Dr. Paul Mason – ‘Low Carb from a Doctor’s perspective’

Dr. Paul Mason – ‘Low Carb from a Doctor’s perspective’

July 30, 2019 100 By William Morgan


So, my name is Dr. Paul Mason, I’m a sports and exercise medicine physician
and today I’d like to take you all on a journey
exploring the science that underpins low carbohydrate diets and in the process
I’d like you to take away a few things. Firstly
We wanted to debunk the “calories in calories out” low fat hypothesis of weight loss.
I want to demonstrate to you that a low carbohydrate diet is actually good for longevity
People live longer when they eat low carbohydrate
And sugar because of fructose has some particularly unique and toxic effects on the body
So to begin our journey, I’d like to introduce you to one of my patients
Now this is the kind of patient that as a doctor. I loved she was very very compliant
So she first came to my clinic with joint pain
And she was overweight and it was very clear
to both of us that if she could lose some weight that would help her condition
so we had a conversation
and started talking about her existing attempts to lose weight
and it seemed that she had a very conventional approach the kind that is
recommended by most doctors: eat low-fat
So let’s hear her account this in her own words
And I was doing all low fat you were to see my fridge was just full of low-fat cheese
No oil touched any frypan in my kitchen all the meat was as lean as you could possibly get and I ate
salads and I was starving all the time
and were you exercising Oh madly six days a week and
I was doing those classes. I was doing back-to-back classes. So an our hit classes followed by a pump class and
Six days a week. So and then I felt really guilty on the seventh day
Because I wasn’t exercising
So
She was following the conventional advice
She was slavishly following that advice. She was exercising
She was eating low-fat, but the trouble is it was not working.
At the time she saw me she was 30 kilograms overweight and gaining. So
When I’m faced with this scenario as a doctor, I have to ask myself
¿Who is responsible? ¿Who is to blame?
So the patients following the medical advice that they’ve been given
So is it the patient or is it the doctor or the medical professional who gave the advice?
So I would argue the blame should actually lie with the doctor or the health professional
because the implication of the advice is that
If you fail to lose weight
You’re lazy and you’re greedy
You’re just not trying hard enough
But this very premise overlooks the key essence to understanding weight loss and that’s hormones
The conventional “calories in calories out” hypothesis
ignores the effect of hormones very a very strong science
So we’ve got a lady here. She’s 35 years old and she’s got a problem with a hormone called
cortisol, and she’s just been gaining weight
And this is what happens when her hormone problem was treated she didn’t get given advice to exercise more
She didn’t get told to eat less. We fixed the hormone problem and the weight problem goes away
This boy here three years old. He weighs 42 kilograms and he’s got a problem with a hormone called leptin
Seven years old he now weighs 10 kilograms lighter and a very healthy weight
See what happens when you fix the hormone problem
Now the most common
hormone in the population that causes obesity
Is not one of those, it’s called insulin and this lady has a problem with insulin, but she’s got a unique problem
She’s got a tumor in her pancreas that secretes insulin
And pumps it into her circulation in this picture. She’s a 107 kilograms and she’s only 152 centimeters tall
So she had an operation to remove the tumor which lowered the insulin levels in her body
Now these photos were taken 50 days apart
Her weight dropped to 89 kilograms. She lost 18 kilograms. And if we have a look at a graph of her weight loss
You can see that in a 10 day period she lost 14 kilograms
So clearly there’s a problem here with insulin. It makes you fat
Now this patient also had a problem with insulin. This was one of my patients you can see her here
46 years old and a size 20
This is what happened when we fixed her insulin problem, she lost 40 kilograms and
Here she is about a size 8
The big difference is she didn’t have surgery to fix her insulin problem. We changed her diet
