00:02
Hey everyone, it's Mikki here, you're listening to Mikkipedia, and this week on the podcast, I speak to Dr. Marcus Hawkins.

00:13
Dr. Marcus is a general practitioner and collaborator in research for using low-carbohydrate diets to improve health amongst his patients, specifically those patients with pre-diabetes and type 2 diabetes. Marcus and I discuss his approach, his patient's willingness, and the success that he has seen in his clinic. We discuss his introduction to low-carbohydrate diets.

00:41
his research in the field and why he thinks the New Zealand guidelines are slow to move in the face of emerging research that clearly shows a benefit of low carbohydrate diets for type 2 diabetes. We also discuss Marcus's thoughts and his published work on the ancestral diet for Māori in New Zealand and how the modern diet played a detrimental role in the overall health outcomes. This was an awesome conversation to have with Dr Hawkins. I've been very happy to be here.

01:09
been aware of his work for a number of years given he works closely with my former colleagues at AUT University and also New Zealand is a small place so if you're interested in low carbohydrate diets you're generally speaking in some of the same groups etc. So this was actually a long time coming for me to have Marcus on the show and I was thrilled for him to be able to join me. For those of you unfamiliar with Marcus

01:35
Marcus Hawkins is a GP in Botany Downs, Auckland, New Zealand, who has spent over 30 years practicing medicine. The first 15 of them were as a hospital-based doctor, and the next 15 years as a family physician in both the UK and New Zealand. He discovered the low-carb keto diet in 2017, first through the movie The Magic Pill, and then through his own extensive reading and research. He

02:03
has become a passionate advocate for low carb and keto eating, as you will hear. And he's convinced it's the best way of eating for humankind and is based on good scientific evidence. And particularly for the clientele that Marcus sees, it's absolutely a robust approach to achieving better health outcomes for those people. Now I've put a link to where you can find Marcus if you are after a low carb GP in the Auckland area.

02:33
But also he's super approachable and loves to connect with anyone who has insight in this area. Just before we crack on into the interview though, I'd like to remind you that the best way to support this podcast is to hit the subscribe button in your favourite podcast listening platform. That will increase the visibility of Makipedia in amongst literally thousands of other podcasts that are out there. So

02:59
more people get the opportunity to listen to experts that I have on the show like Dr Marcus Hawkins. Alright team enjoy the conversation.

03:13
to Dr David Unwin a couple of weeks ago and he was like have you spoken to Marcus Hawkins yet because he is an amazing doctor doing amazing things down your neck of the woods which of course then made me think I haven't spoken to Marcus and I've been meaning to touch base it was a perfect opportunity for me to reach out. David's a rock star, he's a lovely man.

03:36
I think we share something in common in that we're coming to the ends of our careers, but we're actually getting involved in something that we feel very passionate about. That's a really positive thing, I think, at this time in your career. He's a bit older than me, but we share that. But he's a rock star. He's just amazing, so supportive, and been very helpful over the years. So Marcus, how did you get interested in diet and interested in chronic disease? Has this always been something that...

04:05
has from a career perspective sort of been your major sort of interest or is this just developed? It just happened upon it. I mean, at university we get no education in terms of dietary education and you just end up following the guidelines, treating people with drugs to make numbers better. So really about 2018, I went to dinner at a friend's place and we were talking about

04:34
low-carb it and how his cholesterol profile had improved because that's my first question, what's going on with all this fat you're eating? Because I was very much for the last 30 years, or 30 years from that point back, very much following the guidelines and doing a really good job at it. And it was really just an eye-opener. And then I thought I've got to explore this and there's maybe something in it. And I watched the magic pill, which was an eye-opener. I couldn't believe what I saw there, you know, it's just so well explained.

05:04
And I felt really, I won't swear, but I felt really angry because all these years I'd been led to believe that all this I was doing was based on scientific evidence and really it wasn't. And what you see is people getting fatter and sicker across the world in developed countries. And so I then started to explore that. I did a nutrition network course or a couple of courses and then tried it on some patients, with some patients I should say.

05:34
and got results and it's taken off from there. I just had to document it, hence a number of publications with various other people, an audit that I did, because I've got to get the word out there. I feel very angry and very passionate at the same time. And, you know, it's actually really nice now to actually do positive things with people, take away medication, see them lose the weight they want to lose in real time. It makes me feel better, makes them feel better. So it's a win-win. So it's worked out really well.

06:03
And in regards to your colleagues who you see around you, was there any pushback initially, Marcus, for you in terms of the approach? Because at that time, 2018, I'm just thinking, you know, at AUT, we'd sort of begun that journey, I don't know, maybe six or seven years earlier, and there was a lot of pushback then. But the education for GPs that, of course, Professor Grant Schofield and Dr. Karen Zinn,

06:32
are really involved in that would have been occurring at the time that you were sort of embarking on your journey? Well, I'm fortunate in that I'm a solo general practitioner. So no one's here looking at what I do. But I'm also involved in the local PHO, that's Primary Health Organisation, on the clinical advisory board. So I've been fairly vocal about the need to monitor for obesity and the need to try and reduce carbohydrates. And I get on well with my colleagues there and they hear me.

06:58
And it's got to the point now when I go to meetings, they actually put on food, but they also put on a low carb spread for me, just for myself, which is really, really nice. And we have a good understanding. So there hasn't been pushback from anyone yet, at least in my local sort of area. I'm expecting one day I might get pushback from someone in higher authority, but this time it's just a matter of spreading the word as far as I can say. I...

07:28
do know that in my peer review group, we get together once a month with other GPs. They tolerate what I say. None of them have made the change despite me telling them about what can be done, although I haven't formally presented to them. So maybe I should try doing that at some point. So no pushback so far. Yeah. And what do you think it is about your, in your peer group that's prevented others from sort of following in your footsteps or trying to seek out more professional...

