In this episode, Dr. Ian Lake, a GP from the UK, shares his revolutionary approach to managing type 1 diabetes through a ketogenic diet. We explore the science behind insulin dosage, metabolic flexibility, and the challenges of advocating for low carb, high fat diets in the medical community.
Key Takeaways:
Resources and Links:
Timestamps: 00:00:00 - Introduction and Dr. Ian Lake's background 00:02:30 - Dr. Lake's diagnosis with type 1 diabetes 00:08:15 - Conventional diabetes management and its challenges 00:15:00 - Discovering the ketogenic diet and its impact on diabetes control 00:22:00 - The importance of reducing insulin dosage and increasing metabolic flexibility 00:28:30 - Challenges in advocating for low carb, high fat diets in the medical community 00:35:00 - Dr. Lake's efforts to educate and promote the ketogenic approach
About Dr. Ian Lake:
Dr. Ian Lake is a GP in the UK who was diagnosed with type 1 diabetes in his mid-thirties. After initially following the conventional high carb, low fat diet recommended by guidelines, he discovered the benefits of a ketogenic diet for managing his diabetes. Dr. Lake has since been advocating for the use of low carb, high fat diets in the management of type 1 diabetes, despite the challenges faced in convincing the medical community.
Connect with Dr. Ian Lake
webpage: www.type1keto.com
linkedin:
Chances are, you wouldn't be listening to this podcast if you didn't need to change your life and get healthier.
So take action right now. Book a call with Dr. Ovadia's team.
One small step in the right direction is all it takes to get started.
How to connect with Stay Off My Operating Table:
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Theme Song : Rage Against
Written & Performed by Logan Gritton & Colin Gailey
(c) 2016 Mercury Retro Recordings
Any use of this intellectual property for text and data mining or computational analysis including as training material for artificial intelligence systems is strictly prohibited without express written consent from Philip Ovadia.
In this episode, Dr. Ian Lake, a GP from the UK, shares his revolutionary approach to managing type 1 diabetes through a ketogenic diet. We explore the science behind insulin dosage, metabolic flexibility, and the challenges of advocating for low carb, high fat diets in the medical community.
Key Takeaways:
Resources and Links:
Timestamps: 00:00:00 - Introduction and Dr. Ian Lake's background 00:02:30 - Dr. Lake's diagnosis with type 1 diabetes 00:08:15 - Conventional diabetes management and its challenges 00:15:00 - Discovering the ketogenic diet and its impact on diabetes control 00:22:00 - The importance of reducing insulin dosage and increasing metabolic flexibility 00:28:30 - Challenges in advocating for low carb, high fat diets in the medical community 00:35:00 - Dr. Lake's efforts to educate and promote the ketogenic approach
About Dr. Ian Lake:
Dr. Ian Lake is a GP in the UK who was diagnosed with type 1 diabetes in his mid-thirties. After initially following the conventional high carb, low fat diet recommended by guidelines, he discovered the benefits of a ketogenic diet for managing his diabetes. Dr. Lake has since been advocating for the use of low carb, high fat diets in the management of type 1 diabetes, despite the challenges faced in convincing the medical community.
Connect with Dr. Ian Lake
webpage: www.type1keto.com
linkedin:
Chances are, you wouldn't be listening to this podcast if you didn't need to change your life and get healthier.
So take action right now. Book a call with Dr. Ovadia's team.
One small step in the right direction is all it takes to get started.
How to connect with Stay Off My Operating Table:
Twitter:
Learn more:
Theme Song : Rage Against
Written & Performed by Logan Gritton & Colin Gailey
(c) 2016 Mercury Retro Recordings
Any use of this intellectual property for text and data mining or computational analysis including as training material for artificial intelligence systems is strictly prohibited without express written consent from Philip Ovadia.
Back, folks. It's the Stay Off My Operating Table podcast with Dr. Philip Ovedia. And our guest today is joining us from the other side of the Atlantic Ocean. I love it when that happens, mostly just because there's something that the English accent does to American ears. Don't know why, never really understood it, but Do you remember the TV show? I mean, the movie love actually where the guy he's just he's like a food service waiter who just can't get a woman to look at him in England and he realizes if he goes to America, he will be. Yeah. That's the reason it's funny is because it's true. Okay. Phil, I've taken us the wrong direction. Introduce our guest.
Dr. Phillip Ovadia:Very good. May, maybe we can ask Ian.'cause I haven't figured out if you know, the if hearing an American accent in the UK has the same effects. I don't think it has from my experience, but, Dr. Ian Lake: oh, There are so many American accents. I, there's so many English accents. I'm a hybrid. I was born in the east of the country, moved up to Liverpool, which has its own accent, then moved down to the south. So you hybrid eyes after a while, don't you? But there's lots of different accents in the States, aren't there? Yeah, definitely. So I have a mutt US accent as well with all my various travelings around. But so really excited to have Dr. Ian Lake on today. Ian is a GP in the UK, and really has an amazing story to tell around his experience with the diabetes being diabetic, which we'll get into and some of the amazing things that he has been able to do to manage his own diabetes and now to help the diabetes community at large. So with that Dr. Ian Lake, why don't you give a little bit of your background to our audience?
