Dr. Stephen Phinney - 'Troubleshooting the Ketogenic Diet for Optimal Weight and Health'

okay so let me just tell you a very quick tale of trauma four years ago when I first my first trip for Locard down under rod brought me to Epworth Hospital down in Melbourne and said you know give this talk to the cardiologist but after that we have a bunch of people who want to learn from you so I'm just going to put you in a room with 75 people and you can just answer their questions and the room was scheduled for two hours and after 2 hours and 45 minutes you know we called the hall because I think that the cleaning people came in anyway but what I found was it would help if I had a few slides that covered some kind of key issues so what I'd like to do here we haven't never tried this before with this size audience is that I'm going to put up a slide talk to it forward about one minute and then if people have questions or issues about that sly raise your hand and we'll hopefully have maybe two mics in movement and the key here is that we will have six minutes per slide because only actually got less than an hour now and your question has to be 20 seconds or less long and my answer has to be less than a minute long and that's that's where the trauma comes okay and let's see if we can do that tempo and get through a lot of questions so the first point I skipped through this slide yesterday because I know I was gonna talk about it today but this is kind of our depict a ssin of nutritional ketosis and the difference between essentially no ketones where your ketone fueling and your ketone signaling is put to sleep by eating carbohydrates to a level between 0.5 and and 3 milli molar which is an area in which ketones function is a fuel and a epigenetic signal and this is what we named nutritional ketosis because when I went through my training we it was either no ketones or ketones are bad for you because of ketoacidosis the key point is there's a tenfold difference between having had you know two poached eggs and some bacon for breakfast versus having you know toast and pancakes for breakfast so point 1 point 3 is carb fed 1 2 3 is new Trishna ketosis oh that's a tenfold difference but then from 1 2 3 up to 10 to 30 is nutritional ketosis so it's a difference between 1 to 10 200 and that's not subtle and yet very much often in the literature people say oh well you know ketones are bad for you but they don't differentiate between 10 and 100 so if people have questions of why we got to why we said 0.5 is a starting point why 3 is the upper level here post exercise ketosis if anybody has questions about that I'll try to answer them ok pressure now that mic is coming from from being on here it stays there any advantage to being one no like being higher on that on that scale to say 3 rather than just being on one excellent question our clinical experience is that one is better than 0.5 but 0.5 is we're clear beneficial effects begin we have not been able to delineate a benefit in terms of diabetes reversal and weight management above between 1 and 3 now there are people doing cancer research particularly in animals and work by Dominic D'Agostino and and others suggests that 5 to 7 is the optimum if you're a mouse or a rat with cancer we don't you know it's hard to translate from animals to humans but to get there most people would have to take ketone supplements in addition to carve restriction and so that's really a combination of exogenously tones plus and dodge mosquitoes but we still don't know that that's the optimum area ok I'm into something when you show how the clinician is this diagram to illustrate the difference between ketoacidosis and nutritional ketosis are they convinced in your experience are physicians convinced it least helps define or frame the issue that you know we're not talking we're talking about the inch of rain watering your garden versus a foot of rain washing it away but clinicians you know we're altought to do what we were told and you know practice within the standard of care and to convince people to take to something like this was really still outside the standard of care and incorporated that's something that the person has to be a little bit bold to do but I know people I've talked to five years ago who were skeptical and now they're practicing it dr. cross you can just just pass it down nobody's going to steal it okay this one might end up being a little bit on the technical side of things you comment there about ketoacidosis kicking in insulin deficiency with K times at about 10 to 20 millibars police' talking with dr. Jake Kirchner yesterday he was saying that and his people with type 1 diabetes you can start noticing a lot of the symptoms of ketoacidosis with very small fluctuations at the lower end of the scale of the blood ketone range no sir about that sort of 23 money multiply so have you noticed that in your experience good question this whole thing's been you know kind of upended particularly with a and again normal glycemic ketoacidosis associated with that's yield two inhibitors and again that seems to happen lower and the other thing is that physicians who monitor people with type 1 where they know that reading carbohydrates if they see a two or a three that's a harbinger of something bad happening and if someone has say gotten the flu and can't eat and they're then they're beginning to get sick if it's a type one you get worried at that range but for and I should make that distinction but for non type one patients who have insulin reserve there's very little if any concern as far as I know in that the one to three range in the non diabetic people who apply to you know this ketosis thing do we experience any clinical signs or symptoms at the optimal zone of the ketone zone without testing the ketone can you physically notice any signs or clues that you might be in ketosis good question the signs are subtle and that's people feel more energy they feel less compulsion around food cravings get better but those are very subtle signs yeah I'm typically in the 0.8 to 1 in the morning and by I'm a person goes low and comes up in the afternoon I don't really notice anything for instance people talk about ketone breath which is acetone which is coming I don't really notice and and my wife doesn't notice ketone breath till 0.5 but if I go for a two hour bike ride and come home she says stay away ketone breast thirst there's an increased natural resis so one needs more sodium and more that's I think slide 5 but it's really not something where someone says oh my ketones are out because I'm thirsty those are tend to be more