Analysis of Type 2 Diabetes, Fatty Liver, Insulin Resistance, and Internal Starvation
Dr. Jason Fung
Dr. Jason Fung completed medical school and internal medicine at the University of Toronto before finishing his nephrology fellowship at the University of California, Los Angeles at the Cedars-Sinai hospital.
He now has a practice in Ontario, Canada where he uses his Intensive Dietary Management program to help all sorts of patients, but especially those suffering from the two big epidemics of modern times: obesity and Type 2 diabetes.
Dr. Fung uses innovative solutions to these problems, realising that conventional treatments are not that effective in helping people.
A .PDF version of the slides used in this presentation is available here; http://denversdietdoctor.com/wp-conte…
Transcript
How to Reverse Type 2 Diabetes Naturally
0:19so today what we’re going to talk about is insulin resistance because that’s really the heart of type 2 diabetes and
0:26uh this is my disclosure so I don’t really have any commercial interest um
Presenter Disclosure
0:32so type 2 diabetes is a really important disease because it causes most or is
0:37associated with most of the diseases that we care about today which is heart disease cancer Alzheimer’s disease and
0:42so on but we really have to think about this insulin resistance in a new
0:48paradigm because the one that we’ve been taught the one that we understand actually isn’t the one that’s really true and so type two diabetes is a
0:55disease with two phases right so there’s uh if you look at the time course of the
Two Phases of Type 2 Diabetes
1:01blood glucose before the diagnosis of type 2 diabetes there’s actually two phases so there’s a long slow phase
1:07where the blood glucose Rises very very slowly and that’s where the insulin resistance is rising okay but the body
1:13produces enough insulin to overcome this resistance so the blood glucose stays relatively normal it’s compensated right
1:20so it’s called a compensatory hyperinsulinemia at some point the the
1:26pancreas doesn’t produce sufficient insulin either the insulin resistance is too high or the the amount of insulin
1:33drops so because you lose this compensation the blood glucose goes up in type two diabetes is diagnosed but
1:39that’s relatively late in the game the slide shows you that even up to 14 years
1:44prior to the diagnosis of type 2 diabetes you get this Rising insulin resistance so you can see this when you
1:50look across the spectrum of lean people and obese people then as they develop more and more pre-diabetes than diabetes
1:57the insulin resistance goes up and up and this is a slide of the beta cell so the beta cell in the pancreas produces
Beta Cell Dysfunction
2:03insulin and this is the black circles you can see as you go across the Spectrum from normal to obese to
2:09pre-diabetes to diabetes insulin uh production initially goes up so as you
2:14go to the middle the black circles you can see that it goes up but at some point it drops and the white circles is
2:20the blood glucose and you see as the insulin production drops the blood glucose goes up and you make the
2:25diagnosis of type 2 diabetes but the key problem there’s two key problems right resistance and the beta cell dysfunction
2:32and for this reason people tell you that the beta cells are burning out right and that’s why type two diabetes is chronic
2:39and Progressive and eventually you know you take medication then you take insulin then you take more insulin then
Learned Helplessness
2:45more insulin more insulin and that’s the way we tell people to think about type two diabetes unfortunately it’s not
2:51really true so the key is to understand what instant resistance actually is okay
2:58where where does it come from how does it develop so in order to understand insulin resistance you got to think
3:03about what insulin normally does so when you eat food insulin goes up right
3:09insulin basically tells the body that food is coming in and you should store some of it so you store sugar in the liver which is glycogen and you store
3:16fat also so if you produce if you eat too much uh carbohydrates then that is
3:21going to be produced by a process called denovo lipogenesis into fat and when you
3:26don’t eat which is simply called fasting right that’s just the flip side of eating when you don’t eat instant Falls
3:33and as it falls it tells your body to pull some of that sugar and pull some of that fat back out of the system so as
3:39long as you balance your feeding and fasting you got a well balanced system you don’t actually gain any weight right
3:45because you eat you store Sugar you don’t eat you fast you burn sugar right
3:51that’s that’s basically all it is so insulin does a couple of things so it lets all the glucose into the cell but
3:57it also produces uh this new fat right that’s the denovo lipogenesis so there’s
4:03two functions not simply one and this is the way we think about type two about insulin resistance it’s this lock and
The ‘Lock and Key’ paradigm
4:09key Paradigm that insulin acts like a key on the cell so this is for example a
4:15liver cell so you have receptors which is like a lock when insulin is produced it opens the gate and it lets all the
4:22glucose in so what we tell people is that insulin resistance is actually a
4:27state where this mechanism this lock and keep Paradigm is completely gummed up okay so it’s not that the lock is
4:34defective or the key is defective because you can easily sequence the insulin or the insulin receptor they’re normal but something is gumming up the
4:41system so all the glucose stays outside and the cell faces this state of quote
4:47unquote internal starvation right because it can’t go in what that means of course is that the
4:53liver cell cannot produce fat right you got no glucose in there you’re not going to produce fat so so what internal
5:00starvation looks like is this because we know in type 1 diabetes untreated type 1
5:05diabetes that the cell faces internal starvation and you look like the uh the
5:11patient on the left so she’s starving away you can feed her whatever you want she can’t use it and she basically Wass
5:18away until she dies if you give her insulin her cells now don’t have the internal starvation and she regains the
5:25weight so great we know that’s what happens when the glucose can’t go in but
Internal Starvation?
