[Preview] Keto diets for epilepsy

So the idea of using diets or fasting for epilepsy goes very, very far back probably 400 BC with Hippocrates And they really didn't even know what seizures were back then

They thought maybe it was possession or demonic possession They really weren't sure, but they knew that periods of starvation would help They thought maybe that was ill humors and that by not giving foods that would provide those ill humors, patients would get better And it actually worked if you sort of read these articles way back These references from Hippocrates, they talk about prolonged periods of fasting being helpful

And then Galen in 200 BC was a little more specific again getting to ungendered humors that may be necessarily negative We didn't know exactly what was going on back then This is where a lot of people think sort of the reference of using ketogenic diets for epilepsy goes back to But again it was probably 400 years earlier but the widely described references from Jesus in Mark 9, where they talked about an adult who had what appears to be childhood-onset epilepsy, they didn't know what it was, the patient had a convulsion on the ground and Jesus's prescription was prayer and fasting Neither are bad ideas

And it worked, so they knew about this for hundreds of years even through the Middle Ages that periods of abstinence for whatever this condition was seemed to be beneficial

DRF 17: Science and Practice of Low Carbohydrate, High Fat “Keto” Diets

(indistinct chattering) (uplifting music) – Good afternoon everyone, and welcome to Research Forum Thank you for being here today

Today it is my pleasure to introduce our two speakers, Dr William Yancy and Dr Eric Westman, who will be telling us a little bit today about the science and practice behind low carbohydrate, high fat keto diets, which I know is a great topic of interest, especially to those of you who work in prevention of cardiovascular disease and know the difficulties of managing obesity as a risk factor Our first speaker today is Dr Eric Westman

Dr Westman is an Associate Professor of Medicine and the Founder and Director of the Duke Lifestyle Medicine Clinic He received his MD from the University of Wisconsin-Madison and his Master's degree in Clinical Research from Duke Dr Westman has been at Duke since 1990 and has over a hundred peer-reviewed publications, is a past president and Master Fellow of the Obesity Medicine Association and Fellow of the Obesity Society

He's authored multiple books, including the New York Times best seller, The New Atkins for a New You, Cholesterol Clarity and Keto Clarity, and is a co-editor of the textbook, Obesity Evaluation and Treatment Essentials And then after we hear from Dr Westman, we'll be hearing from Dr William Yancy, who's a General Internist and Obesity Medicine Specialist and Associate Professor of Medicine here at Duke Dr

Yancy received his undergraduate degree from Duke and his medical degree from ECU before obtaining his Master's in Health Sciences from Duke He did his training in internal medicine and was chief resident at University of Pittsburgh, and his primary role is Director of the Duke University Diet and Fitness Center Dr Yancy is a fellow of the Obesity Society and a diplomat of the American Board of Obesity Medicine and has over 100 scientific publications and has led multiple clinical trials investigating the safety and effectiveness and tolerability of diets and medications for weight loss Please join me in welcoming today's speakers, Dr

William Yancy and Dr Eric Westman (audience clapping) – Thank you for that introduction and it's a pleasure to be here I feel like I'm coming home to where I grew up And I know you never can really go home, but we both went through the clinical research training program under a different name back in the early '90s, and so this is back into the, at least the evidence-based home and clinical trial home

It's great to be here Now I also have had kids and had them go through school, and so I'd like you all just to close your eyes a moment and raise your hand if you're following a, wait, you have to close your eyes (audience laughing) Close your eyes for a moment Raise your hand if you're doing a keto diet Okay, I'm opening my eyes

Close your eyes, okay So I can just tell you that, oh, close your eyes Or wait, lower your hand (audience laughing) I can just tell you, you're not alone but I can't tell you a percentage of folks But it's great to see that there's some headway being made even in a house that cardiology built because you need to know that this is okay for heart disease

Now before we get to the science and practice of low carb, high fat keto diets, I need to just tell you that there are lots of ways to lose weight Obesity medicine actually involves not only lifestyle, which is what we're gonna talk about in the lower left hand corner here, but also medications There are four new FDA-approved medications that I don't use in my clinic but other obesity medicine doctors can You can do a very low-calorie diet, which Dr Yancy has

I don't use that myself And then last but not least, you can go have that down the street to, our surgical colleagues have bariatric surgery But in my mind, in my view, you would never have surgery before you tried lifestyle, lifestyle and medication, you try the barn shake programs, the very low-calorie diets In our crazy world today, you can walk in and get the surgery without having tried any of those things So just to show you in the medical obesity world, we're talking about risk and cost

In the lifestyle medicine world, we're just talking about changing the food It's just changing the food Just put that in context This is from an obesity algorithm, obesityalgorithmorg or

com You can download these slides and become an expert in obesity medicine in a minute Looking at the nutritional slide, there are low-calorie diets, which you could restrict fat as the method of lowering the calories, or you can restrict carbs as the method of lowering the calories These are just different ways to do it Not wrong, not one right or wrong

They both can work And as you're gonna see, we're gonna focus on the evidence behind the low carb diets But it's not the only way to do it And then the very low-calorie diet on the far right is the program that Dr Yancy has here at Duke

So when you get to the low carb diets, the science and the simplified way to look at this says that the lower in the carbohydrates you go for the whole day, the less carbohydrate you eat, the more your body has to find fuel from fat And so if you go to 50 grams or 20 grams of carbohydrates for the whole day, your body has to find a fuel source, and it looks too fat because generally as humans, we store fat as the fuel And so you're gonna start burning your own fat, you call this the ketone threshold, and now a keto diet It's all confused now because you can measure the breath ketones, you can measure the blood ketones, you can measure the urine ketones, and they don't always go the same way Well, we don't measure ketones at all in our clinical program, we just keep the carbs low enough so we know that you're in ketosis

You don't even have to measure them How's that for simplification, huh? So here are the other, this is the other demonstration that if you go lower on the carbs, your appetite goes down and the keto diet or low carb ketogenic diet becomes a low-calorie diet without even talking about calories So there are good carbs, there are bad carbs In general you can think of the vegetables, non-starchy vegetables as the good carbs I don't know of any popular diet program that would really recommend that you have Fritos or Cheetos or Dr

Armstrong, a couple Snickers bars? (audience chuckling) Yeah, so we're talking about real food That's what we're talking about Dr Yancy – Good afternoon everybody

It's a real pressure to talk with you all about this way of eating that we've been studying for almost 20 years now and we've been using in clinical practice for about 10 years now And so I've been charged to talk to you about the evidence, primarily evidence from clinical trials, and so I'm gonna go through a number of clinical trials that we've done and that others have done and just try to give you an idea of what some of the health effects of these, this kind of eating can have So before I start with the evidence, I do wanna kind of help you to understand what we're talking about when we talk about a low carbohydrate or a very low carbohydrate diet, particularly these ketogenic diets So I'm gonna go through how we teach our patients and our participants in our clinical trials, first off, I just wanna point out how simplified this approach is So if you look at these instructions, they're pretty simple, they fit on one page

Now there are some other instructions that we give patients, but essentially this is what we tell them And we teach them how to reduce carbohydrate intake to less than 20 grams per day, okay? 20 grams is not magical There are some people out there that say you're not getting to 20 grams, you have to get to 20 grams It's just a starting point that we have noticed that most patients have success with if they start there and then we can add carbohydrates back into it, into their diet to a certain level where they can continue to have success So 20 grams is really just a starting point

If you follow these instructions, you don't even have to count the carbohydrates You will be eating to a 20-gram per day carbohydrate diet So pretty straightforward, notice that certain foods are unrestricted So meat and eggs are zero carbohydrates So you can have unlimited amounts of these foods

This is really helpful to patients who are trying to lose weight and might get hungry while they're following a diet approach So you don't have to think of this as a diet, a diet we think of as a transient thing that you do for a period of time just to lose weight We think of this as a nutritional approach, a lifestyle, a way of eating, and we don't want them to think of themselves being or feeling restricted So they have foods they can eat if they need to There are some other foods on here, cheese, several cups of vegetables, salad vegetables or things like lettuce, spinach, collard greens, parsley, things like that

And then the one cup of low carbohydrate vegetables are foods like asparagus, broccoli, cauliflower, cucumbers, mushrooms, tomatoes So a wide variety of vegetables that are low in carbohydrate, and you can incorporate into your diet without going over 20 grams per day, okay? Notice that I don't call this a no carbohydrate diet too A lot of people will say that I'm not a no carbohydrate diet or I'm not eating any carbs These foods, after the meat and egg, these foods do have carbohydrate in them so it's not a no carbohydrate diet