subtle effect do we know why some people naturally tend to run an a higher ketone level and others never get higher than 1.5 excellent question the more insulin resistant a person is the more impediment there is to fatty acid mobilization and we think that that's why some people are struggle to get ketones up in even the 1 to 2 range there may be other factors the other is we know that that when people have an acute inflammatory illness their ketones go to the basement but so ketones are a I'm sorry inflammation acute inflammation is the enemy of ketosis and I don't know the mechanism for that but it we saw it in the hospital when we had put patients on the intravenous ketogenic diets in preparation for surgery if they had a wound infection or something we could tell the infection was coming because the ketones disappeared I don't think that low-grade inflammation associated forces with diabetes so you know someone who Co see reactive protein and white cell counter trending upwards I don't think that's enough to suppress them and but the common cause of low ketones is that people are eating more protein and more carbs than they they really think they are and so it's basically cat you have anti ketogenic calorie creep so one more question and then we'll sum it up here and then then we'll go on the next slide or do this with regard to the down the back here okay okay so just with regard to urinary ketone monitoring obviously becomes a bit of a waste of time after a few weeks and some people at which stage do we say that for the for those that really want to track their ketones that they should just be doing blood ketones instead of urinary ketones excellent question again we we have trouble each is not to measure urinary ketones because the kidneys actively excrete ketones when they first appear in the bloodstream and then over the course of weeks or months the kidneys become conservative of ketones typically that and and so the you get this varying response where it's not linear but they linearly related to the level in the blood so we go with straight recurrence currently with blood testing because that's the most dependable value if you want to be really encouraged you can measure your ketones for as you say for the first few weeks and you'll see nice purple strips or nice purple tablets from the nitroprusside test but generally we did the blood level is the most definitive inaccurate assessment let's move to the next slide this is an attempt to kind of depict and in the two-dimensional form how different diets where carbohydrates are shown on the vertical axis and protein on the this axis and this is in percent of energy relative to not the ones intake but one's daily energy expenditure so this is percent as if one we're eating a maintenance diet and say say well if there's 30 percent carbs and there's 20% protein where's the rest and that would be the third dimension which is fat and we're not showing fat intake on here so you just have to add in fat intake but the point is that popular diets ranging from what I would call an extreme low-fat diet like the Ornish diet in the US which is mostly plant mostly are all plant-based diet and in about 60 to 70% carbs would be way up here very low in fat and I'm sorry very very low and low in protein and very low in fat this is our standard American diet but you can probably call s ad the standard Australian diet again in around 50 to 55 percent of energy's carbs the Mediterranean diet issed has many definitions and probably the people in the Mediterranean the Mediterranean region would argue over who's who's region sub region is the best but typically it's between 30 and 40 percent of energy as carbs and and 10 to 15 percent as fat and paleo again has lots of definitions but but professor Loren Cordain who really was a scientist who did the initial research on this and define this defined it as 20 to 30 percent of energy as carbs and and centering around 30 percent of energy as fat and I asked him why do you want do they have to have 20 percent of carbs of energy of carbs he says Steve that's how many carbs you need to feed your brain and I do explain that maybe you want to do it with ketones but you know he was a professor of nutrition in a school that taught a lot of dieticians and what they taught them is that the only fuel to brain can effectively use is glucose so it fits that in that model my point here and I'm over my 1 minute I'm not shut up in a second is to be in nutritional ketosis it's actually a very small island metabolic island here you have to stay under typically under 10% of energy as carbs and the higher you go in protein the less carbs you can tolerate because the protein is anti ketogenic so we try to get people in the 12 to 20 percent of daily energy expenditure as protein and keep the carbs under 10 percent and of course when you look at that it's horrifying because when you add up the rest of it it's 75 to 80 percent of energy as fat when you're in maintenance and again I talked about that yesterday I'll come back to that in another slide questions state to calculate protein you use a term called reference body weight could you define what reference body weight is yeah that's a kind of a hand waving number because we like to do it per kilogram of lean body mass but it's hard day even with some of the bioelectrical impedance devices it's hard to get an accurate measure of actual lean body mass so we're trying to feed lean body mass so what we take is a the stature of a of a quote normal weight person of that height male or female and that's the reference right so let's see if if you're my age remember we used to have ideal body weight tables and we pin them up in our office and on the wall just next to the scale and a person can look at that and say oh I'm supposed to weigh 147 pups the idea there is no such thing as ideal body weight because you can be metabolically healthy in a very different way above or below that number but we use that as kind of a reference to estimate lean body mass and we're feeding that protein to feed the lean body mass and these numbers are centered around 1.5 grams of protein per kilogram of lean body mass okay and in the u.s. our recommended dietary allowance this point eight so this is about double the RDA but it's actually in the range where most people in developed countries who are not pure vegan vegetarians this is around where most people people's protein intake is so this is not high protein even though it's above the the minimum RB RDA value question here or someone that whoever has to Mike go ahead sorry Steve is there any studies with