Beyond Blood Sugar: Why Insulin Matters More Than We've Been Told - Dr. Ian Lake

Most conversations about diabetes focus on controlling blood sugar. Dr. Ian Lake spent 20 years following this playbook—counting carbohydrates, injecting insulin, managing his type 1 diagnosis according to conventional medical guidance. Then a serious hypoglycemic episode and early signs of retinopathy forced him to reconsider everything.

What he discovered became the foundation of his practice and his new book Shifting Gears: insulin itself may be more important than the glucose it controls. By reframing type 1 diabetes as a metabolic optimization problem rather than a glucose-management puzzle, Lake unlocked something most people with the condition never experience—stability without constant mental and physical strain.

But here's what makes this conversation essential for everyone: type 1 diabetes isn't just a disease. It's a window into how your body actually works. Understanding insulin's role as a master metabolic regulator reveals patterns that affect weight, mental health, inflammation, and longevity in all of us. Lake has run 100 miles fasted. He's cycled 1,000 miles while managing type 1. His approach challenges core assumptions about fuel, performance, and what our bodies actually need.

BIG IDEA

Insulin management—not glucose control—is the key to metabolic flexibility and long-term health, whether you inject insulin or not.

Contact Info: 
Book: Shifting Gears by Ian Lake on Amazon
Website: Type1Keto.com

WEBSITE: Stay Off My Kitchen Table

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Theme Song : Rage Against
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(c) 2016 Mercury Retro Recordings

