Ep. 250 Denver’s Diet Doctor: Metabolic Health, Toxic Food Environment, & Therapeutic Fasting

Cynthia Thurlow: Welcome to Everyday Wellness Podcast. I’m your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent are to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.

Today, I had the honor of connecting with Dr. Jeffry Gerber, who is a board-certified family physician, speaker, author, conference organizer, husband, father, and owner of a Medical Practice in Colorado, where he is known as “Denver’s Diet Doctor.” He’s also incredibly savvy with low carb, high fat, ancestral health, paleo, primal, intermittent fasting, and whole foods, and is frustrated with spiraling healthcare costs related to the treatment of conditions like obesity, diabetes, cardiovascular disease, and many others. Today, we dove deep into Dr. Gerber’s background, how his 40-pound weight loss really got him interested in looking at metabolic health. We talked about the impact of our modern-day lifestyles in the toxic food environment. The role of deprivation versus mindfulness. Common challenges that we find in the current medical system, the role of mitochondria in longevity. The impact of altitude on our metabolism, carbohydrates and other macros. The role of perimenopause, menopause, andropause, and weight loss resistance. The differences between insulin sensitive versus insulin resistant individuals, the role of therapeutic fasting, deprescribing and assessing cardiovascular risk. I hope you will enjoy this conversation as much as I did recording it. Dr. Gerber, will absolutely be back for a second podcast episode. 

Well, Dr. Gerber, it’s such an honor to have you on the podcast today. Welcome. 

Jeffry Gerber: Great to be here. 

Cynthia Thurlow: Tell listeners a little bit about your background, because I know you started in family practice, but you’ve now evolved into Denver’s Diet Doctor and this low carb, keto metabolic health space. How did that journey happen for you? 

Jeffry Gerber: Yes, Cynthia. I’ve been a doctor for over 30 years. I got my degree back in 1990. The first ten years, I really didn’t know much about nutrition. However, my family, we were a bunch of overweight people. My mom and dad, I really have to give them credit for pushing me to go to medical school and also develop an interest in nutrition. Initially, as you know, you’re in healthcare. We weren’t really taught much about nutrition. The basic advice eat less, exercise more. It’s a matter of sacrifice and just struggling for the first ten years with patients really didn’t have results. So, about 20 years ago, 20 plus years ago, we had patients come to us, telling us that they were going to try some of these nonstandard diets such as Atkins, Suzanne Somers Diet. And, I’m like yourself, I always enjoyed thinking outside the box, being an independent thinker. So, I said to these people, “Okay. Well, I think your heart’s going to explode from all the fat that you’re going to be consuming, but we’ll watch your metabolic markers.” Lo and behold, they actually lost weight. They felt better, and their metabolic markers including lipid profiles improved. My father-in-law challenged me to lose 40 pounds, and I did so doing a low-carb Atkins style of diet. I found it very easy to do, and it controlled appetite. Later I found out that I was insulin resistant to a certain extent having metabolic syndrome. I started to do my homework and reading about the science, and the light bulb went off in the head and it was like, “Aha, we’ve got it wrong in terms of nutrition.” From that point forward, we continued to work with our patients and educating patients that turned into going out and lecturing. We wrote a book with Ivor Cummins. Now, we have these conferences coming up. I’ve realized that my passion is education science. So, that’s the short story. 

Cynthia Thurlow: Well, and I’m so grateful for that journey, because from my perspective, when I started down the metabolic health journey, my whole background as an NP is in cardiology, and I kept saying, we’re missing opportunities. There’s something we’re missing, when I’m putting patients on five antihypertensives and I’m putting them on more diabetes medications and we’re sending them for more procedures. I was like, something that we are doing is not effective. I too used to tell patients, eat less, exercise more, eat to stoke your metabolism, eat those heart healthy grains. I shudder when I think about kind of the conventional wisdom that were trained with, and the information that were sharing with patients, which was likely contributing to a worsening of their metabolic health. So, I really applaud you for doing the work yourself first and then applying that to your given patient population. Now when we start to think about what’s changed? When I say in our lives, I say as a society over the last 50, 60 years, I like to speak to the fact that there are a lot of adulterated products that are in our food supply. And for individuals that are eating a standard American diet, which generally is devoid of enough protein, too many refined carbohydrates, and really poor quality, highly toxic seed oils. I feel in many ways our food has become poisoned effectively. So, as you’ve had this 30-year history, what do you feel like has changed for so many of your patients as it pertains to nutrition? Where have we gotten things wrong? 

