How to Improve Your Blood Sugar, Energy & Metabolic Health | Dr David Unwin

1. 0:00 – 4:24

   Early warning signs of insulin resistance: fatigue, belly size, brain fog, mood shifts

   1. RCDr. Rangan Chatterjee0:00

      David, welcome to the podcast.

   2. DUDr. David Unwin0:01

      Rangan, thank you.

   3. RCDr. Rangan Chatterjee0:03

      I have been so looking forward to this for a number of years. In fact, I can't believe we're only doing it now-

   4. DUDr. David Unwin0:08

      [laughs]

   5. RCDr. Rangan Chatterjee0:08

      ... because I think we share quite a similar philosophy-

   6. DUDr. David Unwin0:10

      We do. We do

   7. RCDr. Rangan Chatterjee0:11

      ... about health, and maybe life in general.

   8. DUDr. David Unwin0:14

      Yeah.

   9. RCDr. Rangan Chatterjee0:16

      To start, I wanted to talk about the continuum of health. You're someone who has helped over 150 people in your practice put their type 2 diabetes into remission, which is amazing, and we're gonna-

   10. DUDr. David Unwin0:33

       Yeah

   11. RCDr. Rangan Chatterjee0:33

       ... talk about how you've done that. But at the same time, I don't think there's an awareness out there that type 2 diabetes is the end process. Things have been going wrong with your-

   12. DUDr. David Unwin0:47

       Yeah

   13. RCDr. Rangan Chatterjee0:47

       ... metabolic health for a number of years.

   14. DUDr. David Unwin0:49

       Yeah.

   15. RCDr. Rangan Chatterjee0:49

       So what would you say are some of the signs that we can look for in ourselves that might indicate our metabolic health is a little bit off, and maybe we're on the road to getting type 2 diabetes?

   16. DUDr. David Unwin1:03

       That's a fabulous question. You're right, it starts years before, uh, you actually have type 2 diabetes. And the things I would say, or the things I noticed in myself actually, because I have type 2 diabetes, so I know a bit about this. The first thing is I used to find myself tired, particularly after meals. So I remember after lunch, even in the practice, I'd have to have a little nap on my own doctor's couch. Isn't that terrible? And I was only 55. I... And I thought that was aging. So the first thing is tiredness, particularly after meals, and also the... I was always ready to lie down in the evening. I was always thinking I'd put my feet up instead of doing anything. That's one thing. Um, another one is, is your belly size, and I, I think loads of us have noticed that. That you, you... We, we, we call that just middle-age spread, but I think that is, that's a euphemism really, because if your belly is more than half your height, you may have a problem. So all you have to do actually is get a piece of string as long as you are tall, cut it in half, and will it reach round the biggest bit of your belly? And in my case, it wouldn't have done. So belly size is another early, uh, thing that people might notice. What else might they notice?

   17. RCDr. Rangan Chatterjee2:36

       Cognition.

   18. DUDr. David Unwin2:38

       That certainly happened to me. Yeah. They call it brain fog, don't they?

   19. RCDr. Rangan Chatterjee2:42

       Mm.

   20. DUDr. David Unwin2:43

       Again, I thought this was normal ageing, so I was 55, which s- I'm now 67, so it's kind of crazy. I just noticed that the younger partners in the practice seemed to have s- intellectually more horsepower, and that was another thing for me, sort of fogginess. Um, but then another odd thing, I remember a thing at Christmas. I got sleepier and sleepier through Christmas and, and slightly depressed. And again, all of that turned out to be reversible, and all of it turned out to be those early signs that I was becoming insulin resistant.

   21. RCDr. Rangan Chatterjee3:26

       Yeah.

   22. DUDr. David Unwin3:26

       And my insulin wasn't working properly. I mean, and then you have the, the various biochemical tests that doctors might do. So, uh, any sign of fatty liver, but maybe we'll come onto that. A third of everybody in the world now has fatty liver.

   23. RCDr. Rangan Chatterjee3:44

       Mm-hmm.

   24. DUDr. David Unwin3:45

       So I had that as well.

   25. RCDr. Rangan Chatterjee3:46

       Wow. Okay.

   26. DUDr. David Unwin3:46

       Um, and then in blood tests, uh, a high triglyceride, uh, is a thing that people may have and not know why, why they've got that. So that's on the lipid, fasting lipid panel-

   27. RCDr. Rangan Chatterjee4:00

       Yeah

   28. DUDr. David Unwin4:00

       ... if you do a triglyceride, and it might be high. One final thing with me, I became fretty, so I would sort of chew on stuff for days and sort of circular thinking. It was funny 'cause when I improved my diet, all of those things went away and my confidence increased. So that's my personal experience, actually.

2. 4:24 – 6:40

   From ‘middle-aged and tired’ to fit at 67: reversing multiple markers without medication

   1. RCDr. Rangan Chatterjee4:24

      Yeah. It's really interesting. You're talking about what on the surface seems to be quite a variety of different symptoms.

   2. DUDr. David Unwin4:32

      Yeah.

   3. RCDr. Rangan Chatterjee4:32

      Right? Belly fat, a bit of brain fog-

   4. DUDr. David Unwin4:36

      Yeah

   5. RCDr. Rangan Chatterjee4:36

      ... what you call frettiness, low mood-

   6. DUDr. David Unwin4:40

      Yeah

   7. RCDr. Rangan Chatterjee4:40

      ... fatigue. There has been a tendency in medicine for many years to look at these things as separate. Okay, what's the cause of your tiredness? What's the cause of your brain fog? What's the cause of your low moods?

   8. DUDr. David Unwin4:52

      Yeah.

   9. RCDr. Rangan Chatterjee4:53

      But you found-

   10. DUDr. David Unwin4:55

       Yeah

   11. RCDr. Rangan Chatterjee4:56

       ... what I have also found in my career, that often the root cause is the same. The other thing that's really interesting in what you said is you were using the past tense in all of them, right? You used to be tired. You-

   12. DUDr. David Unwin5:09

       Mm

   13. RCDr. Rangan Chatterjee5:09

       ... used to have belly fat.

   14. DUDr. David Unwin5:11

       Yeah.

   15. RCDr. Rangan Chatterjee5:11

       Right? You used to struggle with sleepiness in the evening, whereas you don't anymore. So that's the empowering message that people are gonna get throughout this conversation. Those are things you had, but you no longer do.

   16. DUDr. David Unwin5:24

       I'm changed. Really changed. So yeah, I'm 67 now, and I run regularly, which would've been impossible when I was a younger man. Uh, it didn't occur to me it was, uh, a thing I c- I could do. So I can, I can out-sprint my grandchildren.

   17. RCDr. Rangan Chatterjee5:45

       [laughs]

   18. DUDr. David Unwin5:46

       And I'm 67. I've got eight amazing grandchildren. They think it's hilarious seeing an old guy run. They say that I win because they, they laugh so much-

   19. RCDr. Rangan Chatterjee5:56

       [laughs]

   20. DUDr. David Unwin5:56

       ... 'cause they think it's so funny to see an old guy s- actually sprinting.

   21. RCDr. Rangan Chatterjee6:00

       [laughs]

   22. DUDr. David Unwin6:00

       But I can, uh, and all of these things have changed, and I'm not on any medication. Oh, I didn't tell you. I had high, significantly high blood pressure And do you know, I didn't want to be a patient. Isn't that stupid of me? So I put my head in the sand. I knew it was high. It wasn't that bad. It was like one sixty over ninety-four, ninety-five. I never went to a doctor, but, uh, now my blood pressure's a-about one twenty over seventy.

   23. RCDr. Rangan Chatterjee6:30

       Wow!

   24. DUDr. David Unwin6:30

       So that's another-- yet another thing, high blood pressure, that I sorted out, and all of these things, no medication. And I'm so lucky. So very, very lucky.

3. 6:40 – 12:58

   A dissatisfied GP meets a patient in drug-free remission—and everything changes

   1. RCDr. Rangan Chatterjee6:40

      There's so much I want to cover with you today, David. So let's perhaps start off with your personal story.

   2. DUDr. David Unwin6:46

      Yeah.

   3. RCDr. Rangan Chatterjee6:47

      Yes, you've helped, I think, hundred and fifty-three patients now put their type 2 diabetes into remission. I wanna hear how exactly you've done that because I think that's gonna be very helpful for everyone listening-

   4. DUDr. David Unwin7:00

      Yeah, I hope so

   5. RCDr. Rangan Chatterjee7:00

      ... as to what they might be able to do in their own lives.

