Beyond Medicine: Dr. David Unwin's Approach to Type 2 Diabetes

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This week on the podcast I speak to Dr David Unwin about his phenomenal work in the medical space with reversing type 2 diabetes. He works at the Norwood NHS Surgery in Southport near Liverpool, UK where he has cared for the same population since 1986 as a family doctor. Along the way he has received both criticism for his approach and accolades for it, being the winner of prestigious awards for his effectiveness. Mikki and Dr Unwin chat about his approach and its success on today’s podcast.

Dr David Unwin is an internationally renowned family doctor at the Norwood NHS Surgery in Southport near Liverpool, UK, for using a carbohydrate-reduction approach with his patients with prediabetes and Type 2 Diabetes.
For the past few years, David has been a UK Royal College of General Practitioners expert clinical advisor on diabetes. As a result of his interests in both better communication with patients and Type 2 diabetes he was made Royal College of General Practice National Champion for Collaborative Care and Support Planning in Obesity & Diabetes in 2015. In 2016 he was the proud UK National winner of the NHS Innovator of The Year Award for published research into lifestyle changes; working with patients’ personal health goals as an alternative to drug therapy in type 2 diabetes –so that his GP practice spends £68,000 per year less than expected on drugs for diabetes.

David Unwin
https://twitter.com/lowcarbGP

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Creators & Guests

Host

Mikki Williden

What is Mikkipedia?

Mikkipedia is an exploration in all things health, well being, fitness, food and nutrition. I sit down with scientists, doctors, professors, practitioners and people who have a wealth of experience and have a conversation that takes a deep dive into their area of expertise. I love translating science into a language that people understand, so while some of the conversations will be pretty in-depth, you will come away with some practical tips that can be instigated into your everyday life. I hope you enjoy the show!

00:04
Hey everyone, it's Mikki here, you're listening to Mikkipedia and this week on the podcast I speak to Dr David Unwin about his phenomenal work in the medical space with reversing type 2 diabetes. Dr David Unwin works at the Norwood NHS surgery in Southport near Liverpool, UK and he has been a GP caring for that same population since 1986 as a family doctor. And

00:33
David is well known and revered in this space for working with people to reverse their type 2 diabetes and along the way he has received both criticism for his approach and accolades for it, being the winner of many prestigious awards for its effectiveness. In addition to that, he has been able to move beyond his surgery walls and transform the lives of thousands of people through his

01:01
published work and also infographics that he has shared on social media and he really has this message of a low carb approach for type 2 diabetes. He's really lead the way in terms of its use in general practice. So we talk all about this, how he discovered the low carb diet, what it looks like to go low carb with his patients, the awards that he has received alongside the criticisms that he's also come up against.

01:30
and just his general view of where it's going and it was such a great conversation and those of you who are familiar with David Unwin or Jen Unwin will know of course that he is the husband of Dr Jen Unwin who I spoke to a few months ago now on the podcast all about food addiction. For those of you unfamiliar with David he is an internationally renowned family doctor as I said at the Norwood NHS surgery in Southport near Liverpool.

01:57
and he uses a carbohydrate reduction approach with his patients for pre-diabetes and type 2 diabetes. For the past few years David has been a UK Royal College of General Practitioners expert clinical advisor on diabetes and as a result of his interest in both better communication with patients and type 2 diabetes he was made Royal College of General Practice National Champion for collaborative care and support planning

02:27
in 2015. And in 2016 he was the proud UK national winner of the NHS Innovator of the Year award for published research into lifestyle changes. Working with patients' personal health goals as an alternative to drug therapy and type 2 diabetes has meant that his GP practice spends £78,000 per year less than expected on drugs for diabetes, which is a phenomenal result.

02:54
I've put a link to where you can find David on Twitter because I think that's where you'll be able to pick up on his infographics, his published research and everything that he has going on. And he's a great follow so I really highly recommend it. Before we crack on into the podcast though today I'd like to remind you that the best way to support this podcast is to hit the subscribe button on your favorite podcast listening platform.

03:21
because this increases the visibility of Micropedia in amongst the literally thousands of other podcasts out there. So more people get to hear from experts that I have on the show, like Dr. David Unwin. All right team, please enjoy this conversation.

03:39
David, thank you so much for taking the time with me your morning, my evening to sit down and chat. You are very well revered, obviously internationally, particularly here in New Zealand, because you and your wife, Jen, were just here earlier this year, which I'm sorry that I missed you. And I'm really looking forward to diving into your work in so many areas we could speak on, but obviously I'm really interested in the low carbohydrate approach

04:09
You've been advocating for several years now and have really sort of lead the helm of practitioners in this space. David, can we start by you just giving us a little bit of your background? What initially drew you to medicine and specifically diabetes and obesity management? Well, let's draw back, far back. So as a young man, I absolutely, I was fascinated with wildlife.

04:39
And this has relevance later on. I was the kind of kid that's always rearing baby birds or wild rabbits or some bedroom was full of newts and frogs and animals of all types. And I really wanted to be a vet because of that. And I used to work in a bird hospital from the age of 13. I was busily working in a bird hospital, learning to set.

05:09
birds wings when that kind of thing and feed baby birds. I remember particularly we used to have to snip up with a pair of scissors dead mice to feed to baby owls. So it was all a bit grisly. And I wanted to be a vet and the school said they were going to be brutally honest. I wasn't clever enough to be a vet because it's harder to become a vet in the UK than it is to become a doctor.

