Transcript: Diabetes Doctor Dr. Andrew Koutnik on DOAC Podcast

ANDREW KOUTNIK: Yeah, so on my stomach here is a CGM, which is a continuous glucose monitor. CGM is a way of tracking sugar levels or glucose levels.

STEVEN BARTLETT: And both of those devices link to your phone, which is in front of you. I’ll throw that up on the screen so people can see what that kind of looks like.

DR. ANDREW KOUTNIK: So on this device, you have a green line that is glucose levels. My blood sugar says that it’s 109 right now, which means that the interstitial signal of glucose is interstitial, meaning within.

STEVEN BARTLETT: Not in the blood, but in the tissues.

DR. ANDREW KOUTNIK: Yeah. So the amount of glucose right outside the blood, around the tissues, and that signal is an indication of the amount of glucose in the blood. That’s the green line. It says that I’m 109 right now. So average blood sugar levels using milligrams per deciliter is 70 to 120. That’s considered normal.

Below that is blue lines, almost like looks like squares and triangles. Those are illustrations of insulin being administered. But they’re not perfect devices. Despite them being premier and the most advanced technology on the market, there are significant limitations to them.

Blood Sugar Control: The Foundation of Health

STEVEN BARTLETT: I actually saw a clip of yours that I was watching earlier that said you think having high blood sugar over a long time is the biggest cause of long term health problems.

DR. ANDREW KOUTNIK: When you’re focused on improving your overall health, you have to find out what matters most. Right, so what’s the hierarchy in the health? 1, 2, 3, 4, 5. What matters most on that? And we can look at that by looking at risk factors for future disease.

Well, the number one cause of death in the United States and across many parts of the world is cardiovascular disease. Well, it’s also the number one cause of death in people with diabetes. And when you look at what are the strongest predictors of developing some form of cardiovascular disease, a measure called HbA1c comes up at the top.

HbA1c is a average measurement of your blood glucose over a two to three month period of time. And that is incredibly powerful at predicting future risk for diseases of the eye, diseases of the kidney, or even cardiovascular disease.

And so when I think about how do we tackle improving health or in particularly in these much more common diseases, glucose control sits at the very top of that pyramid. And if unregulated, it’s equivalent to analogy I often use, which is you’re driving a car and you’re focused on what type of rims you have, but you don’t even have an engine in the car. Your engine doesn’t work or you don’t have a chassis or an axis, but yet you’re focused on rims or a sound system.

And so the number one factor, particularly in diseases like diabetes, that matters most is HBA1C.

The Role of Nutrition in Blood Sugar Control

STEVEN BARTLETT: So does that just mean that we should be eating less sugar?

DR. ANDREW KOUTNIK: So if we wanted to control the most powerful risk factor in diabetes, we would need to understand how to regulate it. Right, so then let’s look at the science of this. Well, the science says that carbohydrates, food is the most potent factor in regulating elevations in glucose at every single meal of the day. Well, most people are eating three to four plus meals every single day.

And so the very first logical thing to look at is food, because what you’re consuming has the most potent impact on glucose control, and glucose control has the most potent impact on your health, not only today, but in the future. And so focusing on nutrition makes sense, but this isn’t a new phenomenon.

We’ve known that nutrition could be potentially life saving for people. There’s something called a ketogenic diet, if someone’s heard this before. It’s a diet that dramatically reduces the amount of carbohydrates in the food. And the dramatic reduction in carbohydrates in the food was used to save lives of patients with type 1 and type 2 diabetes.

Since there was the first report ever known, to my knowledge, is in 1796 by a gentleman named a physician called John Rollo. He published a report on two cases of diabetes mellitus using basically a carbohydrate, replete or reduce diet to resolve the disease.

But we know that some of the most premier diabetologists, meaning people who study diabetes or treat people with diabetes, were utilizing these strategies for over 100 years before we then discovered in 1921 that this diet could also help neurological disorders like seizures and beyond.

And so the phenomenon of nutrition playing a role in overall health is certainly not new. It’s actually only recently that we’re rediscovering century old wisdom of what nutrition can do for overall health due to the emergence of explosion in science that has really drove a ton of public interest into this kind of unique dietary strategy.

The Ketogenic Diet: What It Really Looks Like

STEVEN BARTLETT: So the ketogenic diet then, it’s a diet that I’m familiar with because it’s a diet that I cycle in and out of throughout the year. Probably I’m in a ketogenic state three or four times a year and I use the little keto reader just to check my blood ketone levels. For anyone that’s unfamiliar with the ketogenic diet, I’m a bit of an advocate for it, so I’m fairly familiar. But that’s also taught me how unfamiliar people are with it because I can talk to my friends about it and there’s a lot of misconceptions.

DR. ANDREW KOUTNIK: Yeah.

STEVEN BARTLETT: If you’re on a ketogenic diet, what are you eating?

DR. ANDREW KOUTNIK: So typically when someone visualizes a ketogenic diet, I think there’s a lot of misinformation. They think it’s just steak and bacon. And I guess for some people it might be that, but it’s actually if we’re talking about a well formulated ketogenic diet, we’re talking about green leafy vegetables, things that we typically associate with health.

Salads, broccoli, asparagus, cauliflower, these kind of nutrient dense green leafy vegetables that are high in fiber and phytonutrients. Then you also have protein as a component of that. That can come from meat, that can come from fish in the form of salmon, eggs, cheeses. A little bit comes along for the ride and things like nuts.

And then you also have the rest of the diet which is made up of fat. And this can come a lot of times from various plant forms. This can come from olive oil, avocado oil.

STEVEN BARTLETT: And what are you removing then?

DR. ANDREW KOUTNIK: Sugary, starchy carbohydrates. So you’re not having bagels, you’re not having donuts, white rice, pastas, these type of foods. The reason they’re not a part of this diet is because these foods rapidly elevate blood sugar levels. And the rapid elevation in blood sugar also spikes insulin.

Insulin shuts down fat breakdown and the ability to take that fat to the liver. The liver built this amazing mechanism to be able to convert fat to ketone bodies. Because ketone bodies fat can’t actually long chain fatty acids, which is the primary form of fat that you consume in the food you eat, and also the type that’s broken down from your own fat tissue, can’t readily cross the blood brain barrier.

And we know that glucose is a fuel for the brain. But what happens if you fast or you don’t consume a lot of carbohydrates and you have low insulin levels and you can’t transport the fat, which is now your primary fuel source on a ketogenic diet, because you reduce glucose or carbohydrates in the diet, which causes a reduction in glucose. The reduction in glucose lowers insulin. The reduction in insulin causes fat to be rapidly broken down and now becomes your primary fuel source.

The Evolutionary Basis of Ketosis

STEVEN BARTLETT: And so there’s an evolutionary basis for this, right? Because once upon a time, we might have gone long periods of time without eating something. And so our body turns inwards and starts using our fat stores as a mechanism to fuel our body, and that’s why it produces ketones.

DR. ANDREW KOUTNIK: Basically. The evolution of this diet was believed to be a cyclical, meaning, on and off pattern in human history. Because if we were to go through bouts of abundance in food, we’d probably consume it as much as we can in one moment, and then we’re seeking the next meal and seeking the next meal.

What happens in that in between time? If you’re 100% reliant on having food 24/7 like we do in our current food environment, you would never survive evolutionarily beyond a few days with the ability to switch from a carbohydrate based metabolism over to a fat based metabolism. We store months and months and months of fat energy in the event that we don’t have nutrients. So it’s one of the most powerful survival mechanisms we have to survive moments of famine.

But we also have known since times of biblical texts that fasting has therapeutic potential, you know, most potently and the ability to what would be described as attenuate seizures, you know, convulsion like behavior was described when you just completely eliminate food. It’s actually a common strategy in many religious practices because of its “healing properties.”

Well, now we actually know that fasting induces a state of ketosis. We know that ketosis is actually shown to, in many of these cases, have a therapeutic impact in many of these environments, like seizures. We’ve known since 1921 out of the Mayo Clinic that ketogenic diets not only mimic the physiology of fasting, but also attenuate the seizures in children with epilepsy.