Dr. Ian Lake:Yeah, thank you very much. So my name is Ian Lake. I'm a GP. I'm in the West country, so the West of England, near Bath, really which a lot of people from the States visit. So I developed type 1 diabetes later on in life. So it's often thought of as a childhood disease, but type 1 diabetes has several peaks, and there are teenage onset and child onset, and then there's an adult onset. So mine, mine came to me in, in, in age. Mid thirties, and that's called LADA or latent autoimmune disease of adulthood. So it has the same connotations as type 1 in childhood in that you, you develop antibodies to various parts of the glucose producing pathway. And that happened to me. So I had that now nearly 30 years, 29 years I had type 1. For the first 20, I, so I was a GP when I developed type 1, and I diagnosed myself, which is quite quite useful. And I put straight onto insulin because my presentation was a classic type 1. It was raging thirst, urinating. Very frequently, tiredness about a month or two before that. And then ketones and a high blood sugar on diagnosis. So I was put onto insulin straight away. And what happens when you go onto insulin is that you have this thing called honeymoon period, which some people do anyway, in which For some reason, despite all that autoimmune destruction of your pancreas, the pancreas recovers. And then you can use very little insulin for a year or two. But I was adopting what I call the classic guideline diet, which is a high percentage of carbohydrates compared to a low fat diet. And After 20 years of doing that, because that's the way I was trained, that's the way I was taught to do it, so why question the evidence put in front of you as a GP to manage type 1 diabetes? Because as GPs we have a lot of disciplines to cover. We have, for example, ear, nose, and throat cardiology, gastrointestinal. So we rely on experts to provide us with enough information to keep us on the ball and able to provide a good service so we know when to refer on to specialists. So I was using a high carbohydrate diet for 20 years or 50% of my energy came from carbohydrates and that didn't serve me well. So my insulin volumes went up and up. My HB one C, which is a measure of long term, longer term control of diabetes, is a three month how well you're controlled in the past three months was going up and up into. Not very good control ranges. For example, the normal range is 6%, or 42 millivolts per mole in our country. And I was achieving that for a year or two. Then it went up to the 50s, and that was considered okay at the time, because the NICE guidelines, the UK guidelines, and probably your guidelines in the States, accepted mid 50s as a good measure of control. And then, and that's 7, sorry, 6. 5%. 7%, sorry. And then it went up to 8% towards the end of my 20 years of living on a high carb diet. Because at that point, one, I defocused. And two, I was trying to adopt what we call DAPHNE, which is dose adjustment for normal eating. So you just ate what everybody else ate and just injected insulin to suit. I'd read a book by a guy called Richard Bernstein who himself had type 1 diabetes, and he sort of wrote a manual on how he managed his diabetes with something called a ketogenic diet. And I read it and put it down. I thought that's a bit a bit extreme, you know, and all that fat in the diet, I can't be doing with that, because I was trained to think otherwise. And then I got my first letter from my retinal screen to say, you've got early diabetic retinopathy. And just before that I had a near Which is? Sorry, eyes. My eyes were starting to show signs of complications due to diabetes. Which ultimately leads to blindness, correct? It can do, but it needs to be managed. But the thing about, you can see what's happening to the blood vessels in the body by looking in the eye. And of course, that's happening in lots of other organs in the body. It's happening in your kidneys, it's probably happening in your brain, it's probably happening around your heart, it's probably happening in your periphery. Diabetic retinopathies, You know, a sign that your diabetes is starting to take hold of you and starting to cause complications. So that, that worried me quite a lot, obviously. And just before that, about a year before that, I was doing some wild camping in Norway as it happened, cycling and ran out of glucose in the middle of the night. And I had a very near miss with a very severe hypo. And I managed to be very lucky to find some discarded food on the side of the road.
Jack:For those of us who. Who don't know what's, what you're talking about, I'm guessing. Okay,
Dr. Ian Lake:yeah. Can you, go on. So a hypo sorry is when. Yeah so I had problems with my sugar control, so we all stay conscious partly because of our blood sugar, and because we take insulin to manage our type 1 diabetes insulin is a hormone that lowers blood sugar so if you get the amount of food that you're taking in estimated to be wrong with your amount of insulin you're taking, you can be vulnerable to low blood sugars and that can cause you to either behave rather strangely or you can lose consciousness and that needs rescuing with sugar. And I'd run out of sugar and my blood sugar was still very low and that was a bit of a worry for me because I was on my own with no help available. And so those two things in combination prompted me to revisit a different way of managing type 1 diabetes, which was the low carbohydrate, high fat medium protein diet. And it was that led me to discover the benefits of this type of diet. And from the very first meal, I was able to get very good control of my blood sugar. And that persisted on my second meal and my third meal. And I suddenly felt, for the first time in my whole life, I'd got control of my type 1 diabetes. Which, before that, had become, was proving very difficult to control indeed. And then my blood glucose normalized over the past nine years. And my level of good glucose control, my something called HbA1c, is always now around 6%, which some people say is a bit high, but it's actually the top end of the normal non diabetic range. And I feel great, and I have lots more energy. And my diabetic retinopathy, Has nearly disappeared. He just goes and comes, but it's under control as well. So it's been a remarkable transformation for me to completely change my luck over the past nine years by accidentally discovering a low carb, high fat diet called ketogenic diet. Managing,
Dr. Phillip Ovadia:yeah, just to kind of, emphasize some of this. You know, you're a physician in what. I believe was, you know, good health. No, no real health problems. And then all of a sudden, essentially you know, within a very short period of time you develop type one diabetes, get very sick. And it. Any indication about what may have caused that?
Dr. Ian Lake:There are lots of theories as to what might promote type 1 diabetes, ranging from lack of vitamin D, to milk, to wheat to viruses. And I, I think an autoimmunity caused by we know not what, possibly something gut related. But I think in my case, it was a very bad flu. I had three months before that. That's the only thing I can pin it down to. It was a very bad case of flu. for several days. So I presume that it was a viral cause that made my body start to recognize some elements of the pancreas as foreign and produce antibodies against it and destroy my pancreas basically.
Dr. Phillip Ovadia:And so prior to that and even, you know, I guess after your diagnosis of type one what was your lifestyle like, you know, were you active sport kind of be good because of course I sort of know the end of the story, but let's set the stage properly.
