#199 Are Glucose Hacks Worth It? with Dr Rupy Aujla

Dr Rupy: On today's podcast, we are going to be talking specifically about practices, tactics, strategies to reduce blood glucose spikes, specifically after eating high carbohydrate meals, to keep us more insulin sensitive, to reduce the risk of insulin resistance so we can prevent the downstream effects of poor metabolic health like type two diabetes, certain types of cancer, dementia, and even cardiovascular disease, and even improve the management of some more vague symptoms like brain fog or pain or headaches. And then there is also the relationship between insulin resistance and things like PCOS as well. I'm diving into the studies that many people use to recommend certain glucose-lowering strategies, and I'm asked frequently to comment on them, so I think this is going to be a nice, honest, diligent dive into some of those things that I've looked at before. And I'm going to give you my opinion as to whether I think they're worth trying as well, which is which is great. And actually, in doing this exercise, I've actually become more bullish on certain elements in glucose-lowering therapies as well, so non-non-pharmaceutical glucose-lowering therapies.

Dr Rupy: Overall, like I said in the previous podcast where I did a dive into insulin resistance and insulin sensitivity, which if you haven't listened to, I would listen to that first before listening to today's episode. But I believe these things are the extra elements that you'd want to stack on top of the real core foundational things that I think are going to have the biggest impact on insulin resistance and improving one's insulin sensitivity. I think these will definitely provide certain benefits depending on the person as well and their health status, as we'll get into, but these are not the mainstay of my suggestions.

Dr Rupy: Like I said in the previous podcast, the best things you can do to prevent insulin resistance and keep yourself insulin sensitive, and you'll know about those things if you listen to the previous podcast about what those mean, you want to focus on exercise, diet, stress, and sleep. And I hasten to say exercise, that's going to be the biggest impact, even though I'm a food guy, I love talking about diet. Exercise in the context of insulin resistance is going to be the biggest impact. So keeping good amounts of lean muscle mass as we age is the mainstay of improving metabolic health. These are the key interventions, right? But if you're if you're listening to this episode first, I would highly recommend that if you want to learn more about insulin resistance, what it is, how it impacts your risk of disease, your and your your risk of chronic conditions, go and listen to that. It's a couple of episodes before. You'll learn about the importance of blood sugar regulation in the body, how tightly controlled it is, how insulin works and all the different mechanisms of how insulin resistance can occur and what we can do to become more insulin sensitive and specifically those those key pillars that I talked about earlier in terms of exercise, the different types of exercise, the dosing of those exercises, dietary strategies, and reducing overall saturated fat and focusing on fibre and plants.

Dr Rupy: But today's podcast, we're going to talk about these popular strategies, specifically vinegar, which a lot of people ask me about, the order of food, also also referred to as nutrient sequencing. So if you if you type in order of food glucose, you don't really get much in PubMed, but if you type in nutrient sequencing, you'll get more more studies. The the impact of having a veggie starter or fibre whole food supplements, something that I'm really interested in, and moving after eating as well. And then I also want to talk a little bit about supplements. I don't really talk about supplements that much. I'm more of a whole food kind of person, but I think some whole food supplements are really interesting to to talk about and some that I've never heard of before. And do stick around to the end because I have a supplement that I think could be one to watch, and no one is really talking about right now. So definitely stick around to the end because I want to briefly touch on that.

Dr Rupy: Before we get into this, if you have type one or type two diabetes or you're on any medications, you must discuss doing any supplement changes or dietary changes or whatever it might be with your practitioner before you do this because you don't know, and actually, quite honestly, I don't know, a lot of people wouldn't realise the interactions that certain supplements or practices can have on your medication regime. So definitely, definitely go and speak to your practitioner, your doctor, your medical advisor, whoever it might be, before you do any of these different strategies because that's super important.

Dr Rupy: A quick refresher. What do we mean? I'm going to I'm going to say the word metabolic health a number of times in today's podcast. What do we mean? What I'm referring to is a state of optimal metabolic function within an individual's body. What that means is you have a state of optimal energy production from your mitochondria. These are the powerhouses in your cells. These are healthy. Your nutrient utilisation from your cells and your gut microbes is optimised, plus hormone regulation is well balanced, your blood sugar control is normal, and you're essentially in a state of balance. That's really what we mean by metabolic health.

Dr Rupy: Practically, and in investigation terms, what do we mean? So when I'm looking at a metabolically healthy adult as a doctor, and they come to me as a patient, I know that they are metabolically healthy because they have good insulin sensitivity, they have normal blood lipids on a blood lipid panel, they are of normal weight. And we do weight, like I said in the previous podcast, the the the rough way is BMI, although I think there are a lot of reservations around that. The best way is going to be using investigations like DEXA scanning or waist-hip ratio as a quick sort of rule of thumb. Normal glucose responses to food that we can either measure using a formal oral glucose tolerance test or a continuous glucose monitor, for example. These measures are all suggestive of good metabolic health, not a whole clean bill of health, but suggestive of good metabolic health that coalesce to reduce your overall risk of disease.

Dr Rupy: But let's say, for example, you don't have access to all these tests and stuff, you just want a sort of an intuitive measure of whether you are metabolically healthy. A metabolically healthy person intuitively knows that they are so because they are of lean weight, they feel energetic, they sleep well, they don't have crashes after eating, they have clear skin, they have less cravings, they feel clear-minded. These are all sort of vague suggestions of metabolic health as well. Obviously, there are lots of confounding. I mean, these are these are things that are influenced by more than just one's diet or metabolic health status. It can be influenced by physical activity, your stress state, your sleep schedule, emotional health, all these play a part. But overall, that's what those are the things that you want to be thinking of when it comes to metabolic health without those investigations. If you do have cravings, if you do get headaches, if you do have fatigue, they can be as a result of other things that I would always recommend you go and get checked out with your doctor, but overall, those are the things that we think of when we think of metabolic health as well without those investigations.

Dr Rupy: The best way to see whether these strategies that we're going to talk about on today's podcast are useful is to become a lot more intuitive about how you feel after consuming food and using these strategies. If you're into testing, a bit like myself, you could simply get a blood glucose monitor and measure at regular intervals after consuming food, what your responses are like, or continuous glucose monitors that are quite easy to access these days, particularly in the UK, and do your own mini experiments. I don't think it's useful to do it every single time after eating for months or years on end. I think a strategy of seeing how you're responding to your normal diet over, let's say, seven to 10 days and doing that periodically, maybe once or twice a year, is probably going to be something that gives you good behavioural nudges in the right direction and gives you insight into how your body is specifically reacting to the different types of nutrients that you ingest. But again, horses for courses, I think it really depends on the individual and as to how how specific they want to get with their biology.

Dr Rupy: Okay, let's start off. So we're going to talk about vinegar. It's a really easy one to start off with because I'm asked a lot about whether you should be consuming vinegar before eating a couple of times a day. I think vinegar had a bit of a thing during the sort of early wellness boom in California, everyone's having that apple cider vinegar in the morning. There's surprisingly very little research on this, but some really interesting mechanisms of actions that have been proposed, right? So there was a paper in Diabetes Research and Clinical Practice entitled, 'Vinegar consumption can attenuate postprandial glucose'. So attenuate, reduce, postprandial, post meaning after, prandial after eating, glucose, this is sugar in the blood that they're specifically referring to as measured by capillary blood. In this case, you can take it from a venous draw, but this is capillary, and insulin responses. So that's your response of the hormone insulin that is used to yes, drive glucose into cells, but it has a whole number of other uses in the body, as we described in the previous podcast, including stimulation of of fats in the liver, etc, etc.

Dr Rupy: This was a systematic review and meta-analysis of clinical trials. So what they did is they, using some search criteria, grouped all the vinegar trials together and they looked at the overall benefit or lack of benefit or lack of anything after analysing all these trials. So this is really interesting because this is a good starting point. If you're if you're just getting into studying or perhaps you're you're studying at university, looking at a systematic review and meta-analysis is sort of where you want to start to get like an overall grasp of an area. But the quality of the review that you generate by doing one of these is dependent on the quality of the studies that you put into the review. So if the studies are of poor quality, then what you're going to get out has to be taken with a lot of salt. And I know we're talking about vinegar here, I'm not trying to make a food joke. It's a very bad food joke if it is. But you've got to really be careful about the interpretation of these results. And I and I make this point now because we're going to go into exactly what went into this, what what went into this systematic review and meta-analysis of the clinical studies.