So you’re probably asking how on God’s green earth can a diet lead to such dramatic
Changes in your insulin level that you’ll lose that much weight. So let’s have a look. This is a graph here
And the height of the lines there represents how much insulin your body is releasing
And each of those individual lines
represents one of the three main sources of energy in our diet: Carbohydrates
Protein or fat
So let’s have a look at carbohydrate. Let’s see what happens when you eat carbohydrates to your insulin levels
this is called the area under the curve you get a massive and
prolonged release of insulin for over two hours
let’s have a look when you have the same amount of energy contained within protein much less
And the surprising thing for many people
Fat is even less. So think about that for a moment high levels of insulin are associated with obesity and
Carbohydrates are the most potent stimulus we have on our bodies to release insulin
So in order for us to lose weight, we need to control that insulin level ergo
We need to control our carbohydrate intake
Now we can broadly classify
Diets into one of two groups on the left here
We have what’s called low carbohydrate diets and on the right
We have low fat diets, which tend to be higher in carbohydrate
Because the energy has to come from somewhere
So let’s have a look an unbiased look at the evidence
Comparing these two types of diets in terms of weight loss
Between 2003 and 2018
There were 62 published randomized control trials
comparing low carbohydrate diets less than 130 grams a day
to low fat diets in terms of weight loss
31 of these studies had statistically significant findings
what that means is
That the results were not likely due to chance
You could probably trust them
So what I’ve done here is I’ve graphed these 31 studies that had statistically significant findings
No cherry-picking here at all.
And I’ve compared the average weight loss on the both diets
the low carbohydrate diet is depicted in blue and the low fat diet is depicted in red
And you’ll note that in every single one of these studies that we’ve got here the low carbohydrate diet
Led to more weight loss than a low-fat diet
So the question is which horse would you back?
Now
let’s
Change pace a little bit and have a look at fat and see exactly how insulin makes fat tissue grow
Because if we understand this we can understand the cause of obesity, by the time you’re 2 years old
You’ve got every fat cell that you’re ever likely to have
So if you gain weight after the age of two
It’s because your fat cells have gotten bigger not because they’ve multiplied
So if we can work out what makes an individual fat cell bigger
then we can determine what makes you fatter
so what I’d like to demonstrate here is that you can see
how the circulation, these blood vessels are intimately related to each and
every fat cell now we understand that hormone
Is released in through the circulation and because of this relationship with the blood vessels
It can be delivered to each and every fat cell in our body
and these blood vessels also contain fat called triglycerides
You can see here in these
These wiggly line depictions down there. So what happens to gained weight Is that these triglycerides
Get transported into the fat cell and the fat cell gets bigger.
The problem is this triglyceride molecule is very big
It’s composed to four different parts
You’ve got this glycerol backbone, and then you’ve got three
Separate fatty acids and as a whole this molecule cannot enter into a fat cell
It has to be snipped up first and that’s where insulin comes in
So what you can see in the left-hand side
we see the triglyceride molecule
and then it’s being converted to glycerol and fatty acids
it is being snipped up
and the LPL transfer lipoprotein lipase
This is an enzyme that is stimulated to act by insulin
And then once the fatty acids have been released they’re able to cross and store fat without insulin to activate
Lipoprotein lipase you can’t store fat.
And if we have a look on the top there
you can see glucose can also enter fat cells
and it does this through a little doorway or a transporter
called the glute 4 transporter
and again insulin is what activates this transporter
once the glucose is inside the fat cell
it gets converted to glycerol
then the glycerol will then combine with the fatty acids
And then you’ll have a complete triglyceride molecule.
