What does that mean, cellular energy levels? Yeah, so inside the cell,

we have this energy currency called ATP. And in order to metabolize fructose, we end up using all of that within the cell. And you can get to this point where it's almost a stressor on the cell in order to metabolize it. And that's maybe one of the reasons why fructose is an issue for some people. And it's certainly high amounts of fructose consumption and or sugar which is 50% fructose can increase the risk of things like fatty liver um fatty liver disease which is increasingly common although the other side of that is that there are potentially other nutritional deficiencies that are affecting the your risk of that um as well particularly choline which is important for for packaging uh fat out of the liver and if you don't have enough of that then the liver the liver can accumulate fat with with high amounts of sugar but in reality when I think about individual food components and there are several other things that we could talk about that are controversial in addition to sugar but it's really the context of the sugar that we're currently consuming and like you said the quantities of it i like to think that the majority of our diet should be minimally processed and nutrient-dense foods so they you know support the function of our bodies and other than just being a source of energy there's nothing else in sugar that's really beneficial. So if you're consuming a large proportion of calories from sugar, you're not consuming foods that have nutrients in that are then important for doing everything else. And that's really the same with all ultra-processed foods or highly processed packaged foods. They're nutrient poor calorie dense they negatively affect our ability to understand our hunger and satiety signals and we know that we over consume them because they're hyper palatable we eat much more of them we would have something else that's less processed and people get into the issue of what processing actually is or what processing means and so like the definition of ultra processed foods basically means that it's highly refined and they've usually added additives fillers and things like that in order to keep it shelf stable so you can just like stick it in a packet and it can stay there for for months or years on end yes yeah um and so i don't particularly ever focus on sugar individually because it would be very easy to remove sugar, but you just replace it with some other highly processed food that is going to have the same effects because it's outcompeting more nutritious foods. So in general, I would think about the entire dietary pattern because there's no evidence that some sugar is detrimental to our health, really. What

do you mean by that? Because some people are going to go, what do you mean? Wait a minute, I thought sugar was bad for me. So when you say there's no evidence that some sugar is detrimental, just expand

on that a little bit. Yeah, so in general, if you are eating within your caloric requirements and you're otherwise healthy, then consuming some sugar doesn't really seem to have a negative effect. Right. It's a source of energy. There's no real reason to assume that, you know, a large part of our metabolism runs on glucose. When we metabolize fructose, which is the other half of sugar, it gets turned into glucose, it gets used as an energy source. So if you're in otherwise good health, and you're eating, you're consuming enough of the nutrients in general from your diet, there's no reason why sugar should be detrimental. It's when it then becomes the major source of energy and you're not getting all these other things that we might need from our diets. So usually when people cut out sugar, what they've done is they've dramatically improved the quality of their diet because they're eating other things now. So I'm not exonerating sugar in itself, but I think that focusing purely on that doesn't really tell us the greater story of what's the overall quality of your diet and what's the overall sort of balance of nutrients you're taking in and fiber and other things. And

I think, again, it's that point of context and what else going on in your life kind of influences whether sugar's a problem for you or not. And it's interesting, you know, Mark Sisson, the, would you call him a paleo guy or, you know, primal, primal, yes. And Mark, for people who don't know Mark, I think he's just gone 70 years old. He's in fantastic shape. Fantastic shape. Eats a very primal, ancestral way of eating for a number of years. He's been talking about it, promoting it. But if he ever tweets about the fact that he will, I think he enjoys sugar in his coffee each morning, like one spoon of sugar. Oh my God, people go nuts on it. And I would imagine that that really speaks to exactly what you're saying, that 90% of his diet is really good. Whole foods, nutrient dense, he's fit and active, he moves his body every day, he looks after himself. In that context, one small spoon of sugar in a coffee each day probably not a issue right yeah in that context someone else who let's say has a highly processed food diets eating to excess not because they're lazy or gluttonous because they struggle we all struggle right in that context they may find that sugar or the amount of sugar in their diet is problematic is that is that another way we can look at this yeah

i think so and and some of it can also be you know there's a big debate in the scientific world as to whether sugar is addictive or not and you'll have people who have some uh some evidence on both sides and