Dr Rupy: So they discussed the non-pharmacologic intervention of using vinegar, so it wasn't in a tablet form or anything or like an acetic acid powder, it was just vinegar, to reduce glucose spikes and thus reduce insulin requirements. And they conducted this review using 11 from 744 analysed studies. So the the the big bulk of them was over 700 and they whittled it down to 11 that they used in the review to give a more precise estimation of the of the potential benefits of using vinegar. The largest study out of this whole, out of all the 700 plus that they reviewed and whittled down to 11, was 12 individuals. So they only had 12 participants in the largest study that they put into this meta-analysis. The smallest had five. So, and this is going to be a running theme throughout today's podcast. There is really, there are really small trials looking at these interventions. So you have to take everything with a pinch of salt. We're not talking about big cohort studies here, we're not talking about, you know, really well-funded trials either, because no one really stands to benefit from having a bit of vinegar in your diet before you have food, which is why there is a real lack here. And I think citizen science is going to be a big thing when it comes to testing these things because a pharma company who has the capital and the manpower to be able to do or people power, whatever you want to say, to to be able to do these kind of studies is going to be lacking because there's no financial upside for them.

Dr Rupy: So anyway, the largest study of 12 individuals, smallest had five. They used different types of vinegar in the studies as well. So there's a lot of variation in the study. Some used apple cider vinegar, some used red wine vinegar, some used grape vinegar, you get the point. And the range of vinegars and the range of doses of these vinegars in these different studies ranged from two to 50 grams. And there were also different disease states as well. Some people were healthy individuals without any metabolic disease, some had type one diabetes, some had type two diabetes. So overall, the review, I'm going to get to the punch line, did reveal a benefit, but there was a significant variation in the results and also the reviews that they put into this meta-analysis were really, really varied as well. So it's very hard to derive whether vinegar is going to be a beneficial thing for you or whether you're going to derive the same benefits as a result of this particular study.

Dr Rupy: The net effect does appear to be beneficial. So they do something called a forest plot where they look at the magnitude of effect throughout all the different studies. You can reference all these studies at the bottom of the podcast and you'll find out on the doctorskitchen.com, the website. It did it does find a benefit looking at the forest plot, but I think it would depend on a number of different factors, like the glycaemic index of the actual meal that one is consuming, whether it's high or low in sugars or refined carbohydrates of that existing diet, the the the type of vinegar that you're using. I mean, you know, that is definitely going to have a difference because there are different concentrations of acetic acid in different vinegars, ranging from 5 to 10%, sometimes more. Just as a side note, if you are using vinegars for pickling, you want to use a high acetic acid one because the the pickling process would require you to have an antimicrobial effect so you don't, you know, you don't want the food to spoil. So if you are going to be pickling, you want to use a high acetic acid, something like white wine vinegar or malt vinegar or something like that. And if you're not having a very high carb diet and if you are of healthy weight and and and don't have a metabolic disease, is this going to have much of an effect? I think the honest answer is we don't know. It could do, it could not do, but we don't know. It depends on the health of the user, it depends on the food matrix, so the combination of different foods that we're going to get onto in a second, and the amount of starches and refined carbs in the meal as to whether vinegar is going to have an effect or not. So I just want to say that from the start.

Dr Rupy: Mechanisms of action. Why might vinegar have a beneficial impact on your ability to to mellow the glucose the glucose spike after eating? And we'll get into exactly why we'd want to mellow it in a second as well. Well, the potential mechanisms include inhibiting the activities of the sugars in the small intestine as well. So reducing the activity of that of that sugar. It could also, the acetic acid specifically can stimulate the uptake of glucose into peripheral tissues. Remember, the previous podcast we talked about these different savings accounts for your sugar balance, right? So you don't want to keep it in the blood. It's very, very tightly regulated in the blood, around four grams of sugar is in my blood right now at any point in time. And if it goes outside of that for long periods of time, that's not a good thing. That's where you get hyperglycaemia, that's where you get the diagnosis of type two diabetes and all the downstream complications of that. The other peripheral tissue states that we tend to have, muscles, flexing my muscles right now for those of you watching on YouTube, liver and fat cells. So it can potentially improve the uptake of glucose into those peripheral cells. It can also suppress digestive amylases, we'll get into that a little bit later when we talk about supplements and why that might be a good thing. So again, further reducing the absorption of those sugars so they pass through the digestive tract without going into your bloodstream, and maybe even improving the sensitivity of insulin receptors on the on the peripheral tissues as well.

Dr Rupy: Another thing that a lot of people cite is it delays gastric emptying. That when you have delayed gastric emptying, it can lead to early satiety, bloating, nausea, vomiting. This is a very severe condition, a very uncomfortable condition for people who have who have this delayed gastric emptying to a pathogenic degree. And we have medications for this as well. The abdominal discomfort that can be caused from that and the poor appetite can be very, very troublesome for a lot of people. It can be caused by things like medications, nerve damage, hormonal disorders, lot lots of reasons as to why. But just slightly delaying the gastric emptying rate slows the amount of sugar that your intestines are exposed to, which would stand to reason that it would blunt the rise in in sugar in your in your bloodstream. So essentially mitigating those spikes of sugar, which can potentially reduce the the postprandial glucose excursions, the the PPGE, as we'll talk about a little bit later.

Dr Rupy: Then it stands to reason like if you do have a condition called gastroparesis, which is where you have a a pathological delay in the absorption of of sugars, sorry, absorption of food, could it could it worsen the issue of gastroparesis? Again, I don't know. I can't really comment on that. It it would it would stand to reason potentially, but, you know, I haven't seen any adverse studies or or or paper reports, but I'm not too sure. It might be something to just be aware of if you are diagnosed with gastroparesis and if you have that condition.

Dr Rupy: Long-term studies looking at vinegar, pretty non-existent. I mean, like if the the short-term studies are that that scarce and that small, it's going to be very unlikely that we're going to have any long-term studies. So we don't really know whether having more vinegar in your diet regularly would reduce the impact on, so reduce your likelihood of insulin resistance, say, or have a meaningful impact on HbA1c, which is a marker that we we test in the blood to see whether you're at risk of type two diabetes or how well you are removing glucose from your your blood sugar, your your blood bloodstream. So at the moment, I would say it's an unproven option for type two diabetes. And the dosing is is a bit of a difficult one as well. Because of the variability of the doses used in the studies, it's hard to determine what dose would be adequate if it is going to have any effect whatsoever, but around one to two tablespoons of vinegar before meals is what I would experiment with if you were interested in experimenting with it. One thing I would say is don't just take a tablespoon of vinegar, dilute it in water because it can be very abrasive, depending on the concentration of the acetic acid as well. It can be very abrasive to your throat. And I think there have been case reports of enamel damage in in um dentist uh uh dental journals from people overusing lemon in water as well as um uh vinegar uh without properly diluting it as well. I don't think it's going to be an issue if you dilute it, but it's just something to to to be aware of.

Dr Rupy: Should you try it? This is where I get asked about a lot. Look, I don't think it's going to cause any harm. So in my case, it's like, why not? Can I say it's generally safe? Probably, I would say so, depending on whether you do have gastroparesis or any other conditions that could be worsened by delaying, further delaying the gastric emptying. But I think it's probably going to have a modest effect. And whether you're if you're a healthy person, is it going to have an impact? Who knows? I would say it's probably one of those to worth testing. See how you feel, see how convenient it is. If you're going to have a high carb meal, is it worth taking it? Probably. And actually, this is something I might try do myself and do a little experiment with a continuous glucose monitor. Have like a high carb meal, like burger, chips, shake, I mean, I barely have this kind of stuff. But, you know, if I'm going to carb up, maybe I'm going to have a little bit of vinegar before and just see what happens. I think it could be an interesting pre-emptive action if you know you're going to have that and you don't want to feel horrible later. And I hate that feeling of like bloating and crashing and all that kind of stuff. So, you know, I don't want to give up eating those delicious foods. So maybe this is something I might do to just mitigate some of the potential effects. You know, it's kind of like when I drink alcohol, which I do fairly irregularly, I would say these days, I take uh what we we have something in the UK called Dioralyte, which is basically like a a salt and sugar solution. We tend to give it to kids who've got diarrhoea and vomiting or adults to replace the salts that you're losing as a result of diarrhoea and vomiting. It's hydrating, it's got a a real easy sort of mellow taste, and I'll have one of those diluted in three, 400 mils of water before I have drinks later on today. I'm not recommending you drink, I'm not recommending anyone uh over consume alcohol as a result of like, you know, mitigating the potential hangover effects with a salt sugar solution, but it is something that I feel for me works to hydrate myself because I hate getting a headache the next day. And I, you know, I'm such a loser with this. Like, I don't I barely drink these days. And if I have more than two drinks, if I have two drinks, two glasses of wine, two whiskeys, whatever it might be, the next day, I feel it. And so that for me is, you know, I've just kind of um reduced my alcohol to only really drinks that I absolutely love and when I want to. But if I am going to drink, uh one or two drinks, then I'll have a sugar salt solution. So I digress. That's sort of the way I would view having vinegar. It's not something I'm going to do every every meal time, but maybe as a pre-emptive action when I know I'm going to carb up.

