. OMAD (One Meal A Day).
John 00:31:43 Because that’s what worked for him.
Ivor 00:31:46 Yeah.
John 00:31:47 And to have, you know, so much better, his sense of well being and it was like to go from, “I was shy to go to the locker room in high school,” to “I’m satisfied that I got this problem I’ve got the answer even though I can’t get up and walk freely,” you can get out of his chair and take a couple steps. It’s like, “I got my answer and I’m 70.” It’s amazing.
00:32:15 So, I deal with a lot of people that are really very seriously damaged. It’s very satisfying to see people come alive, because life is mentally alive. Yeah, I mean, you can still be pretty debilitated and still be happy to be a going thing. I don’t know how else to put it.
Ivor 00:32:43 Oh no, you’re absolutely right. I mean, to have that draw [Inaudible 00:32:47] to engage with life, if you lose that, like that gentleman would have, it’s a dark place. You’re looking down the barrel of a gun. When you recover them as you described he did and all the others you’ve helped, you know, they’re getting this lease of life back, they’re getting another shocked. There’s something huge about that.
John 00:33:05 Right. And if you’re running activities in a nursing home that has been barely open, because of unable to get enough staff, I could almost imagine that the nursing home is still open because of him. He’d wonder if he was the straw taken off the camel’s back, as far as staff. And that might be a little exaggerating, but they can’t take patients because there’s not enough staff.
Ivor 00:33:34 Well, yeah. If you mount in your small community, if you multiply him by more and more people, and then the kind of the generation effect of word of mouth, getting to other people, overcoming this idiocy, that low carb keto is a fad, it’s evolutionary appropriate. That’s why it fixes disease. But as it spreads, we’re going to see more of this.
00:33:55 I might ask you a question, John. If in America 340,000,000 people, whatever. I don’t know the numbers of people over, say 45. But if tomorrow everyone magically switch to a healthy real foods, lower carb diet magically, how do you think the chronic disease landscape would look like in just a couple of years, if that actually happened?
John 00:34:21 It would be phenomenal. Having been 40 pounds heavier person who 20 years ago, I couldn’t do what I can do today, physically. So if you just imagine that everyone who does manual labor could just move that much faster and could go up the ladder one step quicker, it’s hard to hard to believe in, and fewer medications and then being bright in the afternoon. I mean, I used to struggle with… I hope I don’t fall asleep talking to a patient and I’d be telling my nurse, “Hey Jody, go get me a soda.” You know? Or, “I better go say hi to the ladies in the gift shop and tell them how much I appreciate them.” No, I’m buying a Snickers bar.
Ivor 00:35:10 Candy bar, yeah.
John 00:35:12 And that’s gone. I tell my patients you know, it’s like, “Oh, today is a fasting day.” And it’s 5:30 in the evening. “Why don’t we just stay longer and talk more?” It’s like, I’m wired.
Ivor 00:35:26 And you do start, you mentioned your hours but normally you’re doing from…
John 00:35:30 I’d start at 6:00 or 7:00 in the morning, go until 10:00 at night because of the paperwork. The electronic record really stumps me because this is kind of a funny thing is it doesn’t acknowledge metabolic syndrome. So I have to talk about sometimes morbid obesity where the obesity is causing physical problems, the sleep apnea, the hypertension, the diabetes, the lipid issues, which may be treated with medication. I have to put those, and those are like individual notes in the record. And so it’s tedious documenting this. But when your document in success somehow you just put your earbuds in, listen to your favorite music, and don’t hate life. It’s just like I can’t wait for tomorrow.
Ivor 00:36:25 And that is the way to be. It all comes thanks to basically knowledge and understanding of how the physiology really works, what the primary drivers of disease really are and what the root causes that can be addressed are.
