Nutritional Biochemistry

For effective Obesity Treatment

The primary lever that has to be pulled for overall health and disease improvement is food quality.  The standard American diet (SAD) is perfectly designed to cause the standard American diseases – lifestyle diseases – diseases that stem from metabolic syndrome.

Without changing food quality long-term, very few people are going to make any significant changes in their overall health or weight.  

Some patients understand this completely and are committed to making the changes.  

Some people understand this and want to make the changes but keep finding reasons they can’t.  These people are constantly seeking information but are not ready to implement it.  

Some people are convinced that they can figure out hacks around the system and want us to give them the “secrets” or the “magic pills” that will allow them to improve their weight and health without turning this lever.  

For the patients who understand the need to make sweeping dietary changes and want to do it, the execution is the hard part.  Our job (once we’ve helped them understand the concept of healthy eating”) is to help them with the implementation process.   

Once the nutrition (big) lever is pulled, pulling the smaller levers has a lot more power.  

This is the cliff-notes version of what we teach patients about nutrition:

Weight-Reducing Foods 

PROTEIN: 

minimum 4 servings daily (minimum 80 -120 grams) Lean protein coming from fish, birds, and eggs is extremely healthy and weight-negative when consumed in its natural form.  

• The easiest way to identify protein: it had a mother.  Anything that used to walk, crawl, swim, or fly is going to be a protein.  And typically, the less leg volume the mother had, the better.  (fish: no legs – really healthy.  Cows: 4 legs – less healthy)
• Unflavored Greek yogurt and cottage cheese didn’t have mothers but they are also great sources of protein. Make sure the yogurt is unflavored. Adding sugar or fake sugar makes it no longer weight-reducing. 
• Beans and legumes can be substituted for animal proteins.  ½ cup of cooked beans or legumes is about equal to 3 ounces of lean meat.  
• Red meat and processed meats (like pepperoni, hot dogs, and deli meats) are much less healthy than eggs, fish, and chicken.  In fact, recent data indicates that for some people, they can be weight-positive.  We recommend limiting red meat, shellfish, processed meats, and organ meats to two servings (total) per week.  
• Sweetened powdered protein drinks or protein bars do not count as protein. ,

WATER:

minimum 8 servings daily.  Most people need at least 64 ounces daily

• Patients can make water more interesting by adding bubbles: Lacroix, Bubly, & Waterloo are just bubbly water with essential oils added to them.  Tell patients to make sure the ingredients in these things are just “water, natural flavors”- some companies sneak sweeteners in them  
• For caffeine:
  • Tea – be careful of flavored tea – most iced tea found in stores/restaurants is artificially sweetened
  • Coffee is also fine -black or w/ heavy cream, half & half, milk or coconut oil
    • stay far away from sweeteners or creamer of any kind 

VEGETABLES: 

minimum 4 servings daily.  Vegetables are nature’s favorite carbohydrates and most of them are fantastic for weight loss. More often than not, the more vegetables they eat, the healthier people get.  There are a few caveats: 

• Corn, peas, and potatoes (even sweet potatoes) are starches & are not weight-reducing  
• A good variety of vegetables is optimal but quantity is more important. 
• A typical serving size for leafy greens is 1 cup.  For all other vegetables, the serving size is about ½ cup – or about the size of an adult fist. This is to ensure minimum consumption – there is no maximum!
• Turning veggies into juice or pills changes them (not for the better), so chewing them (as opposed to drinking them) is essential. 

Weight-Neutral Foods

FRUITS: 

Fruit helps curb sweet cravings and can be a great source of fiber, so we don’t recommend staying away from it.  In fact, we tell patients to have up to three servings of fruit every day.  However, like everything else, there are a few caveats:  

• When consuming fruit, it needs to be consumed in its whole form.  No squeezing the fruit into a glass or putting it in the blender.  The fiber (the stuff surrounding the sugar that you have to chew) is what keeps it healthy.  
• Drying fruit destroys some of the compounds that help blunt the way the body responds to natural sugars.  It also removes the water.  Think of dried fruit as candy.
• Jams and jellies are not fruit.  They are fruit mixed with a lot of sugar.  
• Fruit should be consumed after or along with a meal containing protein and/or fiber – and no more than one serving at a time.  
• The serving size of fruits varies widely. What follows is a list of the serving sizes of various fruits:
  • 1 cup of most berries (strawberries, cherries, blackberries, raspberries)
  • ½ cup of blueberries
  • ½ of an apple, banana, grapefruit, papaya, pear, peach, or orange
  • 1 whole clementine, apricot, plum, kiwi, guava, or star fruit
  • ½ cup of grapes
  • ¼ of a mango or papaya
  • 1 slice of watermelon, pineapple, or honeydew melon
  • Figs, dates, and dried fruit are very high in natural sugar and should be avoided during active weight loss.  

HEALTHY FATS:

Fats are essential for health and help with satiety when combined with protein and/or fiber- therefore Fats should always be eaten in combination with a protein or a fiber; avoid eating fat on its own. 