Dr Rupy: Some of the authors have suggested that it's a promising functional food to improve glycaemic control. It might be useful for type two diabetics, but, you know, from from a cultural point of view, I think, you know, it's commonly consumed in traditional foods, whether you look at Korean kimchi, for example, or Indian achars, pickles, uh chutneys, uh it's also used in soups, you know, like a tom yum soup, uh it's used in salad dressings, sauces, all that kind of stuff. So, you know, maybe there is a a cultural element or like an ancestral uh knowledge that has been passed down somewhat. Um and you know, maybe it's just one of those things that would normally be consumed as part of our traditional diets. Uh whether or not that was specifically to prevent things like obesity and the uh post-glycaemic spikes, the the post-prandial spikes, who knows? But, you know, interesting to know that vinegar is a very, very common part of our diet as probably because of the uh the um antimicrobial effects as well and the preservation of food before we had fridges, which is a relatively new invention uh along our evolutionary journey.

Dr Rupy: Okay, the second strategy, hack, tactic. I'm pretty interested in this one. I think this is a a good rule of thumb and this is the order in which one eats their foods, also known as sequential nutrient ingestion or nutrient sequencing, the order in which you have your different macronutrient components of your of your of your food. I think this is this is a good heuristic, you know, a useful tool that you can use in day-to-day life. Simply switching the order in which you consume foods, I think is um uh just just a a good sort of tool to have in your in your toolbox of like how you might uh like to consume foods when when you're out, for example. There have been studies looking at pre-loading before having foods and they usually use things like uh whey proteins uh prior to meals, um and other sort of like high protein uh uh supplements. But I think those are pretty impractical. Um I think when you're away from your kitchen, you're not always going to be like having these these these pre-load sachets or whatever. Um which is why I'm bullish on the use of this simple order of foods tactic rather than actually having to have something with you at all times before you eat foods.

Dr Rupy: Again, very limited studies unfortunately, looking at sequential nutrient ingestion, I just like saying that. Um this one from Nature, uh 2016, entitled, 'Manipulating the sequence of food ingestion improves glycaemic control in type two diabetic patients under free-living conditions'. I just want to segue a little bit here. A lot of the studies look at people who have pre-existing metabolic issues. Probably one of the reasons, like type two diabetes and pre-diabetes, probably one of the reasons is there would be a lot of negative results from healthy users using these kind of tactics because they don't tend to have many high glucose excursions after eating food that would be significantly different when they do these kind of strategies. So that's just something you have to be aware of. A lot of the studies that I'm talking about today are actually uh directed are actually using participants that have uh metabolic conditions. But as, you know, millions of people worldwide have type two diabetes or pre-diabetes or don't even know that they're metabolically unhealthy and are probably on that very early insulin resistant journey that leads them to have the diagnosis of those conditions and all the other ones that we talked about in the previous podcast. I think it's still relevant for most people listening to this as well.

Dr Rupy: So in this study, again, very small, only looked at 20 individuals between the ages of 50 to 75, so you have to question the generalisability of this particular study to you listening to this at home or wherever you are in the car, in the gym. Um they there were specifically, as I said, type two diabetics, some of which who were on metformin, which is a an anti-diabetes drug. Um they were asked to monitor their their blood glucose using a glucometer um in a single day. So it wasn't a continuous glucose monitor study, which is I in my mind easier, but this is 2016, so I don't think the routine use of CGMs uh were were common place. Um and they also looked at some other biometric uh details other than the bloods, but we'll we'll stick with just talking about the bloods. Um they were randomised to either a controlled diet, which was mildly hypocaloric, so they were mildly underneath their caloric needs, their energy needs. Um and the experimental diet, which was the same, exactly the same diet, but allowing the consumption of high carbohydrate foods only after the high protein and high fat foods at each main meal, lunch and dinner. So, for example, they would have meat as the first course, then the veggies, and then the bread or pasta and fruit. And the results, particularly after lunch and dinner, were pretty impressive at reducing these postprandial, post-eating glucose excursions that were seen just at four weeks of the of the um uh the the diet. So pretty interesting that they were able to see these significant results. And they the authors concluded manipulating the sequence of nutrient ingestion might reveal a rapid, feasible, economic, and safe strategy for optimising glucose control in type two diabetes.

Dr Rupy: So as a GP, as a doctor, if I'm listening to this and I've got a patient that doesn't want to change their diet whatsoever, uh is not motivated to do all the other things that I would love all my patients to do, is this a viable strategy? Potentially, yeah, absolutely. I would say so. I think any nugget or any tiny habit you can instil in yourself or if you're a practitioner, in in your patients, would be wonderful. So if there is an inkling of this potentially having an impact, then I would most likely uh suggest this in the first instance and see what their glucose control is like after four weeks. Now, you know, this isn't generalisable to everyone, like I said, it's a very small study, but interesting nonetheless.

Dr Rupy: Another one from um the BMJ, another one, DJ Khaled, uh if you know, you know. Carbohydrate-last meal pattern lowers postprandial glucose and insulin excursions in type two diabetes. This was in 2019. This was a better and more rigorous study, but shorter in in in length. Still very, very small, 16 type two diabetes patients between 35 and 65 on metformin. They ate exactly the same meal across three days. So the previous study was more real world, but this was very, very tightly regulated in terms of the exact amounts of uh foods that these these guys were were consuming. They had uh one uh uh diet one was carbohydrate first, then 10 minutes later protein and vegetables. The second diet was protein and vegetables first, and then 10 minutes later they had their carbohydrate. And the third meal was like all the components together, so like a big sandwich. Um so that was one, two, and three. And the meal that they've been very specific about exactly what the meal was, it was orange juice, ciabatta bread, butter, tomatoes, cucumbers, all the calories and the amounts of all those were detailed in in the study notes. And then they had their bloods taken at very regular intervals, 30 minutes up to three hours, every 30 minutes up to three hours. And they looked specifically at glucose, insulin, glucagon-like peptide, and glucagon at baseline and then all those different intervals.

Dr Rupy: The results, which I know you want to hear about, um the peaks of glucose after eating food were 53% and 54% lower when carbohydrate was consumed last compared to when carbohydrates were consumed first. And 44% and 40% lower respectively when all the components were consumed together than the control meal. So I'll just reiterate that. The first meal was when they had the carbohydrates first and then the protein and the vegetables. When you reverse that order, so you have your carb last, it was much, much lower in terms of the highest peak of glucose after consuming those foods. So that that for me is is pretty effective as a behavioural strategy to improve postprandial glucose control in patients specifically with type two diabetes. And they've got these wonderful um uh graphs in the paper itself where along the x-axis, so if you imagine an XY axis, so just a very simple graph, along the x-axis you have minutes at 30, 60, 120, etc. Um and then on the y-axis you have your your glucose measured in millimoles per litre or if you're you're listening in the states, it's milligrams per decilitre. And then you can very, very clearly see that the carbohydrate first diet has a a peak of a lot higher, 50% higher than the carbohydrate last pattern. So this again, really, really interesting um to to see that just this this little change can have a quite a drastic effect at least in the short term.

Dr Rupy: The the interesting thing about the study is that they crossed over the patients into different eating patterns. So this was seen as an average across the whole study design. And we'll get into a bit about study design a little bit later as well. The mechanism of action, why on earth might this be happening? Just simply changing the order of food. If you're eating the same food, you're eating the same calories, you're eating the same time period, how on earth can this actually have this much of an impact? Because, you know, this is why I think the calorie in calorie out uh uh dogma is is flawed in a lot of ways because you've got to think about the downstream effects of having those glucose excursions to high amounts after eating. It's not just going to have an impact on how you feel afterwards and the crashes, it's going to have an impact on your likelihood of putting on weight, on your uh the production of fats via the liver, on your overall cardiovascular disease risks. These things over time are going to accrue. So, you know, calories in calories out doesn't capture these kind of nuances. And it might be small, you know, we can't generalise, but I think it's still very interesting to to um uh to be aware of.