John 00:36:42 I gotta hit, this is funny about Gerald Reaven. We grew up just a few miles apart. He’s one of my science heroes who told the truth well enough that I think he had a good conscience but he didn’t the truth quite as loud as John Yudkin. And so I think Gerald Reaven did it right by telling about metabolic syndrome. Because when I heard him talk, it was like, you are just confirmed that you can’t fix this except with diet. And this was like about three or four years ago. And this is the sad thing is that he published posthumously in a journal, his name was on an article last December or November, about surrogate markers for insulin. And I work in a hospital where insulin is… now we don’t estimate insulin by looking at HDL cholesterol, or triglycerides, HDL ratio. We don’t measure insulin, I look at those numbers. But those are only so sensitive. And if you look at the insulin directly… in here, Gerald Reagan didn’t… he was still working on finding out how we could predict insulin levels. And now the technologies here and the x, it’s amazing. And to have that in our hospitals, phenomenal. You know, like I was saying pairing it up with all the other metrics to help people say, “Work a little harder, work a little harder. You’re burning fat. Your insulin is down. Watch the fat melt away.”
Ivor 00:38:24 So gratifying. Yeah. Saving people and knowing what you’re doing, not handing out a kind of pale figure, not really sure where to be quite honest, you just know they should help so it’s off your back.
00:38:36 But insulin I think, I agree, it’s fantastic. Now that can be measured so readily in your hospital. I think across America and the world insulin measurement is still resisted. So that’s a challenge. The understanding across all the doctor population, probably the vast majority are not enlightened like you and that’s another big challenge and the calcifications scan actually see the disease and find the people at risk. The AHA 2018 guidelines, fantastic, but there’s a long ways to go too. But we’re on the road now I think.
John 00:39:07 The problem with insulin is that it isn’t nutritional fix, because drugs don’t do much about lowering insulin. And when you start looking at what insulin does, it has these harmful effects throughout the body, independent of even what we measure. Like what insulin is doing to the kidney is just independent. When I was in medical school, I can remember back in ‘87, here in the nephrologist giving a lecture saying, “At the time of diagnosis of type 2 diabetes, there’s already kidney damage.” Well, I was implying that it isn’t the sugar alone that bothers the kidney; it’s the insulin. But that wasn’t said. For some reason, you have those little blips in your memory where you think, “Oh, that explains something I heard ages ago.”
00:40:01 And one of my interests in, back to the hyperinsulinemia is its direct, harmful effect on the heart. I’ve only read a few papers on it, but to me, when I hear the word heart failure, I just say, “What’s your insulin level?” and it’s up. And oh, the literature is full of checking insulin level when somebody rolls in the ER and you know if they’re gonna make it or not. Like C peptide, if you have a… because if your blood sugar’s really high, when you’re having a heart attack and you’re diabetic, that’s to be expected. But if it’s really high and you’re not diabetic, they just say, “Oh, that’s bad outcome.” Well, high blood sugar is a sign of stress. And so that means that’s it’s the worst heart attack.
00:40:54 You just see so many things if you can go physiology instead of, “What’s the right med to hide this number under the carpet?”
Ivor 00:41:07 Yeah, it’s going back to an old age of medical doctors where they really had to be root cause specialists and find out what’s going on and look more at lifestyle. But now there’s so many meds for so many things in fairness, and they’re so busy and stressed in the system. It’s extremely hard for medical doctors to try and do extra research, find the answers and spend time with patients and lifestyle. I think they’re just overstressed.
John 00:41:34 Right. And I also point out to patients, I go through this little talk really quickly of saying, because I don’t want to cast the profession in a hazy light, because 1) is I’ve studied the history well so I understand how we got here, and less critical by just seeing how did you get lost. But also at the same time if you show up in an emergency department with an acute medical problem, like you show up with chest pain, quickly, the emergency room doctor is going to say, “Am I pulmonary embolism, aortic aneurysm, pneumonia, pneumothorax,” on down the line. They’ll drill down to a root immediate cause. They will treat you, and whenever I see somebody in clinic that’s been in the emergency room, and they’d say, “Oh, they seem to be so fast or they didn’t…” I say, “Look, you were sitting here talking, they did their job. Their job was to get you with life and limb to sit with me. Now I’ve got it a little tougher because I have to try and get you drill deeper.
00:42:40 So what I’m trying to say is, the medical profession does stellar at keeping people alive in the emergent situation. And we got lost by taking that same philosophy into the chronic. And you can’t fix chronic with drugs.,.
Ivor 00:43:00 Yeah, a quick interventiion.
John 00:43:02 … as a first step.
Ivor 00:43:03 Yes, absolutely.
John 00:43:04 It’s, we have to have the drugs.
