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--:-- Steven Bartlett: What can you tell me about this?
--:-- Dr. Andrew Koutnik: Well, if you look at the science, it's enhancing cognition. We've seen a 50% improvement in how individuals were able to read and absorb information for better decision making. We also did a study and showed that it delayed the progression of metastatic cancer. I've actually taken this a number of times because having been in research for the last 15 years and having lived with multiple chronic diseases, one of which I reversed, some of the most powerful strategies like this were not being told to me when I went to the doctor's office.
--:-- Steven Bartlett: So let's dig deeper. Dr. Andrew Koutnik is a research scientist who's worked on over 100 studies on metabolic health, diabetes, and the keto diet. Through his findings, he's helping people prevent chronic diseases, improve cognition, and optimize performance. I went through some pretty dramatic moments in my childhood. I did everything I was told. I exercised all the time. I ate what I was supposed to eat, but I still became obese.
--:-- Steven Bartlett: You weighed about 255 pounds?
--:-- Dr. Andrew Koutnik: Yep. I had no idea how damaging that actually was to my body. I think the vast majority of people also don't. Over 20% of children have obesity. That's quadrupled over the last 30 years. A big part of that is when it comes to food, what looks healthy isn't always healthy. And it's not by accident. It wasn't soon after that I ended up getting diagnosed with a chronic irreversible disease that obesity puts you at risk for. That immediately turned into a journey to understand how to be healthy. I came across this diet a little over a decade ago called the ketogenic diet. I went into the science of this diet and found positive impacts on things like diabetes, obesity, Alzheimer's, serious mental illness, chronic diseases. I was like, "Wow," because a lot of people don't realize that many of these are not just preventable, but also reversible.
--:-- Steven Bartlett: And you did the longest study ever done of its type on the impact of the ketogenic diet on a patient that had type 1 diabetes.
--:-- Dr. Andrew Koutnik: Yes. Let me tell you all about it.
--:-- Steven Bartlett: Just give me 30 seconds of your time. Two things I wanted to say. The first thing is a huge thank you for listening and tuning into the show week after week. It means the world to all of us. This really is a dream that we absolutely never had and couldn't have imagined getting to this place. But secondly, it's a dream where we feel like we're only just getting started. If you enjoy what we do here, please join the 24% of people that listen to this podcast regularly and follow us on this app. Here's a promise I'm going to make to you: I'm going to do everything in my power to make this show as good as I can now and into the future. We're going to deliver the guests that you want me to speak to, and we're going to continue to keep doing all of the things you love about this show. Thank you.
--:-- Steven Bartlett: Dr. Andrew Koutnik, if you had to try and summarize and encapsulate what you spent the last couple of decades of your life focused on and really trying to accomplish, prove, understand from the highest level, what exactly is that?
--:-- Dr. Andrew Koutnik: The core of my mission, Steven, is really to empower individuals to take control of their own health. It's empowering them with science, bridging science to actual action. Science is very complex. It's very hard to break it down. But having been in research for the last 15 years and having lived with multiple chronic diseases, one of which I reversed and one of which is irreversible, my mission is to empower patients with the same tools and strategies that I had access to so they can take control to maximize their health and performance.
--:-- Steven Bartlett: For the average person who may not be as knowledgeable about health and fitness, what are the areas of health that you've spent the last 15 years researching and trying to understand?
--:-- Dr. Andrew Koutnik: I would call it, Steven, metabolism in broad terms. To break that down further for people to understand, metabolism is trying to understand how the body metabolizes or utilizes things like nutrients or food. So you have oranges here. What's in that food? When you ingest it, how will your body respond to it, both from glucose levels, which I'm sure many have heard of, to insulin responses, to all this different nuance? A lot of that comes down to nutrition, but it also includes things like exercise. Exercise has such a powerful impact on metabolism, incredibly important for overall health. But from a personal perspective, this journey has been very honestly selfish for me. I wanted to understand how to get the best performance, the best health for myself. I very quickly realized that some of the most powerful strategies out there were actually not necessarily the ones that were being told to me when I went to the doctor's office, because I went through some pretty dramatic moments early on in my journey trying to overcome some of these challenges.
--:-- Steven Bartlett: So take me back to the start of your story, the earliest context that's relevant to understand why you became the person you became. I've got some photos here from your childhood which are very, very telling. Some of our listeners might be listening on audio alone, so they might not be able to see these visuals on the screen. If you could describe some of these pictures for me.
--:-- Dr. Andrew Koutnik: It brings back some powerful memories of the challenges with obesity for me. The picture on the right is just a picture on a family adventure where we went fishing with my dad. I'm very heavy at the time, I was obese. The picture on the right here really gets me because I did everything I was told. I exercised all the time. I ate what I was supposed to eat, what my doctor recommended, what the fitness magazines recommended. But I was just constantly challenged with gaining more and more fat tissue. I had no idea how damaging that actually was to my body. I think the vast majority of people also don't. Over 68% of America right now is obese. That means seven out of 10 people walking around the street in the United States of America have obesity. We know that the second you start building more and more fat tissue on your body, insulin levels rise almost double immediately before you even have symptoms of obesity or tissue damage or organ damage. We know that that almost immediately reduces insulin sensitivity. How well insulin, a very powerful fat storage hormone, is able to actually bring nutrients from the blood into tissues goes down around 34 to 35% in early stages of obesity.