5:30this is what type two diabetes looks like right this is what we’re calling
5:37internal starvation there’s something a little bit wrong with that Paradigm of a gummed
5:42up lock and key system because there’s a paradox here that is not explained by
The Central Paradox
5:48this gummed up locking key because if you look at this liver cell okay so
5:54insulin it pushes the glucose into the cell and if your insulin resistant it
5:59doesn’t do that so okay that’s great but the other thing this liver cell is supposed to do is turn on production of
6:06new fat so if you’re insulin resistant you can’t produce any new fat so like that untreated type 1 diabetes you waste
6:12away but that’s not the case in type two diabetes if the glucose is not going into the cell how is this cell producing
6:20tons and tons and tons of fat because we know that the type two diabetes the insulin resistant patient has a lot of
6:27insulin resistance has a lot of fatty liver in fact you always see the fatty liver right so how can this cell the
6:34very same cell the very same insulin the very same insulin receptor be resistant on the one hand to
6:42one of the functions and super sensitive to the other function it’s not correct and we’ve based our entire
6:49treatment of type two diabetes on an incorrect Paradigm so what happens in
Liver Cells
6:55this liver cell of course is that you have insulin as you have insulin it puts
7:00the sugar and the fat into the liver so I’ve depicted the liver as a balloon
7:05right so it blows up when you eat as insulin Falls it comes back out right that’s all it is it’s a storage problem
7:13but the problem with fatty liver is that if it fills up with persistent insulin
7:20so if you eat a lot of glucose if you eat a lot of fructose you’re going to fill up this liver cell right because
7:25insulin you’re acting all the time you’re going to keep pushing it into storage what happens is that you get
Fatty Liver causes Insulin Resistance! Stored Sugar
7:30fatty liver right that’s not so hard to understand but it’s this fatty liver that’s the key to understanding insulin
7:36resistance because if you have a huge fatty liver that same dose of insulin is
7:43not going to be able to shove any more fat into this fatty liver and if you don’t have insulin then it all of this
7:50fat and sugar just comes whooshing back out right so the reason that you have the central Paradox is because this is
7:57an overflow Paradigm right the the glucose can’t go into the cell but the
8:02fat keeps coming out if the glucose couldn’t go in you couldn’t make the fat but it’s not a underfilled cell it’s an
8:09overflowing cell right and this fatty liver precedes the diagnosis of type two
Fatty Liver precedes T2D
8:15diabetes because it’s on that long slow rise where you get the slow rise in the blood glucose slow rise in the insulin
8:21resistance so this is the White Hall study which shows you the time course of the liver enzymes before the diagnosis
8:28of type 2 diabetes and what you can see is that they broke the group into two groups one that
8:34eventually developed diabetes and one that eventually didn’t and what was the big difference well if you look at the
8:39markers of liver uh test you can see that the liver is slowly getting
8:44distended and slowly getting inflamed those alt which is the marker of liver damage is slowly going up and what they
8:51called it is the long Silent Scream from the liver you can’t hear it you can only see it on the blood test you might be
8:57able to see it on CT or M ey but it’s this big fatty liver that’s the key to
9:02understanding the insulin resistance so it’s really an overflow Paradigm right so the cell is like this
Insulin Resistance is an Overflow Phenomenon
9:09luggage right as you fill it up it’s harder and harder to put in more stuff
9:15so at first you can put in your clothes fine but that those last two T-shirts you just can’t shove them in right so
9:23you use more Force you use more insulin to keep shoving stuff in but that’s not the problem
9:30the problem is not the insulin the problem is that your cell is overfilled it’s an overflow Paradigm just like this
9:38your cell is like a train right and it’s got passengers and normally they go in insulin opens the door stuff goes in but
9:45what happens if that cell is already filled right if it’s already filled with glucose and fat that liver cell you keep
9:51shoving it in with insulin that’s not the solution right because you have the wrong Paradigm you think that the the
9:58train is not opening the door so you hire these these guys to keep shoving
