00:08: Introductions

00:31: Dr Dharmapriya’s personal health background

01:09: The impact of menopause

02:37: Dr Dharmapriya’s diagnosis of pre-diabetes

03:32: Why  insulin resistance is at the root of metabolic dysfunction

04:00: Transitioning to low carb a diet

05:28: Health improvements after starting low carb

06:58: Coronary vascular disease risks

12:46: Metabolic health in South Asian populations

16:00: Addressing South Asian patients who claim low carb is not possible

20:00: Shifting the mindset of South Asian populations 

22:13: Cognitive decline and the impact of nutrition

24:10: Standard tests to determine metabolic health

24:58: The importance of the high-sensitivity CRP test

27:12: Vitamin B12 in South Asian populations

27:29: Lipoprotein-a and South Asian populations

28:29: The importance of fasting insulin test

32:59: The importance of cholesterol

35:00: How fatty liver disease develops

36:00: Reversing fatty liver with dietary changes

37:00: Body Mass Index (BMI) references for South Asian populations

41:45: ‘Is fatty liver the cause of type 2 diabetes?’

42:22: ‘Is there any damage caused by yo-yo keto dieting?’

43:00: How many grams of carbohydrates for a low carb approach

44:00: Practical approaches to transitioning to a low carb diet

45:00: Dr Dharmapriya’s Wholefood Revolution

48:07: The importance of understanding mindset

Dr Peter Brukner (00:01.496)
Hello and welcome to our latest Defeat Diabetes webinar. this week, it's my pleasure to introduce my very special guest, Dr. Nelum Dharmapriya. Nelum, welcome.

Dr Nelum Dharmapriya (00:01.498)
Thank you, Peter. Thank you for having me on.

Dr Peter Brukner (00:01.499)
It's our pleasure. Now, you've probably watched some of these before and we have a set format in that my first question is always tell us about your journey. So take us through it, Neilham, right from day one to now.

Dr Nelum Dharmapriya (01:31.242)
Okay, well, maybe not day one, it's a lot of years. I'll just start from, well, you know, I was originally, I'm born in Sri Lanka and raised in Sri Lanka. And I went to university in Scotland in Aberdeen and learned what everybody, all medics learn about, you know, medical stuff. And so I graduated just under 30 years ago and I've been a GP for 23 years. And I was a GP in partner in a practice in North of England for about seven years before I moved to Australia in 2009 and moved to Brisbane. yeah, so I and my husband and I, we built a medical centre in the North of Brisbane about 2012. And, you know, we were just happily going along. I thought I was doing wonderful things for my patients, you know, doing the usual GPing.

And until I started going through perimenopause and menopause and really struggling with my health. Now, I have always considered myself healthy. You know, I've exercised most of my life. I thought I was eating well, was definitely low fat and, you know, I don't smoke, I don't drink. So I was, you know, doing fine. And but I was gaining weight, particularly around my middle.

I was really, as I say, becoming like my mum because she's an apple shape, so that was me. But really, was things like very bad memory. I mean, I couldn't leave my computer at work without forgetting words, without forgetting medical conditions, medications, and that was terrifying. I snored. It was terrible snoring. I mean, really felt for my husband. Heartburn, you know, all these. And then my blood test showed that I had pre-diabetes. Now, this was a little bit of a shock because I'd always considered myself, as I said, healthy. And my mum was diagnosed with diabetes at the age of 52. So that was around, that was the age I was at the time. And all her family had diabetes. And my grandfather and a lot of her brother, siblings, died of diabetes related complications. So this came as a big shock and I thought, well, how can this be? Here I am. I'm a GP. I advise other people on what to do. Then I realized that it wasn't just me, that what I was telling my patients, because that's what I was doing, wasn't working for them just as much as it wasn't working for me. So that's when I thought, well, I need to look into, well, I must do something different.

And it was really hard to figure out what that something different was. But it took me a little bit of research. Well, I mean, I did so much reading and found insulin resistance and metabolic health. And it was like a revelation. was like everything fell into place. eating low carb, how... not just the diet, but our lifestyle, how it impacts insulin and how insulin, you know, all of the stuff that we talk about. And so I then started, I thought, well, I need to eat low carb. Now, this was not easy. It was not easy for me coming from Sri Lanka and loving my Sri Lankan food. So first, there was about a month where I couldn't, I couldn't possibly even think about it because I thought, what am I supposed to eat? I eat rice and roti and all the lovely Sri Lankan food. And how would I socialize? And then I thought, well, I better give it a go because really nothing else had worked. what I start, and I think I've heard you say this, first I started with increasing my protein. Just thought, OK, I'm just going to cut down my carbs a little bit. I'll increase my protein.