This is the storage form of fat
Now to add insult to injury if you want to actually burn that fat
it has to be snipped up again to leave the fat cell because as you know,
It can’t cross the fat cell membrane and to be snipped up. It has to be activated by or
Cleaved by an enzyme called hormone sensitive lipase
Insulin turns this enzyme off
So you end up with a triple whammy you have
lipoprotein lipase and the glute four transporter being activated that’s stuffing fat into the cell and
And then you have hormone sensitive lipase being deactivated
so that you can’t burn the fat so insulin biochemically is the cause of weight gain,
So for a final proof that insulin causes weight gain
Let’s have a look at what happens to people who habitually inject themselves with insulin
in the same site over a long period of time
It leads to a condition we call lipo hypertrophy
Hypertrophy meaning get bigger now
these two
On the left and on the top right
These two gentlemen injected insulin habitually
into these sites in their lower abdomen over a long period of time
the person on the bottom right
their preferred injection site was on the front of their thighs
about twenty to thirty percent of patients with type 1 diabetes
Will actually end up with this condition
because they inject insulin
high enough doses for long enough
So whatever happened
To my perfect patient, you know
The one who was slavishly following the low fat exercise advice before she saw me
was thirty kilograms overweight
Well, we had a discussion
She cut the carbs out of diet
and she increased the fat
and by doing that she fixed her insulin problem
And then this happened
At last count three years later
She’s maintained a loss of 36 kilograms
and she lost 28 centimeters off her waist and these are her actual photos. So
Let’s have a look at what is it about carbohydrates that can lead to this increase in insulin that causes
Obesity. So begin to understand we have to have a look at what carbohydrates are
on the top here we have a molecule of glucose and
Across the middle there. We have a depiction of what we call a complex carbohydrate
You know the kind of carbohydrates you’re getting brown rice and
whole grain bread the stuff that you’re told is good for you
It’s made of glucose
is sugar
Carbohydrates are made of sugar
and when you eat them and digest them
they end up entering the bloodstream
To increase your blood glucose level
When you saw Rod and he decided to have some rice
The glucose that made that rice up entered his bloodstresm
And in response to this increase in blood sugar
the pancreas this organ tucked up in our
abdomen here release something called insulin
And then the job of this insulin
is to remove
the sugar from our circulation
it puts it preferentially into our muscle tissue and our liver tissue and
then if there’s any leftover that gets stuffed into the fat
the problem is that if you have high insulin levels
for long enough
that create a condition called insuline resistance
Se we know that when you eat carbs
you get this masive spike of insulin
and if you do that habitually six times a day
As many of you have probably been recommended to do
your body becomes insensitive
To the high level of insulin. It’s like when you walk into a room with a bad smell
At first its overpowering and after a few minutes you don’t notice it anymore
It’s the same with insulin
Except it only happens mainly
at the muscle and the liver tissue so they stopped taking in the sugar
Your body compensates by releasing more insulin
and then the body is able to stuff that extra sugar into your fat tissue
so this actually explains
why a lot of people come in and they say
You know what
when I was 20
I sat on the couch eating potato chips
no exercise and I was skinny
and as I’ve gotten older I’ve just gradually stacked on the kilograms
and this is despite becoming
Health-conscious
I now go to the gym three days a week. I now eat salads
So the reason that they’re gradually gaining weight is because
over the years and this happens over 10 15 or even more years
They’re becoming insulin resistant
And we can actually test for this so in my clinic with my patients
We do a test where patients will drink 75 grams of glucose
And then we mesure their glucose levels and insuline levels
Over the course of a 2 hour period
And
We can actually
assess their level of insulin resistance based on the results.
So let’s have a look
So in the red here this represents insulin level
and the blue line represents blood glucose level
So this is somebody who’s metabolically healthy.
We give them the load of glucose and two hours later
We’re having a look
They say that blood Sugar’s not elevated beyond what it should be
and the blood insulin is not elevated beyond what it should be
perfectly healthy
Then in the first stage
of insulin resistance or metabolic i’ll health
you’ll note that inlsuline level starts to creep up
But it’s still doing a good enough job of keeping the sugar out of the bloodstream
So the blood sugar is not yet elevated
if you had a blood test a standard oral glucose-tolerance test done at this stage
Your doctor would tell you you’re perfectly healthy.
Don’t worry go home you are fine
And yet you’ve got the first signs of insulin resistance.
You’ve probably already gaining weight at this stage
as it progresses
And it starts to creep up a little bit.
