66. Artificial Light, Diabetes, & Decentralized Endocrinology | Kelsey Dexter, MD

Kelsey Dexter, MD is a world leading endocrinologist pioneering diabetes reversal using principles of circadian & quantum biology and low carbohydrate nutrition in Jackson, Tennessee.

In this interview we discuss how to reverse metabolic diseases using lifestyle practices, the role of light & food in metabolism, leptin resistance & thyroid, GLP-1 agonists, diagnosing LADA, sunlight & Vitamin D and much more... 

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TIMESTAMPS
00:11:36 Treatment Strategies for Type 2 Diabetes
00:20:37 Light, Diet, and Metabolic Health
00:35:13 Advancements in Type 1 Diabetes Treatment
00:41:29 GLP-1 Agonists and Diabetes
00:46:52 Sunlight and Vitamin D Importance
00:59:53 Improving Metabolic Health Through Lifestyle

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DISCLAIMER: The content in this podcast is purely for informational purposes and is not a substitute for professional medical advice, diagnosis, or treatment. Never disregard professional medical advice or delay in seeking it because of something you have heard on this podcast or YouTube channel. Do not make medication changes without first consulting your treating clinician.

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Transcript

Dr Max Gulhane: 3:43

I had the pleasure of sitting down with Kelsey Dexter. Now Kelsey is a practicing consultant endocrinologist currently working in Jackson, tennessee, usa, and Kelsey came onto my radar as a doctor who is really applying the light and circadian practices to the subspecialty of endocrinology, which is very, very special and very, very interesting. So, kelsey, thanks for coming on the podcast.

Dr Kelsey Dexter: 4:13

It is my great pleasure. I've learned so much from you and your guests over the last few years, and I'm honored to be here.

Dr Max Gulhane: 4:21

Great. Well, let's start with your individual story, because, as an endocrinologist, I think you have such disproportionate power in terms of helping to educate patients. But, like most of us, you had your own journey, so please share that with us.

Dr Kelsey Dexter: 4:38

Yeah, I'd love to. So I pretty much knew I wanted to be a physician from a tiny age and my path led me directly there. I didn't take any breaks. But my goal in getting into medicine was always to help heal people right. And when I got into medical school and sort of realized the burden of chronic disease and that we were being taught that drugs effectively like we are glorified pharmacists when we come out of medical school in a lot of ways to manage chronic disease processes, it was really frustrating to me. I actually went to medical to be a dermatologist because I was very interested in skin and skin cancer and I was a person who slathered myself in sunscreen and avoided the sun at all costs and told other people to do that for years and years. And I realized when I got into medical school that I wanted to have a bigger impact on metabolic health and that led me through internal medicine and then endocrinology down the road.

Dr Kelsey Dexter: 5:45

Metabolism was my main interest because we can see the root cause of disease in a lot of ways in this country, you know, related to metabolism and insulin resistance. So, interestingly, like I've always also been interested in integrative health. So I back when I was in residency there weren't any functional programs that you didn't have to pay for yourself. But I did a few rotations in at the Osher Center at Vanderbilt and was trying to find a pathway into more of a bridge to functional plus traditional medicine. I went to the University of Colorado to study endocrinology and they have a huge obesity research center there, so that was part of my background. I was the research fellow of my year but bench research did not really interest me that much and I was actually working on a project in public health looking at community gardens and how they impact chronic disease parameters in people who are new gardeners, which was pretty interesting. But let's see as far as how I ended up on the quantum health path, it was kind of a crazy thing but, if you believe, and kind of following golden threads and signs, I was working every day in this centralized paradigm and just feeling the weight of the burden of disease and how little impact I was making on people's long-term vitality and I was having chest pain every time I walked into the building because of this discord. It's the malalignment right to the mountains and I was hiking through the mountains and I hear a word in my ear agrimony which I've never heard before in my mind's ear, and when I got to the car and I Googled it I realized it was a plant. And then I do a quick Google search on that, this blog post pops up describing a man who left his corporate job and now is sort of a professional wild man promoting regenerative health practices and things. I ended up two years later doing a program with him and learned all about ancestral diets and earth connection and that was one step toward me realizing how much impact our disconnection from nature has on our vitality. So since then I've done some herbalism training programs.

Dr Kelsey Dexter: 8:41

I am a Reiki attuned practitioner. I have a pretty big tool belt aside from my Western endocrinology training, but in the day to day I interact with a lot of patients in a centralized paradigm, patients in a centralized paradigm and I try to figure out how I can improve the trajectory of everyone's health. And usually that relates back to foundational health practices and quantum practices. And it's so shocking to me because we're in this world where we talk about these things all the time, right that it seems common sense that being in sunshine is good for you, or optimizing your sleep, or being in contact with the earth, grounding and gathering electrons and the average person just doesn't get it, because when you see everyone around you living the same way, you never question that what you're doing is hurting you. And I tell patients all the time that modern life sucks our vitality right in a lot of ways and if you are sick you have to focus on foundational health practices to begin to heal, and that has nothing to do with Western medicine. So yeah, I have been. I've been sort of pushing light as light as therapy for a couple of years now in my patients. And the thing to note is people don't come to me to talk about quantum and foundational health practices. They come to me because they're sick and they're on medicine and they want medicine management primarily. So it's a really interesting dynamic when I try to fit this into every office visit and do educating, and many patients don't want that, you know.

Dr Kelsey Dexter: 10:48

So it can be a little bit tough, yeah, but I see patients all the time that think they have hormone problems, Right, and they want hormone testing, and that. That can range from. You know, I'm tired all the time. I can't lose weight no matter what I do, or have irregular periods or, you know, transition through menopause etc. And I can do labs on that person and know that they're all going to show up as normal, Right. So there is relative hormone dysfunction just in the average American because of metabolic issues, and we know that that 93 percent of Americans have metabolic dysfunction, meaning, you know, 93% of Americans have metabolic dysfunction, meaning we can't efficiently switch between fuel sources. We're not fat adapted relative mitochondrial dysfunction and that plays a part in pretty much every disease process that affects Americans today.

Dr Kelsey Dexter: 11:54

So I, you know, I really try to think about how what kind of actionable steps we can, we can engage to move the needle slowly but surely in patients that don't seem overwhelming.