And that was when I noticed that I wasn't very hungry. I was able to keep full for longer. And then slowly, slowly, I could go longer periods of time without this constant hunger. And that it made it easy and I could see results. I could just see that my waistband was a little looser and, you know, just things were changing. And then about three months into it, my husband said, you don't snow anymore. And that was after 20 years of snoring. You know, I couldn't believe it. And then I, you my memory was improving. My blood test then three months later, completely reversed. So I was no pre-diabetes, all my lipids, you know, really excellent metabolic markers, my insulin, my inflammatory markers. I mean, they were excellent.

So, and I lost the weight. I lost all that weight in the middle that I was carrying, which was just amazing. And, you know, as a post-menopausal woman, I you won't know, but all other post-menopausal women know that it is incredibly hard to lose any weight whatsoever. And to have lost, you I'm a very short person. I lost 12 kilograms in three months, which was unheard of for me. So it was amazing.
But then I thought, okay, I'm on this health bandwagon now. I better do my calcium scores and things like that because it turned out that I was a hyper responder. So what happened was my LDL levels went up, all those my triglycerides went down and my HDL levels went up, but my LDL levels, so my bad cholesterol levels went up quite significantly. And my GP at the time who wasn't low carb said, whoa, Nellum, what's going on here? We better do some further investigations. And when I did my CT-connery calcium school, I was really, really dismayed to find that my levels were over 100. And that was a bit of a shock because as you know, readings over 100 particularly in women who are, you I was just over 50, put me in a moderate risk of cardiovascular disease. this was, and coronary calcium score looks at past risk. So despite all of this that I've done, now I have this risk, which I went to see a few cardiologists in Brisbane and well, all I was told was you have to start on a stat, start on a stack. Anyway, so I kind of redid my research and for me personally, I decided that I would stick with really making sure that I reduced, I really maximized my lifestyle, you know, in terms of I improved all my other risk factors rather than going on medication. That was my personal strategy. I feel, so that's where I am. And in this process,

I realized that, you know, I do it now. So then I realized that, you know, the people who come to see me, my patients who are predominantly women between 40 to 70 years of age, they all struggle with the same problems in different ways. And I realized that if this helped me, then it would definitely help them. And so, you know, I worked really hard to create a, well, I, to learn this stuff and to then create a metabolic health program that I now implement at work. But also really looking at my community, my Sri Lankan and South Asian community and realizing that, you know, for many years, I kind of had heard of low carb in the background, but it was like blinkers on because that wasn't for me. How could I be low carb? You know, I eat rice, right? So.

So I realized that now three years down the line, it is possible to be South Asian and to make this lifestyle work. And I think it is really important for this ethnic group. So that's why I'm here trying to raise awareness, Peter.

Dr Peter Brukner (10:36.220)
Great. I want to take you back to your childhood in Sri Lanka and tell us about what sort of foods you would eat as you were growing up and what was your diet like in your years in Sri Lanka?

Dr Nelum Dharmapriya (10:36.226)
Yeah, so every single meal has a carbohydrate base, a starch base. was so rice, roti, which is mainly coconut roti that we eat, hoppers, string hoppers, every single, you know, it was always starch, some kind of a carbohydrate base. And then and some sometimes it would be three meals of rice, breakfast, lunch and dinner. But they're always proteins. that means, and we weren't vegetarians. So we would have any, whatever we had, you know, kind of chicken, beef, pork, lamb, fish, seafood, and lots of vegetables. like a lot of, so I grew up in a middle-class family in Sri Lanka. And at the time, most of these kinds of middle-class families had a maid who would do the cooking.


So was all freshly cooked. We very rarely went out. wasn't we would if we entertained, it was going to each other's houses. So it was all freshly cooked food. And most Sri Lankan food is cooked with coconut milk, coconut oil at the time. So, you know, I and yes, we did have a bit of sweet, but it wasn't all the time. It was as and a lot of fruit, lots of fruit because we had such abundance of fruit. So that's how I grew up. And yeah, so I mean, I don't know if you've tasted Sri Lankan food, and I might be biased, but it is the most the the best tasting. So, you know, you grow up and you Yeah, so I grew up enjoying my food. And I was a bit on the chubby side, actually, and which was unusual for a young girl growing up in Sri Lanka, very, very skinny, usually. But, but you know, that was that was the way it was.

Dr Peter Brukner (12:33.510)
Yeah, there obviously a lot of very good elements to that diet. You I mean, you mentioned using the coconut milk and lots of protein and vegetables and so on. It's just that starch. And as you said, most of your family at some stage have developed type 2 diabetes. And is that, do you think that's related to the starch?

Dr Nelum Dharmapriya (12:33.510)
Well, I mean, I do think there probably is a genetic component there as well, because my father's family, his, my father, none of his family actually had type 2 diabetes, but my mum's practically all her siblings and her extended family as well. Yeah.