05:37
So, I'm a sort of failed vet, actually. But that had that, yeah. Who knew? I know. So, maybe, you know, people might be better with a vet than coming to see me, but still had relevancy later because I have a lifelong passion with wildlife and I'm very observant of the natural world. So, people who go walk with me will say I see more of the natural world.

06:06
maybe than they do, I'm really noticing the things that are around me. So I couldn't be a vet, not clever enough. And so I thought, okay, medicine. Um, I think what, what I was hoping for and why I became a general practitioner was I wanted to work in this, um, I wanted to be a large fish in a small pond. As a young man, I wasn't very confident. And so I didn't.

06:36
I wasn't up to working in a big city, but I thought maybe in a small community, I could make a difference in a small community. And the thought of general practice, I thought was friendlier, less daunting. And I could maybe go to a small town and make a difference to the community there. And that's what I did. I went to Liverpool University. And then I came to the small town of Southport, where I am now, as an old man.

07:05
So I've been here for nearly 40 years looking after the same community of people. Yeah, so here I am. The practice has.

07:18
Nearly 10,000 patients, but they don't move around very much. And we have a bit like New Zealand really, a really lovely community and continuity of care. So that's the background I wanted to make a difference. I was a failed vet and I thought I'll find a small community to make a difference. And I suppose what's a surprise is how through my life I've changed and

07:47
Arguably, my impact has changed from the small community to speaking to somebody in New Zealand. It's really surprising. It is remarkable really, David. And it's, I think about someone in your position where you could have easily gone in your career, be completely fulfilled in your work and in your role and with the community around you. But was there something that sparked your

08:16
interest in diabetes, low carbohydrate? Was it the cohort that you were working with? I talked to many doctors where their actual introduction to something like low carb comes through their patients. Was it the same for you? Slightly complex, but similar. Yeah. So it began with a sneaking suspicion in my 50s that what I was doing wasn't working. So I can spot a healthy animal.

08:43
And I was noticing that human beings were really not healthy. No matter how many drugs I gave them, they just didn't look good. And it seemed as if I was managing for many people a slow decline with diabetes as a chronic deteriorating condition where I added drug after drug. And the results were, if I was to be honest, really disappointing for me to a point.

09:12
where somewhere around 2015, I actually decided that I wouldn't have anything to do with type 2 diabetes and obesity because it was so depressing. So I was seeing a partner by this stage and I just brought in the junior partner and said, listen, I want you to head up our care for type 2 diabetes. So I actually washed my hands of the whole subject of diabetes.

09:41
because it was so depressing for me. And what's really odd is that now, as a much older doctor, so I'm 65, people with type 2 diabetes and obesity are my favorite patients, so it's completely changed. Because now I see people with type 2 diabetes and obesity as full of potential, and I do not agree that it's a chronic deteriorating

10:11
condition. And in fact, many other conditions that previously like hypertension, all sorts of other things I now see as diet can make a difference. So I hope you're, you've got to think, well, how did he, what went on to change the guy that hated, hated is too strong a word, but I just felt despairing about people with obesity and type two diabetes. And now I don't.

10:40
Do you know, David, I understand that. And I imagine as well that people coming to see you might have also felt like, personally, they probably felt despairing that things that they were doing wasn't working, the medications that their doctor were giving wasn't able to control it. So there's just not a lot of hope in that situation, for the doctor or the patient. Yes, that's true. It's a hopeless scenario. So the...

11:08
The patient expects the slowly deteriorate and the do, and the doctor expects it. So it's a folie adieu, as they say in French, where you almost collude together with low expectation. Yeah. So what changed? What changed? Two amazing women is what changed. You've interviewed one of those amazing women. That was my wife. Yes. Jen.

11:39
I hope she's here. She's creeping through the room at this very moment. So, I'm gonna leave the room because I'm gonna be nice about it. Shut the door, darling, won't you? Yeah, so one was Jen with her understanding of the use of hope in life. And she could see that I was despairing. So I was thinking of retiring, age 55. And she was talking about, well,

12:08
before you go, wouldn't it be, how about you do something you enjoy? Why not finale with something you enjoy? And what would you like to do? And I was excited by that stage. I actually was beginning to think about diet. And so she said, well, why don't we do a project on diet together? And then I explained, well, because we're not paid to do anything with diet.

12:38
Again, she's a bit ferocious and she said, well, what's this not being paid nonsense, David? How many cars do we have? We don't have a mortgage. Why can't we do a good thing in the world? What's this paid business? And so it was Jen's idea that we would do the work for free, whatever the project for free in our own time. And she and I would work for free on a Monday night. So that was the first idea that...

13:07
Why don't we do something we believe in? Why don't we forget about money and payment altogether? I was just wondering, where did you get that glimmer of hope? I mean, obviously, Jen helped sort of... The framework. Yeah, yes, but also just the feelings of sort of hope and opportunity. At what point did, so you started saying that you recognize humans weren't very healthy. What about yourself, David?

13:37
Also, did you also change your diet and that's when you started to see hope? Was that a personal thing for you? Yeah, it all comes together. So at that point, I didn't realize it, but I had type 2 diabetes and I had high blood pressure and I was sort of lethargic and slightly mildly depressed and anxious with a big belly. So it was all a bit gloomy, isn't it? And then really the...

14:05
The thing that brought it all together was one single patient, one patient who had stopped taking her metformin for type 2 diabetes. I knew she wasn't using her prescriptions because the computer system tells me that patients are not behaving. And I called her in to wave shrouds at her to say that what you're doing is dangerous. Anyway, she was hopping mad when she came in because she said,

14:34
I know you're going to tell me off for not taking the drugs, but actually I've turned my health around and certainly I, she'd lost three stone in weight. She looked really fabulously well. This was the first patient. She looked fabulously well. She'd lost three stone. She looked terrific and her blood sugar was normal. And she said, Dr. Raman, you never once mentioned the fact that bread becomes sugar.