--:-- Steven Bartlett: Just to summarize for a muggle like me, insulin is basically the Uber which takes things out of your blood and puts them where they need to be.
--:-- Dr. Andrew Koutnik: It's essentially like a thermostat for blood glucose. That's how most people know it. As blood glucose levels rise, it works as a thermostat to release cool air to bring it back down. In this case, it releases insulin to bring blood glucose back into range. As blood glucose drops, insulin is stopped. It stops releasing insulin out of these cells called the beta cells. Ultimately, your body's trying to keep the one teaspoon of sugar that's in your blood that is critical for your life. If it goes up, it can cause damage. If it goes low, it can be life-threatening. It's a very, very tight range. It builds a number of mechanisms to ultimately make sure you don't go outside of that range. But imagine losing the one molecule that directly controls it.
--:-- Steven Bartlett: You're wearing two devices, I believe, on you at the moment. You've got this. What is the device on your arm?
--:-- Dr. Andrew Koutnik: It's an insulin pump. Steven, your body produces insulin. Most people who are probably listening to this, their body probably also produces insulin unless they have type 1 diabetes. When my body no longer produces this molecule anymore, there's got to be a way to get it. It sits on my arm 24/7 because it's a way of essentially packaging a pancreas that I don't have anymore and putting it on my arm as a way of getting that same type of insulin.
--:-- Steven Bartlett: And you have a CGM as well.
--:-- Dr. Andrew Koutnik: Yeah, on my stomach here is a CGM.
--:-- Steven Bartlett: Which is a continuous glucose monitor.
--:-- Dr. Andrew Koutnik: CGM is a way of tracking sugar levels or glucose levels. Both of those devices link to your phone, which is in front of you.
--:-- Steven Bartlett: I'll throw that up on the screen so people can see what that looks like. On this device, you have a green line that is glucose levels.
--:-- Dr. Andrew Koutnik: My blood sugar says that it's 109 right now, which means that the interstitial signal of glucose is...
--:-- Steven Bartlett: Interstitial meaning within, not in the blood, but in the tissues.
--:-- Dr. Andrew Koutnik: Yeah, the amount of glucose right outside the blood around the tissues. 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. Average blood sugar levels using milligrams per deciliter is 70 to 120. That's considered normal. Below that are blue lines, almost 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.
--:-- Steven Bartlett: I saw a clip of yours that I was watching earlier. You think having high blood sugar over a long time is the biggest cause of long-term health problems. When you're focused on improving your overall health, you have to find out what matters most. So what's the hierarchy in health? One, two, three, four, five. What matters most on that?
--:-- Dr. Andrew Koutnik: We can look at that by looking at risk factors for future disease. The number one cause of death in the United States and across many parts of the world is cardiovascular disease. It's also the number one cause of death in people with diabetes. 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 an average measurement of your blood glucose over a two to three month period of time. That is incredibly powerful at predicting future risk for diseases of the eye, diseases of the kidney, or even cardiovascular disease. When I think about how we tackle improving health, particularly in these more common diseases, glucose control sits at the very top of that pyramid. If unregulated, it's equivalent to an analogy I often use: 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 axle, but you're focused on rims or a sound system. The number one factor, particularly in diseases like diabetes, that matters most is HbA1c.
--:-- Steven Bartlett: So does that just mean that we should be eating less sugar?
--:-- Dr. Andrew Koutnik: If we wanted to control the most powerful risk factor in diabetes, we would need to understand how to regulate it. Let's look at the science of this. The science says that carbohydrates, food, is the most potent factor in regulating elevations in glucose at every single meal of the day. Most people are eating three to four plus meals every single day. 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. 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. The dramatic reduction in carbohydrates was used to save lives of patients with type 1 and type 2 diabetes since the first report ever known, to my knowledge, is in 1796 by a physician called John Rollo. He published a report on two cases of diabetes mellitus using a carbohydrate-replete or reduced diet to resolve the disease. 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. 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 an explosion in science that has driven a ton of public interest into this kind of unique dietary strategy.
--:-- Steven Bartlett: The ketogenic diet is a diet that I'm familiar with because it's a diet that I cycle in and out of throughout the year. I'm probably in a ketogenic state three or four times a year. 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 talk to my friends about it. There's a lot of misconceptions. If you're on a ketogenic diet, what are you eating?
--:-- Dr. Andrew Koutnik: Typically when someone visualizes a ketogenic diet, I think there's a lot of misinformation. They think it's just steak and bacon. For some people it might be that. But 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, fish in the form of salmon, eggs, cheeses, and a little bit comes along for the ride in things like nuts. The rest of the diet is made up of fat. This can come a lot of times from various plant forms like olive oil, avocado oil.
--:-- Steven Bartlett: And what are you removing?
--:-- Dr. Andrew Koutnik: Sugary, starchy carbohydrates. You're not having bagels, 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 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. 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? You can't transport the fat, which is now your primary fuel source on a ketogenic diet because you reduced 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 it becomes your primary fuel source.