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Transcript

0:56

It is Stay Off My Operating Table with Dr. Philip Ovadia. Today we're going to be discussing type 1 diabetes. But wait, don't run away. Dr. Ian Lake, who is our guest has got information that is going to appeal to literally everyone. It just so happens that type 1 diabetics focus the light on a problem that affects all of us. I've probably already said too much, Phil. I'll shut up. Awesome. Yeah, I'm really excited to be having another conversation with Dr. Ian Lake. And I'm gonna let him get into his background, but yes, he is doing some groundbreaking work around Groundbreaking work both as a practitioner but also as a self experimenter, a citizen scientist as we often talk about on the show around type 1 diabetes. And like you were alluding to, it can teach us a lot that goes beyond type 1 diabetes. And really excited for his new book that just came out, Shifting Gears. And so we're gonna be talking about that as well. Dr. Lake why don't you give a little bit of your background to our audience, and then we'll start talking about all of the great work that you've been doing. Thank you very much for inviting me on. Yes, don't go away everyone because I inject the hormone that you naturally produce. It's not quite an analogy, but what I do is what your body does. So I think it's important for us to understand how insulin works, and type 1s are a good model for how insulin works in people without type 1 diabetes really. So I'm getting on a bit now. I was diagnosed with type 1 diabetes in my 30s, and I've had it for over 30 years now. I'm a general practitioner primary care physician in the UK, and I have been now for nearly 40 years, so I've done my time, as it were. When I was diagnosed, I really stuck to the system that I knew 'cause I couldn't think that there's any other option but to c- count my carb- The thing about type 1 diabetes, it's a lack of insulin. Our bodies cannot produce insulin, and i- if type 1, it's di- it's defined as an autoimmune reaction really. But other people have to inject insulin for other reasons. But when you inject insulin it obviously lowers the blood sugar. That's what it, one of its roles is. It is a master metabolic regulator as well, which I hope to get into a bit later on. But I was taught to count my carbohydrates, which are the prime macronutrient, the prime nutrient that raises blood sugar. And because blood sugar goes up, insulin is the only hormone we have in our body that brings it down. There's plenty of hormones that bring it up, but insulin's the only one that brings it down. So my model of care was really counting carbohydrates and injecting insulin. And the whole idea is to choreograph this so that you estimate how much insulin you need per meal, estimate how long it's gonna take for that meal to get absorbed into your bloodstream to raise the blood sugar. Then you time your insulin and the estimated dose to choris- to c- to choreograph, if you like, with a raised blood sugar. So the, as the blood sugar's going up, the insulin will bring it down. And it sounds such a no-brainer and such an easy thing to do. It is actually virtually impossible to get it right every time. But that's the model I grew up with, and that's the model I believed was the right way to go. Because the funny thing about having type 1 is that, I'm in a privileged position, as a doctor, that I know a lot of people with type 1 diabetes. It's part of what I see every day or m- couple or three times a week i- in my job. So I, I understand type 1 and the people who live with it quite well. But a lot of people I speak to have never met anyone with the condition. They're literally on their own. And it's a funny thing really,'cause when I was diagnosed, I thought, "Yeah I know what to do." But then I was shocked that I actually couldn't do it. And every Monday was a reset. Every Monday, I thought, i'm gonna start today. I'm gonna really try really hard. I'm gonna count my carbohydrates. I'm gonna weigh my porridge, have my porridge for breakfast, inject the right amount of insulin. Then I cycle to work, get some exercise." Half, halfway through my morning, I was crashing, and then I was having to correct with sugar. That's quite hard when your doctor's hypo. You gotta try to avoid that at all costs. So I believed a lot in that model and realized really it's almost impossible to do. But I spent 20 years doing that. And as I said, people with type 1 don't know anyone else, and I didn't really know anyone well. To talk to about how they manage their condition. In fact, I was so embarrassed that I couldn't manage it that I ha- kept it to myself a lot. And I think a lot of people identify with that. You just don't want other people to know, especially if you're not doing very well. And that's the thing about about being isolated. You- what you've got and how you manage it is as good as it gets. You think everyone knows it's a difficult condition so it must be as bad as it is because I'm not doing very well." A- and that's my type of type 1 diabetes. So I grew up with that. 20 years later I discovered the brilliant Richard Bernstein's book on how to lower carbohydrates to ma- to manage your diabetes better. And I put it down for a year. I thought, "Now my training tells me that fat's gonna be really bad for me, so I'm not gonna do that. I'm just stick with what I know." Then I had a ne- not a near fatal, but a very serious hypo when I was o- I was on my own and which shook me quite a lot. It's the first big one I'd ever had where I was out of control. A serious what? Hypo- hypoglycemia, low blood sugar. Oh, Okay. And I didn't have any any glucose tablets to correct it. I was away camping on my own, and I was in dire straits, but I re- I recovered from it and soon after that I got my first letters from the retinal screening department to say that I've got a few little sign, a few signs of early diabetic retinopathy. Not serious, but it's there So when you can see it in your eyes, it's, you know it's happening in your brain, around your heart, in your joints, in your liver, in your kidneys. You know that process is starting to take hold. So I quickly got Richard Bernstein's book out again and thought I've nothing to lose now, I'll try it." And for the last 13 years I've been doing something that is not r- routinely recommended for diabetes management. I'm on a high fat, h- moderate to high protein diet, and the very first meal I had was a revelation to me. It was such an emotional meal. I still remember it. Because after three, a three-egg omelet, my blood sugar didn't budge, and that was the first time in 20 years I'd actually got away with a breakfast that didn't alter my blood glucose. And the next meal, and the next meal, and the next meal, et cetera, et cetera. And ever since, I've been adopting a very low carbohydrate diet because it makes so much sense, and I've I've researched it quite a lot ever since, done some studies of my own, done some experiments of my own. Because, as a doctor, when you're swimming against the tide you really question yourself every day."Is this the right thing to be doing?" Am I … is everybody else driving the wrong way down the road or is it me? And i- in most cases it's probably ourselves. So every single day I question myself, "Is this the right thing to do?" But more and more the evidence is in favor of, the science of m- metabolism is becoming mature now. We're starting to find that, yes, it is the logical thing to do for type one diabetes. So that's me really. So I, I now promote not just car- low carbohydrate diets, but what I call insulin optimization, how to understand insulin as well as we understand glucose. Because, if w- with the automated insulin devices now the artificial pancreas, not, but that's what it's promoted as with those you can get a pretty reasonable glucose trace. But I put it to people, say, what if you're using, what if your pump is whirring