Discussion between two doctors on metabolic health
1. Background and Experience of Dr. Andrew Koutnik
Dr. Andrew Koutnik is a researcher with a PhD in molecular pharmacology and physiology. He holds a degree in exercise physiology and a PhD in biomedical sciences. His research experience spans nearly two decades and includes collaborations with organizations such as the United States Special Operations Command, NASA (with the astronaut corps), and work on chronic metabolic diseases (type 1 and type 2 diabetes, prediabetes, obesity).
His personal journey began with a diagnosis of obesity at the age of 10 or 11, which he struggled with for about half a decade. A dietary restriction helped him overcome obesity, but the biggest change in his life was the diagnosis of type 1 diabetes (T1D) a year later, at around 16 to 17 years old.
2. The Relationship between Obesity and Type 1 Diabetes (T1D)
Although T1D was traditionally not considered a lifestyle-related disease, Dr. Koutnik now recognizes that his period of obesity absolutely increased his risk for T1D.
Data show that obesity dramatically increases the risk (by 300% to 400%) for autoimmune diseases, including T1D. Obesity is estimated to explain up to 25% of all new T1D cases today.
In collaboration with the National Institutes of Health (NIH), Harvard Medical School and Boston Children’s Hospital, a study is underway on how ketogenic diets can extend the “honeymoon period” in T1D. There are reports that implementing this diet immediately after diagnosis may reverse the progression of the disease and, in some cases, increase C-peptide, which is the definitive measurement for reversing an autoimmune attack.
3. Diet vs. Drugs and Technology
Dr. Koutnik emphasizes that while drugs have played a very important role (especially insulin, without which he would not be alive today), the increased use of new drugs and technologies over the last decade has not dramatically improved glycemic control in patients with T1D, while obesity rates in T1D have risen.
In contrast, dietary change is a low-cost, high-effectiveness intervention.
Historical Standard of Care: Low-carbohydrate and ketogenic diets were the standard of care for preventing and reversing diabetes, as well as obesity, for more than 200 years (since 1796). Before the invention of insulin, very low-carbohydrate diets extended the lives of children with T1D for many months or even several years. Physicians such as Joslin and Allen allowed patients to consume fats and proteins, which had little or no effect on glucose, instead of adding “fuel to the fire” of diabetes with carbohydrates.
Current Recognition: The American Diabetes Association (ADA) has stated that the ketogenic or very low-carbohydrate diet is the most well-documented dietary approach for improving several of the most important risk factors in type 2 diabetes (T2D). In T1D, this approach is the most powerful and reliable way to improve the number one risk factor, which is glycemic control.
4. The Challenge of Medical Guidelines and Funding
The current recommendations for glycemic control in T1D (keeping A1C between 6.5 and 7) provide false reassurance to parents. This is mainly due to fear of hypoglycemic episodes if insulin is managed aggressively. However, maintaining an elevated A1C leads to devastating complications (heart attack, neuropathy, vision or kidney problems) already by the age of 30. Changes in the body of a child with T1D are very rapid: it takes about three years for early signs of atherosclerotic progression to appear, and about four years for anatomical changes in the brain and neurodevelopmental decline to occur.
Dr. Koutnik explains why dietary interventions are not the primary point of reference in guidelines:
Economic Power: To change guidelines (e.g., those of the ADA), millions of dollars are required to conduct large randomized controlled trials (RCTs). Pharmaceutical companies have both the resources and the incentive to fund such studies, whereas no nutrition company is equally focused or capable of doing so.
Bias: There is often bias within NIH review panels against dietary interventions. For example, funding for one of Dr. Koutnik’s ketogenic diet studies, worth 3 million dollars, became possible only when the study was framed as research into the problems of the diet, rather than as a means to revolutionize patient outcomes.
5. Lack of Guidance and Improvised Management
Despite the fact that the ADA recognizes the low-carbohydrate diet as the most well-documented for T2D, there are no guidelines for health professionals on how to implement a ketogenic diet (or a reduction of therapeutic carbohydrates) in T1D.
