Cardiologist REVEALS Why LDL Cholesterol Is Actually Good for You (It DOESN’T Cause Heart Disease)

And people are getting more comfortable... in saying... that a high "LDL" cholesterol in the setting of metabolic health... is not something... that needs to create a concern, but is something that may require a celebration.

People who have had heart attacks, when you go and take out their blood vessels... and you analyze it with histochemistry, you will definitely find elements of cholesterol and "LDL" cholesterol. But the important question is, why is it there? Is it there as an arsonist or is it there as a firefighter?

There is... no real reason... in my mind to lower "LDL" cholesterol. There is every reason in my mind to improve... your lipoprotein quality.

Doctor "Ali," why is it that when we go on a low carb diet, our "LDL" cholesterol goes up?

That's a very interesting question, "Jesse," because I get that asked all the time. And... the reasons are that first is that you are eating a diet that is high in cholesterol... Animal food has cholesterol, and almost... all low carb food is animal sourced food. And as a result of that, since you're eating all the cholesterol, the liver goes on vacation. So in a vegetarian who is not eating any cholesterol, the liver is charged with the task of providing cholesterol for necessary body functions, because cholesterol is needed by every... cell in the body. So when you start eating cholesterol, the liver says, hey, I can focus on other important things that I have to do. And the liver stops making cholesterol. And when it stops making cholesterol, it doesn't need the cholesterol because it's getting all the cholesterol from food. So it down regulates the receptor on its surface which is picking up cholesterol or "LDL" cholesterol from the bloodstream. And as a result of that, people's "LDL" cholesterol goes up. So it goes up for a few reasons. One is that you're eating a lot of cholesterol, and high cholesterol is good for the body. And so the body says, hey, I should keep this high cholesterol because it's good for me. And number two is that the liver stops picking up cholesterol. And so the "LDL" cholesterol remains in the bloodstream, and that's good for us.

Okay, a couple of nuances I want to get into before we move forward. You mentioned that... if somebody wasn't eating meat or animal products, they wouldn't be taking in cholesterol. Are there a couple exceptions when it comes to coconut oil and... tropical oils?

No, -- there is no cholesterol in plant based food. So... plant based food has an interesting molecule which is called phytosterols. So phytosterols is plant cholesterol and our body cannot use phytosterol. In fact, if somebody is having a lot of plant based fat. For example, avocados or any type of oils. And they are taking statins. Statins are medicines that our body the body takes up and it goes and tells the liver to shut down the production of cholesterol. So in these individuals the body is really saying, hey, I am really struggling. The reason I'm struggling is for some one reason or the other, the liver is not making cholesterol and hence I should... take as much cholesterol as is present in the diet. So bear with me. We are going off on a little bit of a tangent, but it's an important tangent. So the body says, hey, I need to pick up... all the cholesterol that is there in the food and let me become a little bit less choosy, let me become a little bit... indiscriminate. And instead of just picking up animal cholesterol that humans can use, it starts picking up phytosterols, which is plant cholesterol. And picking up phytosterols is dangerous for us. It's not good for us because phytosterols gets into our cell membranes. The cell membranes have different orientation... The phytosterol doesn't work the same way that cholesterol works. So if you look at people who are on statins. They have a lot higher blood levels... of plant based cholesterol or phytosterols.

For somebody that's not on a statin, do we need to avoid these plant cholesterols?

I don't think so, because the body has an active mechanism to spit it out. For example, if the lining of our gut picks up the phytosterols, the body can spit it out unless it becomes indiscriminate, in which it really... is struggling to keep up cholesterol supply to the body. And it says, hey, I'm just going to pick up whatever I can get.

And coming back to my follow up question there about cholesterol in the diet, a plant based diet, I think what I was actually getting at there is saturated fat which is converted to cholesterol. And the saturated fat would be in things like coconut oil.

Sure, yeah, saturated fat is there in coconut oil and all that. But the body, I'm not sure as to how much of the saturated fat actually gets converted to cholesterol. The body has about 25 different enzymatic steps to make cholesterol. And I think the one of the reasons why cholesterol goes up predominantly on an animal based diet is because of the amount of - - cholesterol that you're ingesting.

Now, there is one of the theories that I have propounded, which I'm not sure exactly how accurate that is, is that when you go on a low carb diet the body is making a lot of ketones. So since the body is making a lot of ketones, the ketones are predominantly made in the liver... The cholesterol is also made in the liver. But the ketones are made in the mitochondria, which is a part of the cell. Whereas cholesterol is made more in the cytoplasm, which is a different part of the cell. But what many people do not know... is the first six steps of making ketones, the first five or six steps of making ketones are the same steps that body uses to make cholesterol. So it would make sense that if somebody is on a low carb diet, eating and consuming a large amount of saturated fats, and they're making a lot of ketones, the ketones... provide a substrate to make additional cholesterol. Now, whether this is accurate or no, I'm not sure that the enzymatic steps have been worked out or the studies have been done to corroborate this. But this is one of the theories that I had propounded and I don't think it's either been refuted or confirmed.

All right. The other follow up question I had for you was you mentioned that if somebody is on a low carb animal based diet, the body stops making cholesterol. And in that case, if it is coming in through the diet, the cholesterol, does the body still make a very small amount... or does it totally stop making cholesterol?

I don't think anybody can answer that for sure, but I would say it depends on your age, it depends on how physically active you are. It depends on your inflammation status because for example, infants neonates have the lowest levels of cholesterol in the blood. And you would think that they are not. The reason they have low cholesterol levels is because they're not making cholesterol. In fact, they have the highest synthesis of cholesterol. And the reason for the highest synthesis is that they're growing, they're making new cells. These new cells need cholesterol. All the cholesterol that the cells need cannot be provided by cholesterol production within the cell itself. So the liver has to supplement that. So for example, if somebody is very physically active, like a marathoner or an exerciser, then perhaps the body still makes to some degree its own cholesterol because you're not eating enough. It needs to supply cholesterol to the tissues for the tissues to be repaired and new tissue to be laid in. Perhaps the body makes new cholesterol if it's undergoing inflammation and infections because the "LDL" molecule is needed to dampen inflammation, to fight the invaders and to repair tissue. -- I think that the rate of synthesis of cholesterol... by the liver... has not been completely worked up. So nobody knows these concepts perfectly. So if somebody sits there and says, hey, I know it for sure that when you're on a low carb diet that the liver completely stops making cholesterol or is making a small amount of cholesterol. They are guessing. They don't know for sure.

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Okay, but the general theme is that when the body makes cholesterol, that is a fallback system for when we're not taking it in through the diet.

That's correct. The body wants to take the path of least resistance. -- Imagine having to go through 25 different expensive steps... to make your own cholesterol. Instead of doing that, why not just take something that you have eaten? You will save so much in terms of energy.

The only exception to that, and many of the doctors don't know this. In fact, I have not come across a physician in my, that I know of who knows this fact. And that particular... fact is that there is one organ in the body that refuses to take any cholesterol from the liver or from the food that you eat. It makes the entirety... of its own cholesterol from scratch. And it is the organ that has the highest amount of cholesterol in the body. 25% of body's cholesterol is in that organ. And it's making its cholesterol entirely from scratch from basic molecules. And I'm sure you guessed which one this is, it's the brain.

The brain, yeah.

Blood brain barrier keeps things from going in.

Exactly, exactly. You've touched on, we're going to get to the brain, I'm sure here in a little bit. But you started to touch on some of the roles of "LDL" cholesterol, when you talked about inflammation and infections, take that even further and let's get into the benefits of "LDL."

Absolutely. So I think it is very unfair to call "LDL" the bad cholesterol. I just call it the other good cholesterol. And there's good reasons for that... because there's a ton of literature... which has been propounded by "Malcolm Kendrick" and several other scholars who talk about people who are older. The prediction of lower mortality comes in these people, from them having higher levels of "LDL" cholesterol. So let's explore the roles of "LDL" cholesterol. It has antioxidant properties, so it is fighting inflammation, it's dampening up inflammation... It has properties to neutralize invaders into the body, such as bacteria and viruses... So people with high "LDL" cholesterol are at lower risk of infections. We know that by studying people who have a genetic tendency to have high "LDL" cholesterol. These are people with familial high "LDL" cholesterol because they lack a receptor in the liver... that picks up "LDL" cholesterol from circulating.