so that's like most things like

most things and i would say that i'm i'm not really sure i can in some people who consistently overeat they do you know get a large activation of reward centers in the brain when they eat sweet things whether that's the same as addiction is very difficult to really pass out although some people certainly have very problematic eating behaviors and that's its own psychological disorder that requires specialist intervention but you're right that when we think about how we respond to certain foods part of the problem and with the processing is that and so when you're taking refined sugar um you've extracted it from sugar cane or sugar beets you've taken it or you know we're as a species we've very regularly have consumed sugar either from honey or from fruit right and nobody would tell you that eating an apple is going to be bad for you even though you know there's a few grams of sugar in there some people would these days actually but generally I think we can say is, I'm confident saying that's not correct. But when you process foods with industrial modern methods, you divest the calories from their context. And so... Divest is a big word, Tommy. Sorry, what's another word for that? You separate them out, right? So say we're historically, evolutionarily, if you did eat some fruit, you eat some sugar. And it comes in this context of water and fiber and all these other things. And the body expects some context for that sugar in terms of, and then how it affects your physiology and your hunger signals and stuff like that afterwards. When we process those foods and strip them out, the response that you get physiologically is no longer the same from the same amount of that food. So they've done this with various grains, right? If you take a whole grain, you could cook and eat a handful of pearl barley, say. You know, it's minimally processed. That's how it looked on the stem. It's still got all the fiber, all the context. And then you look at how that affects your blood sugar. It probably has quite a small effect on your blood sugar. If you then take that same thing and you cook it and you grind it, or you grind it and you cook it and you turn it into a paste or you turn it into bread, it has a much bigger effect on your blood sugar. It's exactly the same thing. But what you've done is you've changed the context of the food and then that affects how your body responds to it. you're no longer getting macronutrients like things like carbs and fats or protein in the context that our bodies are used to getting them and so that's where it starts to become problematic so when when you create processed foods you might add sugar to something that doesn't normally have sugar in it and then that makes you want to eat more of it. Because you've started to create, and that's the idea of creating high palatable foods. So even savory foods have some sugar in, because you start to activate different receptors. You start to then drive a greater likelihood of overeating them. So that's where it starts to become problematic.

So let's say the population we were looking at was all healthy. Everyone was of a, you know, healthy weight in inverted commas. They were metabolically healthy. Then in that context, of course, which isn't the context we're living in today, certainly not in most countries around the world these days. If that was the situation, then sugar here or there in our tea or coffee or whatever, you know, a sweet treat if you want. And I'm not convinced I love the word treat, but I think people know what we mean when we say that, you know, maybe once a week or once a fortnight or whatever, you know, or whatever you choose to do may be okay. How does that though sit in the context of what we have today? So we know in the US, example, what is it now? Is it 90% of US adults may have some degree of metabolic

dysfunction? And actually the UK and Europe and most of the world are catching up. So we can't even single out the US anymore. So if we're saying the bulk of the adult population, and it's not just

adults, I know, but the bulk of the population, unfortunately these days have a degree of metabolic dysfunction. So the way they're processing energy in the body is not as efficient as it could be. And that's leading to an increased risk of all kinds of diseases. In that context, is sugar now becoming even more problematic? It's

absolutely contributing due to the way that we're using it. But again, I think it comes down to the entire context of the diet. Because you could certainly get to a point where, say we dramatically reduce sugar in foods. If that then comes with a parallel decrease in overall caloric intake say there will absolutely be benefit but when other people are in charge of creating these foods you know these ultra processed foods those sugar calories are just going to be replaced by something else and you're going to you're going to overeat it just as much. And it's not really going to change anything. So I think that if by reducing your sugar intake, you decrease your overall caloric intake and you improve the overall quality of your diet, that's absolutely going to be beneficial. But if that doesn't happen, and this often happens with the way that we engineer foods nowadays, is just it'll be replaced by something else and it may not make the same difference. So I think it really depends on how that gets enacted. If people, so if you say that I want to reduce my, I'm going to focus on sugar and you focus on reducing sugar intake. And then with that comes, you know, you're not eating cakes or biscuits. And with that, you've dramatically both decreased your overall energy intake and improved your diet quality. That's going to come with health benefits. But if you then say, well, I'm not going to have cake, but I'm going to have, you know, an extra serving of fries instead. Right. There's no sugar in that. But I'm not convinced you're not going to get any healthier. So it really depends on how those changes then what the knock-on effect is. When