regard to a ketogenic diet for athletes doing more high intensity based exercises whether it's your CrossFitters or your Olympic weightlifters or cow forty players and sox soccer players and some of them think that they lose a bit of strength in the beginning so is there any explanation for that and is there anything they can do to mitigate it I think that's one of Jeff Volvox favorite questions and we go up to 2 grams per kilo and particularly for athletes doing high-intensity training will go up to 2 grams per kilo rather than 1.5 we haven't seen any benefit above there in terms of studies where Jeff has actually had people do resistance exercise and measure that not their ability to retain but their ability to gain tissue while losing way so again it's the the 2.0 at top and 1.2 at the bottom end and people need to find their place in the middle and again if your ketones aren't desirable and you think you're yeah you may want to titrate down a little bit if you're maintaining good ketones and you want to build lean body mass you could titrate up a bit can you speak to the rise of the coniferous start and where that fits in and pricing economies of that oh boy 45 seconds okay humans have been carnivores for go without hundreds of thousands of years when we looked at at modern carnivores where we actually had people who wrote things down it appears that groups like the Masai the Native Americans who who nomadic peoples who tracked the Buffalo and the Great Plains didn't practice agriculture the in Whitney arctic tended to eat in the range of this value of one point five or two grams per kilo there were times in in the food cycle when up when the game was lean and they would eat higher but it's it's yeah we're still guessing we're trying to reverse engineer from a few points of data you know we got three square inches of the Mona Lisa and we're trying to figure out what she looks like so there's room for from maneuvering there one of the things that I worry about will come to this is potassium intake and if somebody does pure carnivore and keeps their protein relatively low therefore not eating vegetables where does the potassium come from and so they a person may need eat more more of the lean protein to get the intracellular potassium to meet that need so it's a complex multi-dimensional map and there's a there's room to study the pure carnivore but I haven't seen any prospective studies of the pure carnivore diet and titrating protein and meaty mineral needs over spent my time yeah as an older person I've read about does for older people in the sort of the low-carb sphere and there's a lot of recommendation to eat more protein than you did when you were younger yes what do you feel about that yes but that's where there people are starting from 0.8 grams per kilo we have evidence that for older people eating at carb rich diet 1.2 is required top you may preserve lean body mass and function with aging I've not done studying in people over age 60 well 65 because we're 65 is the upper limit for our study in Indiana but it appears that the 1.5 value appear is still is is reasonably good for people up to age 65 but again to measure that precisely be got to get some older people with time on their hands lock them up in a metabolic research warden studying for no literally if this is to do it well you have to do it you know fastidiously and that's expensive and you know just one of the things we'd love to do at some point of time after all that's my my period now where's the like hi I just have a quick question regarding carbs and when you say was that still working you and when you say like up to sort of 10% do you count that as like your net carbs so like you with your green veggies and stuff your fiber - that all total carbs to make it simple because what's most on what's most labels and in most books of food composition is total carbs we make it total cups unless you're dealing with manufactured foods where people have purposely added a lot of what they call you know the soluble fibre to a product so for some manufactured foods more than half the carbs are soluble fiber but in most real foods it averages out in the 10 to 15 20 percent range so if somebody's eating 30 grams of total carbs are getting about 25 grams of net carbs but and I don't it promote you know eating a lot of the manufactured bars and things like that which you know with aware that would be give people a wider range one more question we'll move on any research on osteopenia or osteoporosis yes there is but we haven't published it yet excellent thank you we have we have femur and lumbar spine values at two years if you promise not tell anybody because they don't think anybody's going to consider this earth-shaking but at two years we see no sign in no sign of change in mineral density and lumbar spine in a group of people who's lost lost and maintain more than ten percent of their body weight on a ketogenic diet and we're really happy to see that because of this idea that ketones make your kidneys waste calcium and so it's it's one of the situations where there's no change is good news the next question I showed this yesterday this is the ketone data from our our patients in the Indiana University Health Study and this is 216 people followed out two to twelve months and again with what we see is again people with type 2 diabetes or highly insulin resistant and it's a victory get people to 0.5 and they say we're able to say above 0.5 out to here out to 8 months now they were becoming more insulin sensitive and yet the ketones are going down and so their questions about increased ability to use them so you know maybe they're they're using them more efficiently but our experience is for these people that they're they're expanding the range of their food intake and so you know they're experimenting with their their tolerance coming out to this point but still they're maintaining ketones at point four where as a fully carb fed person who's going to be in the point 1.2 range here but questions about intermediate individual variation or physiological effects hi and I was just interested to know what you think is the optimal time of day to test ketones given that there are very bit there's variability after exercise and first thing in the morning for example with the Doorn affecting diabetics and that sort of thing we tell for among other things we want people to get positive feedback if they're doing things right so we tell people to test their ketones when they first start out 2 or 3 times a day and determine their personal pattern some people are low in the morning because of