15:02
You never told me about breakfast cereals or potatoes or rice. And you just gave me drugs and I feel that you neglected my care. And that really scared me because though that's strong words and I could feel a complaint coming on. And she was very angry with me and even wondered, she said, I'm wondering if you're medically qualified, how can you never mention the foods that

15:31
blood sugar up. And she even said, you know, this is schoolboy biology that starts your sugar. It's not medicine, it's schoolboy biology. I was shocked because of course she was correct. And that woman in that day changed my life. And that, so with the framework that Jen had set up, all within a very short period of time, within weeks, that woman

16:01
And then I was thinking about how she'd done it and she told me with cutting the carbohydrates, I researched that. And we decided to experiment with a low carbohydrate diet, collaboratively with groups of patients. So we did it with the patients from the beginning on a Monday night, learning together. And the results for me personally,

16:31
were astonishing, but also for the patients. The blood pressure was improving, the liver function was improving. I was having to take them off medication because the blood pressure suddenly would go low, my own blood pressure. I had low blood pressure for the first time in decades. I was really surprised me. The whole thing absolutely astonished me. And so that's how it all began with me being astonished.

16:59
And me seeing for the first time healthy animals, people with skin that looked better, they were brighter, they were cheerful. They were grateful too, they were so grateful for the change. So I went from being so very disappointed in the medicine I had practiced, so all of a sudden I'd achieved in medicine what had eluded me for 25 years, which was

17:28
and helping people find true health, proper health. I'm not, you know, they weren't really patients anymore. They were just healthy people, not on medication. And this was, I can't tell you, it was so exciting. It was really, I felt like a pioneer in the wild west or somewhere where I've suddenly discovered something amazing. But...

17:56
it wasn't something that my colleagues agreed with. So a couple of comments and a couple of questions actually. Well, first of all, I resonate quite strongly with what you said initially about looking around and seeing that humans aren't healthy and your sort of perception of what naturally we should look at. Because I often when I'm you know, I'm just observing people around me and I often think, gosh, was it supposed to be like this? Are we supposed to?

18:25
live this, you know, like I get quite almost overwhelmed by that sort of, that's a big picture sort of thought. And it's almost, yeah, it's, um, I, so I completely appreciate what you mean with that. Um, and the fact that it's interesting as well, her reaction to you, because I don't often hear that actually, like patients being angry with their doctor and actually that she had a bit of a go at you.

18:55
Not a bad thing really. Like, no, it was because we'd known each other for a long time. I wish more people actually did that. I agree. And this is, we're part of a grassroots revolution that started with intelligent people noticing the things that you've just, you know, you go around a supermarket, how do the people look? How do children look? How do young mothers look these days? But the, her bravery was in part because she'd known me for so long, you see the continuity of care.

19:25
means that people have known me for a long time. And she was justifiably angry because she felt, well, wasn't it your responsibility to look after me? And the drugs actually gave me diarrhea metformin, the communist side effect is diarrhea. And she'd had that for years and not mentioned it because it was too embarrassing. And I'm really grateful. And at least I, at least I

19:55
started listening and thinking because I was so shocked. So yeah. David, who were your early sort of mentors in this space? Like, because 2015, like I'm thinking of the likes of Tim Noakes, of people like that, were they Zoe Harkham? Were they initial people that you... No, it was, sorry, it was actually 2012. It was actually 2012. Oh sorry, 2012. Yeah, yeah.

20:23
The mentor was somebody called Dr. John Briffa, who wrote at that time some quite famous books. A young man, still in training actually, in his speciality training. And he was such a hero of mine and he agreed to meet me in London and I was so kind of, I couldn't believe that this amazing person with a brain like a planet actually met me.

20:53
but he was excited by what my patients were achieving and very encouraging. So it was really Dr. John Briffer in 2012, and apart from that, I was quite alone. And worse than alone, I was ridiculed. And so the partners, even though I was senior partner, the partners hated that. They didn't like this. It made them anxious. When you look back, it's odd really, because all I was doing was saying, eat food that doesn't put your blood sugar up.

21:23
But oddly, they really tried to dissuade me from doing this work. And in some public meetings, I was actually shouted down and told that what I did was dangerous. I got hate mail, particularly interestingly from dieticians. They were cross. They were very cross. And why they were cross, I was so mystified because I was saying like, diet really matters. Diet can make a difference.

21:51
I felt I was saying to dieticians, here's the keys to the kingdom. Diet can make a huge difference. And yet, what I said, I assure you, made them hopping mad. And of course, they were to go on to pursue, it was the dieticians who pursued Tim Noakes and then Gary Fetteke.

22:18
several warnings about her low-carb practice by the Dietitians Board here in New Zealand, even as latest, or most recently, like last year. How curious. You know, there were issues around her practice. It's mind-boggling, isn't it? It is. What I would say, and it's important to be fair, is the British Dietetics Association is now working with me actively. And we have written joint papers.

22:48
published in their own journal talking about the effectiveness of a low carb diet. So in the UK, the situation since 2012 has changed completely and there are now some amazing dietitians working with me. So it really has, we've come a long way, but we've got a bit ahead of ourselves there in the story. Yeah. And how was it David, like obviously feeling a little bit isolated from your, you

23:17
colleagues in your profession, were there moments of uncertainty at your end or were you so obviously convinced by what you were seeing in front of you? And of course you had the support of your amazing wife, Jen. Was that enough during those years of sort of friction? Not really. Yeah, I was scared. I was frightened, but that's a good thing. And those early people did me a favor.