The insulin goes even higher
and this stage
is where your doctor would say: oh you’re pre-diabetic
you know, have you thought about doing a little bit of exercise?
still not too worried about the whole process
And then over time this blood sugar starts to damage the cells in the pancreas
That release insulin
so even though you’re becoming insulin resistant and you need more insulin your body produces less
And then when your insulin levels start to fall you have a precipitous
increase in your blood sugar levels, and that’s when diabetes is diagnosed
So let’s have a look at a couple of examples
So this patient here
low blood sugar
low insulin level
Perfectly healthy.
I like this comparation
This patient here probably putting a litle weight
You can see the blood Sugar’s quite low at two hours 5.6
but you can see the insulin has now risen to 83
Okay, we’re starting to see insulin resistance here. We’re starting to have a problem
And here you can see that blood sugar has now come up of the floor
insulin is a bit higher again
and the blood sugar is rising to 8.3.
And then what happens in the more advanced stage?
Blood sugar 11.4
this is when you would be diagnosed with diabetes under standard blood tests, by the way,
And the insulin level has dropped
the pancreas is starting to fail
Now it’s all well and good to say, okay you’re a doctor
you can test for insulin resistance in your laboratory
but a lot of people are curious to know if they have insulin resistance
And whether they can check themselves
and you’ll be interested to know that you can see a lot of
signs of insulin resistance by looking at the skin
And
I’ve got several patients here today and you know that i’ll
inspect your skin
These are what’s called skin tags
The most common cause of skin tags it is insulin resistance
If you have skin tags
You are almost certainly insulin resistant
And a lot patients tell me
Well, I go to my GP and ask what causes it they say in one sentence
I don’t know, but would you like me to burn them off?
They’re a warning sign
They’re usually in the armpits around the neck in the groin region
This sign here is called pay can ptosis nigricans it’s
Pigmentation of the skin we often see it around the neck in the armpits in the groin
Or more interestingly on the back of the fingers
The skin creases here
and there’s good research that shows
that even before you start gaining an excess amount of weight
You can see
The changes on the back of the fingers
before anything else. I can see a few people having a look at their fingers now
I see a lot of patients who come in with
problems with their skin complexion and what we find is that when we improve the insulin resistance that
Significantly improves have a ketogenic diet lower your insulin levels skin gets better.
It’s very nice. And that’s one of the reasons why
Acne is very common in the state
of adolescence because the state of adolescents puberty is associated with insulin resistance
Now for the good news
that had to be coming
We can actually reverse this
If you go on a low carbohydrate diet and reduce your chronic elevated levels of insulin
your insulin sensitivity will improve
have a look at the insulin levels of this patient here and
three months later
big drops
Here’s another example
we can see that one hour insuline he was 114
an again to 71
just in the space of a few months
An there is also a nice asocieted weight loss to boot
So, I think it’s pretty clear
A low carbohydrate diet is the best diet for weight loss
But some of you are probably still concerned you probably thinking well, it’s all well and good to be skinny
But what happens if it’s going to kill me all that saturated fat, right?
so let’s have a look at the
Bigest study that’s been done to date on this topic. It was published last year
And it had over 135,000 participants
they were followed for more than 7 years across 18 countries.
This was a big big study
So what we can see
is that the group that was having the least amount of fat had a mortality rate per 1000 person years
of just under 7
Let’s see what happens to the group
that was getting more of the energy from fat
more than 3 times as much from fat
their mortality rate dropped at 4
more fat live longer
and if we have a look at a graph from that same study demonstrating this
where your risk of dying
Is on the axis going up the higher the worse it is and the effect you’re having is going to the right hand
Side and you can see there’s no point at which having more fat becomes problematic in actual fact
It seems the more fat you have the total mortality continues to drop
So now let’s flip this on its head and have a look at carbohydrate intake if you have 46.4
percent of your energy
from carbohydrate
the mortality per 1000 person years risk was about 4
And by the way, this is not considered a particularly low carbohydrate diet, but it’s low
Carbohydrate compared to the average diet.