Unlimited:

• Olive oil
• Avocado oil

A little less:

• Coconut oil
• Nut oils

Even more sparingly:

• Cheese
• Butter
• Cream
• Sour cream
• Fatty meats (bacon, etc)

Avoid Completely:

• Trans fats
• Vegetable oil
• Corn oil
• Soybean oil 

Fats are greasy and slippery in our mouths.  

The easier it is to obtain it on a farm, the healthier it usually is. Olives and avocados grow in nature and can be easily plucked and eaten, and it’s easy to smash these foods and get the oil out of them. Mother Nature also gave us coconuts and nuts.  Along these same lines, smashing these to make oil is also pretty decently healthy – although it takes more work to smash a whole bunch of nuts, so nut oils and coconut oils should be eaten in smaller quantities than olive oil or avocado oil.  

You could make cheese on a farm, but it would take a lot of work and time.  Although cheese also contains a little protein, it’s primarily fat. We don’t count cheese toward daily protein goals!  Cheese is not a food group.  It’s a condiment. 

Although bacon, sausage, pepperoni, salami, & brats come from mothers and contain some protein, they also contain a lot of fat and should be consumed in minimal amounts.  These processed meats do not improve weight or health.

If you can’t figure out how the fat is made or if it requires a factory to make it, you should avoid it.  Making oil out of corn or soybeans isn’t normal and can’t be done on a farm.  Avoid all trans fats – they raise our risk of developing heart disease, diabetes, and stroke and are strongly correlated with obesity. There is no safe level under which the amount of these fats is thought to be safe, so they are best avoided altogether.  

NUTS:  

A serving size of nuts is no more than 2 oz. Nuts do have protein in them but are higher in fat, so they should be considered a fat, not a protein.  We don’t count nuts toward daily protein goals!

MISCELLANEOUS FOODS:   

• PEAS: When peas occur in their whole form (as in sugar snap peas) they are a vegetable and are weight-reducing.  However, when most Americans think about peas, they conjure up a picture of a bowl of little green balls – which is what happens when someone throws out the fibrous part of the peas (the pods) and saves the middle (the starchier part).  Peas in this form are considered weight-neutral.
• MILK: A splash of milk in coffee is one thing.  Drinking it from a glass is another.  Milk isn’t likely to cause weight gain, but too much of it (or others) can push you into the weight-neutral zone, which isn’t the plan during active weight loss.  Avoid sweetened milk (yes, even sweetened almond milk) and oat milk.
• PEANUT BUTTER/NUT BUTTERS: These aren’t the same thing as nuts – they are what happens when you destroy the fiber and mix them with honey or sugar.  They are also decently high in fat – which makes them a condiment.   We have patients limit these to two tablespoons per day.  (And Nutella is NOT a nut butter).  As with nuts, these don’t count toward a daily protein goal.
• CONDIMENTS: Given the foods we recommend, there isn’t a lot of place for excess condiment use, but it’s good to give some guardrails:
  • Condiments that taste sweet (ketchup, barbecue sauce, teriyaki sauce, and sweet salad dressings like French, honey mustard, or raspberry vinaigrette) should be avoided.  
  • Look at the nutrition label.  If it has more than 2 grams of sugar per serving, put it back on the shelf.  If it doesn’t have much sugar but the ingredient list contains a sweetener, put it back.  
  • Forget about gravy or sauces that look like gravy – they are flour mixed with fat

Weight-Inducing Foods

This category can pretty much be summed up as “everything else”.  If we haven’t mentioned it so far, it’s probably going to be considered weight-inducing.  

ALL SWEETENED BEVERAGES (real or artificial) stimulate fat storage.  

ALMOST EVERYTHING THAT COMES IN A BOX OR A BAG stimulates fat storage.  If it comes out of a factory and has more than a couple of ingredients, it’s more than likely going to act similarly.  If it has ingredients in it that a third-grader can’t pronounce and draw a picture of, it’s probably true as well.

SUGAR – white, brown, powdered, honey, dates, high-fructose corn syrup, etc. There is no such thing as “healthy” sugar or sugar that doesn’t behave like sugar.  If you have to add any kind of sugar or flour, it’s weight-promoting (even if the flour or sugar is slightly brown or yellow).  Cookies, candies, cakes, pies, pancakes, etc. (even those that are marketed as keto- or low-carb) are all going to promote fat storage.  Pretty much anything that tastes sweet is going to trigger the body to store fat.  Sugar has a lot of names (so that you don’t recognize it).  Some of the more common names are:  

• Agave nectar
• Allulose
• Barbados sugar
• Barley malt
• Beet sugar
• Brown sugar
• Buttered syrup
• Cane juice
• Cane sugar
• Carob sugar
• Castor sugar
• Coconut palm sugar
• Coconut sugar
• Confectioners sugar
• Corn sweetener
• Corn syrup
• Date sugar
• Dehydrated cane juice
• Dextrin
• Dextrose
• Evaporated cane juice
• Fructose
• Fruit juice concentrate
• Glucose
• Golden syrup
• Grape sugar
• High fructose corn syrup (HFCS)
• Honey
• Invert sugar
• Maltodextrin
• Maltol
• Malt syrup
• Mannitol
• Mannose
• Maple sugar
• Molasses
• Monk Fruit
• Palm sugar
• Powdered sugar
• Raw sugar
• Refiner’s syrup
• Rice syrup
• Saccharose
• Sucrose
• Sweet sorghum
• Syrup
• Turbinado sugar
  

Aside from almond flour (which is just crunched-up almonds), pretty much any type of flour is going to trigger the body to store fat.  Adding a whole bunch of baking soda/baking powder can turn almond flour into flour – don’t fall into this trap! 

