Dr. Frank Tortorice – Blood sugar and Diabetes – Podcast #35

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In this podcast Dr. Justin interviews Dr. Frank Tortorice on blood sugar and diabetes. Dr. Frank reveals the blood test he uses to reveal blood sugar imbalances. Dr. Frank also uses specific blood test to detect metabolic syndrome in the early stages so it can be reversed.

Dr. Frank TortoriceFind out about the functional tests that can be taken before one can be diagnosed with diabetes and other lab tests and markers for CBC, fasting blood glucose, hemoglobin A1c, fasting insulin and frustosamine. They also discuss about the dawn phenomenon by the stimulation of glucose and Dr. Frank tells us the damage that can happen with diabetes and blood sugar and some of these AGEs or advanced glycation end products. Discover what is the recommended standard of care for diabetes which is also discussed in this interview including recommended diet and foods for diabetics.

In this episode, we review:

2:22   Difference between Diabetes Type 1 and Diabetes 2.

9:05   Dawn phenomenon and metabolic syndrome

12:39   AGEs or advanced glycation end products.

28:49   Standard of care and diet

40: 24   Diabetes, cardiovascular, and cancer connection








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Dr. Justin Marchegiani:  Hey, there!  This is Dr. Justin Marchegiani.  Welcome back to Beyond Wellness Radio.  Again, just a reminder for everyone, check out beyondwellnessradio.com, click on the Contact Us button to ask us questions.  You can actually speak your questions and we’ll play them back on the show.  You can also subscribe to get your content or the newest episodes of Beyond Wellness Radio emailed to you directly.  Also subscribe on iTunes.  Subscribe on YouTube.  If you like the show, give us 5 stars.  If not, /ve us some feedback.  The show is here for the listeners.  Again, you can always schedule a consult on beyondwellnessradio.com, click on Just In Health or you can click on Really Health Now and get in contact with Baris Harvey.  Again, today this is a real treat.  We have Dr. Frank Tortorice, my Italian brother from another mother.  And today we’re gonna be talking about diabetes and functional medicine and Dr. Frank went to med school over at the University of Rome over in Italy and he did his residency and internship in Youngstown, Ohio.  And it’s really a privilege here to have Dr. Frank Tortorice on the show.  Dr. Frank, how are we doing?

Dr. Frank Tortorice:  Great, Justin.  Nice talking with you.

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  Thanks for inviting me.

Dr. Justin Marchegiani:  Oh, thank you, thank you.  So Dr. Frank, how did you get to be known as the diabetes doc?

Dr. Frank Tortorice:  Well, you know, we have some diabetes in my family and many family members have a diabetes or enough have diabetes type 1 and type 2 so it became something personal to me.  And then, you know, when I finished my internal medicine residency and then added the functional medicine, it became clear that the standard way of treating diabetes doesn’t always get a permanent solution, so the–the thought was that it was something I felt that I could–I could make some in rows into and I enjoyed and that I can see people with diabetes all day and–and have some positive influence in their life and their health.

Dr. Justin Marchegiani:  Awesome, Dr. Frank.  Well, talk to me about diabetes type 1 and type 2.  What’s type 1 and what’s type 2?  How are they different?  Can you touch on that?

Dr. Frank Tortorice:  Well, type 1 diabetes traditionally has been due to pancreatic failure where the person cannot–can no longer produce enough insulin and because they could no longer product insulin, they became–can become very ill and–and then have some conditions or  even hospitalizations because of unregulated blood sugar.  Type 2 which is the majority, it used to be only in adults but now we’re seeing it in adolescence and even younger kids, is due to insulin resistance.  The patient produces insulin but the insulin they produce isn’t enough to get their blood sugar back to normal levels.  They have insulin resistance so the insulin doesn’t really help, you know, getting their blood sugars into a–into the normal range.

Dr. Justin Marchegiani:  Got it.  So we have type 1 which is the autoimmune condition where your body is destroying those pancreatic cells and then type 2 essentially is the receptor sites are just getting numb to all of the insulin from all the high blood sugar in our diet.  Is that correct?

Dr. Frank Tortorice:  Yes, it is.

Dr. Justin Marchegiani:  And in your practice, what are you seeing more?  Are you seeing more type 1 or type 2?

Dr. Frank Tortorice:  No, by great majority we see type–type 2 but then we also see type 2 that have to give–on insulin because they’ve–they’ve maxed out of oral medications and they’re put on injections of one type or another.  So that’s becoming, some we’ve seen in the last 10 years that we never used to see. When they are type 2 you just increase the medications, they’re oral medications and usually then you get them back into a reasonable blood sugar.  Now we’re seeing patients that are on 3, 4, 5 oral medications and not doing it.  Even though they produce insulin, they have so much resistance that they need additional insulin from injections to help regulate their blood sugar properly.

Dr. Justin Marchegiani:  Oh, that makes a lot of sense.  So they’re coming in to you, right? They’re blood sugar is high.  So like diabetes for instance, that’s like a blood sugar of 126 or greater and we know that even over 100 potentially could be pre-diabetes.  So can you tell me how you’re diagnosing these people and is there more functional test you’re using to pick them up before they’re full blown diabetes?

Dr. Frank Tortorice:  Yes, Justin, what we do is–you know, if you go to Jack Kruse’s book, he said blood sugar 88 or above already shows insulin resistance so we–we will check the standard, you know, medical tests, laboratory tests that–

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  Doctor’s get such as a chem panel.

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  We also add, even if they’re not diabetic, I add a hemoglobin A1c–

Dr. Justin Marchegiani:  Uh-hmm.

Dr. Frank Tortorice:  Which is a 3-month measure of their–their average blood sugar. and you can get a lot of information with that, but the one piece I add to that that some doctors don’t add is the C-peptide or an insulin level, and by getting that you see pretty much how much work the pancreas has to do to maintain a normal blood sugar if they’re normal or if it’s abnormal, how much insulin they’re secreting in their present condition.

Dr. Justin Marchegiani:  I like that, so yeah, C-peptide is basically it’s like a–a meter for how strong the pancreas is or how much insulin the pancreas is pumping out.  Is that correct?

Dr. Frank Tortorice:  That’s correct, yes.

Dr. Justin Marchegiani:  And with your some of your type 1 diabetics, you’ll probably see that C-peptide very low if not at all, right?

Dr. Frank Tortorice:  Right.  Yeah, usually, I will manage them sometimes with a diabetic or an endocrinologist and they’ll get–

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  GAD, maybe a GAD–G-A-D-65, looking for antibodies.