--:-- Steven Bartlett: There's an evolutionary basis for this, right? Once upon a time, we might have gone long periods of time without eating something. 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: The evolution of this diet was believed to be a cyclical, meaning on and off pattern in human history. 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. 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. It's one of the most powerful survival mechanisms we have to survive moments of famine. We've also known since times of biblical texts that fasting has therapeutic potential, most potently in the ability to attenuate seizures. 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. Now we actually know that fasting induces a state of ketosis. We know that ketosis has been shown to 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. 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. It all starts with the reduction of carbohydrates in the diet.
--:-- 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 podcaster that spends a lot of time talking, you notice high variance in your ability to think and 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 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. When you're consuming that diet, what is often happening is near constant elevations and dips, highs and lows in blood sugar levels, that we know are ascribed to changes in energy levels. We know that high blood sugar levels, hyperglycemia, or low blood sugar, hypoglycemia—if someone Googles the symptoms, they'll see a laundry list of things like fatigue, irritability, lack of concentration, shakiness. These are all symptoms of a lot of what you're describing: changing your ability to concentrate, your energy levels. It's very clear that glucose levels are linked to that.
--:-- Steven Bartlett: Just to be clear, is that when I'm at the high or the low in the glucose?
--:-- Dr. Andrew Koutnik: If you ate one of these right now—what are these, oranges or tangerines?
--:-- Steven Bartlett: Oranges.
--:-- Dr. Andrew Koutnik: If you ate one of these right now, your blood glucose levels are going to go up, presumably.
--:-- Steven Bartlett: Yes.
--:-- Dr. Andrew Koutnik: Because these oranges are composed of bound sugar molecules together. Most fruit has a structural component to it, which is why you see it has mass to it. It's not just a liquid. That structural component binds together as a part of it, sugar that's bound together. They call them polysaccharides. When you consume them, your gut 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. Yes, we would presume that with this, oranges, or even most fruits, pastas, rices, would all elevate blood sugar levels. But that accompanies a high insulin load. The more of the oranges, the more insulin that you would need. Despite many of these foods being considered very healthy, those with metabolic disease or metabolic dysfunction may be more vulnerable to even what would typically be considered healthy foods. Type 1 diabetes is a powerful example of that.
--:-- Steven Bartlett: So you said you're 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. 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: 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. Oranges are considered a superfood by the American Diabetes Association. It's a fruit highly recommended by almost every organization—USDA, American Diabetes Association, and beyond. The amount of oranges is three oranges. That's probably going to make up around 70 to 90 grams of carbohydrates. For me, my energy needs are calculated at around 3,000 calories per day. If I were to eat the amount of carbohydrates recommended per day, which is around 55% by the USDA guidelines, I would need to consume at least or more than this if I split up all my calories over four meals. This is an opportunity to see what this will actually do to blood sugar levels. In type 1 diabetes, if you consume this, it will be a near equivalent to around 50 grams of carbohydrates that I would consume per day if I was on a standard diet.
--:-- Steven Bartlett: The ketogenic diet, they typically say that to stay within it, you need to be below roughly 50 grams of carbohydrates a day?
--:-- Dr. Andrew Koutnik: 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: There's variants depending on your insulin sensitivity and insulin response. I guess body weight is going to be a factor.
--:-- Dr. Andrew Koutnik: Major factor. Anytime you're talking about things like glucose, insulin, there's always very individualized responses to each individual person.
--:-- Steven Bartlett: I don't really try and stay away from fruit these days. I eat berries and raspberries and stuff like that because people tell me there's polyphenols and blackberries. But those 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 it is fiber. So it's more about the net carbohydrates. It's the glycemic metabolic impact of the food. If the fiber is non-digestible, which in fruit it isn't, then it shouldn't count, right? So higher fiber content, most of the vegetables on a ketogenic diet are higher fiber. The total carbohydrate to fiber ratio, the net carbohydrates, that's what really matters because that's the metabolic impact of food. A lot of keto-friendly foods say net carbs at one gram or something, but you look at it and it says 20. It's total bullshit, man.
--:-- Dr. Andrew Koutnik: Oh, 100%. I've tested two different foods that are keto-friendly on the label, same calories, same fat, protein, even fiber. They can produce completely different responses. 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's on the label. I don't want to sit here and say, "Oh, they don't know." No, they know. There are 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. There are all these studies on ketogenic diets that can show to improve health, 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. 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."
--:-- Steven Bartlett: If you've been on the ketogenic diet since you were diagnosed with diabetes, have you cycled in and out of it yourself? If so, what have you noticed in terms of when you are in that diet and when you're not?
--:-- Dr. Andrew Koutnik: I came across this diet a little over a decade ago. What I found is that almost every blood meter that I was taking—this was before CGMs were present, I had to prick my blood six to 10 times a day to see what my blood sugars were—I was finding that I was very rarely outside of the normal range. 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 a little over 40%. The amount of insulin I needed to take dropped dramatically. But I didn't have a continuous glucose monitor. I didn't have this instant feedback of what my blood sugar was doing. I just knew I needed a heck of a lot less insulin. I went into my doctor's office at the time. He happened to be the American Diabetes Association president at the time. He said, "I've never seen a blood sugar level in the normal range with someone with type 1 diabetes before. What are you doing?" From that point forward, for me, it transitioned into a lifelong journey of realizing that 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. Within three years, we see neuroanatomical changes within the brain of children who are diagnosed.