Dr Peter Brukner (12:33.516)
What about the South Asians in general? mean, you know, the rates of obesity, the rates of metabolic disease, type 2 diabetes and so on. How does that compare to sort of Western countries like Australia?

Dr Nelum Dharmapriya (12:33.516)
Yes, so first, I'd like to just define South Asians because what I realized in the process of talking about this to people is that people aren't aware of who South Asians are. so let's just say it's Indian, Pakistan, Bangladesh, Sri Lanka, Nepal, Bhutan, Maldives. So this is the kind of group. it's different from the East Asians who are predominantly the Chinese and the Japanese and the Southeast Asians, which who are further down, so Indonesia and that. So the South Asians have a particularly high risk of type two diabetes, heart disease, stroke, high blood pressure, all of that. So in terms of diabetes, it's three to four times higher risk of developing type 2 diabetes than let's say in Australia, the wider Australian community. So that's a prevalence of about 15 to 20 percent of diabetes risk and they develop this about five to ten years earlier and also progress rapidly as well. about 30 percent of the South Asian community have pre-diabetes. And they develop diabetes quite rapidly from there. So it's a massive risk, particularly because currently the South Asian population in Australia sits at about 8%, but by 2050, it's estimated to grow to about 12%. And because of the younger age, its impact on not only the individual but also on healthcare, know, kind of cost with chronic disease. So I think it's something that's very important to look at.

Dr Peter Brukner (14:36.803)
And do you get the impression that the South Asian community in general in Australia are concerned about this or are they just blissfully unaware sort of?

Dr Nelum Dharmapriya (16:20.805)
Well, think they do bury their head in the sand. I think they are aware because you look around, now I'm 55 years old and so many of my friends, my peers have had, you know, they've had some kind of an event there. A lot of them have type 2 diabetes. A lot of them have had some kind of cardiac event.

And it's like, it's become like type two diabetes is just so common. It seems to be like every other person that you talk to has it. But I think truly what I feel is that in our low carb community and as metabolic health practitioners, I feel that we have offered something different to just the population in general. And I think that this low carb way of eating or lifestyle can really benefit the South Asian community. But I don't think that they are aware that this is for them.

Sure. Okay, so I want to put you in the position of you when you first looked at low carb and many of your patients who would immediately say, I can't do low carb. I'm South Asian, my diet is rice based and lots of starchy carbohydrates. I can't do it. Yes. So how do you tackle that patient? Yes, so I think the key thing is to make sure that you don't say, well, you can't have this. Because I think, you know, the food is an essential part of South Asians, like a lot of other cultures. But South Asians, you know, we revel in food, all our social engagements, activities, festivals, celebrations, all around food. And it is such an important part. So I think it's about compromise. It's about saying, can we reduce a little bit? It's not that you can't have any of this, but what alternatives can you have? Can we compromise on certain things? So could we cut down on the amount of rice, for instance? And David Unwin, that in sugar infographic of that white rice, this much, I'll show you.

Where is it? This much, which I've actually measured it. 150 grams of white rice is the equivalent of 10 teaspoons of sugar. And you know, Peter, never in my life until I heard about this, did I ever just eat that much. I would have eaten three to four times that much easily. just showing people, I think that, you know, this is and, we know that anything above one teaspoon of glucose in the blood is toxic at any one time. So you can imagine. So I think that and giving alternatives like, know, you could have instead of the white rice, could you mix it with a little bit of cauliflower rice? Could you have cauliflower rice instead? Could you have things like the rotis and the naans and all the other bases that we use? Could we use alternative ingredients for it, like the nut flowers and things like that, which might be a better alternative. then really kind of, you so other things that you can do, which I think simple strategies, if you cool the rice, cool the rice and then eat it and then reheat it, the rice, the starch turns into a resistant starch. So that's like a prebiotic. So that reduces the glucose spike.

Dr Nelum Dharmapriya (18:43.726)
If you have two teaspoons of apple cider vinegar before or after you have a meal or just before you have carbs, that reduces the glucose rise and the insulin response as well. Could you actually have fried rice, fried with butter, ghee, coconut oil, lots of veggies, lots of eggs and eat kind of a smaller quantity because that will fill you up. So there are ways, there are ways that we can do this. But it's just kind of showing people that it's not about not having this, but it's about modifying and how you can make it. So it's always about compromise, I think.

Now I'm a great fan of cauliflower rice. Lots of cauliflower rice. In we're having it tonight with our stir fry. But how's the response? Do they sort of turn up their nose when you speak to your South Asian patients and you suggest maybe cauliflower rice? Do they look at you bit strangely and say, you know, that's not real rice? Or how do you go about them convinced about?

They do, particularly because, know, well, it's cauliflower, right? But I think once you show, I think once people see the benefit to themselves that, you know, they start seeing a little bit of change in their measurements, they might see a little bit of weight loss, they see the changes in their metabolic markers.