As I mentioned with the unrestricted amounts of meat and eggs, calories are not restricted So this means that people can eat when they're hungry Now the unique thing I'll show you in a few minutes is that people end up self-restricting their calories They're not hungry on this diet approach And so they don't end up eating as much calories as they used to eat before they're eating this way

And as I also mentioned earlier, carbohydrate intake is slowly increased as someone reaches their goal weight And we teach people that there's a certain level they need to stay below in order to lose weight, and then there's another level that's higher than that, that they need to stay below in order to maintain their weight, okay? So one of the biggest pitfalls people run into is adding carbohydrates back into their diet too quickly or too much, and that's when weight gain or weight regain occurs Most of the studies have been done with people taking a multivitamin, and so we encourage people to do that And then as I'll show, the diet can be dehydrating, it causes a diuresis and so we encourage people to drink lots of water And I'll talk about that a little more later

So we call this a ketogenic diet, and I wanna talk a little bit about ketones because as health professionals, we learn that ketones are harmful and dangerous So we learn from Type 1 diabetes that ketoacidosis is a hazardous condition, and it is; but that's not exactly the only role for ketones So I wanna explain them Ketones are simply molecules that deliver energy So just think of them as your backup fuel source

So if you were to reduce carbohydrate intake to a certain level, then you will need to find another fuel source and that will be your fat, or the fat that you're eating And that fat that you have, stores in your body, is broken down into fatty acids and ketones And these ketones can be used to deliver energy to most of the tissues in your body In fact, there are only a few pretty energy- not-requiring tissues that need something besides ketones So the erythrocytes, the cornea, the lens and the retina need glucose, and there's ample glucose left in your body to supply energy to those tissues and all the other tissues, in particular, your brain, can survive and get energy from ketones

Now notice this table, the table shows that ketones are in our bodies at any given moment So those of you who just finished eating your lunch, you still have ketones in your body at a very low level, but you have some This morning when you woke up before you ate breakfast, you had them in a higher level And then if you were to go on the induction, the most strict phase of a low carb diet, then they would be at a little bit higher level, at about one to three millimoles per liter Now it's not until you fast for many days or in particular, go into ketoacidosis from not having insulin if you have Type 1 diabetes that you go into a derangement where the ketones are so high that they cause acidosis, and that is harmful for your tissues and your health

So this was obviously a concern when we first started doing our research on this nutritional approach, and so we actually wanted to look to see what happened to people following this diet, and we checked blood gases on a lot of our patients Yes, they did agree to have me stick them in the wrists over and over again during a study, and we found out that their pH never went below 737 That's actually in the normal range So we didn't see acidosis occur while they were in ketosis

So let's talk a little bit about the weight effects of these diets This table shows some of the earlier studies, including ours, that showed a weight loss effect at six months and 12 months, depending on the study And the kind of general consensus that came from these studies is that a low carbohydrate diet has a beneficial impact on your weight regardless, but it seems to have an advantage over a low fat, low-calorie diet, particularly initially in the first six months or so And you can see in blue here that there's greater weight loss, and that asterisk means there's statistically greater weight loss at six months for those four studies, whereas when it stretched out to about 12 months, the weight loss was not as clearly statistically different between the two approaches There was still weight loss, so both diets were creating benefit, but there wasn't such a distinction between the two diets

So this is where a lot of people will say well, low carbohydrate diet is better for weight loss initially, but it's not necessarily better in the long run Well, I think we've got more evidence to actually argue against that, but I think it's important for us all to know that this means that we have two approaches that can work, at least two approaches that can work and not just one So I don't think of this as well, which one wins? I think of this aa well, this is another approach if this works better for you So we have two studies now that are really well done, well controlled, randomized studies that have extended the duration of follow up to two years And in the first study down here at the bottom left was a study done in Israel, and that was actually a three-arm study

If you can't see the three arms, one was a low fat, low-calorie diet, that's the red line; the yellow was a Mediterranean diet; and the blue was a low carbohydrate diet And this again confirms what I've said earlier, is that a low carb diet seems to do better early on, and it seems to kind of converge as time goes on But in this particular study, the low carbohydrate and the Mediterranean diet did better than the low fat, low-calorie diet at two years And then in the upper right hand corner, the two diets basically paralleled the entire duration You can see there is similar weight loss, good weight loss with both of these approaches

And if you look at meta-analysis now, and I'd like to show this one just to show you how many studies have been done, and this is not all of them, it's not exhausted, this is just the 12-month or longer studies, we now see that a low carbohydrate diet seems to have a small advantage in terms of weight loss at 12 months or longer So about a kilogram, not quite a kilogram, that's about two pounds greater weight loss with that approach But again, both of the approaches are working So how does weight loss occur on a low carbohydrate diet? It's a question I get a lot Why are people losing weight? Aren't they just losing weight because they're restricting calories? Well, that's right, they are

So they're restricting calories, but they're not trying to We're not teaching them to restrict calories, we're just saying lower your carbohydrate intake and then spontaneously they eat fewer calories So that they're still losing weight because they're eating less calories, and this is probably one of the, you know, this a good example of that This is from one of our studies where we put people either on a low carb or a low fat diet, and the black bar is their baseline diet So both groups were eating over 2,000 calories a day And then with the low carbohydrate participants, they reduced it to a little over 1,500, something around 1,600 calories per day, even though we didn't tell them to pay attention to calories at all And on the other side, the low fat group, we taught them specifically

We want you to reduce your calorie intake by about a 500-calorie deficit per day, and that's what they did So they ended up both reducing calories So another thing that's out there is, could this be water loss? And yes, that is part of the equation So with the low carbohydrate diet, there's a diaeresis that occurs primarily in the first couple of weeks And this is important to know for a few reasons

First of all, because that's part of the initial weight loss that occurs So that can come back on quickly if you start eating carbohydrates Another reason why you should know that is because it's really important to hydrate, especially in the first couple of weeks, okay? So you can see the lines up here that the real drop is just there in the first two weeks, and then thereafter, the water loss or the water level, this is measured by bioelectric impedance, is pretty comparable between the two diet approaches So we really encourage people to drink water, particularly in the first couple of weeks, and we'll actually encourage them to make sure they increase their salt intake I know we're gonna talk about increasing their fat intake, now we're talking about increasing their salt intake

This is different from all the guidelines that are out there but it is important, particularly in the first couple weeks, to get salt or broth in your diet so you can hold on to your fluids, and then you don't have some of the symptoms that people will have early on when they're doing a low carbohydrate diet Some people call it the Atkins flu or the low carb flu or the keto flu, people can feel rundown, tired, have headaches, get muscle cramps And if they hydrate well enough and they get their salt intake, this doesn't happen and they tolerate it quite well Even if they do have those symptoms where they can stick with it, usually after two weeks those symptoms go away and they feel fine after that So it's typically in the first couple of weeks

And then one other question that we frequently get regarding the weight changes that occur regards this possible metabolic advantage So everybody wants to know what's the best way for me to keep up or boost my metabolic rate? And if you're not familiar, when people lose weight, their metabolic rate goes down That's, if you haven't heard the Biggest Loser study that came out a few years back, was really kind of the first study that told me, we knew this but it's the first one that really showed us this really clearly, and this is what makes weight loss difficult and particularly weight maintenance difficult When people lose weight, their metabolic rate slows down and so they're not able to continue burning energy like they used to be But this diet wanted to see if there's a metabolic advantage

And so it's a randomized crossover study and they had a run-in phase where they put people on a diet and found out what their maintenance diet would be And then they randomly assigned them to either a low fat diet, a low glycemic index diet or a low carb diet And that's this part down here, I don't know if this laser works so well, but this table right here shows you the composition of the diet So the low carbohydrate diet was 10% carbohydrate and 60% fat and 30% protein So participants successively randomly went to the next diet approach until they've done all three of the diets, and for four weeks of each each one

And they measured really carefully the resting energy expenditure using indirect calorimetry and then total energy expenditure using doubly labeled water So these are gold standard techniques to measure energy expenditure, and they show the low fat, low glycemic index and the very low carbohydrate diet in succession in both of those graphs there And what happened is that the energy expenditure was a little bit greater with the glycemic index diet than the low fat diet, and it was even a little bit more, a little bit higher with the low carbohydrate diet So this shows there might be a little bit less reduction in the metabolic rate using this particular diet during a dietary intervention So I want to go into some of the metabolic effects that can happen too

So this is a big question that we receive What's gonna happen to my risk for heart disease? If this is a high fat diet, I've just told you it might be a high salt diet, what's gonna happen to my blood pressure? What will happen to my cholesterol levels? We know that fat raises the cholesterol, raises your risk for heart disease, or that's what we've all been told, but that's actually probably not so accurate And these meta-analyses I'm gonna present to you will show you a little bit about the effects on these risk factors So again, this confirms the weight effects that we saw in a previous slide, about a kilogram greater weight loss with the low carb versus the low fat diet, and that's what the middle column shows you there It actually shows you that blood pressure seems to do just a smidge better with a low carbohydrate than a low fat diet, but it wasn't statistically significant in this meta-analysis in about, it looks like, 18 trials

