Mendosa Interview with Dr. Bethea

Interview with Morrison C. Bethea, M.D.

This interview with Morrison C. Bethea, M.D., one of the authors of Sugar Busters!, was conducted by telephone on May 20, 1998, with Rick Mendosa, a freelance writer specializing in diabetes who was writing an article about Sugar Busters! for Diabetes Interview magazine. That article was published in the September 1998 issue.

MB: If one steps back and looks at the concepts behind Sugar Busters!, if we break it down to the medical basis, to the biochemical and physiological basis, if we get one to eat in the fashion as you go through the day with lower insulin levels and hopefully higher glucagon levels, so that you tend to burn more fat and store less fat. Now, if you could have pecan pie and Häagen-Dazs ice cream and achieve those goals, we would recommend it. But I here to tell you that you cannot.

And so we think that we have identified or brought to light a very important concept. We haven’t come up with any new science or any new physiology or biochemistry. It’s all there. I think that if one looks at the nutritional forest, to use that as an analogy, it has four trees in it. There is the carbohydrate tree, there is a protein tree, there is a fat tree, and there is a fiber tree.

We have been so consumed with fat that we are not seeing the forest because of that one tree. And as you know, Americans have been doing a pretty good job in reducing fat intake. Since 1970 overall fat consumption has dropped about 16 percent. But unfortunately obesity has gone up significantly over the last 20 years in the United States and so has diabetes, so we are missing something. And the only thing that we are saying in Sugar Busters! is look, we applaud what many of you have done to reduce your fat intake, especially saturated fat and you need to continue doing that. But wait a minute. That’s not enough. We need to look at sugar, because the average American is consuming an excessive amount of refined sugar and processed grain products and they may not even know in many instances or are deleterious to them and they are not aware of this.

RM: And sugar goes by so many names too.

MB: Right. We have reduced fat and cholesterol in food products and have often substituted refined sugar products, like Snackwell or like many of the quote sports drinks and so forth that are full of refined sugar. So we doing ourselves a disservice by consuming the amount of sugar in the processed or refined form that we are consuming. So the only thing that we are saying is that we are not a no-sugar diet. We may not be a low-sugar diet. We will be a low-sugar diet for a lot of people because we want them to address that unnecessary excessive amount of refined sugar they eat. More importantly, we are a commitment to making correct carbohydrate choices. We want you to take your sugar in forms that are whole grain or high-fiber carbohydrates, because that fiber is going to modulate or slow down digestion, absorption, and elevate the blood sugar concomitantly with the elevation of insulin levels and then we achieve what we are trying to do, which is to get you to go through the day with lower insulin levels.

We also want you not to go to an extreme with fat, so that you don’t eat any meat, because then you lose the source of glucogon, which helps you burn fat. So we are saying, yeah, we want you to be careful about food, but not to the exclusion of lean and trim meats, which are good sources of protein. Basically, that’s it. It’s not anything really revolutionary. It’s not anything that we have invented or come up with. It’s not any science. If you could go back to Arthur C. Guyton’s textbook of Medical Physiology -- that’s been the standard textbook of medical physiology in all medical schools and training programs for many decades -- if you read the section on carbohydrate metabolism, if you read on metabolic rates of temperature that deal with all the metabolism that deal with the breakdown of carbohydrates, then you see very quickly that most of the fat on our body does not come from fat. It comes from sugar. It’s all there. It’s been there. We read it in medical school. Lot of times we forget it by the time we get out in practice. What we’ve tried to do is go back and pull this data up and say we need to realize what we are eating and what happens to it after we are eating it, make adjustments so that together with being careful about fat we do some other things that help our weight, help us if we happen to have a disease like diabetes, help us maybe not become pre-diabetic, help us with our lipid chemistry.

RM: You are a cardiothoracic surgeon?

MB: That is correct. Heart and blood vessel surgeon.

RM: Since you are the heart specialist on this team -- it’s neat that you have such a team of authors -- comment please on fat. I know you don’t talk about counting calories or weighing or measuring, but do you have any general guidance on saturated fat and other types?