As a result, patients are adopting low-carbohydrate diets at extremely high rates on their own, as it is one of the most frequently used diets in T1D, despite the lack of professional guidance.
6. The Importance of C-Peptide and Fasting Insulin
Dr. Koutnik points out that diabetes diagnosis usually focuses only on glucose. However, C-peptide is a cheap, powerful marker of insulin production.
In T1D there is an insulin deficiency, whereas in T2D there is an excess (resistance). C-peptide is a precursor of insulin. Low C-peptide levels indicate T1D (or very advanced T2D).
C-peptide is produced in a 1:1 ratio with insulin. Measuring it can help in diagnosis, especially in cases where T1D is misdiagnosed as T2D for years, causing substantial damage.
While the GAD antibody diagnoses about 65% of T1D patients, C-peptide could detect nearly 100%.
Measuring fasting insulin can also predict the risk of developing T2D in people with metabolic syndrome, even if their A1C is normal.
7. Diagnosing Type 2 Diabetes as a Toxicity Syndrome
Dr. Berry describes T2D as a “carbohydrate toxicity syndrome” or “carbohydrate overdose syndrome.” From this perspective, the solution is simple: reducing carbohydrate intake leads to reversal of T2D markers (such as A1C) to non-diabetic levels.
Dr. Koutnik agrees that reducing carbohydrates is the most powerful intervention both for preventing and reversing T2D.
8. Challenges in the Health System and the Role of Patients
The structure of the U.S. health-care system is based on volume-based reimbursement, forcing physicians to see many patients in a short period of time (for example, 15-minute visits with a timer). This makes it impossible to provide optimal medical care and reverse chronic conditions such as T2D.
Patients must be informed and practice self-advocacy in the clinic. Scientific data show that patients who ask difficult or “annoying” questions achieve better outcomes.
The Role of Health Coaches: Specialized health coaches are expected to play an increasing role in the future, accompanying patients to appointments or providing remote support. This is essential because many older patients have been taught not to question medical authority.
Lack of Lifestyle Expertise: Medical schools teach disease management primarily through pharmaceutical and technological interventions, with lifestyle receiving, at best, a brief mention. Most dietitians also feel unprepared or unsupported by their teams to recommend interventions such as reducing therapeutic carbohydrates.
9. The U.S. Dietary Guidelines
The official dietary guidelines of the U.S. government (which influence food served in schools, prisons and the military) must address the average American, 90% of whom are metabolically ill.
Dr. Koutnik expresses both hope and concern that the 2025 guidelines will allow equal access to all forms of nutrition that can improve health, including low-carbohydrate diets. This requires removing certain limits and regulations (such as the Recommended Dietary Allowances, RDAs, for saturated fat) that currently prevent dietary flexibility.
The current guidelines have created problems: school meals, for example, often resemble convenience-store foods, allowing a high amount of sugar.
10. Final Message: Thrive, Not Just Survive
Dr. Koutnik urges patients with chronic metabolic diseases to demand to thrive with their condition, rather than merely accept surviving.
He notes that he himself refused to accept the predicted complications of T1D. After 20 years with the disease, his cardiovascular health is better than that of many people without diabetes.
Finally, he warns that an “apocalypse” is coming for traditional sports nutrition guidelines. Many recommendations push athletes to consume excessive amounts of carbohydrates (over 1,000 grams per day), sacrificing health on the altar of performance. Research conducted by his team, examining more than 100 years of data, is expected to overturn this way of thinking.
Undoubtedly, the discussion between Dr. Ken Berry and Dr. Andrew Koutnik offers a deep analysis of the metabolic epidemic, the management of diabetes (type 1 and type 2), and the challenges faced by the modern health-care system, with a strong emphasis on the role of nutrition.
Note: Dr. Koutnik can be found at andrewkoutnik.com and is active on Instagram, X and YouTube (search for “Andrew Koutnik PhD” or “AKOUTNIK”).
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