We said that there are other... good properties of... "LDL" cholesterol because it's supplying cholesterol to... the testes and the ovaries. The testes and the ovaries cannot make enough cholesterol. And... they pick up cholesterol from "LDL" and convert that into estrogens and testosterone. So... that's a very important hormone for our body, for well being, for muscle strength, for insulin resistance. In fact, there is a whole group of people, and I'm not an expert in that, and it's something that I want to get into, which is called bioidentical hormone replacement. And one of the reasons why they want to give bioidentical hormones is because it... is... a mechanism, just like a low carb diet and intermittent fasting and exercise, to improve on insulin resistance.

We can get into some of the other... nuances... of cholesterol itself, not necessarily "LDL" cholesterol. And one of them is that it is a component of... an important... part of our cell membrane. Every cell in our body has a cell membrane. And that cell membrane... is doing important functions. It's interacting with other cells, it's interacting with other molecules. And in the cell membrane is a cholesterol rich domain, which is called the lipid raft. Now, it is fair to say that there is some controversy whether the lipid raft actually exists or no. But suffice it to say that cholesterol is a very important... component of the cell membrane and an important component that helps the orientation... of certain... receptors on the cell membrane. One of these receptors is the insulin receptor. The orientation of the insulin receptor... depends on cholesterol, appropriate amount of cholesterol in the cell membrane. And if you reduce the cholesterol through artificial means like statins and stuff. The orientation of the insulin receptor is disrupted. Insulin doesn't work well and it can give rise to a phenomena of insulin resistance.

We also just got through talking that brain is that cholesterol is very important for the brain. Since cholesterol is very important... for the brain. - We need to find out the reasons for that... One of the primary reasons is that interaction between brain cells is mediated through cholesterol connections. One brain cell talks to another brain cell through cholesterol mediated connections. Because the neurotransmitters which... help one brain cell talk to another brain cell are in a part of... the neural cell membrane that is cholesterol rich. So if you reduce cholesterol in the brain and you would ask me, how can I reduce cholesterol in the brain? I would say maybe about 20, 25% of North American population is doing that currently... by taking drugs called statins. We just went through a little while earlier and said that cholesterol does not cross the blood brain barrier. The brain makes the entirety of its own cholesterol. But you'd be surprised that most physicians dismiss, and perhaps many of them don't even know that statins cross the blood brain barrier and disrupt the cholesterol production in the brain. So it's not unusual for people... who are on very high doses of statins to come talk to me and tell me that, hey, they're cognitively a little bit impaired. One of them was a neurologist.

For the lay audience. - We may want to say who a neurologist is, because a neurologist is a brain doctor. A young brain doctor in his 50s. - He had a cardiac event, he had a stent, and he got placed on 80 milligrams of a certain drug called Atorvastatin. It's also called "Lipitor." So he was telling me that, hey, I see a patient and I know that... my ability to synthesize all his clinical information, what he's telling me. It happens in a matter of milliseconds. - You see him and you're listening to information and you're synthesizing. - It started taking me a lot longer to do that. And I was wondering... why this is the case. And I thought I was getting older and it was not until I started talking to you that I realized that perhaps it's a side effect of statins. In fact, if you look at the "FDA" label for statins, it talks about cognitive and memory impairments in several individuals as a result of taking statins. So those are some of the other things... that cholesterol does in addition to some of the good properties of the "LDL" molecule.

Well, so far, when it comes to "LDL" and cholesterol in general. It sounds like there's all upside, no downside. Why are we fearing "LDL" in cholesterol? Where did all this begin? And is there any merit at all to that?

I first want to make clear that I'm not giving individual medical advice. And I want to make sure that people understand... that mainstream medicine thinks that... lowering "LDL" cholesterol in almost... everybody... helps reduce the risks of coronary artery disease and strokes. - However, we are having a scientific discussion and for anybody who wants to use some of this information for deciding whether they want to reduce or not reduce their cholesterol or take a statin or a different drug that alters their cholesterol. That please consult your physician. Don't rely on this information because this exchange is a scientific exchange.

So, in my mind. I think that... the most important aspect of your lipoproteins. Now, lipoproteins means the molecules in our bloodstream that are carrying cholesterol, fat, "CoQ10," other substances, and one of them is "LDL," which gets the name bad cholesterol. I think, like I said, I love to call it the other good cholesterol or the good cholesterol. There is... no real reason... in my mind to lower "LDL" cholesterol. I think there is every reason in my mind to improve... your lipoprotein quality.

So what do I mean by that? The lipoproteins in your body are... a surrogate marker of your metabolic health. So metabolic health, meaning somebody who's got normal blood sugars, who's got normal levels of fat in the blood, normal levels of "HDL," or what many people call traditionally the good cholesterol and perhaps high quality "LDL." In other words, "LDL" can also be a reflection of your metabolic health. So let's take such a person, let's say a person is physically active. They have some degree of time restricted feeding, that they're not constantly gouging food all the time. Let's say that they are on a diet that is relatively free or low and... sugar and refined carbs and in seed oils, vegetable oil. So if you look at these individuals, as a rule, they will tend to have low levels of triglycerides. Triglycerides is fat and blood because they are fat burning. -- Their fat cells have a lot of space to pack fat in. So the fat, extra fat gets packed into the fat cells. And they have high levels of "HDL" cholesterol, which is the good cholesterol. And in most of these individuals, they will have high levels of "LDL" cholesterol. But if you look at certain markers of their "LDL" cholesterol, predominantly the large and fluffy type. So it's not the small and dense type of "LDL" cholesterol that is associated with metabolic ill health. In people have high triglycerides, low "LDL," have high insulin levels, high levels of blood sugar, inflammation markers and stuff like that. So if somebody comes to me and they have high "LDL" cholesterol, and their cholesterol is small and dense. I don't tell them to reduce their "LDL" cholesterol. I tell them let's work and improve... on your "LDL" quality, but let's reduce your triglycerides, let's increase your "HDL," let's make you less insulin resistant. Let's do that all with lifestyle changes because fortunately there are no drugs that can really alter any of these parameters in a meaningful way... Yeah, there are some drugs that'll help you get there but not in a meaningful way.

Let's move into oxidized "LDL." This is another one that you hear being problematic when it comes to "LDL."

Yes -- So oxidized "LDL" is an "LDL" molecule that has gone into an area of inflammation and sacrificed itself to protect the body. And... the "LDL" itself gets oxidized. And people think that oxidized "LDL" is a problem. And what I want to tell those people is that, yes, oxidized "LDL" is trying to tell you that something is wrong. And it's trying to tell you that I'm here, I'm trying to protect you. See what you're doing wrong, so that there is less oxidized "LDL." Oxidized "LDL" itself is not the problem. It is like a firefighter who's gone in to dampen out the fire, dampen out the inflammation, dampen out metabolic ill health that has caused tissue injury and in the process... got injured and got oxidized. So -- it's not the causal agent in my mind. It's the... one that is the firefighter trying to help put out the fire. It's not an arsonist. And -- there are several if you really look into literature and if you look at molecular studies... and I have a "YouTube" video that talks about is oxidized "LDL" a firefighter... or an arsonist. I think it's a pretty good one. It's very nerdy. Most of my conversations with people are pretty nerdy. -- The oxidized "LDL" undergoes a change in the way it looks. And since it's a change... it no longer gets picked up by the regular receptors that pick up "LDL." "LDL" is constantly needed by cells that are going through injury... So there is an "LDL" receptor on every cell that picks up "LDL" from circulation just like liver does. But oxidized "LDL" does not have an expressible "LDL" receptor. So the "LDL" receptor is not very robust in them. And so the liver does not pick up the oxidized "LDL." On the other hand, there are scavenger cells in our body. - For example, the US army says that, hey, we're not going to leave any injured soldier on the field. We're going to go pick up every single one of them. Similarly, the body has scavenger skulls that are picking up damaged debris. Damaged cholesterol of which or damaged "LDL" molecules of which oxidized "LDL" is damaged "LDL" cholesterol. And so the scavenger cells, like macrophages, monocytes, they have receptors to pick up this oxidized "LDL" cholesterol. All of these are repair mechanisms in the body. And I think it's a matter of convenience and probably a very good story to try to sell them as a problem so that you can reduce the cholesterol. Given the lay public the... feeling that, hey, by reducing cholesterol, I'll reduce oxidized cholesterol. And by reducing oxidized cholesterol, since that's the culprit, and causing atherosclerosis or plaque buildup or blockages of the blood vessels that I will benefit.