Because when you can show this to them, then that inspires them even more. So I think definitely, I mean, it's not for everyone and everyone, and it's not that everyone will take this on board. But I think if they've seen, you know, family members or themselves, they've been affected and they're in pain, they're struggling, they're worried about their health, I think, yeah, I think some of them will take it on board. And I think having others who have done this, gone down this path and are able to maintain it. So, you know, and I say like for me personally, if I'm out with my South Asian friends, family, know, like Sri Lankan family and friends, I just have what they have. I just have it and I enjoy it and I don't feel guilty about it. But when I'm at home, so I call it my default. So when I'm at home, I have low carb when I'm out. that's the way I manage it. And then there's no, you know, there's no issue. And for me, that really works. And I think it does work for a lot of others as well. it's, think, yeah, they do poo poo it, but I think once they start seeing the results, think it, yeah, they see how beneficial it is. Yeah.

Dr Peter Brukner
Yeah, I think the important thing is just getting people to give it a try, isn't it? I as you as you did, you know, you were reluctant, you thought, well, I'll give it a try. then, you know, within a week or two, you start to feel that different. was fascinated to hear that you talked about your your memory and your your sort of brain function improving almost straight away. That's not something that that is well recognized.

Dr Nelum Dharmapriya
It, for me, I remember Peter just before all of this happened, going for a medical conference. And in the past, as a younger woman, I've always had good memory. And I never used to take notes because I could retain it. I'd go, I'd listen, and I'd come out and I'd be really, you know, fine. So this particular time I went and I sat and I was like, oh my gosh, this is so wonderful. And 24 hours later, it was all gone. There was nothing left in my head. And I decided I would never pay for a medical conference again because that was a complete waste of time. But, you know, I couldn't do this, what I'm doing now. If that person three years ago couldn't do it because I could, I didn't have the capacity. I couldn't remember things. It's amazing.

Dr Peter Brukner (22:57.901)
Why do you think that is? What's going on do you think?

Dr Nelum Dharmapriya
It's you they talk about brain fog and the perimenopause the postmenopausal and I think it's I don't know whether it's inflammation and you know we I as soon as I cut down on the carbs I could feel it you know things are different so I don't know well I mean we do know we do because the brain and the the body are connected aren't we we now know that there's so much that metabolic psychiatry and metabolic, you all the mental health stuff and all the brain related stuff, it's all to do, it's the same underlying processes that affect metabolic, the brain function and all of that as it does the rest of the body. So I'm sure it's just improved metabolic function.

Dr Peter Brukner
Fascinating. Yeah. Okay. I want to take you to a situation where you have a patient in front of you who has all those issues, perimenopausal, maybe obesity, maybe type 2 diabetes. Tell me about how you work up a patient. Okay. So you obviously take a history and an examination, but what sort of investigations do you do as your standard sort of a test basically to assess their metabolic health?

Dr Nelum Dharmapriya (24:43.342)
Okay, so I always, so when somebody comes to me, I would say, let's do a metabolic screen. And I explain what metabolic health is, I explain the importance of it. I do, so the standard ones are, it's a fasting test, it's actually a minimum of 12 hours fasting. And so it's fasting blood glucose, blood fasting insulin. Lipid testing, full blood count, kidney, liver, thyroid function, inflammatory high sensitivity CRP.

Dr Peter Brukner
Let's talk about that because that's that that high sensitive CRP is a really important measure that I don't think a lot of people really appreciate. Tell us the use or what value you put on HSCRP high sensitive.

Dr Nelum Dharmapriya
I mean, I it's a really important reading and it gives you an idea of general inflammation within the body. The problem with it is it's it's it is there's so many things can impact it. So if you did have some kind of infection or inflammation, then it can raise it. But and also to say that if it is low doesn't necessarily mean that you don't have any inflammation going on but I think if it was high is when you would really worry about it but it because we know that a low-grade chronic inflammation and insulin resistance are the drivers of chronic disease so I think it is really important to check this and so yeah so for me I tend to use a cut off of less than one I know that but because I feel that if we have and consistently if you have a a high sensitivity CRP of less than one. I think that shows particularly good metabolism there. But yeah, I use that quite a bit and I think it's a really good measure.

Dr Peter Brukner (26:24.034)
Yeah, I think that's a really important point that I mean, some labs say anything under three or something like that. I I had one of my children had a test recently and his age, their HSC, I think came back at 13 and the doctor said, that's fine. I was like, my God, you know, and that's, that's certainly not fine. So I think you're right. think anything over one is just shows some evidence of, of inflammation and often it's that chronic inflammation. It seems to be the center of a lot of chronic disease.

Okay, so I did interrupt you I'm sorry about that, but I thought the CRP is really important. Continue on our metabolic screen.