And then look what happens to the cholesterol effects And this is kind of the hallmark of the metabolic effects of a low carbohydrate diet It's a higher fat diet, and what fat does to your cholesterol results is it raises your HDL cholesterol It raises your good cholesterol, okay? A lot of people know that if you want to raise your good cholesterol, you exercise more, right? Not many people know that you can do that also by eating more fat And it's any kind of fat

In fact, saturated fat probably boosts it the most But unsaturated fat will also boost your HDL cholesterol, okay? Now the difference between those two is that saturated fat also boosts your LDL cholesterol, or potentially can boost it, whereas unsaturated fat does not, okay? So this is what you see when you're comparing low carb versus, or minus the low fat diet You see that you get a boost in the good cholesterol, the HDL, but you also have a little bit of a boost with the LDL cholesterol And so really, the risk is a wash, or maybe if you remember that HDL is a little bit more of a powerful risk factor, you probably get a little bit more benefit with a low carb diet just because that HDL is going up three points there And then the other consistent effect you'll see is that the triglycerides go down

And we actually can use this, follow this risk factor, this triglycerides, just actually to see how adherent people are So Eric was talking about ketones being one of the ways that we can look for adherence, but triglycerides will go down when you reduce carbohydrate intake, okay? It's really, really consistent, also not really well known, not really intuitive Why would the fats in my blood go down by cutting back on carbohydrate intake? But it's what happens So this looks just like the last slide, but it's not, okay? So this slide actually is a different meta-analysis, and what they did in this one is we, actually I should say we did in this one, we looked at the change from before and after just in the low carbohydrate arms of these studies, okay? And I think this is useful to know So not in comparison to a low fat diet, just what happens on a low carbohydrate diet

And again, you can see the changes there Now you can see how much weight loss can be expected on average, the blood pressure changes that you can expect on average on a diet like this, but I think what's meaningful is to look at the LDL level Notice that on a low carbohydrate diet, your LDL level doesn't go up necessarily It just doesn't go down as much as it does with a low fat diet And that's why in the last slide, you could see a benefit going towards a low fat approach

And look how dramatic the effect where their triglycerides are So diabetes is probably the issue that we think that a low carbohydrate diet might have the most benefit And so I wanna spend a little bit of time going over some day regarding diabetes This is a systematic review It shows you that as a number of investigators have looked at this issue and wanted to see how much reducing carbohydrate impacts our blood sugar control

So this is a little bit of confusing of a slide, but they took any trial that had less than 45% carbohydrate recommendations and followed people for at least two weeks, up to 26 weeks, and they plotted it on the horizontal access as the percentage of carbohydrates, carbohydrate and calories I should say that were recommended; and then on the y-axis, it's what change in A1c occurred, okay? And so the line shows you that as you restrict carbohydrates lower, then there's a greater decrease in hemoglobin A1c, or improvement in glycemic control So we reviewed this study, among other studies, with the American Diabetes Association in 2010 and wrote some recommendations These are probably the first recommendations that have come out that actually supported a low carbohydrate diet for diabetes, and there's still several guidelines out there that don't recommend a low carbohydrate diet and sometimes caution people against using low carb, lowering carbohydrates for diabetes But the American Diabetes Association guidelines in this year actually did support it, and it is based somewhat on what we found in the literature We updated a literature search looking at this diet approach among other diet approaches for diabetes, and we found quite a number of studies, 11 trials done with a low carbohydrate diet compared with similar other nutritional approaches

And six of the 10 studies showed an improvement in A1c, whereas with the other diet approaches, less than half of the studies that were looked at actually showed an improvement in A1c And then most recently, this just came out in January of this year, they did this network meta-analysis which is pretty interesting way of looking at studies that might not have the exact same comparisons, not all necessarily low carb versus low fat, they might be comparing low carb to another diet approach or to a high-protein diet or a Paleolithic diet And so they tried to combine all of these studies and compare each of these nutritional approaches to see what they can find And first off, I think what's interesting is to see that the low carbohydrate node, that's the blue dot at the end, is one of the bigger dots, meaning that it has one of the bigger sample sizes of participants that have been studied in multiple studies But these are the different nutritional approaches that were studied

And their summary was the bottom bullet here, that for reducing A1c, the low carbohydrate diet was ranked as the best dietary approach in the ranking order, the sucrose statistic that they used, followed by these other diet approaches So we think that for blood sugar control, and this makes intuitive sense, actually it's one of the few intuitive things that we'll talk about metabolically that happens with this diet approach, is that carbohydrates are what drive our blood sugar level And so reducing carbohydrate intake lowers the blood sugar level So I just wanna show just a couple of other studies that we've done over the years since we originally did the head-to-head kind of low carbohydrate, low fat studies This one was one that stemmed from, first of all, we heard or we we saw from our own research and other's research that a low carbohydrate diet might be more effective than a low fat diet

So what about a low fat diet combined with a medicine? How would it compare against the medication? And in this study, we compared it to the one medication that was available at the time, Orlistat, and you may have heard of this as Xenical, it's now over-the-counter as Alli, and this is the result from that study in terms of weight loss And then you can see there's a little bit of a benefit to the low carbohydrate diet initially, but at the end of a year, there seems to be comparable weight loss in the two approaches, one being a diet alone and the other being a diet combined with a medicine I'd like to show this slide also, and I don't know how well it projects, but the blue line, the dark blue line, is the average for the Orlistat group; and the dark red line is the average for the low carbohydrate group But you should also see in the background hopefully some lighter red and blue lines, and this shows the variability that occurs in a weight loss trial and also with our patients There is a wide variety of response to either of these approaches, and we see this repeatedly

And I think this is something that's really lost in a lot of the press about these clinical trials We talked about which one works better On average, what happens? But in any individual, somebody might actually gain a little weight during the study, and there might be people in each arm, and believe me there are blue lines and red lines down here at the bottom, people who are losing in one year more than 30% of their original body weight with diet too This is not surgery, this is just with diet So it can be really powerful in the right individuals or the people who are really motivated or stick to it, or maybe it's just the right approach for them

This last one I'm gonna talk about addresses an issue a lot of even experts have come up with after all of this information has come out, and that is well, we have a lot of nutritional approaches that work, maybe we should let people choose Well, maybe that's not the best idea So we wanted to test that So obviously, letting people choose what diet approach they follow might be beneficial because it might mean they adhere to it better This is one they picked, it might be based on foods they prefer and therefore they might be able to stick to it longer

But it also might be the foods that have been causing the problem all along So we tested this in a doubly randomized preference trial where we actually randomized one group to get a choice and one group did not get a choice And then those participants who did not get a choice were randomized again to either a low carb or a low fat diet, okay? And this was a year-long study and yielded some pretty interesting results Turns out the control group, even though it wasn't statistically significant, did slightly better So it was the different direction from what we expected

So no difference between the two groups Choosing certainly did not create a benefit and potentially could have gone the other direction It might have actually gone the wrong direction All right, so hopefully this is a message that you snicker at after hearing some of the metabolic benefits you can get from a low carbohydrate diet I see people craning their necks so I'll read it

He says, "You went on Atkins and lost 90 pounds, "lowered your cholesterol, cured your high blood pressure, "and now you're walking five miles a day "But I'm warning you, "a low carbohydrate diet is bad for your health!" Something we still run into periodically All right, I'm gonna pass the baton on to Eric, and he's gonna take over from here and tell you a little bit about his clinical experience in our clinic, where we teach patients this approach – Thank you, well done And I should translate Atkins, it's not Atkins, it's keto now

So the first phase of Atkins is keto And then I'm also gonna add in, "And my LDL went up 10 points, so it's gonna kill me" So as a joke because this is the last vestige of what has to change, is only the focus on a certain part of the lipid profile It's the metabolic syndrome that saved the low carb diet in terms of producing cardiometabolic risk So about 12 years ago now, the Duke Lifestyle Medicine Clinic was founded in 2006 after what we thought was the equivalent of phase III clinical trials for FDA approval of a drug

So oh, except there's no requirement for a diet But we were trying to apply that same metric When do you start using a diet in a clinical practice? Well, when it reaches a certain level of evidence And why not use a metric that the FDA uses for drugs? It's something we're all familiar with So we opened a clinic at university, within the Duke private practice