07:58
advice? Is it a lack of... I don't believe it's that they don't care, but is time an issue, Marcus, for your colleagues? It is. I mean, don't forget, GPs are very busy. So time is a factor. It's much easier to prescribe a drug and follow the guidelines and it's take time out to talk to a patient or their family about how they might change nutrition. You also have to learn about it, which takes time. So we're all under the pump. We're burning out. We're busy.

08:26
and we do what's easiest. Now that's not the same for everybody, of course, but I think that is probably the prime reason why there's no one saying, oh wow, this is amazing what you've done, can I do that too? Having said that, in recent days or weeks, as part of a project that I'm involved with, with AUT, we're starting to see more and more interest from GPs and health coaches, and starting to build a bit more in terms of some momentum. So I think really...

08:56
things are changing to some degree, but there's a good reason why people don't want to change and it's much easier to prescribe and save time. Yeah. And I of course noted that you published a paper with Karen on the resistance in the New Zealand public health space to adopt a carbohydrate restricted diet for people with type 2 diabetes. Can we chat a little bit about that?

09:22
topic Marcus and just the genesis of the paper and just what we know and what we don't know? Well, I think that it's certainly true that various jurisdictions around the world, that is diabetes in Australia, Canada, USA and the UK have actually accepted that low carb diet can have an impact on the management of diabetes, type 2 diabetes specifically, whereas New Zealand hasn't done that. And so we thought we'd actually write to, I think it was the New Zealand Medical Journal.

09:50
and just say, well, what's going on? You know, these are international guidelines by major authorities. Why is New Zealand not following suit? And we got the response, well, you know, there's no evidence that it works long-term. And as a result, yeah, it basically was published, but also rejected at the same time. Yeah, that is crazy to me that that would be their response actually.

10:14
because if you look at the literature, I mean, I don't know what they're expecting. If their major end point is mortality, then you have to wait 25, 30 years to see that sort of borne out. Whereas we've got these long term trials of one year, two year follow ups and possibly longer. I mean, you'll be able to tell me that clearly show a benefit when people adopt a carbohydrate restricted diet. Absolutely. I mean, you know, just to...

10:41
to look at Virta Health, for example, a company in the United States. They do remote health coaching with patients with type 2 diabetes. They've had amazing results and long-term results up to five years showing, I think, 20% of sustained reversal remittance of type 2 diabetes. So we have the evidence now. But I'll also maintain, anecdote is huge because even in my practice, I've got someone who's

11:11
low carb diabetes reversed for five years and just by changing diet and save a hell of a lot of money in doing so. So you actually are seeing benefits and you can't ignore those because they are real. I agree actually the thousands of anecdotes that you see out there, if someone pulled them together as individual case studies and published that, that would therefore be some sort of like... That would be that...

11:40
peer reviewed evidence that clearly the Diabetes Society of New Zealand, is it the Diabetes Society of New Zealand? Yes, the Immunisation Society for Study of Diabetes. Yes, yeah, yeah, yeah. So clearly that's what they're after, but, or at least that's what they say that they're after. But, because obviously evidence that's there already isn't enough for them. Why is that Marcus? Like, what, like, what do you think? Do you think there's anything else?

12:09
underlying that, you know, we've got no long term evidence comment? It's, that's a wide open question, that one. Why don't people change? I think going back to my former comment about GPs, especially being burned out and tired and busy, that is one reason. Why don't the academics change? Why don't they listen? Why don't they look at the evidence? Rather than take a stance, they still say it's not

12:38
sustainable, it's only out to two years or one year. Well, we've got evidence to five years now. Plus, I say anecdotes are so useful. Of interest, I'm going to be talking to the endocrinologist at Middlemore Hospital in about a month's time to present my audit. So that will be an interesting discussion, presentation, because they know what I do, and I think some of them are picking up on it a bit. So somehow we've got to change minds, but why they don't change?

13:05
You could argue maybe there's financial incentive. I mean, you do see endocrinologists, in specifically terms of diabetes, giving talks funded by drug companies about the latest drug. That is not right, in my opinion. So there's bias there. Yes, the drugs work, but other things work as well. We're highly underfunded in New Zealand in our health system. We can save a lot of money. David Unwin in the UK, when he...

13:34
analyse this. He says something like 56,000 pounds in the year at his practice, just by reversal or remittance of diabetes. That's huge. And I've saved nearly four and a half thousand dollars in one patient for one year. So, you know, this is something that needs to be looked at. And that's why we're getting the word out there. And Marcus, it's interesting with what you say about the pushback being it's unsustainable. And I find it infuriating that we have people, authorities who

14:04
have yet to even try it personally themselves, decide for everyone what is sustainable and what isn't. Like you're almost putting a value judgment on it for that individual and you're assessing, well, they're not going to be able to sustain or adhere to this approach, so there's no point. But they have no idea about that individual's motivation or drive to actually get healthier, which for a lot of people, that would be the, obviously the end goal.

14:34
that as an argument against a particular approach, it just drives me nuts. Absolutely. And we do have anecdotes, I keep saying, and reports now of sustainability. I'm constantly on the lookout for a fat politician, so I can work with them and just try and change some minds, you know. Mate, seriously, you don't have to look far. I know. I'm there everywhere. Yeah, but how do you approach them, you know? I know. But, you know, I try and network and try and get something going eventually. Yeah.

15:03
But the other thing is the current dietary guidelines are not sustainable. They're not working, are they? People get fat sick and that's been happening for 50, 60, 70 years now. It's not working. So you can't argue sustainability if the current system is not working, but you've got another system that actually does work. Um, you should be looking at that. And, uh, I say trying to change minds is really the, the interesting side of this. You talk about health coaches for behavior change. We kind of need health coaches for.

15:33
mind change in health professionals. I don't know if that's ever going to happen. But, you know, that's kind of where I think I and others in this area are coming from. No, I agree. And it is an interesting point with the food guidelines that haven't changed one iota in the last 20 years. And I recall I was part of the working group that put a white paper together or ended up being a white paper, but a submission.