   6. DUDr. David Unwin7:02

      Yes. Yeah.

   7. RCDr. Rangan Chatterjee7:03

      But why don't we start off with you? Because you were the patient.

   8. DUDr. David Unwin7:07

      Yes.

   9. RCDr. Rangan Chatterjee7:08

      You were skeptical of any kind of approach that could perhaps work, and I believe that there were two, what you call two very intelligent women-

   10. DUDr. David Unwin7:19

       [laughs]

   11. RCDr. Rangan Chatterjee7:20

       ... who helped you see things differently.

   12. DUDr. David Unwin7:23

       Yeah. They were two formidable women, I would say. Formidable. Uh, so yeah, what a shock. The-- Little bit more background before we come to that.

   13. RCDr. Rangan Chatterjee7:33

       Sure.

   14. DUDr. David Unwin7:33

       So I was unhappy in practice. So I, I was the senior partner of a large practice, ten thousand patients, and I'd-- I wasn't... I was dissatisfied somehow in my mid-fifties with what I'd achieved. You know, we all become-- You-- When you-- Do you remember when you're young, you know, why'd you become a doctor? And it's all like-- you're all excited by the difference you're gonna make, aren't you?

   15. RCDr. Rangan Chatterjee7:57

       Yeah.

   16. DUDr. David Unwin7:57

       And you can't wait to, you know, get into practice. And I, in my mid-fifties, I was disappointed because it didn't really feel that great because actually the health of the population that I cared for had got worse, not better.

   17. RCDr. Rangan Chatterjee8:12

       Mm.

   18. DUDr. David Unwin8:13

       S-- I, I mean, an example, we're talking about type 2 diabetes. So when I first joined the practice, which was in nineteen eighty-six, so I've been there since nineteen eighty-six, we had just fifty-seven people with type 2 diabetes. Fast-forward, we've now got six hundred.

   19. RCDr. Rangan Chatterjee8:31

       Wow!

   20. DUDr. David Unwin8:31

       So that's a tenfold increase, and it's the same population. But along-- So that-- there's an epidemic for you, an epidemic of type 2 diabetes.

   21. RCDr. Rangan Chatterjee8:42

       Mm.

   22. DUDr. David Unwin8:42

       But I'd also seen an epidemic of obesity. Really just astonishing. So back-- we're going back now to twenty twelve, and I, I'm aware of all these epidemics of poor-- lots of chronic ill health. And so how, how, how was I doing? The answer was poorly.

   23. RCDr. Rangan Chatterjee9:02

       Mm-hmm.

   24. DUDr. David Unwin9:02

       So... And I had a sort of feeling. It felt depressing, all the prescribing. Don't know how you felt about that. But I was... You know, you, you add one drug, and then people deteriorate, and you add another drug, and it feels sort of wrong somewhere. Also, they didn't look well. So nobody came in like they were amazingly well, and that's how we come to the first very formidable woman because, um, part of the payment in general practice was to be sure that your patients are taking metformin for their type 2 diabetes. Metformin, I mean, it, it's the baseline treatment for type 2 diabetes. And I had a lady, we knew she wasn't cashing in her prescriptions for months. She was somebody I'd known for years. And so I, I wrote to her to say, "Please, can we, can we have a chat? Because I'm a bit worried about your, your type 2 diabetes." Nothing prepared me, uh, for that woman marching in, um, because she'd, she'd actually got her diabetes into drug free remission, so she wasn't taking any medication. She was a woman who'd had diabetes for a decade. And when we did the blood test, her blood sugars were normal. So I didn't know that could even be done after years of medication.

   25. RCDr. Rangan Chatterjee10:31

       And this was in twenty twelve?

   26. DUDr. David Unwin10:33

       This was twenty-twelve.

   27. RCDr. Rangan Chatterjee10:34

       Wow!

   28. DUDr. David Unwin10:34

       Towards the end of twenty twelve, and she marched in. But the point was, she was angry with me, and she felt I had let her down. And she said-- she explained, really, she said, "I never told you, but the metformin you'd been giving me, uh, gave me diarrhea. But that was a bit embarrassing to mention, so I didn't. I carried on trying to take it. Um, and if only you had told me that it wasn't just sugar I should be avoiding, but the starchy carbohydrates that break down into sugar, I could have had better health years ago, 'cause I had to find out about bread and rice and potatoes-

   29. RCDr. Rangan Chatterjee11:17

       Mm

   30. DUDr. David Unwin11:17

       ... as sugar all by myself. And you're my doctor, but you never mentioned that once, and I, I wonder why you didn't. Surely, Doctor, I mean, this is schoolboy physiology. You know, bread, you should know, uh, from O-level biology that bread is starch, and starch is sugar molecules holding hands. So, you know, I'm even wondering whether you're medically qualified. How could you not have mentioned this in ten years?"
4. 12:58 – 17:45

   Support, behavior change, and a late-career reinvention

   1. DUDr. David Unwin12:58

      Lots of pivotal moments, and there was another one. The other formidable woman is my wife, Jen. She's a, a clinical health psychologist, and her, her expertise is, um, behavior change and the use of hope in chronic disease.

   2. RCDr. Rangan Chatterjee13:15

      Wow.

   3. DUDr. David Unwin13:16

      So that's really relevant.

   4. RCDr. Rangan Chatterjee13:17

      Mm-hmm.

   5. DUDr. David Unwin13:17

      And, uh, she read a book, which was Beat the Diet Trap by Dr. Briffa. Perhaps you remember Dr. Briffa.

   6. RCDr. Rangan Chatterjee13:26

      John Briffa, I do.

   7. DUDr. David Unwin13:27

      John Briffa. And he was talking about, uh, diet, insulin resistance in this book, and she kept reading it out to me. "David, you have to listen to this. You've got to," and I was a bit resistant to that as well, 'cause it's-- I was too tired. You know, why is she going on at me like this? But she-

   8. RCDr. Rangan Chatterjee13:46

      It's a vicious-

   9. DUDr. David Unwin13:47

      Yeah

   10. RCDr. Rangan Chatterjee13:47

       ... it's a vicious cycle, isn't it?

   11. DUDr. David Unwin13:48

       It is.

   12. RCDr. Rangan Chatterjee13:48

       You, you're feeling frustrated at work.

   13. DUDr. David Unwin13:50

       Yes.

   14. RCDr. Rangan Chatterjee13:51

       You know deep in your heart that you're not helping as many patients as you thought you were gonna help-

   15. DUDr. David Unwin13:55

       Yes

   16. RCDr. Rangan Chatterjee13:55

       ... when you were at medical school. There's this sort of evidence coming in front of you that there is a better way to do it, but you're, you're probably too knackered to act on it.

   17. DUDr. David Unwin14:05

       I was.

   18. RCDr. Rangan Chatterjee14:05

       Plus, you've been doing it that way for thirty years.

   19. DUDr. David Unwin14:07

       Yes. Well, my expertise lay in using medication, um, and I was really tired. I was really tired, and I was actually thinking of retiring anyway. I was thinking of going probably when I was fifty-five. And many GPs do go when they're fifty-five now. So I'm, I'm now, I think I'm the oldest practicing GP maybe in a hundred-mile radius. They've all gone because they get fed up and tired. I was really tired. I wasn't actually well.

   20. RCDr. Rangan Chatterjee14:37

       Yeah. It's kind of interesting hearing that and putting it in the context of what you do today. You're very, very active on social media.

   21. DUDr. David Unwin14:47

       Yeah.

   22. RCDr. Rangan Chatterjee14:47

       You are constantly on X-

   23. DUDr. David Unwin14:50

       Yeah

   24. RCDr. Rangan Chatterjee14:50

       ... sharing helpful information, showing you what you're able to do with your patients, publishing data. You're being-- you know, you're traveling to different places.

   25. DUDr. David Unwin14:59

       I do.

   26. RCDr. Rangan Chatterjee14:59

       You're starting charities to help people improve their lives.

   27. DUDr. David Unwin15:02

       Yeah, yeah.