I want to make sure I understand where the oxidized "LDL" comes from... You mentioned the scavenger cells that can pick it up. It's not binding to receptors like normal "LDL." Mmhmm. But... how is it becoming oxidized? I want to make sure I understand that piece.

So let's say you have a site of vessel injury. You have high blood pressure. You have inflammation of some sort going on. And that those cells in that area are damaged. There's a lot of free radicals that are causing injury to the cells. So the "LDL" cholesterol goes to the side and... it is trying to dampen out the inflammation. First of all, the "LDL" cholesterol has "CoQ10" it's got vitamin E, it's got several antioxidants inside it. It will consume those to dampen out the inflammation. Then it will use the phospholipid layer of the "LDL" molecule... to dampen inflammation. In that process, it gets oxidized. So the "LDL" is getting oxidized, going to a site of injury, going to a site of the fire and getting converted from a regular "LDL" to an oxidized "LDL."

Okay, so at this point, we know that big and fluffy "LDL" are definitely not a problem. They're actually to our advantage. But what about when that number gets really high? Do we ever have a certain threshold that we cross, even if the "LDL" is healthy, that we want to be wary of?

It's a very interesting question, and I'm not sure that there is a perfect answer for that. For example, there's a lot of debate and literature about people with high familial "LDL" cholesterol being high. They have a genetic tendency. This is called familial hypercholesterolemia. And these people... have sky high "LDL" levels. Now, when I say sky high, they have them in the mid-300s, low 400s. Somebody will have even in 500 levels. So this is 500 milligrams per deciliter. So... the American Heart Association thinks that the healthy levels of "LDL" cholesterol is 100 and below in normal individuals and below 70 milligrams per deciliter in individuals with heart disease, with coronary artery disease. So now here we are talking about levels of "LDL" cholesterol that are three to four to five fold higher. Mid-200s, mid-300s, mid-400s, even 500. We are saying that... these individuals, because they have familial high cholesterol, are at higher risk of cardiac deaths. And there's a lot in literature that says that people with familial high cholesterol have higher risks of coronary artery disease. But there's an equal amount of literature... that substantiates the other viewpoint. And that other viewpoint is that these people have just about the same average lifespan as somebody who does not have this genetic mutation. And that they are at no higher risk of getting heart disease... compared to a normal cohort. So now here you're talking about people who have a genetic mutation to have high "LDL" cholesterol. Now, most individuals who are on a low carb diet do not have that genetic mutation. And there are several people who maintain "LDL" cholesterol... of 200s, 300s, 400s, even 500s. And the conventional wisdom is that these people... are at higher risk of heart disease... and hence they require treatment. And that used to be the case a sliver of hope is coming... And I'll plug in "Dave Feldman" and I'm sure you may have interviewed him too. But "Dave Feldman" is... an engineer. He's done some very seminal work for being a non physician in whom he has taken individuals just like I described. People who are on a low carb diet, who do fasting, who are physically active, who have the phenotype of what is called a lean mass hyper responder. They are lean and they have... high levels of "LDL," low levels of triglycerides and high levels of "HDL." So this is the kind of population... that any mainstream medical physician would... look at. If an individual like that with 500 of "LDL" cholesterol went to their office. They would say, Mister "John Doe." You have levels of "LDL" cholesterol that is going to result in a stroke or heart attack before you leave my office. And before you leave my office, I want you to take this 80 milligrams of this cholesterol lowering medicine and take it... for the rest of your life. And immediately stop your diet because it's creating a dangerous metabolic health and numbers in you. But we have for the last we have been in this field now for about 11 to 12 years and have routinely seen individuals like this and I have followed them for about 10 to 12 years and they have lived a healthy life free of cardiac events. In other words, there has not been an excess incidence of heart attacks or strokes. In fact, these are individuals who feel good. They feel really very healthy, they... are physically active, they have lower risks of infection. And "Dave Feldman," along with Doctor "Budoff," just as in the process of publishing a study in which these people, these lean mass hyper responder patients had high "LDL" for about 4.7 years. And when you looked at objective markers of plaque buildup such as calcium score... or plaque buildup on coronary "CT" angiograms, these are angiograms done with a "CAT" scan in which... not only can you look at the... flow through the blood vessels, the size of the lumen. But also can look at plaque buildup inside them. He found that these people have no higher plaque buildup than age matched cohorts. In fact, they may have a little bit of lower plaque buildup and... a... similar or lower event rate. So, fortunately, some of this information is now emerging. And people are getting more comfortable in saying that a high "LDL" cholesterol in the setting of metabolic health is not something... that needs to create a concern. But is something that may require a celebration.

Which then brings me to the obvious next question. Because "LDL" is so looked at as the culprit of heart disease. If it's now innocent. What do we look to as the cause of heart disease and stroke?

Well we have several culprits in this area. You can take insulin resistance as one of them. That creates inflammation. We can look at aging. We can look at high blood pressure. We can look at diabetes. These are all factors that would accelerate vascular disease. We don't need to incriminate... "LDL"... as a cause in it when there are all these factors that are leading to heart disease. No question that "LDL" is a part of the plaque, the plaque that is built up and blood vessels that have... blockages. And people who have had heart attacks, when you go and take out their blood vessels and you analyze it with histochemistry, in other words, you analyze what's there in the plaque, you will definitely find elements of cholesterol and "LDL" cholesterol. But the important question is that why is it there? Is it there as an arsonist or is it there as a firefighter? And in my opinion, and this is not mainstream opinion, I think it's there as a firefighter. It's there as a molecule that tried to dampen inflammation, that tried to repair the damage. And it got caught up in that damage. It was overwhelming. And it's there for that reason.

Earlier you mentioned "Malcolm Kendrick," and he's a previous guest of the show, and his. Well, it's not actually his hypothesis, but the one he stands behind is the thrombogenic hypothesis. How do you feel about that?

And there is a lot of merit to that. There is also called instead of the inside out, there's an outside in hypothesis. So let's take the thrombogenic... hypothesis... first. So the thrombogenic hypothesis is stating that there is... a formation of a blood clot at a location of vessel injury. Our blood vessels, aligned with an endothelium. Endothelium is a lining of the blood vessel. And it prevents blood clots from forming. So in other words, blood is flowing through it normally without forming blood clots. One of the first factors of vascular injury is endothelial damage... That means the endothelium either get removed because of high blood pressure, because of... metabolic ill health, because of insulin resistance. Because of inflammation from other causes. And when that happens, the sub-endothelium gets exposed to blood flow. Now, the sub-endothelium is very thrombogenic... By that I mean the sub-endothelium starts to incite... blood clot formation because that's a very primary defense mechanism in us. If we had a blood vessel that got - injured for example, we were in the back in the savannah, we were fighting an animal, and we got injured in the process, and we started bleeding. If we didn't have blood clotting mechanisms, we would bleed to death. So... the clotting mechanism that's happening is trying to heal the vessel, and it's trying to prevent the blood vessel from leaking blood all over and causing bleeding. And as a result of that, blood clot starts forming... And... in a blood vessel... that... is... small supplying the heart. The... blood vessel can get occluded by the blood clot going to completion, blood flow stops, and that will result in damage to the area supplied by that blood vessel. So his hypothesis is that every time you have endothelial injury, you're forming some amount of blood clot. Now, that blood clot may not go to completion, but that blood clot is the early plaque. And as the body starts responding to dampen inflammation, that plaque grows bigger and bigger. If injury continues, then people will have more and more plaque in that area. Now, that's an accepted theory... of plaque formation. - It's not just... "Malcolm Kendrick," but several mainstream physicians like "Valentin Fuster" and many others. It goes back all the way to an ancient physician by the name of "Virchow," V-I-R-C-H-O-W. And he is the one who -- propounded all the three major properties of the blood vessel that prevents blood clot formation. One of them is the endothelium. The other one is your blood hyper-coagulable? Is your blood have a tendency to clot? And your blood will have a tendency to clot if you're insulin resistant, if you have inflammation. And the third thing would be flow. In other words, at branch points where the blood vessel is branching. There will be not... normal laminar flow, but there will be disruption of flow. In other words, there will be turbulent flow. And so if you look at blockages... of the blood vessels of the heart or the body. Generally they format bifurcations where the blood vessel is branching into two. And those are the areas where you will find -- plaque buildup.