And that work has subsequently gone on to John Hopkins and other research institutes to show that this is a very verified strategy for not just epilepsy, but it has been used for obesity, type 1 diabetes, type 2 diabetes, for centuries at this point. And it all starts with the reduction of carbohydrates in the diet.

The Impact on Cognitive Performance

STEVEN BARTLETT: One of the things that’s been most beneficial to me, but also I know Joe Rogan has talked about this before, is as a sort of a podcast that spends a lot of time talking. You notice high variance in your ability to think, articulate yourself for long periods of time based on my blood ketone levels and my diet broadly, but specifically the amount of ketones that are in my blood.

Why is that? Why is it that I feel like I’m more effective in communication and thinking when I’m on the ketogenic diet or taking exogenous ketones versus when I’m having a normal, western, high, higher carb diet?

DR. ANDREW KOUTNIK: A lot of people would know why this is if they had the same tools and insight that type 1 diabetes gives. Because when you’re consuming that diet, what is often happening is near constant elevations and dips, elevations and dips, highs and lows, and blood sugar levels that we know are ascribed to changes in energy levels.

So we know that high blood sugar levels. Someone can Google, if they’re so interested to look up the term high blood sugar hyperglycemia or low blood sugar or hypoglycemia, and just type in symptoms and you’ll see a laundry list of things like fatigue, irritability, lack of concentration, concentration, shakiness. These are all symptoms of a lot of what you’re describing. Right. Which is changing your ability to concentrate your energy levels. It’s very clear that glucose levels are linked to that. We also know that the change, just to be clear.

STEVEN BARTLETT: So is that when I’m at the high or the low in the glucose. If you ate one of these right now, what are these? Oranges, Tangerines.

DR. ANDREW KOUTNIK: Oranges, yep.

STEVEN BARTLETT: If you ate one of these right now, your blood glucose levels are going to go up.

The Orange Experiment

DR. ANDREW KOUTNIK: Presumably, yes, because these oranges are composed of bound sugar molecules together. So most fruit has a structural component to it, which is why you see it has mass to it. Right. It’s not just liquid. And then that structural component binds together as a part of it. Sugar that’s bound together, they call them polysaccharides.

And those polysaccharides, when you consume them, your gut actually takes those breaks them down into individual glucose molecules to then be absorbed into the bloodstream. That’s when the insulin’s released. That’s when insulin takes that glucose and stores it into tissues like the muscle and the liver for future glucose needs.

And so, yes, we would presume that with this high or oranges, or even most fruits, pastas, rices, would all elevate blood sugar levels. But then that accompanies with a high insulin load. Right. So the more of the oranges, the more insulin that you would need. And, you know, despite many of these foods being considered very healthy, those with metabolic disease or metabolic dysfunction may not maybe have a be more vulnerable to even what would typically be considered healthy foods. And type 1 diabetes is a powerful example of that.

STEVEN BARTLETT: So you said you’d open to eating one of these. We’ve got your blood glucose and insulin levels, which we’re going to put on screen for people that are watching. And it’ll be interesting to see how quickly we see that orange, which is considered a health food by many people, have an impact on your glucose and insulin levels.

DR. ANDREW KOUTNIK: So, yeah, so what I’m going to do is normally I would never do this, but I think it’s very important for people to understand, especially those at home who either have a chronic disease, which is most Americans at this point, or kids who have a disease like diabetes, what the impact really could be.

So let’s say oranges are considered a superfood by the American Diabetes Association. So it’s a fruit highly recommended by almost every organization, USDA or USDA, American Diabetes association and beyond. The amount of orange is three oranges. Three oranges is probably going to make up around 70 to 90 grams of carbohydrates.

For me, my energy needs around calculated it around 3,000 calories per day around the activity I’m consuming. If I were to eat the amount of carbohydrates recommended per day, which is around 55% by, let’s say, the USDA guidelines that I would need to consume at least or more than this if I split up all my calories over four meals. And so, so this is an opportunity to see what this will actually do to blood sugar levels. And type 1 IVs if you consume will be a near equivalent to around a 50 amount of carbohydrates that I would consume per day if I was on.

STEVEN BARTLETT: A standard diet, the ketogenic diet, they typically say that to stay within it, you need to be below is it roughly 50 grams of carbohydrates a day.

DR. ANDREW KOUTNIK: And it’s roughly because 50 grams of carbohydrates per day is a rough number that we suspect most people will be able to get carbohydrates low enough to where insulin would be sufficiently low to produce ketone bodies.

STEVEN BARTLETT: Okay.

DR. ANDREW KOUTNIK: Yeah.

STEVEN BARTLETT: So there’s variance depending on your insulin sensitivity and insulin response. And I guess body weight is always.

DR. ANDREW KOUTNIK: Going to be a factor, big factor, major factor. Because anytime you’re talking about things like glucose, insulin is always very individualized responses to each individual person.

Understanding Net Carbohydrates

STEVEN BARTLETT: I don’t really, I try and stay away from fruit these days. I don’t know berries and raspberries and stuff like that because people tell me there’s polyphenols and blackberries, but those.

DR. ANDREW KOUTNIK: Are totally cohesive with the ketogenic diet because they’re higher in fiber. So half of what you’re consuming, not half, but a large portion of its fiber. So it’s more about the net carbohydrates, it’s the glycemic metabolic impact of the food.

So if the fiber is non digestible, which in fruit it isn’t, then it shouldn’t be. It doesn’t count. Right. So higher fiber content. Most of the vegetables on a ketogenic diet are higher fiber, you know, because you know, it’s the total carbohydrate to fiber ratio. So the net carbohydrates that really matter because that’s the amount of, that’s the metabolic, real metabolic impact of food.

STEVEN BARTLETT: Yeah, a lot, a lot of keto friendly foods say net carbs at 1 gram or something. Then you look at it and you go fucking. It says 20.

DR. ANDREW KOUTNIK: It’s total bullshit, man.

STEVEN BARTLETT: Is it so?

DR. ANDREW KOUTNIK: Oh, 100%. So I’ve tested two different foods that are keto friendly on the label. Same as that, calories, same as fat, protein, even fiber. And they can produce completely different responses. I mean the food environment nowadays you essentially need almost a PhD in nutrition or biochemistry to walk into a grocery store and be able to understand what the hell’s on the label.

And I don’t want to sit here and say “oh, they don’t know.” No, they know. I mean there’s a. Companies who have tons of resources, food scientists galore, and they’re putting zero sugar on the label and keto friendly as a trick because it’s associated with health benefits. Right. There’s all these studies on ketogenic diets that can show to improve health and so they want to have that on their label.

But what is often happening if you look on the back of the label. There’s about 100 different ingredients they can swap sugar for, for something that has the same exact metabolic effect as sugar. So maltitol, maltodextrin, all these different ingredients that are going to cause glucose to go up rapidly. They’ll just swap it. And now you can put on your label zero sugar.

Personal Experience with Ketogenic Diet

STEVEN BARTLETT: If you’ve been in a ketogenic diet since you were diagnosed with diabetes, have you cycled in and out of it yourself? And if so, what have you noticed in terms of when you are in that diet and when you’re not?

DR. ANDREW KOUTNIK: So I actually came across this diet a little over a decade ago. What I found is that almost every blood meter that I was taking, this is before CGMs were present. I had to just prick my blood, you know, six to ten times a day to see what my blood sugars were. I was finding that I was very rarely outside of the normal range. And I was also finding that I wasn’t feeling these extreme highs and lows anymore.

When I transitioned to a ketogenic diet, almost immediately, my insulin requirements dropped substantially. Around 40, a little over 40%. So the amount of insulin I needed to take dropped dramatically. But I didn’t have continuous glucose monitor. I didn’t have this instant feedback of what is my blood sugar doing? I just know I needed a heck of a lot less insulin.

And so what happened was I went into my doctor’s office at the time. He happened to be the American Diabetes association president at the time. He’s like, “I’ve never seen a blood sugar level in the normal range with someone with type 1 diabetes before.” He said, “what are you doing?” From that point forward? That’s when, for me, it transitioned, Steven, into a lifelong journey of wow, you know, obviously, nutrition had a huge impact on me losing weight when I had obesity.

