The Kick Sugar Coach Podcast
The Kick Sugar Coach Podcast
Dr. Annette Bosworth: How to Lower Your Insulin and Reverse Metabolic Disease
Think you understand insulin resistance? Think again. Dr. Annette Bosworth (Dr. Boz) takes you inside the cellular battlefield where metabolic disease really begins—and shows you exactly how to win the war.
In this eye-opening interview, Dr. Boz reveals why so many people get stuck in "metabolic purgatory"—feeling better initially on keto, then hitting a wall where progress stops and weight loss stalls. Using powerful visual analogies, she explains what's actually happening inside your cells when insulin resistance develops, why your mitochondria are dying, and how your beta cells hold the key to your metabolic future.
You'll discover:
- The "Russian doll effect" of cellular damage and how to reverse it
- Why it takes weeks (not days) for some people to feel better on keto
- The hidden reason one cheat meal can undo weeks of progress
- How continuous glucose monitors reveal what your doctor can't see
- Why your body fights to keep blood sugar normal—even when it's killing you
- The real difference between insulin sensitivity and insulin resistance
Dr. Boz also tackles the controversial debate around high-fat vs. low-fat diets for reversing diabetes, explaining why context matters more than ideology when it comes to your metabolism.
Whether you're struggling with diabetes, weight loss plateaus, or simply want to understand how your body really works, this conversation will change how you think about food, insulin, and metabolic health forever.
Dr. Annette Bosworth is an internal medicine physician, bestselling author of "Anyway You Can" and "Keto Continuum," and a leading voice in metabolic medicine.
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Welcome everybody to an interview today with Dr Boz, as she's known Dr Annette Bosworth, and I'm going to just hit you up with some of the highlights from her bio. She describes herself as a doctor of internal medicine. She's an author, a mother, a wife, a teacher and, as we all know anyone who's read her books a heck of a storyteller. She was born into a family in South Dakota and picked up some pretty good work ethics that she applied to get through medical school and then she needed that same sort of tenacity to sort of break away from some of the mainstream thinking around what actually helps reverse chronic disease. And she sort of started to. I think the story is is she started to see her patients doing some things and getting results and she started to say, hey, wait a minute, what are you doing? And you know her open mind and her genuine, genuine desire to try and help make her clients healthier. You know her patients healthier. She started to do some digging and the world opened up and she hasn't stopped her research and her teaching and turning the lives of her, of her patients, around her first book. Anyway, you can tell us a story of her 71 around Her first book.
FLORENCE:Any Way you Can tells the story of her 71-year-old mother. It is gripping if you haven't read it. It is literally the story of her moving through dying in the hospital of cancer and how Dr Boz came in with some new understanding of the potential that moving into ketosis could do to support her fighting cancer. It has a happy ending, but you really need to read it to get the whole nail-biting experience of it. And then she followed that book up with Keto Continuum, where she tells the story of another patient, david, and how moving into ketosis and leveraging food as medicine can actually help reverse obesity.
FLORENCE:I think diabetes, heart disease, depression, and it was all those sort of metabolic, cardiometabolic syndrome symptoms that most of us are suffering with. So, yeah, I think she has been featured on CNN, time, us News, world Report, fox News, you name it. She's everywhere. She spends hours and hours and hours every week literally sharing free content. I don't know how she's still standing One of the most generous of individuals out there on the Internet who's sharing her passion for what we're learning and what we're discovering together, really through trial and error, through science, coming in and sort of keeping us current on what we need to know to stay ahead of the diseases that are exploding everywhere. Welcome Dr.
DR BOZ:Baas. Thank you, Florence, it's an honor to be back. Last year I had my debut with your conference and had quite the positive feedback. So a lot of people were helped and your message clearly is ringing out at a time where we just don't have enough folks singing the truth behind reversing these problems and how dangerous it is to fight that drive for wanting sugar on the brain. So thank you.
FLORENCE:So Dr Boz has prepared a presentation. So we know, most of us know that we need to cut back, if not completely eliminate, our consumption of ultra processed foods. We know that. And then the question becomes okay, I'm really damaged. Where do I turn to to sort of reverse this damage and repair? And so Dr Boz's presentation is on insulin resistance, so understanding it and then offering us some hope and some very concrete ways of walking out of that cardiometabolic problem, and so you can take it away.
DR BOZ:Right. Well, you know nothing like some beautiful pictures to help tell a story better. I have used this slide deck a few times to explain this to patients while in the exam room, because the idea that what bounces around in my mind can come out in articulate words. Well, especially when a patient is in distress, they can't often join me in my dance around the discussion of how do you explain something that's so hidden. And so I chose today's discussion because I find this is where people get stuck when they are trying to reverse medical problems. They have been, well, they've usually had a few trips around the sun and they are on the precipice of something that's greater than what they can see.
DR BOZ:As an internal medicine doctor, our industry is supposed to be the doctor that if we do our job. You never knew we were there. We prevent the problems that we can see coming. Unfortunately, they're coming so young and so often that we've failed quite a bit in reversing and preventing those problems. And when we are stepping back through, how do we undo it? I can usually see a great improvement in their lives short term. And then they get to this spot where if they could see how the problem unfolded in the first place and then to know what is the sabotage that people do not appreciate when they're trying to reverse insulin resistance.
DR BOZ:So let's start that this is not a ham bone. This is actually a picture of a bone with a tendon and I am trying to show you that you're just like a Russian doll. There is a segment inside a segment inside a segment and the final little cell at the bottom of all this Russian revealing looks like a hot dog, but it's really a muscle cell. So a muscle cell. My team was right. It does look like a hot dog, but those are nuclei on that muscle cell and each muscle cell has this lining on the outside. So that's the yellow fat on the outside, a biphospholipid layer, and you will see those little blue things. In the center are these healthy mitochondria.