There are two rooms adjacent to an internal medicine teaching clinic because that's the general medicine home that we're in academically There's an obesity medicine specialist, yours truly; a clinical nurse assistant; and the payment is within the public or private insurance system The first-line treatment is a low carbohydrate ketogenic diet I should have said this at the beginning, I have two conflicts that may change how you hear what I say, but not what Dr Yancy says, is that after 12 years of research in clinical care, I started two companies with other entrepreneurs, one to make low carb products and one to make a teaching company to teach doctors and health practitioners how to do this

So I'm actually owner of those two companies But I still work at Duke full time (audience chuckling) A busy life So thanks to some of you who are here in the room, students, patients, colleagues We now have over 10 years of data in the Duke system

We moved to Epic about five years ago in our outpatient clinic, so we've seen now 4,000 patients at the Duke Lifestyle Medicine Clinic with 28,000 clinic visits which keeps me in business and makes my paycheck Most of it is insurance payments, Medicare, Medicaid The average patients we see are 505 years old 75% are female, half Caucasian, half African-American, which is our Durham patient mix

Most are from our area When I visited doctors who were doing this for a living, many of them were kind of in a guru-type practice You would go visit someone, and then you'd go home Actually, most of our patients live in the area here And the payer mix, 50% private, 50% public

And over the last five years, sorry, that's the last five years, 2,000 patients have lost 28,000 pounds in a quality assurance, quality improvement sort of data analysis we want to make this publication quality, which means I wanna replicate it again doing it in a different way Because if you've used the Epic and deduced, there are some quirks to using it But that's pretty exciting Someone says, do you believe in low carb diet? Do you believe in the keto diet? I'll say something like do you believe in gravity? (audience chuckling) You didn't see it in the back, so I do believe So it's science

It's not a belief Well, although you might argue philosophically science is just a belief system that you can replicate over and over and over So this is known as the clinic of last resort I'll have people say they've done everything twice Ah, but I'll say but you haven't done this with me

So most doctors don't get trained in how to help people lose weight Anyone wanna verify that? You doctors who never were trained? We didn't get nutrition training It even occurs today Medical students do not get trained I went out to get special training

And then with Dr Yancy, we were privy to data that no one else really had collected on the low carb diet So we treat obesity, Type 1 and Type 2 diabetes, polycystic ovarian syndrome, irritable bowel syndrome, fatty liver and GERD We have papers, at least proof of concept papers, published in the literature for all of these conditions in that first bullet We look back and we say well, okay, yeah, there were five people over six months with liver biopsies that show that fatty liver goes away, so it's not enough to like FDA approval for that indication, but that's pretty good evidence it's the carbs that cause the fatty liver, not the fat in the food

It's the carbs in the food Think foie gras, where you feed geese carbs to make fatty liver And that's a delicacy in some parts of the world Heart failure, pre-heart transplant So I'm an old general internist from Duke who you know, we could treat anything, and now I realize there is a specialty called obesity medicine, we can't treat everything

But I still have that vestige, so the heart failure folks started to get wind of what I was doing without pills, without products and just changing the food and now we have over a dozen people on the heart transplant list So the the cardiothoracic surgeons are sending us their patients because they're too heavy to get a transplanted heart Just last week, one of the patients came back and said, you know they're starting an ex plant program Oh, what's that? Well, I've lost so much weight that my heart is now working at a 45-percentage ejection fraction and they're thinking about taking out my LVAD Well, that's pretty good

How are they gonna do it? Well, they say they're gonna, I'm just making it up on the fly, right? So how are you gonna do that? Well, put them in the hospital and turn off the pump If you have any VADs (mumbles) and so you're gonna turn off the pump and see how he does And then how are they gonna take out the tubes and all that? I have no idea, remember I'm not a surgeon So I will treat anybody who is treatable, and it works better if you follow the plan, no question about it Post bariatric surgery, weight regain

A lot of patients who never learned how to change the food, the harsh reality is perhaps even half of folks who get bariatric surgery regain their weight over time Early on, it looks really great, but then you follow them for 10 years if they haven't learned how to eat and live in today's world, often they'll regain the weight And that 50% is kind of sad when you think about it with all of the stuff that those people went through So this is the clinic of last resort So this patient back in the 1980s went to

A little trivia, does anyone know where the Roux-en-Y gastric bypass was created? (indistinct chattering) Oh no (indistinct chattering) Will's alma mater, it's ECU in Greenville Walter Pories

So this patient sought out Walter Pories back in 1984 for the Roux-en-Y gastric bypass because she wanted the best surgeon on earth And so then the surgeons did a revision on the Roux-en-Y, you can see she lost from 280 to 200 and then they've actually said you're done, you're at 210 And she said no I'm not So she sought out this obesity medicine specialist, another expert but not at ECU, at Duke And then over the next five years, she's down to her high school weight just by using a keto diet, low carb ketogenic diet and some Lasix

And it was 54 visits over five years, we estimated about $4,000 to insurance She didn't pay much, it was a copay, and you can compare that to the operations that were done before But it's kind of a team effort here She's thrilled, she's 70 years old, going on 15 years old and just retired and now they're moving to a mobile home And anyway

So this is the kind of medicine you can use and do as an obesity medicine specialist It's exciting, it's fun We have great practices We get to teach people and learn from them This 25-year-old male at baseline had a BMI of 49

Now the younger you are, the faster it works, better it works do it now because you're never getting younger, yeah So he said okay, I got this, there's a one-hour teaching class we do at the clinic, I teach the basics, like Will mentioned; and he came back losing 15 pounds a month just eating at McDonald's I said, well, what do you eat? He said, well you know, you're really not very hungry And so I have three double cheeseburgers off the dollar menu with no bun, no fries, and I drink green tea and a diet soda And then he goes down to spring break in Daytona Beach and he drank some carbs, beer; and he didn't lose weight, he didn't gain weight, but he was thrilled that he didn't, you know, he's coming back and now he has a McChicken every now and then on the dollar menu

It doesn't have to cost a lot of money You can do it within the lifestyle of someone, knowing the principle that it's kind of like knowing how a bicycle works You can make different kinds of bikes So you can do it anywhere, you can do it in the mountains, you can do it on a road So knowing the principle of carb restriction, being the

going through blood sugar and insulin, we didn't get into the details of that, but it's basically the control knob for dialing your appetite and your weight Basically, your fat burning So this is pretty fun

And now getting to diabetes, there's no patient more thrilled, in my experience, than those who get off insulin And then they don't even have to measure their blood sugars anymore because no other doctors repeatedly tell them that it's possible In fact, a lot of doctors will say you're gonna have diabetes forever Wow, that's because they've never seen it! It would be like me going to Africa and saying there are these big animals with necks like this, and no (mumbles) so I'd take a picture Here's a picture of people coming off insulin, and it can be really fast

So I'm recalling, we were sat last night and it was kind of like a retrospective We've been doing this 20 years now And when I first showed these data to Rob Califf, it was our first 50 patients over six months and I showed him the cholesterol, he said that's a fibrate And I said, no, that's a low carb diet So for you medication people, he was used to medications

He saw the lipid profile change and he said that's a fibrate, the effect of a fibrate I said no, the low carb diet He said we need to randomize people who have heart disease, who have diabetes and follow them for two years You'll have an event so high that you'll know whether it works or not And I said wait a second, this is the first study I've ever done on this and you're talking about diabetes? So here's what we know about diabetes now that we've been doing this 12 years in the clinic

It's that you add up all the insulin, 100 units a day, cut it in half on the first day if their blood sugars are in the hundreds, fairly well controlled; and so you have to cut the insulin in half on the first day or you risk hypoglycemia So can you imagine us 15 years ago having a couple, well, 500 people on insulin not knowing that they're gonna have to come off half of their insulin on the first day? It would have been a disaster So now I'm ready to do that study though We can monitor people, people have home monitors We know that when the blood sugars are getting down, you're at 120, 100, you can't take insulin

So I tell people, don't take insulin if your blood sugar is under 100 or 120 And I'll have people call me that night saying my blood sugar is 90, what do I do? I said, well, I told you this morning not to take insulin So you can tell people to do it but it's so bizarre and unexpected, they'll still ask for guidance I said don't take your insulin, you'll go low Oh right, if it's 90 and I take insulin, I'll go low

So now this person's off 100 units of insulin in six weeks 80 units of insulin in one day So you add up all the insulin, this person was on 40 units twice a day here, I asked the high, the low blood sugar, insulin, the weight, and nobody knows the right way to do it If someone's on 40 twice a day, I might say just take 40 once a day Or I might say 20 twice a day, I don't know

We need research to know how to do that best I try to work within the insulin that a given person has Off 60 units, now I'm trying to show that this person was on insulin, glimepiride and metformin You could just kind of get rid of the pills We keep people on metformin partly as a safety blanket