Dr. Justin Marchegiani:  Uh-hmm.

Dr. Frank Tortorice:  With immune component as you mentioned earlier and if we know they’re not gonna produce insulin, it makes no sense to give them a medicine which is gonna stimulate insulin production.  They just don’t have it and they–they have to be on insulin.

Dr. Justin Marchegiani:  Got it.  Yeah, and for all the listeners–and for all the listeners, what stimulates the GAD65 antibodies the most is gonna be gluten.  So if you got type 1 diabetes, getting off grains and gluten is gonna be important.

Dr. Frank Tortorice:  That’s correct.  A lot of times, Justin.  They’ll come to me, they’re not diabetic but they’re pre-diabetic.

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  And we can–and we could even reverse that condition.  We’ve had a number of patients that were right on the cusp for being a diabetic but through their, you know, they’re working through their lifestyle, their–their sleeping, their–their nutrition, getting rid of gluten and getting rid of processed foods, managing their–their stress better, and doing a better job with sleep, getting regular exercise no matter what present state of activity they’re at, it can make a–a world of difference for–for them.

Dr. Justin Marchegiani:  Alright, that’s great.  So if I’m, you know, the average patient here and I’m going into my doctor and I’m–I got my blood test here right in front of me and I’m looking at it, so your basic CBC, we’re gonna have a fasting blood glucose, what’s that–what the number that you’re looking at for potential pre-diabetes?  Are you greater than 100, greater than 105?  What’s that cutoff?

Dr. Frank Tortorice:  Well, I mean, really I–I don’t wanna see it above 88.

Dr. Justin Marchegiani:  Really?  Above 88?

Dr. Frank Tortorice:  Yeah, again, as I referenced earlier in–in Jack Kruse’s book he uses that 88 and I find that pretty true.  Yeah, yeah.

Dr. Justin Marchegiani:  Alright.

Dr. Frank Tortorice:  I mean, if you get an athlete or people–we have some athletes and some people who are high level, you know, either in excellent physical conditioning, their blood sugars will be in the 70s even and–and not–and they’re doing really well or even young people.  We check a lot of adolescents that are of a normal body weight or even young adults, they’re blood sugars can be in the–you know, if they have no insulin resistance, their blood sugars will be in the 70s, maybe 78, maybe 80, 82, they’re–they’re rarely over 90.  We just see 90 so often that we think it’s normal, but it’s really not.

Dr. Justin Marchegiani:  Interesting.

Dr. Frank Tortorice:  So, so I know there’s other experts that may disagree, I don’t know, it’s a 100 is your marker, but again I mean, do you wanna, you know, be two-thirds out of the–in trouble before somebody–

Dr. Justin Marchegiani:  Uh-hmm.

Dr. Frank Tortorice:  Does something about it?  I mean, at 88, I think you can–you can really start to make changes.

Dr. Justin Marchegiani:  Uh-hmm.

Dr. Frank Tortorice:  I mean, obviously if they’re 95 or 100, you’ll see that their A1c is probably in the mid fives.

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  And I think that Dr. David Perlmutter, once you start getting above 5.6, you’re at risk for type 3 diabetes which to your listeners who don’t know it’s another–he believes that the new, you know, Alzheimer’s, dementia is like a type 3 diabetes because of inflammatory changes in the brain.

Dr. Justin Marchegiani:  Right.  And you said 5.3, that’s for the hemoglobin A1c.

Dr. Frank Tortorice:  No, 5.6, 5.6–

Dr. Justin Marchegiani:  5.6.  Okay.  Alright, so a couple of things here.  I noticed because I’m doing a lot of blood sugar testing in my office and I do notice blood sugar, if you’re using blood sugar as a marker, it tends to take about 10 years for someone with diabetes to really even show up.  So blood sugar on a fasting CBC is–is gonna be a very late stage indicator for diabetes.  So would that be something you agree with Frank?

Dr. Frank Tortorice:  Yeah, I agree, 100%.

Dr. Justin Marchegiani:  Okay, and my biggest concern is I see some patients with their blood sugar, you know, in the 90s when they wake up fasting, and one thing I think maybe isn’t taken account is the dawn phenomenon which is cortisol potentially upregulating or mobilizing glucose.  What’s your take on the dawn phenomenon by the stimulation of glucose?

Dr. Frank Tortorice:  Well–

Dr. Justin Marchegiani:  Or cortisol?

Dr. Frank Tortorice:  Yeah, you–you’d have to get like a 2AM blood sugar.  And I know that some–some doctors tell their patients the first week to prick their finger at 2 in the morning but what I use is a certain marker checking the C-peptide.  If their C-peptide is chronically elevated then, you know, that they have some insulin resistance.  They’re not getting the sugar into the cells, their body secretes more insulin to try to overcome that resistance, so–so I think that’s a good way. The other thing is there’s–there’s a phenomenon called the metabolic syndrome.

Dr. Justin Marchegiani:  Hmm.

Dr. Frank Tortorice:  And if they have overweight, if they have borderline or hyper–hypertensive numbers, if their cholesterol is either fractionated with the bad cholesterol or the total is elevated, all those different things.  Plus if they have central obesity.  All those things are–are telling you that this is a person who–who is–is on the wrong path in terms of their blood sugar management.  I mean, as you know, you know, blood sugar is just one of the things we see.  I mean, these patients come in, they have 3 ort 4 co-morbidities together because they really have been not managing their health well or because they’ve–they’ve, you know, things.  They have stressors in their life and–and you know, things are changed.

Dr. Justin Marchegiani:  That makes sense.  And one of the things that I do on my practice, I wanna get your take on it as well, is using a glucose tolerance test.  So essentially taking your fasting blood sugar and then looking at 1-hour and 2-hour and then getting a sense of where they’re at, because if you read Jenny Ruhl’s book, Blood Sugar 101, she talks about at 1 hour in, you wanna keep the blood sugar under 140, at 2 hours in, you wanna keep it under 120, and then at 3 hours in, you wanna be down to a fasting state.  So what’s your take on fasting glucose or glucose tolerance test?