Ivor 00:43:07 Yeah. And an antibiotic in fairness is an example of a drug back and fix the local short term problem and then it’s resolved. But of course, chronic disease, the drugs are relatively weak and ineffectual. And the only real thing is you need to fix the driver.
John 00:43:21 Yeah.
Ivor 00:43:21 Yeah. But I agree. And it came up in the WidowMaker movie about the calcium scan as well that Professor Budoff has said many times. You know, “We are doing fantastic work. With acute events, saving people’s lives, you know, getting in there were catheters opening up. And that’s fantastic. But we just need to get the system to work on the preventative as well, because that’s how we’re going to save them before they ever end up there.”
John 00:43:47 Right. So it’s all that sense of well being and control. I should also say living at what I do, you couldn’t do better than being… we live in the area that’s famous for Lewis and Clark, when they were almost going over the mountains to the west coast. So we live in an area that’s very clean environmentally, because there’s nothing upstream for us we have access to… you can garden; it’s high desert. And so it’s a great place to say to folks, “What did your grandparents do? Let’s do that.” And they actually remember. It’s multigenerational, you can go back. And it’s like, I have plenty of patients that have milk the cow and raised hogs, and so I always go through the little deals, “Tell me about how that how that worked; the milking the cow, the skimming the cream, the skim milk going to the hog. What did you have to buy for the hogs?” “Grain?” “Okay. What did you have for breakfast?” Literally, somebody will say, “Cornflakes and skim milk,” you know?
00:44:57 So I live and work in a place where you can just spin it around and say, “Look, if it made a pig fat, it’ll make us fat.” And that’s the joy of working in a place where it’s… we’re not in a food desert, I must say. It’s pretty much of a word, “If there’s a will, there’s a way.”
Ivor 00:45:19 Yeah.
John 00:45:20 It’s a good place to test things.
Ivor 00:45:23 Yeah, you can steer people back to the real food of our forefathers…
John 00:45:27 … and it’s out the window.
Ivor 00:45:28 Yeah, relatively easily. And they understand. I guess everyone even in those areas which are not food deserts, you know, they were they were just beguiled by the modern foods and without knowing it, they slipped into them until ultimately they have to suffer the diabetes, obesity and heart attacks that go with those fake foods.
John 00:45:48 Yeah. One of rancher patients, he was one of the first ones that was just a word cured him, because it was just like, “Oh, you’re right.” He didn’t take much for him to realize that he should just be eating the work of his hands. And he came back a year later for his annual physical and it’s like, “Oh, my migraines are gone. I feel great.” And it’s like, “Wow, I wish it was all that easy,” but he wasn’t addicted. All he just needed to be told was, “processed foods don’t work for you.”
00:46:22 That doesn’t happen that much. 90% of my work is trying to get people to a point where they can see, “Oh, it’s an addiction. I have a goal, something a reason to put it behind me.”
Ivor 00:46:40 Yeah, to be motivated. Understanding gives you motivation, because you understand what’s happening and you are unable to tackle it. Some people still may not tackle it, a small proportion. But most people do not want to be fat, do not want to be sick, they want to live for the grandchildren. And once they’re explained and they understand what the problem is and how to tackle it, many people are going to be successful.
John 00:47:02 Oh yeah. And also the community tipping point of saying, “This is one of my dreams is, will you refrain from taking carb food to potlucks where that will hurt your neighbor? And Ben [Inaudible 00:47:17] gave a good talk at BYU? [Inaudible 00:47:19] on this subject. And it was so funny because, and I shared that with a lot of patients. It’s like, here’s a world famous fat metabolism researcher saying, “Ah, take care of the body you’ve been given.” That’s the killer is to not offend people. But that’s the cultural part where you just say, “If there’s going to be sugar starch, at function, it should at least be in a separate dish so that you don’t have to fish the corned beef and cabbage and out from the potatoes.”
Ivor 00:48:05 Yeah. The healthy foods should not be mixed in. And society as well, there’s a backlash that some fruit is being encouraged by industry and some of it is just human pride, not wanting to admit we’re incorrect. But there’s a societal pressure against things like low carb things like keto, there’s a sense that, you know, we’re not comfortable with this. It’s a fad, because they have spent 50 years being told to do the opposite. And people resist that they in their society have all been wrong for 50 years. It’s a bad feeling. So you get this pushback. And of course, the industry is funding various campaigns to keep that pushback. But you know what, I think John the next 10 years, we’re going to see a load more doctors doing the kinds of things you’re doing and I really feel it’s going to kind of get a tipping point in the next five or 10 years. What do you reckon?