--:-- Steven Bartlett: What does that mean?
--:-- Dr. Andrew Koutnik: When we look at MRI scans of the brain, we see that children with high and variable glucose levels with type 1 diabetes have shifts in the type of white and gray matter. The sections of the brain that are associated with normal brain development in childhood are not developing the same way. 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 four years.
--:-- Steven Bartlett: Atherosclerotic progression, what's that?
--:-- Dr. Andrew Koutnik: One of the primary causes of death in individuals across the world is cardiovascular disease. How do we get that?
--:-- Dr. Andrew Koutnik: 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 blockages within the blood vessel, which ultimately cause things like heart attacks or strokes.
--:-- 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—they're going to see changes in how their blood vessels functionally and structurally change. Their blood vessels shift from being very compliant, almost like a smooth wave, to becoming very rigid. They start to build collagen, more and more collagen around them, becoming stiffer and stiffer. It's almost like taking a hose and turning it on, then pinching it. When you pinch the hose, as it gets stiffer and you shrink the size of the blood vessel, the blood goes faster. We can measure that by the speed of the blood in the body. It's one of the most powerful signals that the blood vessel is starting to change before you see plaque or blockages—decades prior.
--:-- These are all happening in childhood, by the way, in 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 sheer stress, Steven. So, let's say you go for a run this morning. Your blood pressure initially increases because as your heart rate increases, the speed of the blood increases, and the amount of pressure on the vascular wall increases. That phenomenon, when the blood moves fast through blood vessels, 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 vasodilator; it causes the blood vessels to open up. This is how your body responds normally to stress. You go for exercise, vasodilation or vasoconstriction, then vasodilation. These are normal responses.
--:-- 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 load. So not only are the blood vessels becoming stiffer, but now they aren't able to respond as well to the stress. As you look at this 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 retinopathy where you start to lose vision, eventually going blind within 20 years of diagnosis. Most people are diagnosed at 10 to 14 years of age, which means by 30 to 34, you're going to see a lot of patients with altered eye function, and some who are blind. That timeline 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, there is no pharmaceutical intervention, no technology that normalizes this disease. The effects of these high and variable glucose levels and the insulin resistance that accompanies it are cumulative, dose-dependent, and not completely reversible. Once you're diagnosed, the clock starts ticking. It's 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.
--:-- Steven Bartlett: 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. When you do a diet known as the ketogenic diet, you're reducing carbohydrates. When carbohydrates are consumed, they elevate glucose levels. If you dramatically reduce the amount of carbohydrates consumed, you're not having those same glucose elevations and fluctuations because you're not consuming the most potent glucose elevating factor in our life, which is carbohydrates. 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 that is being controlled within a normal, healthy range.
--:-- Steven Bartlett: So is your goal then to encourage people to restrict carbohydrates in their diet? Because carbohydrates and sugar have been somewhat demonized—you never really hear many good things about sugar. What is your goal here? What is the advice to the listener? Is it to restrict their carbohydrates?
--:-- Dr. Andrew Koutnik: To be very conscious of what they're consuming, because nutrition has a powerful, potent impact on overall health. For those patients who have chronic disease—which is unfortunately the overwhelming majority of us—carbohydrate restriction can have a powerful therapeutic effect on diseases like type 2 diabetes. The American Diabetes Association, in their 2019 consensus report, described it as the most evidence-based nutritional strategy. We know it can have potential positive impacts on things like Alzheimer's disease; there are studies that have looked at this. We also know that for...
--:-- Steven Bartlett: Carbohydrate restriction.
--:-- Dr. Andrew Koutnik: Yes. I like to term this "therapeutic carbohydrate restriction" because it's the therapeutic outcome of a carbohydrate reduction. The goal is: can you improve your overall health? Many people will do this simply to lose weight, to feel more cognitively alert. But in my case, where you're further along the metabolic spectrum with diseases like diabetes, it has an even more potent impact on how you feel and your overall health. Unfortunately, about 93% of Americans have some form of metabolic derangement, as cited by multiple studies and research groups.
--:-- 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 the longest study ever done of its type, where you took one individual and over 10 years, you controlled their diet?
--:-- Dr. Andrew Koutnik: We had access to the ability to monitor a unique patient who had type 1 diabetes. 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 initiation of the diet, they had DEXA scans. They controlled their calorie intake and their body composition. They weren't taking any additional medications. We were able to monitor the impact over a 10-year period while controlling all those variables.
--:-- Why that's so important is because one of the common concerns of a ketogenic diet is the hypothetical risk that it can increase cardiovascular disease. The reason they hypothesize that is because of the elevation in LDL that often accompanies an increase in saturated fat in the diet. Saturated fat comes from things like animal proteins and coconuts. What we found was 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. We found that despite doubling LDL, they had maintained completely normal glycemic control, which based on all the data is 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.
--:-- In fact, we 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, patients were completely able to normalize their glucose control, normalizing the most potent risk factor for the disease of type 1 diabetes.