Jeffry Gerber: What you’re referring to is the toxic food environment that we really live in. I was asked the other day about what’s the single biggest problem with our food chain, and that’s it, you nailed it. And that is the toxic food environment. The industry has unfortunately found the right formulas to create food products that are processed, that drive appetite, stimulate food reward, and we just come back for more and more. With our patients over the years, we want them to be well informed consumers. And to understand this, when they look on packages, what’s in the food product, and in general, if it’s in a package, we might want to avoid it and stick to eating more whole foods. That is really the overwhelming message that we send out to the patient and it’s really frustrating because there are some good points to the traditional approach. The traditional approach is looking at calories in and calories out and calories do matter, but that approach involves self-sacrifice. You have to consciously reduce the amount of food that you’re consuming and increasing the energy output. I mean, some people can do it, but it’s hard to do, when you’re living in this toxic food environment that’s driving you to eat more, it’s going to fail. 

Cynthia Thurlow: I think that’s interesting that one of the aspects to metabolic health and people being able to buy into these different nutritional paradigms or methodologies is satiety. That’s something I never talked to my patients about was satiation, eating enough protein so that you are stimulating specific receptors in the body that will allow you to be too full to eat more, versus the standard American diet where it is designed to do everything to dysregulate that communication between our brains, and our stomachs, and our hormones so that we are driven literally, driven to continue consuming more and more food. 

Jeffry Gerber: Yes. The point is, we’re trying to shift the focus away from deprivation to what I refer to as mindfulness, and that is to find foods that satiate. To start listening to your body, to the signals of when you’re full, when you’re hungry, when you need to move, when you need to sleep, when you need to enjoy the company, and the friends. Just to really revel in life and to be mindful, paying attention to the foods, and how they drive appetite, and eating foods that are nutrient dense and tend to satiate. Like you said, that’s where we go with our patients these days. 

Cynthia Thurlow: Absolutely. Do you feel like there are specific items in our food supply that are particularly toxic? I’m getting you to move towards, I’ve asked many guests that have been on the podcast, what’s worse, high fructose corn syrup or seed oils? I’m curious to know what your answer is, because it’s interesting that almost everyone has leaned in one direction versus the other. But I’m directing the conversation so that we can touch one of my favorite subjects, which is mitochondria. 

Jeffry Gerber: Yeah. I always say our genetics haven’t changed, but the conversation always does and that’s what makes this fun. I like to find common themes, Cynthia. I’m not hardcore, at least try not to be hardcore with a stance of opposition. So, my answer to your question is that I think high fructose corn syrup and industrial seed oils are both things that need to be considered in the diet. So, when we clean up the diet, you realize that those are really manufactured things. In a sense, you do get some seed oil, you do get some high fructose corn syrup, but the industry has concentrated it because it’s tasty, it’s addictive, it has a long shelf life. There’re all these reasons, and our health is at the bottom of it and so I think they’re both important to consider.

Cynthia Thurlow: Definitely and it’s interesting. If you are not familiarized with reading food labels, you will start to recognize if you’re walking through a grocery store, that nearly everything you put your hands on, that’s in a package, a bag, a box, or a can has these seed oils, more often than not. The number one consumed fat in the United States right now, according to Dr. Ben Bikman, who I know we both are colleagues with, is soybean oil and it just proliferates. So, I remind people I will do videos in Trader Joe’s and Costco, and all I do is search for seed oils. That’s the only exercise in trying to explain, how challenging it is to navigate, because the food manufacturers have gotten very savvy. They’ll say things like cold pressed sunflower seed oil, or they’ll use a terminology that doesn’t make it entirely clear about what is contained in these products. It any surprise that consumers and patients are confused about what to eat? Because even with best intentions, it can be very challenging to navigate the grocery store. I’ll give you an example, recently. I do quarterly Trader Joe’s videos and usually Costco, even with my eagle eyes, I brought home bacon and for sure, I was going through everything. I was getting ready to do a video, and the bacon the very last ingredient in tiny print with sunflower seed oil. And I thought to myself, “Dang it.” The point being that even I sometimes will miss these things, of course it went back to the grocery store. But the point of why I’m sharing this is that there’s so much confusion about what to eat, that keeping it more or keeping it simple is probably the best advice we can be giving our patients. To not overthink it but if you read food labels and try to eat foods in a less processed, more nutrient dense environment, you’re less likely to be exposed to these toxic chemicals. 

Jeffry Gerber: Yeah. So, I agree. Keeping it simple is best and real briefly looking at the mechanisms, because just to shout out, okay, fructose and vegetable oils are bad. Well, what’s the mechanism behind that? The idea behind fructose is that it goes right into the liver, and it drives fatty liver disease. The other aspect we just actually did a really great podcast with Rick Johnson, who’s going to be speaking at the conference. He says, that fructose is the switch that leads to obesity, leptin resistance, the mitochondria stop working. There’re all kinds of mechanisms that implicate fructose corn syrup, also carbohydrate in general, and then switching to the industrial vegetable oil. So, there’s always a lot of controversy. Okay, they’re not so bad from kind of the mainstream people, to people in our group who say, “They’re just as bad as the fructose.” So, as I’m very much interested in cardiovascular health and what we see is that because of the molecular shape of these industrial seed oils, they’re very highly prone to oxidative stress, and leading to events, glycation, end products. I always bring up the point that when the pathologist looks at the cholesterol plaque, atherosclerosis in the arteries, they’re actually filled with these industrial seed oils. They’re glycated, and they’re inflamed. So, the argument is we want to avoid those and eat more natural fats that include both monounsaturated and saturated fat that don’t have this molecular structure like industrial seed oils and they tend to be very stable in the blood. This is why we make the argument that they’re healthier. 