Let’s have a look at the group of the population that was getting far more
72.2 percent of their energy from carbohydrate
their risk of dying went from about 4 to over 7
With more carbohydrates. And again, we have a look at this graph
the more carbohydrates you have your mortality just keeps on climbing
So low carbohydrate high fat diets you will live longer
Now this is not a one-size-fits-all diet
Some people might be able to have 80 grams of carbohydrates a day
Rod says his limit was 50
Some other people may only be able to have 20 grams of carbohydrates a day to be in optimal health
And we use something called the ketone meter
to determine your optimal level of carbohydrate restriction
now the only difference between a low carbohydrate diet and a
Ketogenic diet is the degree of restriction of carbohydrates
If you reduce your carbohydrates enough to lower your insulin levels to permit fat-burning
Some of that fat when it’s metabolized will be converted to a chemical called a ketone
Now the thing to realize is that in the human body. The only source of ketones comes from fat metabolism
nothing else
So if you have ketones in your bloodstream that indicates that your body is burning fat
So we can take a drop of your blood put it on a meter and within 10 seconds
We’ve got the answer now down the bottom. This is the scale that we generally use and it’s also useful
As well as indicating your degree of fat metabolism
For suppressing your appetite what we find in the clinic is over
The last few years is that people who come in with ketones hovering around point 4 or higher.
They often say you know what
I’ve only eat twice a day now, I’m just not hungry
And this is demostrated in the research
we know when you have higher levels of ketones
that has an apetite supresing effect
So not only
Are you burning more fat
But the whole “calories in calories out” first law of thermodynamics equation
you put less energy into the system
So this actually dovetails in quite nicely with the conventional wisdom of “calories in calories out”
But it adds another layer. It starts to explain how you can put less calories in so
This is an example here of a food diary
with ketones being recorded down the right-hand side the numbers down the side
and the reason we do this is because
By recording your ketones and comparing it to your food.
You can actually start to understand which foods are stopping your burning fat let’s zoom in a little bit
so we can see down the right here. We’ve got a few ketone numbers 1.1 that’s good
0.7 That’s okay. 0.4 That’s still okay, and then we drop to 0.2
why?
A small piece of sponge cake, okay
Probably not the best
But it’s ok because the next day they’re back up to 0.7
Piece of toast
Bumps it down to 0.2.
This person is very very sensitive to carbohydrates
And without doing this
They would never have known so now I’d like to take a closer. Look at sugar
and the
uniquely toxic effects that that has
So we’ve already seen about this glucose molecule on the left the one in the yellow
But the one on the right
is called fructose
and when you join one of each of these molecules together
it forms table sugar, sucrose
and you can see that it’s
Sucrose is exactly 50% fructose
And that’s important
because a lot of people say we don’t have a problem in Australia because we don’t have high fructose corn syrup
well high fructose corn syrup
is only between 42% and 55% fructose
So they’re very very comparable
the table sugar we have here in Australia is every bit as bad as high fructose corn syrup
Now
When we have a look at the swetness of diferent sugars
the reason fructose is a problem
is it’s more than twice as sweet as glucose and
And this is a problem
Because as humas
we love self-gratification
We’ve got this pathway in the brain
called the mesolimbic pathway
and this is the reinforcing pathway
reinforces our behaviour
And when we stimulate our brain with something sweet
we get a release of a chemical called dopamine
and it says yes do that again
and fructose
Activates this pathway by virtue of it being more than double the sweetness of glucsose
It activates this pathway more strongly
And when we sacan the brains of obese individuals
And have a look of dopamine receptors
we can see there’s a reduced number
Of dopamine receptors in the brains of obese people.
So this means to get the same level of satisfaction from a meal
Obese people need to eat more
And this is where sweetness fits into it.
Over time this changes will down regulate
But the problem is
that untill they down regulate over time you have to restric the sweet foods in your diet
Now fructose has another particularly toxic effect
and that
Leads to insulin resistance
Fructose far more powerfully than glucose leads to a fatty liver
So when you eat fructose
Normally about 80% of it gets taken up by the muscle, gets taken up by the liver
and then
It goes to the liver and there’s a capacity for storage in the liver for glucose has something called
Glycogen so that sets up a little bit more
So the amount of energy that ends up going to the liver
and going to the mitochondria within the liver
Is only a fraction of what you ingest
but with fructose
it doesn’t go to the other tissues
and it doesn’t have this reservoir
where it can be taken up or stored so
Every gram of fructose you eat gets delivered to the mitochondria in the liver.