Dr. Frank Tortorice:  Yes, that’s–that’s an excellent thing you’re doing there, because we will do it well, because sometimes you’ll get a C-peptide as elevated or you’ll get a hemoglobin A1c.  I had a patient today with a hemoglobin A1c, it was 5.9–

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  Which is pre-diabetic.  6.5, depending on what lab you’re using is actual diagnostics for diabetes mellitus.  But his C-peptide is only 1.16, which is–but we like to see it below 2 in our–in our clinic.  So–

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  So the question is why is this guy having so much resistance apparently with an A1c of 5.9 but not producing very much insulin at all?  1.16, I expect it to be 3, 4, 5, sometimes you see it 8 or 9.  So something’s not right.  So I said, do you know what, we need to do a 2- or 3-hour fasting glucose–

Dr. Justin Marchegiani:  Yes.

Dr. Frank Tortorice:  Tolerance test, because I gotta figure out what’s going on with your insulin and I’ll also get a C-peptide at all of those 3 stages.  And if you do that, then you see how–it’s kinda like I tell patients, if I want to see how you run 100-meter dash, I can think about it and talk about it in–in the office or we could have you just go down to the local park and–and we’ll just time you.

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  The same thing with insulin is a functional type test where we stress the pancreas by giving a–a standardized load of 75 grams of sugar and then we see how the patient performs.

Dr. Justin Marchegiani:  That’s great.  That’s great and I just took my fasting blood sugar about an hour after a meal and I’m at 118 right now which is a little bit high for me.  Typically I never go above 110 but I had a little bit of plantains and squash after my meal so yeah, the–the goal is, the research shows about 140 or higher at any time is gonna create some level of inflammation and/or advance glycation end products.  I want you to talk about some of these–some of the damage that happens with diabetes and blood sugar and some of these AGEs or advanced glycation end products, Dr. Frank.

Dr. Frank Tortorice:  Well, the–the problem with diabetes is not so much just the sugar, it’s what it does to end organs.

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  So end organs for diabetics are the eyes, the kidneys, the peripheral vascular system.  It can cause fatty liver which can–can lead to liver damage or even liver cancer according to some reports.  What we–what we worry about is that the–the patient’s cells and–and organs become affected by this sugar which is very noxious and toxic to the body and causes, you know, causes a lot of inflammatory changes which lead to, you know, a lot of bad side effects to the individual organs.  So what we see a lot of is–in this population is kidney damage.  We see patients that are on dialysis, hemodialysis 3 times a week–

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  As an end stage.  But then we see that they start–their filtration system starts to diminish and–and the kidneys normally reabsorb most of the–the useful products of the blood and–and give it back to the system and only the waste product goes into the urine which gets discarded.  But when you start having diabetes, it’s like having a SIV and you start losing valuable protein, and when you start getting above a certain level then the kidneys are really no longer able to filter and then you can getting either–either infections or you start getting damaged by these–these products going back into the blood systems that aren’t adequately, you know, gotten rid off by the body.  So that’s–that’s one thing.  The second is the eyes and we’ll have sometimes that patients that haven’t seen me in a while goes–go for an eye exam because they can’t see, and then the ophthalmologist says, “Well, you have these, you know, peripheral, you know, these proliferative damages–”

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  “Into the back of the eye or the retina of the eye.”

Dr. Justin Marchegiani:  Hemorrhages, right?

Dr. Frank Tortorice:  Yeah, they could be that.  There can be, you know, the–the vessels can be swollen.

Dr. Justin Marchegiani:  Glaucoma, right?

Dr. Frank Tortorice:  It could be increased pressure.  Yeah.  And they say, “You better see your doctor and have a blood sugar checked.”  And they’ve caught 1 or 2 before I have because either the patient hasn’t seen me or they, you know, weren’t complaining of anything and hadn’t seen the doctor, had some change in vision and the doctor looked at the back of his eye, and said, “Yeah, these are changes that are consistent with a new diagnosis of diabetes mellitus.”  So those are the two, probably we see the most of, is the kidneys and the eyes.

Dr. Justin Marchegiani:  Right, and so essentially what’s happening here is we have these advanced glycation end products and a good analogy is AGEs, that’s the abbreviation which does kinda make sense because it’s aging you faster.  And imagine what they’re doing is they’re just sugar coating all these proteins in your body, right?  And these proteins are in the kidneys and the vasculature, and it’s like basically taking a blow torch to your crème brulee if you will and browning the crème brulee.  That’s what’s happening to these arteries and it’s basically a free radical magnet.  These free radicals come away and they just chip away your electrons and your DNA, and they create damage.  Is–is that something you would wanna answer, Dr Frank?

Dr. Frank Tortorice:  Yeah, very well said.  Very well said.  The–the proteins usually have structures which allow them to–to somewhat, you know, they are somewhat mobile and they usually are very flexible.  Once you start getting glycated end products, you turn them–you turn them very hard.  So think of the difference between, you know, like rigatoni that’s raw and rigatoni–

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  Rigatoni that’s cooked.

Dr. Justin Marchegiani:  Right, right.  That’s makes a lot of sense.

Dr. Frank Tortorice:  So I mean, yeah, if–if these proteins can’t configure themselves properly, then a lot of bad things happen.  So–so, you know, it’s–our bodies are supposed to be very flexible.  Our arteries are supposed to be flexible. That’s how we propagate the blood pressure. When they start getting hardened and you start getting plaque in them because of the inflammatory changes because of the–the glycated end products, that’s not good.  So–so, yes, Justin.  You’re absolutely right.

Dr. Justin Marchegiani:  Well, that makes a lot of sense.  So let’s kinda recap for the listeners here some of the lab tests.  So you’re–you’re taking the fasting glucose 88, which–that’s definitely–that’s very conservative, I like it 95 but 88, we’re–we’re right there in the same–same level.  So 88 fasting glucose–fasting blood glucose.  You like hemoglobin A1c 5.3 and below, is that correct?

Dr. Frank Tortorice:  It’s depending who you talk to.  Some people say above 5.5 you start getting changes.  So, yeah, 5.3 is excellent.  Sometimes I allow them to go as high as 5.5.  It depends on the full picture.  But yeah, I don’t like to see it any–any higher than 5.5.  You think––you start to get a lot–a lot of–some changes that shows that when you have even a little elevated sugar–what people don’t understand is with even without the diagnosis of diabetes, if you’re A1c is elevated you have all the risk for diabetes–if we’re–

Dr. Justin Marchegiani:  Hmm.