Dr Nelum Dharmapriya
Yeah and so then if they have any gut issues I would do a celiac screen and what else? vitamin D, really important. Iron studies for this ethnic group B12 and folate is another thing that I do. So generally that covers most of it. Yes that covers most of it. Now just to say that in this South Asian group, if there's a strong family history, it is worth doing LP little a, because this South Asians do carry 30 to 35 % of South Asians have a higher LP little a, which is known to again, increase your risk of cardiovascular disease. Now there is no treatment for it, but it just then will highlight the need really to make sure that every other risk factor is mitigated.

Dr Peter Brukner (28:03.662)
Yeah, think LLPA is probably more relevant than LDL, although it doesn't get as much publicity. Maybe because there's no drug for it. might be just a coincidence. yeah, I agree. think it's a really important measure. And just to alert people that risk, because part of the reason we do this is to try and convince the patient, isn't it, that they need to take some measures. They need to do something about their metabolic health.

What about serum insulin? Is that something that you...

Dr Nelum Dharmapriya
Yeah, fasting insulin. Absolutely. I just do a regular fasting insulin. I don't do the 2R test because it's a real pain for patients. So I just do a fasting insulin. my cutoff, I think I got these cutoffs from you, Peter. Under six, I'm happy. Under nine is acceptable. And above 12 is a concern. And that's how I kind of work it. sorry, HbA1c, really important because obviously that's your diabetes test. And for South Asians, I would be worried about HbA1c above 5.7. Well, for anybody really, because that's pre-diabetes. Yeah.

Dr Peter Brukner
Yeah, that's an important important point. I think that, you know, the cutoff for type two diabetes of HbA1c is 6.5. And, know, if you're 6.3, you know, a lot of doctors say, Oh, you know, you're fine. You've got no problems. But that's not what what you believe.

Dr Nelum Dharmapriya (29:40.846)
No, absolutely. think the risks, I mean, now that we have these tests and we know so much, we can see these changes so many years ahead, like 10, 15 years earlier. Why wouldn't you start it then when that insulin is just about kicking off? And it can make a huge difference to somebody's future health.

Dr Peter Brukner
Yeah, I think that's wasted opportunity, as you say, when the HbO1c is between, 5.7 and 6.5, which we would classify as pre-diabetes. And similarly, when the insulin is high. And often in those situations, they'll be hyper-insulinemic. insulin might be 12 or 15 even, and so on. And again, most doctors don't even test for serum insulin. And yet I think it's probably, after the HbO1c, it's probably the most important test we can do.

Dr Nelum Dharmapriya
I don't understand why there's this, well, I do understand it's because of ignorance, really. They don't understand the importance of insulin resistance and hyperinsulinemia. And yet, you know, it's such a sensitive test. I mean, I know in my own case, my HbO1c was fine. thought, I'm fine. And then I had this this massively increased insulin because my pancreas was pumping out all this insulin to keep my blood pressure under control. And eventually the pancreas says, know, hang on, mate, that's enough. I'm struggling with that.

And so, you we keep talking about prevention and early pick up of these things and, you know, health systems love screening and yet they don't screen for the right things. If we screen for serum insulin, we would pick up a lot of early insulin resistance and be able to take some measures. It's very frustrating that there's that lack of understanding, if you like. And I'm sure it's the same in the South Asian community as in Western society, mean, listen, the South Asian community has been traumatized by cholesterol because that's all anybody wants to know. And it's really difficult to kind of say, actually, let's look at lipids in a slightly different way. because that's all that is, they are so, that is over the years, they're so conditioned with this high cholesterol is the problem. So nothing else seems to matter apart from the cholesterol.

Dr Peter Brukner (32:05.166)
And what is your attitude to the patient who comes in with a high cholesterol? know, let's say they might have cholesterol of six or so, and their LDL is three and a half or four or whatever. you know, what's your approach to that sort of patient when they do their metabolic screen and they come back with those elevated numbers? How do you counsel them?

Dr Nelum Dharmapriya
So, know, right. So first I say, I go through the elements of the lipid screen. I do not call it cholesterol screen because there's so much more to that than we, well, actually the triglycerides, which is the second reading is so much more important than anything else on that panel. So I tell them about what triglycerides are, they're fats in the blood. They have nothing to do with fats that you're eating. They come from excess sugars and starches that are converted into fat by the liver.

And so I tell them, so I prefer that to be less than one. And then I say that the next reading that is important is the healthy cholesterol, the HDL, and that we need the higher it is the better. So I really go through that. And then I just kind of say, really, LDL, I mean, listen, my patients have known me for a long time. So I can get away with saying, don't worry about the LDL. It's a complete waste of time. We are not going to talk about it and I give them the ratio. So I tell them the ratio, the triglyceride to HDL ratio, that is really important for heart disease risk. And so we go through all of that. And I use some information leaflets as well, and to show them the benefits, the importance of these two markers. And then we monitor that. then if... they really are concerned about their cholesterol, want to know more, then I get them back. So I do like what I call a comprehensive appointment, which is a 60 minute appointment for certain areas that really then I go into detail. show them all the information, the data behind it, because you can't do it in a 50 minute appointment. It is completely impossible. So that's how I do it.