Dr Kelsey Dexter: 12:10

One of the biggest battles I have is liquid sugar, of course, because you know southern sweet tea and soda consumption can be staggering. So that's one of my general first rules is every patient that I see I ask them to stop all liquid sugar. And we talk about time, restricted eating, circadian meal timing, and then we talk about life and those are the three first steps to getting someone on a healthier path that I generally kind of dip into. But I kind of see dysregulated cortisol too and the average American living with this sympathetic activation that's chronic, as a big problem when it comes to trying to improve metabolism, since cortisol makes us insulin resistant too right, and we need cortisol to live. We need it for, you know, facing stressful events, but when it predominates because we don't sleep well, we're exposed to too much blue light and don't have good coping mechanisms, etc. You have this imbalance of cortisol in relation to melatonin. So too much activation, not enough rest and repair. So we talk about that a lot in my office as well.

Dr Max Gulhane: 13:37

Yeah, yeah, fantastic, and the setting or the role that we're practicing in I mean it plays a big influence on how we eventually change or adopt different practices. And it sounds like working in where you are in Tennessee and you mentioned before we started that this is the land of the 400-pound patient and it sounded like you saw the worst of the worst, so to speak, and that was one of the prompts to change your approach. And it sounds what you're recommending in terms of those foundational health practices of time-restricted eating, light regulation and eliminating liquid sugar and refined foods. I mean, that's exactly what I teach in my circadian reset course and I think that just is so, so, so important. But describe, paint a picture for us, for the listeners, about the environment and about the people in your area, in your local area. What are the factors? Obviously, we've mentioned the liquid sugar, but why and how have they gotten to be so metabolically sick?

Dr Kelsey Dexter: 14:51

Yeah, I really think that primarily this has to do with diet culture primarily, and I really believe it's dietary fructose, because it's just so much higher in our population whenever you're drinking sugar, it just is. So one of the issues is when a patient's diagnosed with type 2 diabetes, ok, the manifestations of that's the worst manifestation of insulin resistance, right? So in the past, our medicine options, our options of treatment are we decrease the glucose load that's going into the body so that, you know, the pancreas can take care of the amount of glucose that's coming in. You can decrease the excretion of glucose through certain pathways, using medications, and then you can improve insulin sensitivity with building muscle by taking, you know, metformin or a GLP-1 agonist, and it decreases the burden on the pancreas and then you can give insulin and overcome the resistance, right. So a lot of you know I work in this medicine paradigm and those are tools in my tool belt and so I have been using all of these medicines to try to treat type 2 diabetes for my entire career. And older physicians not just older, but like less, less um the word. So these primary care doctors that have been working in my area, in these rural areas, um, aren't as familiar with new treatment guidelines and new medications that are not insulin. So the worst manifestation of this that I see the patient that's 500 pounds typically has been diagnosed with diabetes put on metformin. It was not sufficient. Nobody ever talked to that patient about diet, exercise, restricted windows, anything. And then the next step was insulin, right.

Dr Kelsey Dexter: 16:58

So when you give someone who is already insulin resistant more insulin, well, insulin is a storage hormone. It's an energy storage hormone and it prevents the body from being able to break down fat stores for fuel. So you see weight trend up over time in nearly every insulin treated patient, trend up over time in nearly every insulin treated patient and that makes the patient more resistant to insulin. So as the dose of insulin goes up and the weight trends up, metabolic dysfunction gets worse and worse and worse. So whenever I am working with patients with type 2 diabetes, my main goal is to use the smallest amount of medicine possible. In the end that's where we're headed. So sometimes I have to use medicine as a bridge to get there also, which I have seen in some individuals to be life-changing and as an example, you know, if I have a patient who is morbidly obese and on hundreds of units of insulin a day, that patient will not lose weight with dietary intervention.

Dr Kelsey Dexter: 18:05

I am a big fan of metabolic resets from a diet standpoint, but if a person who's taking all this exogenous insulin doesn't cut carbs down to nothing, they're still going to stimulate their body's need for insulin and it just metabolic dysfunction never improves. So the average person that I interact with is not going to do that anyway, even if I tell them that this is a path to no medicine. I have to meet. Meet an individual where they are and what is your best effort? How much can you do from a behavior standpoint? Can I make up the difference with medication to help you achieve goals and help us get your blood sugar down, which can help, you know you, avoid long term complications? Yeah, so yeah, that's kind of my general strategy yeah, do?

Dr Max Gulhane: 19:04

do they? How? How? I mean? And I've had this experience too, which is raising lifestyle changes with people who perhaps didn't come to you for specific lifestyle advice, and my experience has been that some people will be interested, some people won't be interested. Often you can't tell who was interested in an offhand comment that made you know at the end of the consult might be enough to stimulate a massive change on someone and then spending 20 minutes with another person and they all they sound bought in and they're smiling and nodding, yet they make no changes. So what's the receptiveness of these messages around light, around food and obviously you're encouraging to eat a lot of meat. If you're encouraging basically zero-carb or ketogenic diet, so tell me how that's received by your patients.

Dr Kelsey Dexter: 19:52

Most of my patients, when they've had any doctor talk to them about diet, have heard the common narrative watch, don't eat red meat, don't eat eggs, don't eat butter. And so whenever they say, oh, I know I want you, you're going to want me to eat healthy, so I'm going to eat more salads, right, that's what they all say. I've been eating lots of salads, dr Dexter. Well, so I have to do a little bit of education around, like what's nutrient dense and what's appropriate, and how our body handles nutrients, et cetera, and I think the average person is really surprised that I recommend that they start eating more red meat, eggs and butter, right, and I fight against the recommendations of some of their other providers, because nearly all of my patients you know they who have diabetes have a cardiologist too who's giving them a completely different story.

Dr Kelsey Dexter: 20:47

I would say that most people I interact with end up commenting, even if they didn't come for any kind of behavioral recommendations, that they learned something. They always learn something when they come to see me. And, yeah, I have seen many, many patients make great shifts in their overall health over the last 10 years of working in this field by changing their diets. And then occasionally I have a patient I've seen for five years and I give them the same advice every time they come in and then one day they decide to take it and it took me five years to get them there and I'm. But I walk that road with a lot of folks and this, this doctor patient relationship. We're a team and I just keep trying and meeting people where they are and doing the best I can to let them know how much power they have in their own health.