Cynthia Thurlow: It’s interesting. There was a rabbit study that I presented in a talk that I gave earlier this year, and it was looking at in a rabbit model, looking at seed oils utilized that were not heated, then heated once versus multiple times. Like, think about the fryers, at most of the fast-food restaurants, and the toxicity that went up even with just heating it once versus multiple times. Increased oxidative stress, increased inflammation, ages, etc., and what was interesting is, in the study, it was talking about the connection with insulin resistance in rabbits, based on what they were exposed to in terms of vis-a-vis these different types of seed oils. Someone may argue, well, a rabbit is not a human, but if animal models were seeing this connection. I think it’s particularly powerful and much to your point, Dr. Rick Johnson loved Dr. Rick. We had an amazing podcast with him earlier this year, and for many, many people, I got more feedback about his infectious enthusiasm for teaching us about fructose that I think for many people, not only his book and his work and his research, but really starting to put those pieces together about why fructose is of such a great concern, it is not benign. 

Jeffry Gerber: Yeah. It’s great what Rick’s doing and he’s so approachable. He looks like a scary professor, [Cynthia laughs] distinguished professor of 30 years’ experience, but he’s super passionate, and he’s very approachable, and he’s a lot of fun. 

Cynthia Thurlow: No, he definitely is. I was trying to explain to someone that his enthusiasm about fructose and having us understand the dangers and concerns surrounding it made me even more in fact, before we even had our podcast discussion, we had multiple conversations over email. He’s just as delightful and down to earth as anyone could be, which is really just a godsend. So, let’s touch on mitochondria, so my listeners are certainly familiar with what the mitochondria are vis-a-vis in relationship to intermittent fasting. When we start thinking about these powerhouses in our cells, and how these toxic foods can impact the health of our mitochondria. We start to put pieces together about things that we can do to improve our metabolic health. 

Jeffry Gerber: Yes, Cynthia. We’re both fascinated about mitochondrial health, and it really takes us to longevity. I gave a great talk a couple of years ago, and I can give you a link to that to share with your listeners today. We could go on for hours and hours but I like to kind of simplify it. Again, the mitochondria, as you say, is the powerhouses of our body and my perspective is, what do we want to do in terms of longevity, in terms of fuelling our body? What is the best fuel for longevity? I always like to say, this expression that longevity is an endurance sport. That really ties into this idea of how do we find the right fuel. The argument here is that fat or fatty acids is actually a slow burning fuel throughout life that produces less oxidative stress than, say glucose and carbohydrate.

So, how do we know that? We have to kind of dive into the biochemistry and how the mitochondria work. For my patients, I like to try to explain it simply, as you do as well. Sometimes I oversimplify, [Cynthia laughs] but for the purpose of the podcast, we’ll try to oversimplify a little bit. We have the mitochondria all over our body and our muscle, and they basically process the energy that come in. It can be carbohydrate, it can be fatty acids, fat, it can be protein also and the output from mitochondria are ATP. ATP is then used by all parts of our body, muscle, digestive, brain function just that is the energy pack that is used for life. If you stop producing ATP, you’re dead in seconds. I think of the mitochondria as actually a battery and a motor, tiny batteries and motors all over our body. The energy that comes in has to be processed. Now, the energy is processed actually in the cell itself before it dives into the mitochondria. 

There’re things like glycolysis and the citric acid cycle and beta oxidation. We could go on all day about that. But when it comes to this topic of oxidative stress, we have to really talk about mitochondria because what the mitochondria do is something called cellular respiration. The mitochondria actually breathe, it uses oxygen oxidative stress, it’s all tied together so this is where the oxidative stress comes into it. Just to explain it simply is that when glucose or carbohydrate come into the mitochondria, they actually rapidly charge the battery. And that’s actually the inner mitochondrial membrane and that’s because the substrate that comes in goes through three complexes of the inner mitochondrial membrane. Just to simplify it charges this battery rapidly and when you compare that to fatty acids or saturated fat coming into the mitochondria, fatty acids actually charge this battery much slower. It’s got to do with the ratios of NADH and FADH2. When glucose comes into the mitochondria, it turns out that most of the substrate is NADH, like 75% compared to 25% that’s FADH2. When the fatty acids come into the mitochondria, you’re producing about 50-50 NADH to FADH2. When the triglycerides come in, they can only go through two of the complexes versus glucose, which can go through three of the complexes. As you can see, the battery charges faster with glucose versus fatty acids. 