Dr. Ian Lake:Yeah. So I've always been sort of, I'm not an athlete, but I'm interested in the great outdoors and I've always been a jogger and I've always done quite a bit of cycling as a sort of leisure type touring cyclist. And I always commute on a bike and any journey less than three miles is. It's a cycle ride for me, so I've always been interested in sport, and I sort of use that as a way of trying to manage my cardiovascular risk for diabetes, because as we know, type 1 diabetes carries with it an increased risk of having heart disease, so I felt I couldn't control my sugar very well, despite my best efforts, you know, every Monday morning I'd start off right, this week I'm going to have a really good go at controlling my blood sugar. And by sort of Monday afternoon, it was all over and, you know, I had the porridge in the morning and then glucose is about 180, you know, or something like that.
Jack:Remind me because I'm not an expert. Where the, where normal or healthy or whatever it is in terms of.
Dr. Ian Lake:Normal is about 80, 83 to that sort of area. So it's going up two, three times normal, and then it would come back down again. And it was just a matter of trying to get good control by controlling the amount of carbohydrates in your diet, balance of the insulin. So I had a relatively sedentary job being a GP. And that was quite a full, you know, it was a nearly full time job and I had a young family as well, which I looked after when I wasn't working with my wife. And it all went on quite nicely like that for years and years, really, until I defocused on my type 1 due to various reasons and then my health started to deteriorate.
Dr. Phillip Ovadia:And were you you know, one of the common side effects of insulin therapy is actually gaining weight? Was that an issue for you? Were you getting overweight or obese?
Dr. Ian Lake:For me personally, I've been very lucky with my weight. My weight has never changed throughout my whole life since I was sort of an adult. So I've been very lucky with that. It has a tendency to increase if I, certainly in the days when I was injecting insulin just to match my, my diet, my high carbohydrate diet, certainly it was, the weight was on the higher side rather than the lower side, but it's always been controllable just by changing the amount of insulin you use really.
Dr. Phillip Ovadia:And so you go through 20 years, essentially, of, you know, managing it the way that you were taught to manage it, that we were all sort of taught to manage it. And you're having worse and worse control, like many people in that situation. And then you sort of, I guess, really rediscover, you had come across it, but kind of ignored it, but then rediscover this other approach. And of course, you know, Dr. Bernstein, I think we've mentioned him a few times on this podcast with other guests. He also was a physician with type one diabetes and he's figured out this alternative way of managing it. You try it and you get great results right from the get go, basically. What were some of your thoughts then, you know, kind of trying to reconcile, you know, what you had been taught and what you had practiced for all this time versus this newer approach?
Dr. Ian Lake:Yeah the first thought was relief that, hey, I can actually, I probably have some hand in my destiny, if whereas before that, I was, as a lot of people think, type one's just downhill from here all the way down, and you just, it's trying to sort of Really, so when I found that I could control my blood glucose and I felt that I could influence how I control my diabetes That was quite a revelation to me. And of course, quite naively, I thought all I have to do, like Dr. Bernstein did, is just tell my fellow colleagues what how easy it is, and then they'll all fall into line and say, oh yeah let's, we'll all try that. And of course that at all wasn't the case. There's a huge amount of hostility at the start. And of course, I was rather evangelical about the whole thing at that time, and I still am, I suppose. And it was therefore frustrating to hear that. To think that you know, my, my fellow type ones are not getting this information. You know, I don't honestly mind if people don't want to take on a low carbohydrate diet, that's their choice, but A lot of people don't know about it, and when they do find out the most common response I get from people, and I've, you know, I've looked after quite a few now, is, why didn't you tell me about this before? And they get quite cross, really and I think that's such a shame, because people are losing, you know, You know, if you have an HbA1c of 58, which I think is 7. 5% and 70 percent of people in the UK, and I'm sure 70 percent of the people around the world, have that level of HbA1c. There's some evidence that's published evidence to show that you lose 100 days of life for every year. It's like that. So I've lost about 5 years of life just as a result of my diabetes control. And to realise that is preventable. It's so frustrating when you cannot get that message across to, to, you know, to help people to change because people just need that information. I honestly respect a person's choice to, you know, take whatever diet they want once they have a range of choices to to choose from. You know, like smokers, they get horrendous pitches on cigarette packets of all sorts of ways that their end is going to come to them, but some of them still choose to smoke cigarettes and you have to respect that. At least they know they've got, they know that is not a good practice. But Type 1's, we're encouraged to eat what we like and inject as much insulin as it takes. And I think that approach is leading to a lot of, Morbidity and a lot of unnecessary long-term complications. Personally, I have,
Jack:I, I realize my utter ignorance about type one. We've had oh gosh, what's her name? Nai Ian on. Yeah. Yeah. And
Dr. Phillip Ovadia:we had Andrew Knik on as well.
Jack:Oh, that's right. Yeah, that's right. But. For some reason, it just hasn't, I don't think it's registered for me that you're still, you still have to inject insulin.
Dr. Ian Lake:Oh, absolutely. I mean, type 1 diabetes is a complete lack of the body's ability to produce insulin. Some people with type 1, I think, produce a little bit, but not enough to keep their. their blood sugar at a low, but the majority of type ones have no insulin production at all. So we have to inject that insulin to cover the requirements of our body. Now, you know, the biggest driver of of glucose change in the body is the consumption of carbohydrates. That's by far the biggest driver of glucose change. So clearly we are made, we are recommended to count carbohydrates and then we estimate the amount of insulin we need for that amount of carbohydrate. Then we put the insulin into the skin and in the hope that when we eat our carbohydrates, the peak of insulin corresponds with the peak of sugar and everything's harmonious and flat. We know that's a big ask and the reason it's a big ask is because Insulin is a, is an energy molecule. It regulates energy in the body and it doesn't just it's one of the few hormones that reduces blood sugar levels, but it responds to so many other parameters other than other variables other than diet. For example, physical activity stress is a big one, lack of sleep you know, mental health affect our ability to control our blood sugar. And we are only taught conventionally to inject insulin to compensate for the carbohydrates in our meal. And it's almost impossible to do. There are so many variables just in that, that one simple act alone. Estimating carbohydrates. If you're nervous, it won't be this. The stomach might not absorb that amount of carbohydrates that quickly. For example, if you have a mixed meal, your carbohydrate load will be absorbed at a different rate. Some insulins aren't as potent as others. You know, they get warm sometimes or they just go off in. Due to storage problems, sometimes you inject into a scar and or sometimes you inject into blood vessels. So the rate of absorption of that insulin isn't necessarily easy to predict. So it is an absolute minefield of control day after day. It's difficult to control diabetes.