10:03people in they do this in Japan um because because it’s cool um but the
10:11problem is the glucose stays outside right the passengers can’t get in so you keep trying to shove it in which is fine
10:16at first then you go to the next stop you hire more guys right hire more insulin guys keep shoving it in right
10:22and H happens works for the next stop then you hire more guys you keep shoving it in until you can’t anymore then
10:28everybody stays outside you make the diagnosis of type two diabetes so the key to understanding type two diabetes
10:33is it’s all about the fatty liver as Mark just talked about right the cell the liver cell is just packed with fat
10:41so you can’t shove any more in that’s the whole point in the meantime the liver is busy trying to decompress
10:47itself of all this fat right so what it does so it’s making all this new fat
10:53through denovo lipogenesis and it packages that through triglycerides in the blood right and it’s pouring out
11:00this triglycerides and that’s why denovo lipogenesis is so high it’s not
11:05resistant remember this is the effect of insulin it’s super sensitive it keeps trying to push it all out so how do you
11:11get fatty liver well it’s not so hard in geese right this is how you make fagra
11:17right so you take a goose you shove a tube down his neck and what do you feed it well you feed it starch right because
11:24you want the liver to make new fat you don’t make new fat by fat humans don’t
11:30do that the dietary fat does not go to the liver it goes directly into the bloodstream through kyom microns into
11:36the thorasic docked into the lymphatic system but what happens is when you feed it starches and fructose particularly
11:44you get fatty liver and that’s what happens in humans as well when you overfeed carbohydrates glucose and
11:50fructose you get fatty liver and that’s how you get insulin resistance so the
What causes Fatty Liver? Hormonal Obesity
11:56keyy again to understanding this is that it’s hyperinsulinemia high insulin but
12:02also this insulin resistance that’s the key to obesity that’s the key to insulin resistance that’s the key to everything
12:08so if you eat a lot of fattening carbohydrates on the left you can stimulate insulin right and that will
12:14lead to obesity but High insulin levels over a long period of time are also going to stimulate fatty liver right as
12:21you produce this new fat through denovo lipogenesis which is going to lead to insulin resistance which is then going
12:27to lead to high insulin level again but fructose doesn’t do this right so this
12:34is why everybody used to say fructose ah it’s not that bad for you sugar is not that bad for you right because fructose
12:40does not raise your blood glucose it’s a different sugar altogether and it doesn’t raise your insulin levels so
12:46people said ah great fruit sugar right it’s great it’s not great the problem
12:51with fructose is the way it’s metabolized in the body it’s metabolized solely in the liver okay so if you take
12:59sucrose so sugar is sucrose which is equal parts glucose and fructose when
13:05you eat glucose and fructose you have equal amounts if you take an average
13:10size man 170 pounds you eat a pound of sugar so you get half a pound of glucose
13:16and half a pound of fructose 170 pounds of the glucose is metabolized by the body okay so every
13:23tissue in your body every part of your body is going to use that glucose
13:29but none of it uses the fructose right so that half a pound of sugar sorry half
13:36a pound of fructose is metabolized by 5 pounds of liver okay so what does the liver do
13:43with it well the liver could turn it into glucose but you got lots of glucose
13:48so it turns it into fat right so instead of 170 lounds of tissue using glucose
13:57right so your cells are kind of helping themselves to you this all you can eat glucose Buffet nobody touches the
14:03fructose right so the fructose goes into the liver and gets turned directly into
14:10fat so what it means is that if you only have five pounds of liver me using it
14:16the the the glucose and the fructose are not equally bad for you the fructose is
14:22like 20 times as bad as the glucose so the starches the rice and the passes and
14:29stuff that’s all glucose but the fructose is really where the money is so glucose plus fructose is
14:38what gives you fatty liver which gives you the insulin resistance and what’s glucose and
14:44fructose right is sugar and everybody knows this right every diet says to to
14:53to cut the sugar even those diets that say oh you should eat starch oh but by the way you shouldn’t eat sugar as well