Now, this is not hypothesis. This is biochemistry, I actually looked it up this morning again, I found several other papers that explain this. We all know if you need a quick charge, you take glucose because you get energy right away. We’re basically just describing the biochemistry here and what happens. Now, what is hypothesis? This comes from my background in ham radio as a little kid. I love ham radio electronics. I still build things, computers, networks, we build ham radios but it reminds me of electrical circuits. We all know that when we charge things, say, our phone we want to get the charger that gives us a rapid charge. What usually happens is you can feel the battery and the charger, they really heat up. So, when things charge rapidly, it produces heat versus a slow charge you don’t get as much heat on the charger. The hypothesis here is that the heat itself is a product of oxidative stress. The rapid charge from the glucose denatures cells on a certain sense. If you think about this throughout lifetime, look, we have to eat glucose, we have to consume glucose, we have to consume fatty acids. But the idea is, sometimes you do need glucose when you’re in a fight or flight situation. The idea is that glucose is there for winning the battle, but we want to win the war, which is longevity. The hypothesis and what we’re proposing here is that fatty acids, fat for longevity is the preferred fuel. 

Cynthia Thurlow: I think that’s one of the best explanations I’ve ever heard about mitochondrial metabolism. For the benefit of listeners, when someone is new to intermittent fasting or new to a lower-carb ketogenic lifestyle, the challenges are that their body is not efficient using these different types of fuel substrates. This can be, for many people why they will struggle. I mean, there can be many reasons, but this can explain why many people will struggle with those new ideas about meal frequency and or a lower carb ketogenic lifestyle. 

Jeffry Gerber: Yeah. So first of all, there’s many mechanisms to explain oxidative stress in mitochondria. So, I’m just presenting one but there’s reverse electron transport that goes on and you can study and research that forever. The problem with most individuals is they don’t exercise enough and they’re metabolically unhealthy. As you say, their mitochondria aren’t working properly and there isn’t the density of mitochondria that we see in somebody who exercises. An individual, say, is not at their ideal body weight or they’re insulin resistant and they try to go out and exercise. Mark Cucuzzella actually says they’re starving for energy and all they can resort to is glycolysis, which is actually the fermentation of glucose without oxygen. It doesn’t produce a lot of ATPs, it produces little bit, but it produces lactate and that causes the muscle to burn and the individual is huffing and puffing. The way to slowly come out of this is to exercise and to move, and to fuel your body properly long term. 

Cynthia Thurlow: I think for a lot of people, they might be able to do one at first, but not both. I find for many people, maybe they’re more on the exercise. It’s easier for them to commit to exercise versus changing their diet. When they can do both, it is really impactful. Now, when I think about exercise, it’s different now that I’m a middle-aged person, maybe years ago I would do CrossFit type classes and a lot of hits. As I’ve gotten older and I’m interested in hearing if you see the same changes in your middle-aged population of patients. I start to find more Zone 2 training, more walking, more lifting of weights is very, very important for metabolic health. Do you see both men and women struggling a bit in andropause and perimenopause and menopause with their metabolic health? 

Jeffry Gerber: Oh yeah, absolutely. Look, movement and activity changes throughout life and you have to worry about orthopedic injuries. My whole life, I’ve struggled with weight, but I’ve also been very athletic and I have my fair share of injuries. We always joke the question is, do you want to drop dead in a wheelchair being a cripple, or drop dead from a heart attack and diabetes? I’m just using the extreme there, [laughter] but so we have to find a good balance in between. I just like to tell my patients, do something, move, be active. It’s also important what you do in between exercise. I have a kneeling stool, but I like to stand. I’m running around at work today, I fidget. One of the patients pointed out to me that I love the fidget and I just naturally do that. I also like to participate in sports, I like to go to the gym. This is what we share with the patients. It can be high intensity; it can be CrossFit, you have to be careful for injuries, you have to go slow. It changes as time goes on in terms of the activity. 

Cynthia Thurlow: Well, it’s interesting because I was a skier in my teens in 20s. We live in a part of the country where there isn’t a lot of really good skiing. I know you live in Denver, so you have fantastic skiing being out west. The last time I skied, I remember saying to my husband, I’m very conscientious at this stage of life. I don’t want to get injured, and certainly not on a ski slope. So, recognizing which is not to suggest people that are middle aged can’t ski. But the point being, I am very conscientious about doing things where within a safe parameter. I just said I don’t ski often enough anymore, so for me, I’d rather watch my family ski, and I’ll do something else. Certainly, that self-preservation is formant in my mindset. 