DR BOZ:But we're going to talk about the players today that are insulin and its parking spot inside our cell membranes, called an insulin receptor. You'll notice this insulin is cheerful, it's not angry, it doesn't have veins pumping out his forehead and there's no flames around it. We'll meet that ultra ego, the Dr Jekyll, mrs Hyde, part of that hormone in a bit. But the other two major parts of the story include glucose and something called a GLUT4 receptor. Glut4 receptors are like the straws that go in and out of our cell membranes, allowing glucose to travel across certain cell membranes, and they are very important when we are trying to teach people what's going on with insulin resistance. So here is the basics. Here's like a biology 101 or biophysiology 101, biochemistry 101 maybe.
DR BOZ:Where insulin is in the area of our body it's an endocrine hormone which kind of goes in lots of cellular, intracellular and inside our circulation, and then the glucose is also in circulation there. So your circulation is represented with the dark blue area of the slide and when you prick your finger to look at your glucose, that's the part that you would see in the blue. That parking spot of an insulin receptor is always in the membrane. How many places are able to bind to insulin is dynamic. This changes over time and really is a very good barometer for saying how insulin resistant is the patient. When insulin is working correctly, it binds to that receptor, sends a message to those glute. Four those straws to advance up to the cell membrane and once those straws are in place, the glucose outside the cell and inside the cell will try to reach homeostasis. Now, almost always there's more glucose in the blood than in the cell. So you'll see the glucose hop through the straws inside the cells and you will then be able to burn that fuel as energy.
DR BOZ:Once it's inside the cell, when the blood sugar lowers, the insulin dissociates from that parking spot, if you would, and when that happens, those straws disappear back into the cell matrix and wait for that signal to happen again. I like to contrast this with what happens when there is no insulin in a type 1 diabetic. That insulin absence means that the glucose in their finger, in their circulation, when they prick their finger, is going to be very high. And when that glucose is missing from the inside of the cell I don't know if you saw those little blue things vibrating there the hunger, the starvation happening inside the cell is very unsettling. The cells will die, the mitochondria will die if they don't get fuel.
DR BOZ:It's during that time of a type 1 diabetic that you'll also see this wave of ketones that can enter the cell. They don't need that straw to get across the cell membrane and this is a place where, if you're going to create ketoacidosis, it's because insulin couldn't get there at all. There's no glucose allowed and the desire and the signal to put fuel inside the cell is well, it will scream and scream at that liver until it gives it the ketones they want. So in an insulin sensitive patient those we have, you know a couple of you can have one insulin as a representing, or maybe it could be a little more than that in some people, and they are still insulin sensitive. The insulin does its job. It binds where it's supposed to and the fuel moves around. Insulin resistance, on the other hand, that means it's taking much more of the insulin to get the job done.
DR BOZ:And the word inflammation has really been overused to the part where people don't appreciate what the word means. But that flame around the insulin was designed to signal you to remember. It is causing inflammation, it is causing the attraction of water, a bogginess to how cells and bodies work when you get that much insulin. This image is a picture of a pancreas and you can see a whole bunch of islets of Langerhans there, where this is where insulin is made.
DR BOZ:If you have a diabetic, that's type 1, or they develop type 1 diabetes the body has antibodies that take away the cells that make it. But that's not how most people have struggles with their blood sugar. They have these beautiful pink cells. Those are the beta cells. I guess they're all pink on there, but the lighter pink ones are supposed to represent the beta cells. And beta cells are what make insulin. Healthy people have one or two of those insulin units, if you would coming from those beta cells. But as they put on weight, as their bodies change and they have more mass to represent, or they're in a time of stress, they may increase that insulin a little bit, and that is normal.
DR BOZ:That healthy insulin level is what we expect your body to be able to rise and fall during different seasons of your life, different seasons of growth, even times of trauma, where it's trying to protect you from the next range. It's when that amount of insulin becomes pathologic that each of those cells is producing three to four times what it should have produced originally. That those beta cells are. They're working extra hard. They do burn out over time and it is that your body will do everything possible to make sure that that blood sugar stays in a healthy range. As blood sugar rises and rises, it causes swelling within the brain and that swelling isn't compatible with life. That inflammation of excess fluid in the brain as a result of increased blood sugar is one of the many ways that high blood sugar is deadly. So your body will save you. It will continue to produce insulin until your blood sugar returns to either the best it can do, but we hope that it's back to what we would call a normal range. It will fight, fight till death to keep that blood sugar in the normal range.
DR BOZ:So let's advance to insulin resistance. Insulin resistance happens over a period of time where the blood sugars don't just rise or the blood sugars are being kept in check, but the amount of signal from this hormone has risen to a level that is five to 10 times as high as it should be. So the first thing that happens to cause insulin resistance is you have a higher blood sugar. That blood sugar is driving the increased amount of insulin and we need to sweep that blood glucose out of the circulation and the hormone in charge of doing that is insulin. Before people get insulin resistance, this is what their mitochondria look like. I want you to imagine. This has that shine to it. It's supposed to represent a very full-taught microorganal. It's not wimpy, it's not wilted, and there are multiple folds within that mitochondria. That's what a healthy mitochondria looks like. And when we add fuel to that mitochondria, it will not waste energy as the fuel processes out of that space.
DR BOZ:I'm having just a hiccup here with my slides. Oh, you know what Operator error. I totally pushed the up button instead of the side button. Okay, hang tight. We might have to cut this out of the recording, but you can just see the pretty slides again. So here come your insulin, here come the insulin resistance. Okay, so there's the blood sugar coming in and that beautiful slide as that glucose is being burned inside that mitochondria. Notice there isn't a leakage of fuel. Those sparkles stayed inside that mitochondria and you turned that glucose into energy without a bunch of free radicals being produced. As we progress, you're going to see that the mitochondria inside people with insulin resistance is not the same. That inflammation has already taken a toll at the most microscopic part of our bodies, which is inside the tiniest cells, and those microorganisms called mitochondria are probably the first line of defense that is injured by high insulin. And patients don't feel it, they don't know this is going on.