Dr. Phillip Ovadia:What so one of the, you know, technology is kind of helped with these problems a little bit. And we have continuous glucose monitors and we have insulin pumps, which can kind of continuously deliver insulin. And they even now have what are called kind of closed loop systems where you can have your continuous glucose monitor talking to your insulin pump to try and adjust dosages. And that all makes it somewhat easier. But it's still a very challenging problem to solve because, like you said, it's in the human body. It's not as simple as you know, insulin is only responding to carbohydrate and, you know, and there are so many variables that go into that. What has your experience been around some of those technologies? Because obviously 20, you know, now almost 30 years ago, I think since you've been diagnosed those things weren't available and now they are more available. How is that the situation for you?
Dr. Ian Lake:For me personally, I'm still on insulin pens. But the pens suit very well, and my insulin volumes are very low. I use half the insulin that I used to use nine years ago, for example, as a result of my diet and lifestyle. But I'd love a pump, and I'd love a hybrid lube, but I'd only think it's useful if I'm on the right diet. Because I don't think just chasing glucose alone is going to do it for us. I think we have to chase the insulin more than the glucose. So my experience suggests that it's the insulin that's going to get us as well as high glucose. You know, if you know, everybody with type one, we always post our great flat traces on, on, on Twitter or X or on all of our social media channels to say, Oh, this is perfect control with the keto diet, but you know, you could do that with a closed loop system, a hybrid loop where the your insulin pump is linked to your continuous glucose meter and there's a complex algorithm that will work out whether your sugar is going up or down and whether you need to, you know, Whether the system needs to inject insulin or not, and that's a fantastic great system, and I think it's good. It's not without its problems. I mean, all technology comes with day to day managing problems, but. You know, if you get a flat line of, say, 58, say, 50 or 60, so if you've got a flat line of perfect sugar control throughout the whole day in your blood, I always ask the question does it matter how much sugar, how much insulin you need to get that line flat? You know, and I think it does. So I just think chasing glucose alone is not going to stop us getting complications. It will stop us getting some of the complications caused by high sugar, which is, for example, blindness and probably kidney trouble. But it probably will not stop us getting heart disease, strokes. probably neuropathy, because they're not as sensitive to glucose levels, and I think it's the high insulin that drives that process of inflammation. Insulin's an anabolic hormone and it, you know, it makes us store fat, and fat is inflammatory in itself, and high doses of insulin in the long term are inflammatory in themselves. I don't think if you've got a flat line of glucose and a good, therefore a good HbA1c, but if you're using, say, 10 units to achieve that probably fantastic. If you're using 100 units a day, which is a lot, would you be happy with that as a doctor? If your patient's using 1000 units a day and still getting perfect glucose control, would you be happy with that? I certainly wouldn't, but their HbA1c, which is the marker we use, it would be perfect. So I think we have to take technology and say is it the technology we'll get as the numbers we want? But will it actually stop the disease process from happening? But it does have its benefits in that it reduces the number of hypos people have and smooths out the blood sugar control day to day. But I think unless we adopt the right diet for that, I think we are still not going to show in 10, 15 years time that it's been as wonderful as we think it's going to be, for the reasons I've given. Okay.
Jack:You said something that, uh, contradicts a belief that I have. Remember, I'm not the medical professional, so asking for education here. I was under the impression that the HbA1c was kind of the, I don't know, not the gold standard, but as long as you're, as long as that was within range, that meant that the inflammation in your body was under control. And inflammation is the big enemy that we're fighting. And you said something that sounds like maybe I'm not right about that.
Dr. Ian Lake:I think you are right in that HBO and C is. is the gold standard. We're all striving to get good HbA1c's. I've spent the whole of my last 30 years striving to get a good HbA1c. But I think a good HbA1c, it is, should be associated with minimal amounts of insulin required to achieve that. So I think if you're on a ketogenic diet which lowers the amount of insulin you use then you can get, because if you control your insulin, you control your sugar. If you just control your sugar at the expense of how much insulin you use, I don't think that's the, I think we've got it the wrong way around. I think we have to say, let's understand how insulin works in our body let's understand how it works in stress, how it works in sleep, how it works in physical activity and diet. And let's work out what the, how a person without diabetes would be able to minimize their insulin dosage. And then let's try to work out how we can do that as people with type 1. Because one of the problems with injecting insulin into the skin, and it doesn't matter whether you're on a hybrid loop, a closed loop, a pump. of any saw or a pen, your insulin is going into your skin. Now, when insulin goes into the skin, it's not in the right place. It should be injected close to the pancreas, of course. We have this ratio called the arterial portal ratio, which is the ratio of the amount of insulin in the periphery in the skin areas and compared with the insulin where it should be. And that's completely skewed in people with type 1 diabetes. So people with type 1 diabetes are always having a higher concentration of insulin in their bodies, even if they're well controlled because of where we inject our insulin. So even if we're squeaky clean, perfect sugar control, and really low levels of insulin, we're still higher levels of insulin than someone who doesn't have type 1 diabetes. And I think that is something we should bear in mind, because we are making ourselves what's called hyperinsulinemic. And of course, over time Hyper Okay. Too much insulin in the blood, and of course that, they are the perfect conditions for type 2 diabetes.
Jack:Okay, yes, that's starting to sound familiar.