Security blanket, people think they're still taking something for insulin, I don't know, for diabetes; I don't know really how much it helps Add up all of the insulin, 100 units a day, off in three weeks, blood sugars are better or as good or better than before, and this is a common situation I get with endocrinologists They'll see this patient and say, well Dr Westman, the blood sugars aren't perfectly controlled I say yeah, but they're not on insulin anymore

Well, we need to put them on insulin to get their blood sugar better controlled But wait, when you had them, the blood sugars were worse on more insulin So this is the push and pull you get with different specialists If I don't fix the obesity, the underlying cause of diabetes, they're always gonna have diabetes It's just a different point of view

You have to treat the underlying cause, which is insulin resistance and obesity Insulin for 10 years, it doesn't seem to matter how long someone's been on insulin So be careful Someone said oh, I've been on insulin 20 years, I've taken it everyday No, you might not need it tonight

Off 180 units of insulin almost in one week In retrospect, some of these patients are drinking soda they don't tell you about They're drinking sugar, their insulin is treating the sugar they're drinking and they don't tell you about it So you just monitor the blood sugar, it's okay So now we're getting to industrial strengths of insulin here but oh no, they're making U-500

No, so that's not the fixing of diabetes by using stronger insulin The insulin is already too high in the blood You want the insulin to go down And anyway, so insulin for 25 years Are you getting the picture? I mean, this is pretty reliable

Now this person's on 40, 55, 60 units of the short-acting, 60 of the long-acting twice a day 500 units of insulin a day This person is still on insulin, on about 80 units now about a year and a half into it He's not totally off, but he has a hundred pounds of weight to lose So the average BMI in my clinic is between 35 and 40, depending on your ethnicity

And so if someone still has a lot of weight to lose, you might not get perfect control on the blood sugar because it's the weight that's causing the insulin resistance, that's causing the diabetes But this guy's at high risk for seeing another endocrinologist or doctor who says look, the blood sugars aren't perfectly controlled, I need to put them on insulin again And so then they're gonna go back on the insulin, gain the weight back and then go back and not have perfect control on 500 units of insulin because the problem is not insufficient insulin, it's insulin resistance Insulin isn't working right So anyway, this is pretty fun

Insulin pumps, fine, just lower the insulin and people are in less insulin Now hemoglobin A1c is just a reflection of the daily blood sugars, in general the three months average although you can get changes pretty quickly Here you have A1cs on the right-hand side, someone whose A1cs were not controlled The weight is about 300 pounds, 67 year-old female, and her meds come off, her A1c is under six where it hadn't been for 10 years off medication So mild diabetes

I mean, this is like yeah, it's just kind of easy But remember, we had all those studies about obesity, and now a growing number about diabetes This person, this is an internist's dream If you like to take care of complicated patients and fix them, this person is on medicine for diabetes, high blood pressure, GERD and had A1c over seven for 10 years and now on a low carb diet within two years has a blood sugar A1c under six, off all the medications So now Dr

Yancy has taught me, Will has taught me a lot of things, that it's nicer, you can attract more flies with molasses than vinegar But gosh darnit, this is fantastic! (audience laughing) When you get the emotion of people in the clinic, holy cow I just had someone who had a renal transplant from his wife, from diabetes that he's had for 15 years and then lost his kidneys and just had a transplant, so he's on prednisone and now he's off his insulin in a week So he's starting to go through this, I didn't have to have diabetes, I didn't have to go through, this is pretty heady stuff It's great and it's just changing the food

So when we get people who say, oh that dialogue there are a lot of irrational fears that we've been taught You're welcome to come to my clinic, which was the answer that Dr Atkins gave me in 1998 because there were so many things that just didn't compute But what about the fat, what about this, what about the salt? So even today people come to our clinic to see it in action, to overcome all of these irrational fears that are out there It's fascinating

Sociologically, this is a goldmine of information So anyway, other folks So Dr Yancy worked his way through the system and is now Director of the Duke Diet and Fitness Center And by, I think popular demand, and by his reading of the science, has a low carb program there as well, I worked at the Diet and Fitness Center around 2001 and got motivated to change my life from a pill pushing internist to an obesity medicine doctor that takes away medication and then realized that well, not everyone can afford the DFC but it's a great place, and so we opened The Lifestyle Clinic to use that model of lifestyle change

And the DFC has been part of the Duke Health System for over 40 years To our knowledge, it's the only medically supervised residential-style weight management program within an academic medical center in the US And so someone really wants the credibility of the University and then seeing the doctors often on a daily basis if needed It's staffed by medical providers, dietitians, exercise physiologists, behavior experts, swim instructor, certified coaches and massage therapists It's helped more than 50,000 clients from around the world

And if you haven't been there, it's just right around the corner on Douglas Street behind the VA hospital The old metro sport, the old fitness center, turn there So where do we go from here, and then some questions Let us have it There is an ongoing two-site VA study with diabetes going on, Durham and Greenville, and Will is the PI on that 260 folks and in progress

They haven't stopped it yet due to adverse events, Dr Yancy? They have not stopped it yet due to adverse events according to Dr Yancy We're gonna do retrospective analyses of the Lifestyle Medicine Clinic and the Duke Diet and Fitness Center We're happy to help and appreciate the help of students on our rotation of residents, of faculty if you have an interest here to look at what's happened

For example we're gonna pull out all the people with polycystic ovary syndrome because a current student on the rotation is interested in PCOS, we're gonna go into GYN and see what's happened So we have over 100 people, and I mean this is like hot off the press information as you're on deduce right there And then what's really needed, and we got kind of sidetracked I mean, we wrote paper, we wrote study proposals 15 years ago to do the diet trial to end all diet trials Never got funded

We have proposals sitting around, maybe it's time to dust them off but the limiting factors, where does the money come, right? Who's gonna fund the study that takes you off insulin? Well, not the insulin providers, right? Or not the company So we're still trying to fix that There are at least two people through NIH funded, probably gonna make their careers, young investigators, K awards are a great place to start or the VA We still need the multi-site randomized controlled trials of LCHF with clinical endpoints for heart disease, for, I'm ready to do that study with people with diabetes and heart disease who've had events because I think we can take people safely off the insulin now And there was just a recent paper, a couple hundred people with diabetes, it was a single arm study done in Indiana at Purdue, and it's fantastic

The low carb, the keto approach for diabetes, 95% of folks with insulin were taken off their insulin, something like that It's so unbelievable, nobody believes it That's the saying that we say So I think that's it So thanks so much for your attention, and we have some time for questions

(audience clapping) Yeah Do you want to moderate or do you mind? Okay, yeah – [Woman] Thank you for the great presentation My question is like how do you compare the low carb diet with a mini fasting diet? Mini fasting, like interval fasting? – Interval fasting? – Yes – Yes, so I don't think there has been a comparison of those two approaches

Most of the time that I've seen the intermittent fasting, it's been compared to just a standard low calorie, usually low fat diet And it's a daily calorie restriction for the control diet I haven't seen the low carb compared to interim fasting In terms of what's going on, we actually think metabolically that a low carbohydrate diet is a fasting-type physiology So there might be some benefits that people attribute to fasting, and which they also attribute to intermittent fasting that might be attributable to the low carbohydrate diet

But at this point, the intermittent fasting has just recently been looked at in clinical trials, probably in the last three or four or five years or so So we're still waiting to hear more about that approach At this point, what we've seen is that intermittent fasting works as well as a calorie reduction diet, not necessarily better although there is some kind of physiologic evidence to show there might be some benefits We haven't seen that in human clinical trials yet – [Kevin] Thanks Eric and Will, this has been great

Just to go back to the story, because I think the story is so important for everyone to hear, your first trial got the American Heart Association to change their recommendations for diet – Oh, shucks – Yeah (audience laughing) If you go back, remember how crazy this was when we first talked about this forever ago, the NIH turned down the first study recommendation because they didn't wanna do a mortality study of diet They didn't think you needed to do that

And then go forward 15 years, over the last 15 years, we've seen lots of things about the harms of sugar in our diet, there's now when we first started, there was like six people in the country who believed what you believe It's obviously much broader now

And you've been amazing at continuing to both practice medicine and furthering this in the clinic and doing the research studies So it's a huge kudos to you both to do that here at Duke And hopefully we can finally do this trial We also got turned down from the NIH to do the trial over mobile phones So we tried Internet-based studies of diet, mobile phone-based studies of diet and they frankly weren't interested in doing the clinical trial

– [Dr Yancy] That would be great, thank you – Yeah, if I was starting a new medical school or if someone asked me to help out, which I've never been asked, the first day would be nutrition The most important thing for a doctor is knowing what you put in your mouth And we get nothing