Jeffry Gerber: Well, we would love you to come out when you come out to talk at the conference in February to join us for some skiing. Look, it’s like anything, you go slow, you take it easy. The altitude brings up a point about mitochondria that I love to talk about, if that’s okay. 

Cynthia Thurlow: Absolutely.

Jeffry Gerber: Yeah. So, in the East Coast, you ski on the Appalachians, and they’re not very tall, but our mountains go up to 14,000ft, and we’re skiing up at 10,000ft and 12,000ft. So, what I have found over the years is that because of my diet, I seem to do exceptionally well at altitude and it’s a curious finding. In fact, we can go skiing all day, and we go in to the cafe or the restaurant around noon to take a break. I just want to hydrate, have some tea, some water, I’m not even hungry. You’ll find out that a lot of people who spend time in the mountains and eat healthier seem to do fine. It’s a curious thing because the altitude people will tell you that carbohydrate is the preferred fuel because it requires less oxygen.

Cynthia Thurlow: Interesting.

Jeffry Gerber: That’s actually true. I’ve actually taken a deeper dive looking on a molecular basis in terms of the carbon that is in the molecule, in the energy molecule, either glucose or lipid and how much oxygen you need. Now, we all know that per gram, there’s more energy in fat than glucose, and that’s simply because fatty acid doesn’t have a lot of oxygen molecules in it. That’s where the O2 comes in, and that actually gives you way more energy. Now, that doesn’t mean you need way more oxygen on a molecular basis to metabolize fatty acid. You do need a little bit more; you do need a little bit more oxygen to metabolize fatty acid. I’ll give the altitude people that they are correct. You do need slightly more oxygen to metabolize fatty acid on a molecular basis, but there’s so much more to it. If you’re a trained athlete, your mitochondria are doing well, they can metabolize both fuels, breathing the muscles of respiration are working maximally. What happens is that the, say, fat adapted athlete at altitude, they’re living at peak performance. I mean, I wouldn’t say I’m living at peak performance, but I’ve adapted to it. The idea here is that at altitude, I’m burning fat much better than, say, somebody my age who’s 62 that’s a carb burner, my body has learned to burn the fat, and there’s more energy in the fat, so I can go skiing all day long. And so, it’s just interesting we see that with fat adapted athletes at altitude all the time. 

Cynthia Thurlow: That’s amazing. It’s interesting that altitude impacts our mitochondria, but if you are already metabolically flexible that it allows you to function more optimally. Now, I’m curious because I got several questions surrounding this. In your practice, I’m sure you work with a wide variety of ages. But for those people that are hitting middle age and I’m saying this in generalities because it could be men or women. What are some of the common challenges you start seeing in your middle-aged patients vis-a-vis metabolic health? What are some of the things that they will come to you? I know weight loss resistance is a huge one. For me personally, it seems to be that’s, like, the common resounding concern is, why can’t I lose weight when everything I used to do is no longer working? But I know there are some hormonal fluctuations that can impact weight loss resistance. For you personally and your practice, what are some of the common challenges you see your middle-aged patients dealing with? 

Jeffry Gerber: Yeah. Well, first of all, Cynthia, as we age as healthcare professionals, our patients usually follow along with us, so they age with us. You seem to get like, a similar population. We see all age groups, and because of what we do get all age groups, but we tend to see middle and older age individuals. And the beauty of what we do and we’re still in the healthcare system because we want to help our patients navigate through all the time bombs that healthcare landmines, rather navigate through all the landmines that healthcare has to offer. We have a lot of people that have given up with the healthcare system in general, but not myself. I still enjoy seeing patients under this context. So, obviously, we’re dealing with the big three all the time. So that’s diabetes, obesity, and heart disease. In the context of what we do here is we’re approaching it through lifestyle and diet. Our goal is to deprescribe medication. We’re also very good at prescribing medication, and we still do that so we’re kind of bridging that gap. We deal with all these traditional medical issues and it’s an interesting thing that we’ve done literally thousands of glucose tolerance tests over the years, including insulin levels. And it’s really given us some great perspective and we really have to thank Dr. Joseph Kraft, who spent his 40 years of research looking at the insulin assay. Ivor Cummins and I had the opportunity to interview him when he was 95 years of age. A few years back, he passed away, bless his soul. Because it’s through that we started doing these glucose tolerance tests. What has been revealing is that not everybody is insulin resistant. Everyone seems to think, “Okay, the whole problem is insulin resistance.” Insulin resistance, just treat that and you’re going to be gold. 

In particular, we have women who are not at their ideal body weight, and they tend to be insulin sensitive. I would say it may be a third or even more of the women, again, insulin sensitive. The question is, well, what’s going on there? First of all, their personal fat threshold, which simply means their ability to store fat, is actually much greater than men. We have women who come in and they are definitely not at their ideal body weight, but we do their metabolic measurements and they’re really very, very healthy. Why is that? Well, clearly it probably has something to do with reproduction and hormones. We have to put it all in context with our particular patients and the approach to diet. Look, if the individual is diabetic and full-on insulin resistance and there’s this whole spectrum of insulin.