Dr. Frank Tortorice:  Diabetic and complications such as nephropathy or kidney damage, eye damage, liver damage–

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  And then the cardiovascular effects.  So–so, you know, I tell people, “You don’t have the diagnosis but you’re gonna have all the complications.”  And they don’t, you know, they really don’t get that.  They say, “Well, I’m okay.  It’s not 6.5, so I’m okay.  I can do what I’m doing.”  No, you can’t.  You’re–

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  You’re starting to have inflammatory changes even at–at an A1c of 5.6.

Dr. Justin Marchegiani:  Interesting.  And one of the things that I’ve noticed and I’ve–saw it in Jenny Ruhl’s book, Blood Sugar 101.  Chris Kresser also mentioned it, too.  It’s that as you start decreasing the inflammation in your diet and you start eating more low toxin anti-inflammatory nutrient dense foods, auto immune or paleo diet, you know, relatively lower carbs, is your red blood cells start to live a little bit longer.  And one of the things that I notice in some of my patients is because the red blood cells are living longer, you know, maybe past that 90-day window is they have a longer life span to accumulate glucose.  So that glycosylated hemoglobin on the A1c portion of the–of the blood sugar there starts to have a little bit higher of an A1c marker, not because the person’s eating more sugar but because the red blood cells are hanging around longer and is able to accumulate it.  What’s your opinion on that?  Have you noticed that at all?

Dr. Frank Tortorice:  I haven’t really seen that to any tremendous degree.  I will tell you it really depends on what–what your patient population is.  If you have, you know, Olympic athletes and people for whatever reason, they’re in excellent physical shape, probably, you know, you gotta see that.

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  With most of my patients, you know, they’re working 1 or 2 jobs–

Dr. Justin Marchegiani:  I see.

Dr. Frank Tortorice:  They’re maybe 25 to 30, 35 pounds overweight.  They’re sleeping 5 hours a night.  They’re–they’re dealing with mortgages.

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  They’re–they’re not people I would think that–that, you know, I think the stress is caused, again, remember we talked about the metabolic syndrome, that they have blood pressure issues, blood sugar recent–

Dr. Justin Marchegiani:  Yes.

Dr. Frank Tortorice:  Control issues, sleep issues.  We’re seeing a lot of that.  It’s really–I mean, we do have some “elite” type patients, but I say for the most part, we–we take care of, you know, just regular families and–and people that they’re just trying to make a living, and–and–

Dr. Justin Marchegiani: I see.

Dr. Frank Tortorice:  Do the best they can.

Dr. Justin Marchegiani:  Got it.  So the population that you have that–that marker may mean more to you.  I see it in my own, like my marker for hemoglobin A1c is 5.7 and yet, I don’t eat any grains.  I keep my carbohydrates around 75 grams of carbohydrates a day.  I exercise.  I’m not overweight.  So I see that in myself and I see it in some of my professional athletes that I see, too.  So–and I hear Kresser talk about it in other people, so that makes sense.  It probably has more value to you in the patient population that you’re–you’re seeing or treating.

Dr. Frank Tortorice:  Yes, you know, you’re absolutely right.  You have to look at the patient as a whole.  I mean–

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  You know, I mean, what–what I do and what you do–we don’t cookie cutter medicine.

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  Each person is individualized and we–we treat them as an individual.  So–so the–I’ve seen–I’ve seen some athlete type.  We have a couple of athlete types that I–I’ve been seeing recently and yeah, it’s–that’s funny you mentioned, their A1c is–is not the lowest.  It is a little bit higher.

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  But then you look at all their other markers, their inflammatory markers, their–

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  Their HSCRP or whatever marker you wanna get and they’re–

Dr. Justin Marchegiani:  Yup.

Dr. Frank Tortorice:  Consistently in the lowest–lowest tertile of the, you know, of the–of the population.

Dr. Justin Marchegiani:  Population.  I’m glad you’re seeing that in your athlete’s ranges.  That’s good.  So let’s cut–touch back on some of the labs.  We mentioned the CBC, fasting blood glucose, hemoglobin A1c.  Are you running a fasting insulin?  You mentioned the C-peptide.  Are you running a fasting insulin?  And if you are, what levels do you like?

Dr. Frank Tortorice:  Yeah, sometimes we’ll–we’ll measure that but not all the time.  It’s–a lot of the patients we’re seeing use their insurance for their labs.  So sometimes if they don’t have a diagnosis of diabetes, it can be a little of a problem, so–I mean, I’ll go with a C-peptide which I like to see 2 or below, sometimes I’ll get insulin.

Dr. Justin Marchegiani:  Yup.

Dr. Frank Tortorice:  I think 7 or below is–

Dr. Justin Marchegiani:  Yup, that’s what I like.

Dr. Frank Tortorice:  Is reasonable.

Dr. Justin Marchegiani:  I like 7 and below.

Dr. Frank Tortorice:  Yeah.  But it depends.  I mean, we have a whole range of patients, some with better insurance plans than others and I kinda–I kinda try to see what I can do for them to make it affordable, yet take excellent care.  I never compromise their care because–

Dr. Justin Marchegiani:  Of the insurance.

Dr. Frank Tortorice:  Of the lab, yeah, I always–

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  The lab is first.  Their health is first.  Insurance is second, then fighting the, you know, the insurance bills is probably third, you know.

Dr. Justin Marchegiani:  Yeah, and that’s kind of the problem with most doctors these days is they have to justify what they’re doing to the insurance and–and the problem is, insurance is more about saving the money than getting the patient the answer.  So I’m glad that you’re not compromising that.

Dr. Frank Tortorice:  No, I think–I think we-we have this discussion many times with our patients.

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  And I–I go to–I go to battle with them.  I fight for them in terms of talking to the insurance.  I had one for example that they say, “Well, we’re not paying for a gluten–the gluten HLA genotypes.”

Dr. Justin Marchegiani:  Yup.

Dr. Frank Tortorice:  The person has Hashimoto’s thyroiditis.

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  So I had to write a letter and say, “You know what?  There’s a pretty strong correlation between this.”

Dr. Justin Marchegiani:  Absolutely.

Dr. Frank Tortorice:  “I think you should really consider this.”  And then I didn’t hear back from them.  But you know, it’s always things like that.  But, you know, I mean, I think it’s an honor to take care of these patients and they come for you–come to you or me, and sometimes it’s the last stop and they’ve never had a doctor really care about them or they got that feeling.  If the doctor–if the patient doesn’t feel that the doctor really is gonna go the extra mile for them, then it–it’s hard for them, you know, it’s hard for me to say, “You know, take these vitamins or do these exercises or sleep this amount.”  I think it has to be a mutual trust because a lot of times, the relationship with your doctor is a very personal thing and if you feel this person is–is a friend or a mentor or a coach, you’re gonna go the extra mile and I think you’ll get better health results.