14:59well right because the fructose is really the big problem and it’s the fatty liver so that’s insulin resistance
15:06it’s all about predominantly fructose also glucose and a lot of fatty liver
15:11what causes this beta cell burnout doesn’t it burn out doesn’t it die out right and that’s why once you get type
15:18two diabetes it’s irreversible right well again we know that’s not true
15:24because we can prove it if you look at studies on bariatric surgery well this
Surgery cures diabetes
15:30is a study comparing medical intervention to bariatric surgery so this is weight loss surgery they cut
15:35your stomach to the size of a walnut right and then they rewire your intestine so you can’t absorb what you
15:41put in your stomach and what happens of course is that the people on the left started out with almost three diabetic
15:48medications and very quickly within three months many of them were off all
15:53their medications with normal blood glucose their diabetes completely reversed and this happens even far
16:00before much weight is lost right so if you’re telling me that the pancreas has
16:07burned out this tells you that you can take a man or woman with 20 30 years of
16:13type two diabetes with three four five medications and completely reverse it
16:20completely not just in one person in everybody and you can do the same thing with gastric banding so again if you
Gastric Banding cures Diabetes
16:27look at their weight it goes down but if you look at their blood glucose gric banding is where you put a little it’s
16:33essentially a belt that cinches around your stomach so you can’t eat but again you look at the blood glucose when you
16:40start it’s eight which is type two diabetes within a week it goes down into
16:45the normal range right again before a lot of weight is lost so this pancreatic
16:50beta cell that produces the insulin is completely functioning again
16:57it wasn’t burned out at all and if you compare fasting versus bariatric surgery you can actually get
17:04the exact same effect right so here’s a comparison where they fasted people using very very low calorie diet before
Fasting vs. Bariatric Surgery
17:11and after surgery the point of the the fasting was not because they were very Advanced thinkers is because they wanted
17:17to shrink that liver because when they do the surgery if you have a big fatty liver it’s very hard to get in hard to
17:23work things right so they know that if people don’t eat that liver shrinks right down right when that fatty liver
17:30shrinks right down of course the insulin resistance goes away because insulin resistance is from fatty liver so you
17:36can see from the left hand side the weight loss comparing the fasting to the DI to the surgery and the fasting
17:42actually causes more weight loss and if you look at the blood glucose it gives you lower blood glucose so it’s actually
17:49better and if you look at the Counterpoint study what you see is that the pancreatic fat slowly goes down so
Decrease in Pancreatic Fat
17:58your body when it has nothing to eat is pulling that Sugar pulling that fat
18:04preferentially out of the liver and then out of the pancreas because it’s the fatty infiltration of these organs that
18:12is causing the type 2 diabetes so as the pancreatic fat goes down the beta cells
Restoration of Beta Cell Function
18:19recover so they weren’t burnt out at all right this is the restoration of the
Restoration of First Phase Insulin Response
18:25insulin response they were merely logged with fat and that’s tremendous news because
18:33it means that this whole notion this whole Paradigm that type two diabetes is
18:39chronic and irreversible is completely untrue it’s a completely reversible
18:46disease so the idea the way you need to think about type 2 diabetes is basically
18:54like a sugar bowl your body is like a Sugar Bowl right it can hold a certain amount of sugar but once it’s completely
19:01full as you eat the sugar it just spills out into the blood remember Sugar We’re
19:07talking glucose and fructose it spills out into the blood right and so if you
19:13have type two diabetes somebody says well you have type two diabetes now let me give you insulin because we think
19:19that you’re the the the sugar can’t get into the cells right so we need to give you insulin so what does that insulin do
19:26well it doesn’t get rid of the sugar in the blood what it does is it takes that sugar in your blood and crams it back
19:32into your body right and then the next time you eat that Sugar Bowl is still
19:38full so you take more insulin and then you cram it back into your body again