The insulin spectrum, you have to consider if they’re diabetic fully insulin resistant or they’re insulin sensitive. The diabetics ones really do great with higher fat diet because glucose is what’s driving insulin, carbohydrate is driving insulin. If you remove the fuel that’s driving insulin very rapidly, you’ll reverse insulin resistance. Patients will get better, but actually, as those individuals get better, they become more insulin sensitive. So, like the insulin sensitive individuals, if you put them on a high fat diet, they’ll respond. The fat is very filling, of course, but we have to consider that fat is also caloric dense, calories do matter. So, with these two individuals and what is the common theme there, is that we do want to focus on mindfulness and satiety. Looking at how we can control appetite in these patients. We don’t want to, again, tell them to eat less and exercise more. We don’t want to deprive them of the joy of life, that life has to offer.

It’s just the point with these insulin sensitive women is that we probably– we want to think about fat calories, we want to eat enough fat to fill. Ben Bikman is great at saying this. The way to do that is by eating more lean cuts of animal proteins, increasing protein, because protein is nutrient dense and filling by itself. It’s not just about eating under 20 or 40 grams of carbs a day. These are the individuals that can eat more carbohydrate, but the mindfulness, again, looking in as to what are the foods that are satiating to me. Am I hungry? Do I need to eat? Do I need to not eat? Can I skip a meal? Do I need to go out and move? So, this is the difference in patients and I think it’s critical. Again, I’ve challenged you to give a talk at the conference in February on these insulin sensitive individuals. I hope you’re up to the challenge. Cynthia. 

Cynthia Thurlow: Oh, I absolutely am. I’m really excited. What’s interesting for me is that these insulin sensitive females that I have had the honor of working with, I find for them that I agree with you 100% that they can still have fats, but they’re usually leaning into plant-based fats, which tend to be a little lighter. I think they still have to be very conscientious about the quantity of fats that they eat because as you very appropriately stated, that fats–we’re looking at macronutrient’s, protein, fat and carbohydrates. Carbs and protein or four grams per calorie, and fats are nine. Really thinking this is why I would say measure your fats if you do nothing else, just if you’re trying to be conscientious about it. I find many women can overdo it very easily with seemingly innocuous and benign foods, like whether it’s nuts or cheese. Those two seem to be the biggest culprits because it’s very easy to overeat those delicious, salty, satiating, fatty foods. I would also agree with you that it is more than just insulin. I find for many of these women, especially in perimenopause and menopause, as they are getting closer to twelve months without a menstrual cycle, their bodies are having these profound metabolic shifts.

The understanding that when you have low estradiol, so predominant form of estrogen, as you are transitioning into menopause, you are at greater risk for replacing, not only you’re going to have more adipose tissue, less muscle tissue, which is less metabolically active, but just by virtue of having low estradiol, high FSH follicular stimulating hormone, your body will start creating unfortunately, we’ll start creating additional fat. In that fat you’ll have estrone which is this weaker form of estrogen. And why I’m sharing this, women will say, why am I having like there’s all this extra fluff that I haven’t had to deal with before and remind them that our bodies are trying their darndest even though there’s less estrogen circulating, their bodies are trying to figure out a way to produce more estrogen. This is one of the ways that this happens. 

Jeffry Gerber: Yeah. Well, I talked to Jamie Seaman, and she really impressed upon me, how women are the reproductive species. The bodies go through so much change throughout life, including menopause and so that’s a critical time. I don’t want to call it male menopause, but some of these issues also apply to men as well, as we get older, we have to really work hard to maintain our hormonal health, and diet and lifestyle are the way to do this. I also wanted to say, Cynthia, that this can all be done through a low-carb vegetarian diet. I mean, there are ways to do it. The other point is that there are two camps, there’s the hormonal camp and the calorie camp. The thing is, there shouldn’t be camps, they both interplay. That’s kind of my whole perspective where I try to find some common themes and balance and bring it all together. 

Cynthia Thurlow: Well. I’m so grateful that you are a resounding, balanced perspective in this space. I know that you utilize intermittent fasting as a strategy with some of your patients and what have been the results that you’ve seen in terms of metabolic health, mitochondrial health for both men and women in your practice. 