Dr Rupy: So what what is the mechanism? So the the best article I found on the mechanism, potential mechanism of why carbohydrate last pattern or nutrient sequencing might have an impact was from a review article in 2019, Frontiers of Endocrinology. Like I said, all the references will be at the bottom of the um podcast show notes on the doctorskitchen.com. If you're not signed up to the newsletter, you should definitely sign up to the newsletter. Uh it was called the impact of nutrient type and sequence on glucose tolerance. Um pre-loading with fats and proteins before carbohydrates, again, delays gastric emptying. So very similar mechanism to uh potential mechanism of vinegar. Uh that delayed gastric emptying consequently slows the rate of carbohydrate absorption into your bloodstream. Potentially, another mechanism is it enhances insulin secretion from beta cells. So these are the beta cells in your pancreas, which is where insulin the hormone is generated. And it also may reduce insulin clearance. So you have more insulin floating around your bloodstream and probably in lower amounts, doing its thing of pushing your glucose into peripheral tissues and the other things that serve to lower your blood glucose level.

Dr Rupy: We've talked a lot about postprandial um glucose excursions, also known as postprandial hyperglycaemia if it is to a level that is in the pre-diabetic or diabetic type two range, which is above 7.8 millimoles per litre if you're thinking about the oral glucose tolerance test or above that 11.1, looking specifically at the UK guidelines. It's a very important therapeutic target to reduce these excursions. Now, there is some controversy around this, which is why, you know, you've got one camp which is kind of anti using continuous glucose monitoring for people who are otherwise healthy. And then you have the other camp, which is which is more so the camp that I'm in, which is where we should really know what things are spiking our glucose levels, even if it doesn't suggest that we are pre-diabetic or type two diabetic. And the reason is because, like I said in the previous podcast, insulin resistance can precede the diagnosis of metabolic diseases like type two diabetes by 10 to 15 years. So I would want to know as an individual, what kind of foods are spiking my glucose and what I can do about it to mitigate that.

Dr Rupy: The other thing is, what happens when you have this big glucose spike? And I've had big glucose spikes after eating upwards of, you know, 11, 12, 13. Um it doesn't necessarily put me in the diabetic range because it goes back down very, very quickly. Um but what's happening is you have a pro-atherogenic vascular environment that is characteristic of type two diabetes if it's persistent. But what happens when you have this excess glucose floating around the blood, like we described in the previous pod, is you get lots of inflammation, you get oxidation that damages your cells, you have this pro-thrombotic environment, so pro-thrombotic, so these these proteins that can cause clotting, and it stimulates the production of fats from your liver that ends up in the blood and overall increases your risk of cardiovascular disease over time as well. So if you're consistently throwing yourself into this uh pathogenic microenvironment, even if it is for short periods of time, you can imagine that these uh periods of time accrue, right? So you you're constantly putting yourself in this state of of stress. And your body is really resilient. One off, completely fine. Doesn't matter if you're going to have like, you're going to have a blowout, you're going to have some cake, you're going to have a burger, absolutely fine. But if it's continual and it's daily, which I believe a lot of people put themselves into this environment. If you think about a typical meal deal, you've got white bread, you've got fried uh fried chips in a in a bag of crisps, or I don't know what you call it in the states, probably chips. Um chips is very something very different in the UK. You have a fizzy drink. You know, this is a normal uh uh deal. This is a very normal lunch for, I would say, the vast majority of the population as as it's so cheap as well. And I would bet that this is causing a lot of glucose excursions for for millions of people, um without even knowing it. And so these little uh these these little glances toward this pro-thrombotic environment, this pro-inflammatory environment, over time will have an impact on your body's resilience against uh that that uh impact. So I think it's very important to to just realise that it is beneficial to a, be aware of postprandial glucose spikes, but also be uh be mindful of what we can do to reduce those as well. So that's just sort of one segue as to uh because you're going to hear me say postprandial glucose excursions or postprandial glucose or hyperglycaemia a lot in in today's podcast. And an excursion is, it sounds quite fanciful, doesn't it? Like going on holiday. Um it's uh it's where you uh your excursion is above what is uh normal uh for um in your bloodstream. We we discussed what was normal in the in the previous podcast as well.

Dr Rupy: The other thing it can do, which I think is probably more from a um uh a real world perspective, is these glucose uh uh dips and crashes that occur as a result of high glucose in the blood for a short period of time, is statistically significant in changing your hunger signalling, as suggested by a number of different papers, including one in Nature, um 2021, where they looked at 1,000 participants using a CGM uh in an at-home setting. So they they recorded over 8,000 controlled meals and they found that if you have a postprandial glucose excursion, you are more likely to be hungry. And if you think you're more likely to be hungry, you're probably going to be reaching for those savoury snacks or the sweet snacks that are probably going to be unhealthy. And again, the sort of cycle uh continues. And I think everyone's had the experience, including myself, you know, particularly when I was working as a general practitioner, and you know, I mean, uh probably five, six years ago now when I was working as a GP, um in uh in in London, and you have these biscuits that that um patients bring in for you and you have this, you know, this dopamine rush and you have it and then you have a corresponding crash and you get hungry again. That's that's most likely what is happening at a macro scale and and what has been demonstrated to improve increase hunger levels and potentially those downstream effects of overeating as well. So my opinion is that even people who are otherwise quite quite healthy should understand uh postprandial glucose excursions and why we want to reduce them as well.

Dr Rupy: Okay, third thing. So we've already talked about vinegar, we've talked about nutrient sequencing. Let's talk about another thing that I'm really bullish on as well. I'm really excited about this one because I have learned some things that I'm probably going to put into into practice myself. This is all about extra fibre, veggie starters, and whole food fibre supplements. Not only does this impact the postprandial glucose excursions, but it can also have an impact on your gut microbiota in general as well, because you're upping your fibre content. You've heard me talk about it on the podcast many, many times again, that more fibre in the diet is associated, more variety of different fibres in the diet is associated with drastic reductions in all-cause mortality and specifically the types of diseases that impact uh uh us mostly in the Western world and in the UK and US healthcare systems.

Dr Rupy: A lot of the studies that I'm going to mention are supplemental in nature, but the best evidence we have at reducing the risk of disease is from whole foods and getting more fibre from whole foods in your diet as well. So I want to make that caveat at the start. I am going to be talking about supplements, but in my head, in the back of your head as well, you should always understand more fibre from whole foods is the key. Okay. Two further distinctions I want to make uh from the start. You've got lots of different types of fibre subtypes. Broadly, you can categorise them in soluble and insoluble fibres. There is controversy about, you know, actually categorising them in two. Can you really? In reality, you know, when you eat a nut or you have a whole grain, it's going to have all these different types of fibres in it. But broadly, for the purpose of the of these studies and just getting it clear in your head as to why as the difference of mechanism of action, we're going to categorise them as soluble and insoluble. Soluble fibres like psyllium, uh and methylcellulose, pectin that you get from fruit, beta-glucans, you get them from like vegetables, oats, barley. These are the types of fibres that create a gel and they improve uh uh hyperglycaemia after eating by slowing the absorption of glucose in the bloodstream. I'll talk a lot more about the mechanism in a second. Insoluble fibres that you tend to get from things like nuts and seeds and pulses and certain whole grains, they don't appear to have that gelling effect, but they are associated with reductions in things like type two diabetes in longer-term studies, suggesting another mechanism which is unknown. Probably, if I'm if I'm a betting person, which I'm not, not really, it's going to reduce insulin resistance um by improving your gut microbiota. So giving your gut microbes lots of interesting stuff to eat when they're feeling hungry.

Dr Rupy: Um overall, there was a study that was uh published in the American Diabetes Association uh journal 2019, it was entitled, 'Systematic review and meta-analysis to measure the effect of viscous fibre supplementation on glycaemic control'. Viscous, they're specifically talking about soluble fibres like psyllium. Um and they looked at 28 randomised control trials of type two diabetes patients in specifically. So this is just for type two diabetes patients. You've got to really think about whether this is generalisable to you if you don't have this diagnosis. But like I've said throughout this, I think it's generally something that could be beneficial for a lot of people. The in this meta-analysis, you remember, they group all the best studies that they could find on the subject of having fibre supplements in the diet at reducing and improving glycaemic control. Um they were mainly were looking at psyllium that you can get in psyllium husk. We'll talk a bit about exactly where psyllium comes from in a second. Beta-glucan, which most people will recognise is from barley and oats, konjac, I'm actually a big fan of konjac noodles. A lot of people don't like them, but they come sort of pre-cooked um in in packets and you just throw them into stir-fries and stuff. Uh I believe it's grown in Asia. And guar gum, which is um uh an additive that you tend to find to uh change the sort of physical properties of food. Um so it's it's sort of like gel.