15:58
to the New Zealand guidelines with Karen and Grant and George Henderson and a bunch of others. And we just got so much pushback with regards to what was already then this emerging body of research to show the negative health outcomes of elevated blood sugars that were caused by diet. And the fact that the dietary guidelines still are underpinned by whole grains.

16:27
and carbohydrate and there aren't any whole grains in the modern diet other than barley. You know like a Vogel's packet for example, people look at bread as like, oh it's whole grain bread. I mean originally once it was a whole grain but it's got like very few sort of health benefits from basing our diet on that and I think that's the real issue. Absolutely agree. Yeah it's all about what we've been told by.

16:56
the food producers, I think, and corrupted science. Yeah. It's interesting when people talk about that, like it's a, some sort of conspiracy theory, you know, like, oh, like if you were to mention that the American Dietetic Association was funded by General Mills or Nestle or whatever the big sort of overarching company is, it's like owned by three different companies, uh, as a potential for bias. Like you often get sort of.

17:26
tainted with the brush of being a conspiracy theorist. Like how on earth could that be the case that these health authorities who are supposed to have our best interests at heart be influenced one way or the other? And you look at the American guidelines when it first came out, the whole thing was funded or organized by the American, I can't remember what they're called, Agricultural Association of America. So they have invested interest in growing wheat and other such crops.

17:54
they're going to formulate the guidelines in the food pyramid. It just doesn't make sense. No. And if I think about the food guidelines as well, Marcus, I'm curious to hear your thoughts on this actually, because I do think that for a healthy individual, if they were to follow the guidelines, if they were metabolically healthy, insulin sensitive, and also regularly active, I mean, they would be missing nutrients, I do think. But

18:23
They wouldn't necessarily be any worse off potentially by following the guidelines. But one, you can't follow the guidelines. They're next to impossible given, you know, they certainly don't. People find it very hard to adhere. And two, we aren't a healthy population. If 70% of us are overweight or obese, then why do we have these guidelines as population guidelines when they're so inappropriate for most of us? Yeah, I agree. It doesn't make sense. And my constant phrase or constant...

18:52
cry is the fact that we've got fat and sick over the last 50 years. And, you know, the guidelines haven't worked. The other thing is you get slim people who get insulin resistance and pre-diabetes diabetes. So it's not just about the weight, although the weight is a huge driver, but it just shows that if people who are slim and follow to a large degree the actual guidelines, food guidelines, still can get sick. So again, we're seeing all this disease happening. And then

19:22
from then the complications of the disease or the other diseases that follow. I was really interested in your paper regarding the once were, am I right in thinking, it wasn't once were warriors, I don't know if that was it actually the title of- It was were warriors once low carb. Yeah, there you go. But actually I think once were warriors wouldn't have been a bad name either given the history of our Māori and Pacific sort of populations. Can you-

19:50
chat me through your Genesis for that paper because that really interested me. For sure. I did have the Once Were Warriors theme initially and then decided to change that as a title because that might have been a bit too corny. And when we published, we got real bad feedback from Otago from, I think it was six academics down there saying you can't use the term warrior. You know, this is just a, what do you call it? It's a...

20:15
you just can't use it. And I rebutted that and I think I did that reasonably well to say well they were warriors, what are you talking about? So yeah, basically I noticed that if you go to Papa or to Auckland Museum, you see lots of pictures on the walls, photographs of Maori at the time of colonisation or before even. And you see that there's hardly anybody overweight. So you know, I thought, well, what's that about? So I researched it and I thought, well, it would be really good.

20:45
If I could show that Maori and Polynesians, but Maori in this paper, were not overweight, pre-colonisation, and when you look into it, you see they were taller, they were leaner, they were healthy, they were taller than the Europeans, in fact, but also lean and healthy. And it's only since the carb-rich diet has come in that they started to get fat and sick. And it's happened with Polynesia, it's happened with Aboriginals, it's happened with Inuit. It's just clear what has happened.

21:15
And, you know, when you look at the diet of the times pre colonisation, there was hardly any carbs. You know, people talk about kumara. Well, kumara was revered. It wasn't eaten every day. It's not like we might have meat and three veg. It was stored and celebrated. So the rest of the time they were eating meat and fat and vegetation. And there was practically no carb rich vegetation available. So there was a wealth of food, which was low carb.

21:44
I think proved the point that they were lean and tall because of how they ate. You only have to look at first Australians, 60,000 years of a low carb diet. There again were no carbohydrates of any consequence until Europeans came along and made them fat and sick. It was interesting because at the time that the paper was published, I was doing some research in for a paper that I was writing for...

22:10
Unitech, which is where I was teaching. So I was writing up a lecture on the health of our indigenous population and came across Western prices stuff on YouTube. And there's this super interesting documentary where he, we are in it's, I don't know, maybe 16 minutes long, but it takes you through sort of footage of what the Māori population looked like. And across

22:36
one generation, it didn't even take a generation for health outcomes to change. You could see the differences for those that were not colonized, who still lived on the coast, who still foraged and hunted and fished for their food versus those that had the refined oils and flour and sugar. And Western Price really put it like he was so onto it with regards to the dietary changes.

23:04
And the other really interesting note that I got from it from a nutrient perspective was that the traditional foods, so the vegetation and the fish and the meat that was procured for their diet was super high in nutrients, at micronutrients actually. So you've got this double-edged sword. Not only do you now have this carb rich diet, but it's also really nutrient poor compared to what it was previously and fertility rates reduced.

23:32
bone structure changed, cognitive difficulties emerged, like all of these things, which, and again, that is just an observational, what do they call that? Anthropology? Is that what that is? Yeah, anthropology, yeah. Yeah, yeah. The other thing he noticed was that there was a lot more dental disease as a result of the carbohydrates. But what was really fascinating is that then altered the facial morphology of people.