And now it was directly regulating this very powerful disease where, upon diagnosis, nearly all patients are going to have high and variable glucose levels for the rest of their life. 99% of patients will never see normal metabolic control again for their life. 100% of them are expected to get insulin resistance. And within three years, we see neuroanatomical changes within the brain of children who are diagnosed.

STEVEN BARTLETT: What does that mean?

DR. ANDREW KOUTNIK: So it means that when we look at MRI scans of the brain, we see that children with high and variable glucose levels with this disease, with type 1 diabetes, they have shifts in the type of white and gray matter, the sections of the brain that are associated with normal brain development and childhood they’re not developing the same way.

And we see this within three years, and it’s directly linked to the poor glucose control. We also know that we see signs of the early signals of atherosclerotic progression in children within 4 years.

STEVEN BARTLETT: Atherosclerotic progression, what’s that?

Cardiovascular Disease and Type 1 Diabetes

DR. ANDREW KOUTNIK: So one of the primary causes of death in individuals across the world is cardiovascular disease. And how do we get that? Well, you have changes in your blood vessel, and how it functions is the first and earliest signal of future. What will ultimately be plaque or this kind of blockages within the blood vessel, which ultimately cause things like heart attacks or strokes.

Well, in type 1 diabetes, we see that children who have high and variable glucose levels, again, 99% of patients are expected to just live this way for the rest of their life. If they follow standard of care, if they follow the doctor’s orders, they’re going to see changes in how their blood vessels literally functionally and structurally change.

Their blood vessels will now shift from being this very, very compliant, almost like a smooth wave, to that. Blood vessel now becomes very rigid. It starts to build collagen and more and more collagen around it, becomes stiffer and stiffer. It’s almost like taking a hose and turning on a hose and pinching the hose. When you pinch the hose, as you become stiffer and as you shrink, the size of the blood vessel, it goes faster. And so we can measure that by the speed of the blood in the body.

Another clear signal and one of the most powerful signals that the blood vessel is starting to change before you see plaque, before you see blockages, I mean, decades prior. These are all happening in childhood, by the way. You know, 10 to 14 year olds diagnosed with type 1 diabetes, we see that the blood vessel isn’t able to respond to what they call shear stress, Steven.

So that means, let’s say you go for a run this morning, Steven, and your blood pressure initially increases because as your heart rate increases, the speed of the blood increases, the amount of pressure on the vascular wall increases, a phenomenon when the blood moves fast through blood vessels, it causes stress against the blood vessels. That’s not a bad thing. It’s actually a signal for the blood vessel to release something called nitric oxide.

Nitric oxide is a potent called vasodilator. It causes the blood vessels to open up. And this is how your body responds normally to stress. Okay, you go for an exercise, vasodilation or vasoconstriction, then vasodilation or, you know, and these are normal responses the body has.

Well, what happens in type 1 diabetes very early on is that the ability to produce nitric oxide is diminished. You’re not able to respond to high stress loads. So not only are the blood vessels becoming stiffer, but now the blood vessels aren’t able to even respond as well to the stress.

And so as you’re looking at this and you’re looking over time, you see these early signals of atherosclerotic progression. You also see very early on that it was once expected that all patients with type 1 diabetes would have eye damage, some form of eye damage called retinopathy, where you start to lose vision, eventually can go blind within 20 years of diagnosis.

So most people are diagnosed in 10 to 14 years of age, which means by 30 to 34 years of age, you’re going to see a lot of patients who have altered eye function and, or some who are blind. Now, that has extended out over time. But we know that all patients with this disease, because of high and variable glucose levels, are expected to get at least one complication in their lifetime if they follow standard of care advice.

Today, even with the best technologies out there, there is no pharmaceutical intervention, there is no technology that normalizes this disease. And the effects of these high and variable glucose levels and insulin resistance that accompanies it is cumulative dose dependent and not completely reversible. Which means that once you’re diagnosed, the clock starts ticking, just like smoking. The more you do, the earlier you do it, the earlier the impact and the more lost life you probably will get.

The Ketogenic Diet and Glycemic Control

STEVEN BARTLETT: And there was a study done with 326 participants that found that the keto diet can increase glycemic control of patients with diabetes. That was in the Precision Nutrition publication. When it says it can increase glycemic control, what does that mean? Is that what we were talking about there?

DR. ANDREW KOUTNIK: Yes. So when you do a diet known as the ketogenic diet, you’re reducing carbohydrates. Well, when carbohydrates are consumed, they elevate glucose levels. Well, if you dramatically reduce the amount of carbohydrates consumed, you’re not having those same type of glucose elevations and fluctuations because you’re not consuming the most potent glucose elevating factor in our life, which is carbohydrates.

And so when they talk about improvements in glycemic control, it is the measure of 24 hour over multiple day levels of glucose in the circulation. And how well is that being controlled within a normal, healthy range.

STEVEN BARTLETT: And so is your goal then to encourage people to restrict carbohydrates in their diet. But, you know, because carbohydrates and sugar have been somewhat, I guess, demonized because you never really hear many good things about sugar. So what is your goal here? What is the advice to the listener? Is it to restrict their carbohydrates, to be very conscious of what they’re consuming?

DR. ANDREW KOUTNIK: Because nutrition has a powerful potent impact on overall health. And for those patients who have chronic disease, which is unfortunately the overwhelming majority of us, yes, carbohydrates can be a very restricting. Carbohydrates can have a powerful therapeutic effect on diseases like type 2 diabetes.

The American Diabetes association and their 2019 consensus report described type 2 diabetes as the most evidence based nutritional strategy. We know that it can have potential positive impacts on things like Alzheimer’s disease. There are studies that have looked at this. We also know that.

STEVEN BARTLETT: For carbohydrate restriction.

DR. ANDREW KOUTNIK: Yes. Yep. So, and I like to term this therapeutic carbohydrate restriction because it’s the therapeutic outcome of a carbohydrate reduction. And that’s really the goal of this, is can you improve your overall health?

Many people will just do this simply to improve, you know, to lose weight, to feel like you say, to feel more cognitively alert. But in my case, where you’re further along the metabolic spectrum with diseases like diabetes, it has a even more potent impact on how you feel, even more potent impact on your overall health. But unfortunately, about 93% of Americans have some form of metabolic derangement as cited by multiple studies and multiple research groups.

The 10-Year Ketogenic Diet Study

STEVEN BARTLETT: You did a 10 year study on the impact of the ketogenic diet on a patient that had type 1 diabetes. I think this is most certainly the longest study ever done of its type where you took one individual and over 10 years, you, I guess, controlled their diet.

DR. ANDREW KOUTNIK: So we had access to the ability to monitor a unique patient who had type 1 diabetes. And they were diagnosed and had followed the American Diabetes association diet, a healthy diet, for six years, and then switched over in 2013 to a ketogenic diet.

Upon the initiation of the diet in post, they had DEXA scans, they controlled their calorie intake, their body composition, they weren’t taking any additional medications. And we were able to monitor the impact over a 10 year period while controlling all those variables.

And why that’s so important is because one of the common concerns of a ketogenic diet is the hypothetical risk it can increase cardiovascular disease. And the reason that they think that it can increase cardiovascular disease or it’s hypothesized that it will is because of the elevation in LDL that often accompanies an increase in saturated fat in the diet. Now, saturated fat comes from things like animal proteins. It’s in coconuts as well.

What we found is that despite a near doubling in LDL cholesterol on this diet, which again should be associated with worsening cardiovascular health, we did an advanced cardiovascular assessment in this patient and found that despite doubling LDL, they had maintained completely normal glycemic control, which again, based on all the data, says the number one risk factor, they reduced their insulin load over 40%.

And their cardiovascular health was not only better than the average patient of similar age and sex with type 1 diabetes, it was better in almost every single category than people even without type 1 diabetes. Despite the doubling of LDL cholesterol, it illustrated that over a 10 year period it maintained not only no sign of cardiovascular disease, but remarkable cardiovascular health.