You've mentioned insulin resistance a few times, and I know a number of years back you had a pivot in how you look at that. I'll have you talk about your traditional thinking of insulin resistance and then how it's changed over the years.

Insulin resistance is very interesting, and I think the lay public has a better understanding of insulin resistance than physicians do. Insulin resistance is defined as the amount of insulin that is required to keep blood sugar at a certain level. So let's say you have normal blood sugar of about 90 or so. And you're fasting -- insulin level is around 4. So 90 times 4... gets to I think, 360. And that divided by 404 gives you, 405 gives you a number called the "Homa IR," the homeostatic model of insulin resistance. And that number will be less than 1. So that is considered to be somebody who is insulin sensitive, who does not have high levels of insulin to control their blood sugars. So insulin resistance is a phenomenon in which in order to keep the blood sugar -- in normal range, the body has to create... higher and higher and higher levels of insulin. So... people would say, hey, okay, no problem... What's wrong with just keep higher levels of insulin, keep the blood sugar in control, just give people... extra insulin doses if they don't make their own insulin. But the problem with high insulin levels is that it's going and doing several bad metabolic things for you. Number one is that it shuts down fat oxidation. Your body, in the setting of high insulin level, cannot burn fat. Number two, insulin is a very anabolic hormone. So in its... also good and bad. Anabolic hormone means that it makes the body store fat. It's a storage hormone. So people who are... diabetics who are given 100, 120, 150, even 200 units of insulin, in other words, medical profession... has no problem prescribing 200 units of insulin to somebody. And these individuals... will keep gaining more and more weight because they are not fat burning, they're just continually depositing fat. So that's a major problem. High insulin levels prevent fat burning... and... promote fat deposition. Also, high insulin levels through several... different... mechanisms increase your blood pressure. High insulin levels also cause inflammation. High insulin levels are also associated with an increased cancer risk because you're activating several... factors that are increasing cell division that are causing growth. So it's not a surprise... that several decades of hyperinsulinemia... or insulin resistance leads to high blood pressure, heart disease... increased risk of cancers, obesity, and finally, what is called dementia, because insulin resistance in the brain is one of the primary factors for type 3 diabetes. Which is another name... for dementia. Brain insulin resistance is type 3 diabetes.

And the piece I was getting at, where your thoughts changed over the years is before you thought of the cell as being full of glucose. Insulin gets ramped up by the body to try and jam more in. And your latest thinking is that there's some kind of change or missing receptor on the cell for insulin, and the cell is actually starving inside for glucose. So talk about that pivot.

So yeah, and these may be semantics, and there are certain physicians who have propounded the theory that -- the reason... for all this disease is that the cell is already filled with a lot of sugar, and - sugar cannot be driven into the cells, and so the body makes more and more insulin. That's not the way it works. The way it works is that insulin resistance is a mitochondrial disease. So I have to explain what mitochondria are in the first place. So mitochondria --- are -- part of every cell that is... creating energy for the cell to function. So a cell has a nucleus, which is the nuclear material. It's got a cytoplasm, it's got a cell membrane. And then there is an engine of the cell, which is called the mitochondria. So mitochondria... are organelles that are taking nutrition. They're taking glucose. They're taking fat, they're taking protein. And through the mitochondria, through... the Kreb citric, they have an engine, a cyclical engine, which is called the Kreb citric acid cycle and the electron transport chain. And they're converting fuel to usable currency called "ATP." So the fuel is made. -- The fuel is burned, "ATP" is generated, which is energy currency for cellular function to maintain the integrity of the cell membrane... of the receptors and all. So insulin resistance... is associated with mitochondrial damage. When you're doing mitochondrial damage, the cell is not able to maintain certain very viable cellular functions. It's not able to and... maintain the integrity of the insulin receptor. It's not able to maintain the integrity of the... transporter that transport glucose into the cell. So insulin resistance is a situation in which instead of the cell - having excess energy. There is mitochondrial damage that makes the cell vulnerable to not getting enough energy from glucose from the outside. So I think it is the opposite.

Earlier, when we talked about statins, you talked about a couple of the side effects, one being the cognitive decline. The other was the fact that within the cell membrane, the cholesterol in there is impacted in a negative way. Does that tie into the Insulin resistance, that latter piece? When the cholesterol is disrupted.

No, absolutely. Come back to that and explain... and try and tie those together. Let's do that -- first for the brain. And that'll help us in terms of trying to figure this out. For every cell. Like we said in the brain. The body makes the entirety of its own cholesterol. There are 25 different steps through which it's making cholesterol, and statins prevent cholesterol formation at about the fifth step. But as the body is making the cholesterol, it is also... making... "CoQ10." It's making other intermediates before cholesterol is formed that are also important. So let's take "CoQ10" it's very important. The brain cells also need energy to function. They also have mitochondria. They also have the electron transport chain. So as you are stopping cholesterol production, you're also stopping "CoQ10" production. So when you stop "CoQ10" production, your mitochondria that are making usable currency called "ATP," that are burning fuel, can no longer burn fuel. As a result, your brain cell is energy starved. And when your brain cell is energy starved, it will not function well. It cannot use glucose well, because it can't transport glucose inside. It cannot use insulin well, because you will get insulin resistance. Now we can take back to the regular cell and see that the same phenomena is happening here. Not only are statins disrupting the amount of cholesterol and cell membrane, but they are also... reducing "CoQ10" levels in the mitochondria of the cells. So they are disrupting the orientation of the insulin receptor. They are disrupting mitochondrial function, mitochondrial repair, mitochondrial energy production. So when they're doing all of these things, of course the cell is not going to function well and it's going to lead to ill health.

Now, as far as the body is concerned, many people say, okay, yeah, we can maintain mitochondrial health in people taking a statin. Let's just give them "CoQ10."

So first important thing to realize is that the brain is never going to get any of that "CoQ10"... that you're eating, because the blood brain barrier is going to prevent any "CoQ10" from crossing. The second thing is that whether... a regular cell... outside a brain cell can take the "CoQ10" that you have ingested as a supplement is... like saying that I'm going to put something into the glove compartment of my car... and expect it to get into the engine. Because... you're going to have to have the "CoQ10" absorbed packaged into an "LDL" molecule that "LDL" molecule circulate to the cell. The "LDL" receptor of that cell, picking up that "LDL." Taking that "CoQ10" inside it and transporting it to the mitochondria where it's required. So studies that would show that such a process is happening are simply not there. And I think it's just plain wishful thinking that the "CoQ10" that you're ingesting is getting into a site where it's required.

Okay, so that goes for the brain and regular cells, outside in the rest of the body. Right. For the brain, especially for the brain, nobody can even... doubt it because no amount of "CoQ10" that you ingest will ever get into the brain.

Okay, coming back to how we opened up here. If we go low carb, our "LDL" is likely going to go up, but it's not a bad thing. Let's talk about the specifics of the diet you recommend for people.

The nuance is the most important... and the devil is in the details. So a low carb diet, people who are walking into my office are not... the healthiest of people that you would come across. - These are not people who are young individuals... who have... fairly decent metabolic health. And with a combination of a... low carb diet, intermittent or time restricted feeding, and exercise, they can rapidly get transitioned to a good health. These people are obese. These people have very high insulin levels. These people have very high triglycerides. These people are hypertensive, they have some heart disease. Some of these people are on very high levels of insulin. And it is irresponsible for somebody like me to just give them a blanket statement that says, hey, go on a low carb diet, go on intermittent fasting, go on exercise, and you'll be fine. Because these people... already have very high triglyceride levels. And on top of those high triglyceride levels, you are asking them to eat a lot of fat. And when they eat fat, the fat is going to remain in the bloodstream. It's not going to be packed into the fat cells because the fat cells are already overstuffed. So the triglyceride levels are going to go even higher in these individuals. And that extra fat is going to try to find a... place to park it. And it'll park itself in the liver, in the pancreas. Or in the blood vessels, creating more plaque that can, in my clinical expertise, I think will put them at higher risk of getting cardiac events. So an initial diet for somebody who is metabolically unhealthy who has high triglyceride levels, who's got high insulin levels, who's got low "HDL" levels should focus primarily on intermittent fasting, exercise. And the diet should be what I call as a lean, low carb diet. A diet that is low not only in carbs. But relatively low to moderate in fat. Because you first want to burn the fat that you have accumulated in your bloodstream empty your fat cells to some degree before you can... eat fat with impunity. Because if I take somebody who is... healthy, who is young. Who is not metabolically unhealthy. The fat that they eat will get rapidly packed into the fat cells... or will be burned for energy. And very little fat will be left in the bloodstream. So until that situation is obtained in my patients, I prescribe them a lean, low carb diet. In some... individuals, it might be as short a period as a few months, a month, two months. And some people, it might be three to six months before they gain metabolic health. What we ought to remember is that people don't become metabolically unhealthy overnight. It takes them several decades of poor habits to get there. And they're not going to become metabolically healthy overnight by changing their diet the traditional low carb way either. So in my opinion. A diet has to be individualized. It just cannot, one blanket diet would not serve everybody.