   28. RCDr. Rangan Chatterjee15:02

       You're talking at international conferences. So, you know, h- what does that feel like? If you reflect back and we compare the David Unwin of today with the David Unwin of just thirteen years ago-

   29. DUDr. David Unwin15:15

       Yeah

   30. RCDr. Rangan Chatterjee15:15

       ... right? Con- can- contrast that for me.
5. 17:45 – 24:21

   Normalizing chronic ill health—and why diet change can improve many conditions

   1. RCDr. Rangan Chatterjee17:45

      Is this one of the reasons you're so passionate? Because the thing I get from you, David-

   2. DUDr. David Unwin17:50

      Yeah

   3. RCDr. Rangan Chatterjee17:50

      ... and you're very kind and compassionate online, which I've always respected about you.

   4. DUDr. David Unwin17:56

      Mm-hmm.

   5. RCDr. Rangan Chatterjee17:56

      And whenever I see you at a conference, or when we were filming for this new TV show-

   6. DUDr. David Unwin18:01

      Oh, yeah. Yeah

   7. RCDr. Rangan Chatterjee18:01

      ... recently, um, there, there seems to be this really genuine desire to help people. You, you, you-- I, I get the sense that you're really frustrated by how many people don't know the basics-

   8. DUDr. David Unwin18:14

      Yeah

   9. RCDr. Rangan Chatterjee18:14

      ... of good health.

   10. DUDr. David Unwin18:16

       Wow. You've-- yeah. When I look around, what I see in society shocks and appalls me and makes me so sad. It really does. You know, everywhere you go, I see people who could feel better, who could look better. I see young people living half the life they could lead, and that drives me and drives me. I can't rest because I know there's a better way.

   11. RCDr. Rangan Chatterjee18:48

       Mm-hmm.

   12. DUDr. David Unwin18:48

       And every... You know, I see it with every patient. But then again, what about all the many, many people whose lives are deteriorating and they have no hope? And so that, yeah, I just can't let it go. I can't let it go. And it- it's, it's almost difficult to stay sane with it because the magnitude of what's going on in society. And I have a particular thought, and that is, so I remember a time when I was little when most people were, were fit. I didn't know anybody with type 2 diabetes or asthma. I didn't know any children or young people with depression. The world was so different. And I, I think we're beginning to normalize chronic ill health.

   13. RCDr. Rangan Chatterjee19:34

       Yeah.

   14. DUDr. David Unwin19:34

       And the danger of that. So I know it is possible that kids don't have to have-- be overweight or suffer with that. I know it's possible that most people wouldn't have type 2 diabetes because I remember a world before all that. I am the last generation of doctors. When I am gone, will anybody remember that there was a life and that society could le- lead a healthier life without the need for all these drugs? So that drives me because-

   15. RCDr. Rangan Chatterjee20:07

       Mm

   16. DUDr. David Unwin20:07

       ... I know it's possible that all of these chronic diseases of modern life are not genetic. It's not inevitable that I grow up, I get sick, and I have type 2 diabetes and heart attacks like my mother and father. It's not inevitable at all. What we've got is, um, we have a changed environment in the world, which I believe a lot of it is dietary, but there's other things as well, acting on possible genetic triggers.

   17. RCDr. Rangan Chatterjee20:40

       Mm.

   18. DUDr. David Unwin20:40

       But those, those triggers don't have to go off.

   19. RCDr. Rangan Chatterjee20:43

       Yeah.

   20. DUDr. David Unwin20:43

       They don't have to go off. And so that, you're right, it's huge. And the more you... of it you see, unfortunately, the worse you think it is, uh, the harder we all have to try to do something better.

   21. RCDr. Rangan Chatterjee20:57

       Yeah. Uh, I think you made such a key point that we are normalizing poor health.

   22. DUDr. David Unwin21:03

       Yeah.

   23. RCDr. Rangan Chatterjee21:04

       You know, what people accept as normal these days is so far removed from how we can be, and they-

   24. DUDr. David Unwin21:10

       Yeah

   25. RCDr. Rangan Chatterjee21:10

       ... accept that. I mean, we were just chatting in my kitchen before we started recording. I was just sharing with you, I still to this day haven't seen a more powerful intervention with patients, no matter what you come in with, than trying to have a whole food diet exclusively for maybe two to four weeks.

   26. DUDr. David Unwin21:30

       Yeah.

   27. RCDr. Rangan Chatterjee21:31

       If you can do that, and we can talk about what that actually means, it is amazing how many of the things that you thought were separate issues just start to disappear.

   28. DUDr. David Unwin21:41

       Yeah.

   29. RCDr. Rangan Chatterjee21:41

       So I, I got to the point about a decade ago thinking that, well, I actually don't know how many of these symptoms are related to nutrition until I sort their diet out.

   30. DUDr. David Unwin21:51

       Yeah.
6. 24:21 – 32:26

   What Dr. Unwin says to a newly diagnosed patient: choice, tracking, and food swaps

   1. RCDr. Rangan Chatterjee24:21

      But let's start off with people who do have type 2 diabetes.

   2. DUDr. David Unwin24:24

      Yeah.

   3. RCDr. Rangan Chatterjee24:24

      Which is, you know... Do you know the latest stats in the UK? I mean, how common is this now?

   4. DUDr. David Unwin24:30

      It's somewhere, I'd say somewhere between five to ten percent of the population, something like that. But we don't know because I'm finding people all the time who don't even know they have diabetes.

   5. RCDr. Rangan Chatterjee24:39

      Yeah. So they're not showing up on the research.

   6. DUDr. David Unwin24:41

      No.

   7. RCDr. Rangan Chatterjee24:41

      Right.

   8. DUDr. David Unwin24:42

      But it's going up, that's for sure. It, it's going up. So yeah, let's start with what-- Do you want to start with, say, a person that's just been diagnosed or?

   9. RCDr. Rangan Chatterjee24:49

      Yeah, let's-- In fact, maybe the best way for the audience is to just imagine, you know, what would you say to a patient, right?

   10. DUDr. David Unwin24:57

       Perfect.

   11. RCDr. Rangan Chatterjee24:57

       Who-- A patient who's just been diagnosed-

   12. DUDr. David Unwin24:59

       Yes

   13. RCDr. Rangan Chatterjee24:59

       ... with type two diabetes. What do you say to them?

   14. DUDr. David Unwin25:01

       Yeah, I can think of a good example. So yeah, I had a, a guy who, who has given his permission called Dan. He was thirty-nine years old. And, uh, we did a, the hemoglobin A1C, which is the average sugariness of his blood. And if you have the result which is above forty-eight, then that means you've got type two diabetes. So he came into me, and his result was ninety-six, which is sky high. That's really, really high. So what I'm saying to Dan is, "Okay, we've done this blood test, which is the average sugariness of your blood, and it's really, really high. It looks as if your insulin is not working properly. So your insulin is there to get rid of blood sugar, and you're not doing that properly." Um, so the, the point for Dan, uh, right that day is we've got al- you and I have alternatives today. I'd, I'd love to suggest a lifestyle change that could have you with much better health and change all sorts. Or it's lifelong medication. Which would you prefer? And the important thing, I think, is to give the patient the choice so that it becomes a collaborative approach.

   15. RCDr. Rangan Chatterjee26:23

       Mm-hmm.

   16. DUDr. David Unwin26:23

       And, um, so Dan, uh, was interested in, in avoiding lifelong medication because he thought, "Well, I'm only thirty-nine, so I'd quite like not to be on, on drugs." And then we're talking about, okay, so if your problem is a high blood sugar, what are you eating that puts your blood sugar up? It's as simple as that. What are you eating? Because a high blood sugar for most people is what they've eaten in the few hours before. So we have to acknowledge that stress can put up blood sugar-

   17. RCDr. Rangan Chatterjee26:55

       Yeah

   18. DUDr. David Unwin26:55

       ... and, um-

   19. RCDr. Rangan Chatterjee26:57

       Sleep deprivation

   20. DUDr. David Unwin26:58

       ... illnesses.

   21. RCDr. Rangan Chatterjee26:59

       Yeah.

   22. DUDr. David Unwin26:59

       All various things. But really, in clinical practice, ninety-five percent of the people you see with a high blood sugar have eaten something that put it up. And I broke the rules for Dan. I actually gave him a continuous glucose monitor to say, "Well, why don't you find out?"

   23. RCDr. Rangan Chatterjee27:14

       Hmm.

   24. DUDr. David Unwin27:15

       You need to know what you're eating that puts up your blood sugar. This is years ago. I did this five years ago. You need to know what puts up your blood sugar and eat something else. And he discovered it in-- for him, it was bread and breakfast cereals were really spiking his blood glucose. And then I'm, I'm teaching people about a nutrient-dense diet. So I want you to get your nutrients of the macros and the, and the, and the micros, you know? Uh-

   25. RCDr. Rangan Chatterjee27:42

       Well, what-- For people who don't know what macros and micros mean.