And in fact, we actually followed on that study with the largest ever analysis of the impact of nutrition, particularly carbohydrates, in over 46,000 patients with type 1 diabetes. We showed that in over 70% of all reports of very low carbohydrate ketogenic diets that patients were completely able to normalize their glucose control, normalize the most potent risk factor for the disease of type 1 diabetes.

Understanding Blood Sugar Levels and Diabetes Categories

STEVEN BARTLETT: And is this, this is a sort of a spectrum of. I’ll put that on the screen for people to see the different sort of stages and categorizations of being normal, pre diabetic and diabetic. Right?

DR. ANDREW KOUTNIK: Correct. Yes. So normal is anything less than 5.7% HbA1c pre diabetic is that 5.7 number up to 6.4. And then diabetic is anywhere between 6.5 all the way up into essentially there’s no cap on how high that number can go.

STEVEN BARTLETT: I mean, I noticed your blood sugar levels have risen quite dramatically.

DR. ANDREW KOUTNIK: Yeah. So what you see initially is probably only the first phase of this. Right. So started at an average of around 100 milligrams per deciliter on average. And once the food is then consumed, because once you consume the food, it takes some time to break down into glucose.

That glucose then goes into the blood, and then the blood then moves glucose into this compartment around the cells, which is called the interstitial fluid. And now we’re starting to see the direct impact of just consuming probably a fifth of the amount of carbohydrates I should consume from a superfood, oranges are considered both a citrus and a fruit. And it’s considered like a superfood by the American Diabetes association in the context of diabetes.

How Blood Sugar Spikes Feel

STEVEN BARTLETT: So when the glucose spike is high, so you’ve just eaten some oranges, the spike is going up. What does someone feel and then what do they feel when it then crashes down and goes below? Because it started at about 100, so I imagine that it’s going to go up to whatever it goes up to, and then it’s not going to drop back down to 100. It’s going to drop below 100, typically in a normal, non diabetic person. Right.

DR. ANDREW KOUTNIK: So 100 is right around the normal. So what you’d hope would happen is that you’re going to go up just a little bit, insulin’s going to respond quickly and you’re going to come back down to normal if you have total healthy metabolic function. Again, the vast majority of us do not.

But in this case, what would be predicted to happen is that as blood sugar elevates and insulin responds, it’s going to go as high as the amount of glucose that’s present in the food. But at the same time, the my pod is also, which is holding, my insulin is immediately trying to respond. It’s immediately trying to say, “Okay, oh no, we need to bring this and keep this into a normal range.”

And so it’s trying to release insulin. And so you can see on the screen that there’s this massive uptick in the blue line, which is the initial response in insulin immediately to the elevation in glucose. This is exactly what happens in normal physiology. Yet no one can measure it. But you can see it here.

STEVEN BARTLETT: So how would I feel when the glucose spike is high? Do I feel energetic, do I feel focused, or do I feel tired?

DR. ANDREW KOUTNIK: My personal experience here, Steven, is that as blood sugar becomes very high, I become, my focus reduces, I become fatigued. I can also, according to my wife, become irritable. But you can even look this up. You know, you can look up what are the symptoms of hyperglycemia, what are the symptoms of elevated glucose levels above the normal range, which is normal, 70 to 120.

That’s when you can start to see very clearly that the evidence over time has shown it a very clear impact on not only how you feel physically, but also your mental health status as well.

STEVEN BARTLETT: I’ve just looked at the symptoms here and it says the common immediate symptoms of having a high glucose spike is you feel thirsty, dry mouth, frequent urination, headache, brain fog, fatigue, sluggishness, blurry, vision. And then once you go down and you crash or your glucose really drops below the normal range, what do you feel then typically?

DR. ANDREW KOUTNIK: So a lot of how I like to describe this is almost like imagine you’re outside and it’s sunny outside and you’re having a great day, great conversation with other friends, and then all of a sudden, very rapidly clouds come over top, everyone kind of dissipates and it starts to rain.

It’s almost like we know that glucose levels have a direct impact on the neurobiology of the brain, meaning how the brain functions, how it operates, and particularly at very high glucose levels, typically above 180 milligrams per deciliter, you start to see signals of inflammation, signals of stress, like oxidative stress in the body, if people have heard of that before.

And that can start to cause damage on tissues, a stress response. But the problem here, Steven, is that most patients are living there 24/7.

The Glucose Crash and Its Symptoms

STEVEN BARTLETT: I was looking at some of the symptoms here and it says the short term crash you get after a spike, after a rapid rise is a bit of an insulin overshoot. So it’s reactive hypoglycemia, which is the sugar crash. And then you might feel in that crash jittery or shaky, hungry, often craving carbs and sugar again, irritable, anxious, weak or lightheaded.

You did a study in 2025, I believe, on the impact of the ketogenic diet on physical performance.

DR. ANDREW KOUTNIK: You know, if the ketogenic diet has all these therapeutic potentials, you know, going back for over two centuries, what is truly the impact of it on performance? Because that’s one of the primary reasons where if someone were to walk into a clinical setting and say, “Well, yeah, you can do this, but I’ve heard it’s going to decrease my performance.”

STEVEN BARTLETT: Physical performance.

The History of Carbohydrates in Sports Nutrition

DR. ANDREW KOUTNIK: Physical performance. And so we were very, very interested in this because we thought, okay, when we look at why carbohydrates are currently being recommended as sports nutrition is because since 1921, they’ve been shown to improve performance.

And how they showed that in 1921 was that physicians out of Harvard and in Boston actually watched Boston marathoners, half of which wouldn’t even finish the race. Slurred words. They would have, like, almost pale skin, shaky, weren’t able to articulate their words, or some wouldn’t finish at all.

And what they were finding was that these, when they tested the blood of these individuals, that they were finding that glucose levels were low, basically they reached what they call hypoglycemia. It’s a medical term to describe very low blood sugar levels.

And the next year, they provided carbohydrates to these marathoners in the Boston Marathon, and all of them improved their performance. And so since 1920 or 1925, actually, we’ve known that carbohydrates can improve performance.

But what has happened, though, over time is that in 1960s, there was a measurement technique called the Bergstrom method, where you actually did a muscle biopsy, pulled out muscle tissue, and found that, “Oh, wow, there’s actually glucose stored in the muscle.” So it must be really important for physical performance if the muscle, which is used to contract and move the body during physical performance, that if glucose is in that tissue, it must be essential for performance.

And then after they discovered that, there was all these associations between low glucose levels in the muscle called glycogen, low glycogen, and fatigue. Then after that, in the 1980s, they were able to look at the amount of sugar or carbohydrates and fat that the body was burning during exercise.

And what they found at that stage is that, “Oh, wow, it looks like the amount that people are able to sustain intense exercise is proportional to how many carbohydrates they’re burning.”

And then there was a few modeling studies, Steven, that then looked at, okay, what’s the relationship between, let’s say, the intensity of exercise and what type of fuel you use, whether it be fat or carbohydrates. And they found that, they modeled it. Okay, and said, “Okay, well, at lower intensities you must burn almost all fat, and at very high intensities you must burn carbs.”

Previous Studies on Ketogenic Diet and Performance

And there was a number of studies in 2017-2020, three different studies that looked at the ketogenic diet over a five day to three week period. And they saw that in those studies that there was a decline in performance by around 2% if you were on the ketogenic diet.

STEVEN BARTLETT: If you were on the ketogenic diet.

DR. ANDREW KOUTNIK: Correct. Compared to a high carb diet.

STEVEN BARTLETT: Yeah.

DR. ANDREW KOUTNIK: And so what did that tell these researchers? Well, it said, “Okay, well obviously the ketogenic diet must impair performance.” And there’s all this evidence since 1921 that the amount of carbohydrates, glycogen, how much carbs you’re consuming is essential for performance.

But here’s the kicker, is that one major confounder of all this is that we’ve known for quite a long period of time that the adaptation to a ketogenic diet is not one week, it’s not two weeks, not even three, it’s four weeks or more.

