Thank you and very much likewise!

Thank you, Zoe. Feel free to share the videos far and wide. Strictly speaking everything is physiological. That said if by physiological you mean with no untoward risk associated, keto can drive insulin resistance that is physiologically pathological. Keto doesn’t buy definition necessarily do so because there are ways to do keto without overload of saturated fat, valine and iron, for instance. But most people don’t follow that type of keto One could argue that even though the insulin resistance is there, the low carb approach prevents it from being “triggered“. Fair enough on that, but the manner by which people follow low-carb is typically one that does not improve, and often worsens, dyslipidemia, particularly apolipoprotein B levels, as well as less impressive improvement and blood pressure per weight loss. Regarding mitigating age related insulin resistance, there’s nothing special. It’s a simple, but more urgent, focus on all of the things that we know drive insulin sensitivity: Calorie balance as reflected by healthy eating, physical activity. Avoiding excess iron (foreign occasionally we find people regularly cooking in cast-iron skillets, which is great for someone with low iron but not so much for someone with high), which can be an issue in postmenopausal women because they’re no longer losing blood every month. In that regard, if someone has insulin resistance, particularly any level of glucose intolerance (why restrict only type 2 diabetes?), whether male or postmenopausal female I would encourage blood donation (not therapeutic phlebotomy, let someone benefit from the blood) if their ferritin was even over 200 , but certainly over 200 in a female and definitely if >300 in a man, all in the process of developing a lifestyle that doesn’t cause the type of hyperabsorption and accumulation of insulin resistance aggravating levels of iron.

@@DrTomMD thank you so much for such a detailed response.

Fully sympathize with your sentiments and thank you for your comment @zoe.thebody360 The other issue of courses after you test, what to do with the results. There’s a huge gap in understanding what is optimal, and how to get there at the lowest risk whether it’s from the lifestyle medicine coaching perspective, for the webinar that I posted in the description area provides a good background and how to coach regarding stages of readiness for change, pharmaceutical intervention which is a form you have really understood how to leverage at the spot of high efficacy/low risk. If you ever want to do a discussion for our mutual communities, happy to consider..

No IMO. It is not worth the IV contrast risk to kidneys or even the radiation to prove what is almost assuredly there - ie soft, noncalcified plaque. The question is whether atherosclerosis is advanced enough to have calcified, for which a CACS can do the trick without contrast and less radiation than CTA. At that age, it’s questionable whether even a CACS (coronary artery calcium score via CT scan - no contrast necessary and much cheaper than a CTA) is worthwhile, but it might be if the 33-year-old has significant family history of early cardiovascular diseas, in which case they should have their lipoprotein(a) checked as well. CACS may be helpful if it in fact would motivate them to agree to intensify their prevention approach, preferably in terms of lifestyle but even pharmaceutical. It’s typically a “tiebreaker“ on decision-making for “yes or no to pharmaceutical enhancement over and above lifestyle for reducing lifetime risk of ASCVD (atherosclerotic cardiovascular disease) My concern is that when there is a zero CAC score that people over interpret the finding as more than simply a low risk over the next 3 to 5 years. Ie if a zero score is found, it should be cherished (as I do with my zero score in my 50’s despite very high lipoprotein(a). In other words, even with a 0 CAC score, everything done lifestyle-wise to maintain zero as long as possible. With zero CAC, argument could be made that adding risk of pharmaceutical intervention with a zero score may not have benefit that outweighs risk. All that being said, for 33 year-old to have full-blown type 2 diabetes means that there is some serious story to unpack (and should likely be investigated for having LADA or MODY -discussed in lesson 2 of module 1 of the Flex5 Lifestyle Masterclass) like a likely family or tight social network pushing risky lifestyle behaviors or living in a high risk zip code.