This is really important. So this could be up to six months... We want to lower the carbs, lower the fat. So obviously it's going to be a high protein diet. You mentioned intermittent fasting... and exercise. How do we know... as a person's going through that period, that can be up to half a year, say, and they're slowly getting more metabolically healthy. How are you determining that when they can make changes to more of a maintenance diet and lifestyle? Is it objective testing or is it just something more subjective? How do you go about doing that?

- It's objective testing. So a person would start feeling better, their blood pressure starts dropping, they start losing weight, they start feeling better. They come back, you do blood work on them, you notice that the triglyceride levels have dropped from 300s to 90s or low 100s. You notice that their "HDL" has gone up from 34 to 55. You notice that... their insulin levels have fallen from 25, 30 to about -- 7 to 10. You notice that their blood sugar levels have improved. You also notice that their "LDL" levels have gone up... So you're seeing all these laboratory parameters along with some clinical factors, blood pressure, weight, how they feel. So then you can say, hey, Mister "John Doe," Mister "Smith," you're ready. Now you can start increasing your fat. It also is very important to point out it is difficult to be on a lean, low carb diet. It's not a pleasant sensation. It's not a pleasant feeling. And there are many people who doubt that. In fact, I have gotten a lot of hate mail for... promoting a lean, low carb diet because people say that fat is one of the most satiating aspect of your diet, that when you eat fat you tend to eat less. And so don't take that away from individuals. And... there can be an element of truth to that for the normal person. But I'm completely convinced that these people who are sending me hate mail do not know the kind of patients that I deal with. And that... there is a variation amongst us that people who are wanting to improve their health are not just young individuals with fairly decent metabolic health. There are many middle aged and older people with heart disease and diabetes and obesity who are trying to improve their health. And to these people you're saying, hey, I want you to be on a lean, low carb diet... So let's kind of dive into the... minutiae of it. So let's say we tell people, hey, you can have about 50 grams of carbs. So 50 grams of carbs from whatever cauliflower, cabbage. Whatever their complex carb source is that'll give them 200 calories. Because every carb has four kilocalories... 50 times 4, 200. Let's say that they can have even up to 200 grams of protein. You generally say that you can have about... 2 grams... per kilogram body weight. So let's say you are 80 kilograms. Most of these people are heavy, 80, 90 kilograms. So let's say they take in 200 grams of protein. So 200 times 4 is... 800 calories. So they've gotten 1,000 calories so far. Let's say we tell them, okay, you can eat as much as 100 grams of fat because you can't eat protein alone. Eating protein alone would be like eating cardboard. You would have to have some fat. So let's say 200 grams of fat in

It. So 200. Now fat has eight kilocalories. So let's say double... So that's seven to eight. So you would say that from that... 200 kilo. 200 times. 100 times eight, you're getting 800 calories. So you're eating a diet that is 1800 calories, which would be a caloric deficit diet.

In other words, you're not even replacing all the calories that you're burning. And... there is a good reason for... giving them that kind of a diet, because the remainder of the calories are coming from... burning your stored fat, from your endogenous fat. It's not a sustainable diet long term. But it's a diet that people can sustain for three to six months until they get metabolically healthy.

So you got to sit down and explain all of these to the individuals, and it's difficult. It's also important... for a practitioner to recognize... that, it's one thing to know, that several people, if I get 100 patients. Probably about 10 to 15 of them would follow your advice, would become metabolically healthy, lose weight and do well. But the vast majority, some of them try their best. I would say 50% would try their best. But would essentially fail... because even though they know in their mind what is the right thing to do. There is a significant failure to implement it. And that is one aspect that physicians don't understand, that healthcare workers... and people who are working in the area of metabolic health, weight loss, fail to understand. That knowledge is one thing. But implementation of that knowledge may be extremely difficult. And that you need to give these people the tools not only of what is right, but how to implement it.

And what would you say to somebody in that boat? Because you've worked with people, a lot of people, I assume. How do you help somebody cross that bridge? They have the information. But they're having trouble implementing.

Those are good questions, and that would be a subject of another two hour podcast, but we can try to kind of touch on some of those. I try to learn newer and newer things... to not only help myself, my patients and my colleagues. And some of the things that I am learning is... how the reward center in our brain works. Because we are currently living in the world of overwhelming abundance. We are being constantly bombarded when we go any place, even into our own kitchen of highly palatable engineered food that is creating high levels of dopamine in us through the reward center for us to get tempted to consuming these foods in excess.

So in the words of somebody that I enjoy reading, we are living in a "Tantalean" world. A "Tantalean" world is the world of "Tantalus." I don't know if people know who "Tantalus" was. But "Tantalus" was a Greek God. And this Greek God did some very evil things. So the higher gods punished him... to the world of "Tantalus" in which he was... in a very beautiful stream... with lot of fruits and other things within easy reach. But he could never reach them completely. So that's where the word tantalizing comes from. So... humans, we have created a "Tantalean" world for us. - Whenever you walk into a supermarket, whenever you walk into a bakery, whenever you go outside. You're constantly being bombarded by these queues of highly palatable... engineered food to make your dopamine system go into high gear... and want you to consume these things.

Would you agree with that? Yes, for sure. So the challenge for us would be to explain to them how the reward center of the brain works. And that many people confuse dopamine as a neurotransmitter of pleasure. They say high levels of dopamine equate to pleasure. But that is one of the essential myths and wrong concept that has been propagated, that has not been corrected, and it's our responsibility to correct. Dopamine is not a pleasure substance. It's not a pleasure neurotransmitter. Dopamine... is a neurotransmitter that increases wanting. It increases desire, it increases motivation. Because... our brain, the reward center of our brain was designed... when we were several thousand years ago, when we were living on the savanna. When... we needed to... have high levels of motivation, high levels of dopamine in order to get that reward. That would occasionally happen. Fruits would be hyper seasonal, hyperlocal. Obtaining food was not that easy. Now fast forward into the modern world. Something that was highly adaptive and helped us survive is now a source of... metabolic ill health and obesity. So there is a dissociation. If I were to tell you that biology does not care whether you have pleasure or no at all in life. All biology cares is that you have high drive and high motivation. Because that's needed for survival of species. If you were back in the savanna and when you saw an animal that you could consume, kill and consume for food, if you didn't have high energy levels. You wouldn't, the species would not persist. So our biology is designed for us to have a high want and a high desire, but that... there is an uncoupling between our desire and the pleasure we derive from food. So if we can train people, saying that when you're seeing these substances and they are jacking up your dopamine levels, they're creating a strong want and a strong desire. Can you understand... that that doesn't necessarily... consuming those is not equivalent to deriving pleasure and satisfaction from. So we not only have to be healthcare workers and individuals who care about our own health... in terms of knowing what is the right thing to do. But we also need to find out why we fail to do it. What is our neurobiology that prevents us from doing the right things?

All right, so pretend I'm your patient, metabolically unhealthy. And you're telling me about this diet that I need to be on for six months or up to six months. Low carb, high protein, low fat. Take me through what a typical day might look like because you've gotten into it. But I want to know specific foods that somebody might be eating.