 Some of the more common flours are:

• White (traditional) flour
• Whole wheat flour
• Bread flour
• Coconut flour
• Brown rice flour
• Cassava flour
• Arrowroot flour
• Buckwheat flour
  

HIGH STARCH CARBOHYDRATES-PASTA, BREAD, RICE, CEREALS, POTATOES, OATMEAL, GRANOLA, (even sweet potatoes), and products made out of grains (even those that are marketed as keto or low-carb) should all be considered weight-inducing. Some options for “wrap alternatives” that can be utilized are egg-based or cauliflower-based (such as EggLife and Outer Aisle) but make sure to double-check the ingredients on the nutrition label.  

NON-NUTRITIVE SWEETENERS sometimes called “artificial sweeteners” do not cause blood sugar to increase, but stimulate insulin and therefore, trigger fat storage. Consuming things containing these sweeteners raises insulin – indirectly, but it does. Anything that tastes sweet can stimulate insulin. Non-nutritive sweeteners are up to 700X sweeter than natural sugars, this can lead to more sugar cravings and increased hunger. Additionally, new studies suggest they may negatively affect the gut microbiome.

Some of the more common sweeteners are:

• Allulose
• Aspartame
• Equal
• Erythritol
• Maltitol
• Mannitol
• Monk Fruit
• Naturlose
• Nutrasweet
• Pure Via
• Saccharin
• Sorbitol
• Splenda
• Stevia extracts
• Sucralose
• Sweet’n low
• Swerve
• Truvia
  

ALCOHOL is weight-inducing. When the body is working on processing alcohol it slows down or even stops the body’s ability to break down fat cells. According to some studies, drinking alcohol can halt weight loss efforts for up to 3 days. 

Pretty much: If it tastes too good to be true, it’s probably too good to be true!

Metabolic “Reboot” – Improving Metabolic Flexibility 

Eating really well is the foundation of sustained weight loss.  A handful of people just need to learn and apply the nutrition portion and they are off to the races.  Problem solved.  Most people need more than education.  Even with a robust understanding of the “why”, most people struggle with implementing this.  There are two ways to approach it.  

Some people need to change their habits and behaviors slowly, making a gradual shift from their normal eating pattern to something like this.  

Others prefer to move quickly.  For those people who can jump in and apply it in its entirety, we encourage them to. 

Metabolic flexibility – the ability to switch between using glucose for fuel and using ketone bodies for fuel (ideally, derived from the breakdown of adipose tissue) is associated with successful weight loss.  

Going “all in” has been shown to give us more metabolic flexibility – to restore our insulin sensitivity faster and more efficiently – which, in the long run, is usually easier (Palmer and Clegg, 2022).  Complete abstinence from the offending substances gives our liver and pancreas a much-needed rest, which helps rebalance our hormones more quickly. 

These hormones don’t like to be suppressed.  In fact, they typically intensify before they settle down, so we counsel patients to be prepared for some intense cravings and mood swings during the first week of the reboot.  

Many people also have physical symptoms such as headaches, fatigue, insomnia, and nausea.  

People who are regular exercisers often have a temporary decrease in their exercise tolerance. It’s very normal and transient and not dangerous.   

For most people, these symptoms peak on day #4, and then they start to wane.  

Helping them understand this in advance makes it easier to plug through it – especially knowing that once the hormones are down, they make the process easier.  

Understanding the WHY behind the nutritional intervention

Most patients just want to know the what and not the why. As healthcare practitioners, you need to understand the why and be able to explain it to the patients who want to know. 

Patients who understand the reasoning behind their treatment are more compliant in general, so if you run across anyone slightly interested in learning the stuff – educate away! 

The three themes that we use to explain the why of the nutritional biochemistry piece are:

1. Keep insulin down 
2. Protect the liver
3. Feed the gut. 

Keep Insulin Down

Insulin is one of the key players in the development (and exacerbation) of cardiometabolic dysfunction.  Insulin resistance is the core problem and you are going to be hard-pressed to find patients with obesity that don’t have some degree of insulin resistance. 

You can occasionally find patients with overweight who have a gluteofemoral distribution of excess fat – “pear-shaped” people with tiny waists and no excess visceral fat, but they are rare.  A subset of the population can store quite a bit of excess energy in adipose tissue before it starts spilling over into visceral fat, but those are few and far between.