Dr Max Gulhane: 21:51

Yeah, yeah, that's fantastic and it is. It's a, it's a partnership, and some people might not just have the bandwidth or space in their life to make radical changes, but, yes, it's a progressive thing that we can help with over time. Talk to how you think about the relative contribution of light and food to metabolic dysfunction, because I liked how you mentioned that 93% of Americans have one marker of metabolic dysfunction and that is something that I talk about as well which is we shouldn't be waiting for a frank diagnosis of type 2 diabetes, but we actually shouldn't be waiting for a frank diagnosis of metabolic syndrome, which is obviously the five markers waist circumference, triglycerides, hcl, fasting, blood glucose and blood pressure. We shouldn't be waiting for, um, someone to fulfill one of those criteria, let alone, um, you know, getting all the way to metabolic syndrome, let alone getting all the way to to type 2 diabetes. So talk about this relative metabolic mitochondrial dysfunction and and how you think about, maybe, what is contributing. Obviously, we talked about the liquid sugar, but kind of beyond that.

Dr Kelsey Dexter: 23:07

It's definitely a multifactorial issue, right? What I think is interesting in the grand scope of things is our ancestors were outside all the time, right, so the light environment wasn't an issue, but they were also looking for food to support survival, so more likely to be hungry than fed, and the choice of food was limited to what was available or able to be killed or caught or gathered. And now we live in an environment where nutritional energy is abundant and we can eat essentially any food that we can think of. I mean, maybe there's some nuance with that in regard to, like, food deserts and transportation and accessibility in certain populations, and we can talk about that too. But now we are trying to figure out how we can limit the excess, right. What do I think about? Whether diet or light plays a bigger part, what relative part?

Dr Kelsey Dexter: 24:11

I do know that the rate of obesity and metabolic dysfunction is progressively getting worse and worse, and it's really skyrocketed in the last 15 years. And I think about when I was young and I grew up in this area, to you know, the rate of childhood obesity and the incidence of type 2 diabetes in children was very low and we still had sweet tea and soda and Pop-Tarts and the diet was effectively the same. Some would argue that the same. Some would argue that over the years, high fructose corn syrup has sort of infiltrated all processed foods to a greater degree and there are people that think about how they can make this particular processed food more addictive by changing the sugar and salt content. So a lot of that goes on in the background and that kind of gets worse when it comes to processed food, adulteration of fructose. But what really shifted about 15 years ago was our light environment and you know we've moved from incandescent light bulbs, which emit red and infrared light, to LED lights that are mostly blue light emitting. In our homes Our screens have all shifted to LED, which is blue light, and then every person has a device in their face all day long shining blue light into their eyes. And you know I go out and see kids all the time on tablets in restaurants while they're eating. I have I think Dr Cruz posted a study looking at bumblebees and feeding bees under red light versus blue light and the prandial glucose excursion being about 50 percent higher, percent higher.

Dr Kelsey Dexter: 26:06

And you know, we know the mechanism by which blue light increases blood sugar and increases insulin by CLIP right. So I know that this is a big part of what's going on in chronic disease. And also, you know, hormones, all hormones, chemical messengers in the body have a circadian drive. They all do. Every cell pretty much does Right. And whenever we alter our light environment and we're crushing our melatonin release when we should be resting, sleep gets disrupted and that dysregulates all hormones downstream. So cortisol in particular has a it's very circadian driven with this diurnal release and it's very easy to dysregulate cortisol. And dysregulating sleep on its own will dysregulate cortisol, which increases insulin resistance. And then whenever you add blue light's independent mechanism to increase insulin by clip, it's just a tangled web overall.

Dr Kelsey Dexter: 27:19

Yeah, I really think that your food diet and your light diet are probably equally important.

Dr Max Gulhane: 27:27

Yeah, I love that, kelsey, because you are as I said this before, you're probably the world's first decentralized endocrinologist who is actively talking about the effect of light on metabolism and metabolic disease. And, yeah, no one as far as I've talked about in terms of endocrinologists are really acknowledging this. And we're really two steps removed from the standard of care here because and obviously the standard of care is not even advising patients of, or earnestly of, these dietary changes like getting rid of processed foods. This base layer is simply, you know, here's the insulin prescription, here's your GLP-1 agonist prescription, here's your metformin prescription. You know, go off, do your thing. The next level is the metabolic-focused doctors, the low-carb carnivore practitioners, who are doing fantastic work and looking at this at a food-centric point of view, again having fantastic results, still helping to reverse chronic disease, get people off insulin, reverse their diabetes. But really I don't think they're getting the whole picture here and the metabolic story, as you've just alluded to, is so much a circadian story because all those metabolic hormones and leptin, even insulin itself, insulin sensitivity, has a diurnal circadian influenced secretion and effect. The fact is that we really, in my opinion and your opinion too, we need to really encourage and recognize the role of light in affecting glucose sensitivity, blood glucose levels, insulin sensitivity, and all this and the paper that I think you might be.

Dr Max Gulhane: 29:10

There was another paper that was actually published in January and they used red light and they had a. I'll quickly read out the results. They found that 15-minute exposure to 670 nanometer light so that's in the visible red range reduced the degree of blood glucose elevation following glucose intake by 27.7%, integrated over two hours after the glucose challenge, and maximum glucose spiking was reduced by seven. So what they said is that photobiomodulation with 670 nanometer light can be used to reduce blood glucose spikes following meals. So that is the evidence. I think that provides so much great evidence that it's the light environment that is essentially modulating the effect of food on our blood glucose. Maybe talk now a bit about the kind of approach that you have to someone with metabolic syndrome and insulin resistance, particularly with regard to leptin, because a lot of people have talked about leptin and how that can make. Basically, leptin resistance can influence our ability to lose weight. So do you measure leptin in your practice or do you talk about leptin to your patients and how do you think about leptin in this picture?