Dr. Ian Lake:So we have to be careful with insulin in my view, I think we have to be careful how much we use, and I would say as much as necessary. but as little as possible. And I think that's a good formula to work with. So you're not saying we should never drive to the lowest possible number. It's not a race to the bottom. We should say if we get an infection, for example, when I had COVID, it was such a pathetic COVID, it wasn't even worth talking about, but I measured it and had to, you know, take precautions and all that. But my insulin volumes went from 20 units a day to over 60 units a day. to get a reasonable level of control. You know, when you have different circumstances in your life, you need to adjust your insulin. So in that case, it isn't as little as possible. It's as much as necessary but as much as necessary, you still try to minimize it. You know, with diet and lifestyle and all the other things to cut down your insulin use. And that's my view on it. I think that's, I think that's the way I would want to live my life by reducing my insulin volumes as well as controlling my blood glucose.
Dr. Phillip Ovadia:Yeah and really this goes along with what we should be recommending for non-diabetics.'cause we see the same problem in non-diabetics. You know, people can have perfect. Hemoglobin A1Cs, but they have hyperinsulinemia, insulin resistance, and, you know, and we see them developing heart disease and cancer and all the other problems associated with that, and it really, you know, it just makes sense. And yet somehow it's not the standard of care. It's not, you know, what we all get taught as physicians.
Dr. Ian Lake:I think that's right. And of course, type ones we can tell any non type one How much insulin they need at any time of the day, because we have to supply it to our bodies. We, it's all hormone replacement therapy. So it's not an exact mimic for not for physiological non type 1 insulin, but You know, when we wake up in the morning, our cortisol, which is obviously an anti inflammatory hormone, but for some reason it puts our blood sugar up, because cortisol rises first thing in the morning. And I think that's something to do with our immune cells, because they sort of like sugar I gather. They like glucose. I mean, there, there are certain types of cell that, Prefer certain types of fuel, but we have to, that's happening in everyone, whether you have type one or not, but we have to recognize that and inject a tiny amount of insulin to cover that. Whereas if you don't have type one, your body would do that for you. You know, when you get COVID as a non type one, you would also need 60 units of insulin, but your body would do that for you. The problem then starts when you start eating high carbohydrate diets regularly, You will always, and if you have three meals a day, plus two snacks a day, plus a bedtime drink, you'll always be in a high insulin state. And of course, a high insulin state is a fat storage state, and it's not a fat burning state. So you put your body into a permanent high insulin state which is the hyperinsulinemia. And of course, a high insulin state will encourage fat storage. And therefore, you cannot burn fat if you're in a high insulin state, so you're always storing fat, and fat is inflammatory in itself. And that leads Stored fat. Stored fat, yeah. And that's inflammatory in its own right, or can be if there's too much of it. So that leads us to a problem, doesn't it? Because we're starting to understand now, A lot of the diseases that we treat with medication can be treated with a ketogenic type of diet. For example, there's a lot of evidence in mental health, certainly bipolar disease and migraine. There's emerging evidence that insulin is implicated in the genesis and maintenance of some cancers. And, you know, as type ones we are being told according to the guidelines that with type 1 diabetes, we should never be in ketosis. We should never put ourselves into a fat burning state because a fat burning state produces these chemicals called ketone bodies, which are the end result of burning fat. And of course, if you've got ketone bodies, some people still who are diabetologists think that is a risk factor for a complication of diabetes called diabetic ketoacidosis. That is completely wrong thinking. It doesn't make any sense if you study the metabolism at all, but that is the way people think.
Jack:So I've actually heard, I've heard healthcare professionals say that, again, I know zip Zabadoo, but I've found out. Just because I was curious that therapeutic ketosis is not the same thing as ketoacidosis. They're not the same things.
Dr. Ian Lake:But the other important thing is that it will never lead to diabetic ketoacidosis. And you have to have other things, you have to have other things operating in order to Get diabetic ketoacidosis, such as not taking your insulin or having a severe infection or septicemia or something like that, blah, blah. So there's orders of magnitude different. So because of that fear, and it's a misplaced fear, and it's not based on actual metabolic science that we know at the moment, Type 1 diabetics are encouraged never to be in ketosis. Because ketosis is a sign that you may be going into diabetic ketoacidosis. And of course, if you're on a high carbohydrate diet, which we're all encouraged to be on you should never be in ketosis, because you're in a fat storage mode. So if you're on a high carbohydrate diet, you're storing fat, because your insulin is high, and you're storing fat. So if you're storing fat, you can't burn it, so you can never produce ketones. We've got this problem right now, where we have Certain conditions, certain diseases or certain medical conditions, which seem to respond well to ketone bodies. And people are now starting to talk about metabolic flexibility. You know, the ability of your body to switch from sugar burning to fat burning and back again if it needs to. And it somehow is the case that type ones have gotten to this state where we're not allowed to be metabolically flexible. And we're not allowed to burn fat. So type ones are limited to burning glucose all the time. And of course that is probably not helpful when you know, what if you have a type, someone with type one diabetes who has bipolar disease and they say, and their psychiatrist says, Oh, this person would do really well on a keto diet. And their diabetologist says, Oh no, they won't because they'll end up in diabetic ketoacidosis. You know, where is the battle going to be played out between those two silos. Because there is a way of achieving metabolic flexibility and that is allowing your insulin levels to drop. And therefore you stop fat storage and then you free up fat burning. And then you can produce ketones that are very healthy for neuronal tissue, certainly. So I think for many reasons we need to reduce our insulin volumes to give us metabolic flexibility. Because otherwise, I call it metabolic constipation. And nobody wants to be metabolically constipated. Where we're limiting our bodies to sugar burning entirely. And I think we need be able to free our bodies up to have that metabolic flexibility. So I teach metabolic flexibility. So we can burn ketones and if our bodies need sugar, they can produce it as well.