Insulin’s primary job is to facilitate energy storage.  When the body is actively storing fuel it can’t access stored fuel. It’s one or the other – it’s a swinging door.  In addition to driving energy storage, elevated insulin acts as a primary contributor to endothelial damage and mitochondrial dysfunction, and its presence disrupts production and our ability to access many hormones and neurotransmitters. 

People with insulin resistance not only have an exaggerated insulin response to food but that exaggerated insulin stays around for much much longer.  Which gives those insulin molecules lots of time to wreak havoc.  We have to bring the insulin down – and the best way to do that is to avoid simulating it in the first place.  How do we go about that?  Dietary fats don’t raise insulin. Dietary proteins (in the form of real food, not protein powders/bars) don’t raise insulin very much at all. The primary macronutrient that triggers an insulin response is carbohydrates. Now that doesn’t mean that carbohydrates are “bad.”  Anyone who tells you that an entire group of macronutrients is bad (or should be avoided) is missing the boat when it comes to nutrition.  

Glucose is the primary molecule that the body uses for almost every cellular process.  It’s what the body wants to use for energy. It typically gets that energy by consuming food particles and turning food into energy.  When we eat, food is broken down in the small intestine into small particles that can pass through the wall – from the outside of the body to the inside.  Those molecules are sent to the liver via the portal vein.

If the liver is getting low on stored glucose molecules, glycogen, then the liver is going to pull the glucose molecules in for storage and replenish its supply.  If the liver doesn’t need any extra glycogen (the backup pantry is full), those glucose molecules are going to bypass the liver and be delivered to the rest of the body.  In fact, 80% of the glucose molecules that we absorb typically go to the rest of the body – the liver only takes 20%.  Any place in the body that needs fuel is free to take up these glucose molecules (the greediest organs are the brain and muscles).   

Too much glucose in the bloodstream is dangerous (this is an undisputed fact) and so excess glucose that isn’t grabbed by other body parts has to be stored very quickly – to avoid this dangerous hyperglycemia.  The body can’t store glucose as glucose (it cannot pass through cell membranes). To get it out of the bloodstream and into a cell, the body has to convert the extra glucose into something that’s able to pass through cell membranes –  and that is triglycerides.  And guess where the easiest place is for the body to store these triglycerides/glucose-turned-to-fat molecules?  The adipose tissue.  And guess what hormone is required for this process of storage to happen?  Insulin.  So the amount of substrate put into the bloodstream and the speed by which it is delivered is important.  

Yes, we are going to go a bit deeper into carbohydrates, but the debate isn’t about “good” vs. “bad” carbohydrates in the traditional way (white bread and donuts are “bad” but whole wheat bread and whole wheat pasta are “good”).  When thinking about carbohydrates and the effect they have on the body, we need to think about the effect they have on insulin.  We will get back to the concept of junk food vs. whole-grain carbohydrates later, I promise.  

There are a lot of very, very healthy dietary carbohydrates in this world. Remove the ultra-processed foods (we will come back to them) and we are left with things like fruits, vegetables, beans, legumes, and whole grains.  All of them ultimately break down into glucose, but it’s a radically different process than breaking down a candy bar or a piece of bread.  This is due to fiber. All carbohydrates break down into glucose, but those that contain a great deal of natural fiber (like vegetables), break down to glucose very slowly and require a lot of work to get the glucose molecules out – which requires the utilization of energy. Whole fruits have more glucose than vegetables, so they raise insulin a bit more, but they also have quite a bit of fiber.  Whole grains  – real whole grains such as barley and steel-cut oats also have some fiber, but the ratio is quite different, and they stimulate insulin a little bit more than fruits (Lustig, Chapter 12, 2012). Note I’m not talking about processed foods made with whole grains – these are far from being actual whole grains.  Chewing on an intact piece of wheat pulled out of the ground (the whole grain) is dramatically different than chewing a piece of whole wheat bread that has a label on it saying, “made from whole grains”.  Marketing is powerful. 

Both broccoli and bread break down to glucose, but the outcome is very different because of the fiber contained in the broccoli.  That fiber makes accessing the glucose molecules a very slow and tedious process – and that process requires a lot of energy.  Since the body is continually utilizing energy that slow entry of glucose into the bloodstream means that most of it will be used up by the peripheral body and won’t require storage – so again, we keep the insulin down. 

The Glycemic Index was one of the first systems we created to help understand the impact that food has on blood glucose.  You probably learned about this somewhere along the way in training.  It’s a helpful way of thinking about the way the body reacts to food, but it’s not the full picture. First, the values were determined by studying the glucose response in ten or more healthy volunteers.  Second, the glycemic index is calculated based on 50 grams of carbohydrates – the actual volume of food varies widely. If you initially skim the glycemic index, watermelon and honey both have the same glycemic index value.  However, the volume of food that it takes to achieve 50g varies dramatically – 4 ½ cups of watermelon versus 3 tablespoons of honey.  Compare broccoli to honey; in addition to the fact that broccoli has a glycemic index of 10 compared to honey’s 73, you have to consume 8 cups of broccoli to get those 50 grams of carbohydrates – versus 3 tablespoons of honey.  Again, we are talking about 8 cups to get a value of 10 vs. 3 tablespoons to get a value of 73. There’s definitely more to the story than the glycemic index!  