MB: If you look at the proportion or what would make up percentagewise you should eat over a 24-hour period, probably less than 30 percent should be fat.

RM: 30 percent of calories from fat?

MB: Not calories. I am going to address calories in a minute. Of what you eat. 30 percent or less of the mass of what you eat should be fat. I say a little less than 30 percent. Of that, 10 percent or less should be saturated. About 30 percent protein and about 40 or a little higher carbohydrates.

RM: So this is certainly not a non-carbohydrate diet. Not like Atkins.

MB: No, our systems are fueled by carbohydrates. That’s how our cells work.

RM: You will go into ketoacidosis if you don’t...

MB: Absolutely. You get ketoacidotic. Your kidneys, heart, muscles do not function properly in an acidotic state. You can lose weight. But it’s not sustainable and consistent with good health. Like a diabetic. [A few words missed.] That’s the problem. You don’t have insulin to get the sugar in the cells. The cells go to anaerobic glycolysis and you come up with ketone bodies. You get acidotic. You don’t do well. So you’ve got to have carbohydrates.

What we are saying is, wait a minute. Let’s look at the form of that carbohydrates. Let’s eat less insulin-producing carbohydrates.

Now, you mentioned calories. Calories is a term that came about in the 1840s. A calorie is a unit of heat necessary to raise the temperature of one kilogram of water one degree centigrade. To be quite specific, between 15 and 50 degrees. It doesn’t have any weight to it. It is just a characteristic. We think that you would be better served, certainly with carbohydrates in looking at the glycemic index. Picking those foods that are certainly moderate or low-glycemic carbohydrates. Not picking those carbohydrates that are high glycemic, i.e. digested quickly, absorbed quickly, raises the blood sugar quickly, and subsequently the insulin levels. So the glycemic index of a carbohydrate is a better characteristic of that food to look at than the calories. The calories are pretty consistent. There are 4 calories per gram of carbohydrates, 9 for fat, and 4 for protein, and 7 for alcohol.

We mention that it is not necessary to weigh, count, or measure, because people are not going to be compliant with that. If you go into a restaurant and weigh, count, or measure, they will get ready to give you a heave. So people are not going to do that. And I’ve looked as some of these diabetic exchange programs, and I can’t figure them out sometimes! The general public is not going to do it. So, what we try to do is to make this lifestyle, a dietary nutritional lifestyle, it’s more than a diet, it’s a lifestyle because it is going to alter people’s nutritional habits, so it involves exercise, and we think that’s important.

RM: Now, one of you doesn’t exercise. Who is that?

MB: That’s Leighton Steward.

What we do want you to do is to look at portion size. We are giving you a nice way to figure this out. Do you know what a dinner plate looks like? It’s got a flat bottom and flared sides. Your meat and two or three vegetables ought to fit neatly on the bottom of the plate. It shouldn’t be stacked. It shouldn’t be up on the sides. It shouldn’t fall off the side. And when you fill it up correctly one time, you shouldn’t go back and fill it up again. That’s self-explanatory! You know, and every person out there, whether they’ve got a seventh grade education or a Ph.D. or an M.D. degree or a law degree or whatever, they know what a plate proportionately filled up ought to look like. But I was a chemistry major in college and I defy myself to try to figure out how many grams of this or that or how many calories, because foods are combinations of different things. And you can’t do it. So instead of having dietary guidelines or recommendations that people can’t follow, let’s put something out there that they can follow.