   26. DUDr. David Unwin27:45

       So the macros, you've got, you've got three macros. So that is carbohydrate, which is a problem for me, uh, somebody with type two diabetes, because carbohydrates, uh, digest down into sugar. You've got fats, and then you've got protein. So I was-- I'd be talking about increasing the protein in Dan's diet, avoiding the carbohydrates and whatever you think healthy fats. But for me, that would be butter.

   27. RCDr. Rangan Chatterjee28:14

       Mm-hmm.

   28. DUDr. David Unwin28:15

       And he'd be having, um, dairy, full fat, um, yogurt, that kind of thing, and loads of green veg. Then the micros are vitamins. So for that patient, it's do you know what's putting your blood sugar up? Yes or no. If you do know, then could you eat differently? Could you base your meal on maybe protein and add in loads of green veg? If you were gonna have, I don't know, steak and chips, do you have to have the chips? Could you not have lots of green veg? And that's what, uh, that's what Dan did. The idea of trying to work out what is putting your blood sugar up. And that brings me just a little segue into the-

   29. RCDr. Rangan Chatterjee28:56

       Mm

   30. DUDr. David Unwin28:56

       ... teaspoon of sugar equivalence.
7. 32:26 – 36:49

   Teaspoons-of-sugar equivalents: making carbs visible and contextualizing “healthy” foods

   1. DUDr. David Unwin32:26

      So this turned out, this teaspoon of sugar idea that I had, was valid. So I went to the experts on glycemic load, one, a famous one, Dr. Jeffrey Leavey, and we published a paper together-

   2. RCDr. Rangan Chatterjee32:38

      Mm.

   3. DUDr. David Unwin32:40

      -looking at many commonly eaten foods and doing a teaspoon of sugar equivalent. So a big baked potato is about nine teaspoons of sugar. Uh, a portion of chips is eight or nine. A banana is five or six teaspoons of sugar.

   4. RCDr. Rangan Chatterjee32:56

      Can I just pause you there, David?

   5. DUDr. David Unwin32:57

      Yes.

   6. RCDr. Rangan Chatterjee32:57

      Because I think there's a couple of things to tease out here. So first of all, many people believe rice, potatoes-

   7. DUDr. David Unwin33:10

      Yeah

   8. RCDr. Rangan Chatterjee33:11

      ... bananas, for example, are healthy foods.

   9. DUDr. David Unwin33:13

      Yes.

   10. RCDr. Rangan Chatterjee33:13

       Now, of course, what is healthy depends on the context.

   11. DUDr. David Unwin33:16

       It does, yeah.

   12. RCDr. Rangan Chatterjee33:16

       Right? So, and, and also of course, sh- table sugar itself, you know, is not particularly good for your teeth, right?

   13. DUDr. David Unwin33:26

       Yes. Yeah.

   14. RCDr. Rangan Chatterjee33:26

       If consumed in excess.

   15. DUDr. David Unwin33:27

       Fair point. Yeah.

   16. RCDr. Rangan Chatterjee33:28

       Um, whereas maybe white rice, you could argue it... W- I guess what I'm trying to get to, you're talking about, I think, the impact of that food on your blood sugar levels.

   17. DUDr. David Unwin33:40

       Exactly so. Or because if you have type 2 diabetes, your insulin isn't working properly, you're insulin resistant, so that you can't deal with extra glucose, the sugar we're talking about.

   18. RCDr. Rangan Chatterjee33:57

       Okay. So if you were metabolically healthy-

   19. DUDr. David Unwin34:01

       Yeah

   20. RCDr. Rangan Chatterjee34:01

       ... so, you know, not only do you not have type 2 diabetes, but you have no insulin resistance-

   21. DUDr. David Unwin34:07

       Yes

   22. RCDr. Rangan Chatterjee34:07

       ... which is getting rarer and rarer these days.

   23. DUDr. David Unwin34:09

       Yeah.

   24. RCDr. Rangan Chatterjee34:10

       Do you think that these kind of foods are also problematic in that category of people, or is it more in the ones as they get closer and closer to type 2 diabetes?

   25. DUDr. David Unwin34:22

       Great point. I think if, if we took children and fed them perhaps like our great-grandparents were-

   26. RCDr. Rangan Chatterjee34:29

       Yeah

   27. DUDr. David Unwin34:29

       ... fed from a child, they would be metabolically healthy, as they used to be.

   28. RCDr. Rangan Chatterjee34:34

       Yeah.

   29. DUDr. David Unwin34:35

       As they used to be. And for them, uh, bread was all right-

   30. RCDr. Rangan Chatterjee34:39

       Yeah
8. 36:49 – 46:14

   Informed consent in chronic disease care: why medication decisions need real discussion

   1. RCDr. Rangan Chatterjee36:49

      So with that patient, you helped to educate them on the sugar equivalent-

   2. DUDr. David Unwin36:55

      Yes

   3. RCDr. Rangan Chatterjee36:56

      ... of bread, potatoes, and rice.

   4. DUDr. David Unwin36:58

      Yes.

   5. RCDr. Rangan Chatterjee36:58

      And you said to him, "Listen, you now, you have type 2 diabetes currently."

   6. DUDr. David Unwin37:04

      Yeah.

   7. RCDr. Rangan Chatterjee37:04

      "You are very insulin resistant, so insulin is not working as well as we would want it to work."

   8. DUDr. David Unwin37:08

      Yes.

   9. RCDr. Rangan Chatterjee37:08

      "Therefore, I can offer you one of two options."

   10. DUDr. David Unwin37:12

       Yeah.

   11. RCDr. Rangan Chatterjee37:12

       "Option one is I can put you on medication-

   12. DUDr. David Unwin37:14

       Yeah

   13. RCDr. Rangan Chatterjee37:14

       ... which I can, I can do for you, but you have to take it for life."

   14. DUDr. David Unwin37:17

       Yeah.

   15. RCDr. Rangan Chatterjee37:18

       "Or I can help you change your lifestyle."

   16. DUDr. David Unwin37:20

       Yes.

   17. RCDr. Rangan Chatterjee37:20

       "Which one would you like?"

   18. DUDr. David Unwin37:21

       Exactly.

   19. RCDr. Rangan Chatterjee37:22

       Now, what's really interesting to me, that is what I call proper informed consent.

   20. DUDr. David Unwin37:26

       Yes.

   21. RCDr. Rangan Chatterjee37:27

       Right? You're giving the options, whereas unfortunately, I mean, uh, uh, there's a course that me and Dr. Panja teach called, uh, Prescribing Lifestyle Medicine, and we try and teach healthcare professionals the, the basics of lifestyle and how you can actually use the lifestyle interventions for a variety of different conditions, including type 2 diabetes, to help them. And when we used to do it live before COVID, so we used to do it in person, at the end of the day, we would do two, um, role play consultations on stage.

   22. DUDr. David Unwin38:00

       Mm-hmm. Mm-hmm.

   23. RCDr. Rangan Chatterjee38:01

       And I w- I, I'd love to get your perspective on this. And I would say to the, to the audience of healthcare professionals that there are kind of two ways a consultation can go. The patient comes in, they maybe just done their blood test, and you discover that they've got type 2 diabetes. Patient comes in, you have 10 minutes with them. If you say, "Hey, Mr. Jones, um, you've got a condition called type 2 diabetes, but there's nothing to worry about. We've got loads of medication that can sort this out. Okay? So today I'm gonna start you on metformin. If over the next couple of years your blood sugar keeps going up, as it probably will, I've got more medications that I can put on-

   24. DUDr. David Unwin38:37

       Yeah

   25. RCDr. Rangan Chatterjee38:37

       ... you on. And then in a few years, if we really need to, you can start injecting insulin. But don't worry, we've got that." So you, you tell them that, give them a prescription, and as they leave the door, as they're walking out, you say, "Oh, and if you can change your diet and move a little bit more, that would be helpful."

   26. DUDr. David Unwin38:53

       Mm-hmm.

   27. RCDr. Rangan Chatterjee38:54

       Contrast that with the same consultation, same patient, where they come in and you say, "Hey, Mr. Jones, listen, there's a few things that have come up in your blood test today."

   28. DUDr. David Unwin39:02

       Yeah.