Glycemic load is a little bit more helpful – it’s an improved way to categorize the way our bodies react to food, but it’s still not the full picture. It also was determined by measuring outcomes with healthy volunteers, but it does standardize the volume of food.  Using the glycemic load, the difference between honey and watermelon will be more obvious.  

Despite being an improved classification system, using glycemic load alone is still incomplete.  We are still missing the boat on fructose.  We are going to talk about fructose at length soon, but using this system alone, fructose gets a free pass, because fructose doesn’t stimulate insulin directly. Keeping the glucose down helps keep the insulin down, but it’s not the whole story. 

We know that insulin rises with the introduction of a sweet taste on the tongue, anticipating the glucose (evolution taught the human body that sweet things on the tongue mean a big glucose dump is coming).  In addition to fructose being a problem that evades the glycemic load system (and continuous glucose monitoring), nonnutritive sweeteners (NNSs) are also a problem.  NNSs stimulate insulin but they don’t stimulate glucose.  

This is really important.  When insulin is elevated and the glucose load doesn’t come or it’s insufficient to match the elevation of insulin, the body will begin seeking to raise blood glucose, which is usually perceived as food cravings – typically for starch or salt.  Remember, once the insulin is up, the body struggles to acquire glucose from its storage vaults (insulin is like a one-way door), so keeping that insulin down is vital.  When we have that insulin/glucose mismatch, we are biochemically triggered to forage for food – or in layman’s terms “we get food cravings.”   

Protect the Liver

We have to go back to biochem 101 here for a minute.  I will keep it short and sweet and I promise this has to do with the liver.  

Glucose is a single molecule. It rarely exists in food as a single molecule – in fact, it’s usually found in long chains or is organized like a tree branch.  It doesn’t taste sweet – it tastes starchy.  Carbohydrates break down into glucose molecules. All of the cells of the body can and do use glucose.  We use it to make ATP – or energy.   Now, although glucose is absolutely necessary to the human body – without it, we will die within minutes – the human body is a wonderful machine that can make glucose molecules.  Even if we never eat a bite of anything containing carbohydrates, we will make glucose molecules.  It’s called gluconeogenesis.  We can’t make certain amino acids – a few we have to ingest (and without them, we get incredibly sick) and we can’t make certain types of fatty acids either but we can make glucose using gluconeogenesis all day long.  Although having blood glucose is necessary for life, we don’t have to ingest it to have it.  

Blood sugar (referring to it as blood sugar instead of blood glucose was a huge mistake that is going to plague us until the end of time) is the concentration of all of these little individual glucose molecules floating around in the bloodstream.

Table sugar (or sucrose) is not the same thing as blood sugar.  There’s a radical difference between glucose and sucrose.  Sucrose is a disaccharide – a combination of a glucose molecule bound to a fructose molecule.  Once the body cleaves the molecules apart, it gets a glucose molecule (that can be used by all cells – and if it’s not used immediately, it stimulates an insulin release). Upon breaking that bond, the body also gets a fructose molecule.  This is where the liver comes into play.  Fructose can only be metabolized by the liver.  A healthy small intestine can process five or six grams of fructose at a time (if it’s delivered with fiber, slowing down absorption), but the liver has to handle anything above and beyond that – and anything delivered too quickly for the small intestine to handle.  When we eat more fructose than the liver can metabolize, we get fructose overload. The liver has to either export that excess fructose (as triglycerides/VLDLs) or store it as fat within itself (a process called de novo lipogenesis – which quickly turns into something we call “fatty liver”). 

When we ingest too much fructose, we get elevated triglycerides and we get fat in our liver. Fat accumulation in the liver is progressive and dangerous, and it doesn’t take much.  About ½ of a pound of liver fat and we are sick.  Fatty liver (or the equivalent of human foie gras) now affects at least a fourth of the US adult population and a significant portion of our children. This is primarily due to fructose overfeeding.  

Fructose overfeeding isn’t due to overeating fruit.  Fruits aren’t just watery bags of fructose. They contain lots of fiber. It’s very difficult to overeat fruit because of that fiber – and we would have to eat very large amounts to reach harmful levels of fructose and trigger fatty liver.  In general, fruit is a minor source of fructose in the American diet compared to sucrose (and other added sugars). 

Fructose without fiber (liquid fructose or table sugar or any of the other members of that family) is the problem.  Now we tend to demonize high fructose corn syrup (HFCS) as the problem.  It’s certainly not a good thing!  As the use of high fructose corn syrup increased in the 80s and 90s, so did the levels of fatty liver, obesity, and other cardiometabolic diseases.  However, the intake of HFCS has been coming down for a while now and these diseases aren’t going away.  Because we’ve just substituted in other things that contain fructose.  Sucrose is the primary one.  Most of our fructose overfeeding is actually due to plain old sucrose, or table sugar.  