23:47
because I thought, you know, I'm a national health doctor, and I was going against what was normal care at the time. And so I understood that it was really important that I kept data. So I've had really, I've kept really careful data from the very beginning, because what if I was doing something wrong? What if lipid profiles were deteriorating? What if I was worsening my patient's health? I needed to know.

24:17
Um, so that anxiety translated into careful record keeping and data on everything I could measure in my patients. And that has turned out to be an absolute treasure trove all these year on and has led to me being far more effective because my data is now valuable and shows on the longer term, what does happen to people who go low carb?

24:47
and has led to me having data that's worth publishing. So that initial fear, you never know in life who are your enemies and who are your friends always, because those people who are critical of me did me a favor because of the care that I went to around the record keeping. And obviously the dieticians have turned around in terms of their...

25:15
opinions, and also, you know, they've upskilled as well in the low-carb space. What about your colleagues, David? Like, has the perception of your low-carb treatment, has that changed and amongst your doctor colleagues? I'm sure it has, but to what extent? Greatly. Oh, as night and day. So, I mean, if we start with a partnership, they're so kind to me now. They are so kind, and all of them are low-carb.

25:43
So in the partnership, they're all like racing snakes. And then.

25:49
They're amazing and the practice manager and the midwife. So first of all, at that level, but just a far higher level. So I'm now, I was Mr. Nobody from nowhere. I assure you in 2012, 2013, nobody had heard of me. And now in the Royal College, so this is the Royal College of General Practitioners. They've, first of all, they were interested in what I did. And now I am

26:19
clinical expert, a Royal College clinical expert in diabetes. They have published my e-learning module on a low carb diet for type 2 diabetes. The college has published this and it's available for free to all 52,000 GPs in the UK. Amazing. I've published in many, many journals now and in fact BMJ Nutrition

26:48
So one of my papers is the most popular paper that BMJ Nutrition has ever published. So this is weird because we have a GP, just a nobody, and this is Audit on my Practice and it has turned out to be the most popular paper ever published by a very reputable journal. And this is... That's amazing. Unusual. And it shows the interest.

27:16
internationally. So not just locally, not just nationally, but it shows the interest internationally in low carb and type 2 diabetes because the reason our paper is so popular is that it's relevant to so many people around the world. So in fact, if any of the listeners are interested in looking at that paper, all you have to do is Google BMJ nutrition and

27:46
And in the supplementary file, I've tried to put absolutely everything into it that the intelligent reader might be interested to how you would implement this approach in your own life, or particularly if you were a healthcare professional. I've stuck everything in there, so that's very easily accessible. That's amazing. And we will absolutely pop that in the show notes. And before we get on to just a little bit of the practicalities

28:15
for people who are unsure of what low carb is, where they might start. I do just want to ask you David about, for you to remind me, when did you get your Innovator of the Year Award for the work that you did? Like, I mean- I'll tell you that, that's, yeah. So again, in the early days, we're talking what is low carb and how do we communicate that? And remember, I only have 10 minutes appointments. So I need to be-

28:45
fast. And I was trying to find a way to explain about the glycemic index and the glycemic load of portions of food to my patients in Southport. And I came up with the idea of the, well you might look at the glycemic load of foods, but there's a problem with that because my patients don't understand glucose. It's not a thing they cook with.

29:12
And the glycemic load comes out in grams, and they're not familiar with grams. They just don't weigh. So I had the idea, could we reinterpret the glycemic load of carbohydrate foods in terms of something that we all understand, which is teaspoons of sugar? And so I actually rang an Australian, Jenny Brandmiller, a famous professor in, I think she's in Sydney. And I contacted her to say I'd got this idea.

29:42
she worked with me on it. She said she was too busy, but it's to her credit that she suggested Dr. Geoffrey Levesy, who's in the UK, was one of the original investigators around the glycemic load. He said that my idea was absolutely sound and he started helping me do the calculations. He did the calculations on 800 foods so that I can tell you now that

30:11
A small bowl of rice, 150 grams of boiled rice, is the equivalent of 10 teaspoons of sugar in terms of your blood sugar. And that began all these infogrames of, and they're now, oh my goodness, they've been downloaded millions of times. So they show you in a pictorial way the teaspoon of sugar equivalents of many foods.

30:39
A banana is equivalent to five or six teaspoons of sugar. Baked potato, probably eight teaspoons of sugar. And these. So we did the infogrames. They were almost an instant success. And they've now been translated into 35 languages. So we're now going really international. And wow. And this led to. The clarity.

31:09
attracted the interest of NICE, our guideline people in the UK. But yeah, so I won, this is an award given by the British government. So I was announced as the innovator for 2016. And I was given the award by the Minister of Health. And this, of course, again, nationally and internationally lifted my...

31:36
profile and the profile of all of us now at Norwood Avenue. And then I began to go on the international speakers. I'm flown all over the place, including New Zealand. And those teaspoon of sugar equivalents really help people understand the glycemic consequences of carbohydrate foods and how cutting carbohydrates would help you if you had a...