DR BOZ:Double click into what a broken mitochondria looks like. You'll notice there's holes all along the side of that ribbon inside the mitochondria. This is not a very full mitochondria. There's not that many folds in it and it's wilted. It's not as tight as a healthy one, and when that glucose is burned it leaks out energy. That energy is forms of rogue electrons. That's a free radical and that is what damages our cells from the inside out. It's also what prevents us from turning over that mitochondria when there is an inefficiency in it. All of the mitochondria, or most of the mitochondria, are inefficient and even when you replicate and make a new one, it's in short order that they become damaged because of how much of that wasted energy is ping-ponging inside that cell and damaging things.
DR BOZ:So here comes the representation of what does it look like to be resistant to insulin? In this case, the patient has had such a long struggle with excess blood sugars that it took five five insulins binding to those receptors. Before that, one straw of that GLUC4 receptor was now migrating to the edge of that cell. And when that cell is there, you now have five screaming insulin dictators and it will allow the blood sugar to come in. But as soon as the blood sugar sinks just slightly, that one of the five dissociates. One of the five says I'm done here. And when there are only four people screaming at this cell to allow sugar inside it to get that glucose out of circulation. There's no response from the cell, so it dissociates and, as a result, we see the aging process continue.
DR BOZ:Patients say, well, how do I fix that? And the answer is they eat more. They eat more often, they eat foods that give them that sugar rush. Doc, I can feel it, my blood sugar is low, my brain's not working. I know better than to go more than two hours without food and unfortunately, they've trained their insulin to. When that one dissociates, they have to get the higher amount of insulin to get the glucose inside the cells of their brain cells, of their muscle cells, or they feel that sluggishness that is very common, that hangry moment, if you would.
DR BOZ:So what happens when you go keto? Well, the first thing that we tell patients to do is drop the number of carbohydrates you're eating. In my practice we talk about 20 total carbohydrates or less. And when folks do that, especially coming from a typical, standard American diet, they drop that blood sugar by a significant amount and you say, good job, that's the point. We want less blood sugar floating around. You are reversing medical problems. But they would say, boy, it doesn't feel like it, because the second thing that happens after they drop those carbohydrates is the signal to produce insulin is now lower. That insulin is produced by the amount, the rise of the blood sugar. And if you're going to reverse these problems, step one is less insulin. That sounds healthy, right? No problem, let's do this.
DR BOZ:Now those three blood sugar or those three insulins bind to those receptors, giving the signal that, hey, we need some sugar, we need those mitochondria, even in their poor health, to have some fuel. But those straws, those GLUT4 receptors, say no, no, no. We have a contract that we don't listen to the signal to rise to that cell membrane until there's five. And even though the rules just changed, nobody told the cells, nobody informed that GLUT4 receptors. It is a trained process that is very well scripted that you now need five insulin to do that and the way out of this is a little painful. So as you watch what happens next, those mitochondria, they shake and they wiggle and they are starving. They want fuel. The bouncing of the blood sugars outside the cell are in vain. They cannot get through and indeed without that fuel you will see some of those mitochondria crumble and die. You will see a cell instead of apoptosis where the whole cell dies. You'll just see those organelles crumble and die and unfortunately it's usually a significant amount of time.
DR BOZ:And this is one of the most powerful parts about what I've seen in the ketogenic space is when patients have been ill at a cellular level for a decade and they didn't know the problem was coming at first, the symptoms inside their cells. I mean, the signal from inside their cell was very quiet, very subtle. But the next layer of problems were that they had a hormonal problem. They had more insulin than they knew about and that led to some, then finally some symptoms. So when we go to reverse them, they may have had this, the excess weight on, for five or six years, but the dysfunction that's been happening at a cellular level is decades in the making.
DR BOZ:So as you wait for that, 24, 48, and I've had some patients over a week into a fasted state, which is not how I would recommend they get there before their body is able to really produce a hearty amount of ketones. This happens because they have so much sugar stored throughout their body, stored in their liver, stored in their muscle cells, and as the wave of ketones arrives, it does not require the straw, that GLUT4 receptor to be at the cellular membrane. It can pass through that membrane and deliver fuel on the inside of that cell, but it might have been at the compromise of several of those mitochondria. It's also over time that you'll see those two empty insulin receptors. They are required for the first several days. It's probably closer to a good couple of weeks before. Now your cell only requires three of those insulins to push that straw up to the cell membrane, allowing some glucose to come in. And just like with the five versus four, as soon as the one insulin dissociates from the insulin receptor, the straw disappears back into the matrix of the cell and now the fuel that's inside the cell is all that they will get.
DR BOZ:I do want you to take notice that when there is a ketogenic state inside the cell, we are starting to repair. Notice that three of those mitochondria are now those healthy versions, that mitophagy, the turnover of not killing off the mitochondria but replacing it with a much heartier, healthier version with the excessive folds in there. That does happen when you're in a persistent state of ketosis. It's unfortunate that it takes as long as it does for patients to reverse those problems, and where I see people give up is that they have offered a trial at this ketogenic space and many times they even get through the wave that they have to wait for those ketones to arrive at the cell level and that's when they start to feel better. But if they are not, if they don't know what we're about to go through here, they will stall and they will slide backwards.
DR BOZ:Because this is a very sneaky problem. That again, nobody gave you the cliff notes to say sign off on this, that it's happening. It was a secret happening inside your endocrine system. So in the first few years of insulin resistance we can see that your blood glucose is somewhere between you can see the red line. There is as low as 80 and maybe as high as 100. That's normal. Insulin is wavering somewhere between that 5 to 10, and that is again healthy.