Dr. Justin Marchegiani:  Yeah, that makes a lot of sense.  I appreciate that.  Very good.  Well, you used a couple of terms here, Dr. Frank.  Metabolic syndrome.  So I just wanna touch upon that.  Metabolic syndrome is this essential, this kinda sequelae of symptoms, high blood sugar, overweight, high blood pressure, maybe extra adipose tissue in the hip and waist area, increased inflammation, and it’s kinda like a sequelae of all these things and it’s basically like, probably the prime magnet for all chronic to degenerative disease.  Do you wanna add to the whole metabolic syndrome concept you raised, Dr. Frank?

Dr. Frank Tortorice:  I-I think you touched on it very well, Justin.  It’s–it’s a terminology that’s been used, that was used to be called syndrome X.

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  I think, I don’t know if it was Gerald Reaven at Stanford who came up with it or whatever, but now we’re seeing a lot more of it.  The one thing I will say is years ago we never used to see this in kids.  And now we’re seeing it in kids unfortunately.  I think this is very grave for our population.

Dr. Justin Marchegiani:  Yeah, I agree.  So getting back to some of the lab work, just so everyone can write down their list of what they should be getting done or if you’re in the San Francisco Bay Area, go on to look up Dr. Frank and have him run some of these labs for you.  We got the C-peptide and/or fasting insulin.  We got your overall glucose, A1c.  Are you looking at fructosamine at all, Dr. Frank?

Dr. Frank Tortorice:  Sometimes we do but usually–usually I don’t.  Usually I don’t.  I know some doctors get it, I know especially the diabetic doctors like that.  If I wanna like a–a snapshot of what they’ve been doing recently, sometimes I get a fructo–fructosamine but I–I typically don’t. I mean, I don’t have a problem with somebody getting that–that test but usually for what I’m trying to achieve, I really don’t need to know, you know, the latest minute-by-minute blood sugar with them.  And I know that it’s used with a correlation with some other markers but in my practice I haven’t really relied on that as much as the other labs we’ve talked about.

Dr. Justin Marchegiani:  That’s like a 30- to 40-day window of blood sugar, correct?

Dr. Frank Tortorice:  Yes, yes.  It’s shorter term as opposed to a 90- to 100-degree. I–a hundred day test as the hemoglobin A1c.

Dr. Justin Marchegiani:  I see.

Dr. Frank Tortorice:  I think sometimes the diabetic doctors get it because they’ve changed insulin and they don’t wanna wait around for another 6 weeks, they forgot what’s going on with the insulin, so they’ll get and then they’ll tell the patient, “Okay, you take–take more or less of the, you know, some of these injectables.”

Dr. Justin Marchegiani:  Right.  So one thing I’m seeing on a lot of patients and I can’t wait ‘til they come out with blood sugar meters; I have one right here now that has blood sugar on it.  I can’t wait ‘til they have one that actually has insulin because one thing I’m seeing is you have  people with relatively normal blood sugar but I imagine if you ran your C-peptide, while in my practice I’ll run fasting insulin, it’s through the roof.  It’s in that 19 or 20, or I get to thinking in your case you said above 2.0 for the C-peptide, is that correct?

Dr. Frank Tortorice:  Right.  Yeah, usually I like to see 2 or below, but I think as you know, Justin, a lot of times a person that’s gonna be elevated is that they’re post-prandial–

Dr. Justin Marchegiani:  The first thing.

Dr. Frank Tortorice:  Yeah.

Dr. Justin Marchegiani:  Yup.

Dr. Frank Tortorice:  Insulin levels and then their C-peptides.  So a lot of times what will happen is that–the, you know, even diabetics, they take their blood sugar only in the morning on an empty stomach and they think, “Well, I must have not to be too bad just a few points too high.”  I switch to have them taking, you know, within the first hour after a meal, it’s way over 200.  I say, “You know what, you’re either eating the wrong food or you’re not, you know–you know, if you’re on medicine, maybe the medicine is not working, or your–your diet is improper.”  So–so yeah, the first thing you’ll see is you’ll see an elevation of the C-peptide or the insulin level showing that the pancreas is either wearing out and not able to–to control the blood sugar with the amount of insulin it’s secreting or that, you know, if you get a blood sugar right after the meal within the first 60 minutes, it’s sky high.  So those–those are early warning signs that something is–is out of whack.

Dr. Justin Marchegiani:  Yeah, because we know blood sugar is very inflammatory at high levels in the–in the vasculature.  We also know that high levels of insulin is very inflammatory, even with normal blood sugar, and I’m seeing this more and more because we get people that are  able to keep their blood sugar in normal ranges, you know, low 90s or even upper 80s in Dr. Frank’s range, and we’re seeing their insulin levels jacked up.  And so, talk to me about just the–the–are you seeing a lot of people with normal blood sugar yet insulin and C-peptide through the roof?

Dr. Frank Tortorice:  Normally, Justin, those people have elevation of blood sugar to some degree.  They’re maybe 99, 101, 106–

Dr. Justin Marchegiani:  Okay.

Dr. Frank Tortorice:  But then their C-peptide maybe 3, 4, 5–

Dr. Justin Marchegiani:  Okay.

Dr. Frank Tortorice:  I–I try to, I mean, use an analogy with people, I say, “It’s like getting a loan.  If you–you told me I have a loan for 50,000,”  I say, “Yeah, but it makes a lot of difference if your interest rate is 3% or 28%.”

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  And the same thing, you’re producing a little bit of insulin to get your–your blood sugar under control that’s one thing.  If you’re–if you’re got the whole pancreas secreting everything it’s got to keep it down, then you know it’s a whole different story.

Dr. Justin Marchegiani:  Oh, I like that analogy.  I’m writing that one down.  I’m–I’m gonna take that one, if you don’t mind, Dr. Frank.

Dr. Frank Tortorice:  Yeah, feel free.

Dr. Justin Marchegiani:  I like that, very good.  Alright, so we got–talked about some lab testing, I feel like everyone listening has some good markers that they can go out to their local doctor or if you’re in the Bay Area, to reach out to you and get those run.  Now most important out of everything, out of anything I think we’re talking about here when it comes to blood sugar and diabetes, and I think you’ll agree with me, is diet.  So can we talk about kind of what the standard of care is and I know this, what you provide is not–is gonna be above and beyond the standard care.  So what the standard of care is and what you would recommend different than the standard of care.

