Show Notes
Type 2 Diabetes, Bariatric Surgery, Fasting, and GLP-1s: What We Finally Learned About a Disease We Thought We Understood For years, I watched something happen in bariatric surgery that made very little sense, according to the medical textbooks of the time. Patients with type 2 diabetes would undergo surgery, and within days, their blood sugars would improve dramatically. Some would leave needing far less insulin. Others would stop insulin entirely. Many of them would eventually remain off diabetes medications for years. Now here is the important part: They had not yet lost significant weight. That observation mattered enormously. Because if diabetes improvement were simply the result of fat disappearing from the body over time, then blood sugar should improve slowly over months as weight comes off.
But that was not what we saw. Instead, patients barely eating — sipping broth and protein shakes while recovering from surgery — were suddenly metabolically different almost immediately. At the time, we knew it worked. What we did not fully understand was why. And honestly, that story tells you something important about medicine and science: sometimes clinical medicine notices the truth before biology fully explains it. For decades, type 2 diabetes was often taught in very mechanical terms. You gained weight. You became insulin-resistant. The pancreas worked harder and harder until it “burned out.” Then you needed insulin. That explanation was not entirely wrong. However, it was incomplete. Furthermore, it encouraged a kind of fatalism around type 2 diabetes, as though progression were inevitable and irreversible for everyone. Then, bariatric surgery complicated the narrative. Meanwhile, researchers like Professor Roy Taylor at Newcastle University began developing a much more dynamic understanding of what was actually happening inside the liver and pancreas. And suddenly, many of the strange things bariatric surgeons had observed for years started making sense.
The Problem May Not Be Sugar Alone One of the most common mistakes in nutrition discourse is assuming that blood sugar itself is the disease. It is not. Blood sugar is often the visible signal of a much larger metabolic problem involving: the liver, the pancreas, adipose tissue, appetite signaling, inflammation, gut hormones, and the brain itself.
Now, to be fair, refined carbohydrates and ultra-processed foods absolutely can worsen insulin resistance and glucose control. Sugary beverages, highly refined starches, and hyperpalatable processed foods create enormous metabolic stress for many people. However, reducing the entire disease of type 2 diabetes to “sugar is poison” oversimplifies what is actually a highly complex biological system. If carbohydrates alone caused diabetes, then traditional Mediterranean populations consuming beans, lentils, intact grains, and fruit would have universally developed severe metabolic disease. Yet many of those populations historically had some of the best cardiovascular and metabolic outcomes in the world. Similarly, bariatric surgery would not improve diabetes before substantial fat loss occurred. Something deeper was happening.
Roy Taylor and the Twin Cycle Hypothesis Roy Taylor’s Twin Cycle Hypothesis is one of the most elegant modern explanations for type 2 diabetes. The theory proposes that type 2 diabetes develops through two interconnected metabolic cycles, involving excess fat accumulation in organs not designed to store large amounts of fat. First comes the liver. When caloric intake chronically exceeds what the body can safely store in adipose tissue, fat begins accumulating in the liver. Eventually, the liver becomes insulin-resistant. Now the liver starts misbehaving metabolically. Instead of calming down glucose production when insulin is present, the liver continues to release glucose into the bloodstream. At the same time, it exports excess triglycerides and fat particles into circulation. This creates a vicious cycle:
More from Fork U with Dr. Terry Simpson
With all the spices we have access to, it is amazing how bland recipes have become. I have many cookbooks, some from great chefs, television personalities, and friends. What I am always surprised by is how bland the food has become. People seem to think a bit of salt, pepper, maybe onions, and garlic provide the spices one needs. Perhaps it is because some associate spice with heat. Mostly because many have never experimented with some of those great warm spices available. A pinch of coriander, some freshly ground cumin, a little cardamom, or a touch of cinnamon can turn an ordinary dish into something remarkable. And the most astonishing part is that these spices financed voyages around the world, built cities, created fortunes, and caused people to kill one another. Without the spice trade, it is safe to say that the United States, as we know it, would be vastly different from what it is now. The money loaned to the United States, when we were a fledgling country, came from the wealthy spice merchants from what was considered one of the great hyperempires of the world, based in Amsterdam. But before we go to the birth of the United States, let me take you to the meatball.
Tea: The Drink That Built an Empire—and Helped Break One China had the tea. Britain had the appetite. John Hancock had a business to protect.
MesoAmerica and Chocolate In our series looking at foods that built civilizations, today we are going to stay in the Americas with chocolate. Chocolate has been used as currency, consumed by kings, incorporated into religious ceremonies, and prescribed as medicine. Today, it is a multibillion-dollar industry that wants you to believe that eating chocolate is an act of preventive cardiology. I mean, why not? They convinced us to give chocolate to people we love, eat it when we are happy, when we are sad, when only the dog understands us. Don’t feed chocolate to your dog. And we have done all this with a bitter seed that most of us would probably spit out if we tasted it straight from the tree.
I’ve been doing a series about foods that built civilizations. In this episode, we are talking about the potato. It is difficult to imagine that thousands of years ago, people constructed large buildings, managed rivers, built monuments, and created art. We have glimpses of these civilizations through stories, archaeology, and the structures they left behind, but much of their history has been lost. Imagine, we don’t even know where Cleopatra or Alexander the Great are buried, yet we know their stories. As European powers conquered Indigenous peoples, their languages, cultures, and oral traditions were suppressed. When a language disappears, so are the stories preserved within it. Our clues come from archaeology when we uncover a monument, a building, or an ancient settlement. In the Andes, the potatoes they cultivated were not the Russets, Yukon Golds, or fingerlings you find in the store today. Different colors, shapes, and textures. Adapted to survive the elevations, temperatures, and growing conditions. Biodiversity protected their food supply against frost, disease, and changing environmental conditions. If one variety failed, another might survive. The ancient wisdom of diversity that Andean farmers developed over thousands of years was lost when the potato eventually reached Ireland.
In our series about foods that built civilization, we talked a lot about grains, from wheat to corn to rice. Today, we are taking you to the ocean, with the civilizations that salmon built. From California to the interior of Alaska, salmon, a staple, allowed people to settle into villages, develop complex social networks, art, and trade routes. Those trade routes are as large as the ones in the Mediterranean. Some tribes built communal homes and developed complex art and language. Some were Seafaring tribes with canoes up to 60 feet long that traveled across oceans. All because there was a fish that would return in large numbers to streams and rivers, reliably, predictably. So predictable, the people could build their lives around salmon runs. So much so that some built a calendar not only with lunar cycles, but also with the return of the salmon. Civilizations have always gathered around food and water. The Mediterranean connected people who grew wheat and olives, giving people time to make wine, mine copper, build ships, trade with their neighbors, and occasionally go to war with them. Asia had rice and grain near the great river systems. The reliable calories from rice and grains allowed villages to become cities and to travel by water to trade. Today we are going to my home, from the Ventura River in California to my home state of Alaska.