DR BOZ:But as you age, if the amount of sugar that's cycling in and out of your body continues and rises even higher into if we had that blood sugar rising up closer to 120, off and on and off and on, it's taking more and more insulin to keep that blood sugar controlled. It'll spike up and it pushes it back down. This is specifically a problem when the stimulus for insulin is far too frequent. So, instead of an adult eating two or three times a day, there's a handful of nuts, there's a chewing of gum, there are different places where glucose enters the system or any other processed carbohydrate, processed food, that the amount of particles turning into glucose rises way too much and, like I said, your body will fight till death to keep that glucose in that normal range. So you see, the glucose is still normal. It's not exited out of a dangerous range, but it is more frequent. Maybe not easy to see on this image.
DR BOZ:But then we go to the next level, where the insulin resistance is starting to see something that me, their doctor could see. I come in and ask them for a fasting glucose and instead of something between 90 and 100, or maybe I'd give them a grace period like, oh, I'm 110. Now their fasting sugars are in the one teens, they're even in the higher one teens and, god forbid, they get to be a fasting sugar in the 120s. That problem is now a good several years in the making and the insulin that continued to be made in excess, well, it has this timer where you see that orange line dip down is where those beta cells that I showed you in the pancreas. They flattened out, they stopped producing and now they're stuck. So here comes the critical question If you've got a pancreas with your beta cells producing the pathologic levels of glucose and you are saying, all right, doc, I'm yours, I want to reverse this. Show me how to do it, show me how to do it and we offer a decreased amount of insulin. That's necessary. The question is, how long does that last, how long before it's going to be that you take that down yet another notch?
DR BOZ:When we look specifically at the zone where insulin resistance went from that lower insulin to where it advanced to the next level, it's where blood sugars usually have. We can rain them down to less than 120. When I look at blood sugars of the patients struggling with insulin resistance, it's not 180 blood sugar in the morning, it's not even 100, they're not diabetic but it's higher than it should be. It's not a two-digit blood sugar in the morning, it's either the high 90s or a three-digit blood sugar in the mornings. And then when they do this great job of responding to, of staying the course, of resisting those particles of processed food, of eating multiple times a day, and then they get to a celebration and they say I deserve this. I have been so good. I have resisted this about 500 times over the last three weeks and they do that. They binge. The blood sugars shoot up to 100. I've had mine shoot up to over 200 just eating cotton candy grapes and I've been doing this for a decade. Rapes and I've been doing this for a decade that the return of my blood sugar shooting off the charts and then knowing what happens in the background.
DR BOZ:I usually I draw on the slide here, so I don't have a pen that'll do that today, but I want you to know that if their insulin, if their oopsie, if their insulin was in that, you know, 30 range when we started out the process and they spent five or six weeks following the process, not binging, eating a high fat, low carbohydrate diet, keeping, if I can keep, the carbohydrates less than 20, it's one of the fastest reversals. But their blood sugars still look like this. The blood sugars are still hitting at least 120 after meals and many times higher. And then they barf all over things. They have a binge, they eat something, they eat more than they should. They pick up the bad habit that they're trying to reverse and God bless all of us when we're trying really hard to undo a bad habit. Unfortunately, what happens to their insulin production after that binge is it bounces right back up to where it used to.
DR BOZ:When I look at why I am so adamant about the process of guiding people out of that danger zone, that part where they stay the course they're able to do well and then they binge, it's because the reversal had to do with the memory found in their beta cells. So those beta cells had the normal insulin, then a little bit more, and then all the insulin turned to flames. And in order to get back to a regularly producing amount of insulin, you need generations of those beta cells that do not produce excessive amounts of insulin. They are there to shoot cleanup and if you give them the stimulus, which could either be multiple meals a day that's why they needed so much insulin inside those beta cells or they did not get that danger-free zone, that part where you did not binge, you really did hold the course. You held the 20, you kept your blood sugars at 120 or less, even associated with a meal, and that low stimulus was able to give you a new generation of beta cells that didn't produce five insulin, five times the amount of insulin. Now you're at four times the insulin. Then several generations of beta cells are needed again to get to three multiples of insulin and to get back to normal.
DR BOZ:It is an extended period of time without stimulating the insulin and there is nothing better than one of these little goofy things. To keep you honest, I pointed to a continuous glucose monitor and I don't think these, although it has made my job so much easier to help the patient identify where did things go wrong. But who cares? If your doctor knows where things went wrong, you should be the one that knows where things go wrong. When I'm looking at reversing insulin resistance, there is nothing. There's no better truth teller than to monitor your own glucose, because your glucose rise and fall is that stimulus to your insulin. And when patients come to me and say, doc, I'd like that celiac disease to go away, how long do I have to be good? The answer is well, I don't know how long were you overproducing insulin and when we've got three decades of excessive insulin?
DR BOZ:You started eating processed foods in your young teens. You're now in your 40s or 50s and now we want to reverse these problems that are definitely going to cripple you if you age with them. They are reversible, but they require that anti-inflammatory effect of an antioxidant effect, of a ketogenic state. They also require less insulin. When your pancreas goes to squirt out the insulin to cover you, it will always fail by having an excessive amount of insulin ready for you as opposed to having not enough. And that's how we've survived.
DR BOZ:But it's also how people get stuck in the middle zone. Their persistence of keeping that blood sugar in the normal range and finding this satiety, that they don't surrender to cravings, they don't hangry themselves back to that higher insulin place, is because they're eating the kind of foods that not only satiate them but they are associated with pleasure, and that's where a high-fat, low-carbohydrate diet has served. My internal medicine clinic especially has a focus on peak brain performance. But we don't get peak brain performance if we have all of those chronic medical problems around. So we use this approach and when I'm trying to explain to a patient why they're not better, why they're still not losing any more weight after their initial improvement, I tell them it's Mr Insulin's fault. We have to lower that insulin and there's not a prescription that can do that. There are only behaviors that will do that. Well, tell me what you thought of that Florence. Did I lose the audience?