Dr Kelsey Dexter: 30:30

Well, the vast majority of people I see, I know, are leptin resistant right, because leptin resistant pretty much precedes insulin resistance or accompanies it at the very least. And I talk to a lot of patients about leptin, my lab actually has no option to measure leptin, which is insane to me. So I am not accustomed to actually looking at objective levels. I just make an assumption that dysregulation is an issue, and usually I'm talking to women who say my periods are irregular, I can't lose weight, I'm barely eating anything, I'm tired, help me. And I think leptin and regulating leptin really has so much to do with circadian health, less to do, maybe, with the diet, more to do with the light, or you can't have one without the other to get it regulated. So I encourage every patient who comes in with that sort of constellation of complaints to work on their light first. This is what we always talk about, I think, actually, when patients find working on their light environment to be less intimidating than working on their food, and so I really like to get the light environment right before I try to talk a patient into a very low carb, ketogenic diet, and both at the same time can be a little bit overwhelming, but in the average patient who's working on leptin sensitivity with me. I encourage them to see the sunrise with naked eyes every day and start that circadian signal to improve their melatonin production and secretion effectively. Keto breakfast within an hour of waking up to send that meal timing, safety, satiety signal to the brain. Blocking artificial light at night not just blue light, but trying to. I talk to every patient about strategies to decrease their blue light toxicity and that's sort of the first bridge overall that we cross. I really believe.

Dr Kelsey Dexter: 32:45

As far as low carb diets, you know the average person that I deal with with pretty profound insulin resistance. If I ask that person to go straight to carnivore, the body's not fat adapted right. So as glucose in the bloodstream starts to fall with that low-carb diet, the brain is going to get a signal that the patient needs to eat carbs. And because that pathway to flip fuel sources has not really been triggered in maybe decades, the blood sugar tends to get pretty low in patients who are on low carb diets. And whenever glycogen stores are released and glycogen is extended and we get to the point where the body's asking for fuel, it's not really efficient at using ketones for fuel and that person will feel awful weak muscles, low sugar, shaking, sweating and will give up after, you know, a few days. So I do think that diets have to be really individualized with patients.

Dr Kelsey Dexter: 33:54

And one thing that bothers me a lot, just sort of in the health community is all this nutritional dogma right. So carnivores and plant-based folks fight out all the time about which is better and what's the optimal way to eat, and different bodies need different balances of macronutrients depending on health, disease and goals. But in general for metabolic dysfunction, I really don't believe anything works better than a low carb diet for a metabolic reset. So I tend to take patients meal by meal into, like slowly into ketosis after we work on their lights. So we start with the high protein, high fat breakfast and leptin reset and we might do that for a couple weeks and be really consistent with that behavior.

Dr Kelsey Dexter: 34:50

And then we start working on lunch and making cutting out the carbs at lunch and then eventually less than 30 grams of carb a day is what I recommend to sort of as a dietary strategy to work on reprogramming metabolism, and I don't expect patients to eat very low carb long term and I don't know that that's good for every person. I think our body has to be adept at using glucose for fuel and using ketones for fuel. You know, when you eat a long-term ketogenic diet, the metabolism accommodates that and you can get relative insulin resistance and when you have carbs, have really high glucose excursions if you've been in long-term ketosis. So I do really like the idea of long-term cycling of carbs.

Dr Max Gulhane: 35:45

Yeah, yeah, that's something that I've thought myself, which is it is seasonally appropriate to be cycling in and out of a fat-burning metabolism.

Dr Max Gulhane: 35:57

And you know, unless we're living in the Arctic Circle where there's only seal, blubber and caribou available for food, then it doesn't make really much sense to be in that burning mode the whole year round. So that is a nuance that I like to make, and especially that allowance is permitted when people have healed their metabolic dysfunction and when they've got all those markers under control. In terms of, I also really like your approach of gradually introducing or reducing the carb amount and I imagine for the patients that you work with, that is definitely necessary. Tell us about helping people come off these heroic doses of insulin, and my approach too, which I think maybe Dr Bernstein kind of pioneered in his treatment or recommendation for type 1 diabetics, is trying to be using the minimum amount of insulin necessary. Obviously they don't have working pancreatic islet cells, but in type 2 diabetics, who are on massive amounts of insulin, how do you think about getting them off what is essentially quite a dangerous drug and medication?

Dr Kelsey Dexter: 37:12

Oh, yeah, well, I talk to every patient about the fact that the more insulin it takes to control your blood sugar, the higher your risk of chronic disease, right?

Dr Kelsey Dexter: 37:22

So we know it's not the blood sugar per se, it's the insulin level, insulin resistance that's associated with the diseases that kill Americans type 2 diabetes and complications, cardiovascular disease and complications, alzheimer's and cancer.

Dr Kelsey Dexter: 37:38

And so when I lay that out to a patient and say hey, you're on, you know, 200 units of insulin a day, I need to get this down to the lowest amount possible. And can you help me? I can motivate some pretty significant behavioral shifts. But, like I alluded to before, I do often use insulin sensitizing drugs, in this case to decrease the burden of insulin, because if I can get the insulin level down, the patient can start to lose weight independent of the effect the weight loss effect of a GLP-1 agonist like Ozempic or Manjaro, right? So if a patient starts to lose weight and insulin sensitivity improves, I can just progressively drop the insulin and the goal in the end, as long as a pancreas is still making some insulin enough to manage glucose levels at baseline, then we try to come off of all insulin or medicines that increase insulin, because that provides the best long-term health benefit for that patient and that's the way you reverse metabolic disease right.

Dr Max Gulhane: 38:45

Love it.

Dr Kelsey Dexter: 38:47

I have had, and in regard to type 1, I think, in the past. Patients who have type 1 diabetes don't make insulin from their beta cells so we have to have insulin to survive and insulin has gone through many iterations and evolution in the last few years and it's been a really exciting time to be in endocrinology because our options for treating type 1 diabetes have broadened so much. In the past if a person was insulin deficient they would be on a long-acting insulin for basal coverage that works either six hours, eight hours, ten hours, and then over the years these long-acting insulins have improved so that you give one injection and you get a 24-hour coverage of needs. But what we do on injection therapy is we try to estimate the best median need of insulin right.