--:-- Steven Bartlett: This is a spectrum. I'll put that on the screen for people to see—the different stages and categorizations of being normal, pre-diabetic, and diabetic.
--:-- Dr. Andrew Koutnik: Correct. Normal is anything less than 5.7% HbA1c. Pre-diabetic is 5.7 up to 6.4. Diabetic is anywhere between 6.5 all the way up—there's essentially no cap on how high that number can go.
--:-- Steven Bartlett: I noticed your blood sugar levels have risen quite dramatically.
--:-- Dr. Andrew Koutnik: Yes. What you see initially is probably only the first phase of this. It started at an average of around 100 milligrams per deciliter. Once the food is consumed, it takes some time to break down into glucose. That glucose goes into the blood, and then the blood moves glucose into the compartment around the cells, which is called the interstitial fluid. Now we're starting to see the direct impact of consuming probably a fifth of the amount of carbohydrates I should consume from a superfood. Oranges are considered a citrus fruit and a superfood by the American Diabetes Association in the context of diabetes.
--:-- Steven Bartlett: When the glucose spike is high—you've just eaten some oranges, the spike is going up—what does someone feel? And then what do they feel when it crashes down and goes below? It started at about 100. I imagine 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? 100 is right around normal. What you'd hope would happen is you'd go up just a little bit, insulin would respond quickly, and you'd come back down to normal if you have total healthy metabolic function. The vast majority of us do not. In this case, what would be predicted is that as blood sugar elevates and insulin responds, it's going to go as high as the amount of glucose present in the food.
--:-- Dr. Andrew Koutnik: At the same time, my pod, which is holding my insulin, is immediately trying to respond. It's saying, "Oh no, we need to bring this into a normal range." It's trying to release insulin. You can see on the screen 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: 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, Steven, is that as blood sugar becomes very high, my focus reduces. I become fatigued. I can also, according to my wife, become irritable. You can look up the symptoms of hyperglycemia—elevated glucose levels above the normal range, which is 70 to 120. The evidence over time has shown a very clear impact on not only how you feel physically, but also your mental health status.
--:-- Steven Bartlett: I've just looked up the symptoms. It says the common immediate symptoms of having a high glucose spike are feeling thirsty, dry mouth, frequent urination, headache, brain fog, fatigue, sluggishness, and blurry vision. Then once you go down and crash, your glucose really drops below the normal range. What do you feel then?
--:-- Dr. Andrew Koutnik: A lot of how I like to describe this is like imagine you're outside on a sunny day, having a great conversation with friends. Then all of a sudden, very rapidly, clouds come over, everyone dissipates, and it starts to rain. We know that glucose levels have a direct impact on the neurobiology of the brain—how it functions, how it operates. Particularly at very high glucose levels, typically above 180 milligrams per deciliter, you start to see signals of inflammation and oxidative stress in the body. That can start to cause damage on tissues and cause a stress response. The problem, Steven, is that most patients are living there 24/7.
--:-- Steven Bartlett: I was looking at some of the symptoms here. It says the short-term crash you get after a spike, after a rapid rise, is a bit of an insulin overshoot—reactive hypoglycemia, the sugar crash. In that crash, you might feel jittery or shaky, hungry, often craving carbs and sugar again, irritable, anxious, weak, or lightheaded.
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--:-- Steven Bartlett: You did a study in 2025, I believe, on the impact of the ketogenic diet on physical performance. If the ketogenic diet has all these therapeutic potentials, going back for over two centuries, what is the true impact of it on performance? Because that's one of the primary reasons someone would walk into a clinical setting and say, "Yeah, you can do this, but I've heard it's going to decrease my performance."
--:-- Dr. Andrew Koutnik: Physical performance. We were very interested in this because we thought, when we look at why carbohydrates are currently recommended as sports nutrition, it's because since 1921, they've been shown to improve performance. In 1921, physicians out of Harvard and Boston watched Boston marathoners—half of whom wouldn't even finish the race. They had slurred words, pale skin, were shaky, couldn't articulate their words, or some wouldn't finish at all. When they tested the blood of these individuals, they found that glucose levels were low. They reached what they call hypoglycemia—a medical term for very low blood sugar levels. The next year, they provided carbohydrates to these marathoners in the Boston Marathon, and all of them improved their performance. Since 1925, we've known that carbohydrates can improve performance.
--:-- But what happened over time is that in the 1960s, there was a measurement technique called the Bergstrom method where you did a muscle biopsy, pulled out muscle tissue, and found that there was glucose stored in the muscle. So it must be really important for physical performance. If the muscle, which contracts and moves the body during physical performance, has glucose in that tissue, it must be essential for performance. After they discovered that, there were all these associations between low glucose levels in the muscle—called glycogen—and fatigue. Then in the 1980s, they were able to look at the amount of sugar or carbohydrates and fat the body was burning during exercise. They found that the amount people are able to sustain intense exercise is proportional to how many carbohydrates they're burning. Then there were a few modeling studies that looked at the relationship between the intensity of exercise and what type of fuel you use—fat or carbohydrates. They modeled it and said, "At lower intensities, you must burn almost all fat. At very high intensities, you must burn carbs."
--:-- There were a number of studies from 2017 to 2020—three different studies—that looked at the ketogenic diet over a five-day to three-week period. They saw that in those studies, there was a decline in performance by around 2% if you were on the ketogenic diet.