   29. RCDr. Rangan Chatterjee39:03

       "Uh, one of the things is that your blood sugar is elevated. Now, it's elevated to a point that we would call this type 2 diabetes, but I'm not sure if you're aware, there will be things going on in your life for many years now which have caused that. Would you like me to help you figure out-

   30. DUDr. David Unwin39:19

       Mm-hmm
9. 46:14 – 51:18

   Low-carb in practice: what to eat, transition symptoms, and the ‘dual-fuel’ concept

   1. RCDr. Rangan Chatterjee46:14

      No, no, it's fine. But when you say, you know, cut back on bread-

   2. DUDr. David Unwin46:18

      Yes

   3. RCDr. Rangan Chatterjee46:18

      ... and, uh, pasta and potatoes and rice-

   4. DUDr. David Unwin46:21

      They always wonder what shall I eat?

   5. RCDr. Rangan Chatterjee46:22

      Yeah.

   6. DUDr. David Unwin46:22

      Oh my God.

   7. RCDr. Rangan Chatterjee46:23

      So there will be listeners now going, "Well-

   8. DUDr. David Unwin46:25

      Well, what's left?

   9. RCDr. Rangan Chatterjee46:26

      "Well, I'm gonna be hungry all the time, aren't I?"

   10. DUDr. David Unwin46:27

       Yeah.

   11. RCDr. Rangan Chatterjee46:28

       So what have you found in your experience?

   12. DUDr. David Unwin46:31

       Right. So I think one of the main things is more protein. A lot of older people don't have enough protein because you're trying, as you get older, to maintain muscle mass. So it makes sense to eat more protein. So I'm basing meals on fish, on chicken, on eggs, on red meat, and then you're adding loads of green veg and some butter if you want, or some olive oil or full fat mayonnaise, that kind of thing. And there are loads and loads of recipe books, apps, everything online. So I-- my family-- So I've been low carb, my wife, my eight grandchildren, my three children, our entire extended family are low carb, and we do Christmas and birthdays by, uh, learning how to cook low carb. You can actually, you can use almond flour instead of wheat flour. So that doesn't have as much carbohydrate in, hardly any. But you begin with having lots more protein, reducing the carbohydrate. 'Cause how much you reduce the carbohydrate by varies depending on how sug- sugary you are. Not everybody has to cut it out altogether. Some just reduce it. Some people are having, when they actually admit to how many chocolate bars, how many, uh, sugary drinks they have, how many crisps, snacks through-

   13. RCDr. Rangan Chatterjee48:01

       Mm

   14. DUDr. David Unwin48:01

       ... the day, they're having a lot of carbohydrate. So I just would encourage people to have less carbohydrate, and then how do you feel? How's it going?

   15. RCDr. Rangan Chatterjee48:10

       Is there a transitional period where people, of course, are used to having the rice and the pasta-

   16. DUDr. David Unwin48:16

       Yes

   17. RCDr. Rangan Chatterjee48:16

       ... and the potatoes, right? So when you start to cut back on that, what do they complain of? Is it-

   18. DUDr. David Unwin48:20

       Yeah

   19. RCDr. Rangan Chatterjee48:20

       ... "I don't know why I don't feel full, Dr. Unwin. I feel like I need something..." What, you know, what, what are some of the common issues-

   20. DUDr. David Unwin48:25

       Yeah

   21. RCDr. Rangan Chatterjee48:25

       ... that come up?

   22. DUDr. David Unwin48:26

       Right. Well, actually, most people who go low carb would say they feel a lot less hungry. Most of my patients tell you they're surprised not to be hungry. What some people, um, get is what is called keto flu, that's a bit of a strong word, where they don't feel as good for a few days, and that is because it takes up to a week for the enzyme balance in your liver to change. Your body has to think, "Oh, so there's-

   23. RCDr. Rangan Chatterjee48:55

       Mm

   24. DUDr. David Unwin48:55

       ... I'm gonna start burning fat." I think a point I'd like to make now is, is this idea we are a dual fuel-

   25. RCDr. Rangan Chatterjee49:02

       Yeah

   26. DUDr. David Unwin49:02

       ... engine. So we are, gosh, so clever, our design. We can burn sugar or we can burn fat. But what happens is, so if you, if you have a high carbohydrate diet, then your levels of insulin are high, and insulin prevents you from being able to burn your own fat. This is the basis-

   27. RCDr. Rangan Chatterjee49:26

       Yeah

   28. DUDr. David Unwin49:26

       ... of the keto diet. So the keto diet is people who are very low carb, under 50 grams of carbs a day. And because they're very low carb, their levels of insulin are very low, and then suddenly they're able to burn fat. And they- fat is turned into ketones as the fuel, that's why it's called a keto diet. And the keto diet is a type of low-carb diet, which is becoming incredibly popular across the world. Um, and that shows very well this transition from relying upon carbohydrates to burn, which is what I did until I was 55 years old, to a greater emphasis on burning fat, which now I am actually, um, I've been on the keto diet for about eight years and I burn fat.

   29. RCDr. Rangan Chatterjee50:13

       Now, some people listening will have heard negative stories about the keto diets.

   30. DUDr. David Unwin50:19

       Yes.
10. 51:18 – 58:43

    Evolution, ‘perpetual autumn,’ and real-world outcomes data from his NHS practice

    1. RCDr. Rangan Chatterjee51:18

       Do we know, or do you know how many of our ancestors ate in a way that would be consistent with a ketogenic diet?

    2. DUDr. David Unwin51:28

       Well, I do actually. Um, the, just a little aside. So years, years ago, I was giving a, a speech in, uh, in Tel Aviv. And the dinner afterwards, I happened to sit next to, uh, Dr. Miki Ben-Dor, who is a worldwide expert on what cavemen ate. And he spent his life scraping the tartar off caveman's teeth, and also looking at the is- the bone isotopes.

    3. RCDr. Rangan Chatterjee51:56

       Mm.

    4. DUDr. David Unwin51:57

       So we do know what they ate. And his conclusion, and he's published this, is that, uh, our ancestors were a- eating about 70% meat, and the isotope scans were about the same as a wolf. So our ancestors were, ate like wolves in terms of the amount of meat in the diet, and they were surprisingly healthy on that.

    5. RCDr. Rangan Chatterjee52:23

       'Cause that's the thing that what people will say. They go, "Okay, well, maybe our ancestors ate that way because they had to."

    6. DUDr. David Unwin52:30

       Yeah.

    7. RCDr. Rangan Chatterjee52:30

       "But do we know what that did to their coronary arteries?"

    8. DUDr. David Unwin52:34

       No.

    9. RCDr. Rangan Chatterjee52:34

       "Do we know what that did to their longevity?" That's, that's the pushback that sometimes comes.

    10. DUDr. David Unwin52:38

        Yeah, it is. And so just to develop that a little bit, I asked him actually, I said, "Well, didn't they all die when they were about 30?" And, uh, the error in that is that the, if you do the arithmetical mean, it is about 35.

    11. RCDr. Rangan Chatterjee52:53

        Yeah, the average.

    12. DUDr. David Unwin52:54

        The average. But the average is skewed very badly by infections killing children.

    13. RCDr. Rangan Chatterjee53:01

        Yeah.

    14. DUDr. David Unwin53:02

        So if, as a cave, uh, as a caveman, you lived to be 12 to 15, you'd probably live to be 60 or even 70. If you once got over the childhood infections-

    15. RCDr. Rangan Chatterjee53:14

        Yeah

    16. DUDr. David Unwin53:15

        ... they lived surprisingly long lives. Um, and just going back to the distribution of what they, what people ate or what the wolves ate. What, what wolves and people ate was more carbohydrate in the autumn if they could-

    17. RCDr. Rangan Chatterjee53:33

        Mm-hmm

    18. DUDr. David Unwin53:34

        ... because they needed to put on fat. So insulin is, is fat fertilizer. So it makes you fatter, gives you a bigger tummy.

    19. RCDr. Rangan Chatterjee53:42

        Mm. Yeah.

    20. DUDr. David Unwin53:42

        But that actually is adaptive because if you're going to get through the British winter, you've gotta get fat in the autumn. So you've gotta scoff those berries down. So wolves and humans were eating all the carbohydrate, all the berries they could in autumn to survive the winter. And I, I think we should now see we're, we're almost eating in a perpetual autumn now.

    21. RCDr. Rangan Chatterjee54:06

        Yeah.