24:02
across the Pacific. And he documented that how the faces change shape, again, a real effect of dietary change. And so obviously, push back from the use of the word warrior, any other comments or feedback that you've got from that particular sort of publication markers? Just a few positive comments, really. I think that there was no other negative feedback. It was more, I think, positive. And people were perhaps surprised to see

24:31
unraveled, basically, you know. Yeah. And I did that also, because part of the message in the paper was to try and encourage Maori to connect with the past, the good, the goodness of the past. In other words, maybe going back to a former way of eating and and helping them regain their health again, because they've lost out big time. Yeah, are you familiar with Ihi-Ikei? No.

24:59
Yeah, he's got a, he has a program called Matua Atoa, Matua Atoa, and it's connecting Māori back to the land and using their history to sort of teach them about what the land once sort of meant to them. And through that connection, help improve health outcomes because he has a physical education background. He's got his doctorate in, I'm going to say psychology. I think that's correct.

25:28
sport psychology. His method is to try to disassociate from the deficit model that people consider Māori in. Often that's the way that they are identified as in the lower socioeconomic group. They're poorer, they're not as healthy, they're overrepresented in the health statistics, etc.

25:52
recreate that feeling that they were once warriors and they were once healthy and they were connected to the land and they were in control of a lot of this, the things that are seemingly out of control now. And super interesting Marcus, I think that you'd really love a lot of his work. I thought that's awesome. I'd love to connect with him. One of my dreams is to connect with a group of Māori to try and guide them through the process of kābhāhāra reduction.

26:22
as a cohort, maybe Morai based, I haven't been able to find anyone yet. But that's what I really want to do and do much the same as Jay Workman did in Canada's high north. He's an Inuit by birth, he became a doctor and a professor and he did the documentary that's available online, where he took his cohort of people onto low carbon reverse diabetes and obesity. And that's certainly worth a watch. But yeah, I'd love to talk to.

26:52
this man because the thing is that if you're going to make a change, especially with the indigenous groups, there's no point a white fellow coming along trying to tell them what to do. It's got to be by Māori for Māori. But you know, a white fellow can certainly advise and be supportive. But that's where I think this has to come from. Jess Yeah, no, I completely agree, Marcus. And can you chat to me about some of the, well, first, what is your process when someone comes to you?

27:21
And you can see that they're a real candidate for carb reduction. To be fair, I think most people are. I mean, you know, like I don't know, I think it would be, yeah, hard pushed to find someone who isn't. But check me through what that looks like. OK, so they come into the surgery, of course, I've now kindled this desire to make a change. So they come into the surgery for routine checkup, maybe blood pressure pills or blood pressure pills at sale, management of their type 2 diabetes. And I'll say to them, look,

27:52
How do you feel about making a change to your diabetes by changing your diet and maybe reducing some of your medication? And see what they say. And the whole thing is that there are people who do and people who don't. There are people who do, stop for a while and then do. So it is a matter of constantly sort of reminding and encouraging. So if they say, yes, that's something I'm interested in, then I give them a handout. And on that handout, it describes fats, carbohydrates, and protein.

28:19
There's a chart of foods to eat and foods to avoid. And I talk them through it and give them an idea of what this is about. Now, this is not a lecture per se, it's just a brief introduction to what is required to do this. And it is about making it easy, starting slow, and constant review. So I'll see them after a week or two, see how they're doing, if they're keen. It is a matter of having funding to do that as well, of course, and luckily we do have funding to allow people to come back for free consultations to have that follow-up.

28:49
At the start, I'll do baseline measurements, blood pressure, weight, height, blood tests for thyroid diabetes, pre-diabetes, et cetera. And then I'll do those as required subsequently. And it is about persuasion. It's about behavior change. A lifetime of three meals a day, finish your dinner so you can have your pudding, and maybe snacks between those meals is hard to change. So you're supportive. And people say GPs don't like to talk about weight.

29:18
which I find staggering. You know, I lost it. Do they not? No, that's been documented in the literature. They're scared. I think it was in the Journal of Primary Health Care not so long ago. It's like, well, no, you don't say to someone, you're fat. You say, look, I see you've got a bit of extra around the middle like I have. You kind of make light of it. And they know this, you know, it's not something that they don't know, but you're not doing it in a sense of reprimand. You're doing it in a sense of, look, we can make a difference. So...

29:48
It's about behavior change, but also encouragement and leading by example, hopefully. Yeah. And Marcus, so you're going to be talking to primary healthcare doctors on an audit of your, on your audit results. Can you chat to me about that broadly speaking? Like, what kind of results and what kind of information we'd be sharing with the doctors? Right. That's actually, it's secondary care doctors. It's the endocrinologist at the hospital. So I'm like a lamb to the slaughter or as a Christian going to the lions, you know?

30:17
I'm prepared to do that. So, yeah, I had 72 patients. I'll just get a file up here I can refer to. So I had 72 patients. Let's have a look. Yeah, 72 patients, mean age of 54. A third were female and 87% were New Zealand European, which reflects the demographic of where I practice. Data was collected for a mean duration of 21 1 1 1 1 months and entered into an Excel spreadsheet. So it's approaching two years. So that's significant, I think. And I...

30:47
going to talk a bit about weight and then pre-diabetes and diabetes. So of the group, initially 94% of the 72 were overweight or obese and 99% lost weight at the 21 and a half month mark. 13% achieved a normal BMI. I think that's significant. Yeah, that really is. So what kind of average weight loss? Average weight loss, starting weight was 103.4, finishing weight was 92.4, so mean loss of 11 kilos.

31:15
So I'm not sure if you're familiar with the obesity research, Marcus, but I did my master's in obesity. And I can tell you that what is significant in the literature is equivalent to about two to four pounds over six months. So the fact that you've that you're seeing a reduction of like what nine kilos is staggering to me. Yeah. I mean, there are some heavy hitters in there who lost a lot of weight. And that was really cool.