Dr. Phillip Ovadia:Yeah, very important point. Again, that you know, just gets lost and many doctors don't understand, but the high insulin state you know, is forcing your body to stay in that, you know, glucose burning state and that fat storage state. And we can't burn our body fat when we're in that high insulin state. That kind of leads us into, you know, talk about. how this has affected your professional life you know, and kind of what you do differently now as a GP in helping people to manage their diabetes and their overall health.
Dr. Ian Lake:Yeah. So thank you. I mean, the current guidelines in the UK and still in, in your country suggests that we should be on a low fat, high carbohydrate diet. Cause if you. If you, if we are gonna have to have low fat, which, you know, you know far more about this than me, but that type one diabetes is associated with heart disease. So it's generally thought that the heart prevention diet, which is probably not right at all, low fat diet, should be applied to people with type one. So by default we have to have a higher proportion of our energy from carbohydrates. So we have a low fat, high carbohydrate diet, and I have turned this completely on its head. And I think you need a high fat, a low carbohydrate diet. And that's in a, we're in a very sort of socialized healthcare system called the National Health Service, which makes rules from the center and everybody has to obey them because, you know, we get paid by the state funded by the taxpayer. And therefore, the taxpayer expects us to deliver the high quality care that is needed. It's disseminated through the national guidelines. So to to recommend for anyone to go into a ketogenic diet is actually a breach to some degree of the guidelines. Although there is some wriggle room, there are some statements which tends to be on the sort of side of that they're more of a social sort of recognition of people's differences and we can wiggle around that and say if, you know, you should respect people's wishes to have the sort of treatment they want. So for me, that means thank you very much. Then if they want keto diet, I'll respect that. So I always give people information on how to manage their type 1 diabetes with a different method to the one that's conventionally taught. It's not very popular with many of my colleagues, but I get good results with that. But the problem is that it's a minority sport, really, because people go back to their doctors. I'm a generalist. I'm not a specialist. So people go back to their doctors, their specialist doctors, and say, oh, this guy's told me to go on a keto diet. And of course, it's always straight, it's closed down. Oh, it's a fat diet. Oh, it'll never work. It's not sustainable. You'll end up in DKA. All those sort of things come. So then the poor old patient has to decide. Or where are they going to go with this? And mostly they take they look at it all in the round and think why should a GP who's not really doing what the state says why should he be any better than the standard advice? It's a very difficult gig right now. I produce information online for people and I I'm starting to run residential courses, I've just finished one, we've got another one in July. It's a six day residential course where we take people with type 1 diabetes and we teach them all they need to know to be healthy. at the level of a clinician by the end of it. So they understand this idea about insulin blocking, fat burning. They understand metabolic flexibility. They understand how insulin works. They understand how circadian rhythms affect our requirements for insulin, how mental health affects our requirements for insulin and how we should prepare for sleep. And physical activity as well. It's based around a 16 hour, two meals a day sort of program. It's in a private residence and it's a private sort of enterprise right now, but it is spectacularly effective and every single person we started out with a group of 10 just to just because there's any, it was a small group, but every single person did really well and. All of their blood glucoses are flatlined and they remain flatlined four weeks, four weeks later. That's the way I hope it will go and I hope by just people getting out there and the grass roots sort of revolution by people voting with their feet and saying this is effective. I hope we can persuade some of our clinical colleagues to look at this in their own departments. We only need one. We only need one department to take it on and if they take it on and are successful it puts a huge amount of pressure on everyone else to follow suit. So the way I'm doing it is really by promoting it on online and through courses and doing things like, you know, projects of self experimentation projects that hopefully will show people that this is a safe practice and it's a very effective practice.
Dr. Phillip Ovadia:Yeah, and along those lines you did a really amazing self, we'll call it a self demonstration project to really show what's possible. Talk about the you know, the demonstration that you and a few others did I guess it's now over a year ago.
Dr. Ian Lake:Oh, it's three years ago now. Yeah, it was quite a long time. It was born out of frustration that I could not get. Anyone to sort of take keto seriously because there's always opposition, you know, oh, you're going to end up in diabetic ketoacidosis. Not true Oh, you need sugar for energy Not true. Oh, if you're taking insulin, you need glucose. Probably just take less insulin then, but that's sort of a different argument. Not true. So I based this around those three often cited issues that clinicians had with keto management of type 1 diabetes. So I thought how can we do this? I thought we need to burn a lot of fat and we need to make sure we've burned up our glycogen stores because I mean, that's, it's not true that glycogen just gets used up before ketones are produced. It's not, that's not true, but that's a lot of people still hold that view. So I thought we've got two and a half thousand calories, roughly of glycogen, which is our sugar store in our body. And we have, I mean, me as a BMI of 23, I've got 85, 000 calories of fat and I have a normal fat. Ratio of something like 18 percent or something, body fat mass. So I've got 85, 000 calories of fat, then I've got 2, 500 calories of glycogen. So I think let's burn 25, 000 calories of fat. So that's 10 times our glycogen store, so there's absolutely no doubt that we will not be burning sugar for energy, because we won't have any. If we will have some because our body will make some, but we'll have no sugar stores as such. And then, you know, because I have type one diabetes, I thought let's do this without a keto diet. Let's just do it with nothing. Let's just burn our fat stores. Because if you're on a keto diet, you're just adding fat and nutrients. And I thought we could do without those for a few days and let's not make this a test to destruction, but let's see. So how far do we need to run to burn up 10 times our glycogen stores? 