Dr. Frank Tortorice:  Well, typically or historically, the standard of care was to tell patients to have, you know, a varied diet.  They would get away from obvious things that most of us would figure is not good like cakes, candies, crackers, things of that sort.  But the typically ADA diet included the, you know, like whole grains and the, you know, some other things that probably would not be in the best interest of our diabetic patients.  I think a lot of times it just makes it worse, I mean, I even see what they do with patients who get referred from other–either other facilities or other doctors and I–I read what the dietician puts down there as their ADA diet and it’s, you know, it’s–I don’t think it’s–it’s helping these patients long-term.

Dr. Justin Marchegiani:  ADA diet–

Dr. Frank Tortorice:  Yeah, what I try to say to them is “Listen, there’s certain foods that we know historically or even scientifically cause the pancreas to have us secrete more insulin to help in the digestion and assimilation, and certainly processed grains are in–on the forefront of that.”

Dr. Justin Marchegiani:  Absolutely.

Dr. Frank Tortorice:  I mean, the more grains you have despite all the toxins in the grains and some of the other issues with gluten is the body in order to digest these has to–requires insulin in order to get to–get it into the cells.  So–so if you’re doing that and you’re causing inflamed gut response, then you know, you’re not gonna get what you want in terms of health because you’re–you’re gonna have elevated blood sugars eventually because the pancreas is gonna wear out because it just can’t keep up with that.

Dr. Justin Marchegiani:  I agree.  And I see that all the time and I’m seeing conventional registered dieticians still recommend 50-60 grams of carbohydrate for a lot of these patients which we know is doing them a disservice.  I know that in the foreword of Dr. Diana Schwarzbein’s book, The Schwarzbein Principle, and Dr. Schwarzbein was an endocrinologist for 25 years and she made mention in the foreword of her book that the ADA diet causes diabetes.  Can you touch upon that, Dr. Frank?

Dr. Frank Tortorice:  Right.  Well, I mean, I think– I think, you know, we’re–we’re finding that some of the things that were recommended even as recently as 5 or 10 years ago may not be in the best interest of our patients.

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  And I think, you know, healthcare in America is–is a extremely important of our, you know, gross national product–

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  Terms of expenditures.

Dr. Justin Marchegiani:  Yup.

Dr. Frank Tortorice:  So here’s a lot of people who are involved with that.  What I will say is that patients come to me and come to you because they believe us and what I–what I try to do is give them something simple in terms of making dietary changes then have them see themselves the benefit in how they feel, how the look, and–and what they do with their blood sugars.  Well, the problem you–you have I think is patients throw their hands up because they know, “I can’t do all that at once.  I–you know, you’re asking me to do too much.” or “You know, my wife cooks for me, my husband cooks for me, you know, I don’t wanna disrupt the family, the kids are not gonna go–”  So it’s a process of inching forward I think.

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  Of a lot of our patients.  I mean, especially if you’re talking about blue collar or–or families that have both–both, you know, husband and wife working.  There’s kids that are in school.  I mean, we really have to do something that’s sensitive to their individual needs.  So–so, you know, either I’ll talk to them or you know, if we have, you know, nutritionist to talk with them.  We’ll make sure it’s a functional nutritionist and that we–we agree on–on what we’re trying to do for these patients and then we see them back and we–we try to have them have wins, Justin.

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  If they have wins, they have confidence.  If they have confidence, they’ll change.  I mean, I’ve had people with diabetes, one gentleman I can think of, he came in at 255. Now he’s about 197.  And–

Dr. Justin Marchegiani:  Wow.

Dr. Frank Tortorice:  This guy was just, you know, you never know where the heart of a patient is, you know.  And I think we give each patient the–the full gamut and see who’s gonna step up to the plate, you know.  And this gentleman is–is pretty much just on the border now of being a diabetic, wherein before he was entrenching a lot of medications.  His–you know, he had hypertensive issues.  There can be problems with, you know, sexual function in both men and women because of diabetes because it does a lot of bad things.  So–so, you know, people have motivation to try to get this under–under control and–and they have to really buy in to why you’re doing it, not only, you know, what they have to but why they have to do it and I think that’s why we–we have to spend more time with them and–and speak to them on their terms, on their language, but also give them also small victories that accumulate, you know?

Dr. Justin Marchegiani:  I agree, that makes sense.  So from like a dietary perspective, are you kinda starting out with a–a Paleo template where you’re cutting out grains?  Are you primarily focusing on vegetables for carbohydrates?  Are you allowing your patients any fruits at all?  Could you go into that?

Dr. Frank Tortorice:  Yes, what we found is–you know, we think maybe I-I had the mis–mistake of just cutting too much out, you know.  I mean, you––you can go Paleo where you–you don’t allow any types of carbohydrates and I think for a lot of our patients, yes, maybe it’s better, but are they gonna comply?  So I–I talked to Paul Jaminet, you know, who–

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  Wrote The Perfect Health Diet and we went back and forth.  He is a very nice, generous, brilliant man and we–we talked about his concept of using rice and–and the same thing with potatoes.  If you–if you cook the rice and then you put it in the refrigerator and then you reheat it, the molecular structure changes and it–it changes how it–how it–how the body, the glycemic response to it.

Dr. Justin Marchegiani:  Yup, and the starch.

Dr. Frank Tortorice:  And the same thing, yeah.  And the same thing with white potato.  That if you’d–if you cook it, either if you, you know, put it in the oven or however you cook it and then put it in the refrigerator and then you–then you take it back out again the next day and reheat it, again it’s–it’s altered in a way that it causes less of a blood sugar surge.  So what I try to do is because remember these–there are patients that have been eating pasta and then pounding the bread and, I mean, you gotta give them something that they’re gonna go with at least initially.  I’ve seen sometimes after 3 to 6 months that the patient says, “You know what, doc?  I don’t even want that anymore.”  But initially, if–if you just take too much away from these patients, they just either will not come back or they won’t–they won’t comply.  They just–you know, it’s not a question of willpower.  It’s a question of either, you know, I don’t wanna say food addiction, but it–it’s a question where it’s–it’s hard for them to buy in right off from the bat.  So-

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  We–we give them a little bit of starch but I, you know, I don’t give them a limited amount.  I wouldn’t give them 1 or 2 portions of these–

Dr. Justin Marchegiani:  Yes.