Dr Rupy: Um and in this meta-analysis, they found that the absolute reduction uh the overall looking at all these different studies in HbA1c, which is one of these blood markers that we use to determine your glycaemic control over the preceding 120 days, uh was 0.58%. Now, it doesn't sound like a lot, I'll go into that in a second. Um in general, they also showed a reduction in fasting blood glucose of 0.82 millimoles per litre and uh another marker that we've talked about in the previous podcast, HOMA-IR, which is a measure of insulin resistance, it has its caveats, 1.89. So, again, significant reductions. Um and this is for a dose of around 13 grams per day for around eight weeks.

Dr Rupy: Something I didn't know before reading this paper is that the FDA, so the Food and Drug Administration, have a threshold effect on glycaemic markers like HbA1c for new drugs that are targeted at type two diabetics. And it's got to be an impact of over 0.3%. So for for me to have a drug that goes through further development, I've got to demonstrate that my drug can drop your HbA1c by at least 0.3%. In this meta-analysis, they found that on average, using one of those different types of fibre supplements, so psyllium, beta-glucan, konjac and guar gum, reduced HbA1c by 0.58%. So almost double the amount that the FDA recommend uh or have as a threshold before you can even start drug development. So I'm not trying to suggest that this is better than drugs, you know, we should stop all the anti-glycaemic agents, not at all. I'm just saying it's a pretty powerful effect. Now, again, like I said in the previous one, meta-analyses are the quality of your meta-analysis is dependent on the quality of the studies that you put into them. And as we know, these kind of supplement studies or fibre studies, because no one has a a patent on psyllium and beta-glucan, um they're going to be pretty poor studies. But I I really think that the food as medicine concept is an important one that we should all appreciate and it's not a quirky, cute thing. It's actually something that that holds that stands to reason we should be investigating more of because if I have patients that don't do well on drugs for whatever reason, or have an aversion to them or have side effects, which many people do, then I'd want to have a more natural, well-tolerated different uh approach that I could either use synergistically or I can use instead of and monitor the effects of. So I think it's just something that, you know, the the the more studies I've I've read over the last 14, 15 years looking at food as medicine, just sort of heightens my my um uh my my bullishness and my uh my my positivity around this subject and I think it's going to become uh more and more um commonplace as well.

Dr Rupy: Let's look at specific supplements. So that was the overall sort of meta-analysis that I found, the latest one because that was 2021. Let's look at specifically psyllium husk. And I'm particularly excited about psyllium husk because I have mildly elevated um uh uh cholesterol. It's a likely going to be a genetic thing as a result of my heritage. Um and uh I don't do well with statins. Um I uh I was really impressed by the impact of psyllium husk on lipid markers. Uh and so in this, I mean, there are lots of trials on looking at psyllium husk on on cholesterol. I'm not going to go into that today. I'm going to try and keep it to glycaemic control. But a lot of these studies were looking at both together. So in a in a small trial of 20 people, again, very small trial, Nature 2002, they looked at type two diabetics treated with glibenclamide, which is a sulfonylurea. Um a sulfonylurea is a type of medication that directly stimulates the production of insulin from your pancreas beta cells. Um so they were already on medication before this. They were given 3.5 grams of psyllium four times a day before breakfast and and meal time. And they took their bloods at regular intervals as well. Um there was one week, which is phase one, where all the subjects followed a diet for diabetes. So it was the same standardised diet for diabetes. They received the the same medication as well. Phase two, over six weeks, which is where the patients had again the same diet, but they also received the psyllium as a supplement. And phase three, which is for another four weeks where and they they they had very importantly, they had what's called a washout, which is where you don't take uh uh any anything, you don't take any recordings, and then you you do the diet for a time afterwards. And it's called a washout, so you remove the impact from psyllium if there is any impact at all, and then you you measure. This is really, really important trial design because what you're trying to determine here is when you introduce psyllium as the agent or let's say this is a medication, you introduce that agent and you take it away, if psyllium is having an effect, it should diminish when you take it away. And if it doesn't, then you know that there's there's something else that's potentially having an impact, not just the psyllium itself. So really, really important trial design. And that's exactly what happened. So at phase one, which is where they had um uh just a a regular diet, they if you imagine an x-axis and a y-axis again, you have time and you have uh glucose on the y-axis. They found that you have a typical glucose excursion or high glycaemic uh level after eating, uh peaking around 60 minutes and the average for this uh 20 person cohort was around 14 millimoles per litre, which is fairly high. Um when they had the psyllium on average, it was around two to three millimoles less. And then when they went to phase three, which is where they took away the psyllium, it went back to the level that they had in phase one. So further giving some evidence that psyllium was definitely having an effect in this small trial of 20 people. So they they what they record in in these kind of studies where they look at these insulin curves and postprandial glycaemias is something called area under the curve. So the amount of um area under the curve that you've you've diminished as a result of your agent. So you're essentially exposing yourself to less glucose, less sugar in the blood over that same time period. And it was around 12.2% lower in the presence of the psyllium, um but there was variability between the um uh participants. Other trials have shown similar effects. So psyllium for me, we'll go into why that might happen with the the gelling impact in a second. But psyllium for me is a a really interesting agent. It also tends to have a lipid-lowering effect as well, which is which is quite interesting for me. And also patients that I see who uh don't want to take a statin for whatever reason, they don't do well with it, and they've tried all the other ones and they, you know, there are significant side effects with statins. So this could again be something that we we think of when we when we treat patients um who are who are motivated.

Dr Rupy: Okay, other ones, beta-glucan. So uh beta-glucan, like I said, comes from oats and and barley, lots of other um uh veggie plant-based ingredients as well. This trial called the BELT study that was published in 2020 in Nutrients, aimed to look at the effect of lipid profile as well as glycaemia and intestinal health as well. A big caveat for this one, part industry sponsored. So you always got to look at in the acknowledgement section when you read a study, whether this was funded by someone who has a vested interest, whether it's a drug company, whether it's a particular brand of supplement, whether it's uh the sugar industry, although previously they haven't really declared that. Harvard, I'm looking at you. Um in this particular study, uh they looked at Italians, 83 Italians on a Mediterranean diet with moderate hypercholesterolemia and low cardiovascular risk profile. So fairly healthy, but they do have a little bit high numbers in their LDL-C and ApoB and all the rest of it. Probably someone similar to kind of similar to me, although I think this in this group they're a bit older. Um they uh gave them three grams of oat beta-glucan per day. Um so it was a proprietary formula, and that's what I mean, it was industry funded. And they specifically looked at their fasting glucose and and lipids. It was an eight-week trial, double-blind, placebo-controlled, and uh crossover. Uh so they they gave the interventions to both groups, so 40 in each. They have a washout period where they don't give them anything, and then they swap the groups. So you're you're you're literally looking to see if there is an impact and it's not because of uh giving it to a particular cohort or giving it to a particular participant. You're you're monitoring to see whether it has the same effect in uh in the in the people across the entire trial.

Dr Rupy: Um and what they they found was that there wasn't a significant effect on fasting uh plasma glucose, um potentially because these aren't type two diabetics. These people didn't have any obvious issues with uh glucose after eating. They didn't have these big spikes after that you would expect from a pre-diabetic or type two diabetic. But they did reduce LDL-C cholesterol. It reduced it by 12.2% from baseline after just four weeks and then 15% after eight weeks. So pretty pretty big effect. And again, something that I'm looking at myself. Um the equivalent of three grams of beta-glucan, most people are going to ask me about, is around 150 grams of cooked oats per day uh or or pearl barley as well. Um again, similar amount, 150, 160 grams of pearl barley cooked. Um should you try it, uh as in uh beta-glucan? Potentially, uh for cholesterol, doesn't appear to be uh beneficial for glucose in normal healthy individuals, but as far as fasting glucose uh measurement goes, probably not, but maybe for lipids, yes, absolutely. Same thing with psyllium husk? Yeah, potentially, if you're type two diabetic, there does appear to be some evidence for that. Whether or not it would have an impact on you as a healthy individual in preventing crashes and stuff like that, not too sure. But, you know, something I think would potentially be a healthy addition to a diet. And I'm certainly going to be um looking at it as well. Um another review looking at uh a high dose of beta-glucan, so six grams per day for at least four weeks, they did show that it improved blood sugar um for uh individuals with type two diabetes. So, you know, maybe it has an impact in people who are already at that stage of uh poor insulin sensitivity, but, you know, it's hard to tell whether it's going to have an impact if you're a healthy individual.