Why is that, Dr Yancy? It's complicated There's no room in the schedule So anyway, diet is really important and that's the kind of advice you get through our programs Thanks, Kevin

It's kind of like how many times do you scale the wall and try to get in the fortress and then you fall off But another team will coalesce, yeah – Hello, Dr Westman I'm gonna put a plug in for you

If anyone has any doubts about how well this program works, I started seeing Dr Westman a couple of months ago, 27 pounds down It is a very easy diet to follow, but I will retract the word diet and say that it is a lifestyle change It doesn't matter, you have to be motivated and really stick to it, but it is so, so easy So I thank you in front of my co-workers and colleagues

And some of the questions that I had for you, you have answered today, so thank you again – Well, thank you for that and (audience clapping) So we have a support group, we have one once a month, first Tuesday of the month at the Durham Hilton

And this last time, there were 80 people who came out, half had similar stories and they wanna share, they wanna help other people I'm curious, aren't you? What if we looked in the database of people who came through the clinic with all the people with heart disease, with all the people who have an LDL over I don't know, whatever you think is a bad LDL today? I'm reassured the last guideline really doesn't have LDL in it So triglyceride and HDL and age and whether you have hypertension and diabetes are important factors too But if anyone's interested in looking at the data in terms of cardiovascular events or risk or things, it's retrospective but it's eminently publishable because nobody else has this kind of information Yeah? – [Man] Just a second testimony, I'm sure you don't wanna go off in this tangent but people ask okay, is this healthy? I was 275 pounds in 2012, I am 173 pounds as of this morning

I am 61 years old, I take absolutely no prescription medicines So it works (audience clapping) – But you know, there are 99 things better than that one last thing But what about the? The last vestige is kidney disease, right? It's gonna kill your kidneys And what about that LDL? Yeah, so

– [Woman] When do you suggest people who are on the low carb high fat diet, less than 20 grams, when do you suggest they can have an apple again or start eating some fruit or bringing that back into their diet? After they've reached a certain milestone? – Why don't we both answer this? My view now from the Tampa Conference, University of South Florida, now that ketones are being studied, they actually have therapeutic effects And we've gone, in my lifetime, in science from this is really bad and it's gonna kill you, everyone That's what everyone thought so that you would get the pushback, don't do this, from your doctor, your dietician, your grocery store clerk, right? So now we know that's not true

But the studies now being done in animals, mice live 15% longer when they're in ketosis Holy cow You might even prevent insulin resistance, which is the root cause of Alzheimer's, which for some cancers they're actually therapeutic or preventive So now that the science is being done, now I've been doing keto because I like it and the science is looking good, but now oh my gosh! You might even be better by never eating carbs again to the degree of even having an apple Okay, now a more moderate response

(audience chuckling) – So I concur with what Eric said I think we've kept patients, or we've followed patients who have kept at a very low level of carbohydrate intake for years What I've talked to my patients about, about how to decide when to add carbohydrates back in, and first of all that should be done very slowly, like five grams a day is what we suggest to people to do that for a week; and if you're doing okay at the end of the week then you can add another five grams and then another five grams, you do it very systematically like that But I tell them when you're close to your goal, if you're close to your goal, whatever that might be, it might be your goal weight, it might be your goal blood sugar control, it might be your goal of getting off of your diabetes medicine, then that's the time to consider it The other caveat to that is when you feel like you can't do the diet any longer, if you feel like you just can't do it anymore and I'm really convinced that they can't do it anymore rather than like just letting them capitulate, then I'll say well, have a little bit

Why don't you have a little bit of some berries? They're pretty low in carbohydrate Add some berries if that helps you to stick to the diet better That would be the other approach I use – At the Low Carb Conference in West Palm Beach in January, there were a couple talks on how plants put toxins in their leaves so animals won't eat them This is a defense mechanism

So what do you think? We're animals, right? So you look at these toxins that are in the vegetables, the argument that you need vegetables and then the leaves and all of that kind of is debatable So there's actually a subgroup of humans should be carnivores, eat nose-to-tail, make sure you get some liver, get some kidney and it's an interesting debate And I think it's a reasonable one And I know this is changing guideline, Kevin, as you mentioned I have all those American Heart Association, it's the same people on the same paper without any new information and they still have the guideline that's low fat

I think that was last year, made the national news and we're just kind of going, oh my god, it's not a meta-analysis It's just a one-sided story I think it's something that we need science in on that The Nutrition Coalition is a group that is advocating to change the guidelines, started by Nina Teicholz who wrote the book, The Big Fat Surprise Of course, Gary Taube's Good Calories Bad Calories is a great place to start if you're really geeky

And then Gary came out with a book, The Case Against Sugar in January, which again, as Kevin mentioned, people are zeroing in on sugar But we risk the pendulum, well, okay, that's been bad so long, okay that's fine and now sugar is bad, you know? We need science to help guide us there You still eat carbs, Dr Yancy, don't you? – I'm on a maintenance carb diet is what I eat (audience laughing) – I saw you eating carbs

(audience laughing) – I'm maintaining, I'm at my goal – I mean, there is kind of a cult-like atmosphere, but it's only because of the low fat cult, right? And it's not a cult, it's just the way our bodies work But I think I counted seven people in this room, when you're in the minority, you tend to kind of cluster together as a protective mechanism I'm just kind of vamping because I don't see any questions (audience laughing) – Okay, we're actually over time, but thank you so much for a wonderful and provocative talk

We look forward to having you back in 2021, 2022 with the results of the diabetes study (audience clapping) (uplifting music)

Dr. Stephen Phinney and Dr. Amy McKenzie on Ketogenic Diets and Diabetes

– Welcome to our Facebook Live Q&A today I'm doctor Amy McKenzie and this is doctor Stephen Phinney

We are researchers here at Virta and collaborators on quite a few different research studies together Today we're gonna answer any questions that you might have about diabetes, heart health, ketogenic diet interventions, anything you can think of Please list your comments and questions below the video and we'll get to as many as we can – And as we answer questions today, we want you to remember that we cannot give specific medical advise, so our answers to questions will be general rather than specific And for specific medical questions, we would refer those to your physician

– Our first question today is "How does Virta's treatment affect heart health?" This is a very relevant question because we just had a new publication come out today in Cardiovascular Diabetology that really focused on this So we had published maybe two months ago now, we had published the one year Type II diabetes outcomes We showed that A1c improved We showed that glycemic control was better, insulin resistance was better, weight improved And in this paper we really focused on all the different risk factors around cardiovascular disease

– And that's important because in the diabetes paper published two months ago in Diabetes Therapy, we noted that although a whole group of diabetes-associated risk factors got better, one of the more controversial changes is that the LDL cholesterol level in our patient group as a whole rose slightly but statistically significantly We felt it was important to take a much closer look at the full range of heart disease risk factors And that is what's encompassed in the peer-reviewed paper that we had published just today and can be accessed through our website – Yeah, so to give kind of a brief overview of what we've showed in that paper, Steve mentioned the rise in LDL and LDLc in the group on average, but there are a few markers that some researchers believe might be a better predictor of cardiovascular risk or at least equal to LDLc So those are LDL particle number and apo B

Those two markers statistically were unchanged at one year in our cohort of patients And then, we also looked at the particle size Some believe that small, dense LDL particles might be more atherogenic than the larger particles And our small dense LDL particle number actually significantly decreased at one year And the whole, the particle size of all the LDL particles increased at one year

So in terms of looking at the whole picture of risk, we certainly saw that increase in LDL that a lot of people get concerned about But when you put all of the markers together and consider the whole risk profile, we're definitely getting an improvement in a lot of different risk factors And we still are concerned about LDL, but we see a lot of improvements in other ways – Understand that the test that we use to measure LDL particle size and number is a new test, it's not universally available It's a predominantly a research-based test

And there are a couple of different ways that these can be analyzed, and the medical practice community has not arrived at a, kind of a uniform recommendation for these values So this is a research test that we did And it may not be available to the average person through their primary care physician For instance, I saw my physician a few weeks ago and asked, and I get my health care through Kaiser Permanente here in California, and I asked if they could run a LDL particle size and number for me and they said "no, we don't do that" But, it's important that other factors that we did look at, such as HDL cholesterol, which is so-called good cholesterol and triglyceride values, then those are part of a standard lipid panel

When the ratio of HDL to triglycerides goes up, that is, you have more HDL relative, proportionately to triglyceride, that is correlated with an improvement in LDL particle size and number So, again, we've looked at, I think we had 18 different cardiovascular risk factors in this current paper, and those were included in that So the point is, this is a very complex area, it's an area of active research But what we want to provide is a broader perspective of all the parameters, rather than focusing in on what we have with the cholesterol-diet-heart hypothesis where the focus for a couple of decades has been just on the LDL The true picture is much more complex than that and we want to get into some of those details