19:44your body takes it for a while sends that Sugar out into the eyes into the kidneys it turns a lot of that into fat
19:51right and you haven’t fixed the problem you keep doing this year after year you take more insulin or drugs that
19:57stimulate insulin you Ram it back into your body and so what happens after 10
20:0215 20 years well your whole body just starts to rot and that’s what happens
The End Game
20:09your eyes go you go blind your kidneys go you go on dialysis you have Gang
20:16Green and diabetic foot ulcers every part of your body has too much sugar that’s it that’s it that’s
20:23the whole pathophysiology and what we’ve done is we’ve completely misunderstood the
20:29disease because Normal is this right normal is on the left you have glucose you have a cell you have some glucose
20:35inside the cell right so if you think type 2 diabetes about is about internal
20:41starvation then the correct response is to give as much insulin as you need to shove that glucose from the outside
20:48inside but if insulin resistance is really an overflow Paradigm then that
20:55treatment is completely utterly wrong wrong cuz you’re taking that glucose
21:01from the outside and cramming it into the cell which is now overfilled has way
21:06too much glucose inside and it’s desperately trying to pump out this fat
21:11right it’s the wrong treatment and if you give the wrong treatment guess what
21:17everybody dies right you get a huge worldwide epidemic of obesity of type 2
21:24diabetes all because you didn’t understand it right so if you think about this internal starvation model we
21:32already know it’s wrong we’ve known it for close to 10 years because in under this Paradigm you can take the insulin
21:39shove it into the cell and you will get better but the Accord study showed that yes you can give people insulin and
21:45medications what you see is that you give you more medication your blood glucose goes down right but remember it
21:52doesn’t get rid of the sugar in the body it just crams it into the cell and what happens well you die more often there’s
22:00a 22% increased risk of death and everybody says well there’s this problem that problem but it wasn’t one study it
22:07was like seven or eight studies the advanced study was the same you can give medications to lower the blood glucose
22:13but you can’t make people healthier right and the vadt showed the same thing the Tio study the Elixir
22:20study there’s study after study after study and if you look at all of them what you see is that when you take all
Meta-analysis of intensive glucose control in T2DM: mortality
22:25of them together they show you what you new which is that taking insulin doesn’t
22:31make you any healthier so the good news is that you
22:37can actually reverse type 2 diabetes completely naturally as long as you understand this overflow Paradigm
22:44because there’s only two things you need to do if your body has too much sugar
22:49that’s all type two diabetes is your body has too much sugar Step One is don’t put any more
22:55in right it’s a low carbohy diet that’s why it works so well that’s
23:01why study after study after study shows the low carbohydrate diet Works to reverse type 2 diabetes is not that hard
23:09to understand so what’s the drug equivalent of a low carbohydrate diet well we have a drug that can block the
23:16absorption of carbohydrates it’s a drug called acros right so you take the drug
23:23it blocks the absorption of carbohydrates and the blood sugar doesn’t the sugar doesn’t go into the
23:28body which is great right because it’s that Sugar Bowl you’re blocking you’re not putting it in but it doesn’t lower
23:34the blood glucose very much and the other thing is that you get all this um indigestion and so on so people don’t
23:40use this much but there was a study in 2003 randomized study 3.3 years of
Lowering glucose without raising insulin improves outcomes
23:46followup and what you see is that you can reduce the risk of heart attacks and
23:51strokes right cardiovascular events on the left by almost 50%
23:58right you’re not lowering the blood glucose much but you’re lowering your heart attack rate by
24:0550% because you’re not putting sugar in to a situation where you have too much sugar that’s it and what’s step two step
24:14two is you’d burn it off if you have too much sugar in the blood don’t put any more in and get rid of what you have
24:19inside that’s it and that’s intermittent fasting so again do we know it works
24:25well of course we know it works if you don’t eat you’re blood sugar drops right we know that so what’s wrong what’s