32:05
I mean, type 2 diabetes is essentially carbohydrate intolerance. The nutrient, you can't, it puts on your blood sugar and that's essentially, so sugar becomes a poison to somebody with type 2 diabetes. And I often say, how poisoned do you want to be? Mildly poisoned, moderately poisoned or what? But I would say, as somebody with type 2 diabetes, the effect for me on diabetes is,

32:34
cutting the carbs was really, really dramatic. Now we should say, we have to give a little warning, don't we, to people. If you're on medication for type 2 diabetes, don't just stop your medication without, for heaven's sake, go to the prescriber and talk about what you're going to do before you just stop your insulin or something crazy like that. If you're on prescribed medication, be aware that

33:03
cutting the carbs may have an impact and you've got to discuss this with your doctor. So there's the little health warning that we must do. Of course. Yeah. And of course, we'll put links to the infographics in the show notes as well. David, you're... So it's just remarkable, isn't it, that this GP from a small town who want to live a quiet life is now on the speaker circuit for international...

33:31
talks on nutrition and health, which is phenomenal really, because you've got such a powerful message. Can you just give us your brief description of how a low carb diet helps mechanistically, I suppose, with diabetes, pre-diabetes? And I'm interested actually in your thoughts on the sort of cutoffs for diabetes.

33:59
and pre-diabetes as per using HbA1c and markers like that. Like, they're not arbitrary, but at some point, it's sort of, you know, I have people who come to see me and their HbA1c is, you know, 40, and they're like, well, I'm not quite pre-diabetic yet. So don't even have to worry about that. Okay, you've got a few really interesting points there, and we need to divide it down a little bit. So I'll deal with.

34:27
The last one first. So yes, that was one of the things. When we talk about hemoglobin A1c and pre-diabetes, that was the injustice that got me at the beginning. Because I suddenly thought, well really hemoglobin A1c, so this is the average sugariness of your blood for the preceding three months. And sugary blood reflects a high cardiovascular risk. And that's because sugar,

34:56
in the bloodstream is damaging the lining of your arteries very quickly. So that's the link between diabetes and heart disease. Sugary blood leads to damaged arteries. And then of course, pre-diabetes, so there are various arbitrary cutoffs. So we deal in millimoles per mole, and I can't remember what you do in New Zealand, whether it's percentages or millimoles per mole, but it doesn't really matter. The point is...

35:25
The hemoglobin A1c is a spectrum, and as you go up, so diabetes for us is 48 millimoles per mole or above. Prediabetes is 42 to 48. So let's think about prediabetes, 42 to 48. Well, that isn't optimal, is it? Is it optimal for health? No, it isn't. So it's doing a little bit of damage. So we come to this, how damaged do you want to be?

35:54
is a little bit of damage okay? Not really. And also how old are you? And the inequality that worried me was why is the cutoff 42 to 48 no matter what your age is? Because damage happens as a function of time. So if you are 25 with a hemoglobin A1C of 42, that's terrible. That's awful because it's that little bit of damage over a long time. And I realized

36:24
What about thinking about risk and age? And young people should have priority. And we were doing absolutely nothing in our practice for the young people with pre-diabetes. And I thought that was ethically or morally wrong. And they were the people we began with, the young people with pre-diabetes. Or even is a hemoglobin A1C of 41? How's that if you're 25?

36:53
It's a continuum. So what, where does optimal health lie? So that is just, I see it as a continuum. And maybe now, you know, if you're 80 and it's 43, maybe that's not as bad because the time for it to do its damage isn't as great, but if you're younger, I think you should be interested in, and could you improve it? Now let's go to the physiology of understanding what's going on because

37:23
This is key, I'm helping my patients understand what's happening and that helps motivate them and helps them individualize the diet. So we have to, not a deep dive, but a dive at least into insulin. So if we're saying that a high blood sugar is bad news and a high blood sugar damages your arteries, nature's solution is insulin. So insulin has an imperative to get sugar out of your bloodstream.

37:54
And it does this by driving sugar, pushing it where it can do less damage inside cells. And what, so it goes inside cells, well what for? Well, of course, you need energy, and if you're running around all the time, muscle cells are brilliant at using up sugar. But in the modern world, so many people eat far more carbohydrate foods.

38:22
the more biscuits, the more chocolate bars, they eat more breakfast cereals than they actually need to run around. And the excess energy is turned into fat, particularly in the abdomen, so you're seeing central obesity. But specifically, a lot of that fat is coming out, being produced by the liver cells. Yes. So you eat too much carbohydrate, insulin is driving

38:52
the sugar inside liver cells where it becomes fat. And here's the thing, that fatty liver, which is the product of that, interferes with the sensitivity of insulin. Your insulin doesn't work as well because of fatty liver. And this is the beginning of diabetes. But there's another thing that was shown by my friend, Professor Roy Taylor at Newcastle University.

39:19
Fat is building up in the very gland that produces insulin, the pancreas. So they have a double whammy. You have reduced insulin sensitivity because of fatty liver, but you also have a reduced ability to produce insulin because your pancreas gland is filling with fat. So this is the journey to becoming type two diabetic, is one of fat in the liver and in the pancreas.

39:49
So that it makes a lot of sense to prevent diabetes altogether. So if you could get in earlier, people with pre-diabetes or even earlier, then they don't have to become diabetic. In our own work, we've shown that people who go low-carb, my practice, have a 93% chance of a normal blood sugar. If they start...

40:18
going low-carb when they have pre-diabetes. If you wait until you have diabetes itself, type 2 diabetes, then in the first year of diabetes, you'll go down from a 93% chance of resolution to 73%. And if you wait until you've had diabetes for five years, it goes down to 50%. So quite clearly, the earlier you take action, the easier

40:47
it is. And this is one of my messages. It's an imperative. We should be interested in those in prevention, in those earlier. Don't wait and like I did until my blood pressure is high and I'm actually diabetic. It would have been far better if I'd woken up and known about this approach. It may be in my 20s or 30s because I probably came to harm in all those years of eating biscuits.