Jeffry Gerber: That is another tool, and it works for some people, it doesn’t work for others. But we have individuals for which it’s worked that they hit a weight loss plateau and we simply just said, “Pay attention to when you eat and try to eat two meals a day.” If that’s working, try to eat one meal a day. We think that one meal a day is optimal. The other trick is, “Okay, Dr. Gerber, I tried that and I ate breakfast and lunch and I skipped dinner, and that didn’t seem to work for me.” What I did was I skipped breakfast and I ate lunch and dinner and that worked for me. It’s going to be different for everybody. Lo and behold, that helped the individual go off of the weight loss plateau. We also have individuals that can do extended fast, that they can go continuously eating once a day, and that seems to work for them. We’ve done two and three days fast, and I think they’re perfectly safe. I don’t particularly like the patients that come in and brag about not eating, [laughter] that happens all the time. Oh, I’m so proud of myself, but again, you don’t want to force anything. And why does that work? There’re all kinds of theories about urine state and a catabolic state for a longer period of time, extending fast during the nighttime. So, it turns on catabolism or burning fat. Here’s another simple explanation, it reduces the amount of food that the individual consumes at the end of the day. Again, we’re bringing it all together with that one. 

Cynthia Thurlow: I love your explanation about it works for some people, not for all, to really lean into what’s working for you. This kind of intuitive eating, intuitive fasting, I know it’s not possible for everyone up front, but that’s what we hope we can get our patients to a time where they’re able to appropriately respond, I’m hungry, I should eat. I’m not hungry. I should not force myself to eat is a big distinction. Now, we have a shared passion for cardiovascular health, and I know this is an area that I’m really interested in diving into with you. Let’s talk about your approach to cardiovascular health testing labs, I know that you do advanced lipid analysis. I know that you do diagnostic testing, carotid arteries, CACs, et cetera. Let’s talk about this a little bit. Actually, a lot of the questions I received were specific to this, people who wanted to hear your perspectives on heart health. 

Jeffry Gerber: So, you’re telling me you query your audience before these podcasts? 

Cynthia Thurlow: I do. I’m a gigantic nerd. [laughs]

Jeffry Gerber: Well, Cynthia, you’re not a nerd, you’re just super organized. [Cynthia laughs] Kudos. [chuckles]

Cynthia Thurlow: Well, because it’s interesting that I’ve learned it allows me to have a sense of what people are leaning into. There’re always common themes of every guest, however specific guests, in particular, I’ll ask, what are you interested in learning about? Or what do you have questions about? Because that allows me to feel like I’ve got an interplay with my audience as well. 

Jeffry Gerber: Yeah. That’s great, Cynthia. Yeah, my interest in cardiovascular health is personal. As I age, I said, “Look, I want to live a long time. I don’t want to have heart attacks, I don’t want to have strokes, I don’t want to have diabetes.” I just really became fascinated again, 20 plus years ago, that this nutritional advice seemed to be counter to the mainstream, that eating red meat was going to cause cancer and eating saturated fat was going to make your heart explode. So, I started just diving into the data, and that really took me to the metabolic syndrome. That work really dates back to the 1980s and so the idea there with the metabolic syndrome is that it’s really the ratios or the quality of the cholesterol that seems to be more associated with cardiovascular risk than what was traditionally thought of as in terms of LDL by itself. So, for 50 years, it’s the hard associations that have had us focus with blinders on looking at specifically LDL cholesterol. The idea there was that if we can do everything, we can to lower LDL cholesterol, we don’t have to worry about anything else, and we’re going to live forever. Well, that has not really been proven to be the case. When you actually look at the literature, especially, for primary prevention, meaning that individuals that are free of heart disease, meaning that they didn’t have a heart attack or event. If you lower cholesterol, or if you put them in a diet that is lower in saturated fat, it really hasn’t been shown to prolong life. We see that over and over again and it’s interesting Dr. Khurram Nasir, who’s worked with Arthur Agatston, will be speaking at the Conference on Cardiovascular Health, and he understands that there’s a bit of controversy there in terms of the original data, even dating back to Framingham, that there doesn’t seem to be this correlation. 

Getting back to metabolic syndrome, we look at things in terms of the ratio of triglyceride to HDL. If that ratio is less than 2:1, you can be certain that if you did advance lipid testing, that you’d have the large, fluffy, healthy particles. Then more importantly, you have to look at the metabolic health, you have to look at insulin markers. One thing, if you look at a standard lipid profile, it’s just a proxy to insulin resistance. If you have a very high triglyceride and a low HDL, you’re almost certain to see insulin resistance. Here’s the thing about the blood markers, they’re great. I describe it as the fuel in the gas tank, so when you get these blood markers, they kind of tell you the state of the fuel. How’s the fuel doing but if you want to kind of get a measurement of long term, or to look at the engine or the heart pumping itself, this is where you do some heart imaging. That’s why we like to do these heart calcium scores, because they’re really a non-invasive tool, to look at cardiovascular risk. You can look at the total burden of calcium, it’s a $99 test. It’s a tiny bit of radiation. There’re other screening tests that you do that can be a little more invasive, such as a CT angiogram that exposes you to die in a little more radiation. As a screening tool, the heart calcium scan really gives you information, historical information about the health of the heart. We like to do some serial testing and look for progression of calcium volume. I think when a patient comes in and they go on these diets and they see their LDL go up, but their ratios are good. They’re worried that somehow this presents them with an increased risk of having a heart attack. We just resort to the imaging, and it’s great if they have a zero score, their ten-year risk is the lowest possible. But patients come in and they have calcium, and we deal with that. If they have a really high calcium score, say over 400, we do have a discussion about medication. We still prescribe and have a discussion with patients for secondary prevention, meaning if they have had a heart attack. I think with all else being equal, if a patient can’t change their diet, well, again, this is where we can resort to medication. If they’re going to make significant change, we can motivate them with the results of the calcium score. Well, we’ve served our purpose, and so a lot of people argue the calcium score is useless. Well, its primary role here is to motivate individuals to make change in their diet and lifestyle. 