John 00:48:57 Definitely! When a patient came in that I’ve been working with for at least four years with her, easily controlled from a technical standpoint, type 2 diabetes, and I couldn’t get through to her. And then she comes in, she and her husband come in and say, “We’re keto.” And I said, “What made you change?” And she said, “Oh neighbor, she lost 30 pounds and got off her diabetes medications.” And I’m happy because I don’t need to have been the one that communicated it to her. And when my patients said, “We went to the truck stop this morning, had bacon and eggs. No hash browns or toast.” It’s like, “That’s a quote.”
00:49:41 I had another patient come in and say… two patients, they’re friends, they’re both my patients, both have serious diabetes problems. And one of them goes, “We know, it’s what you eat when you eat.” And it’s like, “Oh, that’s one step closer to success because if you in private are making fun of me, that’s one step from listening.
Ivor 00:50:07 Yeah, for sure. No, I get you, yeah.
John 00:50:09 Because isn’t it true? I mean, with Jason Fung’s work, it’s what you eat, and when you eat, and the when is huge. So when I hear these people talking this stuff, then it’s starting to filter out word of mouth. I had a guy and say to me on the street really like what you do, and it’s like, “What’s that?” It’s like, “Well, my guts gone.” And it’s like, “I noticed your shirt’s flapping in the wind.” That makes you happy.
Ivor 00:50:45 Absolutely. It’s beginning to go not just from you to patients, but it’s beginning to come back indirectly from third parties.
John 00:50:53 Yeah.
Ivor 00:50:53 Now that’s really important because you can only do so much, a single person can only do so much but if that’s kind of capitalizes by people converting other people, then you get the wisdom of crowds spreading. So that’s what we need.
John 00:51:08 Right. And being a big reader, I just read a book on the “Crowds Are Scary” you know, because they can turn into a riot, but they can also be a tipping point of success.
Ivor 00:51:22 Yeah, groundswell.
John 00:51:23 Yeah.
Ivor 00:51:24 I think it’s coming for all the efforts of industry and the ludicrous articles we see in the media that are anti what we’re talking about, which means they’re essentially anti helping population health, but there’s organizations who have a lot of money at stake and that’s okay, they’re fighting to keep their turf. But the reality is they’re not going to be able to stand the tide, I think because the n equals 1s are growing. You’re converting other doctors. Once doctors convert doctors and you’ve got seven or 8% of doctors are kind of knowledgeable like you, then the whole medical profession will probably start tipping over. And everyone respects doctor. So when the medical profession starts tipping over, you know, they’ll override the even dietitians who are giving the same old pyramid advice. The doctors will override the dietitians.
John 00:52:14 Thankfully, that was probably another thing that intuited is I tend to be over enthusiastic and really run off at the mouth on this subject. And so in our community, our dietitian and exercise folks, I worked with them and gently shared with them what I was learning and it was a long process, you know? So I tried to do that , not to browbeat and more, just be enthusiastically share the latest neat thing. And then I love when my colleagues come to me and say, “Oh, we thought too, we thought too.”
Ivor 53:03 Excellent! Well, anyway, may there be many more happy moments as the whole world switches over John.
John 00:53:10 And I must say, listening to engineers is a good thing.
Ivor 00:53:19 I’m glad to hear it.
John 00:53:21 I think you know the mentality. And I wasn’t engineering as an undergrad and got distracted from it. But I still had the engineering mentality.
Ivor 00:53:33 The mindset.
John 00:53:34 Yeah. I like the mindset. And so medicine can use some of that.
Ivor 00:53:46 Excellent! Yeah. Well, I mean, the best example are Dr. Michael [Inaudible 00:53:50], Dr. Ted [Inaudible 00:53:51] and Dr. Bernstein. There are so many originally engineers turned doctors, and it’s probably not a coincidence that they’re all amazing guys just like yourself. But we’re going to catch up again, John.