FLORENCE:Florence, did I lose the audience? No, no, it's amazing, Really great, and I do have some some questions. So I really like how much care you've taken to let people know that every now and then we hear of somebody who just goes carnivore or keto and they feel fabulous and they're running around the block and they're, you know, everything turned around. And for many of us it just isn't like that. We're tired, we're depressed, we're miserable, we think we're never going to have energy again and, like you're saying, we might sort of have a few cheats and then we sort of set ourselves back and then we just live in the limbo land purgatory. We don't get to the promised land that everyone on the you know, so many people on the keto carnivore path talk about like just get here.
FLORENCE:It's really amazing. So one of the things um, yeah, so I know you've said it's a couple of weeks. Have you heard of outliers, Like have you heard it take longer for people to start to have a sense of energy again and to feel better? And I don't know if you want to say anything more about that.
DR BOZ:No, this is great. So they're the. My favorite place to reach for the data on this is that they can never do this trial again. It was in the early 70s. It was done in Minneapolis, minnesota, where they locked patients in the hospital and fasted them for five weeks. They measured many metrics in the different people as they lost weight or as they fasted. They got water and minerals only no little bit of food, no crumb. Here.
DR BOZ:It was fasting and so, as you might expect, we saw blood sugars drop within the first couple of days and there are several healthy people, or people that were not too many years away from health, that you would see the ketones rise. In fact, other people would see norepinephrine start to rise on those third or fourth days, fifth days of fasting and boy, I really found this utopia on the other side of fasting. But there were some significant. They were called morbidly obese in that trial and you got to really dive deep into the paper to see them and you say well, what happened to them. And the sad part was they were not making ketones till in the teens, 13, 14, 15th day. Okay, so let me clarify that they made a few ketones, but they did not get this burst of a ketogenic rise because they had so much storage of glycogen, of stored sugar, in their muscle cells and their liver cells that as soon as the sugars would fall, the signal to release that stored sugar would happen and their blood sugar would rise again. So the amount of blood sugar continued forever. The time it took for their insulin to decrease was into the third week. I'm like who's going to fast for three weeks in 2024, 2025 for us to benefit and get them to this ketogenic state where their fuel source changes, where they have mitophagy of that mitochondria, where they really get that spark of metabolism.
DR BOZ:I'm telling you people won't do it. Life is too comfortable. You're going to find way too many experts telling you danger, danger, danger. But when you look at people who come to my clinic and to many people, many, especially Americans they are in that super high insulin state and they've been there for decades. So to ask their metabolism to change the rules, we need generations of new beta cells that are compliant, that are going to save the human and they will hold on to that excessive production of insulin.
DR BOZ:Like to ask somebody who's not insulin resistant to put out, let's just say, four cups of insulin. Their pancreas can't do that, it's not prepared for that. They'll die. I mean that shift of excessive amounts of insulin can be done for a short period of time and then they're empty. So when they get to the edge of failure, when those vacuoles have been emptied, the stimulus to make the next beta cell that holds more insulin is there. And to go backwards, you have to have a long time that you never emptied all the vacuoles of insulin. And then when you have, you know okay, it's been six weeks where we haven't had to use that much insulin. So the vacuoles downregulate and now the next generation doesn't produce as much. Okay, so you're a notch better.
DR BOZ:And I think that's this hidden part where. Why does it take so stinking long? Well, there are tricks you can do to make it go faster, but the most important one is to not go back to the previous behavior and not count that, as the timer just started over. I'm sorry to tell you, but you're human. The timer just started over. I'm sorry to tell you, but you're human. That timer just started over. Your cells are going to keep record on how long it's been since your body has needed that much insulin and when you touch it when you go there, they keep score.
FLORENCE:So interesting. So one of the criticisms that I've heard and I've interviewed some people, even on my own summit, and I'll tell you like I scratched my head so I thought I'm gonna, I'm gonna, I'm gonna give this one to Dr Voss and see what she says. So I've actually and I I did follow up their references so I wouldn't bring it up if I didn't think like the average person looking at this would say, hey, wait a minute. That kind of makes sense to me, so I'm going to quote. So fat in the bloodstream can build up inside the muscle cell and create toxic fatty breakdown products and free radicals and this can block the insulin signaling process. When this happens, no matter how much insulin we have in our blood, it won't open the glucose gates and it causes blood sugars levels to rise in the blood. This mechanism, by which fat, and in particular saturated fat, induces insulin resistance, wasn't known until the modern MRI techniques that were developed and we could see inside people's muscles as dietary fat, particularly saturated fat, came into the bloodstream. They could see in people's muscles that the higher, the higher the fat levels, the more the insulin resistance. It was somehow interfering with glucose transport into the muscles. It was gumming up. They talk about this lock and key and it was gumming up the, the insulin signaling process. This can happen within three hours. One hit of saturated fat can start causing insulin resistance, inhibiting glucose uptake, after just 160 minutes. And you can also do the opposite lowering the fat in people's blood, and the insulin resistance comes right down. By clearing fat out of the blood, you also clear sugar out of the blood because you stop interfering. So on the high fat, this you stop interfering. So on the high fat. This is the last paragraph on the high fat ketogenic diet. Insulin doesn't work as well. Our bodies are insulin resistant, but as the amount of fat in our diets get lower and lower, insulin works better and better. This is a clear demonstration that the sugar tolerance of even healthy individuals can be impaired by following a low carb, high fat diet. We decrease insulin resistance by decreasing fat intake. Now here's the big argument that sort of the evidence is. They'll say we can put people on like a high fat loaf, I'm sorry, high carb, low fat, like almost no fat, like raw vegan or vegan or something diet, and they can show. They can show that even type one diabetics and type two diabetics will actually become very insulin sensitive because their blood sugars their blood sugars are not spiking and they can sort of lower. Some of them can completely reverse diabetes. Now here's what they'll argue. They'll say, dr Boss, or they'll say, florence, here's my argument and I'm giving it to you. They'll say so we can prove that we can reverse diabetes because people remain insulin sensitive.