    22. DUDr. David Unwin54:06

        You can go to the supermarket and buy whatever you like, and have the bananas and the orange juice and the, uh, the waffles and everything. We're eating, uh, in a perpetual autumn for a winter that never comes.

    23. RCDr. Rangan Chatterjee54:17

        Yeah. Not only does the winter not come, certainly in this country, Christmas comes in the winter. So actually it's the opposite-

    24. DUDr. David Unwin54:25

        Yes

    25. RCDr. Rangan Chatterjee54:26

        ... isn't it? Whereby we probably get rather gluttonous and overeat-

    26. DUDr. David Unwin54:30

        Yes

    27. RCDr. Rangan Chatterjee54:31

        ... in that time where-

    28. DUDr. David Unwin54:32

        In winter. We'd be fasting

    29. RCDr. Rangan Chatterjee54:33

        ... we'd be fasting. Exactly.

    30. DUDr. David Unwin54:34

        Yeah. We, we would. And you know, I- It's always, isn't it? It's Father's Day, it's Mother's Day, it's Halloween, it's your holiday. It's, you know... We're eating so much more junk food, so much more sugar than we did when I was little.
11. 58:43 – 1:01:51

    Earlier is better: pre-diabetes reversal rates and why delay reduces remission odds

    1. DUDr. David Unwin58:43

       South America. The-- It has been replicated all over the world. But just going into the, the detail first in my own practice, it's more exciting even than that because if we look at people with pre-diabetes, so we, we've audited that, so the people who have pre-diabetes, of those that go low-carb, ninety-three percent achieve a normal blood sugar.

    2. RCDr. Rangan Chatterjee59:09

       So they're-

    3. DUDr. David Unwin59:10

       Yeah

    4. RCDr. Rangan Chatterjee59:10

       ... so, so they've gone out of the pre-diabetic range-

    5. DUDr. David Unwin59:13

       Yes, into normal

    6. RCDr. Rangan Chatterjee59:13

       ... and gone back into-

    7. DUDr. David Unwin59:14

       Completely normal

    8. RCDr. Rangan Chatterjee59:14

       ... in a way that becomes normal.

    9. DUDr. David Unwin59:16

       That's right. So it seems as if this is ev-ev-- what we were saying earlier about it's not chronological age that matters, it's metabolic age because... So the people with pre-diabetes, they have better metabolic health than me.

    10. RCDr. Rangan Chatterjee59:30

        Mm.

    11. DUDr. David Unwin59:30

        Then if you offer low-carb to people as they are diagnosed with diabetes, like the guy we were talking about-

    12. RCDr. Rangan Chatterjee59:38

        Mm

    13. DUDr. David Unwin59:38

        ... the thirty-nine-year-old, seventy-three percent of those will get drug-free remission.

    14. RCDr. Rangan Chatterjee59:44

        Mm.

    15. DUDr. David Unwin59:44

        Seventy-three percent get drug-free remission. If I wait five years, and you've had diabetes for five years, only fifty percent of you will get remission.

    16. RCDr. Rangan Chatterjee59:52

        Mm-hmm.

    17. DUDr. David Unwin59:53

        So it seems to me like the longer we wait and the more serious or the, the worst is your metabolic health, the less likely you are to get remission. And that's the pressure to think, well, you know, a stitch in time, why wouldn't you do it earlier? Why wait?

    18. RCDr. Rangan Chatterjee1:00:08

        Yeah.

    19. DUDr. David Unwin1:00:09

        Why wait till you're somebody like me who actually has type 2 diabetes? Wouldn't it be better if I'd done something earlier?

    20. RCDr. Rangan Chatterjee1:00:17

        There's a couple of things I wanna just sort of, um, make sure we've covered.

    21. DUDr. David Unwin1:00:21

        Yes.

    22. RCDr. Rangan Chatterjee1:00:23

        Mainly because I understand how confusing diets are these days for people-

    23. DUDr. David Unwin1:00:27

        Yes

    24. RCDr. Rangan Chatterjee1:00:28

        ... and how divisive and controversial things often get. You know, people get quite stuck in their camps and start to throw metaphorical stones at people in other camps, right?

    25. DUDr. David Unwin1:00:39

        Yes. Yes.

    26. RCDr. Rangan Chatterjee1:00:39

        So you're saying- And please correct me if I've misinterpreted any of this. You're saying that you used to have type 2 diabetes-

    27. DUDr. David Unwin1:00:48

        Yes

    28. RCDr. Rangan Chatterjee1:00:48

        ... and now your type 2 diabetes is in remission?

    29. DUDr. David Unwin1:00:51

        Yes.

    30. RCDr. Rangan Chatterjee1:00:52

        You were unable to previously do much for your patients with type 2 diabetes, apart from just keep them on medication, and things would progressively just get worse.
12. 1:01:51 – 1:06:57

    Pushback, safety concerns, and the blood-sugar damage model (kidneys, eyes, nerves)

    1. RCDr. Rangan Chatterjee1:01:51

       I don't want to talk about individuals necessarily, but even when you have the data, have you had pushback from people saying that this is ridiculous?

    2. DUDr. David Unwin1:02:00

       Oh, yes. Pa- well, particularly in the early days, and some of it was understandable. The worst times were sort of 2013 to 2015. So I actually got hate mail, I got heckled in, in, uh, doctor's meetings, I was shouted at. And some of it was understandable because the, the point that worried other healthcare professionals was that if I'm saying it's okay maybe to, you know, have more protein, what's that doing to your kidney function? If I'm saying it's okay to have full-fat yogurt and full-fat milk and use double cream, what's happening to the lipid profiles? And I think that was another reason I kept such careful data. And what we saw, in fact, what we published in our most recent paper, which is BMJ Nutrition 2023, was that every single marker of cardiovascular risk has improved for my patients.

    3. RCDr. Rangan Chatterjee1:03:02

       Wow.

    4. DUDr. David Unwin1:03:03

       The cholesterol, the HDL, the triglyceride, the ratios, their blood pressure, all of those things, every single marker. And so I think people are less worried now by my approach because I've also gone ahead and said, "Fair point. Let's have a look at cardiovascular risk." And then again, let's have a look at high protein. What has that done?

    5. RCDr. Rangan Chatterjee1:03:26

       To the kidneys.

    6. DUDr. David Unwin1:03:27

       Yeah. So I, I paired with Professor Wong, who's a local, uh... He's a professor of nephrology. And we looked at my patients, and actually their renal function, their kidney function improved.

    7. RCDr. Rangan Chatterjee1:03:40

       If, if you really take a step back from that, it seems slightly illogical that metabolism, which is such a fundamental part of-

    8. DUDr. David Unwin1:03:52

       Yeah

    9. RCDr. Rangan Chatterjee1:03:52

       ... the human experience and how we experience health-

    10. DUDr. David Unwin1:03:55

        Yeah

    11. RCDr. Rangan Chatterjee1:03:55

        ... if that's getting better, you kind of think other things are likely to be getting better-

    12. DUDr. David Unwin1:03:59

        Yeah

    13. RCDr. Rangan Chatterjee1:03:59

        ... as well.

    14. DUDr. David Unwin1:04:00

        Well, we-- That's what we looked at actually with Professor Wong when we were looking at kidney function. What is it in diabetes that causes kidney function to deteriorate? And the common denominator of so many things is blood sugar. And, and a, a single fact that really is burnt into my mind is that, um, if you have high-- a spike of blood sugar, you damage the non-stick lining of your arteries. The glycocalyx is damaged within six hours. And so for me, the common denominator is that high blood sugars do damage, and they do damage to the microcirculation, that's your eyes and your kidneys, and they do damage to the macro, that's your, uh, your big arteries. Blood su-- Uh, high blood sugar actually is aging you. It's aging you.

    15. RCDr. Rangan Chatterjee1:04:53

        Talking about the, the, the sort of interconnectedness of the body again for a moment, cataracts are on the rise-

    16. DUDr. David Unwin1:05:00

        Yes

    17. RCDr. Rangan Chatterjee1:05:00

        ... aren't they?

    18. DUDr. David Unwin1:05:01

        Yeah.

    19. RCDr. Rangan Chatterjee1:05:01

        And again, catara- well, that's my eyes. What's that got to do with-

    20. DUDr. David Unwin1:05:03

        Yeah

    21. RCDr. Rangan Chatterjee1:05:03

        ... my blood sugar, you know?