Dr Peter Brukner (34:16.876)
Yeah, I certainly agree. think the triglyceride HDL ratio, which ironically is about the only ratio that they don't report on the standard pathology screen that you get back from the pathology lab. They've got all these other ratios and the one important ratio they don't actually have, which I don't understand. But I think it's been shown very clearly that that is the most sensitive marker of insulin resistance and cardiac risk, cardiovascular risk than anything. so I think really, you know, the three measures that we've talked about the HbA1c, the serum insulin and the triglyceride HDR ratio. I think you've got those three components of the metabolic screen. They're probably the key elements. I think you'd agree of the metabolic screen and the high sensitive to CRP.

The liver function test, the ALT in particular, really I want that to be less than 25. Because ALT is the marker of fat in the liver. And if you have fat in liver cells, the liver cells can't work. And so that then triggers an inflammatory response and over time can.... tell us why that's important.

Dr Nelum Dharmapriya (35:33.742)
Causes fibrosis scarring of the liver leads to over time can lead to liver cirrhosis, which then subsequently can lead to liver failure or liver cancer. it's, you when you talk about this, because Peter, before I knew any of this, like lots of doctors, I would say, oh, you've got a bit of liver, liver, but bitter fatty liver, go and eat less fat. That's what I'd say. Right. And it's a complete, I mean... And now when you show people that once they've been on a low fat diet for even a few months, the fatty liver can be kind of reversed, it's amazing. And particularly in South Asians, fatty liver is quite a common problem. I think it is really important, well, not only in South Asians, but we are seeing more and more of it. It's so prevalent now even in the wider community. So yeah.

Dr Peter Brukner
Yeah, I was the same, had a fatty liver for years and I thought, low fat diet. That must make sense, fat and fat. yeah, surprisingly, my fatty liver remained until I went low carb and then disappeared in three months. It's bizarre, isn't it? I mean, it's just intuitively sort of back to front. And yet, again, there's this lack of understanding in the profession. So, okay, so we've got HbO1c, we've got serum insulin, we've got our... high-sensity CRP, we've got our triglyceride, HDR ratio, and we've got our liver function test, particularly ALT. And that's a pretty good start for a metabolic screen, isn't it, really?

Dr Nelum Dharmapriya (37:09.814)
Yeah, I think that is the basis and then everything else is surrounding that. Yeah, it just supports it. Yeah. But yeah. And the thing to say with the South Asians is that they need to be screened from a BMI of 23 onwards because that is so South Asian with a BMI of 23 is considered overweight and BMI of 27 is considered obese. And in the US, they have a movement called screen at 23 for South Asians. And in the UK, they say from 25, if they have a BMI of 23, then they need to be screened for all those metabolic conditions. So I think that's really important. Yeah.

Dr Peter Brukner
Right, yeah, that is important. I wasn't aware of that. So normally we would say above 25 is overweight, above 30 is obese. Whereas in South Asians the numbers are 23 and 27.

Dr Nelum Dharmapriya
Yeah, and also the waist waist to hip ratio. So the other thing about South Asians is because we're smaller, a smaller kind of the the waist measurements for women should be it's less than over 80 centimeters is considered a problem and men it's over 90. But really, I think it's the waist to hip ratio that's more important. Because, you know, like me, a lot of South Asian women, for instance, are very short. So even at my highest weight, I didn't have a waist circumference of 80 centimeters, but I was an apple. So I think the waist-hip circumference is much better. So anything above 0.8 suggests that that is higher metabolic risk.

Dr Peter Brukner (39:01.172)
Okay and explain to us why the abdominal obesity or the abdominal fat is far more dangerous than more peripheral sort of fat.

Dr Nelum Dharmapriya (39:01.172)
So abdominal obesity is what we call visceral obesity, or that's where visceral fat is deposited within the abdomen. Now, this is not supposed to happen because you're not supposed to have fat depositing within the abdominal cavity and within organs. And if it does, that creates significant inflammation. And so that is what then triggers, again, all these chronic diseases, heart disease, cancer, inflammatory conditions, because of that inflammation that is triggered by the visceral adiposity. yeah, sorry, Peter, South Asians also have a much, much higher risk of ectopic fat deposition in the visceral area plus in organs as well. So liver, pancreas, muscle as well.

Dr Peter Brukner
So this is why South Asians are at so much higher risk of metabolic dysfunction.