Dr Kelsey Dexter: 39:53

So when you have a fixed dose of basal insulin in a patient who is dynamically using glucose, there are going to be days when that dose is perfect, optimal days when they've been more active, eaten less, different cycle time for women, et cetera, when it's going to be a little bit too much. And then there are going to be days when they're stressed, sick, not moving whatever, where that basal need is going to be higher. So in general there's been a tendency to cover mealtime insulin needs with a basal insulin in the background. Even in patients who have type 1, doctors tend to slightly overshoot the basal dose requirement to try to prevent the blood sugar from going too high when the patient eats, and that causes the patient to have to eat to maintain their maintain normal blood sugars. And the higher the insulin dose in the background, the more likely a person is to gain weight, since insulin inhibits lipogenesis, lipolysis.

Dr Max Gulhane: 41:07

Lipolysis.

Dr Kelsey Dexter: 41:08

Yeah, lipolysis, lipolysis, lipolysis, yeah, lipolysis. And so in many patients with type 1 diabetes, when they're started on insulin therapy, they immediately start to gain weight, and the more weight that's gained, the more insulin resistance. And they don't have the option really to suppress insulin, which is what's required to burn fat stores right, because they have this constant injected dose. That's the same all the time. Patients with type 1 are also taught to be scared of ketosis because we have a life-threatening complication of DKA. So patients try really hard to avoid ketones in general whenever they have type 1 diabetes. And when you eat to support your insulin dose, you're consistently gaining weight and you're never in ketosis that creates metabolic disease. So I'm really, really excited about the landscape of type 1 diabetes treatment now because you know, as far as insulin delivery, our gold standard is hybrid closed-loop insulin pumps and whenever you have a glucose monitor that can communicate with an insulin delivery device, you can program that system to turn off whenever glucose levels fall. So for the first time, patients who have type 1 diabetes have this option to only get insulin when they need it, right, and that opens up this pathway to improve metabolic health dramatically in that population. Improve metabolic health dramatically in that population and you know I've got I really I argue with insurance companies about this all the time but I really believe that type one and type two diabetes coexist.

Dr Kelsey Dexter: 43:04

Frequently I have patients who have known pancreatic islet destruction. Our insulin deficient have gained, you know, 150, 200 pounds over the years and I know that if their pancreas were functional it wouldn't be making 200 units of insulin a day. It wouldn't be able to. So they would effectively have type 2 diabetes if they had a functional pancreas based on their insulin requirement. And I have used medications like GLP-1 agonists, like Ozempic and Majaro, in patients sort of off-label, who have type 1 diabetes, to decrease the insulin burden and I've seen incredible improvements in metabolic health over time, which has been really rewarding.

Dr Kelsey Dexter: 43:58

So you know, I've got a patient I can think of offhand who was using about 250 units of insulin a day to control his blood sugar and now he's down to 20 units a day and he's lost 100 pounds. And then, once we restore metabolic health, I try to wean patients off of the GLP-1s and usually if we have been working on light environment diet, changing behavior and they're educated, they know like the more insulin they need, the faster like this metabolic disease can come back. You know they tend to do really really well. So I've had many patients with type 1, you know that are incredibly insulin resistant who have benefited from all these practices as well. But we try really hard. Every patient that's taking insulin I want them to take the least amount possible, yeah.

Dr Max Gulhane: 45:01

Yeah, I love it, kelsey. There's so much gold there for what you just said, for family doctors and for other endocrinologists, and I want to summarize a little bit of it, and specifically around the nuance of these GLP-1 agonist drugs like Ozempic, and what I think is that it's a completely different kettle of fish for people who are sick and the ones that we're talking about on a clinical point of view is not the same as the person who's trying to lose five kilos has nothing wrong with them and is using his to lose weight. That's completely a different story, and what I think you're really showing us is that these GLP-1 agonists can be used very judiciously to help people regain insulin sensitivity and therefore bootstrap this whole process of resolving their metabolic disease and improving their metabolic disease, because it allows us to get that total exogenous insulin dose down quicker. And, as you said, for people who aren't aware, the larger the insulin dose, the more risk of a hypoglycemic event, the more risk of a hypoglycemic coma and something very, very bad. So I really like that nuance there and that's the reason why anyone who is taking medications really needs to see a metabolically trained doctor, because there's all these nuances around drug weaning that we have to go through to make sure that this whole process can happen safely. So that's a great point.

Dr Max Gulhane: 46:28

The other point is that loop of carbohydrate consumption in those with type 1 diabetes. The other point is that loop of carbohydrate consumption in those with type 1 diabetes and this is something that you see not only in type 1 diabetics, who have remember for the listener an autoimmune destruction of their body's ability to make insulin it's not only them, but it's also gestational diabetics. So late in pregnancy we see people become quite insulin resistant and women often get prescribed insulin to again maintain their blood glucose lower. But what we commonly see is that people get put on a high dose of carbs because they're on insulin and there's this drug loop of glucose and insulin. They're both drugs. People are taking a high insulin dose because they're eating carbs and therefore it's a vicious cycle that escalates upwards and upwards and from thinking from first principles.

Dr Max Gulhane: 47:22

I mean, I'm not an endocrinologist, but it's obvious to me that that is not a winning strategy if we're trying to optimize people's health in the long term and maintain the insulin sensitivity, reduce their total lifetime. Insulin signaling in the body.

Dr Kelsey Dexter: 47:38

Yeah, I think this is sort of the old diabetes education framework, right? If you have a fixed dose of insulin that you're giving someone multiple times a day, you need a fixed amount of carb to be eaten with that insulin, or else you have low blood sugar. So I think that's kind of where it came from right, this recommendation to eat what I think it's like 50 grams of carb per meal, which is insane. That's what the average patient who's had diabetes education comes in and tells me. I said, well, I'm eating 50 grams of carb a meal like I'm supposed to, but anyway, we just have to learn better and do better.

Dr Max Gulhane: 48:16

Yeah, it's my hobby horse because I think there's so much harm being done by these high-carb dietary recommendations for type 1 diabetics and gestational diabetics. If they're eating a meat-based diet, a lot less carbohydrates, then the whole body's demand for exogenous insulin goes down and the whole process is much more. The body is healthier. I want to talk about a topic that you just alluded to, which is a disease called latent onset diabetes of adulthood, which is essentially this coexistence of both type 1 and type 2 diabetes, and it is something that we can see sometimes in someone who's perhaps gained weight, but they're essentially not only insulin resistant but they become insulin deficient too. So talk about that and why it's a very important diagnosis for any doctors listening to consider when they have someone who is perhaps making a new diagnosis of diabetes.