41:16
the high blood pressure that I had. You asked me a few questions. Have I answered them all or not? Yeah, no, no, no, you have. And I, and I'm, it's interesting, you're right. Everyone does eat biscuits and chocolate and, and crackers and things like that. But I think, and you mentioned this earlier with your patient and why didn't you tell me bread turns into sugar? And so you've also got the, the very healthy individual that are eating, that may be eating

41:45
healthy, what they would term healthy carbohydrate, yet it is still turning to sugar in their body because that's because they're not utilizing the energy that, you know, they're in excess sort of calorie load, regardless of the fact that their diet isn't junk food. And I think that's a really important thing for people to understand as well. I mean, diabetes is a state of carbohydrate intolerance. So the very nutrient you can't deal with.

42:14
is glucose. So once your insulin is not working properly, so I sometimes think, you know, for children it may be reasonable to say a healthy whole food diet with no junk food, but once your metabolism is damaged, I think that's where you have to nutrient carbohydrates become a nutrient of concern. I, to me, carbohydrate is a poison. I become unwell and sleepy.

42:43
I don't feel great on potatoes. I think the other question is healthy whole grains. So, you know, to my patients, what are healthy whole grains? Well, they say brown bread, but really, you know, brown bread isn't that healthy. That's actually an ultra processed food. They add sugar to it. And for my patients, brown bread isn't that good. And even brown rice, if you have type two diabetes, if you look on my infograms,

43:11
Brown rice itself is digesting down to considerable amounts of glucose and isn't a healthy food for me personally, whereas green vegetables really are. We were trying again to find simple ways for my patients to understand. One of the quick ways was turn the white stuff green. Enjoy a curry if you want or enjoy your steak or whatever. But instead of rice, why don't you have loads of green veg on the plate?

43:41
turn the white stuff green. Instead of the bread, could you have a big salad? Instead of the chips, could you have lots of green beans or broccoli with your steak? And that simple message has made it easy for my patients too. I still want them to enjoy their food. I think that's the important thing. Do you use continuous glucose monitors in your practice? There seems to me to be, for

44:10
people either love CGMs or they absolutely rally against them. For what it's worth, I think they're useful, but I'm not sure about your position on them. So this began with people with type 2 diabetes, whereas a continuous glucose monitor can be a lifesaver because they know what's going on and it helps them know how to look at their

44:40
to people with type 2 diabetes and insulin. There are people with type 2 diabetes using insulin and now internationally it's agreed that for them, a continuous glucose monitor can be useful. But really logically, knowing what your blood sugar is, continuously for somebody with type 2 diabetes is really important.

45:06
there is lots and plenty of evidence that time in range is important because the hemoglobin A1c is just an average over three months. So as an average, I'll give it to you quickly. So if we said 40 add 40 add 40 add 40, so four 40s is 160 divided by four is 40. So the average of what I just said is 40. But you could have

45:33
as a thing where you've got a hundred plus forty plus twenty and ten or whatever and the average of that is probably about forty. So average conceals highs and conceals lows and if you have diabetes those are important too. And so time in range and there's some really good evidence for this time in range for people with type 2 diabetes is important and supplying a continuous glucose monitor.

46:03
can reduce hospitalizations and can improve health. And there's evidence for that. So I've been using continuous glucose monitors as an educational tool for people with type 2 diabetes for years and getting really very good results. And I believe that these are the cavalry coming over the hill because you will.

46:28
You put on a freestyle Libra with type 2 diabetes and you will find out what spikes your blood glucose. You'll find out your individual truth. And so I am using, for me the freestyle Libras is the one I'm very familiar with. And I would encourage people with diabetes to try one and learn. I wonder who would be against somebody with diabetes trying.

46:57
continuous glucose monitor. I mean, the thing is some, if you're not very techy, so I have some people who, you know, are not very techy and it can be confusing for them. So they sometimes need a younger person in the family. So I've got some older people who it isn't suitable for them because they become confused. But that is only a minority, really. Even if you become confused with it, maybe somebody in the family would would help you.

47:28
So what are the arguments you've heard against using it for somebody with diabetes? Yeah, it was more people who were at risk of diabetes and people in that pre-diabetes range. So their markers would be in the normal reference range for blood sugar. So they didn't have...

47:53
they haven't yet been diagnosed with diabetes. That's where the argument lies. Okay. People, yeah. Yeah. Well, again, it's an educational tool. It's an expensive one. So, I mean, there's pros and cons. It does cost money. If you're pre-diabetic, I think you could learn very usefully where the sugar comes from in your diet and eat different things. And then you can experiment and you can individualize your diet.

48:23
You need, you're aiming for a diet that's healthy, a diet that fits in with your beliefs, a diet you enjoy, and a diet you can afford. And a freestyle Libra can really help you refine your diet. Because there's no two of us have the same diet. My wife, Jen and I, we don't have the same diet. It's different. So there isn't a low carb diet. There are many different. What you need is a well formulated low carb diet that supplies all the nutrients you need.

48:52
and doesn't put up your blood sugar. So freestyle Libra, I think this is the cavalry coming over the hill. I think many of my early enemies, I just wonder what the motivation would be for being against freestyle Libra if you're insulin resistant. I'm not saying that children should wear them, but if you're insulin resistant, I think it's probably a no brainer.

49:20
I think their main concern was the overzealous nature with which people may be overzealous about their health. I think that's what they're talking about, the danger of being far too interested. Yes, it could be that you would bring about an eating disorder, for instance. That hasn't been my experience. No, neither. And in fact, often things which...