– Sure And there's evidence even to say that the picture is more complex from that, from the Imbarac trial, because they put people on STLT2s They saw LDL go up but they saw cardiovascular mortality decrease – Dramatically, yes – 38% I think, maybe

So, there's definitely something to say where there are other factors at play, and it's not all about one lipid marker in terms of cardiovascular risk So we'll find out someday – So before we get into specific questions, do we wanna talk about the range of risk factors? – Sure – That we looked at, responses such as hypertension, inflammation – Yeah

I think also when we're talking about different risk factors and looking at the whole risk profile, inflammation is also an independent risk factor for cardiovascular disease Many consider it or hypothesize it be an under, potentially an underlying cause So we looked at a few broad markers of inflammation in this study, we looked at high-sensitivity C-reactive protein and white blood cell count And both of those dramatically improved The CRP response especially was pretty astonishing at one year

And then blood pressure as well, blood pressure significantly increased, and the really cool thing– – No, it actually decreased – Sorry thanks, improved, decreased So blood pressure decreased, so it improved And because of this we actually had to de-prescribe medications for the patients because they didn't need the medication anymore So that's a really unique finding too

– So a lot of patients moved from the hypertension, borderline hypertension area to normal blood pressure with a reduced total medication use in the population Which is a very unusual finding, 'cause usually the way with standard medication treatment for hypertension you have to give more medications to get better control – Sure – We got better control because nutritional ketosis and the Virta treatment that embraces and supports that is such a powerful metabolic tool – So, that's a little bit of a recap on our cardiovascular risk factor paper that just came out today in Cardiovascular Diabetology

You can go to our website virtahealthcom/research and you'll find a link to that paper there And then we'll have certainly more information coming out from Virta tomorrow about that Check back tomorrow and we'll have some more information for you Our next question, "Is it okay to eat one to two "meals per day with half of your protein needs in each, "or is it better to space out your protein?" – That's a good question, and actually kinda leads to the concept of time restricted eating

– Yeah – We actually did a blog post a couple months ago entitled To Fast, or Not to Fast And in that we point out that there is actually a fair amount of published research on time restricted eating As long as people don't do total fasting for more than 24 hours, certainly skipping one, or even two meals per day, when the composition of those meals is appropriate, is safe and for some people turns out to be an effective tool And so yes protein doesn't have to be eaten in three equal portions, it can be eaten in two portions

And there are some people who find that they eat one meal per day, so they're basically fasting, from basically dinner, let's say one evening, til dinner the next evening, and that, as long as that is interspersed with adequate nutrition including adequate vegetables for potassium and other minerals, and fiber on the non restricted days, it can be a healthy way to follow a well formed ketogenic diet – Sure, protein is important, so it is important to make sure that you get it in, and meet all of your needs And then if you, if you are in a situation where you're eating protein in this way, where you're kind of lumping it all into one meal, and your ketones don't go down, don't be too surprised 'Cause that might also be a factor too So depends on what your goals are, but it is definitely really important to get in all of your protein

Next question "Is keto safe and, or recommended if you have no thyroid? "And is there a risk of low TSH "if you do keto without a thyroid?" Doctor? – Yeah, it's a good question Again we have to be careful not to give specific medical advice, but in general terms, taking thyroid medication can fully replace what the thyroid gland normally does And it's important to point out that the thyroid gland doesn't make active thyroid hormones It makes a precursor, called, we just say it's, it's a precursor, it has four iodine molecules on it

Active thyroid hormone has three The thyroid makes the one with four, your liver takes away one of those iodines to make the three So you can take the thyroid hormone by mouth, and then the liver does the final step, and can regulate much of that process And TSH is a useful test because that's a measure of what the brain perceives in terms of what the liver's doing And so that can be used by your physician to help judge the dose of oral thyroid medicine as prescribed

So again this is something that has to be managed between you and your primary care physician We can't give you specific advice for that – Great, so if you're just joining us, I just wanna welcome you to the Virta Facebook live Q and A I'm Dr Amy McKenzie

This is Dr Stephen Phinney We're here to answer your questions about diabetes, heart health, and ketogenic interventions If you would like to be notified of future Facebook lives, or events, please follow Virta on Facebook Our next question is, "Can being in a state "of ketosis enhance your athletic performance?" I think this is something near and dear to our hearts

– Yeah, wow Do we have an hour to– – Yeah, I think we could spend a lot of time on this Our collaborator, Jeff Volek, that is at Ohio State, and also a co-founder of Virta, he actually has been looking at this a lot lately in his research Back at Yukon, a few years ago, he brought in 10 high carb athletes, and 10 keto adapted low carb athletes– – These were elite, ultra runners – Yeah, elite, ultra runners, that do ultra marathons, or some of them were triathletes

So it was elite, ultra endurance athletes And 10 of them were keto adapted, and 10 of them were on a high carb diet He brought them in to run for three hours And looked at all of their performance during that time, and then during recovery Probably not surprisingly, the low carb, keto adapted athletes had higher peak rates of fat oxidation, and a higher mean rate of fat oxidation throughout their run

But the really interesting thing is that, when it comes to athletic performance, people seem to be concerned about muscle glycogen And they're worried that if your low carbohydrate, and keto adapted that you're maybe gonna run out of muscle glycogen Feel like you hit the wall and not be able to perform So they did muscle biopsies in this study And what they found was that the keto adapted, low carb athletes and the high carb athletes had the same amount of muscle glycogen

And that it followed the same pattern even in recovery So after the three hour run, and then also two hours into recovery, muscle glycogen was all the same – But the difference between them was because the keto adapted athletes were burning fat at twice the rate, providing 80 to 90% of the fuel during their endurance run at race pace So as Amy said, they ran them, had them run on a treadmill three hours, in the lab – In the lab, staring at a blank wall

– The Keto adapted athletes mobilized muscle glycogen at the same rate But they, it appears that they recycled it They didn't burn it all the way to CO2 and water So it's like, you know, basically recycling that same carbon, so they didn't need to eat a lot of carbohydrate in their diet in order to regenerate and maintain muscle glycogen stores But from a parental perspective, how many ketogenic enhanced diet performance, one thing that the endurance athlete tells is that when they're keto adapted they're much less likely to hit the wall

That is how the central nervous system begins to shut down saying you aren't providing me enough glucose to keep my brain functioning So A, they can go for longer periods of time And it appears to be that because the brain can function very well on ketones, and is not glucose dependent And so for events lasting longer than three or four hours, when normally, again a full iron man triathlon, they have to eat continuously during the running and the cycling legs of those events One was that the athletes find they need to eat far less calories in the race in order to sustain performance

So that's one aspect that's beneficial And the other is what we call power to weight ratio That many athletes find, no matter how hard they train, they can't train themselves down to an ideal, low level of body fat Say under 10% And for some athletes getting under 10% is really important in terms of the power to weight ratio

And they find that when they adapt a well formulated, ketogenic diet they're better able to achieve that optimum percent body fat that optimizes the ratio of muscle to muscle weight to body fat weight And again for those athletes, oftentimes they will train on a high fat, low carb diet to get ideal body composition down And then they can add back what they call strategic carbs, either immediately before, or during an event in order to optimize glycogen as well And again this tends to be athlete specific Each athlete needs to have some guidance, but their own experience in figuring out what works best for them in terms of the degree of carbohydrate restriction, and the amount of carbs that can be used strategically to maintain optimum performance

– Yeah, and I think we've talked a lot about resistance training, or endurance training, but I think resistance comes up a lot too I think there was a study recently, I hope I'm not miss remembering this I think it was out of Donovan and Stephen's group, or he was involved in it somehow But they looked at 10 weeks of western diet compared to a ketogenic diet, and similar gains in terms of strength and power during that time And also similar losses of body fat and muscle gain between the two groups

So it doesn't appear to impair performance in any way – And not to get too far ahead of the data, Professor Volek at OSU is, has completed the data collection from a study they did with a high carb versus a ketogenic diet in a group of student athletes where they did a intensive resistance training program And hopefully those data will be reported this year But it will I think, emphasize the benefit in terms of resistance training, and maintaining lean body mass and optimizing power to weight ratio – Sure, I think power to weight ratio is really an important point

Alright, our next question "Are there any benefits of fasting "that you can't get through a well formulated "ketogenic diet and what do you think about "autophagi and apoptosis?" – These are hot buzzwords right now in the research community There's a lot of research been done with basically animal models And what people talk about autophagi and apoptosis is basically changing either, you know, regenerating cells, aging cells, regenerating with– – Yeah, it's kinda– – Replacement cells, and also– – It's kinda the cleaning system – A cleaning system, but also cleaning up internal cellular machinery, particularly involving things called mitochondria