away so f- so hot that it's burning your skin because it's using a huge amount of insulin? Is that healthy to have a normal blood glucose but use a lot of insulin?'Cause I think insulin, from lots and lots of studies in different areas, metabolic sorry, mental health lots of neurological conditions et cetera. W- with c- cancer is promoted by insulin, but probably not caused by it, but insulin doesn't help. So there are many conditions, polycystic kidney disease, all respond well to low-carb diets and all don't respond well to high insulin. So I'm looking really that we should be m- not just worrying about glucose, which seems to be the gold standard, but equally about insulin as well. So that's where I'm coming from. Can we talk a little bit about your original diagnosis, right? Because being diagnosed with type 1 diabetes in your 30s is fairly atypical and as a physician going through that, I would love to hear how that came about, what your thinking was around this It's about, about a third of people are in the adult age range when they develop type 1. There's a peak in the sort of five to seven-year-olds, then again 12 to 14, puberty a- age, and then when we get older, we tend to get… we can get it as adults. So about a third of people get… their insulin in their body stops working, and it's thought to be an autoimmune disease where the pancreas is destroyed by the body's immune system. Yeah, so I, my first inkling was about a month before because it doesn't always appear all of a sudden. I think there's a run-in to most people with type 1 diabetes. We start to get a bit thirsty. We probably lose a bit of weight. We're probably going to the loo to pass urine a lot more frequently, and we feel a bit more tired as our blood glucose goes up. So I was doing a lot of work as a junior doctor really at the time. I was doing a lot of work. I was working days and nights and I was do- doing jobs where I was working at lots of different places, so I was very busy. And my first inkling was when somebody tapped on my car window about a month before I was diagnosed and asked me to move out of the car wash 'cause I'd put my car into a car wash and fell asleep, and that was a sign that I was obviously my he- my blood sugar was very high. But I didn't know it at the time. So I just moved on, thinking I'm just tired. I had no reference points at that point. And then one day I just developed extreme thirst. I- I've never known thirst like it. It was extreme thirst. And guess what I tried to quench my thirst with? Coca-Cola. So nothing better than diagnosing your diabetes by adding something that's going up uncontrollably in your bloodstream at the same time. And then I was passing urine so frequently. I was in the car driving an hour, and I had to really stop very frequently to relieve myself. So I… And by then I'd diagnosed it and when I got to my destination, which was a GP surgery, I just tested my blood sugar, and it was in the mid-20s. 20 times 18, 300 and odd. F- 300, 400 milligrams per deciliter. Yeah. So it was quite high. And then I kept myself to myself overnight and just didn't eat knowing that I could be in trouble here, but I managed to get through to the morning, turned myself in and got sorted out. What a shock to diagnose yourself with a condition that you know is not a good condition to have. I've seen all the complications of type 1 diabetes, and here I was, a person about to go on that journey, and i- it was quite a shock really. And I was really just told about all of the complications again, and as doctors seem to be quite keen to tell you about all the complications, what's gonna happen to you. And yeah, I know that. I know that, thank you very much. But what I didn't know was how difficult it is to manage type 1 diabetes. Literally, you get given a pen. Pens in those days, I'm still on pens 'cause I can't get a pump right now on the National Health Service. You get a pen, and you get told roughly count your carbs about 10 to one, and off you go. You're a doctor, you should know what you're doing, and good luck. And three months later I was reviewed, and just kept going on that really. N- I never ended up in massive trouble. Some people don't. Some people have bad luck, and they end up with hypos and diabetic ketoacidosis quite frequently. But I was one of those lucky ones that hovered in the middle. I wasn't a bother to anyone. I never ended up in hospital, never ended up in trouble. So I just kept hovering around the middle zone really, accepting that my glu- glucose surged Yeah. It's mentally very taxing. Yeah. It's certainly interesting to hear your perspective, right? We as doctors and there are many scenarios like this where we give patients instructions on how to manage, whatever condition they have, but we might not really realize how difficult following those instructions are, right? And, I'm sure, before this you probably… when you took care of diabetics and you gave them, the goal of keeping your blood sugar under control, and like you said, just do the calculations and figure out what you're eating and how much insulin to give and, when to give it, and that's, and that's how we control diabetes. But as you discovered, and I think as if we're being honest as physicians, we see patients struggling with this all the time. It is very hard, right? The magic that our body figures it out in people that are not diabetic, right? It's really pretty amazing the complexity of what our body has to do to balance insulin and glucose on a constant basis. A- absolutely. A meal is not just a straightforward meal. You have to plan for your meals. Restaurants are quite fun. You don't quite know what you're going to get, so you try to- … to get the sort of the pattern right of the, of when to inject how much to inject, and hope the meal arrives on time. How to inject. Do you inject, do you go to the loo and inject or do you ra- you know, roll up your shirt and stick it in and get your pen out and show off? Or what I tend to do is just inject under the table through my trousers and some people do that. So it… The day-to-day, it- it's quite a difficult gig. My insulin takes half an hour to work. Your insulin's already finished working 15 minutes before mine even starts working. My insulin lasts two to three hours, and some of the long-acting, basal insulin, lasts up to 30 hours. Your insulin's finished in 15 minutes. So we have to factor in that our insulin's gonna be working for a lot longer than people with no diabetes. I liken it to driving a car and having to input a steering correction to the wheel 30 minutes before you go around the bend. It's quite hard to do that all the time. So everything's an estimation really. It becomes quite stressful sometimes because- Type 1 diabetes, just by correcting blood sugars with protecting your carbohydrates and injecting your insulin is an im- virtually impossible task, and we can do the same thing two days in a row, live exactly the same life two days in a row, and get completely different results. Einstein said, "If you do the same thing over and over again, that's the definition of insanity." Our insanity is doing the same thing and getting completely different results. A- and it leads to quite a lot of stress, to be honest, because you're never quite on it. You're never quite in control. There's all, there's this background noise going on of anxiety about am I gonna be okay, I've gotta come on this podcast. Am I gonna last for an hour? Yes, I am, but I've had to plan to last for an hour. It's so much easier with the diet I have because I don't even have to think about it. But before, I'd have to plan and hope, I had some supper about two hours ago, hope that my glucose didn't plummet with the high doses of insulin I'd typically have had. Say I had a a pasta meal. It might be coming down to hypo levels halfway through this conversation. So there's a lot of noise around. People who've got problems around food it, it impacts them as well