--:-- Steven Bartlett: Compared to a high-carb diet?
--:-- Dr. Andrew Koutnik: Yes. So what did that tell these researchers? It said, "Obviously the ketogenic diet must impair performance." And there's all this evidence since 1921 that the amount of carbohydrates and glycogen you're consuming is essential for performance. But here's the kicker: one major confounder of all of this is that we've known for quite a long time that the adaptation to a ketogenic diet is not one week, not two weeks, not even three. It's four weeks or more.
--:-- Steven Bartlett: When you say adaptation, you mean your body has transitioned to being in a state where it's efficient at burning ketones?
--:-- Dr. Andrew Koutnik: The body's ability to lower its glucose oxidation—the amount of carbohydrates it's burning for fuel—because you're giving your body less of it. The amount of fat being utilized for fuel goes up dramatically. You produce way more ketone bodies, and ketones are now being used as energy for the muscle and also for the brain. It's this transition. But when people were looking at these studies, they were just looking at metrics of what happens when your body transforms when you reduce carbohydrates.
--:-- What we wanted to do was say, "Okay, if there are all these health-promoting benefits of a ketogenic diet, that sounds great. But all these studies and sports dogma say it's going to impair performance. Let's test that." We put athletes on a ketogenic diet for four weeks. We controlled not only their calories, but their body composition and their activity level. We controlled all these key confounders that many prior studies never controlled, so we could truly test the diet-induced macronutrient shift from carbs to fat effect on performance. And we did it in the same person, so we controlled their genetics and their environment.
--:-- Once we did that, Steven, we tested what most people think is a very glucose-dependent form of exercise. We asked them to do six by 800-meter sprints. They were on a high-carb diet, and then they switched to a low-carb diet. It was all randomized and controlled. When they switched over, they had no deterioration in performance.
--:-- Steven Bartlett: At four weeks?
--:-- Dr. Andrew Koutnik: 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: We were interested in studying the end point. We didn't look intermediately. We exclusively looked at the end time point because the question was, "Is there a difference once you stick to this diet?" If you go on this diet, ideally you're sticking with it over time. If it is true that you require carbohydrates, we also measured how many carbohydrates and fat they were burning during exercise. It was over what we call 85% of their VO2 max—85% of their total maximum oxygen consumption during exercise. That is when we would expect almost no fat to be oxidized and almost exclusively carbohydrates. We found that these athletes recorded the highest levels of fat burning during exercise ever reported in the literature.
--:-- Steven Bartlett: On the ketogenic diet?
--:-- Dr. Andrew Koutnik: On the ketogenic diet. When these athletes were adapted to the diet for sufficiently long, they had record levels of fat oxidation even at very high intensity levels. Fat was able to provide fuel at very intense forms of exercise when we would expect only carbohydrates would be relevant and utilizable.
--:-- Steven Bartlett: Many of my friends who are endurance athletes or involved in 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 meaning externally supplemented, I guess.
--:-- Dr. Andrew Koutnik: Right. With a ketogenic diet, you produce them—your liver produces them for you. With exogenous, you're consuming them. Why would you consume them? Why not just do a ketogenic diet? We know a ketogenic diet takes time to adapt—up to four weeks to see the full effect on performance, or more. What happens if you're a warfighter or someone going out into the field who immediately wants to flip into this state? You can't do that unless there was a molecule you could consume that could rapidly elevate ketone bodies in circulation within minutes. Enter exogenous ketone bodies.
--:-- We've known since the 1960s that the product in there—studied by MIT in the aerospace department, called 1-3-butanediol—could be consumed and rapidly elevate ketone bodies in circulation. There was a study in 2016 called the Metabolic Optimization study. It was a $10 million program from DARPA.
--:-- Steven Bartlett: DARPA being the...?
--:-- Dr. Andrew Koutnik: DARPA is an advanced research organization from the United States government that funds very high-risk, high-reward programs. One of which was the use and testing of ketone bodies. The molecule they tested utilized the same molecules in there, and they tweaked the formulations a bit. They showed that when you consume them, it rapidly changes metabolism. It's almost 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 GPR-109A or other key receptors that directly impact inflammation. It directly blocks something called the NLRP3 inflammasome, a molecule that leads to increases in inflammation.
--:-- We also know it changes the way our genes are used in the body—epigenetic signaling. The consumption of ketone bodies can actually change the molecules on our genes and how those molecules are ultimately manifested. That increases our antioxidant capacity, our ability to block oxidative stress in the body. We see all these powerful effects, these rapid shifts in metabolism.
--:-- This 2016 study showed that just orally consuming these molecules could rapidly shift metabolism, and it was also linked to an improvement in physical performance. But if you look beyond that, we've looked at them in athletes, in healthy individuals, and in military settings. There are also studies looking at this in patients at risk for cognitive decline—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: Just to be clear, you're saying it reduces the decline. It doesn't cure Alzheimer's or fix Alzheimer's.
--:-- Dr. Andrew Koutnik: Correct. It just delays.
--:-- Steven Bartlett: Accurate, yes.