@@DrTomMD thank you doc. Diabetes was induced via a vicious cycle of emotional binge eating and sedentary lifestyle during the lockdown period. Was reversed within months of diagnosis via 180° in diet & lifestyle with the help of some supplements. Lp(a) 33, but Apo-B has been elevated since teens. Early ASCVD events have occurred only in paternal grandfather at this point (may it stay that way). The big Q is whether to start pharmaceuticals. Apo-B is now only mildly elevated (80-100) thanks to very rigorous (and possibly unsustainable) lifestyle.

@@Seanonyoutube see if you can find a place to do a carotid CIMT ultrasound nearby. That would give almost as good information as a coronary artery calcium score, but much earlier detection via carotid arteries’ media thickness, which substantially precedes calcification. Of course if a clear plaque is visible that would also be detected, but the CIMT is a much more sensitive way of assessing the level of atherosclerosis progression in a younger person by simply accessing the easy to visualize via ultrasound carotid arteries with a skilled ultrasonographer who knows how to do CIMT. At your age with aggressive reversal lifestyle I am fairly confident you don’t have any un reversible vascular disease of any significance. The more substantial concern is whether you can maintain a continued sclerosis lifestyle. It may not need to be as strict as you are doing now. Honestly, as motivated as you are, I would sincerely suggest considering our Flex5 Lifestyle Masterclass (info: dpm.drtomrifai.com/)

@@DrTomMD thank you doc, I will do that test, and look into your program. I’m always playing with various lifestyle levers to see how it impacts my bloodwork; i’m hoping I can find a balance, especially in terms of minimizing the cost and time involved in it all. Thank you for your response and your great content!

Glad you liked it

Glad it was helpful!

I see high likelihood of discordance between real time actual glucose and the interpretation of such via optically based technology. But we’ll see (no pun intended).

Processed added fiber doesn’t hurt. It may be a little bit better. But what we are concerned about is that people will believe that processed added fiber has the same level of data and benefit as naturally occurring fiber

I love good healthy things stuffed into a tortilla. Am I moving in a helpful direction if I use a high fiber/low-carb tortilla instead of a normal I realize it’s not health food, but is it better?

That’s a good question that requires some nuance. If by chips you mean a no salt added kettle chips cooked in low saturated fat oil, I’m not sure if fiber one bar is better. But is a fiber one bar lower risk than a whatchamacallit bar? I say yes. Lower saturated fat, and combination of naturally occurring fiber and processed added fiber which, again, isn’t harmful. Its problem is that it is advertised to be as good as naturally occurring fiber but isn’t. I like an occasional fiber one bar too … though fiber one cereal stands out as one of the healthiest cereals ever invented along with plain shredded wheat 🌾

Great questions @TheBody360 No question re MTHFR and potential for elevated homocysteine: medlineplus.gov/lab-tests/mthfr-mutation-test/ And yes, there is also an association with an MTHFR mutation and hypertension: onlinelibrary.wiley.com/doi/full/10.1111/jhn.13061#:~:text=The%20C677T%20polymorphism%20in%20the,this%20polymorphism%20(TT%20genotype

Thank you Dr Tom...great chat at the Health Science Academy yesterday! 🙂

@Zoe.TheBody360 Thank you!

Thank you Kristi!

Also, many foods independent of their antioxidant potential induces antioxidant enzymes increasing glutathione production. At the end of the day all of these molecules are natural produced drugs which tend to be weaker then synthetic man directed molecules but they still have the potential to have therapeutic benefits.

@@colin6577 i’m willing to entertain the hypothesis but would like to see serious, peer reviewed evidence and ultimately in the form of a randomized controlled human trials before I start recommending people expend their (precious, limited) bandwidth on things that are unproven (at my level of satisfaction) and conceptual.

Hi there! Thank you for your comment. Please feel free to forward the studies on bergamot and berberine that you find impactful. I have not seen any that impressed me particularly. Psyllium is definitely well proven, and I am fact do take it fairly regularly if not daily. I personally take a purified omega-3 for about 1000 mg total combined EPA and DHA, magnesium citrate, randomized controlled trial proven multivitamin and vitamin B12, the latter for prophylaxis against Metformin related B12 deficiency. But none of those are antioxidants. I will do a separate video on the supplements I taken why if that is helpful.