Dr Rupy: Does it have to be supplements? No, in fact, my my my wife, she hates psyllium husk. Uh and she she's tried it before, um for digestive reasons, sorry for revealing her digestive habits on on the podcast. Sorry, she doesn't listen to the podcast anyway. Um she hates it. Uh she's like, it's jelly, it's disgusting, I wouldn't have it. So are there things that we can do with whole food to prevent uh glucose spikes after eating? And it turns out there is. And it was a very recent paper in the European Clinical Journal of Nutrition from 2023. They showed uh there was titled, 'Beneficial effects of pre-meal almond load'. I love this this term, 'pre-meal almond load' on glucose profile on oral glucose tolerance test and continuous glucose monitoring. It was a randomised control uh trial in Asians with pre-diabetes. I think this is a very, very important uh thing that I probably haven't made clear enough in in this this whole series. We did talk about genetics and the impact of genetics on uh one's uh likelihood of insulin resistance. Looking at South Asians is very important. Um this podcast I did with Professor Kuna, who's a cardiologist who runs the uh is one of the um uh the the lead researchers in the UK South Asian Biobank study, aiming to get over 100,000 South Asians, people of South Asian origin, uh to get their results and and and figure out where the issues are with why we are at more risk of things like type two diabetes and poor metabolic health and all the downstream consequences of that. The pattern of high blood glucose in Asians uh with type two diabetes is characterised by this this big predominance of postprandial hyperglycaemia, these these big glucose spikes after it. So figuring out if there is something that we can do specifically for this population is of utmost importance. It has a big, big impact, a big, big expense, a big, big morbidity on this. And I'm always told like from people from my community, oh, you should be more info for the Asians and all this kind of stuff. Well, I am. If you're listening, I am. So, also another side note, even in lean, healthy South Asians, like myself, um we are shown to have higher postprandial glycaemic excursions and lower insulin sensitivity for the same carbohydrate load as people from other backgrounds, European Caucasians, uh Chinese, Arabic uh Caucasians, we will have a higher excursion and a higher likelihood of insulin resistance than our counterparts. So this is just something we have to be aware of and and that's why I think the study was um uh really interesting.

Dr Rupy: So in this study, they plan to research the effect of ingestion of almonds before major meals, breakfast, lunch, and dinner, and on uh hyperglycaemia after uh eating with pre-diabetes. So these these 60 people, again, small study for obvious reasons now, um 60 people were pre-loaded with almonds. I'll I'll I'll tell you exactly how much in a second. They all had pre-diabetes. So they weren't type two diabetic yet, but they were pre-diabetic, so they're on their way to type two diabetes. The amount of almonds they gave, 20 grams, handful, 30 minutes before having an oral glucose tolerance test, and then per uh before meals, six grams per day, so breakfast, lunch, and dinner. So there were two phases of this particular study. Phase one, which is where they're looking at the oral glucose tolerance test. So that's the test that I referenced in the previous podcast where you're given a 75 grams of glucose load and then you take blood measurements at regular intervals afterwards to see what your response is to that high sugar load. In the second part of this test, in in the second phase of this study, they stuck a continuous glucose monitor on them and they looked at their responses to food in the real world over a period of three to uh seven days, I think it was. So really, really interesting study design. One in a more sort of controlled setting and another in a more sort of real world setting. The important thing, again, with this, there was a washout period in the middle, you know exactly what that means now, and they also crossed over the participants as well. So when they gave them the almonds, they also had another group that was the control, and then they there was a gap in the middle and then they crossed over those participants. So again, you're seeing, you're you're ensuring that there is an effect, if there is an effect, that's present in both populations rather than for some other explained reason as to as to why, you know, almonds might be beneficial for certain cohorts and and not for the others.

Dr Rupy: Um and the results is that this pre-meal almond load treatment of 20 grams, handful before breakfast, lunch, dinner, reduced postprandial blood glucose by 18% on the oral glucose tolerance test, so that's the more formal measurement, and 10% on the more real world uh part of the study using the continuous glucose monitor. That's pretty impressive. Just having a handful of nuts before is very something very, very simple to do. You can always keep nuts on you and stuff, have your nuts before and then have the same meal can have that beneficial impact on your blood glucose. The other benefits of having nuts in your diet, we've explained that before, it's got magnesium, vitamin E, zinc, uh the pretty much study showed that having some some nuts in your in your diet may reduce cardiovascular um uh risk profile. So net net benefit here and and no pharmaceutical uh side effects, complications of that. Obviously, if you're a nut allergy, probably not useful, but um if you don't, it might be something to to um uh to to investigate. Um there was a significant reductions in serum insulin and plasma glucagon as well. So lots of other potential benefits in this. And there's a lovely sort of um uh uh blood glucose graph in this study. Again, the references is is in the show notes at the doctorskitchen.com where you see the test and the control and then the average, you can really see a big, big difference in that, that 10% reduction. And 10% doesn't sound like a lot, but over time, that is that is really impressive. So, you know, I think this again as just another little thing to nudge your patients toward better habits is something that I think is a good strategy if you can't get someone to exercise every day or completely overhaul their diet. These little nudges in that direction can potentially have remarkable effects on reducing morbidity and ultimately mortality. So, and the authors actually state in this, adopting such strategies to manage hyperglycaemia, especially in the pre-diabetes state, can be helpful in delaying or controlling conversion to diabetes or even help reversal to normal glucose regulation. One of the really interesting thing about these this particular study is that on the oral glucose tolerance test, some of their participants actually reverted after having the almond meal, actually reverted to normal levels, i.e. they weren't diagnosed with pre-diabetes anymore. They actually managed to reduce their glucose spike to the normal level, which meant that, you know, they weren't pre-diabetic. So what the long-term ramifications would be of having almond meal every single day, it's impossible to tell using this study alone, but it is interesting nonetheless.

Dr Rupy: Let's talk a bit about the mechanism of action of all these different supplements. So we've mentioned psyllium, beta-glucan, and almonds. Psyllium, what happens, I've mentioned, I've alluded to it, it has this gel-forming property. It's a soluble dietary fibre. So what happens is it turns into like a like a jelly and it and it uh basically inhibits the absorption of the sugars into the bloodstream, which would stand to reason why it blunts that postprandial glucose response. It can also potentially benefit certain blood lipids as well. So these fibres, they go into your stomach, they create this gel, and it slows the digestion of food. It helps lower that blood sugar by delaying and reducing the glucose absorption into blood, and fibre also speeds up the rate at which food moves through your intestinal tract, so it has less chance of being absorbed and spiking your blood levels in your in your blood your sugar levels in your in your bloodstream as well.

Dr Rupy: We've talked a lot about soluble fibres, but the insoluble fibres in long, multiple long cohort studies, those are associated with better insulin sensitivity. So it isn't like the soluble fibre show here, it's got to be about having both insoluble and soluble fibres. So ultimately, you just you really just want to think about getting more fibre into your diet as well. Specifically looking at the almond study, what are the potential mechanisms of action? Well, when you pre-load yourself with uh almonds, you have a handful of of almonds and it, you know, I don't it wasn't uh um it wasn't funded by the the almond uh board of growers or whatever it might be. Um it could it could have a very similar effect with walnuts, it could have a similar effect with pistachios or pine nuts or whatever nut of your choice. Uh mine's walnuts actually. But um the potential mechanism of action is that it it stimulates the release of insulin sooner than uh being stimulated by the food itself. So when you start eating your meal, you're prepared, you're you're ready to go. Um and that way you're more likely to have less of a glucose spike because your body is already in a state where it's ready to absorb food. It's probably speaks to why eating slower tends to have a better um impact on your feeling of satiety, your feeling of fullness, and your um uh your um uh the the likelihood that you're you're not going to overeat as well. So always trying to eat slow, put your fork down in between bites, all that kind of stuff is really important. And I would say it's uh in line with why this strategy might work as well. The fibre content uh of almonds is going to obviously increase the viscosity of your um uh your your intestinal contents, which again hinders the glucose diffusion across the uh into the intestine. And then the other element is that almonds have high zinc and magnesium content that could also stimulate a certain receptor in your fat cells to improve insulin sensitivity. So there are some other sort of more nuanced mechanisms as to why almonds or nuts in particular might have a beneficial impact on post-glucose uh postprandial glucose excursions. Um but those are kind of like not not really well tested at the moment. Most of those potential mechanisms come from my studies and there are a lot of issues with with those as well.