FLORENCE:Now we don't say that they get to eat. That's not a pass to eat any high processed junk. They need to eat whole foods. But they need to eat whole foods healthy carbohydrates, lower fat, so the fat doesn't interfere with insulin working. So the sugar gets into the blood, the body is fueled, they become non-diabetic and they can continue to eat carbs, no problem. But on a high-fat keto diet they can't even eat grapes. They have one grape and their blood sugars spike right off the roof and it hangs out there for really long, proving the point that they're not reversing diabetes, they're putting it into remission. But God forbid, they should eat a blueberry. What would you say to that?
DR BOZ:All right, so let's go back to. I want you to read the second paragraph again, the part about saturated fat, consumption of saturated fat. Read that sentence again.
FLORENCE:Sure, I think that's the third. So the second paragraph was about the modern MRI techniques. Oh, third paragraph, then third. This can happen within three hours, one hit of fat can start causing one hit of fat one consumption of fat, dietary, saturated, all right.
DR BOZ:So I just want to make sure that's step one when you swallow saturated fats and those are not the saturated fats that end up in your arteries Saturated fats by definition when you swallow them they are put into your lymph system, they are processed and you get to break them down. The production of that saturated fat is best done in a high insulin state. When you're saying where does that fat come from? Well, we can make saturated fats. We can produce those in our bodies. So first of all, the direct correlation. I mean we have carbon tagged fats that when you swallow them, are they the ones that end up in your fat cells? No, it is not how that works. The saturated fat that you swallow gets broken down and gets shuffled into what it is your body needs. It is not the same string. So to correlate the swallowing of it and what is in circulation, that's not how that works.
FLORENCE:Then let's go to the second part.
DR BOZ:When you look at fat in the bloodstream, what they're saying there is triglycerides. So, okay, triglycerides are the easiest to measure fat in our bloodstream. They're found in lipoproteins and we know that, especially with that technology they're talking about that. There is a molecule, a lipoprotein, that's going to be the truck that carries those fats around, as those fats are deposited into cells that are hungry, whether that's a muscle cell or a brain cell. What you're really looking at in the bloodstream is that gumming up part is well, how high does it peak? That's one part. How high is the lipoprotein number? And in that, how many triglycerides are found in there?
DR BOZ:When you back away from this and say, okay, so there's a lot of moving parts here, when things get gummed up, it's that there are so many of those lipoproteins that couldn't off put their storage into the areas of the body that needed it, and that delivery of that fat is in part related to well, how long is that little bus been swimming around the circulation we call it residency time that a lipoprotein is produced in our liver. Our fats are packaged in the liver and they exit out into the circulation to be delivering the fat fuel. And when that package leaves the liver, we want to know, well, how long does it take before it's done with its job and it gets recycled, so that residency time is what predicts the disease state. Residency time is what predicts the disease state. This is where the big fight in the world of keto is lean mass hyper responders, where they have these incredibly high cholesterol levels, but they're as healthy as you can find people. I mean they are healthy. You don't need to be a doctor to look at health and they have the metrics to follow them up. Their calcium scores are zero, but they have triglycerides and cholesterol numbers that are off the charts, high, like shockingly high. Yet the time it takes from the moment they make that lipoprotein to the time that lipoprotein's life cycle is over is very short. That is very efficient.
DR BOZ:And when the lipoprotein, when the fat. So they're talking about how can this fat that's in circulation it's gumming up things. Well, the fastest way to remove the fat from the circulation is to not have high insulin. So I think we are both agree let's lower the insulin in those, in people that are trying to get healthier. Yes, we definitely need to do that. And one team saying you have to use low fat and the other team saying you have to use high fat. Uh, I say you've got to use a ketogenic approach. That's high fat, especially in somebody who's insulin resistant. And in part it's because if I'm going to wait for that insulin to drop to a part that's healthy, or a dozen days into getting the insulin to get low enough, and then it's the smallest stimulus that returns me right back to that high insulin level.
DR BOZ:When I also look at when you have a high insulin state, the other part that's missing from their body is insulin not only dictates how fat gets stored quickly, how fat gets into a muscle cell and stays there. Insulin also dictates how fat-based hormones are working. So the delivery of the hormones that actually are going to help transition a sluggish cell, a weak cell, one that needs that hormone, those hormones are vital. That means you must have them for life. Vitamin D and the sex hormones are the easiest ones to just put your thumb on the scale for saying. Without them you cannot transcribe the proteins to get the cell to work, so it acts sluggish, it doesn't have energy, it can't think, you can't process, and you need the fatty hormones in order to get the cell to work first.
DR BOZ:So, as much as both teams are trying to get the patient to the other side of insulin resistance, the approach that I see as favorable and I recommend to everyone that I love is you start by making the cell healthy, giving that fat-based hormone get it to the place where it belongs. You're going to have to lower the insulin sum in order for that to happen, which is what that low carbohydrate state does. We want you to feel good, that feeling of satiation, that energy and joy comes with the percolation of these fat-based hormones. We have work to do to get well. How much food should you be eating? We do not even touch that subject until we can feel that life pulse going through their sex drive and their brain function and their muscle contractility, because it is so powerfully related to those hormones.