@@DrTomMD I tried posting the IDs for the studies but YT did its thing and deleted my comment.

@@Seanonyoutube I am not a fan of censorship at all. Even if I’m not a fan of misinformation - censorship is worse. Apparently the YT people think that the information is misinformation. I would like to see it myself. Feel free to email it to me at [email protected] Fair warning, there’s not an unreasonable chance I’ll agree with KZfaq that it’s misinformation but I will always fight for your right to speak your mind, and anyone’s else as well.

When it comes to short bouts of HIIT, yes. You are correct. I was talking about marathon running and overloading the system with a level that is diagnosable over training. That is not beneficial. Here’s a great podcast with two experts that I interviewed worth considering regarding the “sweet spot” for exercise: podcasts.apple.com/us/podcast/true-health-revealed/id1613534169?i=1000560739526

@@DrTomMDidk man. I’ll listen to the podcast, but you spoke to two people who are dealing primarily with heart patients. Would be more insightful if you spoke with exercise physiologists who primarily deal with athletes. Anyway, I think it’s nuanced. Overtraining is a very individual thing. Kipchoge can run an easy 5m/km marathon every day and for him that wouldn’t be overtraining. It’s all a matter of how adapted someone is. But if indeed someone is overtraining, then yeah, that would not be good for them long term. But we do know that people with the highest v02 max (as commonly seen in elite athletes) tend to have substantially lower risk of all cause mortality compared to lower V02 max. Similar to weightlifting, progressive overload with adequate recovery time will create beneficial adaptations for the heart and metabolic health.

Thanks for your comment @bjornconner8514 but no, it’s not based on vegan starvation body structure. Not sure why you think so, or maybe you were being facetious. Nevertheless, here’s some BMI background. One of the best clinical measures to whether someone could benefit, metabolically some losing weight as a fasting insulin. If in fact at 5‘9“ in 200 pounds your fasting insulin is less than 5 and your fasting glucose is concomitantly on the same blood draw less than 90, certainly less than 100, milligrams per deciliter, you are correct. On the other hand, if either is elevated above the levels above, there could be an argument for losing some body fat. Some people have high insulin levels at lower BMI, and some don’t, consistent with the Content presented in the video. Ultimately, though, one of the most important aspects of weight is insulin resistance/sensitivity status and therefore I don’t guess. I simply check. Your doctor can order the test for you if you wish and ask. It’s typically covered by Insurance. Make it a great day and thanks again for chiming in. www.ncbi.nlm.nih.gov/pmc/articles/PMC8920809/

@@DrTomMD Yes I was being facetious. I understand. Bone mass, hip structure, shoulder sturcture, muscle mass, etc. has determining factors on body BMI. Another thing that determines BMI is diet. I remember that in boot camp years ago, if you were overweight via your BMI, they would put you on rabbit starvation mode aka salads. Today, we know that Carnivore does a better job at fat loss while maintaining muscle.

@@TheWarriorsMind totally disagree regarding carnivore. There is not enough glycogen capacity to produce top performance exercise. This has been published. Consider updating your knowledge base. I appreciate your expressing your opinion, though. We all have a right to one.

@@TheWarriorsMindfor your consideration kzfaq.info/get/bejne/jJekqchqqbObiXk.htmlsi=HsbrjijYD-Ziza6c

Thank you for your covet. I can sympathize that Cheerios isn’t the highest quality cereal (those since it’s made with 100% whole grain, it’s certainly a significant step up from Rice Krispies or Froot Loops). But Dr Franklin is lean, healthy and a regular exerciser. He also eats lots of veggies, beans, whole fruit and lean animal based protein. In total context, I think his lifestyle including his very regular exercise is one that is compatible with low t2 diabetes risk.

If you don’t understand how to interpret it’s varying levels of quality and confounding and reverse causality, survivorship (etc) limits, yes - it could seem that way.