Dr. Frank Tortorice:  You know, starchy carbohydrates but pretty much everything else is off the table in terms of things that you would recognize as, you know, starches or–or matchy carbohydrates.

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:   We have them to have a protein with every meal.

Dr. Justin Marchegiani:  Smart, yup.  Stabilizing the blood sugar.

Dr. Frank Tortorice:  And then all the phytonutrients of vegetables.

Dr. Justin Marchegiani:  Uh-hmm.

Dr. Frank Tortorice:  And–and you know, some of the vegetables if they’re organic or even better.  We if they’re organic or even better, we do let them have a limited amount of–of fruits.  Some of the fruits have actually been shown to help with diabetic control, some of the berries–

Dr. Justin Marchegiani:  Berries, right.

Dr. Frank Tortorice:   And then some of the–but it’s limited and–and again, the–the highest quality and the freshest quality is really important with that, so–and then we see where they are.  They’ll–

Dr. Justin Marchegiani:  Uh-hmm.

Dr. Frank Tortorice:  They’ll bring in their blood sugars.  We’ll check their weight.  We'll check their blood pressure.  We’ll check their cholesterol and then we just modify it.  So if they've been overdoing it, we–we just cut back a little bit.  If they're right on target, well, they can keep doing what they're doing.  So we work–we work with them in a very personalized way to try to be as responsive to them as possible, but yet to get them to go.  I mean, basically, you know, they pay is to–to get them to their goal which is to have, in the case of diabetes, either no more diabetes or at least no more symptoms from end organ damage of diabetes depending on stage of diabetes and how many years they’ve had it.

Dr. Justin Marchegiani:  Right.  Yeah, I used to work in surgery about 10-15 years ago at a hospital nearby when I was in University and I used to–my job was to go on with the surgeon and I would assist in holding the limbs of the diabetic patients as they’d be amputated, and I’d have a conversation with the surgeon afterwards and the conversations was interesting because we’d be outside and he would be smoking a cigarette a lot of times, and I would be asking him, “Hey, doc, you know, what can we do to get ahead of this and prevent all these organs or feet, and toes and such from being cut off?”  And he really didn't have much to it and I think, you know, his perspective on him smoking a butt outside, you know, kinda said it all.  But hundreds of limbs had crossed through my possession down to the morgue and it was really sad, I think from your perspective and mine, knowing that that's all preventable.  Can you talk about how much of this can be prevented and how many people, you know, you are able to totally from a laboratory assessment cure them whether off their meds and their blood sugars back under control?

Dr. Frank Tortorice:  Yes, Justin.  So–so, yeah, we–we think that, you know, if they’re early stage of either pre-diabetes or diabetes with no end organ damage, that they–they have an extra chance of being able to live out a full life.  I remember when I was in training, one of my diabetic teachers gave me this article and the lady was like 97 years old, had diabetes since the time she was 18 and never suffered an end organ damage.  So it can be done–it can be done.  I mean, again it's not so much the diagnosis of diabetes, it’s all the complications you get from poorly controlled blood glucose.  So what we do is we–each and every one of our patients gets those tests I mentioned and then we take it from there.  We’ve discovered a number people that just have no doubt diabetes, they had hemoglobin A1c 7.1, 11.4, or whatever.  At that point, there is no–there is no discussion not to get diabetes.  They already had diabetes.  What–what are we gonna do about it so they don't suffer end organ damage and lose their limbs like–like you so eloquently mentioned or go into kidney failure–

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  Become blind, or so on and so forth.  So–so, you know, I–it’s hard to say there's not a patient we can’t help except maybe somebody who is really, really end-stage–

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  But if they come to me before that then we–we usually are able to help them.  I mean, I just got a new patient.  He’s had both his legs cut off–

Dr. Justin Marchegiani:  Ugh.

Dr. Frank Tortorice:  So I don’t think I can help with that, but I think a lot of his inflammatory changes we can help in terms of, you know, he’s had a triple bypass and just one of those people who–who just doesn't have a tolerance for, you know, if these–if these were caused by diabetes which he said they were and I haven’t received the records but we can still help a lot of people.  I mean, in, you know, in the end, it comes down to improving their quality of life.

Dr. Justin Marchegiani:  And I think you’d already touched upon it but I think people, the average person doesn't realize the fact that diabetes and blood sugar and inflammation are the number one predisposing factor for cancer and for heart disease because of the vascular changes and because of the fact that cancer cells love glucose.  Can you touch upon the diabetes, cardiovascular, and cancer connection?

Dr. Frank Tortorice:  Yes.  I think, you know, early on, we–we thought that it was cholesterol causing the heart disease.

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  But then later on with more, you know, sophisticated studies, we found it was oxidized cholesterol that–that caused problems and then we found out that you didn’t get high cholesterol from eating cholesterol.  You got high cholesterol from eating too much sugar and having inflammatory changes in–in the endothelial and the vascular layers.  So–so then it became a no brainer that, you know, we needed to–to cut down this inflammatory change which is at the root of almost everything that we see in terms of the–the major diseases of–of lifestyle in at least in the Western world and especially the United States.  So, that’s why myself and–and your practice as well is we really target on cutting down inflammatory, you know, instigators in the patient’s diet and their lifestyle and their sleep and their stress levels and so on and so forth.

Dr. Justin Marchegiani:  I like that and it is–it’s very rare to find holistic medical doctors that really understand the aspects of sleep and exercise, nutrition, even the more functional ones that are out there, they just want to use hormones and supplements to cover up other issues where, you know, as you already said and you–and you have alluded to that you really can't replace exercise, you can’t replace sleep, you can’t replace stress management, you can't replace blood sugar stability between meals, so I think that’s, you know, quite an interesting perspective as a medical doctor to come to those conclusions.  Can you talk about how you as an MD came to them?  Because I mean, you have 10-15 years of indoctrination in–in one arena which we know is great for acute and traumatic care, but the acute and traumatic model does not work too well with chronic disease.  Can you touch upon how you came to where you're at now, Dr. Frank?