STEVEN BARTLETT: And when you say adaptation, you mean your body’s transition to being in a state where it’s efficient at burning…

The Ketogenic Adaptation Process

DR. ANDREW KOUTNIK: Using ketones, so the body’s ability to lower its glucose oxidation or the amount of carbohydrates it’s burning for fuel because you’re giving your body less of it, the amount of fat that’s being utilized for fuel goes up dramatically and then you produce way more ketone bodies.

And ketones are now being used as not only a body tissue substrate, meaning energy for the muscle, but also for the brain. And so it’s this transition over. But when people were looking at these studies, they were just looking at some of the metrics of what happens when your body transforms, when you reduce carbohydrates.

So what we wanted to do is say, “Okay, if there’s all these health promoting benefits of a ketogenic diet, that sounds great, but all these studies and sports dogma would say that’s going to impair performance. Okay, so let’s test that.”

Let’s actually put athletes on a ketogenic diet for four weeks. We are going to control not only their calories, we’re going to control their body composition, we’re going to control their activity level. We’re going to control all these key confounders that many of these prior studies never controlled so that we could truly test the diet induced. So the macronutrient, meaning the shift from carbs to fat effect on performance.

But we’re going to do it in the same person. So now we’re going to control their genetics, we’re going to control their environment.

The Groundbreaking Study Results

Once we did that Steven, we tested what most people think is a very glucose dependent form of exercise. We asked them to do 6 by 800 meter sprints. They were on a high carb diet and then they switched to a low carb diet. Now what happened? This is all randomized and controlled.

When they switched over, they had no deterioration in performance at four weeks, at the four week mark in a form of exercise that we would expect would be extremely glucose dependent, extremely carbohydrate dependent.

STEVEN BARTLETT: But before four weeks was there an impairment in that performance?

DR. ANDREW KOUTNIK: So what we were interested in, Steven, is studying at the end. So we didn’t look intermediately, we exclusively look at the end time point. Because the question was, “Well, is there a difference once you stick to this diet?” Because if you go on this diet, ideally you’re sticking with it over time.

And so if it is true that you require carbohydrates, we then also measured how many carbohydrates and fat they were burning during the exercise. And it was over what we call 85% of their VO2 max, which means 85% of their total maximum oxygen consumption during exercise. That is when we would expect almost no fat to be oxidized or to be burned and almost exclusively carbohydrates.

Well, we found that these athletes recorded the highest levels of fat burning during exercise ever reported in the literature, illustrating that when these athletes adapted to the ketogenic diet, that when these diets adapted to the diet for sufficiently long, they had record levels of fat oxidation even at very high intensity levels.

Which means that fat was able to provide nutrients and fuel at very, very intense form of exercise when we would expect only carbohydrates would be relevant and utilizable.

Exogenous Ketones: External Supplementation

STEVEN BARTLETT: So many of my friends that are endurance athletes or that are involved in things like cycling talk about exogenous ketones. I’m a co owner of a company that produces exogenous ketones. That’s my disclaimer. I’ve got the product here. What can you tell me about products like this exogenous ketone products? Exogenous meaning externally supplemented I guess.

DR. ANDREW KOUTNIK: Right. So with a ketogenic diet, you produce them, your liver produces them for you. With exogenous, you’re consuming these. Well, why would you consume them? Why not just do a ketogenic diet?

Well, we know that a ketogenic diet takes time to adapt. We just talked about that with physical performance that we see that, you know, up to four weeks to see the full effect on performance or more. Well, what happens if you’re, let’s say a war fighter or someone who’s going out into the field or immediately wants to flip into this state? You can’t do that unless there was a molecule that you could consume that could rapidly elevate ketone bodies in circulation within minutes. Insert exogenous ketone bodies.

We have known since the 1960s that the product in there was studied by MIT in the aerospace department called 1, 3 butanediol, that it was able to be consumed and rapidly elevate ketone bodies in circulation.

DARPA Research and Military Applications

There was a study in 2016 called the metabolic optimization. It was $10 million program from DARPA. DARPA, being the DARPA, is an advanced research organization from the United States government where they fund very high risk, high reward programs. And one of which was the use and testing of ketone bodies.

And so that molecule that they tested was utilized, the same molecule as in there. And they kind of tweaked some of the formulations a bit and they showed that. And we know that this is the same for this molecule as well, that when you consume them, it rapidly changes metabolism. Almost not identical to what happens with the ketogenic diet, but it has an almost direct impact.

It has a blood glucose lowering effect. It directly binds to receptors like the, they call GPR109A or some other key receptors that directly impact inflammation. So it directly blocks something called NLRP3 Inflammasome, which is a molecule that leads to increases in inflammation.

We also know that it changes the way that our genes are used in the body, called epigenetic signaling. And so the consumption of ketone bodies can actually change the molecules on our genes and how those molecules are ultimately manifested. And that increases our antioxidant capacity, meaning our ability to block oxidative stress in the body.

We see all these powerful effects, these rapid shifts in metabolism within the body. And this 2016 study showed that just orally consuming these molecules could rapidly shift metabolism, but that it was also linked to an improvement in physical performance.

Cognitive Benefits and Alzheimer’s Research

But if you look beyond that, and just like these kind of studies, because we looked at them in athletes, we looked at them in healthy individuals and then also in military settings. But there’s studies looking at this in patients at risk for cognitive decline. So patients at risk for Alzheimer’s disease, they’ve shown that in a six month study, administering exogenous ketone bodies was able to attenuate the decline in cognition that we know happens with advanced age.

STEVEN BARTLETT: And just to be clear there, you’re saying it reduces the decline. It doesn’t cure Alzheimer’s or fix Alzheimer’s. It just delays.

DR. ANDREW KOUTNIK: Accurate. Yes. We know that as individuals age, you’re on a precipitous or steady decline in brain function. And so the goal is to offset or to stop the decline. That’s our goal. We want to maintain normal brain function and our ability to think clearly and to understand things clearly, like reading and doing problems and solving problems.

Mental Health Applications

There have also been this emergence of studies in the world of psychiatry. I think there’s around 11 ongoing active clinical trials looking at the impact and interaction of ketone based therapies and brain health, particularly serious mental illness.

One in four adults in the United States, actually over one in four adults in the United States has serious mental illness. In fact, I believe the numbers are over 20% of adults are taking some type of psycho altering medication.

At its core, we see all these relationships between underlying metabolism being a key factor contributing to mental health status and the application of this unique diet, which we know increases ketone bodies, which appear to have direct impacts on the brain, now seems to be linked to improved serious mental illness.

And it’ll be interesting to see where that evolves. But it’s just a fascinating world to imagine that nutrition not, not a medication, not a technology, but simply going to the grocery store and swapping the things you choose in there can lead to these powerful, powerful therapeutic effects in people of all sorts of different conditions or disorders.

The Impact of Ketones on Brain Network Stability

STEVEN BARTLETT: On one of the studies that I read about the administration of exogenous ketones and the impact it has on brain network stability was from 2020, where they investigated if brain network stability responds to two major brain fuels, either glucose or ketones.

Participants came to the laboratory on two occasions and drank exogenous ketones or glucose. After consuming these drinks, they underwent an MRI scan. Strikingly, the study showed that ketones increased the stability of brain networks. In contrast, glucose decreased the stability of the network.

The network stability was 87% greater after ketone consumption than stability measured after glucose consumption. In that study, which is on PubMed, the last line of the abstract says “dietary interventions resulting in ketone utilization increase available energy and thus may show potential in protecting the aging of the brain,” which is super interesting.

Ketones and Cancer Research

DR. ANDREW KOUTNIK: So we did a study looking at cancer and applying exogenous ketones in a very aggressive form of metastatic cancer. What we saw in my work in graduate school is that when applying just exogenous ketones, that it delayed the progression of metastatic cancer.

But it also, when looking at body weight, reduced the rapid decline in body weight. We sometimes see with cancer, a phenomenon called cachexia, which is a term to describe the rapid wasting of body tissue with disease. It is no more aggressive than in the context of cancer, particularly metastatic cancers, where it’s most common.