Hi Nancy. Thank you for your comment! I like your more intensive criteria versus Tufts, which uses an up to 10 to 1 carb to fiber ratio. The problem with it is that it doesn’t take into account processed/refined added fiber. Such requires a sleuth to look on the label for maltodextrin, polydextrose, inulin/chicory root extract, oat fiber, corn fiber, wheat fiber (all refined and distinct from oat bran, wheat bran and corn bran). Also, there is a way to assess meals more completely once educating a client or patient on the detective work needed to see if processed/refined fibers are added (which either this upcoming or your calculation would need anyway). It’s called PF10™. Calculation goes like this… Take the fiber grams (which for high quality PF10 “score” must be at least 2 g for every 100 cal - to avoid giving high quality scores to meals that are simply high in protein and devoid of Mich fiber) and add them to the protein grams. That sum (fiber grams plus protein grams) is then multiplied by 10 to give the PF10. It is the PF10/calorie ratio that is the target for final assessment. For a good quality meal, PF10/calorie ratio (longevity score) should be at least 75%. For high quality >=100% (for which virtually all beans or lentils meet, notably). If PF10 is low for a day’s worth of food (<75% and esp <50%) we know without question where the calories are coming from. There can only be three sources: Refined/low fiber carbs, refined/low fiber fats (eg dairy butter, oils, nut butters) or alcohol. You’re welcome and all the best.

@@DrTomMD Fiber + Protein then divide by 10. 75% or better. And back to the less ingredients the better. Amazingly I had lentils for lunch. Lol

Then multiply by 10..

@@nancyevans5176 love legumes!👍🏽🙏🏽

Glad it was helpful!

Excellent comment and example of the struggle to find individualization, nuance and a good coach that knows medicine, lifestyle psychology and nutrition. You must talk with you’re doc but I’m not compelled to use doses based on trials. I help patients with lifestyle and using the lowest dose necessary of any drug as an adjunct. Requires regular visits, frequent reassessments and yes, sometimes going back on or up on a drug dose. My proven Flex5 Lifestyle system has helped keep people focused centrally on lifestyle medicine and able to use lower, even intermittent, doses of medications. But again, you’d need to coordinate with your doctor. My concern is one getting too reliant on the drug for the effect rather than as a tool to better learn lifestyle skills well enough that the drug, in your case tirzepatide (Mounjaro), is not needed or only needed intermittently. But without being your coach formally (frankly while possible would be more expensive than the drug), I can’t comment on your personal case. If you want to consider learning The Flex5 Lifestyle skills and knowledge virtually, you can consider taking my online course. Spend at least an hour a week on it and in 3 months or less I believe your odds of maintaining most of your loss will go up significantly, esp if you can find even a low cost coach locally (eg a high quality and compassionate dietitian): here’s the Flex5 info page weblink dpm.drtomrifai.com Best of luck and make sure you make your wishes clear to your doc. If you want to stick with a lower dose, then tell him and that you’re willing to be accountable (see him monthly for weigh ins and if his practice has an RD, see them - that’s how my programs have been designed).

@@DrTomMD Thank you for your kind reply and I will check out your program. My doctor is older and extremely conservative. He does not believe in these medications for weight loss and only agreed to put me on Mount jaro at the lowest dose of 2.5 to see how it would help with my diabetes. My A1C went from 7:00 to 7.6 so he told me he would give it a try. After 4 weeks I approached him pursuant to the protocol and asked him to increase the dosage and he asked to meet with me. When he met with me he explained that this is a powerful drug and that increasing my dosage would also increase the likelihood of side effects. He also told me that the weight loss is a side benefit and should not be my major focus. He also said I was losing one to two pounds per week so the drug was still effective. After 10 weeks on 2.5 he has agreed to increase my dosage for week 11 to 5.0 since all the clinical studies on glucose sugar control were done at 5.0 or higher. To be honest I will take your advice and I will probably park myself on 5.0 and stay there. The drug has lowered my glucose sugar level from 160 to 100 My blood pressure is normal My sleep apnea is vastly improved and for me the drug is extremely effective. The fear that all of us have that are on this medication is what happens around Christmas time when I reach my target. You may not agree but I am a firm believer that obesity is partially genetic and some people have some type of imbalance which makes their food noise extremely loud. I hate when people say if you just had a little more willpower you could lose weight. For some of us it's not a question of willpower and more question of biology. That said I also agree with you that learning how to reacclimate yourself to food is important on this drug I have learned about portion control and track my calories. The scary part is that the research shows that those that come off the medication completely gain back the weight. If I am successful and lose 75 lb no way am I putting this back on. Again thank you for your reply I will check out your course. Also thinking of hiring an nutritionist to better educate myself on dense caloric foods and better healthy eating.