the don't effect and they rise during the day when they're up and about with activity or other factors other people start high in the morning and then even though they're eating the food composition that that is it allows them to remain in nutritional ketosis they had a trend down and the other point is that we when we first started working the area of ketogenic diets we assumed that the majority of the benefit of this is feeding the brain now we know it's feeding the brain and the heart and if this is an optimum fuel for the heart as well and we also know it's an epigenetic trigger and once you trigger a genetic effect we don't know how long that lasts yeah once you flip that switch does it last for half an hour yeah well one bagel kill it or is it going to go on for half a day or a day or something so it may be the cycling through above 0.5 will give you a lot of the benefits even though you're not continuously in that range so again we're looking for the time when people are going to have the highest value and then measure at that point in time and you know so a it gives them a sense of accomplishment and B it may be the best time to obsess epigenetic signaling another one for me hmm the what I've heard someone mentioned about thyroid function and I'm getting into ketosis can you tell us oh yeah thank you for the quick question I'll try to meet the answer quick when somebody goes on a well-formulated ketogenic diet and I first saw this and reported it in 1980 and then pretty much every study I've done where we measured thyroid function the hormone the pre hormone made by the thyroid gland which is tetra Yodo thyromine we call t4 for short has four items on it to make active hot thyroid hormone you have to whack off one of the ions that's done by the liver and so the the when we measure t4 on the ketogenic diet you stays nice and constant when we measure t3 it plummets I mean typically drops 40% in the first week or two and then stays down and it happens in overweight people who happens in older people it happened in my bike racers and so it happened in the guys who were the ultra marathon runners that the ultra marathoners in the faster study had very low t fours compared to the guys of t threes compared to the guys were eating the high carb diet and when when we Jeff elected one study where he actually measured resting metabolism which is probably your best measure of you thyroid state and in a crossover study where guys were on the ketogenic diet I think for three weeks and then they were on the the high carb diet for three weeks or vice versa there was no difference statistically no difference in resting metabolism even though their t3 was down dramatically in fact it trended slightly higher and then since the year 2000 so we've had this thing called TSH which is the brain signal say make more make more and if they if the body was hypothyroid TSH should go up and it doesn't so the evidence is that the body becomes much more t3 sensitive increased sensitivity to hormone so you get a lot more metabolic mileage out of the that that hormone which means there's less work for the thyroid and the liver to do and it fits into the pattern and we also see improved insulin sensitivity so actually there's evidence that we're seeing multiple hormonal and sensitivities improving in lockstep when people go on this diet in other words say you know it's like you know getting twice the mileage other four per gallon of gas in your car dr. Kushner I'm starting to sweat but I'm just saying this points out a potential danger because there's a whole industry in the United States and I'm sure here as well where people are prescribing t34 lo t3 because they claim that the TSH doesn't adequately reflect that the bodies have thyroid exposure in for someone who's on nutritional ketosis this could be a real problem because you would essentially be creating an artificial hyper thyroid state yes actually a guy named Luis VIN Yanni in 1978 did that at the Beth Israel Medical Center in a group of people on a supplement at fast and when he made them brought the t3 up to their previously fed level their metabolic rate went a little bit higher but their protein wasting it was exciting their protein breakdown accelerated it was published back then and people have totally ignored that by the way our data is we haven't published that metabolic rate data anywhere else that in our blog because you know we have a hard time getting stuff published and you know we just will put it in the blog so it's in the blog on fertile health calm and that title is does your thyroid need carbs but in a recent study that Geoff is done on ROTC students that is reserve officers training students at OSU and these are students who are going to college but they're also in training to be military officers and they have some of them have major problems with weight gain in college so we recruited a bunch of them put on the ketogenic diet and we're tracking this including metabolic rate and we will publish the definitive body of data finally after a decade or so say if you mentioned jerk to testament from vegetables you have specific guidelines in sodium and magnesium and particularly here in Australia there's so many different types of salts and other salts and Himalayan salt somewhat like that but do you have specific guidelines you give your patients yes consulting my program card here if I get that far it's the day of the fourth slide from now four slides further we'll get to it thank you I would love to say that the next slide is and again I showed this slide yesterday maybe we can just skip this but this is basically indicating the range of foods that people can eat on a well-formulated ketogenic diet and again it shows the carbs in the five to ten percent range but it includes the fact that we encourage people to eat non starchy vegetables contributing in the range of 10 to 15 grams of total carbs and you know that varies from from Brussels sprouts wit and kale which are fairly high to lettuce which is quite in spinach which is quite low but typically we have people eating four or five servings of of non starchy vegetables per day we add berry fruits which includes avocado and tomato as well as berries reason we have called those berry fruits is there in the five to ten percent by weight sugar or carb in in in prepared form and that five to ten grams means that you can have a hundred grams of berry fruit per day it doesn't mean 100 grams of berries 100 grams of all account 100 grams of tomato it's in total so we're talking about things which are a garnish in the diet and that's those are