When we saw the lack of decline in body weight, I then looked at where the body weight was coming from, and it was clear that the lack of body weight decline was because of the preservation in muscle mass. So it also appeared, and there’s been a number of what they call clinical physiology studies, so studies that actually directly manipulate human beings with molecules and test like muscle tissues and how they function.

We see that exogenous ketone administration can dramatically reduce the amount of muscle breakdown or breakdown of muscle tissue, essentially illustrating it may be a powerful mechanism in promoting healthy muscle mass as well.

Muscle Mass and Ketogenic Diets

STEVEN BARTLETT: In terms of being in a ketogenic diet, one of the things I’m always quite concerned about is am I still able to gain muscle mass if I’m in a ketogenic diet? Because when I go into a ketogenic diet and I stop having carbohydrates, I tend to lose weight rapidly and shred. The fat falls off and I get very lean but more skinny.

DR. ANDREW KOUTNIK: You smiled though, because maybe you like to be more shredded. So a phenomenon with the ketogenic diet – there’s no deterioration in muscle mass with a ketogenic diet. There have been plenty of studies that have shown that you’re able to maintain muscle mass and build it. Yes, and build it. So they’ve shown that as well.

Jeff Volek out of Ohio State University has done a number of studies in this area looking at individuals who were actually on a reduced intake diet. So they’re eating less calories, so they had less energy in the diet. They were also doing the ketogenic diet, it was actually a military study.

They showed that they were able to maintain muscle mass just as much as if someone was on a high carb diet while under a caloric restriction, or another way of describing that is like a semi-starvation state. So there’s no negative impact that we see with these diets on muscle mass.

However, to your personal example, one of the first things that happens when you go into a ketogenic diet is there’s a natural effect – basically you reduce the amount of sodium in the body, so you piss it out, basically, and you hold less water weight. That’s one of the first things. That’s why people see this rapid shift in body weight initially when they’re on a ketogenic diet, which for many people is great, because if they’re trying to do it to lose weight, that’s immediate reinforcement.

But sometimes it’s water weight. Well, water is in both the fat and the muscle. So it’s not necessarily that you’re losing any muscle mass per se, but it just might be less water weight. In some contexts that might be beneficial. If you’re in a sport where you have a power to weight ratio, but you’re able to maintain the same power at a lower weight simply by shifting water, that’s great. As long as you’re able to function equivalently.

STEVEN BARTLETT: Is there anything I do need to be thinking about in terms of my diet to make sure I’m still gaining weight? Just to keep my protein levels high.

DR. ANDREW KOUTNIK: So the most important thing related to your diet when it comes to trying to build muscle mass is to exercise hard and with resistance exercise. That’s the most important thing when it comes to your diet to enhance that effect.

Protein is one of the most powerful nutrients you can consume to augment that response. Another is to ensure you’re having sufficient calories. So if you’re in a caloric deficit – you said that you tend to eat less calories because you’re probably not as hungry. Well, that’s one of the most powerful ways to lose not only fat but also muscle is to just not eat food.

Appetite Suppression on Ketogenic Diets

STEVEN BARTLETT: I think that’s it. Because I lose my appetite when I’m in the ketogenic diet. I also lose my appetite a little bit when I take these exogenous ketones like Ketone IQ.

DR. ANDREW KOUTNIK: Yeah.

STEVEN BARTLETT: I’ve seen some of the studies that show that there’s roughly 20% decrease in appetite when you take exogenous ketones, according to one particular study that I read. But when I’m in the ketogenic diet, it’s like food is – I get hungry, but then I start eating and I stop very quickly.

DR. ANDREW KOUTNIK: Yeah.

STEVEN BARTLETT: It’s really bizarre. I was in Cape Town for 10 days or two weeks writing my book. So I had the chef there, and the chef cooks me my food and makes this amazing food. I’m so hungry. I look at it, I’m like, “Oh, amazing.” I start eating it, I have like five or six bites, and I’m done. Only when I’m in the ketogenic diet, there’s something going on in my body which just doesn’t want to binge eat like I sometimes did.

The Science Behind Reduced Hunger on Ketogenic Diets

DR. ANDREW KOUTNIK: So there’s two things to talk about. One is the type of foods you’re consuming on a ketogenic diet, and the other is what is happening in your body, in your metabolism, on the diet.

There’s a book called “Always Hungry” by a physician endocrinologist named David Ludwig, and he’s coined this carbohydrate insulin model. It’s somewhat controversial, but the reality is that there’s some important notes in it, one related to hunger, which is if you’re able to have a fuel source on a ketogenic diet that’s sustained over time, so you don’t have the ups and downs of glucose and ups and downs of insulin, so these constant swings.

Whereas on a ketogenic diet, you have this sustained level of fuel influx. So you have this nutrient availability in the blood, so glucose levels are much more stabilized, insulin is much more stabilized, and you don’t have those fluctuations in those specific molecules. That might be one potential reason.

But the other potential reason is that when you’re on a ketogenic diet, you tend to not consume the type of foods that drive hunger. So again, we talked about in the grocery store, the 70% of the grocery store, and particularly in the center of the grocery store that is highly processed, where they combine carbohydrates with salt or fat or some combination there, and that makes it highly palatable or very, very tasty.

You know, increase the dopamine response, this positive reinforcement response of the food that drives people to seek more of that pleasure response. As a result, they want to consume more.

So everyone has probably felt this example where you’re in a restaurant, you’ve eaten enough food to where you feel physically full. You’re like, “Oh, I’m totally full. I don’t want to eat any more food.” Someone walks by with your favorite dessert, and you’re like, “Oh, well, I could eat that.” You’re literally physically full, but yet you want to consume more food.

This is a phenomenon that has been the struggle in America and the rest of the world essentially now where the food environment often drives people to over consume. It’s not by accident. These are well conducted strategies in the food industry to lead to these positive pleasure responses.

STEVEN BARTLETT: I think about this with bread in the restaurant. You know, they give you bread first.

DR. ANDREW KOUTNIK: Yeah, it’s a solid strategy, Steven, to cause you to want to consume start to finish, not only the bread, get a big meal and follow on with dessert. It is a great strategy for ensuring that, but it’s also the same strategy that Doritos is using where you combine this mixture of molecules in the food that you consume it and you get “oh, this tastes great.”

STEVEN BARTLETT: Pringles.

DR. ANDREW KOUTNIK: The same exact thing where you combine these different components and it forces you this “oh, this tastes great, I need more.” And you never feel full.

One of the most common tricks that the food industry utilizes in these environments is that they certainly are aware of this. So when you consume these type of foods together, they know they consume more of it. But sometimes people aren’t even aware of it.

Best example of this, go look at the back of most of the bacon on the grocery store aisle. Go look at the back of most peanut butters, almond butters, nut butters in the grocery store. Most of them have added salt and added sugar even to levels where you don’t even taste it. But go look at the label.

The reason those are added is to increase the flavor profile, the positive brain response to the food so that you consume more of it. This is a huge part in why people always feel hungry in today’s food environment. They’re always seeking more food and they can’t get off that hamster wheel. They’re always over consuming or always referring to this phenomenon called food noise where they always feel the drive to consume foods or they never feel full.

STEVEN BARTLETT: And it’s because of the sugar in the salt.

DR. ANDREW KOUTNIK: It is because the food is composed and made in such a way to have a flavor profile that your brain says not just eat one bite, eat as much as possible. Because we’re always seeking these pleasure responses in our lives, in our world, this is even independent of food.

Solutions for Food Cravings

STEVEN BARTLETT: So what do we do about this?

DR. ANDREW KOUTNIK: So the solution for most people in this situation is to try to focus – number one, don’t consume liquid calories. That’s like a dead giveaway bad move because those are abundance of calories will drive people often to over consume them and drive this pleasure response in the brain.

STEVEN BARTLETT: Liquid calories. What’s a liquid calorie?

DR. ANDREW KOUTNIK: So let’s say you have a soda or a Coke. So basically completely void of any nutrients and really high in calories, spikes your glucose through the roof. Insulin through the roof, and then often makes you hungrier afterwards, not less hungry. Orange juice is another great example.