31:42
But I mean, it's a mean and of the mean it was, I think, 11.2 kilos. 11 kilos. Yeah. And statistically significant for both change in weight as well as change in BMI. And I compared that data then with the literature, see what was available, what had been done before. And again, the data is in keeping with what's in the literature. And, you know, the message I have, especially with this process, is that what is clear that this will often work for those who can adopt it. And there's plenty of people who can adopt it.

32:12
there's going to be savings and saving us in terms of lives or morbidity. So I mean, it's this huge advantage here. Yeah. And can I say I chatted to Eric Westman, Dr. Eric Westman. Yeah. On his type 2 diabetes approach. And he has such a good point whenever people say it's unsustainable. If you look at the literature, the weight gain, people gain the weight back. And he's like, it's because through the follow up time,

32:41
There is no, by virtue of what it is, there is no actual extended follow-up. People do not get the monitoring support that they need. And that's such a key thing, is having that support network to help continue to embed these new changes. Well, that's what they do with me. That's what I do. Basically, I'd see a patient every three or six months, not to see that they're up to date with their medication, but to see that up to date with what they're eating.

33:10
Yeah. Right. And may have taken away medication. And I've got people with type 2 diabetes who are on no medication now. And they're managing that just by diet. And we have our checkups though, because you need to be there as a guide, as a to encourage and to keep the ball rolling. I mean, it was silly to do otherwise, I think. So that follow up is vital, definitely. Yeah. Yeah, for sure. And what kind of changes did do you keep a record of cholesterol and

33:39
what it's worth. The reason I'm asking is not about, I mean, I'm interested enough, but I just know that's one of the pushbacks that comes with a low carb diet. It's the biggest pushback, I think, you know. Yeah. So I'm just going to try and find something on that. Yeah, I mean, the whole thing is, again, it seems like the academics aren't listening, because the literature shows that things improve on a low carb diet. So we saw the anticipated improvement in lipid profile, as described elsewhere. So there was no significant increase in LDL, the so-called bad cholesterol. And I'll talk about that in a second.

34:09
There was an increase in HDL, the good cholesterol, and a substantial reduction in triglycerides. Favourable changes in the ratio of total cholesterol to HDL and triglycerides to HDL. One of the things that doctors don't know about, and I'm talking generally, I'm pretty sure this is true, don't want to sound arrogant, but LDL is made up of several components. You've got large buoyant LDL and you've got small dense LDL. Now the large buoyant LDL increases with the low carb diet.

34:38
And that's a good thing because that's not associated with cardiovascular disease. Whereas the small dense LDL decreases. But a low fat, high carbohydrate diet will increase the small dense LDL. So maybe that's the reason why people are getting heart disease as well as obesity. It's clear the numbers do improve, but no one wants to listen. They're scared of LDL. I was going to say that LDL in itself, I mean, I don't believe is a risk factor. And I'm sounding like a heretic here. But when you...

35:08
But when you look at a study of 138,000 people admitted to hospital in the United States with heart attacks, when you looked at the LDL numbers, it was a Gaussian distribution. Now, can you describe that? Yeah, you would expect everyone with a heart disease to have high LDL. But it wasn't. It was what we call a normal distribution. In other words, it bore no relationship to the heart disease.

35:32
So was it like a bell curve, the usual bell curve that we would see? Absolutely, yeah. Amazing. Yeah. And that must tell you something, right? Even things like the LDL, you know, the framing of heart study. William Castelli, one of the lead investigators in later years came out saying, well, if the LDL is less than 7.8, you don't have anything to worry about. So there's lots of evidence.

35:59
But no one's listening. Even the trials or analyses of trials of cholesterol reduction, LDL reduction in heart disease and without heart disease, there's such a variation in terms of the numbers that you can't really say it's clear. But there's this constantly repeated phrase that there's a linear relationship between cholesterol and heart disease. And I think it's probably more related to obesity, to be honest, or insulin resistance than it is to LDL.

36:27
Yes. And if we chat about the insulin resistance, as I understand it, the triglycerides are a good proxy alongside waist circumference or insulin to sort of give you an idea of who might have insulin resistance in the population. Right? Are those markers that you look at, like triglycerides and things like that? What I would say definitely, triglycerides alone are an independent risk factor and significantly

36:56
alcohol push it up, but a lot of people it's up because of carbohydrates. So if you reduce carbohydrates, that drops and goes to normal or even much lower. So the driver of triglycerides is carbohydrates. The other thing is that if you take the ratio of triglycerides to HDL, as long as it's less than 1.3, I think it is, then that's a good surrogate for the large, fluffy or buoyant LDL. In other words, if it's less than 1.3, that tells me that you've got large, fluffy LDL and therefore can be reassured.

37:25
The other thing is that with cholesterol, if it's high and people are worried about it, you can get a calcium score test done. That's a heart CT scan, which can tell you whether or not you've got any risky heart lesions that might require some kind of therapy or intervention. Marcus, is the scan that also assesses soft plaque, is that available in New Zealand for people to get? Not that I'm aware of. I think that's probably talking about a coronary...

37:54
CT angiogram. That's something that you can only get under specific conditions, but we can't have access to that. This has to be via a cardiologist. And that's when it might be too risky to do an intravenous angiogram, whereby they might need to just do the CT scan. But no, soft plaques is an area that I think is evolving. People are focused on the calcified plaques because that's where the

38:23
mitigate risk if your calcium score is above a certain level. It's useful to reassure people, especially with high cholesterols. So yeah, I'm afraid that test is not relatively available. And even calcium score tests cost about $500 to $800, so it's not cheap. So you're looking at a group of society who can afford to look after their health by paying for these tests, typically. Yes, for sure. I was going to say the other interesting thing about cholesterol is there's this big

38:53
fear of familial hype in other words, family history of high cholesterol. The really interesting fact is, yes, some people do get heart disease at a young age, but if they don't, they'd have a normal life expectancy. So there's not a linear increase in heart disease over time. It's something else that is causing people to get the heart disease and die. It's not the cholesterol, seemingly. Yeah. Yeah, that is super interesting. And it isn't, what I also find interesting is that I think people confuse the...