49:48
you know, often things which are helpful for health and people are interested, they're often painted with this, well, just be careful because this particular practice will lead to a, like you say, like an eating disorder, which is actually quite a different, it's a clinical diagnosis. Yeah. Well, it is. Yeah. It is. And it hasn't been my experience. And bear in mind, you know, I've been doing this for 12 years now. Yeah.

50:16
I think the thing that leads to eating disorders are very often ultra processed foods where you over consume. So my patients with binge eating disorder, things like when you get down into it, they're often over consuming maybe chocolate bars or breakfast cereals, all sorts of things, but they're not over consuming steak and broccoli. So that it doesn't tend to lead to binge eating.

50:45
but I think ultra processed foods are far more likely to be the types of food in my patients that lead to problems. So I understand the concern and there is research being done into this anyway, we will find out. So yeah. Yeah. David, anything that you've changed your mind on in the last 10 years with regards to the low carb diet? Oh gosh, I'm in a constant state of flux really.

51:14
I learned at the beginning that I was wrong. And the possibility is there that I'm wrong and wrong. Everything we do is just a model. And then we're refining. So then, okay, you're going to cut the carbohydrates. So are you going to increase the fat or are you going to increase the protein? That's a big debate around the world, which is better. I think it varies. So I think increasing protein is broadly a good idea.

51:42
And I think that helps with satiety. And there's some evidence it may help even with insulin sensitivity. And yet there are other people who benefit from increasing the fat. And too much protein isn't good for them. So that's where I'm bouncing around a bit. Should it be low carb high fat, or should it be low carb high protein, or low carb fat moderate protein? And I'd...

52:12
I'm not sure about that. For many people increasing the, I'm beginning to think probably for many people, low carb and increase the protein and moderate fat seems, if I've got to generalize, but then again you end up trying to individualize it. Then the other thing is, so we're improving our data year on year on year. So we've now got 24% of the entire diabetic register.

52:41
NHS diabetic register, 24% to achieve drug-free remission, which is probably the best of any clinic in the world. And we're not a private clinic for wealthy people. It is an NHS clinic. So that shows what can be done. And we've done it partly by inexorable curiosity, really, about our successes, but also our failures. And this leads into Jen's work.

53:10
Why do people fail on the low carb diet? The commonest reason, I would say, is addiction to carbohydrates. And we see this every Christmas. I hate Christmas in what it does to people because I've got them all sorted out and then Christmas comes along and the carbs go in and it can be months until I've managed to get them safe again. And this you've interviewed, Jen. Well, I take

53:39
carb addiction very seriously, it kills some people. People die for their inability to stop eating bread, to stop eating breakfast cereals. I've had people who are on insulin only because they cannot regulate their cornflake consumption. That's what you find out with the Freestyle Libre. You say, what's that spike? I had one guy and the spike was cornflakes, but he was eating cornflakes.

54:08
a huge mixing bowl of cornflakes when I got a photo of what he was doing. And carb addiction, when intelligent people do stuff, they know harms their health. So people with diabetes know they shouldn't eat sweets. They know they shouldn't have puddings. And if you really struggle to not eat bread, to not eat ice cream, maybe the problem you have is carb addiction and that gents the psychologist.

54:39
And she's opened my eyes to that. And I'm now finding carb addicts. We're discussing carbohydrate addiction in every clinic I do because it's the people, it isn't just about doing a sensible thing, it's about maintaining it. So loads of people do the right thing, but what spoils all sorts of research things are done around the world. And what always happens is initially they do well.

55:07
on a low carb diet, but then the results deteriorate and they deteriorate because of the lack of attention to maintenance. And in our clinic, maintenance is absolutely key to ongoing success for people. And you know, what helps you maintain the approach? How do your families see it? What are you going to do about a holiday? Those all-inclusive holidays where they're pushing carbs. What are you going to do about Christmas?

55:37
What are you going to do about your next birthday? It's really important that you anticipate these problems and that you are supported to make better choices as people go off the rails. And in my practice, you never fail. I always will take you back. That's why we run the groups. We've got a group tomorrow night. We've been doing it for 12 years. People who fall off the wagon can come and we'll help them again. Maintenance.

56:07
is absolutely key. And carb addiction is one of the things that interferes with maintenance. Yeah. And I was surprised with Jen's statistic of one in eight potentially having like carb addiction. And I agree with you, David, it's people, at least in my experience, people are very good at being on a diet. But then when they're off a diet, they're so far off a diet.

56:36
They just haven't had that experience of what it's like to maintain. You do need as much support in that space as you would with the initial sort of dieting phase as well. So I appreciate that. Absolutely. I mean, the number of Jen herself was a yo-yo dieter. You know, her first diet when she was about 16 and loads of people like that. There is a really interesting study from Denmark and they were looking at people.

57:03
with food addiction in Denmark, and they are six times more likely to end up with type 2 diabetes. So people with food addiction are six times more likely, so 600% more likely to have type 2 diabetes if you have food addiction. And that's a really good study from Denmark. And food addiction needs...

57:30
taking seriously and we've just had a very successful international conference in London in the Royal College of General Practitioners, a sellout event in the Royal College and people came from all over the world to learn about food addiction because you cannot manage maintenance without a sensitivity to the question of why do your clients eat what they eat? What is the problem? And we have to be curious and interested in why people eat what they eat.

58:00
completely and I was really interested when Jen was talking about the conference when we spoke about that. And finally, David, with your work in this space, I'm really curious, you run a number of groups. Is your education for other practitioners, does that help set other general practices up?