Excellent. --- let's... start out with... the day. We are imbued... We have biology that gives you the lowest levels of temptation. The lowest levels of dopamine. And the highest level of willpower or control... over our decisions early in the morning. Because while we have this... dopamine reward system that is giving us all these temptations. Evolution has also given us what is called the prefrontal cortex. The prefrontal cortex can be thought of as our willpower. As our agency, as our executive... function, as our awareness. And the prefrontal cortex works best when you have slept well. - When you are well rested, when you're not distracted. So your level of willpower is highest in the morning. So I tell people, you get up in the morning. Your liver is already getting ready through gluconeogenesis to supply you a meal. And you can do fasting. - It'll be very easy for you to continue the overnight fast by not eating breakfast. If you can add an element of exercise at that point. And this exercise should be low intensity exercise. So what do I -- mean by low intensity? So let's say it should be zone two. Now, zone two exercise is where while you're exercising, you're predominantly fat burning. You're not consuming carb resources.

Can we define zone two a little bit better? Yes, we can. So you take... 180 minus age... this is a pretty easy number. Let's say somebody 50 years of age, 40 years of age. Their exercise should be at 180 minus 40. So they have to have a heart rate below 140 when they exercise. If you're 60 years, it should be below 120. So you are in the fat burning zone. And after you finish exercise, if you can hold off... on eating. You will further increase your fat burning. You will further drop your triglycerides, you'll further empty your fat cells. Your first meal of the day should be at around lunch... noon to 1 o' clock. Make it a predominantly animal based food that is low in fat, low in carbs. How do you do that? How do you get animal based food? What does that mean when you say animal based foods? So let's say... you can eat beef, lamb, chicken, but it should be cooked in such a way that you can take the fat out of it. One of the ways to do that is to cook it in an instant pot or a slow cooker. You leave it, after you cook for a little while, the fat floats to the top, you can skim off the fat, you're left with lean food. You can also cook it in an air fryer. -- The fat will dribble down. You will be with a low fat... You can also buy low lean cuts of meat, but that becomes very expensive. You can have above ground vegetables like cabbage, cauliflower, okra, and if you don't have kidney stones or you don't have any problems with oxalates, you can have spinach, broccoli and such. So that gives you your lunch. Now your dinner should be variations of the same and it should be at about 6 o' clock and you should do no snacking. You can have water. You can have water with salt.

I generally don't recommend caffeine to these individuals. Now I used to be big on caffeine. I would say caffeine... mobilizes fat, it promotes fat burning. And that's true in an individual who's metabolically healthy. So if you're metabolically healthy, you can consume caffeine early in the morning, up until 10 o' clock in the morning. Because after 10, I don't like caffeine. It disrupts with your sleep. So... have caffeine until 10 for metabolically healthy people. For obese, insulin resistant, high triglyceride patients, try to avoid caffeine. Because what caffeine does is that... it goes and tells the fat cells to put fat into the bloodstream. You don't want it. You don't want to do that when you already have too high a level of triglycerides. You're trying to reduce the triglycerides and instead of reducing the triglycerides, you're going to add more fat and it's going to worsen the situation. Do that for about three months... Let's come back, redo your blood work, take a look at your blood pressure, your weight, see how you feel. See where you are in terms of your metabolic health so that we can individualize your diet further. Now if you're following this diet, you cannot eat more than 1500-1800 calories. So it's going to be what is called a protein sparing modified fast. The remainder of the caloric expenditure for you is coming from your endogenous fat sources.

Okay, so we've gone over... exactly what that diet looks like now. You mentioned the fasting, the zone two exercise. Are those just during that initial... period of time... that somebody's becoming metabolically healthy and then what does it look like down the line? Let's talk about diet, exercise and fasting... Say six months down the line, the person's metabolically healthy. What will it look like now?

So at that point I would have no restrictions on the amount of fat that they are eating. And depending on their caloric expenditure, depending on their physical activity. -- Fasting... may or time restricted feeding may or may not be required. In my mind, time restricted feeding is required for most individuals. Now let's say you come across a young person in their 30s who's a cyclist. Who's putting in about 15 to 20 hours of cycling per week. And you go ahead and tell him that, hey, I want you to fast. That's going to be unrealistic. On the other hand, you to come across people who are working in an office... who exercise maybe four to seven hours per week. For them, time restricted feeding in which they give 18 hour interval without food is perhaps a necessary -- byproduct necessary for metabolic health. So at this time we remove the fat restriction. We remove the restriction for caffeine... I think caffeine should still stop at 10 o'clock because... I think sleep is very important... Caffeine has a six hour half life. If you have consumed a cup of coffee at noon. 25% of that caffeine is still there at midnight... And it's going to disrupt the quality of your sleep. So I would want it before 10... so that you have metabolize the caffeine. But I remove the restrictions for fat. And in some individuals who are metabolically very healthy, who are young, who have low insulin levels, who have low "A1C," who have normal triglycerides. I think that these individuals should even consider days in which they consume carbs to spike up their insulin levels. Because insulin is not a bad player. It depends on the context. Insulin is there for a reason. It's something that increases muscle mass. So you want these people to maintain their muscle mass. And spiking the insulin level activates "mTOR," activates new protein synthesis and so it's no reason to take away that insulin spike that will facilitate all of this in people who are young and metabolically healthy for them to achieve optimal health.

Okay, what about older and metabolically healthy, somebody in their 50s, 60s, is this still applicable? I think so. People are living longer, healthier. - There are master athletes that put in - 8... to 12 hours... of exercise per week or even longer. - It's important for them to maintain muscle mass because one of the reasons why one of the --- main factors that keeps you healthier is muscle mass. The more muscle mass you have, the better you can dispose of the sugar after the meal, the glucose after the meal that you're eating. It maintains your --- mobility. And mobility is a very important aspect of health as you grow older. So if there are ways in which you can promote and protect and preserve and maybe even improve your muscle mass as you're aging. -- You should not consider occasional insulin spikes, maybe... two, three times a week in extremely healthy individuals as a necessary method to keep your muscle mass.

Okay, and then in between those spikes, let's talk about where they are on the carb spectrum... because there's a big wide range there from carnivore, no carbs or very little carbs and meat to ketogenic to low carb. How low carb do you recommend?

So -- let's give a specific example. That way people would know what we are... referring to. Let's say you have a 60 year old individual who is doing optimal exercise so it's important. For me to... say what optimal exercise is because optimal exercise is one in which you're exercising in such a way that you're not increasing allostatic hormones like cortisol, epinephrine, and creating a detriment to your body. So how do you know you are an optimal exercise? There are several ways to know it. Perhaps the best way to know it is to look at your resting heart rate to look at your heart rate variability. Because heart rate variability and resting heart rate are surrogate markers of how rested you are. And if you're well rested, then you know that your stress hormone levels are lower. So if you're doing optimal exercise and the exercise is let's say upwards of 10, 15 hours. If these individuals come in and I look at their metabolic profile and I see that the triglycerides are less than 100. Their "HDL" cholesterol is greater than 55, 60. They have normal blood sugars, they have very low insulin levels. And they tell me, doc, I want to eat a hundred grams of carbs a day. I'd say fine. There's no reason for you to go to 50 grams. They come and tell me that on Saturday and Sunday I go out with a group of friends and I do high intensity training and I need more carbs. So I would need to eat 200, even 250 grams of carbs on those days. I'd say fine. On the other hand, if you're somebody who is just doing 30 minutes on an elliptical. Doing an hour of walking, let's say that would be probably about three and a half miles. Going to office to work and come back. And... you have similar blood work like the previous individual. And I would say, hey. You probably need to be at about 50 grams of carbs per day. And that maybe one day or so a week when you're going to be more physically active, you can have an insulin spike and go up to 100, 150, 200 grams of carbs. But... you need to limit these events to as minimal as possible.

So what many people don't realize is that nutrition is an individualized prescription. It's not like one size fits all. No, I agree. We're just trying to get that template from you. And then people need to... tailor that to their lifestyle and test different things and see what works for them. I think that my biggest challenge these days is -- not that people don't have the knowledge of what's wrong. The biggest challenge is how do we implement that? How do I give people additional tools to figure out how to implement it the best? And for that, you have to move out of the... nutritional science and go more into psychology... and how our modern world interacts with our brain and come up with novel and new solutions.

Well, you got into that dopamine piece earlier. Is there more in that realm you want to share to get people off on the right foot?