because diabetes is all about food. So if you've got a food issue, it's, the diabetes is certainly gonna amplify that for you. So it's a constant background noise of stress, planning. It never really goes away. You have to be on it 24 hours a day. And then you go to bed, your blood glucose is whatever it is. Do you inject insulin to bring it down? Do you leave it or let it drift up or hope it might come down? Do you have hypos in the night? So is, it's constantly in, on your mind. You get used to it. We all get used to it, but it's one of those things we have to plan for all the time, the constant noise. I, I liken it to a chainsaw really. You got this constant noise going on in the background. Yeah. And, it's interesting the history of diabetes, right? Th- this disease was described, thousands of years ago literally. And the original way it was discovered was centered on sugar. Doctors used to actually taste the high sugar in patients' urine essentially was the way to diagnose this. And insulin was only really discovered, within the past 100 years or so, a little over 100 years ago that we knew what insulin was. So the whole focus of the disease has remained around the sugar, right? And, controlling the sugar at first in the urine, and then when we were able to measure sugar in blood how to control that. But in reality, it's a di- i- it's a disease of insulin. And there's this interesting paradox around type 1 diabetics that you alluded to earlier that y- to avoid the ultimate complications of diabetes that we worry about, things like blindness, and heart disease, and, vascular disease leading to amputations and infections you have to control the blood sugar, but we know that the more insulin you end up using to do that that in and of itself accelerates or worsens the complications. Again, as a physician but also as a patient contrast you talked about these two approaches, right? You spent 20 years doing the sort of traditional approach, and then you discovered Dr. Bernstein's work which is a very different approach of essentially trying to manage the insulin rather than manage the glucose primarily. And talk about those contrasting approaches and, again, a little bit what that change in mindset was like for you as a physician and as a patient. Yeah, that, that's a very good point, and that's the nub of what I'm trying to get at now w- with my learning is at the, my route of travel is at the stage where I think insulin is as important or if not more as important as controlling glucose. But strangely, if you control insulin well, your glucose will follow, and it isn't the same the other way around. Glucose was the symptom that sym- that, that told you had very little insulin that was operating in your body. So when Banting, Best, Macleod, and Collip, the four people that got the prizes for discovering insulin injected into a 10-year-old boy who lived 10 years in 1923, which is incredible they were making sure that the insulin was given to control the blood sugar, and they had very primitive methods, what we call primitive now, we all have continuous glucose meters, of measuring the sugar in the urine. But the insulin was the key thing. And of course, the insulin was very crude. It was a mixture of short-acting, long-acting, eventually became long-acting. And it was all about controlling your diet. So before the insulin was used o- on humans, we were recommended to have a diet that tried to work with a lack of insulin. Insulin does not raise that much when you eat fat. It does not raise that much when you eat protein, but it goes up a hell of a lot when you eat carbohydrates. So their approach was to remove the carbohydrates from the diet. And in adults, they added spirit alcohol, because we know that spirit alcohol, such as whiskey will inhibit the, some of the hormones that raise the blood sugar. So their approach was based around trying to work with the, what they had in the body. When insulin was dis- was used, it was a revolution. People were literally resurrected from death. It was such a wonderful drug. And it was subsequently purified and became a very, I think we got so used to it we ignored it, and we were chasing sugars, and sugar became the gold standard, and still is the gold standard. It's all about HbA1c, our long-term sugar control. Time and range of glucose is the defining standard of good practice in Type 1 diabetes. Insulin isn't considered. They don't… It doesn't matter how much insulin you use. I always called it a hedonistic approach. Eat what you like and shoot up what it takes, shoot to suit. And I think we're not thinking about insulin in the right way. And my approach used to be count your carbs, inject insulin. Now it's definitely how does insulin work in the body across all the foundations of health? What is a healthy hu- what does a healthy human being look like? What does someone without Type 1 diabetes, what's their insulin doing?'Cause their blood sugar's always well-controlled because they have a functioning metabolic system that includes insulin. But we have to inject it, so how much do we need to inject considering it's imperfect, we inject at the wrong time, the wrong place, and it lasts too long. But how do we look at a healthy human being and say, "What do they look like? I want some of that." And a healthy human being, I think, has fairly low insulin levels typically. There's lots of evidence now that, that- Now real quick, just because I'm not a doctor, when you say low insulin levels, you're talking about the insulin that's in the blood- In your body. Yeah. In your body, yeah. In the whole body, okay. Yeah. So typically insulin is released when there's this the blood glucose rises. Now, the blood glucose can rise due to diet. It can also rise due to stress hormones such as growth hormone, adrenaline, cortisol and other hormones have an effect to, to stop the insulin working as effectively as it might. So insulin is a primary metabolic regulator. One of its functions is to reduce blood glucose, but it has many functions bey- beyond that. It's a regulator of energy in cells. Now- If you have if I think a healthy human being does a lot of exercise, or should do, eats two meals a day, has a period of fasting, p- eats primarily protein and fat gets outside a lot, has good mental health, and and has respect to their circadian rhythm. So for example, middle of the night we want all these blue lights on you'd be cutting down your light. So we need to, what I've decided we need to do is look at w- what makes a healthy human being, so can us type 1s have a bit of that, please? So one of the features I think of a healthy human being is something called metabolic flexibility. It's being able to choo- for your cells of your body, your organs of your body, to choose the fuel that they require at the time. So Dr. Phil Ovadia you are a cardiologist, you know that the heart h- is quite happy on fatty acids and ketones, and it will also use glucose. But if you have type 1 diabetes and you take a lot more insulin than your body needs, and because of where we put it in our body, into the skin, we've already got more insulin than we, we really should have because of the absorption issues that we have. So if you have too much insulin, what happens is you stop your metabolic flexibility from happening because if you have too much insulin in your body you cannot burn fat to produce fatty acids and ketones to produce those other energy molecules which the body can happily use So if you have too much insulin in your body, you're a fat storer. You're a fat storer. That's what you do. If you have little insulin in your body, you're a fat burner, so you can produce other nutrients that will provide energy, fatty acids and ketone bodies which derive from fat. Your body will make all the glucose you need. You do not need to eat sugar or carbohydrates in order to survive. Those poor people that get dragged out of earthquake zones eight days later, they haven't been secretly, they