And one thing that is really distressing in regard to diabetics, and I know a lot of diabetics who have gone to their doctor, they’re gaining weight, their blood sugar is out of control, and the doctor says, "Gee, you’re not following your diet." Well, you and I both know that many diabetics, if not most, are very conscientious and try to do the right thing. The problem is that they get the wrong advice. They have been told to eat a lot of pasta and a lot of baked potatoes and a lot of stuff like that, which at the end of the day is converted to fat, because we don’t store sugar in any appreciable amount. Then they go back to the doctor. The doctor says you are gaining weight. You need to quit eating as much fat, you need to eat only starches. They do that and they go back and they’ve gained more weight. It’s not the diabetics fault, because the ones who require insulin or insulin resistant as far as getting sugar in a cell, but they are not insulin resistant when it comes to other actions of insulin such as progressively converting all unused sugar to fat, such as blocking the mobilization and burning of fat [illegible] and such as the production of cholesterol by the liver. All these things insulin potentiates or facilitates and that’s the downside to continuing to give them insulin and let them eat foods that have high glycemic indexes. People would be better served, picking their carbohydrates, if they looked at the glycemic index rather than trying to mess around with calories.

RM: The glycemic index is something that I have favored for years and I have Web pages about it. But it is not at all accepted in the United States!

MB: It’s a shame. And we hope we can change that. One reason is that it is expensive to get accurate glycemic indexes on foods. It’s not cheap to do.

RM: It costs over $1,000 per test according to Jennie Brand Miller.

MB: Right.

RM: And I know that Dr. Wolever in Canada, with whom I have been in regular e-mail contact, tells me that he has been trying to work something out where glycemic indexes would be shown on packaged foods. Have you been in touch with him?

MB: I have not. I know Brand Miller. She is Australian?

RM: That’s correct.

MB: We went to great lengths to get her book. Actually, I’ll tell you a little aside. I am a medical consultant to Freeport-McMoRan. Freeport has the largest copper and gold mine in Indonesia. That is another problem right now as you can gather from the papers. But what I did is that we have an office is Cairns, Australia. And our office got the book, The G.I. Factor, and in fact we have referenced that book in our book. I got in touch with Dr. Miller and got permission to use one of her graphs and also to reference her.

Everything that we’ve done, all of the science, all of the medical-related graphs and so forth I can tell you are 100 percent accurate. We went to the best sources and talked to them and got permission and reread their data and looked at their references to make sure that what we have in there is correct.

RM: Who is the glycemic index expert on your team, which doctor?

MB: Louie Balart would be the best one.

RM: The reason why I ask, and I want to talk to him, because there are about six different foods where there are differences.

MB: Some have different standards. The ones that we have worked with used glucose as 100.

RM: I wrote Jennie Brand Miller telling her where I thought there were some differences...

MB: There are some differences in the way they do foods.

RM: I know how complicated this is.

MB: You take Cheerios that are available in Australia, because we buy Cheerios out of Australia for our project in Indonesia. They are white, they are not a whole-oat Cheerio. However, if you buy Cheerios in the States it is a whole-oat Cheerio. So we kind of push Cheerios a little bit, because even though it appears on her glycemic index to be kind of high, it’s a different Cheerio.

RM: Excellent point. I’m glad you made that.

MB: We are learning. We don’t profess to know hardly anywhere the answers to the questions we ought to know, over the last couple of years we know more than we knew two years ago. I can tell you this: as we have progressed with this, we are seeing now in the medical literature, there is a nice article out of Canada, Després and his group looking at the deleterious effects of high insulin levels in the New England Journal of Medicine, April 1996 [Després, J.P., et al, "Hyperinsulinemia as an independent risk factor for ischemic heart disease," New England Journal of Medicine, 1996 Apr, 334:15, 952-7.] They concluded that high insulin levels is as much of a risk factor for coronary artery disease, arteriosclerosis, as is smoking, hypertension, diabetes, etc. Then in Circulation, January 1996, Dr. Gerald Berenson published a study done over about 20 years looking at a population in a certain community in Louisiana, Bogalusa, the first identifiable abnormality in young adults before the onset of obesity, hypertension, diabetes, or symptomatic cardiovascular disease is a rising insulin level [Bao, W., Srinivasan, S.R., Berenson, G.S., "Persistent elevation of plasma insulin levels is associated with increased cardiovascular risk in children and young adults. The

Bogalusa Heart Study, Circulation, 93(1):54-9 1996 Jan 1.] So, we know that it would be best to try to keep insulin levels as well within the normal range as possible and probably one day now that we can measure insulin levels cheaper the way that they are going to manage a diabetic is not go in and say we want your blood sugar here and throw whatever insulin is necessary to keep it there, they will try to more eloquently manage patients, they are going to try to keep their insulin levels within a certain range and then you are going to control not only the blood sugar, but you are going to eliminate the deleterious effects of high insulin.