Toxicity depends upon volume and speed of delivery.  The faster the fructose is delivered to the liver, the worse it is.  With absolutely no fiber at all, any type of liquid sugar is moved from the small intestine into the portal vein and to the liver very, very quickly.  Turning fruit from a chewable form into a drinkable form involves breaking most or all of the fiber bonds, which means the fiber slowdown mechanism in the small intestine is gone.  It also dramatically increases the volume – to make a small glass of orange juice, you would have to juice about five oranges. That’s why fruit juice isn’t healthy.  That’s why smoothies are not a good idea when you’re trying to protect the liver.  

The story just isn’t about insulin – because fructose doesn’t cause an elevation in insulin. It causes de novo lipogenesis – which causes liver insulin resistance – so it does it indirectly. Fructose isn’t the only substance that causes de novo lipogenesis. De novo lipogenesis happens as a result of ingestion of four things:

1. Fructose
2. Alcohol
3. Trans fats
4. Branched-chain amino acids 

We certainly consume too much alcohol in this country and we as health care practitioners should all be aware that alcohol is hard on the liver.  Before our diet contained so much sugar, fat in the liver was almost completely a disease of people who drank too much alcohol.  It’s a whole different ball game now.  If you want to go down that rabbit hole, look up how alcohol and fructose are metabolized.  It’s pretty much the same process.  This explains why we get the same two diseases related to over-ingestion of both of them – fatty liver and diabetes.  We now see a ton of liver disease in people who have never touched alcohol.  We have an epidemic of kids with fatty liver who have never touched alcohol.  Alcohol is still a player, but it’s no longer a one-man show.

Trans fats are a disaster.  These were introduced into the food supply many years ago and seemed to be a miracle.  They were dietary fats that were modified to be stable at room temperature – almost forever.  They also felt good in the mouth, were cheaper than butter and oils, and being solid, they could be used in higher quantities in solid food without making it runny.  Trans fats were thrown into processed foods – what food company could resist a longer shelf life that required less money to make that people really enjoyed eating?  

However, scientists soon figured out that we couldn’t break down these fats – they stayed in the bloodstream and liver wreaking havoc on the body and dramatically accelerated the cardiometabolic diseases that we’ve been talking about.  In 2015, the FDA took them off the GRAS (generally accepted as safe) list and later enacted a ban on the use of trans fat in food products and food service establishments. 

Though they have technically been eliminated from the food supply, industrial trans fats can still show up thanks to a regulatory loophole. Any food with less than 0.5 grams of trans fat per serving can claim to contain 0 grams of trans fat on its packaging.

While 0.5 grams may not sound like much, even small amounts of trans fat can negatively affect your health. And if a food company doesn’t want to remove them from the formula – they can just decrease the serving size.  Eating a few helpings of a food containing 0.4 grams of trans fat per serving could cause someone to eat more trans fat than is recommended for the whole day— in just one sitting.

Common sources of industrial trans fat include packaged snacks like cookies, chips, and crackers, fried foods, fast food, baked goods like pies and cakes made with stick margarine or shortening, frozen foods, including dinners, pizzas, and ice creams, non-dairy creamers, cake frostings, processed meats, pancake mixes, and biscuits may also contain trans fat.

While we are on the topic of really unhealthy fats, we need to touch upon fats that are full of reactive oxygen species.  When we heat fats past their boiling point (i.e., we fry things in them), we make lots of these very inflammatory compounds. When we eat them, our bodies have to deal with these toxic compounds.  And we eat a lot of fried foods in this country!

Finally, we have to briefly talk about branched-chain amino acids (BCAAs). You have probably heard of these as something consumed by bodybuilders to build muscle. 

BCAAs are actually essential amino acids (leucine, valine, and isoleucine).  BCAAs not only provide an essential substrate for protein synthesis, but also contribute to energy homeostasis, including gluconeogenesis and lipid metabolism.  However, the body only needs so many of these compounds – and when we have too many, the health value quickly swings the other way.

Despite the necessity of a dietary intake of BCAAs, emerging data indicate the undeniable correlation between elevated circulating BCAA levels and chronic liver diseases.  In addition, circulatory BCAAs are positively associated with a higher cholesterol level, liver fat content, and insulin resistance.  

Why is this?  Skeletal muscle is the primary site of metabolism of BCAAs. In cases of severe energy depletion (such as endurance training) or starvation, the consumption of BCAAs triggers an increase in insulin, which redirects nutrients into the cell to generate more ATP production.  BCAA consumption during rest or exercise recovery triggers a pathway that redirects the BCAAs’ metabolism into protein synthesis or restoring and building up glycogen storage in muscles/liver. In other words, if the muscles don’t need them, the liver has to deal with them. 

If you are dosing them right – and actively building muscle while consuming them – they are probably relatively harmless, but most Americans are not bodybuilding and actively building a large quantity of muscle, so ingesting them without that process is just pummeling the liver.  And, most of our consumption of BCAAs in this country actually doesn’t come from powdered body-building drinks, but instead, comes from the consumption of animals that have been fed grains and corn instead of grass. That’s where we now get the majority of our BCAAs. 