Dr Rupy: I wouldn't get too caught up in the whole insoluble, soluble, timing, all that kind of stuff. Go for whole foods, try supplementing if you like. I'm going to be using psyllium husk for reasons other than just postprandial glucose excursions. Should you try it? Yeah, I would say so. I would say a minimum of 30 grams, uh 50 grams a day, the benefits of those kind of accrue, sorry, not uh psyllium, for for nuts. For psyllium husk, it's 3.5 grams, very simple, very easy to get. Um and gradually increasing your fibre intake if you're not used to having fibre uh in your diet. I think those are those are those are relevant things to to do for sure.

Dr Rupy: Fourth thing, let's go. So we've talked about whole fibre supplements, nuts before eating, uh we've talked about um uh vinegar, uh order of foods, moving after eating. This is a a really interesting um uh practice and it's I think it dates back to Ayurvedic teachings actually. There is a saying, I think it's either 100 steps or 1,000 steps after eating. These are things that you should do. Um and it makes sense. You know, we talked a lot about exercise in the insulin resistance podcast. You know, the the mechanism of action as to why insulin exercise over time improves one's insulin sensitivity is because it improves the uptake of glucose into your peripheral cells, it reduces inflammation, it increases muscle mass, um it has improvements in ectopic fat distribution, GLUT4, the the receptor induction induces that, improves mitochondrial size, number, loads of loads of reasons as to why exercise over the long term has this impact. But what about straight after eating?

Dr Rupy: Okay, so there was a a study in 2022 published in a public health journal. And again, very small study, 23 healthy, active young individuals, and they were randomised to one of three different exercises. 30 minutes of walking after eating, 30 minutes of stepping, and 30 minutes of squatting against a control, which is just simply sitting at a desk. And I think this is really interesting because what they're trying to do is mimic what potential things you can do without having to leave your uh work environment. So the worst case scenario is you have your meal at your desk, al desko, as it's colloquially known, I call it al desko, I don't know if that's a thing. Um or uh if you can't leave your work environment, can you do squats, even though I think your co-workers will probably have a few words to say about that. Uh squatting against a wall, uh stepping, again, I don't think that would be very advisable, or just going for a walk for half an hour. Uh they were really rigorous in determining the speed of walking, they used a pedometer or a metronome, I believe, to to count the exact number of steps uh uh per minute in a indoor 50-meter track. Um and then for the stepping and the the squatting exercises, again, they they counted the cycles, the the number of um uh seconds as well per minute uh of of the exercise as well. And they standardised the meal. It was cornflakes, milk, sugar.

Dr Rupy: Really interestingly, I would have thought squats would have had a bigger impact than walking because squats, you're really engaging the the large muscles of your body. Um maybe that would have had a bigger effect. Actually, walking was the most effective strategy in this very small trial of 23 healthy adults at improving postprandial glycaemic response. And the the the peak of of glucose for sitting, so your control, was 7.5 millimoles uh uh per litre. So that again is under the diagnosis of pre-diabetes. So if you're just sitting down, that's what you expect your uh glucose to to be for a healthy adult uh after um 30 minutes. If you're walking, it was six. So you you've got a massive reduction in that glucose excursion. Um like I said, small study, you know, if if the exercise is not performed within 30 minutes after the meal, does that diminish the impact? It wasn't it wasn't um uh determined. There are similar results from different studies. There was a Japanese study from 2021 that used 20 minutes of walking at 6 kilometres per hour, very slow, like me, I ramble when I walk, I don't walk fast. Um only 11 people had a very similar result.

Dr Rupy: Specifically in type two diabetes, does it have an effect? Well, there was another study published in Diabetologia in 2016, a randomised control, a randomised crossover study, 41 adults, all with type two diabetes, two weeks intervention. They were walked 30 minutes each day compared with a 10-minute walk after each main meal. So again, the exercise intervention was the same, but they specifically looked at a random walk in the middle of the day for 30 minutes versus specifically a 10-minute walk after eating your main meal. And glycaemia was measured using a CGM. And they found that it was significantly lower when participants walked after meals compared with on a single daily occasion and particularly striking after the main meal. It was around 12% uh across all the meals, but specifically looking at the the main meal at the end of the day, which is typically when people have more carbohydrates, it was 22% lower. So this is a look again, looking at very low numbers in the studies, potentially very, very uh impactful on um hyperglycaemia after having a meal.

Dr Rupy: The best way to see whether any of these interventions are relevant for you is to check with a blood glucose monitor. You can get one from most pharmacies wherever you are in the world and do it manually or you can get a CGM, which is a little bit more costly, but I think they're worth it because you can actually test these out yourself and actually see whether this is uh useful for you as well. So those those, what would I do this? I would do this. I would suggest this as well. And again, if I have someone who is not motivated to change their diet at all, can I say to them, look, go out for a walk 10 minutes after your meal? Most people can probably commit to that. Most people, it's tiny enough to uh to to commit to that. And even if I was it was just that 10 minutes after your main meal, not even breakfast, lunch, don't worry about that. If you can't get out, don't worry about it. Try just your dinner time. Just try after dinner, 10 minutes walk, can you do that? Most people can commit to that. That's a that's a potentially really, really good outcome. Um if it's 22%, if it's, you know, even 15%, really, really good outcome. So I'm pretty bullish on that.

Dr Rupy: So those are the four tactics that I want to go through today. Supplements. Supplements are things that I don't really talk about too much, um because I think it's not particularly accessible. I think the impact of them uh can can be quite small depending on which supplement we're talking about. Uh but these are ones that I think are potentially useful and these are more in the sort of spectrum of whole food supplements. So green tea polyphenols. I love my green tea. I'm actually drinking one right now. I love coffee. And uh green tea is uh particularly uh interesting because it has all these wonderful different phytochemicals, including similar ones that you find in in coffee as well. So uh EGCG, also epigallocatechin gallate, uh epicatechin gallate, uh and uh catechins in general, all different types of catechins. These are potentially anti-obesogenic and also green tea in those larger trials has been shown to reduce the incidence of type two diabetes in a similar way to coffee as well.

Dr Rupy: So there was um a study in 2015 that specifically looked at um the impact of green tea extracts. So these are extracts from green tea looking at those catechins, the the various catechins uh in there. This study that was uh published in Nature Reports, it's kind of hard to pit against all the other ones that we've seen because they weren't looking at um post-glucose hyperglycaemia uh looking at bloods. They were actually using a breath test uh in humans. So it's kind of hard to to put uh apples to pears, apples to apples rather. Uh but it was placebo-controlled crossover trial, uh looking at 28 healthy adult volunteers. They gave them a single dose of green tea extract. Uh the dose of which was around four grams. They had specific amounts of all these different catechins and as a powder, and then they were given a cornflake-based uh uh test meal. And they collected these breath samples at 30 to 240 minutes afterwards at 30-minute intervals. Um and then they they crossed them over after a week. Uh one arm went into the placebo, the other arm went into the actual green tea extract. And their data suggested that it is, in their words, a viable alternative to pharmaceutical inhibitors of glucoside hydrolase uh enzymes. And they it decreased starch digestion and absorption uh due to the extract. So the reason why this might work is because we have these particular enzymes that break down the starches that leads to the absorption of the sugars into the bloodstream. And green tea extract may reduce the efficacy or inhibit the action of those particular enzymes as well, which would stand to reason you're going to absorb less of the sugars, it's going to spike you less, and you're going to have less uh postprandial glucose excursions.

Dr Rupy: In another crossover trial, a different trial here, 11 healthy men, uh they were given a beverage containing catechins and chlorogenic acid, which is something specifically you get in in coffee. Um again, improved insulin sensitivity in those as well using their particular markers. Um there was another one that I thought was particularly interesting. They uh it was more of a a real world study in that they gave them consumption of of uh green tea uh extract uh and after three weeks, they found that it suppressed hyperglycaemia and insulin after having a high-fat test meal containing 75 grams of glucose and improved um healthy insulin sensitivity in healthy males as well. I think the the takeaway from all these studies, because they are quite hard to interpret, is that the more polyphenols in your diet, the better. The reason why I'm a big fan of um green tea, just taking a sip, is because it's it's a real rich collection of all these different polyphenols that we don't tend to get in other elements of your diet. And I think that the higher density of various polyphenols you can get in your diet, the better. And that's why you see these studies where you get 30 different plants in your in your diet, you know, including things like herb spices, uh coffee, they all count because they're giving a rich variety of all these different plant chemicals that have these anti-obesogenic effects, anti-inflammatory effects, antioxidant uh uh oxidant effects. You know, these are all potentially protective, which is why I'm a big fan of getting more spices and herbs in your diet at every opportunity. So green tea extract, does it work? Potentially. Is it going to have a massive effect? I think it's quite it's very hard to interpret. Um is it worth it as part of your supplement stack if you do want to improve uh glycaemic control? Yeah, potentially, potentially, if you can afford it. Um again, I think these things probably best to to test yourself and maybe even look at the long-term measures like HbA1c uh that you can get done by your doctor after introducing these uh interventions as well.