39:22
medical definition of familial hype I have totally said that wrong because I'm terrible with pronunciation. FH, FH. FH alert. Yeah, so what I, like out there in that sort of general population, they confuse FH with high cholesterol and my parents had high cholesterol and their high cholesterol might be five or six or something that isn't actually high, but they're like, but they almost, they're like, well, I've got high cholesterol, but my

39:50
parents had it so, and they're like, there's nothing I can do. And again, I'll say, I don't think cholesterol is a good risk factor and the thing to focus on. I always look at triglycerides and waist circumference and diet quality and the things that you, I think Marcus, would also, as you've said, they're things you focus on. But a lot of people do have that sense of inevitability about them. And I wonder, in your clinic, when you have someone come in who has type 2 diabetes, what

40:20
if it's something that someone in their family has, is there also a sense of inevitability there that you've experienced? I think to some degree, I will often say to people, well, yeah, your parents might have had it, it may be for the same reason that you've got it. Yeah. Plus also there's possibly a genetic component. I mean, we do know that there's a genetic link with type 2 diabetes. So at the end of the day, I don't focus too much on that anyway. What I want to do is reverse it if I can or omit it. So

40:49
Yeah, if they say that, I say, well, yes, there's a chance of the family history, the family, familial components, but let's focus on trying to reverse it, you know. Is there scope for people to use CGMs, Marcus, and do you use them routinely or not routinely in your practice? And what are your thoughts? Yeah, CGMs are great to give people an idea what food does to their blood sugar. I think they're fantastic from that perspective. And if people can afford them and want to do it, I think it's really, really good. It's much easier than finger pricking.

41:18
It's very educational and you don't need to have an ongoing supply of them. You can just maybe use it for the first month and get a good idea of what happens. I don't use them because I like to keep things simple and as cheap as possible. I'll focus more on looking at the diet history and looking at the blood sugars, HbA1c, what's happening with weight and how people are tolerating the way of eating. But it's certainly got a place in management.

41:46
afford them and if they want to use one, absolutely, I think it's very, very useful. And Marcus, any patient that you see who diligently follows your recommendations slash instructions and fails to see an improvement, like are there people who are just non-responders to this? Yep. Talk to me about those people because they're interesting to me. Oh yeah, and me too and I don't know the answers to some of these. But we've got people who aren't doing it

42:17
as well as they should. You revisit what they're doing, so you take another dietary history. For most people, and that's males in particular, it should work. The perimenopausal femur, perimenopausal women, in whom it often fails. That is because, I guess, fat makes estrogen, and I guess the body's way of trying to continue estrogen production once the ovaries have

42:46
is to keep the fat on the body. Now that's not scientific, not fact, but I just wonder if that's part of the mechanism. So women who are perimenopausal find it very hard to lose weight and often want to lose weight and need to lose weight. And one of the things I've come to realise is that there's a quite a benefit from using hormonal replacement therapy and that can actually help in the process of weight loss in these women. The other thing is if things aren't working...

43:13
It's hard to explain, but the next step would be some kind of intermittent fasting and seeing if we can sort of get the weight off that way. But I think typically it will be people not quite appreciating that they are on a low enough carbohydrate diet. And again, keep it simple. You start with reducing carbs, see if there's an effect. If there's no effect, then you get stricter on it. But again, constant follow-up and encouragement to make it doable long term. This is not a diet. This is changing what you eat and changing your lifetime of habit.

43:43
you know, encouraging people to have a list of their 10 top recipes on the fridge. So it's easy to know what to prepare. They don't have to think too hard about it. You know, something tasty and filling and, yeah, as I say, constant encouragement. But yeah, there's some people who doesn't work. And there's one I'm seeing this afternoon, in fact, who have struggled to lose weight and they're eating practically nothing, you know, and I just don't understand it. But it must be, must be carbohydrates or too much fat.

44:12
That's one of the things that sometimes happens too much fat is being eaten. And so you amend the diet a bit with more protein. And that's in my experience as well, Marcus, because I work with hundreds of perimenopausal women and many of them have come from that low carb space. And this is, and I'll just, because I think you'll be interested, I'm sure you've heard this a lot, like when a woman is told that, you know, just give up carbs, and actually it's a low carb, high fat diet, once they get beyond the fact that they do have to add

44:42
So like, this is something that's been off the menu for us for decades. And suddenly peanut butter comes in and cheese comes in and cream comes in. And in my experience, which is why obviously, um, I have my program, it's protein, it is lean protein really moves the needle for perimenopausal women. And part because of the stress response of being on a very low calorie diet, but then also the unintended calories.

45:12
unable to sustain their diet and then they binge or whatever. Or they might be having three coffees with cream in them, which is like 600 calories, but like no actual nutrition other than fat. So I don't know if that's at all of interest. Oh, definitely, definitely. No, that's really good to hear because that's something I will try. And I've always talked about more protein, not measured it or not.

45:36
thought too highly about cups of coffee, but you're quite right. You know, if you've got cream, then you're going to get a significant amount of energy, which is important in the equation, to some degree. But just going back to something you said before about cholesterol and fats, you know, even for me, having had this this renaissance, as it were, if that's the right word, it still plays in the back of my mind, oh, all that fat, what about the cholesterol? Now, I don't, don't believe that, but it took a long time for me to adapt my way of thinking the gut reaction, you know, I remember

46:06
When I was about, well, 1977, in fact, I remember a letter or a thing from Reader's Digest coming through the door, through the letterbox back in the UK, talking about eggs being bad. And that stuck with me all this time. I still remember that day, you know, and Mozzola oil was the latest thing, you know, corn oil. So that is a brainwashing that goes back a long way. And then you go to medical school and it just intensifies.

46:33
But when you look at the evidence of what happens, when you make the changes that we're talking about, you don't see negativity. You see positivity and the numbers improve. Yeah. And I think you just can't argue with that, right? Even when people pull the cholesterol card, when you've improved so many other of those metabolic markers, it's very hard to argue that it isn't an appropriate sort of response and approach. I think the arts, yeah.