Sure. I think that we can talk about -- the dopamine system being something that gives you a drive. And that's important. Drive is very important. In other words, somebody with a robust dopamine system... is... necessary for health and happiness. Because... you don't want to go and take drugs... If there were such drugs to remove all dopamine from your system. People have tried that. So there are certain brain injuries you get in which it damages all the dopamine system in your brain. Now, these people, you would think, are... free of... desires and free of wants, so they lead a blissful life. But it's completely the opposite. Because these people derive no pleasure out of anything they don't have any drive. You put sugar in their mouth, they will enjoy it, but they will not move a few steps to obtain that sugar. So in other words, they have no motivation, no drive. They have what is called anhedonia complete lack of pleasure. So people who have a very high drive system. They should say, hey, this is good. The drive system is important because it's important for my happiness. I just need to point that drive system... in the right direction so that it aligns with what I need to do to be healthy. And on top of that. We need to give people information... on how to improve the prefrontal cortex function. So the prefrontal cortex is something that will help you curb temptations, that will help you with agency, with executive planning, with awareness. So how can you make the prefrontal cortex work better?

I would assume sleep is a piece of it. Sleep is a piece of it. Would you believe that exercise is a piece of it? Yeah, I would say meditation, maybe. Meditation also. So and also remember that whenever you are distracted. - For example, if I am watching something involved in media. My brain is distracted. My prefrontal cortex is not working good. I will make all the wrong decisions with food choices and stuff like that. You ought to recognize we talked about four factors. Sleep, exercise, meditation, and distraction. So you want to arm these people with all these resources. Not just resources with regards to... what is right to eat, but how the reward center works. You also need to tell them about certain very basic facts of human biology, such as ghrelin. How it works. And how you can ignore ghrelin because ghrelin is a hunger harmer beside the thought of food will make your ghrelin levels go up, would make you want to eat. But if you ignore ghrelin for about 5 to 10 minutes, the granule levels automatically go down. So the temptation will go away. If you can wait for 5 to 10 minutes. The very act of eating... increases ghrelin levels. And you would expect that as you start eating, the ghrelin levels should come down rapidly. But they don't come down rapidly. They don't come down for about an hour and a half for 90 minutes. Imagine the amount of food you can consume in 90 minutes. A lot. Oh yeah. A lot, right? So you need to give people the... tools saying that, hey. I want you to stop eating when -- you feel like you're about 70% full. And then tell yourself that I'm going to consume more if I'm still hungry after 30 minutes of not eating. Because one of the things that increases your appetite the most, the hunger the most. Is the act of eating. - You would have a full stomach or several of my patients tell me, and I've noticed that in myself my stomach is full. But I still have this desire to eat more. Now, why do I have that desire to eat more? Is that because... my dopamine system is very active, my reward system is very active. And there is a dissociation between reward and pleasure. Am I not recognizing the decoupling between the two? Is that because my ghrelin levels are telling my brain to eat? They have not gone down yet. Would waiting for about half an hour be beneficial for me? And if I wait for half an hour, I come back and say, actually, I still feel uncomfortable. I wonder why I wanted to eat more.

As you share that, I think a piece of it at least is the type of food I know for me, if it's steak and broccoli in front of me versus a bowl of chips. I can shut it down and push it aside. If it's real food versus a processed carb.

That brings about a very important point. This is what is called intermittent positive reinforcement. So I'm sure you have heard about that. So intermittent positive reinforcement was first introduced by "B.F. Skinner." So you had the "Skinner" pigeons. And there was a lever, and when this... pigeon pressed a lever they would get a pellet to eat. And every time they press the leverage, if... they would get a pellet to eat, the amount of reinforcement was not as high. But if it was variable, sometimes they press, they would get it. At another times they pressed, they would not get it. The amount of dopamine released now, "Skinner" did not do that, but this neurochemistry got... put on later is that if there is intermittent positive reinforcement. Then... the number of times you would seek that reward would be much higher because dopamine levels go about twice as much as with a predictable reward... If you make a reward unpredictable. The... amount of dopamine levels will be two times as high in your brain as with a predictable reward. Bring that back to food. You just talked about steak and broccoli not reinforcing a lot at all. You talk about engineered food like chips. They're highly reinforcing because they give you an intermittent positive reward. - You look into the engineering behind food, you would understand that why you would consume more a bag of chips of course. -- Nature designed you to value a bag of chips a lot more than meat. Because... a bag of chips like fruit or carbs was hyper seasonal. And hyper local. So a lot higher... value was placed for that food by evolution. So these are some things that we don't recognize. And... if somebody is armed with all of this information, and I hope as the new generation comes along, because they're dealing with many more challenges than we have in terms of distractions, in terms of sleep. And they're a lot more susceptible to these modern diseases than... perhaps my generation was. It is not just essential for these children... or the next generation to learn about basic facts of nutrition. But facts about biology, of how hunger is the pleasure centers of the brain. And all the other stuff that we talked about.

We've touched on the importance of sleep and... the piece of advice we've given so far is that we want to cut off caffeine, if we're a caffeine consumer, by 10am. Given its importance, what other things do you do and recommend to people... to get a great sleep?

Yeah, that's another very important aspect of our health. So we have what is called a circadian rhythm. A circadian rhythm is our day night cycle. - The more you entrain the circadian rhythm, the better you sleep. - The more time you spend outdoors in natural daylight... entrains your circadian rhythm. You don't necessarily have to be in the sun itself, but being outdoors on weekends, when I do three, four hours of cycling with my friends, I sleep a lot better. Cutting out caffeine after 10 o' clock we've already mentioned because caffeine disrupts deep sleep. It doesn't disrupt light sleep, but it disrupts deep sleep. Another important aspect that would disrupt your sleep is alcohol. One of the things that people don't recognize is that alcohol disrupts one of the most emotionally important aspect of our sleep, which is called the "REM" sleep. So the dream sleep or rapid eye movement sleep is disrupted by alcohol. And so cutting out... or reducing or eliminating alcohol -- from your diet is an important aspect. From your life is an important aspect. And another factor that will help you sleep better is if you're media free for a couple of hours before bed. Let's say you're going to sleep at nine. You should have no media from seven o' clock onwards. - Very hard to do in this day and age. We are in front of screens, tablets, --- "iPhones," smartphones. So we are constantly deluded with media. Maybe perhaps an audiobook, maybe just talking, maybe just relaxing, maybe just meditation. That would be an important time to consider meditation. Another factor that helps you sleep better -- is taking a warm shower before you go to bed. The warm shower causes vasodilation, it opens up the blood vessels in your skin. And when that does that, you lose body heat and your core cools down. And when your core cools down. It's a signal to the brain that you know your body is ready for sleep. I personally think that a low room temperature like 66, 67, 68, it's a little hard to do that in summertime. But -- very quite feasible in wintertime. Helps you sleep better. Darkening your room, making sure it's dark with good shades and all that, because a lot of ambient light coming in from the neighborhood. That's important. I highly recommend a cooling pad. - There are all kinds of technologies. I'm not going to promote any, but there are many cooling pads that lower the temperature of your bed and keep it at a certain level and vary it during the night by programming and even let you have a natural wake up... by heating up your bed as you're waking up. I think that's another important tool that you need to look into. I think we gave quite a few good tips about how to improve your sleep.

All right, I want to come back to the diet piece now and again along that continuum, if somebody's going low carb, say in the maintenance phase, carnivore, ketogenic, low carb, somewhere in that realm, if that's new for somebody, one of the questions they might be having is, okay, I'm going to be having less fiber. And isn't fiber important for the microbiome, for bowel movements? How do you think about fiber?