therefore not just the volume and by the way you can put you know olive oil or you know saute your your cauliflower or your kale or things in olive oil and and that's a way of getting good fat in the diet so it takes some of this stuff here and you mix it with some of this stuff here and then cook it together so it's a vehicle to get fat in this volume it spits adds appeal and taste appeal to the foods and then nuts and seeds we like because they're portable and quite satisfying when people eat them and they contain a considerable amount of magnesium which again is the nutrient that that people benefit from and the other source of magnesium is anything that's leafy green and pointed that the Sun contains magnesium because chlorophyll which is the chemical the other the key chemical in photosynthesis has to have magnesium coordinated in the middle of molecule so if you wonder where where to find magnesium it's either in the things that are growing and pointed at the Sun or it's the nuts and seeds that are designed to have that starter startup that makes that green plant come out of the ground because it had magazine magnesium in there is a starting nutrient quick questions on that I think we're gonna get three kilometres of running out of our microphone ladies thank you slight slight tangent on the topic but an Australian gastroenterologist wrote a journal article about ten years ago stating that with weight loss a number of hormonal changes changes in ghrelin changes in reverse t3 and he basically put forward this idea of the physiological setpoint that the body ferociously guards a certain weight and will defend it obviously people lose a lot of weight on the well-formulated Kino genic diet is it just dropping the insulin that's responsible for that and do you ever get concerned with large weight loss about metabolic down-regulation and bounce back a year or two later it's good question certainly if we have this bad this bizarre reality TV thing and the United States called The Biggest Loser and Kevin Hall who I don't agree with most of the time did a study of people five years after they went through that show and showed that with an extreme of caloric restriction and exercise they could see a metabolic impairment five years later that represented about a four to five hundred calorie per day decrement in energy expenditure and that was based on a reduced expenditure per kilogram of lean body mass it didn't mean they had atrophied muscles the muscles they had had a lower metabolic rate so those muscles had been essentially it had suffered long-term damage I won't say permanent but long-term damage so the reason we feed to satiety is we want people to follow the internal signals and we don't think that we see that but again we're you know I've done smaller studies out to two years but in the Indiana study we're gonna follow these people that and study them out to five years to look for that so I'm sensitive to the question and as having a PhD of just an MD as the doctor they taught me to say I know the answer to every question you have there's a PhD I'll have two I have two questions you ask I won't know the answer one more and then we'll move on Stephen some some patients may note that they have percieved tachycardia and the heart racing can you make any comment on that so technical cardiac heart racing one is if people's exercise without maintaining adequate fluid in sodium intake they'll start out hypovolemic so they'll circulate long will be contracted to begin with and as soon as you expand a hundred calories that will warm your body from 37 to 38 degrees centigrade you'll vasodilate and the heart is going to have not in the fluid and it'll you'll have tacker you'll have a tachycardic response because there's even a circular circulatory volume that's easily corrected with a liter of fluid and a cup of bouillon but if people are magnesium depleted and particularly people with diabetes we are surprised by how frequently we see magnesium signs of magnesium depletion and that's muscle fasciculations little twitches and it's muscle cramps and it's persistent hypokalemia too persistent you know even if you give people after potassium our blood level stay low but magnesium depletion in the heart leads to tacky dysrhythmia and hopefully people will notice that early on and get corrected as opposed to having a really serious one that it's a non perfusing rhythm so I would be worried about it and the first thing I go is fluid volume and sodium and if that doesn't help people with the problem then I would and again my favorite test for magnesium to push you because the blood the test is terrible because almost all your magnesium is inside your muscles or inside your bones very little in the blood so it doesn't accurately reflect your status so I just do a simple deep tendon reflex test and if it's hyperreflexia that's a sign that that the person may have inadequate interest Soviet magnesium but for some reason people with the diabetes appear to have either problems absorbing or more likely impaired renal conservation and so they get in trouble with that and so probably two-thirds of our patients within the first six months or on magnesium a modest magnesium replacement and of course we need a lot of green vegetables let's move to so in the question of of resetting persons kind of a set point and there's there's a popularity around this concept of a set point you know that because if somebody loses all it goes on a crash diet loses a lot of weight and you track them down two years later most of them were back at that same that starting point and there was a guy named John Garrow who is a very famous obesity and metabolism researcher in the UK he lived in London but he had a summer home in a village in Scotland and every summer he go and spend a couple weeks in Scotland this is back in the 1950s when there wasn't much money for doing research so he would go to Scotland with a scale and there about 150 people lived in this village and every day or every year he'd set up the scale on the pub and people come in anyway everybody in the village men women kids young old and you know they all knew it's just this crazy doctor from from London you know but over the course of a decade he demonstrated that most of the population unless there were teen kids and teens or women during pregnancy most of them stayed remarkably weight stable from year to year they might have been overweight or a little underweight but they're stable and the average adult eat somewhere between three four so a million and a million calories a year and if your your way to stay with a