47:03
The answer to the question when it's raised about cholesterol is that there's no single statement probably that can counter their argument. They can come out with, there's a linear relationship between cholesterol and heart disease. And I can come out with, well, there's all these papers, some of which show there isn't, some of which show there isn't, but no one wants to hear that. That is the evidence. That is the meta-analysis. That is the reviews that actually show that cholesterol is not important. But it's much easier to come out with that one-liner.

47:31
then the evidence against it and you lose every time I think. I think so. Have you been following along with the lean mass hyper responder? Have you had any people like that in your clinic? Yep, a few people come through usually as casual patients, a couple of people. Yeah, yeah. And what's your approach in that setting? I think we don't understand fully what the lean mass hyper responder long-term effects are.

48:00
We still have to acknowledge the fact there could be risk involved. So it's about explaining what is known. It's about probably getting a current calcium score done. And usually these people will want to do that to reassure them that there are no calcified plaques there of significance. And then it's up to them to do what they want to do. It's not for me to say, oh, it's safe, go ahead and carry on. I think if you weigh up what they've done with their lives, some of them have been significantly overweight.

48:29
and then improved and become lean and lean mass hyperresponders. So the benefits to the weight loss, possibly outweighing the potential negative effects of raised cholesterol. And you just have to present people with the evidence and they make their own choice. You know, people make choices and they should be making choices based on evidence in every aspect of medicine. And I'm not going to come out and say lean mass hyperresponders is a good, safe option.

48:57
I'll just say, well, the jury's out on that. We just don't know. And we're not likely to get studies done, but I don't know. Yeah. Yeah, I'm really interested to see what over the next year, how the citizen, what is that? Is that the citizen? Dave Feldman. Yes, Dave Feldman. And his, yes, in his research and just to see how that continues to evolve. Super interesting. Yeah, he published not so long ago with an American researcher, whose name escapes me right now.

49:27
about some aspects of this and I think it's an evolving area. But we won't have the long-term studies, unfortunately, probably ever to look at this. But yeah, there's a theory about what it all means. That's only a theory. And yeah, I don't know, people have to choose for themselves. I think it's only a minority, small minority anyway. So for most people doing the low carb or carbohydrate reduction thing will be of huge benefit anyway.

49:54
Yeah. And then with your carb reduction approach Marcus, with people who, I mean, obviously you're seeing people with type 2 diabetes, so carbohydrate is actually the toxin that they need to avoid. So does that mean that you rule out things like fruit and all of that? Oh yeah. Famous five, bread, pasta, rice, potatoes and fruit, except berries. Yeah. Yeah, yeah, nice. Fruit is bigger and sweeter than it ever was. Yeah. Yeah. And it's got no nutritional value.

50:24
other than to make people fat and sick. Okay, I coined a phrase recently, calves make you fat, remember that. I can't spread that around because that's the message, right? Yeah, yeah, yeah. And it is interesting, like I do have some clients who have made admirable changes to their nutrition, but unfortunately has swapped out a lot of the junk food for.

50:48
fruit and so eating seven or eight pieces of fruit a day and has an A1C or HbA1C at like 44, 45. And I just have to say to them, sorry, that's just, you just cannot have that. Like that's actually not a good option for you. And this is where I do get, I do believe that there are foods that are good for you. And I do think there are bad foods. And it's really unpopular to say that's a bad food, you know, as a nutritionist, that you're not supposed to say anything is bad anymore. But, but

51:18
in this instance. I mean, I love fruit for people who can metabolize it in a healthy, but for people who aren't, it's just not appropriate. Yeah. And I tell people, you're allowed to have treats, right? You're allowed to have a pie now and again, you're allowed to have fruit now and again, but don't eat it all the time. And you don't eat it on the basis, on the background of a high carb diet. So I think making things a treat. The other thing is really interesting is that when you do this way of eating, you don't miss a lot of things you really like. Like...

51:47
Bread, I love bread. I could eat a whole French stick smothered in butter with cheese, but I haven't had bread for God knows how long. But I might have a treat now and again. And I don't have insulin resistance, but for other people, that is the message. You have a treat. And it's not about restriction and making life miserable. It's about changing what you do for your health. The other thing to remember is that HP1C, when it's above 40, is actually harmful. And we've got this crazy, crazy situation.

52:16
where we have a condition called pre-diabetes. It kind of makes it sound benign. Yeah. Right? I want to get rid of that term. I want to get rid of the term with type two diabetes as well and call it something else. I think Catherine Croft was defining diabetes in a different way in terms of insulin resistance at a recent presentation she gave. But, you know, calling it pre-diabetes means I've got nothing to worry about. I just don't want to get diabetes, but it morphs into diabetes, unless you change what you eat most of the time.

52:45
And similarly, I imagine we're on the same page here as well. It's like, it's that arbitrary cutoff for pre-diabetes just really irks me as well. It's like people will go to the doctor and their HbA1c will be at 39, you know, with a bunch of other risk factors and they're overweight and the doctor doesn't say a thing about them because they haven't hit that magic number. Whereas it's not like your health risk explodes beyond, I don't know, 40 or 41. Like there is a risk with your...

53:12
So even for people who might not have insulin resistance, this is where I see there's still a requirement, like I think from a health perspective, looking at your carbohydrate intake, removing a lot of the refined carbohydrates just to improve the overall diet quality is important. Yeah, what I do is every time I get a new Hb1c or 41 and I was pre-diabetes, I ask the person to come in because I tell them, look, now you have insulin resistance. This is a potential threat to health into the future.

53:41
we should look at making some changes and discuss with them how we might do that. Again, it's about moderate change, not being too radical, because that's not going to work. As you said, cut down your refined carbohydrates and see what happens. Yeah, as you say, you've got the warning bells of diabetes happening once you get above 40. The other thing is once you get to diabetes, that means three medications automatically. It means an explosion of complications potentially.