we think about sugar, do we need to think beyond just actual table sugar that we might put in stuff or might be added to biscuits and cakes and pastries? do we also need to be thinking, in your view, about blood sugar spikes? So for example, one teaspoon of sugar in, let's say, a hot drink, that probably is not going to have as detrimental an impact or as significant an impact, I should say, on our blood sugar than let's say a modern healthy cereal or a cereal that's marketed as healthy. When we know that you have a bowl of those, you can have the equivalent of far more than just one spoon of sugar in. So I think sometimes when we think of sugar, we're not really, and maybe it's the way we communicate as healthcare professionals sometimes, it's not just sugar, is it? It's also foods that are turned to sugar in your

blood. So any or the vast majority of carbohydrates will get converted to either R or get converted into glucose, which then will at least temporarily increase your blood sugar in response. And I think in general, that can be normal, right? We don't want to pathologize, that's another fancy word, we don't want to like create a disease out of spikes in blood sugar necessarily. Of course, there's lots of evidence that suggests that having better control of your blood sugar is associated with better health outcomes. Particularly if people go into, say, pre-diabetes or type 2 diabetes, that's associated with a whole host of long-term chronic health conditions and earlier mortality. So if you can have better blood sugar control, that in general is associated with better health, particularly in those populations if you're somebody who's otherwise very healthy and very active and you once in a while eat something that causes a big big spike in your blood sugar i'm not convinced that's going to have a big impact right it's all about the context like you talked about earlier but you're right that anything that we eat that has carbohydrates in will will increase your blood sugar to some degree. And there's some evidence to suggest that if you can make that spike lower, and you can do that either by the timing of your foods, I know you've had episodes on this previously, maybe eating protein with your foods, there are other things you can do to decrease the size of that blood sugar spike. And for some people that may be beneficial. The problem is that it's really difficult to predict what foods will do that. 10 years ago, you would have talked about the glycemic index, right? So this is a food, it has a high glycemic index. That means when you eat it, you're going to get a big spike in blood sugar what we've learned in the last five years is that that just doesn't hold from person to person where you can have two people eat the identical foods and one person will get a big blood sugar spike and the other person won't get any spike at all and then there was there's a recent study it came out it's um it's a pre-print so it's not formally published yet it will come out as soon as uh by Kevin Hall, who's done all these very complex metabolic ward studies in the US. And they had these trials where they gave people a fixed menu, and they had a plant-based one, they had a low-fat one, a low-carb one. And the menu would cycle over a couple of weeks. So they would have, and then some of the people in these trials wore continuous glucose monitors. And then because the menu rotated, they would get a blood sugar response to the same meal in the same person, but a week or two apart. And what they found was that eating the same meal in the same person resulted in completely different blood sugar responses from one week to the next which just tells us that we don't we have like right now we cannot predict what foods will spike our blood sugar so even if we we have our own i see you're wearing a continuous glucose monitor, that you have to test something out a lot again and again in yourself to see an effect. And even then there's going to be a lot of variability. So then is that even meaningful or feasible for some people? It becomes really difficult. So I think managing blood sugar is obviously incredibly important but right now it's just really tricky to navigate and there's uh you know tim specter's done some recent studies uh where they show that a whole bunch of things affect how you respond so it's how do you sleep what meal of the day is it like what's your genetics like have you exercised recently there's a whole bunch of things that affect how we respond to foods. And even in the same person, the same meal has different effects from one week to the next. But I think that speaks

to what you said, maybe when we were talking about alcohol or caffeine, that in a biological system, it's very rarely just one thing, right? Because you're assuming that everything else in that system is identical when it isn't. And we're not the same person day to day. Anyone who has worn a continuous sugar monitor, and I think for some people that can be tricky to figure out, well, what does this actually mean for me? I feel I'm quite in tune with my body and I guess it's what I do. And I think about this and sort of pay attention a lot and I certainly found for me that you can see correlations quite well where you know depending on if you haven't slept well yeah your sugar's higher and you the same meal can give you a bigger response or if I feel high levels of stress I guess with everything we're talking about, we've done alcohol, caffeine, sugar, but on ultra-processed food so far as well, are we not more and more moving into an N equals one era whereby we can use science to give us good starting points and ideas, but ultimately we're going to have to test these things out on ourselves and go, well, is this working for me? I think so.