25, 000 calories worth, which happens to be about 100 miles. So that's how this all came about. So we thought, how long will it take to do 100 miles? We thought if we go at 20 miles a day, even if we get injured, and no one got injured, no one out of the eight got injured, if we get injured, we can stagger it. If you see what I mean, to get to our next sort of rest stop over five days. So that's how that developed. And once you've got it in your head that this is possible, I had no idea whether it would work or not, but I thought it's actually possible to do this. It's scientifically, it's doable. You know, why not? I mean, I was 62 at the time, so I thought it's a bit of an ask, I've had diabetes for 25 years, I thought, this is probably going to sort of be a bit of a, it could result in, in, in disaster, but I thought in theory, it's possible, so let's go with it. So we formed a big team of seven or eight clinicians who had an interest in sports medicine, and we had an anaesthetist on board, and then we just gathered a team of interested people. Everyone said yes. We managed to get two people with type 1 to agree to do this. One, unfortunately, was in Switzerland. It was a time of COVID, so she had to abandon that. But we had two people with type 1, six others. We all ran 100 miles in five days with no food at all, just water, nothing else, and a bit of salt. And no one got injured. Everyone had, some others were wearing glucose meters as well. The two type ones had perfect glucose control throughout the whole five days, and that's published on my website with the relevant blogs. And, but the key thing about this was we showed that you don't need sugar for energy, the two type ones were still taking insulin, but we were not managing that with sugar, because we didn't need to, because we were using the appropriate amount of insulin for our physiology at the time, but we still need insulin, because insulin is required to get sugar into cells, and it's also required to get protein into cells, and it's also required for cell energy management. So we all need it, but we reduced our insulin volumes quite a lot. So we proved all those things, but the key thing was we measured our respiratory quotient, which is a measure of whether you're fat burning or whether you're sugar burning, and we were all in fat burning stage right through the five days. So we were not breaking our protein down at five days, and we didn't want to do that, because we didn't want any accusation we were actually starving ourselves. So we were confident we were just burning our fat stores. After five days, you might start to burn a bit of protein. So we didn't want to be, it wasn't a destruction test. It was just a straightforward scientific exploration. Thought out, we thought, and it was there to show that if we can fast for five days, a type one could probably skip breakfast. If but the other thing was we measured ketones in everybody. All eight people measured ketones twice a day. for five days. So we've got a huge number of data points. And when you aggregated that graph of all of the people's ketone levels, you could not separate out the tight ones from the non tight ones. They were just blended into the background. And my ketones went up to five and a half, but my blood glucose never went above what was six, about 85 or something like that throughout the whole of the five days. And I only needed to take five times three, 15 grams of glucose. On two occasions, seven grams on one occasion, seven on another, or that sort of thing, eight on another, just because there was just nudging a low blood sugar. So hugely successful. We wrote it up. It is getting traction slowly, more amongst the sports community, strangely, who are interested in this sort of thing. And several type ones are interested right now, but it still hasn't hit the mainstream right now.
Jack:There's A basketball, a professional basketball coach in the U. S. named Greg Popovich, who's famous for thinking outside the box. This is going to sound like it's got nothing to do with what you're talking about, but this is exactly as I listened to you and I listened to professional after professional on our show, talk about this. He's got a quote in his locker room. I looked it up. It says, Let me give that to you real quick. When nothing seems to help, I go and look at a stone cutter hammering away at his rock, perhaps a hundred times, without as much as a crack showing in it. Yet, at the hundred and first blow, it will split in two. And I know it was not that last blow that did it, but all that had gone before. And I can't help but think that what you, what Dr. Ovedia, what all these professionals who are flying in the face of the official recommendations, what you're doing is you're whacking that rock and it often seems like nothing is happening. But I have absolutely no doubt that there's going to come a moment when all of a sudden it's just blindingly obvious, this is the way. The old way was utterly wrong. It's going to be as obvious to us as the fact that bloodletting is really not an effective way of treating infection. But we're in that, we're somewhere between blow number one and blow number 101 right now. I just think that's an extraordinary story.
Dr. Ian Lake:Yeah, I think things over the nine years I've been doing this I think things are definitely changing. I don't know what you think, Dr. Avadia, but more and more I get less, more and more I realize I'm getting less and less kickback. You know, it used to be quite hostile in the early days, but very few people are. Sort of getting at me anymore. You know, they're just accepting that this is okay. And certainly people I know who go to diabetes clinics and try to argue their case. And I say don't do it. Just say you, you just say you're counting your carbohydrates and injecting insulin, which is absolutely true. But if you're asked how many carbohydrates and clearly you have to say, because it's, you know, you have to be honest with your doctor, et cetera. But there's they say as well, they're getting far less kickback than they used to. Which is a great great progress. Because once you get enough people in hospital departments and specialists starting to allow this, they will start to become interested in themselves. And then, you know, the curious ones will lead this. And obviously the guideline drone types, they're not going to be bothered either way is, but when the new guidelines come, they'll follow those as well. So I'm not really worried about those people. I'm more worried about the curious people just to just get this moving. As you say, once, once we've made our hundredth crack and once we've got enough people, then it will just go all of a sudden. That's how change happens, isn't it? It happens very quickly. Yeah.
Dr. Phillip Ovadia:Yeah. I mean, I would echo that and say that I do see less resistance. And quite frankly, many of my colleagues in the cardiology community that are open to this approach. They recognize the failings of the, You know, the current approach. And it's really just like you said those people who all they can do is say the guidelines say and they're not even really thinking about what the guidelines say. They just know what the guidelines say. And hopefully you know, we'll continue to make the progress that will ultimately get those guidelines to say something different. And again, there've been small small glimpses of success there. But still more work to do. Yeah, you know, you mentioned some of the efforts that you're you have undertaken to kind of Start to influence your colleagues and then, you know, hopefully start to get to the people who make these guidelines that are really standing in the way of progress. These days talk a little bit more about what's going on in the NHS on this front and Some of the work that you're involved in there.