    22. DUDr. David Unwin1:05:05

        And actually, on that fact, I, um... Uh, an ophthalmologist contacted me from Cumbria, and she said, "A weird thing's happened in our area. People's retina has started improving." People she'd been screening their retinas every year, and she, in the end, she said, "What's going on?" 'Cause they also were losing weight. Um, they'd gone low carb.

    23. RCDr. Rangan Chatterjee1:05:28

        Mm.

    24. DUDr. David Unwin1:05:28

        And the retina-- So the retina becomes damaged with a high blood sugar. It's a very vascular sensitive organ. And this was yet more proof really. Uh, this, this, this lady contacted me saying-

    25. RCDr. Rangan Chatterjee1:05:42

        Yeah

    26. DUDr. David Unwin1:05:42

        ... "It's so weird. I've never seen retinas improve." Or peripheral neuropathy I've seen improve as well.

    27. RCDr. Rangan Chatterjee1:05:48

        Yeah. Another way I sort of would often talk to patients about this is to help them understand that your body will do whatever it can to keep your blood sugar in a very tightly controlled range.

    28. DUDr. David Unwin1:06:02

        Yes.

    29. RCDr. Rangan Chatterjee1:06:02

        Okay? It's, it's-

    30. DUDr. David Unwin1:06:03

        That's a great point
13. 1:06:57 – 1:15:43

    His personal before-and-after: 300g carbs, constant snacking, and now two meals a day

    1. DUDr. David Unwin1:06:57

       To every organ. And, and just going back to the diet again, what I had missed. So I would start the day with a big glass of fresh orange.

    2. RCDr. Rangan Chatterjee1:07:06

       This is when you were-

    3. DUDr. David Unwin1:07:07

       Yeah, yeah

    4. RCDr. Rangan Chatterjee1:07:07

       ... ta- you know

    5. DUDr. David Unwin1:07:08

       So if we just go back to how the m- the assault on my body started first thing with, you know, we had fresh orange by the liter in the fridge 'cause I thought that was healthy.

    6. RCDr. Rangan Chatterjee1:07:18

       Yeah.

    7. DUDr. David Unwin1:07:18

       So that was... Then I'm thinking, right, muesli, that's healthy, so I had that. But I had loads of extra sultanas in m- because that just made it so tasty-

    8. RCDr. Rangan Chatterjee1:07:27

       It was delicious [laughs]

    9. DUDr. David Unwin1:07:27

       ... and a banana. So that's sugar with my sugar. Then I get to work, and I'm having biscuits with my morning coffee 'cause people do, and then at lunchtime it's sandwiches, that's more sugar, and then you might have a packet of crisps with your sandwiches, that's more sugar you just ate. And, um, then mid-afternoon I'd have a bar of chocolate and more biscuits and go home to some... I used to love pasta. So my life was sugar with my sugar with my sugar. My metabolism didn't stand a chance.

    10. RCDr. Rangan Chatterjee1:08:02

        How many grams of carbs a day do you think you used to have-

    11. DUDr. David Unwin1:08:06

        I, yeah

    12. RCDr. Rangan Chatterjee1:08:06

        ... in your heyday?

    13. DUDr. David Unwin1:08:07

        I know. I think it was about 300.

    14. RCDr. Rangan Chatterjee1:08:10

        So you used to have-

    15. DUDr. David Unwin1:08:11

        Way huge. 300-

    16. RCDr. Rangan Chatterjee1:08:12

        300 grams

    17. DUDr. David Unwin1:08:13

        ... easily.

    18. RCDr. Rangan Chatterjee1:08:13

        And were you relatively sedentary then as well?

    19. DUDr. David Unwin1:08:15

        Yeah, because I didn't run, and you sit-

    20. RCDr. Rangan Chatterjee1:08:18

        A busy GP.

    21. DUDr. David Unwin1:08:19

        Yeah. So you sit behind your desk all day long. You press the buzzer for people to come in, so you don't get up off your bum. And also, people knew I loved biscuits, so the patients-

    22. RCDr. Rangan Chatterjee1:08:31

        [laughs]

    23. DUDr. David Unwin1:08:31

        ... used to hand over 'cause they're fond of me, so they would... Oh, I, I don't know how. My drawers were full of biscuits-

    24. RCDr. Rangan Chatterjee1:08:38

        [laughs]

    25. DUDr. David Unwin1:08:38

        ... that I ate, and they, they even knew the biscuits I liked. So I'm scoffing biscuits all day-

    26. RCDr. Rangan Chatterjee1:08:43

        You s- you stood no chance, did you? [laughs]

    27. DUDr. David Unwin1:08:44

        It's amazing I was conscious. It's amazing. So yeah, I used to have-- I said before, I used to have to have a little sleep on my own doctor's couch at lunchtime after lunch because I was so drowsy after lunch, and then I'd have to wake up. That's when I would wake up with a bar of chocolate and a strong coffee to get me through the afternoon.

    28. RCDr. Rangan Chatterjee1:09:05

        So you used to have about 300 grams of-

    29. DUDr. David Unwin1:09:07

        Easily

    30. RCDr. Rangan Chatterjee1:09:08

        ... carbs a day.
14. 1:15:43 – 1:18:21

    Multiple paths to remission—and the physiology of liver fat, insulin resistance, and collapse

    1. DUDr. David Unwin1:15:43

       We should mention that, yes. There are-

    2. RCDr. Rangan Chatterjee1:15:45

       One of the ways, the way that you've used yourself and you-

    3. DUDr. David Unwin1:15:48

       Yeah

    4. RCDr. Rangan Chatterjee1:15:48

       ... recommend to many of your patients is the low-carb approach, but it's not the only way, is it?

    5. DUDr. David Unwin1:15:52

       No, not at all. And-

    6. RCDr. Rangan Chatterjee1:15:54

       I think it's an important point.

    7. DUDr. David Unwin1:15:55

       Yeah, it's very... You know, so I mean, we must mention the work of, of Professor Roy Taylor-

    8. RCDr. Rangan Chatterjee1:16:00

       Roy Taylor, yeah

    9. DUDr. David Unwin1:16:00

       ... who's a friend of mine, and he was a senior author on my last paper.

    10. RCDr. Rangan Chatterjee1:16:03

        And his work's great.

    11. DUDr. David Unwin1:16:04

        He-- Yeah, so he, he's, he's doing, he's doing it a different way, which is, uh, just over eight hundred calories a day of the soups. Um, and the, the, you can prescribe those. So he's, he's giving people a low-calorie diet, but actually it is low carb as well, of course. 'Cause it, you know, if it's low calorie, if it's low food, if you're only having eight hundred calories a diet, uh, uh, a day, that has to be low carb. But that's actually on prescription and, and what's interesting is bariatric surgery works really fast as well. Bariatric surgery can have people off insulin.

    12. RCDr. Rangan Chatterjee1:16:44

        But of course, there is a consequence to bariatric surgery, right?

    13. DUDr. David Unwin1:16:47

        Well, there are.

    14. RCDr. Rangan Chatterjee1:16:47

        When you, when you're talking about risk rewards-

    15. DUDr. David Unwin1:16:49

        You can't reverse it. Yeah

    16. RCDr. Rangan Chatterjee1:16:49

        ... or the pros and cons.

    17. DUDr. David Unwin1:16:51

        Yeah. It's major surgery, and there's a mortality involved, so again, sharing with patients, which would you like to do? Um, so yeah, bariatric surgery can't be reversed. And it-- Bariatric surgery, for me, doesn't very well address what your problem actually is. And I think one thing you and I haven't talked about is we're both passionate about what-- why is this person suffering in this way?

    18. RCDr. Rangan Chatterjee1:17:17

        Yeah. Exactly.

    19. DUDr. David Unwin1:17:17

        What's upstream? And, you know, what's upstream of diabetes is like, why did you eat like that?

    20. RCDr. Rangan Chatterjee1:17:26

        Yeah.

    21. DUDr. David Unwin1:17:26

        And one of the reasons that you-- I ate a lot of junk food was I was kind of addicted to it. So, you know, I could have had bariatric surgery, but would that have cured me? Would it have taught me to eat better?

    22. RCDr. Rangan Chatterjee1:17:40

        Mm-hmm.

    23. DUDr. David Unwin1:17:41

        I wouldn't have learned. So the drawback of bariatric surgery is it's, it's technically good, but have you learnt how to care for yourself? Have you learnt how to make it a long-term success? And we know that people who have bariatric surgery, after about two years, a significant number of them are gaining weight again by their, they're blitzing Mars bars or so- that kind of thing, or some of them are drinking.