didn't luckily have a stash in the fridge of candy bars. They were pulled out and they were burning their body fat. But in type 1 diabetes, on, on the diet we are typically recommended high carbohydrate diet. We are denying our body metabolic flexibility. We're forcing our body just to use glucose. And we know in some conditions, certainly the mental health space which has accelerated our knowledge of metabolism, that you can do very well with bipolar disease, for example with metabolic flexibility, allowing your body to access ketone bodies. Because there's some evidence that the meta- the regulatory function of the insulin fails in the brain in a high carbohydrate environment. So y- if you've got ketone bodies available, if you've got low insulin levels so you're not storing fat, you're burning it, you are providing the body with what I call metabolic flexibility. And the current method of managing type 1 diabetes denies our body access to those fuels. And so if you have someone with bipolar disease who is fueling their body on a very low carbohydrate diet and they develop type 1 diabetes, it's a clinical problem at the moment to know how to advise them. I know what I would do. I would say, "Carry on your ketogenic diet." But some people would say no, you've gotta have carbs. You gotta have carbs as part of your treatment." And that will of course take them out of recovery and put them back into their bipolar state. So there are lots of clinical questions we need to ask, but over the years I've learned about the f- the positive impact of a multi-fueling system on cancer, on m- mental health, on migraine, on polycystic kidney disease, on type 2 diabetes, and I think it also works on type 1 diabetes as well. It's ironic that the one condition where we do best to respect metabolic flexibility is the one condition that we're not actually helping out. I wish I was surprised. Yeah. Now it it's hard enough just managing type 1 diabetes. You've added a extra layer of complexity by being an athlete, an endurance athlete. You have done such what many people would view as crazy things, such as running 100 miles in five days as a type 1 diabetic. You did that completely fasted. And then in your new book you talk about a thousand-mile bike ride as a type 1 diabetic. So talk a little bit about, what that then adds if you're not just trying to get through your day-to-day, you're trying to, perform as an athlete at a high level. So the Zero Five 100, the project we did a few years ago now, was two people with type one diabetes and six others. We I conceived this because I was… I thought how can we actually show to my clinical colleagues that, the main problems that, that they're worried about aren't actually, they really don't need to worry about them." The fact that if you're in what's called nutritional ketosis, if you're not eating carbohydrates and you're burning fats, producing this energy molecule called a ketone body it's not dangerous. It doesn't lead to diabetic ketoacidosis, that you don't need sugar for sport. You can fuel on fat for sport, certainly the level I was performing at which is not Usain Bolt sort of level where he eats. And if you're taking insulin, you don't need to take carbohydrates. So we proved all of those things, and I thought just doing that alone should convince my colleagues that, hey, this is actually safe. Unfortunately, it was so radical, it was designed to be radical to actually rule out any issues that I might be, there might be other reasons for why we're doing so well. But I thought it was seen as so radical it wasn't relatable which is a shame really. So I got a chance to go to Saint Moritz to do a talk to Keto Life, which is a, sort of a keto conference which covers w- things that we're talking about, mental health neuropsychiatry, neurology cancer, diabetes, et cetera. And it was to do with type one and sports. So I thought I'll cycle there." I had a bit of time on my hands. But it wasn't done as a Lycra-fest man of a certain age sort of type of project. It was done as a, I'm just an old bloke who's cycling 65 miles a day, 60 miles a day, whatever. And it was conceived as a ketogenic, a very low carbohydrate diet, and I measured all of my carbohydrates every five minutes through a continuous glucose meter, and I measured all of my ketones every five minutes through a continuous ketone meter for three whole weeks and published them in the book, which is a big thing to do, I tell you. It's not all perfect. And it I also started to explore the roots of health and how insulin works. So it's half a travel journal, half textbook. And it's a textbook written at the non-specialist non, non-medic. So h- it was to explore- How insulin works and how do we manage insulin across all of the roots of health? So how does insulin operate? Insulin has its own circadian rhythm. We're more insulin sensitive at certain times of day than other times of day. So let's look at that. Let's see if we can manipulate our insulin to get a good result on that. How does insulin, how is insulin affected by the sleep process or bad light? How does infrared, ultraviolet, how does that impact on our insulin sensitivity and our inflammation in our bodies? How does mindset, stress hormones, how do they impact on insulin and what can we do about it? Then of course, physical activity. The great work by Tim Noakes and Jeff Volek and Dom D'Agostino and others who have shown really that you can burn fat at a high level of exercise, and it can perform just as well as sugar. So we thought we'll take advantage of that then. So that's great that they produced that. So it means that people with type 1, we can perform at a good level if we want to. I'm not in that category, but we looked at that, and we also looked at diet in great detail. So the whole of that, the book is based- how can we understand insulin? How can we use it wisely to, to give our bodies the metabolic flexibility that we need? And of type 1 diabetes every day. And I think the book w- is gonna be helpful to people with type 1 to show that, yes it, it is logical scientifically to be able to cut your carbs. Yes, you can skip breakfast if you want to. But y- you can control the noise of diabetes. I did a chapter I called it Silencing the Chainsaw to Hear the Birds Sing, quite a romantic sort of idea. But really- … once you're on to optimize insulin, your glucose follows and once the glucose is quiet you can tune into all of those subtle bodily functions which are hidden by this constant noise of carbohydrates and insulin trying to balance one with the other. You get a really smooth profile overall and you don't worry. There's one phrase in the book, I said I've s- I've injected my insulin, my glucose is now set, and I don't need to worry for the rest of the day," and I still had 40 miles to cycle, and I didn't need to worry for the rest of the day. So that is remarkable if you think about it. I had to double take on that thought because as most people with type 1 diabetes, you don't have that luxury of just cycling for 40 miles and not even having to worry about carb fueling or anything like that. I was fat burning, quite happily fat burning. I was in a ketogenic state. I was r- really alert with my body, my blood glucose was following that. So that's what that's all about really, trying to understand how to use as much insulin as necessary, but as little as possible. There are days when you need more insulin, and I wrote about that in the book. I needed more insulin on a couple of days than than ideal because you have to go with it. If you need it. And there are days when I use less insulin like a few units of insulin. So it's all about metabolic flexibility insulin optimization I call it and looking at all of the roots of health holistically. So let's talk about… Let's apply this to the broader public. Let's ap-apply this to everybody. Yeah. What I'm hearing is as it applies to folks who are not diabetic or not injecting