DR BOZ:When someone says, lower the fat, they've got a bunch of it in them. Yes, there is a season where you should be eating far less than you're eating. You're out eating your insulin. We have that conversation lots in my practice. But they're still eating a very high fat, low carbohydrate diet and they're also at a season where that fat cell is much more responsive to changes in behavior because it's a healthy fat cell and you can say how can the fat cell, the one holding the, the, the enemy, be healthy? But it will listen to the hormones and will listen to the signal of another, lower state. There was one more point that I wanted to make Um, uh. So at the end of that you were asking another question that, um, um, go to the last paragraph that you read.
FLORENCE:It was about how they're they're. They're. They're saying that when you follow a low carb, high fat, eventually become carbon tolerant. And you, you are stuck on that.
DR BOZ:Right, so let's talk about my, my, my, uh cotton candy grapes. So, uh, I this is out on Instagram. It's a little bit too viral because people are fighting over it. Uh, but it was an experiment where I don't put grapes in my life because I like them and I will eat a bunch of them, but I had fasted for 72 days, so guess how many vacuums 72 hours or 72 days.
FLORENCE:Sorry, sorry, 72 hours, wow, 72 hours or 72 days.
DR BOZ:Sorry, sorry, 72 hours. Okay, I was like wow. So guess how many vacuoles of insulin are waiting in my beta cells to be produced when I've gone three days without much stimulus of insulin at all?
DR BOZ:I mean your body's going to naturally produce a little bit. It's very low, right? So if you could take a microscope into my beta cells, there's going to be one or two vacuoles of insulin. Now insulin will upregulate and that's different than what's the capacity of your insulin, of your beta cell, to make insulin that I can upregulate the amount of insulin that my beta cells need pretty quickly. So when I haven't eaten in three days, the vacuoles that are kind of the older ones have kind of been regressed, they've been reabsorbed into that beta cell and there's just a tiny little bit of insulin waiting there on the edge when I ate those grapes. They are bioengineered and they did shoot my sugar up to 225. And I was like at 70, 60, whatever.
DR BOZ:It was very embarrassing how much my sugar went up, but the amount of insulin sitting in those beta cells was low. So what that guy's talking about or saying, oh see your insulin, your insulin resistant, because he's thinking I made all that insulin and let the and let the blood sugar go high. But it's actually the opposite. I had fasted, there was no vacuoles of insulin waiting in my beta cells, or a very minor amount, and if I was being smart I would not have broke my fast with those silly grapes. You can blame my husband. He's the one who bought them and I said, oh, those taste really good, and I knew that until then I had another one and another one.
DR BOZ:But the point is is that you know, when people say the word insulin resistant, they're saying, well, how well did it control your sugar? And, by definition, what you need to accompany that with is, well, how much insulin was in circulation? And when you have a ketogenic state and I don't produce a lot of it, I don't need as much insulin as I've needed over the years. I don't have as many binges as I. You know, each year gets a little wiser and less volatile on what makes me feel good, little wiser and less, less volatile on what makes me feel good. And that that amount of time between either a big binge or something I shouldn't have, it's much less. It's a much lower volume and my body doesn't produce as much insulin.
DR BOZ:But that's a decade into this story. That's a decade into improving behaviors, changing, you know, a lifetime culture of celebrating around food, sorrowing around food, grieving around food. Anyway, you got to put food and carbohydrates together. I'm your fan. But to get that out of your life and to change that behavior. Now I'm 10 years in and, yes, I can still fast for 48 hours and have a blood sugar of 109. That's not normal, but that does happen and it's a reflection to say it wasn't because the insulin was working extra hard. It's that I didn't stimulate insulin for those times and I still have lots of storage, or I had had more storage over the last four before that fast had started.
DR BOZ:So I just think the context of when you're trying to teach people well, what is it? Which one do I got? Do I have too much insulin? Do I have not enough? Well, take an assessment of how inflamed is your body? Do you have arthritis? Are you able to eat food without diarrhea? Is your hair falling out? Is your skin glowing? You know the assessment of health doesn't take a medical degree. Are you healthy?
DR BOZ:If you happen to use your little friend, a continuous glucose monitor, you can also watch what was my blood sugar at three in the morning. Where did it get down to? How well did it stabilize? And without question the improvement in patients over time when they are satiated after a meal, they eat lower amounts. So we only have a couple of stimulus of insulin a day, meaning a couple of boluses of food. We get rid of the gum, we don't do things called snacking and we take that aged pancreas and we go backwards. We try to decrease the amount of insulin it's producing. But it's very confusing to patients because they'll say but they say that that I don't know vegan multi meals a day. I'm like put on a glucose monitor, watch you Quit, depending that. That randomized trial is going to be as good at figuring you out as you are and the tools are not that far away.
DR BOZ:You don't have to wear. I love these. I have a contest with my husband of wearing these silly things, but that's also what keeps me compliant. I know myself right. You do one of these for 10 days and you have. You can't unsee it. You can see that really is how high your blood sugar is going at night when you sleep. It never gets below into the two digits, even fasting for two days. You have a very advanced problem of insulin resistance and I let the patient be the answer to study yourself. Watch what it does on that High carbohydrate, low fat option versus a high fat, low carbohydrate option.
FLORENCE:And it seems to me that, either way, either way, you are committed. Because if you do the high carb and low fat, that means there's no salmon, there's no more than one and a half ounce of nuts a day. That's it for fat. Right, like, either way, like you. Just, maybe you just pick your path, like I don't know, right, like, maybe you choose to try that one, but here's the deal there's no high fat, high carb. That doesn't work.
DR BOZ:I know that's right.
FLORENCE:Especially, especially if we're talking about processed carbs and processed fats. Right, so, like which is often what happens, is people just go back to the junk the Doritos, the baking, the crap.