Dr Nelum Dharmapriya (40:27.918)
Right. And so you said fat in muscle as well. I mean, I was familiar with the liver and pancreas and so on, but it's an issue with fat in muscle as well. And so the other side of this is that South Asians have much less muscle mass, particularly the women. That's an evolutionary adaptation. And so then if you have less muscle, there's fat in that muscle, which then reduces its functionality as well. And so all of those plus, the other thing is that the reason why, one of the reasons... the other reason why they feel that South Asians have this high risk is because of impaired beta cell function in the pancreas. So reduced insulin secretion or impaired insulin secretion. So impaired insulin secretion, less muscle mass and less functionality of that muscle and increased adiposity within the visceral and ectopic, know, adiposity is these are the reasons why there is so much problem within this community, this ethnic group.

Dr Peter Brukner
Right, yeah, very interesting. Okay, we've got some questions. So let me, this first one you've sort of answered is that they would like to clarify whether chronic diabetes can be a cause of liver cirrhosis. So just take us through that sort of link between diabetes and liver cirrhosis.

Dr Nelum Dharmapriya
It's not that diabetes causes liver cirrhosis, but it's associated. So nearly everybody who has type 2 diabetes will have a degree of fatty liver. And that if that is not addressed, then over time, this will lead to liver cirrhosis. Well, it can, not will, it can lead to liver cirrhosis because of that inflammatory process.

Dr Peter Brukner (42:20.498)
Okay, so next question. Going on a yo-yo keto diet, is there any danger? So many people start, get some benefits and go back to old habits and food. Would they be better off not doing it at all?

Dr Nelum Dharmapriya
Well, right. I mean, my practice is low carb because I have no issue with somebody doing keto, but I feel that it is difficult to maintain and therefore people do go off and come up. So, but I think a lot of people, unless there was a specific medical need, you they had epilepsy, they had psychiatric condition or something that specifically needed a ketogenic diet, I think being low carb.

Dr Peter Brukner
Where you're eating, you know, up to between 50 to 100 grams of carbs, I think is a much more strategic way to manage it because you can manage it long term.

Yeah, we should explain to our listeners that the keto or ketogenic diet is really an extreme form of low carb where you're less than 50 or even less than 30 grams of carb today. And as you're saying, you know, I think it's been shown to be very effective in epilepsy and there's some evidence now of other chronic diseases. But I guess, yeah, if you're a newly diagnosed type 2 diabetic or you're morbidly obese or you have these chronic diseases, then it's probably not about to start on a ketogenic end of the spectrum, if you like, you know, and then then you can back off a bit and then find what's right for you. What you know, someone asked you, well, how many you know, how many carbs should I have a day? What's your response to that?

Dr Nelum Dharmapriya (44:00.898)
Well, Peter, I'm really not somebody who advises counting and measuring. I think we need to get away from this. I think we're so focused on this. We've lost all enjoyment of what we should be doing in terms of enjoying our food. So I think really just knowing what to eat and your low carb chart that you do, the low carb food choices, which actually I have pinched and just modified a little bit.

I think it's great because it shows you what you should be eating and then particularly the green, the green section is what you should be eating. Amber is eating some and red is eating none. So if you eat in the green section, you can eat as much as you want because you can't possibly overeat because you're eating more protein and the kind of above ground veggies and all the good stuff. So really, I'm not really a fan of giving numbers. I just say, just know what to eat and eat, eat, eat that. And people ask, well, how much should I eat? It doesn't matter. You can't overeat it. So just eat until you're full.

Dr Peter Brukner
Yep, that's a radical concept that seems to work, doesn't it? So, yeah, I think that's the reason why a low carb diet is sustainable, you know, compared to a low calorie diet, because, you you're not hungry the whole time, which is the problem with those, and which is why you yo-yo out of these low fat diet or low calorie diets because of hunger. And the great advantage, I think, of the low carb diet is that, you know, fat and protein feed you up and it's carbs that make you hungry. And I think that's a key difference between the two different types of diet. I mean, you can lose weight on either diet, but I mean, one is sustainable and one is not. Yeah. Interesting. So, Nellum, you've got a practice now that, you your whole food revolution, which you've got a website and so on. Tell us a little bit about how you set that up and what you provide for people.

Dr Nelum Dharmapriya (46:05.698)
Well, I the reason I set it up was when I first started on my journey and realized that, my gosh, this would be amazing for my patients, I set up what's called a metabolic health clinic, which I was teaching the science to my patients. And it was one-on-one. It was 45 to 60 minute appointments. There were eight appointments because I had to debunk all these myths. So it was wonderful, but it was so much time. And I worked three days a week. And if I had... five or six people doing this, I couldn't fit anything else in. And so I thought there must be a better way, a solution to this. So I decided to maybe have something outside of work. So that's when I created Whole Food Revolution as a, you know, having maybe a more efficient way of delivering this information. So I have a website and I do some workshops and... I work with a nurse and a life coach. So we have this very holistic approach. I teach the science. Deb, she talks about how to implement that science and Rooney, it is all about the mind. So that's how we do it. And on the website, there's a lot of information on the website. And in particular, I have on Whole Food Revolution website, I have a page for South Asian health.