insulin, you said something quite a bit earlier that I thought was noteworthy something about a focus on glucose rather than on, on insulin. And you've talked about optimizing was the word you used, optimizing insulin exposure across your diet, your movement, your sleep, your stress, and your environment. That's not just applicable to type 1 diabetics. That's applicable to all of us. So if you would, unpack that idea of insulin optimization for those of us who don't have to inject it So every single person produces insulin. Pancreas produces it. People with type one don't produce it-… And other categories But so we are in a difficult situation, but we need to know what someone without diabetes is doing with their insulin, and we can find that out by need- looking at how much we need to inject. But we can only find that out when we isolate each variable. So if we're running under a constant noise of carbohydrates we haven't got a clue what the subtle signs of circadian rhythms, day, night cycle. We haven't got a clue what's happening there because it's hidden by this constant high insulin level, and we're not sensitive enough to it. So insulin is secreted by everyone and insulin is secreted as a metabolic regulator and in response to blood glucose control. We know that carbohydrates, so you know, pasta, rice, potatoes, bread, et cetera, that they all convert to sugar in the bloodstream and raise the blood sugar. So insulin will be secreted by your pancreas to bring the blood sugar down, and that happens for everybody with every meal. Now, your blood sugar would be perfect, but your insulin levels might be going up and down like that all the time. If you're stressed your blood sugar will go up because of the stress hormones raise blood sugar. So your body will in concert produce insulin to try to bring that blood sugar down. If you're having a poor sleep, you'll, you become more resistant to your insulin, so your body produces more to overcome that. So over time, you end up with more and more insulin in your body throughout the whole day. And of course we know that insulin's an inflammatory hormone. We know that it leads to weight gain. We know that it leads to salt retention and high blood pressure. And we know that it can, because of the way insulin stores fat, lead to these conditions called fatty liver, et cetera. So insulin will eventually lead to what I call metabolic syndrome. And we know that if you're eating all the time, you're denying your body metabolic flexibility, so you're making your body more vulnerable to those, to making your, some of the tissues in your body more vulnerable to tho- to those that need ketone bodies or need fatty acids and things like that. So for someone without type one, you will produce, be producing insulin. We just have to inject it. So we can pretty well tell you, the book will tell you if you don't have type one, what's going on in your body pretty well. So- and high insulin levels we know are associated, as I've talked about in this talk with diseases. Glucose is a s- is e- eventually a symptom of type 2 diabetes when the insulin just cannot cope with the sheer metabolic load that it has to cope with as the insulin's overwhelmed. But that process has been going on for years before. So it a- it applies. So type 1 insulin requirements apply to people with type 2. So how can we get insulin low to enable metabolic flexibility? It's all about understanding the five foundations of health which lead to situations where we're raising insulin all the time. So insulin, I think, is as important as blood sugar. Blood sugar's a symptom. Cholesterol's a symptom of metabolic disruption. Fatty liver's a symptom. High blood pressure's a symptom. Weight's a symptom. So we can look at all these symptoms and modify them, which of course we do with endless medications. But if you have type 1 diabetes just respecting the insulin will improve all of those symptoms with just with one drug. But you're lowering the insulin. And in- No you're going too fast here 'cause that was profound. If you have type 1 diabetes And you manage it with insulin, you will reduce all those symptoms or manage all those symptoms. Yeah. I… And again, if you would please, list those symptoms. Those, this is important stuff, folks. We really the reason this caught my attention is your long list of things that are symptoms that we have drugs for, but the drugs are treating the symptoms. And what I inferred from what you said is the root cause is something that we use insulin to manage the expression of the root cause, which is these various symptoms with, rather than just muting the noise of the symptom. I'm… I don't mean to distort it, but if you would, just go back again. These things are symptoms. Yeah. So someone with type one diabetes, over time you start to learn that insulin has more effects than just lowering blood sugar. So too much insulin and that is caused by having a diet that is high in carbohydrates, so you need far more insulin to control that. And we're vulnerable because we already, because of where we inject our insulin, have too much of it anyway. So too much insulin will lead to constant fat storage state. You're always in fat storage state, and if you're eating all of the time, three meals a day plus snacks pl- and nighttime drink, which some people have as well you're constantly putting carbohydrates into the body. 60%, 50% of our diet, in the US now they- they've recommended that people invert the pyramid. But in, in my country, they haven't. In fact, a funny aside on that, I wrote to one of the major charities over here and said, "What do you think to the American guidelines?" They said,"Oh we're sticking with the EU- Euro- with the UK guidelines." I said I'm an American living in the UK. What should I do?" And they said, "Oh follow which ones you want." So there's a lot of science behind that Oh yeah, lots of science there. The old guidelines. So high levels of insulin caused by mostly diet and inactivity, I think, i- insulin's a very good meta- physical activity's very good for regulating metabolism. It you can hoover up a lot of sugar into muscle if you're exercising and make your body more insulin sensitive. So there are two things. There's too much insulin and insulin resistance, and eventually your body becomes resistant to insulin, so you need to make more and more of it to cope with the metabolic load caused by your lifestyle, which is predominantly driven by too many carbohydrates in the diet in people who are vulnerable. People are… a lot of people now are overweight and obese, and they're clinically vulnerable to too much insulin. And fat storage is not a feature of fat more a feature of too much carbohydrate. So the sugar gets taken out of your blood, and so the biggest source of fat in, in our bodies is carbohydrate not fat, strangely. So too much carbohydrate leads to the need to clear the blood sugar out of the bloodstream because our bloodstream is, has a very tight level of control. It the blood glucose needs to be very tight because the tissues are surrounded by something called interstitial fluid, and they need a very tight regulated level of glucose in order to work properly. Too much glucose will damage the receptors in the cell. So as soon as the blood sugar goes up, insulin's out of the traps instantly. It's ready to go. I- insulin in your body is stored in granules and released as soon as blood glucose goes up. And then they get rid of the blood sugar. So if you're exercising, that insulin will augment the ac- the clearance of blood glucose into the muscles. If you're not exercising like we're not now the insulin will direct that to the liver, and the liver will make that sugar into fat. And then so people put on weight. And if we're continually eating carbohydrates, we're continually producing insulin, we're continually producing fat. And we know that people with type 1 diabetes tend to put on weight as they go through their diabetes