54:11
misery and death. And as a particular tragedy of the Polynesian and Maori population is a lot of them don't live to get their pension. They worked all their lives to get the pension, but they're dying of obesity-related diseases. That's criminal. No, I completely agree. Marcus, do you work with health coaches? Are they an integral part of or would you love to? Yeah, I would. Yeah, I mean, what we've got in our

54:39
primary health organisation is about three health coaches, no, six health coaches, and only allocated to a few practices because there's no funding for more. I mean, I love a health coach. I mean, to my mind, that's ideal. I work with some private health coaches, but it's really something that's hopefully going to evolve in the future. But it needs to happen because we need behaviour change. That's fundamental.

55:08
the sort of top down, doesn't it? So the government makes the decision to fund these areas here and make it a priority, which I don't think would happen under any government, if I'm honest, but imagine that to then you'll be able to affect a lot more change. But the change you're doing, obviously, is amazing already. Well, it's been incredible. I mean, it's just so rewarding. As I say, you get a happy doctor, happy patient, at a time in your career where things are getting quite...

55:38
wearing you would say. So it's a positive note. Every time I see someone coming in for a consult, casual patients, it just raises my mood because I know I'm going to have fun talking about this, you know, and patients come in and I know who they are and I can keep that ball rolling with them. So it's a very positive thing. Yeah, amazing Marcus. So now are you presenting anywhere where people can come and chat to you or anything like that over the next

56:07
few months? Not, I'm going to talk to some pharmacists about what I'm doing. Oh great. Yeah. With a PHO and I'm going to talk with endocrinologists, but no, nowhere else at the moment, but I love talking about it. No I know and I'm so pleased that you made yourself available because I know that your schedule is like super tight. So Marcus, I will put a link to...

56:29
Botany doctors, I'm sure you've got a waiting list, but I will anyway. And you did sound like you're on the cusp of retiring, but still you might not be able to in the next few years. A little bit too much work to do. Yeah. That's the whole thing I was pointing out in one of the papers was that, you know, at the end of your career, having that positive note is actually a good thing. And it would probably be something I would do even if I retired from general practice. I still carry on seeing people for this. So, you know, it's positive. Yeah. No, that is really positive. So.

56:57
pop links there. Where else can people find out more about what you do? Are you like active on social media and I've just ignored you? I've got a Facebook group called No Carb Doctor New Zealand. Oh yes you do. I actually do know that. Fantastic. And it's got just over 3000 people so far. But it's very active. I'm always posting things, comments I find online or whatever and other people are posting as well. So it's actually quite an active and useful group and people are supportive.

57:26
And is that for the general population to be able to sort of... brilliant. Yeah. What else? Belong to a few other groups, medical groups associated with low carb and ancestral health and things. Nice one. But no, not much else. I don't have it. I have a Twitter account, but I'm not very active on Twitter. It's quite busy, you know. But I do a lot. I'm involved with AUT in terms of a research project that we've counted in and Grant's come and filled.

57:56
Can we just very briefly, and I know you have to go and I'm very mindful of that, but what is this project? Can you just describe to us what you're doing? It's a Health Research Council funded project and it's headed up by Karen Zinn from AUT and Grant Schofield. And it's involving Catherine Cross as well and a group of GPs, myself. I won't try and name them because I'll probably forget, at least somebody off, but about four or five of us GPs spread around the country in Christchurch.

58:25
Dunedin here in Auckland and Taupo. What's been done so far, three phases. The first phase was to gather data from some practices on what they've been doing in the low-carb space, some of them Taupo and here in Auckland. The second phase is now to recruit practices, doctors, nurses, health coaches, HIPs to be involved in this project. The first training session is happening next week in Christchurch where a group are being trained by AUT in terms of

58:55
low carbohydrate or therapeutic carbohydrate reduction. And then we're hopefully going to do some up here as well. And that will then be monitored over time in terms of results and eventually published and with a view to then rolling this out as a usable process throughout the country. Hopefully make enough change and get noticed enough that people will listen. So it's a gather data implement and hopefully make it mainstream. Amazing. That's like change from the ground up.

59:24
Yeah. Yeah. And you know, we went to this meeting, this hui that we had a few weeks ago. I think you were there actually. What was so nice about it was you normally go to conferences and people are in clusters and don't really talk to each other. But at this meeting, everyone talked to each other. We're a real movement or what's the word that Karen uses? We're a collective. And we are, you know, we're trying to make positive change. And that's really nice. Yeah. Yeah. I completely agree, Marcus. It's awesome. And it's so great to chat to someone local who is doing the work here.

59:53
And the fact that it's, you know, this isn't just a New Zealand thing, this is happening worldwide. And for people who are interested in exploring this further, the Low Carb Dr. New Zealand site will be great for them to see who is in their local area, I imagine. Correct. And you know, we're always happy to answer questions, not medical questions, obviously, but questions about where to get help, etc. There's a list of practitioners on that page. So I mean, yeah, it's...

01:00:23
something that we want to help with, you know. Yeah, that's amazing. Marcus, thank you so much. I really appreciate your time this morning, this afternoon. And I really look forward to seeing the progression of your study, it sounds great. Well, thanks to you again for having me on board and enjoy your long weekend. Thank you, see you later. See you, Mickey, bye.

01:00:55
Alrighty, hopefully you enjoyed that as much as I did. And it's always so great to listen to general practitioners going out into their community and helping with the understanding and education of other doctors. Because this is how we spread the word. Because I don't think it is going to happen anytime soon from up top. Next week on the podcast, I welcome back Brandon Cruz. And we have a great discussion around building muscle for the female athlete. And remember, if you're human.

01:01:24
you are an athlete. Until then though you can catch me over on Instagram, threads and Twitter @MikkiWilliden, over on Facebook @MikkiWillidenNutrition and do not forget that 40 over 40 is still available to purchase over on my website. Alright team, you have the best week, see you later.