And it's not just, it's an archive actually. So under the Knowledge Hub, there's a whole archive on South Asian health with all of this that we talked about, why we have so many difficulties, eating healthy, what can you do? What habits can you adopt? Not just eating habits, but lifestyle habits. How can you advocate for yourself? What tests you need? How can you educate your doctor? Because a lot of the time, doctors don't know about these additional risks. All of these things are there. So it's like a one-stop shop. And so people can go there because all of that is in one place. So I think that would be very useful. But the website has lots of information. do not just the science, there's lifestyle, there's mindset. There's a lot of information on there and any courses and programs that we run as well.

Dr Peter Brukner (48:20.75)
You mentioned the mind and you have a mind coach and so on. What role does the mind play in all this?

Dr Nelum Dharmapriya
You know, Peter, when I first started, I was so excited because and I thought, I just need to teach the science. Everybody in my my all my patients will be just this amazing. So this start off really well, start off really well. And three to six months later, there's just like this barrier. Something happens to them. And and first I couldn't understand. I'm like, what's happening? And then I realized that there's that the mind, the, you know, all of these, emotional eating, the sugar addiction or food addiction, unhealthy beliefs from the past, past traumas, all of these things play such a crucial role. So there's so many people who know what to do, but simply cannot do it. And we actually had a, we ran a three day event that said, find peace with food. can't, why, why is it that we know what to do but can't do it? And it's this, it's the mind and I think it's huge. So the last two years, it is really for me as well, understanding all of these things that it's not just about the science, that science is not enough. You need to have these mindset and lifestyle. You need to have guidance. And I really now, I mean, I'm a typical GP. didn't know anything about coaching or anything like that. But now I consider myself a coach, like I'm a coach. And so I think people need that. They need that guidance. It's only a very particular person that can hear the information and run with it. And I think there's really a need for that holistic approach.

Dr Peter Brukner (50:18.222)
And how do you tackle some of those issues, like the sugar addiction and so on? As a mind coach, what are some of the techniques you use to help your patients?

Dr Nelum Dharmapriya
I'm learning from Rooney and she's amazing. I am not a life mind coach, but she is. And she talks about the brain and the mind, the subconscious and conscious connections. I mean, it's amazing. So you're really just recognizing some of the coping mechanisms that we have adopted over the years, that we can't just stop these behaviors, we have to always swap them. And so we swap one behavior for another and recognizing when these are happening, how our subconscious. So she talks about the captain and the crew, and the crew is the subconscious and the captain is the thinking mind and how the crew is constantly looking to really protect us.

But sometimes the way it is done is not useful now because it was something that was helpful many years ago, maybe as we were children, when we were children or whatever. so it's massive and it doesn't, it takes a lot of time. And I think it's difficult and I think that's why people struggle with any, not just low-carb, but any lifestyle change it is these, you know, so I, yeah, so I think that is really important.

Dr Peter Brukner (52:04.962)
And so often, as you mentioned, at three or six months, people struggle to maintain it. And they'll come in and they'll feel like a failure. yet, mean, most people need to, it's like when you give up cigarettes, no one does it the first time around. It's something you've got to keep at, isn't it?

Dr Nelum Dharmapriya (52:04.962)
Absolutely. I think it gets easier. You just need to... And that's when... the other thing that we have through Whole Foods is we have a Whole Foods Revolution community, and it's a Facebook group. And I think that is really important to have a community that supports each other. Because when you're on this kind of journey, particularly if it's not what people around you are doing, you can feel quite isolated. So I think... having that community that supports you is really important.

Yeah, we find the same with defeat diabetes. think it's a really important part of any, you know, you do feel a bit alone and it's so reassuring to know that there are so many other people struggling with the same issues as you and there's a lot of mutual support, think is really, I don't think we do enough in general practice even enough group sessions. mean, ideally, you know, it'd be wonderful to get a group of people together, you know, support. It's not funded, I tried. Yeah, so I tried because that would have been amazing to be able to have five people but no, there is no funding.

Dr Peter Brukner (53:35.406)
Yeah, well, when the revolution comes, we'll sort all that out and then we'll change the world. Our time is up, but I just want to say firstly, congratulations on what you're doing. I it's really groundbreaking that the work you're doing with the South Asian community. as you pointed out right at the start, it's a massive issue for your people and it needs to be tackled.

I congratulate you on what you're doing and thank you for your time today. if people want to know more, wholefoodrevolution.com.au is the place to go. And if you're interested in tackling diabetes, we'd love to see you at Defeat Diabetes as well. But, Neil, thank you once again and all the best for the future. Thank you.

Dr Nelum Dharmapriya (53:35.410)
Thank you so much, Peter. Thank you.