five-pound zone you're you're just spontaneously controlling your at your energy balance within one percent you know that's ninety nine for foals versus 100 for fools I mean think of it that way it's very precise and so what we're seeing here and what we've seen in many people who follow a ketogenic chronically is they may not get down to a perfect yellow LED yellow and the ideal body weight but they achieved metabolic health and they come to a new steady state and so we need to think of this not as a set point that owns you but this is we hope a new settling point that this is what your your body spontaneously defended wages when you're in a mild state of nutritional ketosis can we make that settling point go different they've people are at 1.5 or 2 milli molar versus point four point five which is where these people are we'll have to find that but it's it's really intriguing that well some and we think this law has all the fingerprints that we're getting into that regulatory mechanism and shifting it in a positive direction and with that achieving improvement of all our health now I've been running over so I'm gonna take pop forward here again I showed this slide yesterday but this is basically the attempt to depict what happens when people start on who have weight to lose who start on the ketogenic diet if you've kind of reset they're settling point they eat to satiety at an intake that's far less than what they're burning and there is this slow chronic progression for most people as they lose weight and so we're kind of a an average five foot six inch woman who started a 180 pounds I can't make kilos out of that but you know got down to about from 90 kilos to 70 kilos and over time that if we hold carbs pretty constant maybe add back a little as they become more insulin sensitive keep protein constant in this case about 90 grams per day that person will spontaneously eating to society raise their fat intake up to the point where they come to a new steady state now you'll notice that the calories burned were estimating here come from 2400 down to 2000 because there is a increased energy expenditure associated with carrying around an extra 18 kilograms of body weight you know you it's easier to breathe it's easier to walk and and so on so even with a modest reduction in energy expenditure we reach a balance point which realistically is in this range and again here this is represents 70% fat about 20% carbs and I'm sorry 55% carbs and 15% protein this but this is not something we prescribed this is the natural phenomenon from most people who need to who want to lose and have extra weight to lose when they go on a ketogenic diet dr. J behaves here honoree dr. Hayes yeah we work with women over 40 and Australian women tend to self-medicate with wine you can tell by the love what impact would that have and you're monitoring ketones daily or a couple times a week we started monitoring ketones we started out daily and back off because of the expense of the strips eventually once people learn their own patterns but could you see that they've had a glass of wine so two things about wine and I've studied that extensively one is most dry wines you know so you're you know cabs your Syrah is your Pinot Noirs and then Chardonnay Sauvignon Blanc I'm not gonna say anything about New Zealand and wonderful wines but anyway for white ones anyway most of them are fermented down to less than two percent by weight sugar so if you have a hundred CCS that's one to two grams of carbs so you can have to grant two glasses of drawing wine and less than five grams of carbs so that would go in as an ounce of berry fruit I'm sorry yeah but the fascinating thing about ethanol ethanol does not interfere with ketosis liver can handle that just fine turns it into fat and we burn it you know and we by the way even people who drink in moderation their liver fat levels go down markedly when they go on to ki Jack thought in part because if my liver is making that hundred grams of ketones a day it's got to find 50 grams of fat to make that out of from from liver so you know it's it's actually a great way of getting fat out of your livers is letting it make ketones and secrete him into the blood but here's the problem who here has had say three drinks before dinner and then found that they were weren't hungry enough to eat dinner nobody no make no alcohol was remarkably non satiating if I had 300 grams of fat before dinner I need 300 grams less that the meal if that's very satiating so alcohol to experience and it was never really been studied that well in the States because we had prohibition everybody's been guilty about about alcohol and it's hard to study it in a in a prospective way but it appears that alcohol are run under the appetite radar and so you know more than a couple drinks per day is going to put somebody potentially in the positive energy balance because their calories you know it's made into fat and it has to be burned so I hate to give you depressing news but moderation and alcohol is really really an important part of this this equation with respect to alcohol and key times not so much from the sugar side but doesn't it affect glucagon and therefore impair the ability to make the ketones that let me put it this way I don't see that happening me in when dealing with two drinks and I haven't studied anything I haven't been conscious enough to study at higher levels of alcohol but dr. Krauss do you have any input on that question yeah we want to get this on the record excellent oh really good question I was just starting to google the answer yes we will study it intensely and come back next year when there's one more question then we're not just a brief comment so with for instance concentrated alcohol spirits people with type 1 diabetes can can become hypoglycemic and the mechanism is apparently that alcohol suppressors have had a gluconeogenesis so you can imagine that alcohol in some ways might be beneficial for ketosis because it's going to reduce the amount of endogenous insulin secretion don't tell people that note to the editor cut cut that's nice no no it's actually it's an important point we have a lot of study nutrition is not about single nutrients it's about the fabric of nutrients that we eat and how we vary one from another our responses and you know that's what makes it so exciting and also so complex so anyway I want to get on to my least favorite nutrient sodium why is it my least favorite nutrient because people you know my mainstream colleagues hate it when I put it to slime but this is not my slime this is from a bunch of heretics in Canada Oh