journey. When you're producing a lot of fat, your liver's got- So is it the excess insulin that cause… Okay, I'm I'm following you. I think I'm following you. Yeah. All right. So the excess insulin causes excess fat, and then the excess fat builds up in the liver and causes fatty liver. But before that, the excess fat is sprayed around the body and d- deposited into fatty tissues. And of course, that excess fat also is packaged with cholesterol, and that's where all the problems start. All, you know- … all of the cholesterol evidence is based around high-fat diets. Cholesterol profiles alter with a low-fat diet, a ketogenic type of diet. But we apply the high-fat research to… So we apply fat storage research into fat burning. So it's difficult to know how to interpret cholesterol on a ketogenic diet based around the fact that 99% of evidence is based on a high-carbohydrate diet. So we have cholesterol as a as a symptom of high glucose. High insulin. High insulin makes the kidney retain salt, and with the salt comes the fluid, and with the salt and the fluid in a closed system like the blood vessel system, unless you're bleeding, you get high blood pressure. So insulin generates high blood pressure, and we know that when people go on a keto diet, they flush out a huge amount of fluid and the blood pressure drops within six to eight weeks and it's all sorted out. So all of those things, the high blood pressure, the abnormal cholesterol profiles, the fatty liver the weight gain, are all caused by too much insulin in the body and metabolic dysregulation. So it's not just insulin by itself, it's how that insulin impact, impacts or is impacted by the other 30 or o- th- 30 or 40 other hormones that are produced in the body, and insulin interacts with nearly all of those. So it's a metabolic dysregulation caused by an abnormal amount of insulin in the body, in my view. So it's like every system, every complex system you inject a variable constantly and things change i- in the whole body. If you've got water that contains a lot of lime, eventually your pipes are gonna fur up. But if you reduce the lime, the pipes won't fur up, if so it's getting the metabolism right in the body for your body. I'm not saying it's for everybody, but I think everyone should be aware of it so they can make an informed choice rather than just blindly follow eating, counting carbs, and injecting insulin on the assumption that insulin is not important. It's very important indeed. That's the basis of the book, really. Yeah the the complex interrelationship, right? A- and you've mentioned it. Insulin it the regulation of glucose is o- only one of many things that insulin actually does in our bodies. And again, that, that is a incredibly complex system. And there's just, at a high level we sit back today, knowing Dr. Bernstein's work, seeing, all the work that's being done around ketogenic and low carb diets in both diabetics and non-diabetics, and, it's almost insane to think that the mainstream recommendations around type 1 diabetes are what they are, right? To just tell people, not… a- and, to be clear there is guidance that is given to type 1 diabetics that are diagnosed, today that eating low carbohydrate is actually dangerous, right? You need to have a minimum amount of carbohydrates. And, to just think about how we got here it really is insane that this is where we ended up with the management of type 1 diabetes, let alone the implications that then has for type 2 diabetes and even for, dietary recommendations around non-diabetics. What what's your thinking on what it will take to change this? Obviously, something you're a big proponent of, and really all of us in this low carb community are big proponents of. But again knowing what you know from the inside as a doctor and as a patient what kind of response do you get from your type 1 diabetic patients today when you present this information to them? There are two angles to this. I use my website and I a- attract a certain type of type 1 who's interested, so they're already pretty well easily convertible. And then in my NHS practice, I, most of the type 1 people with type 1 are specialist led, so it's a secondary care special- specialism and generalists like me don't really get involved. But I, I feel an ethical responsibility really to say th- this is something you might want to look at." Not everyone's interested. People have all sorts of reasons why they don't want to change. A lot of people have got a formula that works, and they've struggled for years to get that formula that works for them. So I offer that up to people and support it if that's what they want to do. I think those converted people the commonest question I get is, "Why didn't you… Why wasn't I told this at the start? Why have I wasted 10 years of my life with complications when th- this could have made me so much better?" I had one person who said even if they could, got a cure for diabetes type 1 tomorrow, I wouldn't change my lifestyle now I know what is required. I feel so much better. And that's what we alluded to, the low insulin lifestyle for a healthy human being. It makes people feel so much better and more active. So even if you don't have diabetes, there's a lot of unfit people who don't have type 1 diabetes out there and due to driven by lifestyle. I had someone w- who's been 20 years on a pump, and he says the best ever control he's ever had was with a ins- when he started to understand how to use his insulin doctors are difficult people to deal with. They're under a huge amount of pressure to to operate on a, certainly generalists across many levels. But somehow the ketogenic, the word keto in, in diabetes freezes the room. It, it just cannot get through to people. And once you mention keto, you've lost the whole of the room. So it has to be, I think education. We're all doing a bit. We're all chipping away at the rock. The journalists who report on it, the people the, the experimenters like me who just put stuff out on social media. S- the mental health space, the polycystic kidney space, the diabetes space, the heart space. Everyone's working together and the message is getting out there. So my book is written really for my fellow type 1s. I thought I'd write it a- as a hybrid to attract clinicians, but I genuinely think that the fastest route to progress is to write it for people with the condition 'cause they will resonate with it a lot, and they will be able to implement their own changes or certainly have a very good conversation with their healthcare s- specialist about why they're doing what they're doing. And then if the healthcare specialists do not want to go along with I, I would call it updating the knowledge really, 'cause over the last five to 10 years we've updated our knowledge. And e- and if some specialists don't want to update their knowledge they can say what they like, but they'll become irrelevant because people will just be getting on with it. And type 1s get on with it 365 days a year. You'll never find- … a diabetologist at 3:00 in the morning when you're in trouble. You might find an ambulance. So t- type 1 diabetes are very flexible people and very adept at keeping out of trouble. Good. And once they know that they're not the only ones in the world with that condition and they're living with it alone, and once they've, see that I've been very vulnerable here and I told it how it is for me, and it's not like a doctor, I tell you. It's someone who's not brilliantly controlled but good enough to make the book work. Once they realize that it is a condition you can un- you can understand more deeply and manage more easily and you don't have to worry about it every day, I think that will start to lead the change. That's my contribution to this space is to support people who are otherwise not even find out about other ways of living with type 1, and those on their own that think,"Oh, he does that as well. Oh, he should know what he's doing," and "Oh, he has