Dr. Ian Lake:Yeah. So right now the NHS is being led really by the revolution in type two diabetes and then metabolic management in type two diabetes. And quite a few people operating the UK and also in the US and around the world in, you know, leading the low carbohydrate. So that so low carbohydrate approach to reducing insulin volumes and getting type two diabetes into remission. Is, you know, getting good results. And of course there are those who would say injections of drugs will help. And there are those that say surgery will help. And there are those that say cutting, you know, a very severely restricted calorie diet will help. Because a very restricted calorie diet is, of course, a ketogenic diet, which will free up fat burning. I think there's starting to emerge a consensus that, Low carbohydrate is working in type 2 diabetes, and I think that's helping us in type 1 diabetes. But right now, I can't get anybody in the space to, to listen. However, I do have one or two friends now who may be able to help in, you know, who are in specialist areas, who I think in the next six months we'll be able to get them to take on. A teaching program that, that I have that will enable them to start to understand keto diets. So when people turn up, they'll be able to help them. And also we'll be starting to collect data and as the effectiveness of. This sort of diet within the NHS. What always gets levelled well, there's no long term evidence for this. There is enough long term evidence going up over four years. And of course, even the short term evidence suggests that all of the markers go in the right direction. You know, HbA1c drops which is a As you were saying, Jack, it's a big marker for long term health. And of course, all the diabetes drugs are, you know, they use that standard of HbA1c to promote their own medication. And therefore, you know, we know that a certain percentage HbA1c drop will lead to a certain number of reductions in complications. That's fairly well fixed. So we just need to be able to make our case and get more and more evidence. If it's not in the NHS, it will be with people who contract into the NHS, i. e. patients, people living with type one diabetes. And with these programs we have, we can get enough data. And then we can say this is cost effective too. And if we can just get one hospital department to work, and I think we'll get that within the next six months. You know, come back next year and ask me. Probably still bash my head against a brick wall. But once we start to get that evidence accruing, I think people will then start to think there's nothing wrong with it. But then the guidelines may not change for five years, but it doesn't really matter in some ways if the guidelines don't change, but if the people are. able to give that information out to people and then, you know, individuals can make their own choice based on the information they have. And then the guidelines sort of become irrelevant because if nobody's following them, you know, you can't enforce them because there are any guidelines, if but if a patient chooses to go keto and you're expert enough to help them to do that you fulfilled your ethical requirement for that patient, your, you know, ethical duty to that patient. And, you know, there is regal room within any guideline to to justify what we're doing. The dietary side's a bit more dodgy because the diet guidelines definitely aren't in favor of keto. But the general management guidelines about how to achieve a good HPO and C bar, whatever means needed they will fit really into what we're doing. So I'm hoping that in the next few months, we'll be able to start to collaborate with one diabetes department in the UK and start to move this on. But you know, I've been here several times before, so I've had lots of false. Keep whacking that rock,
Dr. Phillip Ovadia:keep working at it. And Let me say publicly that if you get them and they want to extend that to their heart surgery department please give me a call. I will come across the pond for that. But you know, and we are getting the support, like you said, you know, the guidelines are one thing, but the, you know, the sort of, Community standards are another and you know, we now have a textbook to rely upon. I think it's kind of right over my shoulder. They are the ketogenic textbook. And so and of course, the collective experience now of the, you know, all of the physicians that are working at this. Yes, is allowing us to, you know, support each other. And hopefully very soon, like Jack said, we'll have that 101st whack at it and the whole thing will crack.
Dr. Ian Lake:Let's hope so.
Jack:Tell us how type 1 diabetics And follow up on this conversation specifically, and then generally how to connect with you and the information you can provide us.
Dr. Ian Lake:I have a website providing sort of pretty well everything I've talked to you about today and there's general information on how to get started and what's, what the food looks like and et cetera, et cetera. And that's on type1keto. com, which I presume will be at the end of this podcast. Type one, the number one, Keto. com, all in one word. And all of my resources are on there, including the 0500 project that we did. And that has all of the blogs of the people that did the activity, including the people without diabetes. So that's a bit of fun to look at. And then there are lots of resources to extend from that. Including the six day residential course which, you know, we hope to be able to consolidate and get lots of data from, and within a year, we should be able to publish some quite favorable data on how effective that's been. And then, you know, if people just dial up ketogenic diets in Taiwan, there are several, you know, Nairi has a site, and there's lots of sites in the UK, and lots in the States who, you know, there's loads of companies in the States who, and charities that are doing this. So if you just Google type one ketogenic diets up, it comes really. And you'll have a resource in your country. There are lots of people working in the space. We're just not quite getting the traction we would like, but there's lots of people operating.
Jack:As Dr. Lake says, that information will be available in the show notes. So you can just click on through. You know, it's funny, Phil, I, as much as I've heard this I continue to learn things and it's probably just because it takes a while for things to sink through my thick skull. But realized that type 1 diabetes could, I thought you just were a type 1 diabetic. It never occurred to me that it could. Came on later in life. 100, was that what it was? The five one
Dr. Ian Lake:zero five 100 zero five 100 project.
Jack:That is so freaking cool. That's kind of mind blowing.
Dr. Phillip Ovadia:Yeah, I'm going to put in a little plug for people to go really check that out. And there's a little kind of film on the site and you can read through the blogs and but really an amazing demonstration. I mean, let's be honest. Yeah. Running 100 miles in five days is amazing to start with doing it. Yes. Completely. Yeah. Doing it completely fasted is a whole nother level. And then doing it fasted as a type one diabetic, of course is really a demonstration of what, And you know, I think that's really what all of this is about is really giving people hope and trying to show them what is possible. I really commend Ian and the entire team that was involved in that but really commend him for all the work he's doing to broaden our horizons and really show people what's possible with this.
Jack:I appreciate you being with us. This was an extraordinary conversation for me. I suspect it's closing in on bedtime there in England for you. Will let you go. Phil, thank you, man. I love. Hearing these stories, extraordinary stories. For those of you who want to know more you can check the show notes. It's all there. This has been the Stay Home Operating Table podcast with Dr. Philip Ovedia and our guest today was Dr. Ian Lake. Thanks for joining us. And we will talk to you next time.