⁠@@dab7963 very proud of you. If you’re not taking metformin ER as a “transition to weight maintenance” medication consider asking your doctor for a Rx. Build up to 1500-2000mg (three to four 500mg tabs). Make sure to take 1000mcg B12 supplements at least every other day - or whatever amount needed to maintain blood B12 >500 pg/mL. Also take a Centrum Silver or equivalent for folate and riboflavin - all 3 B vitamins can drop over time on metformin without supplements (which can cause anemia or peripheral neuropathy). While metformin ER is mild in terms of weight loss, in my clinical experience it can safely enhance weight management in those who are truly committed to learning lifestyle skills as the “engine” of metabolic health (and meds only the “turbo chargers”). Of course everything I’m suggesting here is subject to whatever you and your licensed health care provider decide. Best of luck!

In the ideal, free markets of the free(ish) world, mostly - influenced within reason “and just enough” by food policies and education campaigns that are politically “stomach-able” (ex: anti tobacco taxes, warning labels and edu PSA’s). That in significant part means people will have to learn for themselves from compelling and compassionate teachers how to access food and what ultimately goes down our collective gullet. Results of changes in purchasing pressures would subsequently change the food delivery and logistics systems. It’s a long shot, but totalitarian control of food will not happen without war and a fate even worse than our current trajectory IMO.

Hi Sullivan Thank you 🙏🏽 Honestly, I am finding that Robert is starting to make more sense lately. I have communicated with him multiple times in the past. He has exaggerated the differences between carbohydrates in the past to a fault IMO. The most important issue is avoiding calorie overload, overall - and if there’s any overall focus it would be on refined carbohydrate sources, whatever their molecular structure (ie 600 excess calories from glucose or fructose, lactose or galactose, etc. It’s not as important as there are 600 cal excess overall) as well as saturated fat. And even more so overall is the concern of a dietary pattern that is of higher risk (high sodium, low intake fiber, high saturated fat, calorie denze and high in beverage calories - whether alcohol sugar or fat). Re carbs - your question focus - and my opinion, this article I wrote may be of interest:www.truehealthinitiative.org/news/carbohydrate-insulin-model-of-weight-gain/

Interesting. So I’m right and mostly wrong simultaneously? Please note where I said “calories in calories out”. You won’t find it, because I never said it. And of course it’s an interplay of genetics and environment. But it’s our CRRAHP food environment that has changed FAR more than our genetic make up. Not sure what your credentials and clinical experience are. But with all due respect, I doubt you’ve worked with thousands of metabolic patients or built multidisciplinary lifestyle intervention programs. Though you’ve clearly read up and have some grasps. Bravo. Here’s some food for thought. www.truehealthinitiative.org/news/carbohydrate-insulin-model-of-weight-gain/