hypos at 3: 49:46

00 in the morning. Oh, he forgets to inject his insulin as well. Oh, so do I." It's relatable I hope. All right. Let's talk about how folks who want to f- find the book can get the book. So it's on Amazon all all Amazons. It's a e-book as well as a paperback, and it's

called Shifting Gears: 50:03

The Thousand Mile Ride That Changed My Mindset on Type 1 Diabetes, so quite a handful. Yeah. Yeah. If you just Go- If you just put in Shifting Gears Ian Lake, it'll come up. Yes. There we go. Yes. And having done the search for just Shifting Gears on Amazon- Yeah … there's all kinds of stuff that is not what we're looking for. Yeah. I think there's quite a few TV series out there on Shifting Gears. Oh. Oh. Very good. And w- and where can people go to find out more about your work outside of the book? Type1keto.com and IFixHearts is a good place. I've had two podcasts on your show now, so thank you very much. Yes. It's always great being able to catch up with you. And yeah, certainly want to encourage people to check out your website Type 1 Keto. It's a great great website. And like I said, it's the information that we're learning from the work that you're doing is very applicable to those of us that are not Type 1 diabetics as well. And I think your focus on A- and I think it's a great way to reframe the conversation, not necessarily as a ketogenic diet, but as an insulin-controlling diet, essentially is what you're advocating for, and I think it makes a lot of sense and it will help a lot of people. Thank you. So do I. I hope it helps a lot of people. All right. Our guest has been Dr. Ian Lake. His book is Shifting Gears on Amazon. Search for his name as well. And the website Type 1 Keto. One is the numeral, it's not spelled out. Type numeral 1 keto.com. For Dr. Philip Ovadia, this has been Stay Off My Operating Table. Thanks for joining us. We look forward to talking to you next time