--:-- Dr. Andrew Koutnik: We know that as individuals age, you're on a steady decline in brain function. The goal is to offset or stop the decline. We want to maintain normal brain function and our ability to think clearly, to read, to do problems, and to solve problems.
--:-- There have also been the emergence of studies in the world of psychiatry. I think there are 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—has serious mental illness. I believe 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. The application of this unique diet, which we know increases ketone bodies that appear to have direct impacts on the brain, now seems to be linked to improved serious mental illness. It'll be interesting to see where that evolves. It's a fascinating world to imagine that nutrition—not a medication, not a technology, but simply going to the grocery store and swapping the things you choose—can lead to these powerful therapeutic effects in people with all sorts of different conditions or disorders.
--:-- Steven Bartlett: One of the studies I read about the administration of exogenous ketones and the impact on brain network stability was from 2020. They investigated if brain network stability responds to two major brain fuels—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. 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." That's super interesting.
--:-- Dr. Andrew Koutnik: We did a study looking at cancer and applying exogenous ketones in a very aggressive form of metastatic cancer. In my work in graduate school, when applying exogenous ketones, it delayed the progression of the metastatic cancer. It also reduced the rapid decline in body weight we sometimes see with cancer—a phenomenon called cachexia, which is 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 looked at where the body weight was coming from. It was clear that the lack of body weight decline was because of the preservation in muscle mass.
--:-- There have been a number of clinical physiology studies—studies that directly manipulate human beings with molecules and tests, like muscle tissues and how they function. We see that exogenous ketone administration can dramatically reduce the amount of muscle breakdown, essentially illustrating it may be a powerful mechanism in promoting healthy muscle mass as well.
--:-- Steven Bartlett: In terms of being on 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: [Smiles] You smiled, though, because maybe you like to be more shredded.
--:-- Steven Bartlett: A phenomenon with the ketogenic diet—there's no deterioration in muscle mass with the ketogenic diet. There have been plenty of studies that have shown you're able to maintain muscle mass. And build it?
--:-- Steven Bartlett: 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 reducing less calories, so they had less energy in the diet, and they were also doing the ketogenic diet. It was actually a military study, and 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 it as 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 use effect. But basically, you reduce the amount of sodium in the body. So you piss it out, basically. And so you hold less water weight. And 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 like 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 in a phenomenally less water weight. And in some contexts, that might be beneficial, right? 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.
--:-- Dr. Andrew Koutnik: 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, I guess, to keep my protein levels high?
--:-- Steven Bartlett: 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, right? So you're in a caloric deficit. So you've said that, you know, you tend to eat less calories because you're probably not as hungry.
--:-- Dr. Andrew Koutnik: Well, yes, that's one of the most powerful ways to lose not only fat, but also muscle, is to just not eat food. 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. And I've seen some of the studies that show that there's a 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.
--:-- Steven Bartlett: Yeah.
--:-- Dr. Andrew Koutnik: And it's really bizarre. Like I was in Cape Town for 10 days or two weeks writing my book. And so I had the chef there and the chef cooks me my food and makes this amazing food. And 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. And 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.
--:-- Steven Bartlett: 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. So there's a book called *Always Hungry* by a physician, an endocrinologist named David Lugwood. And he's kind of coined this carbohydrate insulin model. And, you know, 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 up and downs of glucose and up and downs of insulin. So these constant swings, whereas on a ketogenic diet, you have this sustained level fuel influx, right? 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, particularly 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 therein 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. And 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. Like, 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 of in America and the rest of the world, essentially now, where the food environment often drives people to overconsume. And it's not by accident. These are like well-conducted strategies in the food industry to lead to these positive pleasure responses.
--:-- Dr. Andrew Koutnik: I think about this with bread in the restaurant. You know, they give you bread first.
--:-- Steven Bartlett: Yeah, it's a good, it's a solid strategy, Stephen, to cause you to want to consume, start to finish, not only the bread, get a big meal, and follow on with dessert. You know, it is a great strategy for ensuring that. But it's also the same strategy that, you know, Doritos is using, where, like, you combine this mixture of molecules in the food that you consume it, and you get, oh, this tastes great. Pringles. The same exact thing, where you combine these different components, and it forces you this, like, 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, one, they certainly are aware of this, right? And 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. And the 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. And 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.
--:-- Dr. Andrew Koutnik: And it's because of the sugar and the salt?
--:-- Steven Bartlett: 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, right, in our lives, in our world. This is even independent of food.
--:-- Dr. Andrew Koutnik: So what do we do about this?
--:-- Steven Bartlett: 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 overconsume them and drive this pleasure response in the brain.
--:-- Dr. Andrew Koutnik: Liquid calories. What's a liquid calorie?
--:-- Steven Bartlett: So let's say you have a soda or a Coke.
--:-- Dr. Andrew Koutnik: Yeah
--:-- Steven Bartlett: 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
--:-- Dr. Andrew Koutnik: Like orange juice. Another great example. Smoothies. Those fruit smoothies people have.
--:-- Steven Bartlett: Exactly. In fact, just taking fruit and then blending it up actually increases the speed by which it's absorbed, changes the hormonal response, and leads to a worse outcome for most people.
--:-- Dr. Andrew Koutnik: Most people think a fruit smoothie is a healthy thing.