There is a method to the madness.  Changing the way we eat (the way we’ve described) helps to protect the liver.  Removing liquid fructose, alcohol, and fried foods is the biggest part.  I would love for everyone to eat only animals that have been allowed to eat their natural diet (cows that only eat grass and chickens that eat bugs and seeds), thereby dramatically reducing consumption of BCAAS. However, making a blanket recommendation that this is necessary pushes our dietary recommendation from financially doable to undoable, so we typically leave this part out and reserve that discussion for later in the game.

Feed the Gut

The lining of the gut is a barrier layer between the outside world and the inside of the body.  Aside from its primary role of converting food into molecules that can pass into the body, the gut has to do several things. 

1. Support the microbiome
2. Prevent ingestion of toxins
3. Make neurotransmitters
4. Dispose of waste products

We have over 3 pounds of organisms from over 500 species that live on the surface of our gut. We don’t exist in isolation. We actually have more organisms lining our gut than we have cells in our body.  Every time we eat we are eating for two – ourselves and our gut microbiome.  All of those 3 pounds of organisms have to be fed regularly. We all have a combination of different types of organisms – some are helpful and some are unhelpful.  When we eat well,  we nourish the helpful bacteria. They proliferate and they work symbiotically with us to keep us healthy. They send blood-borne or neural signals that tell our brains to alter behavior so they can get the nutrition they need.  When our good bacteria are starved to death or when we get unhelpful bacterial overgrowth, things can quickly go south and the neurotransmitters and signals can become a disaster.  What do these healthy gut bacteria feed on?  Fiber.  It all comes back to fiber!  

Of course, there’s more to the story.  We don’t metabolize fiber, but it’s incredibly important.  There are two types of fiber: insoluble and soluble.  Think about insoluble fiber like a fishnet.  When ingested, it creates a kind of latticework on the lining of the small bowel. Just like a fishnet, insoluble fiber has lots and lots of interconnected sections with some holes in the middle. 

Ingestion of insoluble fiber slows the absorption of food.  When food doesn’t contain fiber, it is absorbed quickly from the stomach and duodenum. Fiber allows the food to be carried into the jejunum and ilium, which is where most of the bacteria live.  That’s how they get fed.  If we absorb all of the nutrients in the stomach and duodenum, there’s nothing left for them. And, when we feed them, they will eat a large amount of the nutrients.  So we may chew the carrots, but a lot of the energy in the carrots doesn’t make it into our bloodstream at all – it’s eaten by the bacteria.  (This is yet another reason why the whole calories-in/calories-out hypothesis doesn’t work – if you chew it but something else uses the energy, you didn’t really get those calories).  As we reviewed before, slow absorption also triggers a diminished hormonal response to food – it keeps the insulin down.

Because insoluble fiber is bulky, it triggers the gut to release a satiety signal, called PYY into the bloodstream – that tells us to stop eating.  Insoluble fiber also acts as a mild abrasive in the lumen of the colon, which dislodges and sloughs old dead cells, which reduces cancer risk. It’s great stuff, 

Insoluble fiber isn’t the whole story though. We still have soluble fiber.  Think about soluble fiber like petroleum jelly. It’s gummy. Soluble fiber lays down on top of the fishnet, making a beautiful barrier.  Think of it like a colander – the insoluble fiber is the interconnected pieces that prevent the big items from coming through.  Super helpful, but not enough.  If you were to rub petroleum jelly all over the inside of the colander (soluble fiber), then you have an amazing barrier.  Each of them is helpful, but together, they are more than the sum of their parts.  

Soluble fiber is also metabolized by the gut microbiome into short-chain fatty acids, which the bacteria then eat.  Short-chain fatty acids can also be passed across the lumen into the bloodstream, where they act as anti-inflammatory molecules, and they act to suppress insulin secretion. Fiber feeds the gut!  

Although fiber supplements, like powders, gummies, and pills are technically fiber (it’s not mislabeling), they are only half the equation. These packaged fiber supplements are only soluble fiber. You can’t package up all that fishnet stuff and put it in a pill – or the pill would be as big as a piece of broccoli!  The only way to consume that insoluble fiber is to consume it in whole foods – another example of why whole foods are so much better than supplements.  And soluble fiber by itself (the gummy stuff) in the absence of the fishnet, doesn’t have much ability to stick in place and mostly passes out the other side without doing a whole lot.  It still provides the bacteria with some short-chain fatty acids and pulls some water into the colon, helping us poop – both of which are good things – but it’s not the same as the combo of insoluble and soluble put together.  The two types of fiber working together help create that mucosal lining on the gut – that lining that protects the single cell layer that separates the outside world from the inside of us.