Good question. I'm not necessarily an expert on that, so I'll give you what I know. -- The body does not need fiber. Fiber is not an essential component. In fact, a large amount of fiber can be detrimental because, number one, one of the most important aspect of our human health is stomach acid. Stomach acid is necessary for you to break down protein. It's necessary for you to absorb iron. It's necessary for you to absorb... minerals like calcium and magnesium. So taking in a lot of fiber can create a situation in which you can have mineral malabsorption. You can dilute the stomach acid, and you may not be able to process and metabolize the protein as well. One of the important... aspects is that... our gut, our stomach, our duodenum, our small intestines are sterile environments. By sterile they're supposed to be bacteria. - You're not supposed to have any bacteria in your stomach, in your small intestines, in your duodenum because if there is bacterial overgrowth in these. - It creates a leaky gut situation that's called small intestinal bacterial overgrowth and stuff like that. Most people who consume fiber are consuming fiber that is raw. So you're coming getting it from salads and stuff like that. So you're taking in a lot... of - bacteria with it. And the stomach acid is assigned to the responsibility of neutralizing these bacteria to create a sterile... It's -- an ecological barrier. As we get older, we make less and less stomach acid. And so the more fiber you take, especially in forms of salad and stuff like that. The less protein you're going to have, the less minerals you're going to have, the more bacteria you're going to introduce into your small intestines. And I think all of this is not very good for your health. The only place where we can metabolize fiber is in our... large intestines. And if you look at proportional... volume of our large intestines. We are mostly designed like a carnivore because they're very small. Our large intestines are about... 10% the size of our primate ancestors... who were eating a lot of plant based food. So on the basis of that, you can only break down fiber with the bacteria in the small intestines. And... get the necessary nutrition from there to give nutrition to the lining of the large intestines. I don't know if I said small intestines, but fiber can only be metabolized in the large intestines. So I'm not sure we know what probiotics that we necessarily need to take. I'm not sure we know how much fiber we should take as we get older. My default is that the lower the amount of fiber you take, the better it is. And I've really not found either anecdotally or through clinical practice that constipation is a real problem with a carnivore diet. As long as you're not getting dehydrated, as long as you're eating, as long as you're drinking well as long as you're taking magnesium. I've not seen constipation to be an important issue. In fact, I think the default, I would like to say, is the lower the amount of fiber you eat. The safer it is as you get older.

Okay, so it sounds like fiber, not a concern. What about... and probiotics you mentioned quickly, doesn't sound like that's a concern. What about fermented foods?.. How do you feel about those?

I'm not sure fermented foods are probably very good. - We have had them for generations and generations and there may be some substantial value to it. - They provide probiotics and I'm not sure we exactly know what the right probiotics for us are. So I will say that it's uncertain. I'm not an expert. They need to get information elsewhere. That's fair because... I should not try to push my views in areas that I don't know.

Okay. But I think it's fair to say you don't try and manipulate your microbiome at all. You're eating a low carb diet and... letting the cards fall as is. Correct.

Can you share with us what a typical day would look like for you eating?

Of course I'm susceptible to... temptations and that's why I look into all of these things. So I'm not going to say that I'm perfect. But... definitely this is what I try to do. And it might be better to say this is what I try to do. I certainly try to miss breakfast. Fasting is an important aspect for me and I like to try to live by two meals a day. - I like to exercise in the morning and I used to cycle to work for four years in a row until I had a bike accident about a couple of months ago. So I went to work. It was a 10 mile ride, about a 40 minute ride to work and 40 minute ride back. So I'd get my exercise that way. My first... meal of the day is at around one o' clock, one or two. And usually it's in the hospital... and I go for a protein option because... one of the things that we never really touched on is that - in addition to sugar and refined carbs. ---- One of the most dangerous aspects of modern life is seed oils or vegetable oils. So it almost... eliminates me from eating anything that is cooked outside. All restaurants use vegetable oil. - When I go to the hospital I'm pretty much limited to one or two protein options. - Some beef, some chicken, some fish... and -- of course if anything that is breaded, anything that is deep fried is completely a no no because it'll fill with vegetable oils and that's one of the biggest dangers. So I'd get some food out there and. But my predominant meal would be when I reach home at around 6, 7. And that would be when I would either cook beef for lamb or chicken. And then depending about on the amount of exercise and depending on the day. I would have some carbs. - I have a friend - who is a vegetarian who has improved his blood sugars... "A1C" from 9.3 to 5.3 by being - -- a good investigator. And by preparing vegetarian food that is low in carbs. So he gives me... some advice. Cauliflower, rice, cabbage lupin flour. -- So those are the things that I am trying to incorporate in terms of vegetarian patients that I get, I refer them to him. And so I would have some carbs. I would say, depending on the day, I would have between a 100 to 150 grams of carbs. - On Saturday and Sunday when I would do a three, four hour bike ride. I don't see the benefit of being low carb in that situation. In fact, it could be perhaps a detriment.

Do you notice a difference in performance, say on the bike when you, when you try and go low carb those days versus higher?

Yes, I think it depends on the athlete and perhaps I'm not that good an athlete. So for me for sure. But... I have several of my colleagues who are on the bike who come see me professionally and in them I see that... they can get away with a low carb diet because their fat burning happens at higher and higher heart rates. So in other words, even at 85, 90%... heart rate, they're predominantly fat burning. I am perhaps not in that category. Now, I have not done any formal experimentations... with "VO2" max or with respiratory exchange ratios to figure that out. But if I am on a group ride with the fast group with the racing team and my heart rate is running into the 160s and have average heart rate at the end of the ride of about 135, 140 for three to four hours. If I don't consume enough carbs, I will definitely have a very poor day on the bike.

Got it. So the more carbs you, the higher the intensity of exercise that you're doing, you definitely would have to consume more carbs for most individuals. Now, there are some individuals at home. They get fat burning even at very high heart rates. But you have to figure that out yourself.

Okay, last question for you. I know we got to part ways here. You mentioned a few minutes back magnesium, and it sounds like you're... a fan of taking that supplement. Talk about that and other supplements people might want to consider.

I take only two supplements. I take magnesium and I take vitamin D. I take vitamin D with "K2." Through all the winter months. - Which would be starting sometime in October and ending sometime in March. And then I vary my vitamin D intake based on the level of exposure I have to midday sun. If I have a lot of exposure to midday sun, then why do I -- need a supplement?.. I try not to take it on those days. -- I do take magnesium and I think older people -- should take magnesium. Magnesium is reportedly very... deficient in our diet and I find two benefits of magnesium in me and in my patients. -- In me, the reason I take it is that it reduces cramps on the bike. The second thing is that I think it helps me sleep better. - In my patients the predominant reason for giving magnesium is to reduce the risks of irregular heartbeat. A lot of people are older, they have heart disease. That puts them at higher risk of atrial fibrillation and premature beats. And magnesium is one of the ways to reduce. Not a fan of fish oils. I think fish oils are best obtained by eating sashimi or tuna or... salmon. Because fish oils get rapidly oxidized I think... processing of fish oils is a concern of mine because... the amount of oxidation and aldehydes and commercially available fish oils is probably very high. -- I'm impressed by the data on "EPA." - The so called "VASCEPA" study. But that study has not been corroborated by another study. And by nature I'm very suspicious of the pharmaceutical industry putting out data, truthfully. So if somebody comes to me... and "VASCEPA" or "EPA" is a kind of a fish oil and if they are on high doses of... "EPA" or "VASCEPA" then I don't try to actively take them off of it because the data from that study is impressive. It is very expensive. And since it's very expensive I don't prescribe it myself and many insurance companies don't cover it. I'm not a fan of any of the other supplements many people take. Ginseng, vitamin C, vitamin E, or multivitamins. I really don't see a need for those. I think you're just wasting a lot of your resources that you could put into better nutrition, that you can buy, better food that you can, can buy, or other things you can enjoy.

All right, so really minimalistic. Vitamin D, "K2" and magnesium. When it comes to the magnesium, is there a certain type you like and dosage?

Those are the 3. Yeah... the magnesium should be glycinate or taurate. Chelated magnesium basically because that's the one that gets absorbed. Magnesium oxide is not something that gets absorbed well and, or magnesium sulfate. So I try to stay away from those. Those are more remedies for constipation because that's not something... that gets absorbed... In terms of dosage, I would say, I must say that magnesium is not a necessary component for everybody to take. So if a young person comes, they don't have any palpitations, they don't have any cramps. - They don't have any sleep issues. I'm not going to push magnesium on them. But if you have any of those and you want to see whether it helps you, then I would say take 250mg either once or twice a day.

And you mentioned for you, one of the reasons you take it is for sleep. Do you take it before bed or I take it both before bed and in the morning. when do you take it? Got it. Because it helps with my cramps too.

All right, Doctor "Ali," I really enjoyed the conversation. We're going to link up your website, your social media, everything in the show notes far reaching conversation and I want to thank you for your time. "Jesse," I really enjoyed talking to you. It was -- amazingly two hours and I didn't even notice it. Me either. Thank you. Hey, take care. Now that you're done with Doctor "Ali," you're going to want to head over here and catch my chat with "Malcolm." He shares his alternative views on cholesterol and heart disease. You don't want to miss this. I'll see you over there. And I started looking into it and a bit like the film "The Matrix" where you, you take the red pill instead of the blue pill and you suddenly realize, at least in this area