24:32wrong with that don’t eat blood sugar drops don’t take your insulin that’s it but your body is getting rid of the
24:38sugar so that you’re actually getting better from your diabetes and we have a drug equivalent of this as well so a new
24:46class of medications called the SGL t2s makes you pee out the sugar okay pee out
24:51the glucose in the blood and it doesn’t lower the blood glucose a lot but this
24:56is the recent study Empire was published I think last year and what you can see
EMPA-REG MACE
25:01is that this is the risk of cardiovascular events and what you see
25:07with the emper with the empig loin is that you can reduce the rate of heart attacks by 15 to
25:1420% even though you don’t lower the blood glucose you’re getting rid of the sugar in the
25:20body and that’s what makes you healthier because that’s the whole problem right so this is a very powerful
25:30Paradigm right but we have to understand that this is not some kind of chronic
25:38irreversible disease and we tell people this all the time right you have obesity or insulant
25:45resistance well it’s your fault right you ate too much uh fat right you didn’t
25:50exercise enough you should eat less and move more it’s your fault that’s what we tell people all the time but it wasn’t
25:57it was really the failure of the doctors of the researchers to understand that
26:03type 2 diabetes is not about too much sugar in the blood it’s about too much
26:09sugar in our whole body right that’s what you need to get rid of you can’t simply take the sugar
26:17in your blood and shove it in your body and pretend that you’re better it’s like if you have garbage in your kitchen and
26:25instead of throwing it out you throw it under the sink oh great my kitchen’s nice and clean right and
26:32then when there’s there’s more garbage you throw it into your bathroom right
26:37hey great my kitchen’s clean right your doctor Pats himself on the back oh you know your blood glucose is so good your
26:43A1C is so good right but what’s the problem you haven’t thrown out the garbage and your whole house just starts
26:50to smell right and then the doctor says well that’s what happens you know it’s
26:56chronic it’s irreversible but it wasn’t we’ve proved it already why can’t you
27:03accept that fact you just have to know how to treat it but again the opportunity before us is
27:10enormous because we have now the possibility that you can actually just
27:16completely cure the whole damn disease right and if you think about it it’s an
27:23incredible notion because if you don’t have diabetes then you don’t have diabetic nephropathy
Can We Cure Type 2 Diabetes?
27:31that’s kidney disease you don’t have to do dialysis right if you don’t have you don’t have diabetic foot ulcers you
27:37don’t have any blindness from type two diabetes right you don’t have heart
27:44attacks you don’t have The Strokes you don’t have the cancer none of that right
27:50and it’s all available to us without any drugs without any surgery and without
27:57any CA right if you don’t eat you don’t have to
28:03pay for food right you’re saving money right what could be simpler and you’re
28:08treating your type two diabetes right so this is the whole
28:14idea of this conference is that these diseases which cause so much pain and so
28:21much suffering and we’ve treated them for so long with the wrong paradigm
28:28right just take your medications right no that’s not the case this is a dietary
28:34disease it Demands a dietary solution right and that’s all that’s all
28:41we need and we can do it we can do it anytime we want to because as long as
28:46you have the knowledge you don’t need the infrastructure you don’t need the hospitals you don’t need anything you don’t need any infrastructure you can do
28:53it in that world that world that we can see it now
28:59that world that is free of type 2 diabetes and free of all of these heart
29:06attacks and strokes and all of that it’s there right but it’s not up to
29:13me or Maryanne or Gary or Jeff or Rod it’s up to
29:19you it’s up to all of you to tell your friends your families yes your doctors
29:24like Sam said tell your doctors and if your doctors tell your patience it’s all here for us it’s all
29:31here for the taking right and we can see it through that open door right David seesing it
29:38already he does it already you can see it through that open door and we just
29:43have to walk through that threshold we’re inviting you to come walk with us
29:49through that threshold to that world without diabetes without pain without medication without insulin and
29:56guess what that work world that world starts
30:03today thank you