DR BOZ:Yeah, I mean I'll end with this that I or maybe it's not an ending, but one of the parts that I think is missed in the advanced chaos of our medical delivery, where we can outsource the left kidney to one doctor, the right kidney to the liver, to this person. If you have a processing problem with your brain, there's about 10 different types of professionals that can tell you what to do. But as an internist who also takes care of peak brain performance, you get a collection of what all these teams were doing and then which ones were working, and oh, there are a lot of ways to screw up your brain. But if I look at the hardest to treat brains that I've had over the years and let's just take substance use out of that, let's just look at a nutritional approach it would be the vegans who do long distance running. The trauma found in long distance running should be easy to. The trauma found in running for your brain should be easy to repair. But it's only able to repair that if you have supplied the brain with the kind of facts that are required for brain repair processing and I remember learning this I was probably a few years into my world of being a physician and it was so counterculture to what I'd been taught my friends that all were runners, were lean and they looked great and we're all like 28 years old.
DR BOZ:Right, it's just they look great and they haven't been staying up all night doing residency and running must be the answer. And then they all eat these leafy green things and don't, and I want a steak, and so it looks like they've got the right answer. So now we've aged of 25 years and I can run. I'm not the best runner. I can get a couple of miles in a few times a week. I'm not against running. I'm saying the women who used running to keep their weights stable and they ate leafy greens without fat. That was their whole goal. I am 53 years old and the women who did that path it is a tragedy how far down their brains have gone and this is anecdotal, they're my friends, but the literature supports this that the trauma I mean. It's so counterculture to say what happens when the brain doesn't have the resources to repair that brain, and many of those resources are found in the saturated fats of a good steak.
FLORENCE:Omega-3s, and fishes and other.
DR BOZ:Yeah, steak salmon even better. But I'm a beef.
FLORENCE:Right, right, right. Well, thank you for addressing that, because I do have another speaker on this summit and I just can imagine that I don't want to make people's lives more complicated, more difficult. And they're like what what Dr Baz is saying? This is other doctors saying this, but I appreciate that. That makes sense to me that what you're basically saying is that when you are in a ketogenic state for the most part and you eat something higher carbohydrate, let's say blueberries or grapes or whatever, and your blood sugar goes up, it doesn't mean that you're insulin resistant. Your insulin isn't working. It means that your body didn't actually produce enough insulin because it's so not in the mode of producing a lot of insulin. What you'd probably have to do it a little while for it to go. Oh hey, wait a minute it is, else wake up. We got.
DR BOZ:We got some more yes, and ben bickman does a great job of summarizing that and teaching it, even from a biochemistry standpoint uh, very cool okay.
DR BOZ:So there's there. There are more than one person out there saying this. You got to love the validation, what I do think it is difficult for patients. We are highly committed to saying let us help you, show you how we do this, and I am tirelessly making sure that what we are saying is true and that when we see the studies that you're talking about, that, um, they're not flippantly addressed on our team. They are right that they are dissected and we understand what they're trying to say and where things get twisted. And I think, without a doubt, you've got uh, you got a tough puzzle on your hands, because there are, there are really desperate people out there trying to learn how to do a better lifestyle and to be able to let the professionals hash it out and debate what the right answer is. It's a delicate line to tell.
FLORENCE:Totally, I mean, and if someone like me can even get a little bit confused after decades of studying nutrition and all kinds of experts. So at the end of the day, here's how I would summarize what I heard. What I've heard is that there is no sort of half doing this. There's going to be a period of time where you're going to be transitioning from yours probably standard American diet onto a lower carbohydrate, healthy fat diet, and it's not going to be pretty for everybody. It can take time. There's beta cells that need to be repaired. There's mitochondria that need to die off and be reborn in fresh, new, healthier states.
FLORENCE:The body has to learn how to use fat as fuels. You're going to have to figure out what macros work for you. It's a journey, but stick with it Because I know before we ran the camera you said, florence, if you could come, I invite anybody to come into my office and just sit with me for the next 15 patients and look me in the eye and tell me we're not, we're not. What we're doing isn't working Right, that is. It's just, I mean, when you're working frontline with people like not doing the research, not talking theory, really truly learning from your clients year over year.
FLORENCE:At this point, decade over decade right Like yeah, that's a lot of earned street cred for sure.
DR BOZ:Absolutely. That's the practice of medicine. Is real life patients telling, telling you where you're right or where you're wrong?
FLORENCE:Yeah, Thank you so much for all the work you do for your beautiful presentation day, for addressing my, my curve ball sort of um is there any? Final words? You'd like to say no?
DR BOZ:you're wise to, to, to, to take that as a stimulus for a good conversation. I think people are attracted to say well, they're, they're on opposite sides of the fence, so don't shy away from that. That's the, that's the part that needs to happen in our world.
FLORENCE:So yeah, yeah, good respectful dialogue. Like you're saying what? Let me look into that. Saying what and how do we maybe even go higher and take little bits of everything and gets wiser? Do you have any final words for us today before we wrap?
DR BOZ:up. No, I will praise you for what you're doing, but also say that in my life of continuing to answer patients' problems, I continue to study this and advance my knowledge, and the folks that are watching this are saying that too. So congratulations to yourself for investing the time and energy it takes to learn this. It's not a walk in the park. This is advanced stuff. So good job for attracting the audience and the audience for staying present.
FLORENCE:Thank you so much. And just to find Dr Boz, it's Dr BozMD. She's got courses online really affordable BozMDcom.
DR BOZ:Boz, it's Dr BozMD. She's got courses online really affordable BozMDcom.
FLORENCE:BozMDcom, the Dr.
DR BOZ:Boz and I got all the way to the family that owns it and they were like nope, not selling it.
FLORENCE:Got it. Yeah, sorry I could not put the doctor in front of it, but I know it's BozMD and if you go on there you'll find all kinds of amazing free resources and some courses and, yeah, lots to explore there. Thanks again for your time, you bet.