STEVEN BARTLETT: Smoothies, those fruit smoothies people have.

DR. ANDREW KOUTNIK: Exactly. In fact, just taking fruit and then blending it up actually increases the speed by which it was absorbed, changes the hormonal response and leads to a worse outcome for most people.

STEVEN BARTLETT: Most people think a fruit smoothie is a healthy thing.

DR. ANDREW KOUTNIK: Yeah, I don’t know about that. I think that when you take fruit, which for most reasons isn’t terrible – these are nutrient dense foods. If people can consume them and get away from them, great. If you have a metabolic disease, you might be more vulnerable to let’s say glucose elevations.

But when you then take foods like that, it could be any foods, it could be taking potatoes and then making mashed potatoes. By simply changing or blending that food up, you are now taking a lot of the structural components that your body would take time to digest and you’re removing them and you basically almost are turning on like a small hose that’s just giving you a little bit of water at a time and just turning it on all the way.

You’re rapidly increasing the speed of how the nutrients enter the body and it completely changes the hormonal response of molecules like GLP-1. Normal levels of GLP-1 in the body are completely altered. The insulin response is also altered.

STEVEN BARTLETT: And GLP-1 is the hunger hormone.

DR. ANDREW KOUTNIK: It’s known for being related to hunger because it’s released in response to food. It changes the brain’s hunger drive. Most people know of it because of Ozempic, semaglutide, Wegovy, tirzepatide, all these GLP-1 receptor agonists that are increasing GLP-1 levels, not to normal levels. They’re increasing them to super physiologic levels, levels that would never be observed or ever seen in normal settings of the body.

Practical Health Advice for 5 Million People

STEVEN BARTLETT: So I want to give the audience that are listening some practical ways that they can change their life to live a better life and to navigate the food environment we live in. But just generally the advice that you would give if you had the ear of 5 million people right now and you could say something to them to help them live better lives, to perform better, what advice would you give them?

DR. ANDREW KOUTNIK: Number one is I would say be conscious of the food you’re consuming and what you’re consuming on a daily basis. The impact of food is equivalent to medicine. It is, and sometimes more powerful than medicine.

So what you drink, what you eat, focusing on whole foods, not consuming liquid calories. And if you’re someone who could benefit uniquely from stable glucose levels, lower insulin levels – like someone who has some type of metabolic disorder, like I do – reducing carbohydrates oftentimes can be a very powerful strategy, in fact known to prevent and reverse things like obesity and type 2 diabetes, with emergent evidence for its potential ability to put things like serious mental illness into remission. But we’ll see as more evidence comes out.

Exercise on a regular basis. We know that exercise might not be the primary, the lack of exercise might not be the primary driver for why someone is or isn’t obese. But we do know that physical activity promotes health. We do know that physical activity is extremely important for overall well being.

Exercise and Type 1 Diabetes Management

STEVEN BARTLETT: And so you’ve got big muscles. Is that somewhat linked to your type 1 diabetes at all? Is that part of your strategy?

DR. ANDREW KOUTNIK: Yeah, look, I was obese at one point and so I’ve, since that point taken a very – I’ve become obsessed with trying to find out how to be bigger, stronger, faster, optimize my metabolic health, optimize my performance. And so it’s been a lifelong kind of self experiment in that journey.

But exercise is just important in general. But for me it’s about all the different experiments and strategies I can use with exercise, with resistance exercise and beyond to kind of play around with what affects my body, what affects my insulin, how do I increase my overall metabolic health. And what I have seen is that that’s directly linked to my performance.

STEVEN BARTLETT: How often do you exercise?

DR. ANDREW KOUTNIK: I try to exercise every single day.

STEVEN BARTLETT: How long for and what types of exercise?

DR. ANDREW KOUTNIK: So what I do right now is I typically do weightlifting for 30 minutes to an hour every or six days a week. And then I will go typically ride a bike to jiu jitsu, so Brazilian Jiu jitsu, which can be uniquely, almost like a mixed exercise, intense exercise where it can be extremely intense for like five minutes and then you have a one or two minute break, extremely intense and then a break. And I do that typically around five days a week.

I also try to purposely engage in some type of aerobic exercise when I can. If I wasn’t able to do as much jujitsu one day or as much resistance exercise, I always try to add on some type of cardiovascular work, whether that be a run, a bike or these aerodyne bikes where it’s just lower and upper body. I find those to be incredibly effective and powerful tools and actually just not causing damage to muscle tissue, but also allowing you to improve your overall cardiovascular health.

Daily Eating Patterns on Ketogenic Diet

STEVEN BARTLETT: What does your diet look like?

DR. ANDREW KOUTNIK: So I tend to wake up and not think about food. That’s one thing that I’ve also experienced, similar to you, that when I switched to a ketogenic diet, not only improve my glucose and insulin, but I also found that with a ketogenic diet that I don’t feel hungry, so I would wake up and I don’t tend to eat food right away.

In fact, I enjoy when I don’t eat food more so than when I do eat food, oftentimes just because – not because I don’t enjoy the feeling of sitting down and having food, I love that. But the experience and lived quality of life of not having high variable glucose levels, high insulin levels, and the uncertainty that comes with that in my daily life, I enjoy the 23 hours or 22 hours of my day where I have the stability, not the moments in time where I’m introducing uncertainty and variability.

To dumb that down a little bit, what I’m saying is that I wake up and I don’t eat food because I find that I’m not hungry. But I also find that it makes managing diabetes easier.

STEVEN BARTLETT: And so do you eat once a day or twice a day?

DR. ANDREW KOUTNIK: I tend to eat two to three times a day, sometimes right before jiu jitsu or weightlifting. Jiu jitsu, always afterwards and always before sometime before bed. Try not to do it right before bed because it tends to impact my sleep quality a little bit. But I find that I just eat whenever I feel hungry, and I try to give myself sufficient protein to be able to respond to the exercise that I’m doing.

The Three Pillars of Health

STEVEN BARTLETT: So the first one’s about being intentional about your food choices. The second one is about exercise. Anything else?

DR. ANDREW KOUTNIK: Well, sleep’s really important. These are – Steven, this isn’t like, “oh, this is the most revolutionary advice of all time.” But these core foundational components, good nutrition tailored to your specific needs, exercising as much as you can, and getting good sleep are the pillars of health. If you don’t have those corrected, then you’re wasting your time everywhere else.

Surprising Glucose Responses and Food Choices

STEVEN BARTLETT: And is there anything as it relates to glucose that surprised you because you’re someone that sees a lot of this data? I mean, you walk around with the two devices on that you’ve mentioned, and you’re looking at the insulin and glucose response. Is there anything that people don’t understand is having a really pronounced impact on their glucose levels that they wouldn’t expect?

Like, orange juice is one of the ones that, growing up, I thought I thought this was a healthy thing. I used to drink Sunny Delight thinking I was putting all these amazing vitamins in my body. And now I actually look back and regret it. And not to be judgmental over any parents because parenting is very hard, but sometimes I’ll see parents giving their children like a big glass of orange juice and in my head I just see the glucose spike that that child’s about to have.

DR. ANDREW KOUTNIK: It’s funny when you mention parenting because I have a three and a six year old at home and it’s amazing when they try one of these foods, these very sugary foods, these very tasty foods, it’s almost like they become incessant on wanting it again. Normal food isn’t good enough anymore.

And I think that’s a great illustration of what many of us adults are challenged with on a daily basis. But yet many people are just unaware of the impact that it’s having on their metabolism, impact that it’s having on their hunger, the impact that that’s going to lead to on their future health.

STEVEN BARTLETT: And is there anything that you’ve spotted from your experiments with your CGM and your insulin device that people should most certainly avoid? So you said liquid calories. Is there anything else that causes a really pronounced or unexpected glucose response?

DR. ANDREW KOUTNIK: Yeah, there’s so many, honestly, Steven, over time that it’s really hard to pinpoint any singular one. A lot of the foods that are out there are often surprisingly challenging on glucose levels, on insulin levels, particularly the processed foods.