Dr Rupy: On the subject of spices, cinnamon. Cinnamon is something that I'm asked about a lot because there are lots of pretty good studies actually. It's very, very well studied. Um two two main types of cinnamon. There's cassia cinnamon and there's Ceylon cinnamon. Ceylon is um uh also known as true cinnamon. You get it from uh Sri Lanka. Um the the important caveat other than the the species is um cassia cinnamon, which is the more common type of cinnamon. Uh odds are if you get cinnamon from your supermarket, it's cassia. It's got 200 times more coumarin in it than Ceylon cinnamon. Ceylon cinnamon has very low, almost undetectable levels of coumarin. Um and coumarin can have an impact on your liver at high doses. Um so it it is sort of like one of those caveats, potential interactions with lots of medications. Some studies have shown that only the coumarin, the high coumarin containing uh cinnamon, cassia cinnamon, has the anti-glycaemic effect. So whether you can state that Ceylon cinnamon that has a a less uh lower side effect profile in its interaction with other medications versus cassia, it's quite hard to to say whether Ceylon has the same benefits, but it's certainly is probably going to be better tolerated.

Dr Rupy: What is the potential mechanism of action? Similar to everything that we've talked about so far. Delays gastric emptying, inhibits digestive enzymes, reduces glucose absorption, increases glucose uptake by cells, potentially by enhancing insulin signal, insulin receptor signalling. How much per day? Anywhere between one and two grams. There may be some extra benefits at high doses, but you have to mitigate that against the potential side effects of having likely what you're going to be getting, which is cassia cinnamon in the diet. And whether you're whether it's the coumarin in uh the cinnamon that's actually having the anti-diabetic effect or not, it's it's still something we we I haven't found a definitive answer on that. For certain people, it's definitely going to be toxic at high doses. So you want to be particularly careful if you are on blood thinning medication like warfarin, uh blood pressure drugs, diabetes drugs, statins, like there are lots of potential interactions with cinnamon. Should you take it? Because of the side effect profile, I'd be pretty cautious. The other obvious question, a legitimate question is, should I be having any cinnamon in my diet? Unless you're having cinnamon every single day and it's not in a supplement form, I personally wouldn't worry about it too much unless I was on uh those kind of medications. Um you know, a one-off is probably not going to have a a negative impact. If it's going to be a daily thing, i.e. something that you're taking a supplement for, or if you're just a really big fan of cinnamon and you're putting loads and loads of cinnamon into your into your food, um it's uh it you know, it's something that you should discuss with your uh your your doctor or your practitioner. Um I personally think cinnamon in the diet is fine as long as it's not like a a massive amount and and daily.

Dr Rupy: Other supplements. So those are the two commonest ones that I'm asked about, green tea extract and cinnamon. Other supplements to watch, berberine, which you may have heard of. Um there's not much in the way of studies and I'm not as attracted to the idea of using berberine as a supplement because it has similar issues to warfarin in that lots of side effects, lots of potential interactions with medications. So probably best avoided. And actually individuals tend to have different uh different side effects based on it. Some people complain of headaches or um low mood. Um it's yeah, and again, not not very well studied.

Dr Rupy: One that I think is one to watch, I alluded to this at the start of today's podcast, is a perennial herb um that's been used for thousands of years in Ayurvedic medicine. Probably something that my parents would know all about and I haven't asked them about it yet. And it's closely associated with prevention and treatment and cure of obesity and diabetes as per Ayurvedic texts. It's called Salacia oblonga. I don't know if I'm saying that right. Salacia oblonga. Super interesting, definitely one to watch. Over the last 10 years, I was looking at PubMed, there's only been 200 studies on this. Um and I think it's going to be one of those that kind of explodes, kind of like how curcumin and and turmeric kind of went up. If you look at the number of studies on curcumin, it's in the thousands. Uh but Salacia oblonga, really, really interesting. From the very few uh studies that I've seen, there was one in the American Journal of Clinical Nutrition 2007. It significantly lowered the postprandial uh glucose response by 14% for a small dose of 240 milligrams extract and 22% for 480 milligrams of the extract. And 1,000 milligrams has been shown to reduce postprandial glucose in non-diabetics by 25%. That's pretty big. Uh you know, that's up there with the uh the exercise uh after eating. Um and again, like very small studies, whether or not that these are definitely not funded because no one's got like a I mean, there are very, very few um uh manufacturers of of this particular product. But really, really interesting. And I think it's going to have that magnitude of effect. It needs to be studied in a in a more uh rigorous way in a in a larger amount of uh cohorts as well. The potential mechanism of action is that it's an alpha-glucosidase inhibitor. So similar to uh medications like acarbose that we use in um in in diabetics and uh miglitol, uh it's also known as Glyset as a trade name. Um really, really interesting. I I think uh that's probably one to watch. No affiliation with any of the brands, no affiliation with any of these supplements that I've recommended today. I don't do supplement um uh advertising as you as you guys probably know. Um but really interesting nonetheless.

Dr Rupy: So, you know, I think overall, anything that serves people to reduce those high glucose spikes, improve insulin sensitivity, uh improves people's behaviours around how they approach meals, I think is is really interesting. Everything has to be taken with a with, you know, a a dose of guidance, a dose of like um uh reality, pragmatism. Am I going to have vinegar before every single meal? Probably not. Am I going to have it after uh uh a large or sorry, before a high carbohydrate meal? I might try that. Order of food, am I going to, if I'm planning on having a burger, take the burger bun out, eat the burger bun, the veggies, and then the bun? No, I'm not I'm not going to I'm going to just eat my burger. But with a with a dose of pragmatism, if I'm having a meal that has all the different elements separate, am I going to have the the beans first and then the veggies and then maybe the the carbohydrate stuff a little bit later on? Maybe, maybe I'll try that. Um so everything that I've talked about today, when it comes to the order of foods, the fibre supplements, these are things that you need to make a decision uh for yourself.

Dr Rupy: There are other things that we could also go into. I've decided to stop the podcast now because we could literally go on for hours and hours. Fermented foods, really interesting topic. Should we be having fermented foods at the start of our meal, like a a veggie antipasti? And if you look again at very traditional diets, whether it be Japanese uh diets and washoku, uh Ayurvedic traditional diets, you know, we always have pickles and vinegars at the start of the meal and then you consume all the other elements of your meal later on. Is there some sort of pattern? Is there a code in the way our ancestors have always eaten um that are suggestive of the medicinal qualities of eating in that that sequence? It's hard to tell. Um emotional health, massive impact on on glucose, massive impact on adrenaline and cortisol. We know these have an impact on glucose responses, sleep, stress, uh all these elements I think would would uh be features that we have to take into account. Introducing these uh habits that we talked about in a tiny way so you can stack your habits onto each other. So it's not just you're taking a supplement or a medication, you're actually adding a whole suite of tools that could serve your uh glucose stability. Um and there are loads of other supplements that we could have gone into, inositol, probiotics, functional drinks. I think this is also particularly interesting for uh sufferers of PCOS. Whether all the things that I've talked about today and also all the other things that I talked about that are the mainstay of treatment, so the dietary changes, the um exercise, the sleep and stress things, um I think those could be potentially really, really impactful for anyone who is suffering with uh PCOS and better managing that as well.

Dr Rupy: So today's been a long podcast, a deep dive into all these different glucose hacks. I really, really hope you found this useful. Please tweet at me any suggestions for supplements that you think I've missed out on that, you know, you'd like me to talk about. Do sign up for the Eat, Listen, Read newsletter and also check out the Doctor's Kitchen app. All of our app recipes are fibre-rich, colourful. You know, I'm not going to tell you how to eat the sequence of your of those uh recipes, but you can make that decision yourself, but they are packed with all those different phytochemicals that we talked about today that are going to be serving not just insulin sensitivity and reducing insulin resistance, but improving your overall metabolic health, cardiovascular health, mental well-being, and we do a whole a massive amount of research before we define which health goals uh are served to you as well. So definitely check that out. And uh if you're not subscribed to the Doctor's Kitchen podcast, make sure you click follow or subscribe wherever you get your podcast, and I'll see you here next time.