Canada so in selim Yusuf's group at McMaster University in Hamilton Ontario they have been spearheading a 17 country study called the pure study and in this study they have been analyzing multiple lifestyle factors and outcomes in people in 17 different countries and they're adding to the volume and adding to the durations this is an ongoing thing and you may have heard this last summer that they published a paper they said when they looked at saturated fat intake in people in 17 different countries what they found was as you reduced the saturated fat intake more tau D it under 10% of energy per day of once was fat intake mortality goes up but there's no mortality increase at high in you know they published that in the New England Journal of Medicine this came out in the New England Journal in 9 2014 and what they did was rather than ask people how much salt did you eat yesterday which is how sodium intake is often alized in in epidemiological studies and this is epidemiology what they had people do was do a first morning void pee in a cup in the morning now that's not the the gold standard the gold standard have them collect every drop of urine for 24 hours but in people wandering around in Bangladesh you know carrying a two gallon jug to measure you know I've done 24 hour urine collections on myself for 45 straight days as a research subject man that really inhibits your social life it's not realistic so they got an 85 percent the r-value the correlation coefficient was 85 point eight five for first morning void to 24-hour collections in a sub cohort of people and what they found was so it's validated si what they found was that if you look at mortality risk this odds ratio is the risk of death from any cause and 22.0 means more than double and anything under this line is less but what they you know they found that the low point of mortality followed for three points there's a hundred and two thousand people followed for three point seven years this is a huge data set that the low point of mortalities between four and five grams of sodium intake or excretion per day and we assume that because we don't store sodium in the body in any significant amount the intake equals excretion I mean our my government dictates we should all eat 2.3 grams of sodium per day and if you have congestive heart failure or hypertension you need even less and that's the Saudi associated with 50% increased risk of mortality compared to the 4 to 5 grams per day that add to that that when you're on a ketogenic diet you experience something called natural recess of fasting now tree is a Latin word for sodium it's increased sodium excretion through the kidneys prepares to be due to increased production of good prostaglandins in the kidney because we know that because if you take motrin it'll shut off and if anybody here is taken to motrin after a hard exercise when they gained 4 pounds the next day and that's from fluid retention caused by shutting off the Nattrass as a fasting but the point is that if anything the sodium requirement if somebody's excreting this and a more rapid rate would be on this side of this point and so our range that we recommend is 5 grams a day unless somebody has ongoing hypertension or congestive heart failure and for people exercising in the heat with greater than greater than expected sodium losses due to sweat they can go as high as 8 grams per day I mean this is frightening this is like telling people they should eat 75% of the calories as fat and we tell them to do both which is why we have to have such an intensive education and support system because we're practicing multiple heresies but when we do this here people don't have symptoms of the Atkins flow or keto flow oh stop reaching out yeah and I think I just like to stress that it's sodium not even salt so that's five sorry that would be ten grams of salt yeah Stefan chloride hmm yes this is sodium there was a question in the back there we want to we want to get you on tape I just have a quick follow-up you said it you this claim was if you have ongoing hypertension or congestive heart issues don't go up that high so where do you go back to the recommended levels if you have hypertension chronically we we try to stay around three and we pay attention to symptoms but what's really interesting is people with congestive heart failure and hypertension within the first month of going on a ketogenic diet usually show show market improvement and so we can actually move them from from there to here as they progress to greater metabolic health up front here but it's my own in equals one and when I started eating real food and stopped eating junk no salt and because I suffer from high blood pressure I never put salt in my own cooking and I actually developed hypernatremia so my GP just said puts all your food and I don't count it I just put salt in and he's okay yeah salt to taste yeah when we get the diet right which empowers your instincts we were all born with you're probably gonna get to get you know get it right so if when in doubt trust your instincts and stick to them and therefore coming back again to patients with some ventricular function impairment and hypertension and they taking combination pills what is your comment on patients taking thurzday erratic and on a keto diet when they're taking out the thyroid diuretic or weird loop diuretic we don't add sodium we keep it in the two and a half to 3 grant we counsel two to half three grams per day but those are some of the particularly the thigh sides and and then the furosemide or the things I want to get them off early because what happens is when they you'd like with you have too much insulin when you have too much diuretic you're gonna have people who are out in the Sun and they're gonna pass out because it impaired that and beta blockers impair their ability to respond to a hypovolemic challenge so again less meds is better as long as they're metabolically improved and in terms of health and and these parameters I'm almost done if they're not out of time Rod Taylor hasn't started throwing objects at me but I do want to get to the next slide which looks almost exactly like this one except this is potassium and this is from the exact same paper and this is exact same cohort one hundred and two thousand people followed for 3.7 years and look at the shape of this curve in terms of mortality risk and I guess we're now talking about anybody's numbers but this is one gram of potassium for today that's two and that's three and you it's going from two down to 0.8 now what other nutrient do we know that we can adjust across a threefold