@@DrTomMD The title of the video is polarizing. It could have been, “ MHE continues the semaglutide story where 60M stopped” or “Genetics isn’t the only story” etc… 60 minutes never criticized diet soda. It was mentioned as a counter point for rebuttal. And ED drugs weren’t demeaned by 60 Minutes. An insurance co put them in a vanity drug category. The story wasn’t about solving obesity or life after Wegovy, it was about what semaglutide is and how it can be used to treat obesity. You say obesity is about environment (19:15). I say obesity is a result of our old genetics or epigenetics in a new environment. Humans have faced starvation and feast or famine way, way, way longer than the food abundant environment we have lived in for (you pick the number) 100 years. Probably only 50. As an expert in the field (and an understanding on the topic better than anyone posting here, probably), I’d think you would know the dangers of fat shaming and oversimplifications like calories in, calories out (never said you said that). The public comments (this post and beyond) on semaglutide trend more in the hostile domain. My favorite was “Just put the fork down, fatty” (not this post, don’t think). Is the obesity rise nearing it highest point or still increasing? Maybe semaglutide stops the rise so that broccoli and cabbage can take over in the long game. Oh, and I did finish the video and was surprised to hear you say you’ve prescribed this drug plenty. So, like in most things, there is no definitive position or solution that works for everyone and everything.

Reaching for an injection is better than reaching for an extra piece of cake? Christ, that’s quite a view.

@@DSPsWifesBf Thanks for proving my point. You took an isolated comment and ignored the rest of my position. So I’ll double down. If a monthly injection helps a person avoid sugary foods and extra calories then it’s merit should be considered for the individual. And please don’t dismiss millions of people and say it’s all about choices and control and lack of will power. Christ, that injection’s quite a tool for helping people regain control and make improvements.

@@ale7564 take all the Ozempic you want. Your body.

Absolutely true. That’s where a good coach can foster a mind flame and why Mind Matters (which includes mindset, mindfulness and mental health) is the top of the 5 keys in the Flex5 Lifestyle (dpm.drtomrifai.com).

It enhances pancreatic response to glucose rather than turn on insulin secretion chronically like sulfonylureas, which do cause more rapid beta cell burnout. While I am not “against” it being approved for children, I think it is pathetic that we even have to be at this point as we’re not willing to address the true cause: which is our unbelievably CRRAHP (calorie rich, refined and highly processed) “food” and beverage environments. Thank you for your comment and questions🙏🏽

Not sure what you base this belief on but it’s not true for all. It largely depends on whether the drugs are used as a stand alone (suboptimal) or simply as a support for a comprehensive lifestyle change program: eg DPM.DrTomRifai.com Must wean off carefully. Metformin is a good bridge. Tx for comment.

On Wegovy. I don’t have any cravings. I’m not hungry. I’m eating to live instead of living to eat. This must be what normal,people feel like

@@MarylandMermaid pretty much an appetite suppressant 🤷🏽‍♂️

One issue with appetite suppressants is if you’re not taking them your appetite goes right back up or even increases. I’d be wary of any appetite suppressant. Stimulants (diet pills) used to be prescribed as appetite suppressants which I’m sure caused far more harm than good.

Tell that to Noom and WW!🤣

Thank you for your excellent comment, Tara! I used to use the acronym CRAP for “calorie rich and processed“. Then I was given some great insight by professor Barbara Rolls of Penn State University. The issue she said wasn’t so much processing as the refinement of food. If processing is an issue at all, it would be mostly under circumstances where it was highly processed. As such CRRAHP - calorie rich, refined and highly processed - was born (and trademarked! :) Thank you so much for following this channel! I promise to post more videos progressively as the year goes on

@Christian Toth thank you so much for your kind comment! But I respectfully disagree that a small amount of CRRAHP food while maintaining a healthy environment at home, work is the issue. As you may have heard “the dose makes the poison“. Expecting someone, or certainly most, to have zero tolerance, while being drowned in CRRAHP is a recipe for deprivation psychology. When the inevitable, or certainly almost inevitable, happens they then feel guilty if counsel to have “zero tolerance“ and the lie to their practitioner/coach (whom they would understandably perceive as judgmental) and the vicious cycle of guilt and binging continues. I have seen this thousands of times with over 20,000 hours of clinical experience. I’m not sure what informs your perspective but I must accept the reality in which I have derived mine.

It’s not expensive everywhere in the world. It’s expensive in the USA.

@@michaelramage73point being, people shouldn’t be taught that most obesity can’t be handled so eh exercise, nutrition, and possibly therapy.