    24. RCDr. Rangan Chatterjee1:18:09

        Yeah.

    25. DUDr. David Unwin1:18:09

        And that's because bariatric surgery did not deal with their actual problem.

    26. RCDr. Rangan Chatterjee1:18:16

        Yeah.

    27. DUDr. David Unwin1:18:16

        It sort of put them in low-carb jail, and then they'd find a way around that.

15. 1:18:21 – 1:58:26

    Food addiction, ‘no cheat days,’ and sustaining change long term

    1. RCDr. Rangan Chatterjee1:18:21

       Yeah. I wanna talk about food addiction in just a moment-

    2. DUDr. David Unwin1:18:25

       Yes

    3. RCDr. Rangan Chatterjee1:18:25

       ... 'cause I know you've got a lot of thoughts.

    4. DUDr. David Unwin1:18:26

       I have.

    5. RCDr. Rangan Chatterjee1:18:26

       I know your wife, Jan, has done, uh, loads of incredible work in this area.

    6. DUDr. David Unwin1:18:29

       She has. Yeah, yeah.

    7. RCDr. Rangan Chatterjee1:18:30

       Before we move there, David, though, I just wanna make sure we've covered something off, okay? You mentioned, um, your colleague and friend, Professor Roy Taylor, who's-

    8. DUDr. David Unwin1:18:39

       Yes

    9. RCDr. Rangan Chatterjee1:18:39

       ... who's done some game-changing work-

    10. DUDr. David Unwin1:18:40

        He really has. Yes, yeah

    11. RCDr. Rangan Chatterjee1:18:40

        ... on type 2 diabetes, and he's shown, of course, that, you know, one of the central issues is this accumulation of a very small amount of liver fat.

    12. DUDr. David Unwin1:18:49

        Correct.

    13. RCDr. Rangan Chatterjee1:18:49

        And we can accumulate liver fat in a variety of different ways, but let's assume that we've got the liver fat and the pancreatic fat-

    14. DUDr. David Unwin1:18:58

        Yes

    15. RCDr. Rangan Chatterjee1:18:59

        ... causes the type 2 diabetes.

    16. DUDr. David Unwin1:19:01

        Yes.

    17. RCDr. Rangan Chatterjee1:19:02

        My understanding of Roy's work is that any mechanism by which you can get rid of that liver fat is, is, is a very successful way of reversing the type 2 diabetes, or putting it into remission, which is the technically correct term. Although-

    18. DUDr. David Unwin1:19:19

        It is

    19. RCDr. Rangan Chatterjee1:19:19

        ... I, I wanna, I wanna talk about why we use that term, actually, in just a moment. If patients can lose significant amounts of weight, I think Ro- one of Roy's early papers showed that maybe it was 10, 12 kilos of weight loss, I think, that-

    20. DUDr. David Unwin1:19:38

        About 10%, yeah

    21. RCDr. Rangan Chatterjee1:19:39

        ... 10%, that-

    22. DUDr. David Unwin1:19:40

        He would say losing 10% of your body weight is very likely to get you, uh, drug free remission. But you're right, what he, he- his work has shown it's the liver fat-

    23. RCDr. Rangan Chatterjee1:19:51

        Yeah

    24. DUDr. David Unwin1:19:51

        ... has to go. And if I could just explain-

    25. RCDr. Rangan Chatterjee1:19:53

        Please

    26. DUDr. David Unwin1:19:53

        ... for listeners, uh, something about this. So the physiology here, think back to me in my 50s. As I ate the muesli and the bananas and the chocolate bars, what was happening was the excess sugar that you don't need for running around is being pushed inside cells by insulin. That's the work of insulin-

    27. RCDr. Rangan Chatterjee1:20:17

        Mm-hmm

    28. DUDr. David Unwin1:20:17

        ... to protect me from the high blood sugar. So your body's left with no alternative but to turn that excess sugar, which is dangerous, into something that's less dangerous, fat, particularly in the liver. And so, um, Roy Taylor talks about the long, silent scream from the liver, which is the 10 years while I was overeating carbohydrates, and my liver was filling with fat. And it is the fat in the liver is actually causing insulin resistance.

    29. RCDr. Rangan Chatterjee1:20:47

        Yeah.

    30. DUDr. David Unwin1:20:48

        So that then my insulin didn't work as well, and then my body has only got one alternative, and that's to ramp up the supply of insulin. So if my insulin works less well, you need more of it to clear that Mars bar.
16. 1:58:26 – 2:15:46

    Cost, modern food environment, and prevention-focused policy and testing

    1. RCDr. Rangan Chatterjee1:58:26

       You, you mentioned not having much money when growing up.

    2. DUDr. David Unwin1:58:28

       Yes. Yeah.

    3. RCDr. Rangan Chatterjee1:58:29

       And one of the things that people will often say when it comes to eating more whole foods or eating a low-carb diet-

    4. DUDr. David Unwin1:58:35

       Is the cost. Mm

    5. RCDr. Rangan Chatterjee1:58:36

       ... is the cost.

    6. DUDr. David Unwin1:58:36

       It's a great point.

    7. RCDr. Rangan Chatterjee1:58:37

       How have you managed that in your practice?

    8. DUDr. David Unwin1:58:39

       I've learnt a lot from my patients, 'cause we're north of Liverpool, so I'm not, uh... Many of my patients are on benefit.

    9. RCDr. Rangan Chatterjee1:58:46

       Mm-hmm.

    10. DUDr. David Unwin1:58:47

        So that is, uh, it's a great, it's a great question.

    11. RCDr. Rangan Chatterjee1:58:50

        And that's Social Security benefits.

    12. DUDr. David Unwin1:58:52

        Yeah, yeah, yeah, yeah. They're on benefit. So what they say, the patients tell me, the first thing is be honest about what you're spending at baseline. Because they say if you're being honest, you're buying packets of crisps. People just do.

    13. RCDr. Rangan Chatterjee1:59:07

        Mm.

    14. DUDr. David Unwin1:59:07

        Fizzy drinks in cans at a pound a can.

    15. RCDr. Rangan Chatterjee1:59:10

        Yeah.

    16. DUDr. David Unwin1:59:10

        And a pizza, a Domino pizza at seven quid. So you should look at that budget, and if you include all of the f- the money you spend on, on essentially junk, you will be spending about the same when you go low-carb if you factor honestly in-

    17. RCDr. Rangan Chatterjee1:59:32

        Hmm

    18. DUDr. David Unwin1:59:32

        ... when you bought petrol, what did you buy? You know, most patients are spending a couple of quid. They'd buy the petrol, but then there's about two pounds, maybe a drink and a chocolate bar. So they say if you factor that in, it's about the same when you go low-carb because, yes, the ingredients do cost a bit more. But they also say if you're clever, so frozen raspberries-

    19. RCDr. Rangan Chatterjee1:59:58

        Mm

    20. DUDr. David Unwin1:59:58

        ... are much cheaper. So f- frozen fish, for instance, is a fraction of the cost of fresh fish. Frozen, uh, chicken thighs or go for mince.

    21. RCDr. Rangan Chatterjee2:00:10

        Mm.

    22. DUDr. David Unwin2:00:11

        To make your own burgers takes moments, to make your own burgers. Well, what's the price of a cabbage? Or even a pint of double cream isn't that much, or eggs.

    23. RCDr. Rangan Chatterjee2:00:21

        Mm.

    24. DUDr. David Unwin2:00:21

        So there are many nutritious, nutritionally dense foods. Specifically, as well, I'd like to give a shout-out to the FreshWell app.

    25. RCDr. Rangan Chatterjee2:00:32

        Mm.

    26. DUDr. David Unwin2:00:32

        So the FreshWell app is a free app you can download on your phone. Uh, this is the FreshWell practice, and they've taken my work, uh, they're younger doctors, and of course they've made a free app, and 200,000 people have downloaded that app. And in it is low carb on a budget, all done for you.

    27. RCDr. Rangan Chatterjee2:00:50

        Mm.

    28. DUDr. David Unwin2:00:50

        All the recipes, all there, all for free. And the FreshWell app is approved for use within the British Health Service. It's approved by the NHS. It's Kismt approved.

    29. RCDr. Rangan Chatterjee2:01:00

        Mm.

    30. DUDr. David Unwin2:01:01

        So, uh, I think that, yeah, initially it, it's just working it out. It's planning. It, you, it requires more planning.

Episode duration: 2:15:46