And that's, you know, even going back, say 50 years, this is in a slightly different arena, but looking at elimination diets were once the gold standard for people with certain autoimmune conditions before we invented monoclonal antibodies for these things. And the only way to know if they worked was to change your diet and see how the patient responded. And you would do that individually. And I think that's where we really are at this point. The problem is that, so say, if we go back to blood sugar or we stay on blood sugar, I'm not convinced that the data is necessarily helpful for people. So say, I don't generally recommend that people go out and get a blood sugar monitor um and one of the reasons is that it becomes and i've seen this several times when working with people it becomes incredibly stressful so i'm gonna eat a piece of cake i know that cake is gonna spike my blood sugar i'm now stressed about the blood sugar spike that i'm gonna see because of the cake that I'm eating. And we've had people who've come back and just, we didn't really appreciate how much stress, like the idea of eating and how that was going to affect the data that they see was incredibly stressful to them. So like, is that, at what point does that become harmful? And there are actually studies that show that the expectation of a blood sugar spike drives a bigger blood sugar spike. So there was a study by Ellen Langer at Harvard where they took diabetics and they gave them a milkshake and they showed them how much sugar was in this milkshake. It was a high sugar milkshake and they saw a big blood sugar spike. And then later on they came back and they gave them a different milkshake. It was a low sugar milkshake and they showed them that and they had a lower blood sugar spike. It was the same milkshake both times, but they had a bigger blood sugar spike when they thought that it had more sugar in it.

Biology and psychology. Yeah, biology

and psychology coming together. So I think that, yes, the N equals one experiment is really important. But I think that rather than being hyper-focused on this one thing, which is blood sugar, can you move yourself closer to a less processed diet, right? Increased vegetable consumption. Do I make vegetables a bigger part of your plate or start with a bigger portion of protein on your plate, right? That's going to come with, both of those are going to come with a whole bunch of nutrients and these other things. And then maybe decrease the portion of whatever it is, whatever is it refined carbohydrates or something. So I think that overall shifting your dietary pattern is much more important. And that doesn't need necessarily, unless are different foods that you enjoy, as much N equals one experimentation. So I think we're at a point where you can, particularly with diet, you can give pretty good advice that's going to work for a lot of people. And they don't need fancy tools and they don't need fancy data. And they can still make a big impact on their health.

Yeah, I appreciate your perspective on that. And I've always had a real caution with trackers. I guess the argument you're making around CGMs, continuous glucose monitors, I guess we could also make about, let's say, scales, for example, and weights. And I kind of feel a lot of this becomes personality dependent, whereby for some people, scales and their weight becomes incredibly obsessive and becomes problematic. And then for others, it's like, yeah, they can check once a week and yeah, I'm going in the right direction. I've mentioned, I think before with you that I saw the same thing with blood pressure monitors, which aren't like modern tech necessarily, but for half the patients, it was great. For the other half, it was anxiety inducing. I guess where I see CGMs as being different is I kind of feel that they give a real, and I totally agree, they can be overdone. I think if you've got a history of eating disorders, you've got to be very cautious, probably not the right approach for you. But in the context of a population, as we say, maybe 60, 70% of the UK, maybe 90% in the US of the population having a degree of metabolic dysfunction. I think in that context, I personally believe we have to be open to tools that are going to help people because we've been asking people to make these choices for years. And I feel that we're still struggling. And a lot of that is because of our food environment, I know. But I don't think I've seen a better tool, Tommy, in over two decades of practice now where I don't think I've seen a better tool that helps people start to change their diet in a meaningful way than a CGM. I don't think everyone needs them. But I would say from my own experience with people and also myself, I've found them also to be very, very helpful. So that would be what I would say in response. So I think we have maybe a slightly different perspective on this, which is okay as well. Yeah, absolutely. And there are studies in type 2 diabetics that, and again,

early small studies suggesting that having a CGM improves their adherence to, say, a dietary intervention or dietary recommendation. So absolutely, sometimes that can give people some accountability and help drive some behavior change.