That mucosal lining of the gut protects us from harmful substances we don’t want to have inside of us.  We ingest pesticides and herbicides and heavy metals and harmful bacteria and allergens – and the gut needs to protect us from actually absorbing all of those things into our cells.  And remember, this layer is only one cell thick. It is a beautifully well-designed barrier, but it is only one cell layer thick.  Which is crazy.  This single layer of cells is held together by something called tight junctions – they connect the cells together into a barrier.  If this layer gets damaged, the tight junctions break down and things can pass in between them.  You can hear this referred to as “leaky gut” sometimes.  It’s not a term that is officially recognized, but the process is well-documented.  

What damages the mucosal layer of the gut?  What sets this layer up to fail? Nonnutritive sweeteners have repeatedly been shown to damage this mucosal layer.  Some medications (either taken by us or taken by animals before we eat them – like antibiotics) can damage the mucosal layer of the gut – probably by altering the microbiome living on it.  Our own microbiome can damage it.  If they are starved (if we don’t feed them what they are designed to eat), they will feed upon us.  They are sitting on this mucosal layer and it’s the most natural thing for them to eat.  Certain ingested chemicals can actually damage the mucosal layer of the gut – and probably a lot of other things that we don’t even know about yet.

The third job of the gut is to make and release neurotransmitters. The gut contains its own neural system – called the enteric nervous system.  That single-celled lining of the gut actually contains more neurotransmitters than the brain does.  The gut and the brain are constantly talking to each other.  That’s a story for another day but the gut talks loudly!  

Finally, the last thing the gut does is dispose of things that the body wants to get rid of in the form of bile.  Things that make it into the body that it can’t use have to come back out.  During physiologic processes, the body generates waste products and has to eliminate them. Urine and feces are where these things go.

Pulling It All Together:

A dietary pattern primarily made up of the things we’ve talked about whole, real food (proteins, vegetables, fruits, beans, legumes, and natural fats) does all of these three things beautifully. It keeps the insulin down, it protects the liver, and it feeds the gut.  All of this will prevent the worsening of cardiometabolic dysfunction. 

However, treating disease is typically more difficult than preventing it. Reversing disease is a little bit harder.  Prevention versus treatment. The dietary pattern we introduce to patients (this prescriptive dietary intervention) is more rigid because it’s designed to treat cardiometabolic disease and reduce weight at the same time.  Typically treatment requires even more stringent limitations and that’s what we are aiming for more often than not.

What is missing from this dietary pattern? Ultra-processed foods.  Why? High-quality medical studies consistently show us that ultra-processed foods increase the risk of several chronic diseases, including cardiovascular disease, certain cancers, obesity, and type 2 diabetes, i.e. cardiometabolic diseases (the ones they choose to study).   

Our current food environment, the Standard American Diet, is now comprised of 2/3 ultra-processed foods.  This is what we’re eating now. A quarter is still animal products, although about half of those are highly processed (nature didn’t actually hand us bacon and hot dogs).  Another 12% of our Standard American Diet is made up of plants, but about half of those are French fries (because they are made from potatoes, they are technically classified as plants – and those are fried in oil heated past the smoking point, so they are chock full of reactive oxygen species).  

Although most people acknowledge that many foods are ultra-processed, things such as candy bars and fast foods, most don’t realize that so many of the foods they consume regularly under the heading of “healthy foods” are also ultra-processed. These things have been marketed as healthy and we’ve gone along with it. 

How do we recognize ultra-processed foods? 

1. If you can’t figure out what it is exactly from reading the label it’s an ultra-processed food
2. If there are more than five ingredients, it’s more than likely ultra-processed
3. If the ingredients are things that you can’t draw a picture of, it’s probably ultra-processed
4. If a fifth grader can’t spell at least one of the ingredients, it’s an ultra-processed food 

Typically if it has a label on it, it’s an ultra-processed food.  Think about food labels as warning labels – and the longer the warning label is, the more scared you should be. Most of the foods that we eat – especially those that come in bags or boxes or are wrapped up individually and sold from a shelf or a counter are ultra-processed.  Most of the things that we store in our pantry or cabinet are ultra-processed.

We also consume a lot of food that looks like real food but isn’t – especially when we are eating outside of our homes.  We may order things that seem like whole foods – like grilled chicken.  However, we are often not getting what we think we’re getting.  Chicken provided to you by establishments that focus on speed of delivery and/or mass production is typically made up of chicken and a whole lot of other ingredients.  Those ingredients serve many purposes – they keep the food from spoiling within a couple of days (like the chicken does in your fridge) and the additives make it more palatable.  In fact, most grilled chicken that you get outside of the home is full of sugar, soybean oil, salt, cornstarch, and all kinds of other things that make it an ultra-processed food.

The standard American diet isn’t working out very well. The Standard American Diet has morphed over the past 50 years into what it is today and the shift in the cardiometabolic health of American adults has shifted right along with it.  60+% ultra-processed foods are causing 93% of us to be affected by some degree of poor cardiometabolic health. We didn’t evolve to eat ultra-processed foods and this evolutionary mismatch is killing us. They’re probably doing more than we know, but they are certainly stimulating insulin, hurting our livers, and starving our guts.