Dr Kelsey Dexter: 49:20

Yeah, so you know, in the past we called type one diabetes juvenile diabetes because it tends to occur in kids, and there's a known autoimmune pathway that involves the destruction of beta cells that produce insulin. That result in an insulin deficient state there, and then most often patients with type 2 diabetes get there through an insulin resistance pathway, so the pancreas can't make enough insulin to overcome the body's resistance, which causes blood sugars to rise, and then so it's not a disorder of insulin deficiency, it's you need to improve insulin resistance to help the blood sugar come down. So completely different conditions. Then we know now that type 2 diabetes can occur in children, right, because of severe insulin resistance that we see, which is likely, as we said, related to light environment in young kids, and we also know that the iPad in the mountain I had yes, in the mountain at the same time.

Dr Kelsey Dexter: 50:26

And then we know that autoimmune type 1 diabetes can occur in adults, and I don't really think about LADA latent autoimmune diabetes of the adult right as being a type 2 variant.

Dr Kelsey Dexter: 50:41

It's a type 1 variant. The average person I see that comes in with LADA has been treated as a type 2 by a primary care doctor for, you know, five or 10 years with an A1C of about eight and on four different medicines for type two diabetes and isn't getting better. And so then I check that patient's endogenous insulin reserves and screen for type one antibodies and they are not making much insulin. They're making some, but not much, and then they have positive antibodies. So I call that patient a lot, but when you consider that the average American is insulin resistant already, right, you have these patients that end up with type 1 who still have maybe a little bit of insulin, and so it's this area where we're dealing. They're really two independent pathophysiologies that can coincide in any patient, and so the average person that I have with type one or LADA is also insulin resistant and they can benefit from both types of therapies, you know have to take insulin but also have to work on the resistance pathways.

Dr Max Gulhane: 51:58

Yeah, yeah, and I think that if there's been the way I think about it, if there's been a sudden, relatively sudden, maybe over a year kind of decline in blood glucose control or increase in the HbA1c, despite someone being pretty adherent to a good lifestyle, then that's my kind of prompt to check the C-peptide, check the islet autoantibodies, to make sure that we're not also dealing with a concurrent insulin deficiency process which would necessitate even a little bit of exogenous insulin.

Dr Max Gulhane: 52:29

But that is really helpful and I think it's important for doctors to think about because, like you said, they're coexistence and if we tie in the light environment and we're thinking about how dysfunctional people's light environment is, how vitamin D deficient they are, so we know that immune function is so intrinsically linked to our sunlight exposure and therefore our vitamin D levels that not only does infectious disease susceptibility, but also autoimmune disease is going to be going hand in hand. So if the patient is guzzling the Mountain Dew and on the iPad in front of the TV for decades and they're vitamin D deficient because they never go outside, it makes a lot of sense to me that they would be at risk of this autoimmune process in addition to the insulin resistance process.

Dr Kelsey Dexter: 53:22

And yeah. So there's quite an overlap in endocrinology and sort of autoimmune disease etiology of glandular diseases. So I think about this a lot too because I have, you know, many, many patients with Hashimoto's and Graves' disease, which are autoimmune diseases of the thyroid, and then Addison's disease, which is autoimmune destruction of the adrenal glands. Autoimmune diseases in general are increasing pretty dramatically and I really believe that our altered light environment has played a big part in that. And vitamin D deficiency right. So every I check vitamin D in every patient that I see and unless a patient is actively supplementing consistently, they are going to be low every time.

Dr Kelsey Dexter: 54:14

And I talk to patients a lot about the benefit of making your own D from cholesterol right in response to sunshine. And I view vitamin D deficiency as a surrogate marker of light deficiency, natural light deficiency of light deficiency, natural light deficiency. So I really don't like high dose prescription vitamin D supplements. I don't think that giving huge doses of once weekly vitamin D which is really the only prescription version of vitamin D that's available so that tends to be what physicians give patients I don't think that that's probably the optimal way to replace severely deficient bulbs too In the wintertime. You know, supporting vitamin D levels.

Dr Kelsey Dexter: 55:02

If you didn't get your vitamin D level to a robust place by the end of the summer through sunlight exposure is probably important. I really try to recommend that patients do daily D3 instead of weekly D2. So anyway, but I see some patients that you know I end up getting a lot of malabsorption syndromes that have low calcium. Patients that have low calcium from either gastric bypass or they've had parathyroid surgery and now have chronically low calcium and there is no way for me to supplement their D and get their level to a perfect place. It just cannot happen. And for those patients we talk so much about UVB exposure and building a solar callus early in the springtime and I have seen miraculous improvements in these malabsorptive, low calcium patients who have actually taken this on and and made a commitment to get intentional uh low intensity sun exposure it's, it's so pivotal.

Dr Max Gulhane: 56:19

This the light story. And and tying it into endocrinology, is this this marker that we measure um 25 hydroxy vitamin d is basically a proxy. That's how I think about it too. It's basically a rough proxy of the solar yield that that patient has had and deficiency, which is. In Australia it's defined as essentially above or below 50 nanomoles per liter. But that kind of target was set as avoiding any of the frank bone complications. That's mild deficiency and then more severe is under 30. And I know you guys use nanograms per deciliter, but when you look at the other roles that vitamin D plays in the body processes, especially to do with the immune system, getting it above 75 is much more reasonable still too low in my opinion. And then if you look at these traditional hunter-gatherer peoples and outdoor workers, it looks like a natural vitamin D level is hovering above 100, around 120 nanomoles per liter. So do you target any particular number or what do you do in terms of target any particular number or what? What do you do in terms?

Dr Kelsey Dexter: 57:34

of um aiming to to get people's vitamin d2. Oh, I would love to see vitamin d is over 80 um, but in general um, my treatment goal is over 60, if we can get it there. Yeah, um, in our standard labs we consider less than 30 to be deficient, but you know, I think about 40 as being probably deficient. It's definitely not optimal. So I have so much overlap with other providers and I, you know, see lots of patients come on and off these high-dose vitamin D supplements. They'll get their vitamin D replete to 35, and someone will stop their replacement in the middle of winter and then they can't maintain it, etc. So, yeah, I pay a lot of attention to vitamin D and, like I said, we try to keep patients over 60 if possible and get that through sun exposure when possible.