Cynthia Thurlow: I think it’s a really powerful tool. Certainly, when I started in cardiology a long time ago, that was not an option, and it was more stress testing and echoes and all these other diagnostics. I love that you’re looking at a total cholesterol and the triglycerides HDL, the LDL with a different lens. Because I would say on social media on any given day, one of the things the team has to field questions about, I went on a ketogenic or low-carb diet and my total cholesterol went up. My doctor or my nurse practitioner or whomever wants to put me on medication, and I usually will share the podcast, I did with our mutual friend talking about the fact that it can be a transient. I’m a hyper responder, so when I’m lean mass, hyperresponder.

Dave Feldman is doing all this amazing research. He’s an engineer, which means he’s very nuanced. He’s looking at all the details, and he’s helping to change the mindset methodology around lipid panels, and looking at cholesterol. I remind people that transient changes in an overall cholesterol panel are not, per se, a bad thing. Again, we want to look at those triglycerides. We want to know that they’re as low as they can be. We want to make sure HDL is optimized. I think for many years, were so focused one metric, just the LDL. We would drive that down as far as we could, as fast as we could, and then I would watch a lot of my patients develop side effects. It wasn’t until I took care of a wonderful biochemist who worked at the NIH, she changed my whole perspective on statins use. There was an appropriate time and a place. I’m by no means not suggesting that, but she started talking to me about the net impact of statin utilization and how that can impact memory and cognition. That drove me down this massive rabbit hole. So, these medications, although they can be helpful in specific individuals, are not without side effects. 

Jeffry Gerber: Yeah. Well, I love that you have a background in cardiology, Cynthia. That’s really fantastic, and it is unfortunate, but again, metabolism is there to really transport of fat-soluble vitamins, minerals and nutrients throughout the body. The heart association decades ago, seemed to conflate it with cardiovascular risk. We have to consider it in perspective. Look, it is a very contentious subject, and to me, that makes it fun and actually interesting. It’s interesting and fun, and people are just arguing back and forth. And look, I don’t do research here, I see patients. We’ve been using this approach with our patients for coming up on almost 25 years. We’re really old timers at this. If were giving bad nutritional advice, you would think that our patients would be dropping dead like flies. And I’m joking but I’m serious. That’s not the case, we’ve improved patients’ diabetes. We probably prevented them from having heart attacks. We still have patients that have heart attacks in the office. Some are more compliant with the diet than others, but we think that we’re on the right path. 

Cynthia Thurlow: Well. I’m so grateful for the work that you’re doing, and I’m curious, obviously, Low Carb Denver is coming up in a few months. What is the direction you see nutrition science going into 2023? Any predictions, any ideas of newfound, ideas that are on the horizon? 

Jeffry Gerber: Yeah. Well, as our theme for the conference is where is nutrition headed? I’m going to say that’s going to hopefully be answered by you and the rest of the speakers. [Cynthia laughs] I guess I’m not quite sure where we are going. I want to learn more myself. Again, I think I hope at the end of the conference that we will develop some common themes in terms of where we’re headed. 

Cynthia Thurlow: Well. It’s very exciting, and obviously we have so much in common, we could talk for hours. I’ll definitely have to have you back on the podcast. Please let my listeners know how to connect with you, how to register for Low Carb Denver, at which I am grateful and fortunate to be a speaker at. Let them know how to find you. 

Jeffry Gerber: Yeah. Well, it’s great to have you, Cynthia. To your audience, if you want to support our conference, you support nutrition science, and honestly, we can’t do it without you. It really took a lot of effort, having taken a three-year hiatus, to put the conference on and we want to continue year to year. We can’t do it without the audience is almost the most important group, and that includes the general public, and healthcare professionals. If you want to find out more about the conference, you can visit lowcarbconferences.com, the website, social media. For me personally, you can find me on social media @jeffrygerbermd.

Cynthia Thurlow: Well, wonderful. Thank you again for your time today, Dr. Gerber. 

Jeffry Gerber: A pleasure, Cynthia. 

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