range and and and again this is epidemiology it doesn't prove that if you take people from one to three you're going to cut their mortality rate by more than half but it certainly strongly implies that hypothesis and we have the mechanism now the reason why I put this up here and you know there was a question about the carnivorous diet and if you fall if people follow my protein recommendations which is 1.5 grams per kilo and they use fresh meat you know real meat chicken fish so real food meat not hot dogs and not luncheon meat because when you process food you take the potassium out of it to the great extent it still tastes savory because they put more something so it's not bad but losing the potassium is a big deal so using unprocessed meat and you eat 1.5 per kilo you're going to get about one gram per day of potassium intake that's not enough so if somebody's not eating any vegetables and if they're not taking bones and you know undesirable pieces the animal and putting it in a pot and boil it where there's enough flesh in there you're getting potassium so you know which people talk about bone broth well I like mom broke leg bone and meat broth you know when you make broth you can add a certain amount of potassium and it may be as much as a gram per day if you having two cups of homemade broth so the way you get more potassium is you add vegetables or you add vegetables and broth but the other ways you get from here to here would be to double your protein intake so maybe the reason why people instinctively want to eat more protein when they're on a carnivore you know a pure carnivorous diet is that that's where you get to at least this relatively safe spot and then as I was cooking in with Rod Taylor and and his wife cat in the kitchen and I was talking about and stuff right said oh by the way we have this light salt stuff and you can buy a a of commercial long you know in the gamma grocery shelf it's not a pharmaceutical product this 50% sodium chloride is 50% potassium chloride and the whole idea is there was get people eat less sodium by you know shaking the sodium potassium on there but it's half potassium so if you take a level teaspoon of that you get I think a bit over one gram of potassium by using light salt in cooking I you know this I like the flavor of salt but potassium actually has a bitter flavor and the reason they only make it 50/50 is to cut the bitterness but if you put a teaspoon of that and water and time to drink it every day you develop an aversion I'm pretty sweet diversion to to that but using it in cooking or making broth with it and I do use that in broth to enhance the potassium content of broth so there are ways that you can you can get this much potassium and you know this is mundane you can when the way this stuff sells for what you think rod two dollars for you know 300 grams or something yeah there's something like that yeah it's it's really in all supermarkets light salt Li t a - salt it's cheap it's safe if you don't have kidney failure yeah and yeah but this is nobody makes a profit doing this so nobody's gonna have an advertisement TV saying buy lights all get your potassium up cut your mortality you know they want you to take something it cost us three thousand dollars a year not $3.75 a year anyway I'm just to finish up I want to point out that there are many things and we now understand that ketones do you know when I first got into this business I said it's great you know you got body fat you can release those fats the liver will take it up make ketones a little feed your brain yeah cool this is much more complex and most of it is good we now know that the heart is loves ketones and in the failing heart in particularly prefers ketones because once the liver makes the ketones it takes oxygen to make ketones in the liver so you fat comes the liver you got to have oxygen coming make ketones once they're in the blood is fuel the heart can generate energy with 20% less oxygen so if you have an artery that isn't this big but that big and there's not much oxygen coming into your heart but you got ketones there you can get more ETP from the small from that limited amount of oxygen hey you know 20 about 20% of the advantages again find a drug that did that like retire there's been a study done two studies done in the US on health span and life span in mice with either an intermittent ketogenic diet or continuous ketogenic diet the ones who are given that continuous ketogenic diet lived 13% longer and here's the really two neat things about them when they were they lived to be like 1,100 days most mice when they get to 900 days they're female I can't remember where to go where the food is they can't hang on to things you know they can't walk across a narrow strip over water and they don't notice new novel things in their environment these animals on the ketogenic diet maintain their youthful muscle nerve and awareness out to 900 days so the health spam was dramatically improved and lived 13% longer and when they did autopsies when they died they found less than half as many cancers because these mice the c57 black 6 strain commonly dies of cancer at old age and the frequency of cancer was reduced yet they lived longer and had fewer cancers does that prove it works in humans no I will tell everybody that mice are not a good model for humans but it's a good basis for hypothesis and hopefully this will stimulate a lot more research on that and let me just say thank you just to prove myself that I wasn't that old I could still climb my local 42 or for 4200 metre mountain I did it on the first time a low car back in 2005 and I've been up 4 times since then if you ever come visit me in California maybe we'll well I'll go out and climb my local volcano it was beautiful up there except one no weather comes in anyway thank you much [Applause]

Channel: Low Carb Down Under

Views: 606,970

Rating: 4.8602076 out of 5

Keywords: Low Carb Down Under, LCDU, www.lowcarbdownunder.com.au, Low Carb Gold Coast 2018, #LowCarbGC, Ketogenic Diet, LCHF, Low Carb High Fat, Nutritional Ketosis, Virta Health, Jeff Volek, Steve Phinney, Ketones, Metabolic Syndrome, Stanford University

Id: RYXYfxmQV2A

Length: 59min 7sec (3547 seconds)

Published: Tue Jan 22 2019

Reddit Comments

[u/TomJCharles]

This is also a great article on why some people may have trouble on keto with suggestions on what to do. (tldr: may need to cut fat back a bit and increase protein, and make sure you're not eating hidden carbs)

The Personal Fat Threshold Concept, Tuit Nutrition

(I'm not affiliated with her in any way, just thought it was a good read)