Dr Max Gulhane: 58:28

Yeah, and that's the solar callus concept too, which I think could be one of the most important facets of this whole lifestyle change that could potentially alleviate so much metabolic disease as well as cardiovascular disease and cancer. And my interview with Richard Weller, which will be released by the time this goes out his data has shown that people who have higher UV exposure are living longer and they've got less cardiovascular mortality, less cancer mortality. So we're really kind of up against these skin cancer narratives when we're trying to encourage people to build a solar callus, but in terms of the weight of benefit and risk, I think it's undoubtedly clear that people need to be getting more progressive UVB and full-spectrum sunlight exposure.

Dr Kelsey Dexter: 59:16

I recommend sun exposure to generally every patient that I see. For these reasons, these myriad of benefits and the number of patients that tell me that they cannot tolerate the sun and argue with me on this is significant, significant. I'm allergic, tolerate the sun and argue with me on this is significant, significant. I'm allergic to the sun. I get rashes and hives in the sun, I can't sweat so I can't go outside, et cetera. And my personal anecdote okay, I was a big-time sunscreen lover, like I said, my entire life.

Dr Kelsey Dexter: 59:51

I had a reputation for being the palest person around, especially my family, and I always thought that I was sun sensitive right, because I had no innate protection. And I walked out in the sun in the middle of July, got burned in five seconds, so I thought I had fair skin and was sun sensitive. July and got burned in five seconds, so I thought I had fair skin and was sun sensitive. And then, whenever I started, I had my own health issues. That got me on this journey to it really started with with vitamin D and the sun in relationship to the benefit, um, to the neurologic system, right. So I decided I was going to be my own experiment and I started a couple years ago in March with the D-Minder app, outside in the mornings in the low intensity light, and by the time I got to summer, with no sunscreen, I could, you know, lay out at solar noon for an hour and a half and not get a sunburn.

Dr Kelsey Dexter: 1:00:52

And so I proved it to myself as a person who always thought she was sun sensitive, and I've since done the same thing with my kids. Right, and people around me are sort of amazed at this. So I really, I really believe that anyone can tolerate some sun. Right, we are designed to be receptacles for sunlight Like this is. This is our physiology. It's all wrapped up in this light story and every person can get some exposure safely. Start with low intensity and let the skin be exposed to beneficial protective frequencies in the light spectrum red light and infrared light, right to help mitigate damage, and over time, there's clear benefit to everybody that tries it. I think.

Dr Max Gulhane: 1:01:45

Yeah, I couldn't agree more and it's a misconception that people with Fitzpatrick even one uh skin need to, you know, avoid the the sun. And based on what we know about the benefits of sunlight for health and, as you mentioned, we are receptacles for uh sunlight and our body has evolved these mechanisms to harness ultraviolet light through melanin, um to harness infrared light through things like the cerebrospinal fluid and the work of Scott Zimmerman. So it's so key and that's why I've released a solar callus course so people can check that out if they want to get all the information they need to safely get sun exposure. Can you talk now about thyroid disease, and particularly in the context of both insulin resistance and maybe leptin resistance, because so often I see women who are having problems with their hormones. They're having problems with their sleep, frequent snap or being hungry, frequently stubborn weight, they're pale and they have some degree of thyroid dysfunction. So can you explain to us and the listener how do you conceive about the thyroid within the context of the things that we've talked about?

Dr Kelsey Dexter: 1:02:58

So the average person that comes to me with that constellation of symptoms assumes that they have a thyroid problem, right? So the collective narrative is if you're having trouble losing weight and you're tired all the time, it's probably your thyroid. And so I did a lot of just general thyroid screening to look for thyroid disease, primary thyroid disease, and for me that's pretty extensive. In my clinic I think I probably do more testing than the average endocrinologist and screening antibodies, thyroid antibodies in every person that comes in and a full thyroid panel. And often in that patient there is no thyroid dysfunction or perhaps there is a very like. The thyroid levels are slightly suboptimal but still in the normal range.

Dr Kelsey Dexter: 1:03:53

And then the question always is you know that patient has been reading, it says information is everywhere. So patients come in very well informed and will say to me you know that PSH is not optimal and why. And then we have to talk about the interface between leptin, leptin resistance and how this has an impact on overall thyroid function. But the issue itself is not the primary thyroid dysfunction, it's leptin resistance, which is a really common issue, and so you know. Then again we're talking about low carb diets and light diets in those patients.

Dr Max Gulhane: 1:04:42

Yeah, yeah, no, that's great advice and it's become so simple often, but it's also a process of education and helping people understand that they need those light signals to essentially kick off the whole hypothalamic pituitary thyroid axis and we need those morning light signals to get the party started. From a thyroid point of view, and maybe because you're a consultant endocrinologist and this is kind of these couple more nuanced topics, can you talk about things like something like Addison's disease or maybe some other more traditional endocrine pathology that you see that might be related to or contributed to by lifestyle and light?

Dr Kelsey Dexter: 1:05:38

So autoimmune disease is a little bit nebulous in general, right, because Western medicine says we don't really know why immune systems turn on bodies and there are a lot of theories that have to do with gut dysfunction, leaky gut, post-viral syndromes etc.

Dr Kelsey Dexter: 1:05:54

And I don't really know about a direct relationship in literature or understanding with light, environment and autoimmune diseases. But there is, like you said, a direct impact of vitamin D deficiency on decreased immune function and I'm not sure if that's the primary mechanism by which this interfaces, but it could be. I do think that because our light signaling has such a profound impact on every body system, if you are trying to heal autoimmune disease, you have to get your light right, and we know that there's a direct relationship between D deficiency and multiple sclerosis, which is an autoimmune disease of the nervous system, and we just supporting the body on a foundational level involves getting these factors optimized right. So we get our light environment right, we drink clean water, we eat healthy, nutrient-dense food that's relatively low carb. They're just like it's part of the package to encourage healing in any kind of autoimmune disease, I think.