--:-- Steven Bartlett: Yeah, I don't know about that. I would, I think that when you take fruit, which for most reasons isn't terrible, right? Like it's not, 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 like, uh, almost turning on like a small hose. It's just giving you a little bit of water at a time and it's turning it on all the way. You know, 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 and normal levels of GLP-1 in the body are completely altered. The insulin response is also altered.
--:-- Dr. Andrew Koutnik: And GLP-1 is the hunger hormone. It's known for being related to hunger because it's released in response to food. It changes the brain's hunger drive. And most people know of it because of Ozempic, semaglutide, Wagovi, trisipatide, 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.
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--:-- 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, I don't know, 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 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.
--:-- Steven Bartlett: You've got big muscles. Oh, well. 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 um 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's gonna 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 airdyne 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 cardiovascular health.
--:-- 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 and 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 this stability not the the moments in time where i'm introducing uncertainty and variability to dumb that down a little bit what i'm saying is that when i when i 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, you know, 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.
--:-- Steven Bartlett: So I've got 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. You know, these are, you know, Stephen, this isn't like, oh, like 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.
--:-- 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 as 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, fuck, 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 I, you know, 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. You know, like 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. You know, there's so many. honestly, Stephen, 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 will 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 singular example for you, Stephen. I just, but I've experienced it numerous times.
--:-- 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, pasta.
--:-- Steven Bartlett: All potatoes, in any form.
--:-- Dr. Andrew Koutnik: Sweet potatoes tend to have less of a glycemic response, but it's still going to have a potent glycemic response. So mashed or baked potatoes, obviously French fries.
--:-- Steven Bartlett: For sure, French fries. Most of like pasta is a big one. Cereal?
--:-- Dr. Andrew Koutnik: 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 these heart-healthy cereals, 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, you know, more, more of the less glycemic or less foods that have less of an impact on glucose levels, less of an impact on insulin levels.
--:-- You know, one thing I constantly hear, especially in the research and clinical community is like, well, look, you know, not everyone needs to be concerned about that because, you know, people can respond to a lot of these foods just fine. I say, well, 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 86, 68% are obese. And now children are affected with these diseases, with obesity and prediabetes at around 20%. So it's the fact that we are now less healthy than we've ever been. We don't have the foundation to support.
--:-- Steven Bartlett: 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.
--:-- 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 I don't have any glucose on me and my blood sugar is going down for some reason and it's dangerously low levels, that's when I consume those foods. Otherwise, I would not consume them just because of how quickly they've raised blood sugar levels.
--:-- Steven Bartlett: Do you think everybody should try the ketogenic diet?
--:-- Dr. Andrew Koutnik: Oh, 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 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, Stephen, one of the most important things to appreciate is that we often publish bar graphs, 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 the 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 metal.
--:-- 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 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: sbo2 ah so uh the amount of oxygen in the blood so the the measure that would indicate whether someone uh in these low oxygen environments had more blood or less more oxygen or less oxygen ultimately it's it's important to try i i think it's i would always say yes you should try because 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.
--:-- 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.
--:-- Dr. Andrew Koutnik: Yeah.
--:-- Steven Bartlett: 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 however you want to frame it, I believe is always going to be limited by our brain's ability to understand and articulate that. So what do you think is outside the simulation? Consciousness.
--:-- Steven Bartlett: You think consciousness is outside the simulation?
--:-- Dr. Andrew Koutnik: I think that our ability to have, not consciousness, Stephen, but our ability to operate beyond consciousness.
--:-- Steven Bartlett: Got me on that one, man. That was a tough question.
--:-- Dr. Andrew Koutnik: Yeah, it is a tough question. That's a burner right there. I don't know. Do you think there is a God? beyond all this stuff that we see here?
--:-- Steven Bartlett: I'm going to give you the most real, honest answer possible.
--:-- Dr. Andrew Koutnik: Yeah.
--:-- Steven Bartlett: I don't think we ever can actually answer that question accurately.
--:-- Dr. Andrew Koutnik: 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.
--:-- Steven Bartlett: Yeah.
--:-- Dr. Andrew Koutnik: Okay.
--:-- 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'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 related to that because of you. So please keep doing the research you're doing and spreading the word in the way you're spreading it because it's much needed work and it's important work. So thank you so much and thank you for giving me your time today.
--:-- Dr. Andrew Koutnik: Steve, that was an honor. Appreciate it, sir.
--:-- [End of conversation. Steven Bartlett addresses the audience directly.]
--:-- Steven Bartlett: Make sure you keep what I'm about to say to yourself. I'm inviting 10,000 of you to come even deeper into the Diary of a CEO. Welcome to my inner circle. This is a brand new private community that I'm launching to the world. We have so many incredible things that happen that you are never shown. We have the briefs that are on my iPad when I'm recording the conversation. We have clips we've never released. We have behind the scenes conversations with the guests and also the episodes that we've never ever released and so much more. In the circle, you'll have direct access to me. You can tell us what you want this show to be, who you want us to interview, and the types of conversations you would love us to have. But remember, for now, we're only inviting the first 10,000 people that join before it closes. So if you want to join our private closed community, head to the link in the description below or go to doaccircle.com. I will speak to you there.
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