Because what happens when you make these food products is that you’re trusting the food company to put ingredients in there that you’re going to respond favorably to that your metabolism or respond well to. And the truth is that that’s far from a guarantee and in many cases maybe less likely than it is likely. And so, yeah, I don’t have a single example for you, Steven. But I’ve experienced it numerous times.

Foods That Spike Blood Sugar

STEVEN BARTLETT: So I’ve got a small list here. Sugary drinks, white bread and bagels, white rice. That surprised me a lot because I used to think white rice –

DR. ANDREW KOUTNIK: Oh really?

STEVEN BARTLETT: I thought growing up rice was like a health food.

DR. ANDREW KOUTNIK: Okay, well, so on that note, white rice, potatoes, or potatoes in any form, sweet potatoes tend to have less of a glycemic response, but it’s still going to have a potent glycemic response.

STEVEN BARTLETT: So mashed or baked potatoes, obviously French fries.

DR. ANDREW KOUTNIK: Yeah, for sure. French fries. Most of, like pasta is a big one. Cereal, refined cereals, most cereals are actually worse than the foods I just described on blood sugar and insulin by a long shot. In fact, most of the “heart healthy cereals,” these would – I would never – blood sugar would just spike through the roof portion of the amount I ate.

So yeah, I wouldn’t be consuming a lot of those. And I think most people at this stage in the health and science world would also generally align with that, that those aren’t necessarily the best foods to consume. We would think more of the less glycemic or less foods that have less of an impact on glucose levels, less of an impact on insulin levels.

One thing I constantly hear, especially in the research and clinical community is like, “well, look, not everyone needs to be concerned about that because people can respond to a lot of these foods just fine.” I say you’re right, except that over half of America has prediabetes and 90 plus percent have some form of measurement that indicates that their metabolic health is impaired. And over 68% are obese. And now children are affected with these diseases with obesity and prediabetes around 20%. So it’s the fact that we are now less healthy than we’ve ever been.

STEVEN BARTLETT: We don’t have the foundation to support –

DR. ANDREW KOUTNIK: Correct. And I think when we think about healthy nutrition, we think about exercise, we describe them as medicine, but the reality is these are just normal aspects of things you should do every single day, because that’s what our bodies were made to do. And when we don’t do those things, this is when health deteriorates. This is when we’re challenging our body to maintain normal health.

The Truth About Dried Fruits

STEVEN BARTLETT: One of the surprising ones for me was dried fruits. And it said while fruit contains natural sugars, the process of drying it concentrates those sugars. This removes the water and can make the sugar more readily available for absorption, leading to a higher glucose spike compared to fresh fruit. Typically people think of dried fruit as being a health food as well.

DR. ANDREW KOUTNIK: Yeah, I don’t touch those because unless I don’t have any glucose on me and my blood sugar is going down for some reason and it’s in dangerously low levels. That’s when I consume those foods. Otherwise I would not consume them just because of how quickly they raise blood sugar levels.

STEVEN BARTLETT: Do you think everybody should try the ketogenic diet?

The Importance of Individual Response to Interventions

DR. ANDREW KOUTNIK: That is a good question. I think, wow. What I would say is that you will never know the potential of its benefit or lack thereof if you don’t try. Like anything in life, we’re left to assume what everyone else is like. You might have… We’ve talked about the ketogenic diet numerous times here. We talked about exogenous ketones numerous times here. But if you don’t try it, you don’t know how it’ll work for you.

In science, Steven, one of the most important things to appreciate is that we often publish bar graphs that look like this. You know, a line that illustrates the average outcome of a group of people. But what you don’t appreciate is that that line or that bar graph is made up of numerous individuals who all average to that number.

But what if you’re the person who’s at the very high dot or the very bottom dot, meaning that you’re what they call an outlier or someone who responded negatively or positively to that, and then you just follow the average advice that that study showed? Well, “Oh, look, I tried this approach and it didn’t work for me. I’m just going to keep trying because this study said that I should.” Well, no, you might be the person who was in that study who didn’t respond, just like the person on the opposite end of the spectrum who did, who averaged out to the middle.

STEVEN BARTLETT: So in that study that talked about the impact of exogenous ketones on brain stability, someone might have had 100% improvement in brain stability, and someone might have had 20% improvement or whatever, and they’ve averaged it out across a bigger group of people. So if you are that person that had a 100% gain in brain stability, it’s a pretty unbelievable tool for you to understand based on your body.

DR. ANDREW KOUTNIK: Exactly. And that’s always the case in science. I mean, sometimes we look at this as responders and non-responders, but actually in the study where we gave the product from Atrium and Ketone IQ in the SOCOM study, we actually saw that nearly all of them saw an increase in SpO2. Nearly all of them saw an increase in heart rate. But that’s rare. That is rare.

STEVEN BARTLETT: SpO2?

DR. ANDREW KOUTNIK: The amount of oxygen in the blood. So the measure that would indicate whether someone in these low oxygen environments had more blood or more oxygen or less oxygen.

Personal Experimentation and the Ketogenic Diet

Ultimately it’s important to try. I think I would always say, yes, you should try, or any nutrition strategy, because you should try different ones. I’ve probably tried over 10 plus different diets. Honestly, maybe like 15 or 20 at this point in my life.

I’ve just come to find that the ketogenic diet, for all the reasons we described and because I have type 1 diabetes, and I had… or have type 1 diabetes, but had obesity… find that a ketogenic diet is remarkably powerful at helping me live a dramatically improved quality of life, not have the increased risk for the high and variable glucose levels, high insulin levels that lead to a near guarantee of complications and 10 to 20 years of lost life expectancy. That’s why I do it.

Philosophical Questions About Reality

STEVEN BARTLETT: I have a closing tradition on this podcast where the next guest leaves a question for the next guest, not knowing who they’re leaving it for. And this is a really tough question, so it’s a very strange question as well, but I’m going to ask you anyway. The question is, what is outside the simulation?

DR. ANDREW KOUTNIK: I think it depends on your philosophy, on how our existence is with the limitations of understanding that our awareness of our world is completely limited to our brain’s capacity and our interpretation and then explanation of the world. And the term of a simulation, or lack, however you want to frame it, I believe is always going to be limited by our brain’s ability to understand and articulate that.

STEVEN BARTLETT: So what do you think is outside the simulation?

DR. ANDREW KOUTNIK: Consciousness.

STEVEN BARTLETT: You think consciousness is outside the simulation?

DR. ANDREW KOUTNIK: I think that our ability to have… Not consciousness, Steven, but our ability to operate beyond consciousness. Got me on that one, man. That was a tough question. Yeah, it is a tough question. That’s a burner right there. I don’t know.

STEVEN BARTLETT: Do you think there is… Do you think there is a God beyond all this stuff that we see here?

DR. ANDREW KOUTNIK: I’m going to give you the most real honest answer possible. I don’t think we ever can actually answer that question accurately.

STEVEN BARTLETT: So your answer, therefore, is you don’t know.

DR. ANDREW KOUTNIK: I don’t know, and I don’t think I’ll ever know.

Closing Thoughts and Appreciation

STEVEN BARTLETT: Thank you. Thank you so much for doing the work that you do. Really appreciate it. Because so many of my friends in this field and even Michael, the founder of the ketone product on my table here, talk about you as being the sort of gold standard of research, science and thought leadership on the subject of ketones and more broadly, on the subject of glucose and all of the adjacent subjects, like insulin.

So you’ve really pushed the field forward and the thinking forward in this space in a really profound way. And you’re only just getting started at 34 years old, which is remarkable. We’re basically the same age, and you’ve had such a tremendous impact on the field of health, and that’s born out of the story that you told at the start through your own complications.

So although it was… it’s such a tragic thing to have such a diagnosis at such a young age. What’s come from that is a beautiful thing for so many people that will better understand themselves and their illnesses, but also their performance and everything correlated to that because of you. So please keep doing the research you’re doing and spreading the word and the way you’re spreading it because it’s much, much needed work and it’s important work. So thank you so much and thank you for giving me your time today, Steven.

DR. ANDREW KOUTNIK: It was an honor. Appreciate it, sir.

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