Dr Max Gulhane: 1:07:17

Yeah, yeah, I agree with that totally. Maybe we could finish on a couple more kind of lifestyle practices or aspects that you think people could include to improve their their blood glucose, and we obviously we've talked a lot about light, um, and I mentioned that study about the effect of red light 670 nanometer, which is essentially you can get from from the morning sunrise and, and the evening, um, sunset, um, but and we've obviously talked about a lower carb diet, but tell us how you think about things like cold exercise and maybe stress in terms of that blood glucose, and maybe what people might even measure on something like a continuous glucose monitor.

Dr Kelsey Dexter: 1:08:01

Oh yeah, so I love objective measurements of blood sugar to try to help people determine how they can get better control of their glycemic health and use this a lot. But I generally think about metabolic health as being this ability to bounce in and out of fat metabolism easily right easily and cold thermogenesis. Of course, when you have the ability to make heat in your brown fat from your fat stores, it improves insulin sensitivity, and I've I've done some experimentation with this on myself, where I put on a continuous glucose monitor and get in a cold plunge for three minutes and I can see my blood sugar fall from, you know, 90 to 55 within just a short, short amount of cold therapy. So that's pretty exciting overall and I talked to a lot of patients about getting cold air exposure like just underdressing for the weather, because that's a good gateway into cold therapy for most people and it's not very intimidating and many, many patients are very receptive to that when we're talking about improving insulin sensitivity and helping metabolism, our muscles hold our primary stored form of glucose right, so muscles are the biggest source of glycogen that we have in our bodies. We hold about 500 grams of glycogen in muscles on average and then about 80 in the liver. So whenever our blood sugar falls in fasting state or we're using energy, glycogen is the first thing to be mobilized and so the bigger reserve you have for holding glycogen, the less glucose will be shuttled into fat stores whenever you have a blood sugar rise. So improving muscle mass, increasing muscle tone and strength is a great strategy to improve insulin sensitivity strategy.

Dr Kelsey Dexter: 1:10:11

To improve insulin sensitivity and I really think you know there are lots of health influencers that tell the general public that you know, you know I eat rice three times a day and I have metabolically flexible and you can, you can eat carbs and still lose weight, et cetera.

Dr Kelsey Dexter: 1:10:27

And that completely has to do with how insulin resistant a person is, how much muscle mass they have, how much they move every day, right. So for the average person that I see who doesn't exercise or can't because of chronic pain or issues with very low muscle mass reserve and very low activity, that person is going to benefit from carb restriction, trying to get cold and any amount of activity they can muster. But you have to lean more heavily into diet and light when you can't move and build muscle right, and so it's a stepwise approach. You get a little bit healthier when you can't move and build muscle right. So it's a stepwise approach you get a little bit healthier, you can move more and then you can integrate eventually more carbs into your diet if you improve the metabolic issue and then are able to build some muscle et cetera, and get healthier.

Dr Max Gulhane: 1:11:26

Yeah, no, I know what you're saying. You read posts by guys like Carnivore Aurelius about eating carbs, croissants and orange juice and all this kind of thing, but really they're talking to that 7% of people who are metabolically healthy in society and that advice is just completely inappropriate for someone who is spending 93% of their time indoors. You know on the Mountain Dew and you know TV blue light diet. It's not appropriate and it's not transferable in any way. I agree that we have to fix this underlying insulin resistance and metabolic dysfunction before you can earn back the right to eat things like seasonal carbs.

Dr Max Gulhane: 1:12:11

The points that you made about the cold are very, very well taken, great advice, and I interviewed Thomas Seeger and I really encourage people to check out my episode with that and he noticed the same thing that if he decided to eat a cake or something like this, he could simply pop in his cold plunge, his ice bath and essentially suck the glucose out of the system. And that is the power of the brown fat and the cold adaption. So rather than chasing carbs with insulin, maybe we need to be chasing carbs with cold plunge, because that's a much better way of getting the glucose out of the system. The other point is this concept has actually got a diagnosis, which is sarcopenic obesity, which is the confluence of both sarcopenia so low muscle mass and obesity. So that is something that we see in nursing homes so commonly, which is that really bad combination of having no muscle, very low muscle mass, and being insulin, being insulin resistant and metabolically sick. And you know the antidote to that, I mean, I think sarcopenia, obesity, the reason why people get it is because they're so profoundly disconnected from an ancestral lifestyle and basically everything that we've talked about you know in this past hour, good thing to be aware of.

Dr Max Gulhane: 1:13:23

And if you see someone, you know they're sitting in a chair, frozen essentially in a chair frozen essentially in a nursing home, not moving, and all these endocrine systems are completely you know they're going wrong. They're leptin resistant, insulin resistant. So maybe, yeah, just fixing it starts with doing everything we talked about, but particularly the light and the food, because you don't have to necessarily be physically active to start those two. Fantastic. Kelsey, did you have any other kind of thoughts that you wanted to share with everyone? Maybe to colleagues, because we've talked a lot about some of the technical ins and outs of treating insulin resistance. Maybe you have some message from some medical or doctor colleagues who are listening.

Dr Kelsey Dexter: 1:14:08

I think primarily we have to understand that pharmaceutical medicine is not going to be the answer to heal metabolic issues and we can't just lean on that toolbox. We have to get interested in physiology again, right, and how our body works, and I found that leaning well, learning from other colleagues, being humble and open-minded is probably the most important part of growth as a provider and a healer. And we don't know everything in Western medicine. There's so much we don't know and I have learned and changed my mind and changed my approach on treatment options so much over the last 10 years and we have to get back to foundational health practices and supporting vital functions in patients and letting the body heal itself, because it's very capable in many cases of restoring balance when the right inputs are received. Yeah, Amazing.

Dr Max Gulhane: 1:15:26

Well, dr Kelsey Dexter, thank you so much for talking to me and I think your message is so, so well received. So how can people get in touch with you if they want to send your message or or have a chat or what, or, basically, or see you as a as a patient?

Dr Kelsey Dexter: 1:15:41

well, I, you know, see patients in Jackson, Tennessee and on telehealth, Um. But I I have a a social media presence, um on Instagram. I am sort of active there, not really, but I'm open to getting any kind of messages through that platform too.

Dr Max Gulhane: 1:16:01

Cool, great, all right. Thank you very much.