RM: Excellent. Who actually wrote the book? Did you divide up the chapters?

MB: All four of us divided up the chapters. I made an outline. I assigned chapters. We all four wrote different chapters and then Leighton Steward and I rewrote everything so it would look as if it was written by one person and not four.

RM: No ghost writer?

MB: No ghost writer. You are looking at the writers. In fact, I’ll tell you a funny story. We finished that book, Leighton and I finished writing it, and after we finished it I told my wife, "You know, we are going to send it to the printer." This was the first book, we self-published it. And she said, "You’ve got to have somebody proofread." "What do you mean, ‘proofread’? Leighton Steward has a master’s in geology, I’ve got an MBS and M.D. degree, we know all about this stuff." My wife said, "Just the same we are going to get the chairman of the English department at the school where my kids go to read it for grammar and punctuation." When we got that back it looked like a Christmas tree. The lady didn’t change the text. She just said, "You need a hyphen here." In one instance she said, "This isn’t a sentence." So anyway, that’s all of the ghost assistance.

RM: Are you familiar with

MB: Yes, I am. I am becoming a little more computer-literate. Saw Andrews, who is the endocrinologist in the group, knows more about computers.

RM: has a "Health, Mind and Body" bestseller list. And Sugar Busters! Right now is number 2 on that list. It was recently number 1 on the Los Angeles Times "Healthy Bestsellers" list. Are you surprised?

MB: No, I’m not. And I will tell you why I am not surprised. The first book we self-published.

RM: How many copies did you sell?

MB: 210,000 as of the middle of February. That’s the frst book. The second book, they have printed and shipped about 300,000. Now, do you know what our marketing budget was for the first book? Zero. The first book we knew would do okay, because our concept is sound. If anybody looked into the scientific validity of it, they would see that it is sound. And secondly, it works. And any time you are promoting a product that you have done simply and understandably and it works, it’s going to be a success. Now, I’m not trying to pat myself on the back, but I will tell you a couple other things we did. If you notice, the print in the book is big. There is pretty good spacing between the lines. When Random House, Ballantine, decided to publish this book for us, they said, "You know, the book stores are going to think that you are trying to rip them off, because the book looks fatter than it is." We said, "No, no, no. You missed the whole point. You don’t know who we are writing to. We are writing it for people like me, who now wear glasses to read. When they get home from work at night we are already tired. We don’t want to squint to see anything. So I am not interested whether somebody thinks the book is padded or big or thin, I have x amount that I want to say and I’ve said it. I want people to be able to read it comfortably. So you leave the print (the type size) and the spacing the same." They said, "Oh, excuse me. We didn’t realize that." And they did [leave it the way we presented it].

RM: It’s a beautiful job. It’s a good looking book. You deserve every bit of your success and I hope that I can do my bit to push it forward. It’s helped me!

MB: Thank you, sir. And we have been very pleased with the responses we have seen from diabetics. We do do this: we caution anyone who is diabetic who goes on Sugar Busters! to consult with their physician, because, yes your insulin levels may become less and the requirements [may drop]. If you are taking insulin, you need to let the physician know, so that it can be adjusted and followed. If you are on an oral hypoglycemic agent, you may not need it any longer. We are not saying, go out and treat yourself. This needs to be done in concert with your physician.

RM: Excellent point. You made so many wonderful points for me....

MB: ...the reward and benefit that we have gotten out of this in talking to people such as yourself who have tried it and who have benefited from it, we hope will be healthy and happy as a result of it.

RM: Thank you very much, Dr. Bethea.