And when those mitochondria get overloaded
They produce fatty liver
Process called DNA vapor Genesis. This is a slide those white globules
There are globules of fat
in a fatty liver
and excess fractose can do that
and this is strongly associated with insulin resistance
Another problem is that
Sugar can attach to protein
And you’ve got sugar
Bathing the cells of your body and that sugar over time
Can not only attach to it that can form these
Complexes called advanced glycated end products
and they can affect nearly every type of cell and molecule in the body
the problem is
That fructose does this seven times more than glucose
Yet another problem with fructose
And when we have a look at the consequences of these advanced glycosylated end products
They affect a lot of the tissues that we see people with diabetes have
nerve problems
we’ve already talked about how the pancreas can start to fail and
Reduces it’s capacity to secrete insulin
kidney problems, blood vessel problems
You can go blind
arthritis is really really comon
Now just to illustrate the point
That these advanced glycosylated end products are associated with aging
this is some ground-up rib cartilage on the top left
This is from 2 weeks old and on the bottom right from 88
and this is what normally happens across the lifespan
It’s very similar to a process called the Maori action on the Browning reaction
caramelization if you will not quite the same but along the same lines
and over time
The sugar in our circulation will change
Our tissues and I’d have a question.
Why would you want to accelerate the aging process by increasing your sugar levels even more?
now
We know that the most common sources of added sugar in our diet are sweets
Maybe some people be surprised to know that cereals is one of the major courses of added sugars in our diets
But sugars are also hidden in a lot of foods
Not many people will realize that a squirt of tomato sauce probably
Far less than what they actually habitually put on as good one of the health teaspoons of sugar in it
But the real surprise is down on the bottom right here. This is a medium-sized mango juice
12 and a half teaspoons of sugar
and
There’s other ways that sugar can be hidden. I’ve got an organic almond milk here. Perfect
You can see lactose free soy free. Gluten free no cane sugar.
Okay, you’re feeling pretty good right now
Let’s have a look at the ingredient
Still look okay?
Show our hands who thinks it doesn’t look so bad
organic agave syrup
you know agave syrup is
75% fructose it’s even worse than table sugar. It’s worse than cane sugar
And this here
is a list
The names
That sugar is disguised in in Australian nutrition labels
Food manufacturers are allowed to use every one of these euphemisms of sugar on their label
makes it very difficult
Now some people say but fructose it’s natural, right
Maybe it’s natural, but we don’t consume it in a natural way
You wouldn’t know it but this is a fruit tree on the left. It has no fruit. It’s because fruit is seasonal
We don’t have access to fruit year-round
and if you want, honey
Well, you don’t get to go to Cole’s
traditionaly
You had to go and ask the bee if it would line if you had his honey
So we consume fruit in a very different way. We now
have 500 mils of orange juice which contains 6 oranges
And it’s had all the fiber taken out
So just as an aside, don’t drink your fruit. Just do not drink your fruit
Now I’d just like to touch on one more point before I finish
and that’s artificial sweeteners
So we’ve already talked about them as a Olympic pathway
reinforcing behaviors and
Artificial sweeteners do exactly the same thing
when we have a look at the evidence
all the cohort studies
They show that consumption of artificial sweetness is asociated with weight gain
Increase weight circumference metabolic syndrome
type 2 diabetes and heart attacks
artificial sweeteners don’t get a leave pass
So, I’d like to leave everybody here
with three key points
Number one:
You are not to blame for being overweight
if you’ve been folloing bad advice
Critical
Number two:
low, carbohydrate diets are the best diet for weight loss
because they lower insulin
and finally
people live longer on low carbohydrate diets
Thank you