Dr. Frank Tortorice:  Sure, Justin.  Yes, so early on, back even like in the year 2000-2001, I was introduced to the–in functional medicine through some local seminars I gave, then I went up to Gig Harbor in Washington and got some advanced training at the Institute for Functional Medicine.  So when I heard these lectures and saw these doctors and heard what they were doing, it was really something I wanted to become more of a part of.  It was really interesting.  It was exciting and it was what I believed in.  I mean, you know, the patients are sick not because they lack certain medicines because especially, you know, with chronic conditions of lifestyle changes or decisions they have made and–and, you know, they–they may have read or–or saw an advertisement on TV or read–read a newspaper and thought they were doing the right thing but many times we have to re–reeducate them on–on what’s in their best interest and how to become a critical reader and a critical, you know, critic of what kind of information they're giving.  I mean, to be a doctor to certain extent is to–to really train or–or teach our patients and that's why everybody on my staff has helped–helps the patient with their–their need to learn and–and to exchange–sometimes the patients will teach me things.  So–so it's–it's a way that we’re trying to really up the ante in terms of giving them cutting edge information which we know will have a positive benefit on their–on their health.

Dr. Justin Marchegiani:  Great.  I love that and I actually remember seeing you–I think we talked about this last weekend.  I remembered seeing you 2007 and Dr. Dan Kalish’s office in San Francisco on Fillmore, and so even back then you were still learning, I was learning, and now that was kinda my first interaction with you almost ten years ago.

Dr. Frank Tortorice:  Right, yeah.  It's a–it’s, it's gotten on much more exciting since then with all the different changes with the iPhone, the iPhone apps–

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  And all the Internet, I mean, it’s a whole new world out there.  But I think it’s exciting.  I think we're gonna come up with a–a lot–a lot of patients that are gonna be interested in pursuing their health through–through a partnership.  I mean, with the functional medicine type of model, I mean, the patient and the doctor are like teammates.  It’s not, you know, a condescending thing where somebody with a degree tells somebody who was coming there as a client how to do it.  It's more like a team, you know, and–and I think I enjoy it, because I–I don't think I know everything about everything and I think I learn a lot from a lot of my patients and enjoy using my–you know, my background and my experience to help them get to where they need to be and get better and–and the thing about our community is, you know, Justin, is if I don’t know someone I can call you–

Dr. Justin Marchegiani:  Yup.

Dr. Frank Tortorice:  Or I can call somebody else and–and find out and–and the, you know, people are very gracious to–to help us.  And, you know, and it, you know, and sometimes people will call me and wanna know from me what's going on as well as I–I can add something to some of the cases that they're working with.  So, it’s pretty much a privilege to do what we do and–and to get up each day and–and try to make the world a little better place, even if it's one patient at a time.  It really–really has a lot of meaning for us and I think it has a lot of meaning for the–the patients.  You become very close to a lot of them I think because you share a common bond.

Dr. Justin Marchegiani:  Yeah, I agree, I agree, and oh, last weekend we met up in Houston at a big functional medicine conference down there and one of the keynote speakers was JJ Virgin and she’s got that book, New York Times bestselling book, the Sugar Impact Diet, which I think is very relevant to today’s talk and I think one key point she talked about in there was really the glycemic index.  Maybe it's not all it's cracked up to be because of the fact that it really ignores fructose and the effects that fructose can have on insulin resistance.  So can you just touch upon some of JJ’s work regarding glycemic index and fructose and how it affects blood sugar and/or insulin resistance, Dr. Frank?

Dr. Frank Tortorice:  Yes.  Yeah, I read that book.  It was really well done.  I mean, she really put a lot of effort into that book and I really–I really wanna applaud her for that.  It was really a good job and she makes it easy for patients who feel overwhelmed to get on board and–and she–she holds her hand all the way through it, so I recommend that book as–as a good start with or without a–a functional doctor but obviously better if you can get some personalized care with a functional doctor.

Dr. Justin Marchegiani:  Absolutely.

Dr. Frank Tortorice:  The problem with fruc–with fructose is–is just, you know, as you know the way it’s metabolized and–and––

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  It kinda–the different way it–different effects it has on the liver and then on–on the body as a whole so–

Dr. Justin Marchegiani:  Right.

Dr. Frank Tortorice:  So, you know, the, you know, when–when they used to say you probably hear–hear this, “Eat all your fruits and vegetables, that’s okay.”  Then it got changed to all the vegetables you want but cut down on your–on your fruit, which even if its organic still has fructose and the negative effects of too much fructose in the–in the diet.  So your–you’re right on about that, is–is we really make sure that they, I mean, people think of fructose is like a high fructose corn syrup but they don’t realized that even too much–for we have people that are frutatrians and they come in and they have a lot of negative health consequences.  So you still have to put–put a–a level on or limit on the amount of fructose in the human diet and even patients who think they’re doing the right thing.

Dr. Justin Marchegiani:  Yeah, I agree.  So essentially fructose doesn't really register very high on the glycemic index and glycemic index for everyone is just how fast glucose from the–your–from food actually gets in your blood sugar, right?  So the faster glucose get into your blood, then the faster or the higher the insulin spike is.  So the thing with fructose for everyone is it doesn't have a high glycemic index.  But it goes strictly to the liver primarily, which then can create insulin resistance that is systemic level.  Is that correct?  Because everything is filtered down from the liver.

Dr. Frank Tortorice:  Right, yes.  It does need to be met–metabolized and goes direct to the liver there.  So it–it’s the way the body metabolizes much different than glucose, so–so that’s the problem and then there can be other problems and then, you know, it can cause you to have more hunger, it can cause the cells to become stiffer as well.  It has a lot of negative side effects and that’s, you know, it–especially if you’re eating in–in something that’s been, you know, created like a processed food.  Fructose is used as a common, you know, a sweetener to some degree or even–

Dr. Justin Marchegiani:  Yeah.

Dr. Frank Tortorice:  Combination with so.  So, yeah, we–we are really aware of the fact that we need to educate our patients to what to look out–look out for in that regard.

Dr. Justin Marchegiani:  I think that’s really good and one of the handouts I give to all my patients is by Dr. Johnson.  You probably heard of him.  He’s the doc over in University of Colorado that talks about the correlation with uric acid and fructose and high blood pressure, does he ring a bell?

Dr. Frank Tortorice:  Yes, yes.

Dr. Justin Marchegiani:  One of the handouts I give is his handout basically anyone with insulin resistance or diabetes should not be consuming more than 15 grams of fructose a day and that's 15 grams from whole food sources, so feel free–we will put on the show notes his handout on fructose and uric acid just for the listeners so they can get a sense of what 15 grams of fructose is.  And just so everyone knows, even something like an apple, an organic apple, regular red Apple would have 10 grams of fructose, just to give people a perspective of what we're looking at.%

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