58:27
to run similar groups, is your model in Southport now being replicated in the UK? Yeah, I'm so pleased to tell you. So there are doctors all over the world now who have replicated my work and got really similar results. And you have doctors in New Zealand, you have GPs in New Zealand who have published on this work.

58:57
who are offering this approach. And there's a wonderful initiative coming from Auckland headed up by Professor Grant Schofield. What a charming, amazing guy. An academic, how clever. I love that guy. What energy, what commitment, you know. So he's heading this up with Karen Zinn, but also

59:27
New Zealand interested in this approach and some of them have published. So, oh yes. I mean, the proof of the proof, you know, what's evidence, medical evidence is something that works for one practice, but can be replicated. Replicated in, I've got people in Israel. I've got people in Spain, in North America, in Nepal.

59:56
But in New Zealand and yes, it works all over the world and has been published. The results are published there. Who's that GP's first name is Marcus? Marcus Hawkins. Yeah, Marcus Hawkins in New Zealand. What a hero. You have your own hero. You have him on you. You probably had him on your podcast already. Not yet, but I do intend to. He really is.

01:00:26
I will. Yeah, that's right. He's sparky as Glenn. Sparky, clever. You've got some real clever people quite able to lead this in New Zealand. And it's so serious. I think it's a plea really. So when I was a young man, diabetes was rare. When I was a young man, diabetes was rare in New Zealand.

01:00:53
And when my generation of doctors, so I can remember a time when diabetes was very rare. Nobody in my family had diabetes. As a 15-year-old, I'd never even heard of it. There was nobody, anyway, I never saw anybody. Now it's really common, and the youngest person I've got is 12. Now there's real urgency to this, because when my generation of doctors has died out, nobody will remember that diabetes doesn't have to be common.

01:01:23
It's quite unnecessary. We could have, again, we used to have a world where diabetes was rare and was confined to elderly people. This applied to New Zealand. And the urgency is if you don't act soon, nobody will even remember that diabetes can be prevented. And what a tragedy for your young people. Because it will be normalized obesity.

01:01:48
and diabetes are being normalized, that we accept fat kids, we shouldn't. We shouldn't, it's wrong. Their future, we're selling their future. And that's a terrible, terrible injustice. And I am angry and distressed about what we are doing. We are just destroying the future of our young people. And it requires energy.

01:02:17
and it's urgent that we do something. These shops, just look in any shop, anywhere in New Zealand, go into a supermarket, and most of that shop is selling carbohydrates that's gonna lead to people having type 2 diabetes and gaining weight. Very urgent, we need action.

01:02:38
David, I could not agree with you more on that. And I feel like people can be reassured that even if their GP isn't on board or doesn't have the knowledge, they don't probably have to look too far, particularly here in New Zealand, and obviously especially UK, Australia, the States, to find doctors that do have the knowledge and are willing to help them. So if not just manage

01:03:05
and put diabetes into remission. But even on that preventative note as well, like you're healthy now, what can you do to stay healthy? And I think that's really important too. What you could do, so if we're, again, either if there's a healthcare professional interested, they could print my paper off. 100%. Or if you were considering, if you wanted to work with your doctor, you could print off my BMJ nutrition paper, which has the diet sheet and everything is in there. And you could take that to your doctor and say,

01:03:34
I'm not a doctor, but I've looked at this and I wonder about, could I improve my diabetes by this? And then the doctor would see that this is an approach that has some international following. And it's not outrageous. It can't be outrageous to try and avoid the foods that put up your blood sugar. That's all you're trying to do. You're trying to eat nutrient dense food that doesn't put up your blood sugar.

01:04:03
say that's what I'm trying to do. If you said that to your healthcare professional, I would hope that they would support you do that, or at least be able to explain why that might be dangerous for you. Yeah, no, I completely agree with you, David. Thank you so much for your time this morning. I really appreciate it. And I hope you still have time to go out for your run. I'm a runner. So I felt that, that you were there in your running shorts waiting to go for a run.

01:04:31
I am here in my running shorts. The sun is shining. It's the very beginning. Oh, it's so beautiful. We live by the sea here and the flowers are out. The sun is out. I should be out listening to Birdsong. So I feed my animals. So I have hens and geese and sheep and things. I go and feed those and then off I go running. That sounds amazing, David. And we will put links to the BMJ nutrition paper.

01:05:00
your infographic paper. I will look for it and will find that Denmark paper. I think that's super interesting and I think my listeners will be very interested in that as well. And of course to your Twitter feed or X feed because I always find that super interesting to follow along.

01:05:24
The community is very lively on Twitter. That's how you find out what's going on. There's conferences, there are webinars, there's loads of information for interested people. Good point. Yes, amazing. Thank you. Thanks so much, David. You have a great evening or great day. Okay, thank you.

01:05:52
Alright team, hopefully you enjoyed that conversation as much as I did. You can see he was doing some amazing work out there and the fact that he's working to educate other practitioners, much like Dr Marcus Hawkins is here in New Zealand, means that more people from the grassroots are being able to take back control of their health, which is amazing.

01:06:12
Okay, well next week on the podcast I speak to Professor Tom Seyfried about the metabolic approach to cancer therapy and I think you guys are really gonna love this. It was really a wonderful conversation. That's next week on the podcast. For now though you can catch me over on Twitter, Instagram and threads @MikkiWilliden, Facebook @MikkiWillidenNutrition or head to my website mikkiwilliden.com and book a one-on-one call with me.

01:06:41
Alright team, you had the best week. See you later.