And mitochondria are those little furnaces inside cells that actually do the oxidative energy generation That's where oxygen is consumed, along with either fat or carbohydrate to replace the high energy phosphate ATP, and creating phosphate And so that machinery constantly has to be repaired And there is evidence that periods of fasting can enhance that process – Several

There's been less research with well formulated ketogenic diets done long enough to actually look at that And again the turn over of cells, and the turnover of mitochondria, that is how frequently it is replaced is measured in weeks or months, not in a day or two – Sure – And so particularly for human, you know to have human specific results it takes rigorously done studies And there aren't that many groups who have been able to sustain ketogenic diets long enough to really look at that

And again, stay tuned, because that's an area where Dr Volek and his team are on the forefront of doing that research – Yeah, I think, I'm certainly not an expert in this area But I think, autophagi can be stimulated by reduced insulin, increased glucagon, inhibition of mTOR So I know a lot of the research is in fasting

And ketogenic diets tend to mimic that from a metabolism standpoint in a lot of ways So I would assume that you would be able to get some similar benefits out of doing it for a long time Alright, "Have you tested apo E genetic expression "in study subjects, and does it have any "predictive value in identifying "so called LDL hyper responders?" so we did not include genetic testing in this research study so unfortunately we can't draw any conclusions, or make any statements about that My understanding of apo E is that one variant of that, apo E4 is very highly associated with increased cardiovascular risk – And increased LDL

– And increased LDL, yes So in this case, in terms of identifying the LDL hyper responders, this is a very complicated question 'cause my first question is what is an LDL hyper responder, and also if it's a genetic component, if they have apo E4 they probably had a high LDL to begin with before changing their diet So perhaps, we don't have any data that would be able to answer that question But I would think that I would see high LDL in that person before they would even begin dietary changes – So the simple answer is, we haven't tested it

– Yeah – In terms of doing the genetic testing on our Indiana University Health research population But the other point is, that increasingly the cardiovascular risk area is moving away from a focus just on LDL So we think of LDL as one tree in the forest – Yeah

– And then we will be putting up a blog post in the next day or two, basically summarizing what we have in our research paper So making it a little more digestible for the non science reader to point out that when we look at a bunch of other factors like inflammation, like hypertension, that when we look at those other risk factors, so many of them improve independent of LDL that even we assume that even people with the apo A4 genotype would probably still then get a net benefit from the ketogenic diet, even if their LDL doesn't respond as dramatically or in the same way as the other groups do in terms of particle size and number – Sure, I just spent some time at the National Lipid Association conference and the opinion of a lot of clinicians there is that they like to use a non HDL So even with LDL being a target they have, they tend to also have a target of non HDL And National Lipid Association promotes that, so I think the idea of relying on more than one marker is certainly catching on in clinical practice

So if you're just joining us, we just wanna welcome you to the Virta Facebook live Q and A This is Dr Stephen Phinney, and I'm Dr Amy McKenzie If you like this event, and you wanna know about more in the future you can follow us on Facebook by following Virta Health

Our next question says, "Is it possible "for a person to have a really high "hemoglobin A1c and yet have decent triglycerides, "meaning 150s or lower?" Suppose it's possible – It's on average the higher a person's, or the less controlled a person's Type II Diabetes is, so the higher their hemoglobin A1c would go the more likely they are to have what we call atherogenic dyslipidemia which involves a low HDL and a high triglyceride So on average high triglycerides and high hemoglobin A1c values go together But people vary wide, quite a bit from one another And it's very possible that somebody could have a triglyceride under 150 which is the upper limit of what is considered normal

We like 'em under 100 – Yeah And still have a high hemoglobin A1c The other factor is triglycerides can go down very quickly when you cut down dietary carbs If their hemoglobin A1c – Very quickly

value takes three to four months to change So one might see triglycerides plummet in the first, say month of a well formulated ketogenic diet – Sure – And the hemoglobin A1c is gonna tag along quite a bit behind So typically we wait anywhere from four to six months after people make the change to a low carbohydrate diet before we do that testing so that the hemoglobin A1c can, which is a slow responder catches up to some of the factors which respond more promptly

– Sure (chuckles) So this comment is, "Hi, Amy "Congrats on the award" Thank you very much "Is there a rough estimate of when "two year Virta results get released, "and are coronary artery calcium scores "being calculated as well?" – Tell us about the award

– Oh gosh I mentioned the National Lipid Association And we had submitted an abstract there– – With you as first author – Yes Definitely a team effort from the whole group

We submitted an abstract focusing on the cardiovascular risk factors and their response at one year to our intervention And also we took, because of this concern about LDL, we also took a closer look at the change in LDL over time So we compared early to late change in LDL And what we saw is that people who had an early rise in LDL, either LDLc or LDL particle number, in the first 10 weeks, later saw a decrease in a similar amount And those who had an early decrease had a later rise

So there's a lot of you know, potential explanations for this One is probably, partial to Dr Phinney with, in this case, so if somebody has an early rise in LDLc, and they're losing weight, a lot of weight, a significant amount of weight in that time, there's a chance that their cholesterol will go up during that weight loss, right? – Correct – And then it will go back to normal following weight stabilization – And that appears to be because, when people carry a fair degree of extra body fat it soaks up cholesterol

When you lose the body fat it has to be mobilized So there's a transient mobilization phase So again, we don't draw conclusions even after three or four months if people are losing weight, from the actual, the measured cholesterol levels We wait usually til the end of a year Most people have stabilized their weight by that time

And that gives us a more steady state measure of the cholesterol distribution within the circulating lipids But there was a young investigator award, and of the abstracts submitted to this national meeting Amy was the recipient of that award Congratulations doctor – Thank you (chuckles) Definitely had some good mentors along the way to get there

So thank you Yeah, so we presented this at the National Lipid Association conference last weekend Feel free to write to us and ask us more questions – And the other question is when are we gonna release our two year data – So two year data

We're two years into the trial now, can you believe it? – We're more two years in, but we recruited people over about an eight month period And the last people recruited two years ago have now completed their two year time point So we're collecting the data, and we're analyzing that We can't tell people about it until we have it accepted for publication – Yeah

– And again this is sometimes pretty controversial data, and it takes awhile, but we hope by later this year we'll have that data published in the peer reviewed literature and be able to share it with this audience – And then in terms of coronary artery calcium scores, we did not include that as part of the research study Although I know that sometimes it's used in the course of clinical care But unfortunately not part of the research study We did do carotid intima-media thickness measurements

– That's an ultrasound of the carotid artery to look at the thickness of the lining of the artery And at one year we did not see any threatening changes in the population on the ketogenic diet in spite of the fact that they're eating a lot more fat than our parallel control group So that's reassuring that it wasn't getting worse And we're hoping at two years that we'll may be able to see a difference between the control population and our intervention population – We'll test it and find out

– Um hm – Alright, our next question is, "What definitive total cholesterol numbers "that are healthy for men and women?" Oh, "what definitive total cholesterol numbers "that are healthy for men and women?" Sorry, I can't read today "And can you more clearly elucidate LDLp, "small LDLp, LDLc, HDLc, and what one should look for?" – First point is, these are not standard tests that are available to all of us – But the LDLp, yeah – So particle size and number still remain research tests

And if you can get them done, then you would need to talk to the physician that you went through to have them ordered to be done In terms of total cholesterol numbers, again that's turning out to be one tree in the forest There are a couple trees in the forest And again, we have no reason to, dispute the total cholesterol and calculate LDL values except the have to be viewed in the context of a wider range of risk factors But we can't get into specific numbers for individuals at this point

– Yeah Alright, so if you're just joining us we just wanna welcome you to the Virta Facebook Live Q and A You have Dr Stephen Phinney and I'm Dr Amy McKenzie

We're hear to answer your questions on diabetes, heart health, and ketogenic interventions Our next question is, "Has research been done "to determine if there's a point at which "high amounts of sodium supplementation "can be dangerous or unnecessary?" So there's a paper that looks at sodium consumption and mortality, right? And this is– – There's been a lot of research on it – Well I'm thinking of one I think you know what I'm talking about, Donald– – Donald, and then (interrupted) Journal of Medicine from 2014 If you go on our blog we have a posting on sodium intake and adrenal, and the why adrenal fatigue is not a real medical issue

And this is discussed in that paper as we've referenced there Sodium is obviously a very controversial area And people have almost, let's say, let's say very intense convictions, including dispute among measuring scientists So this is not a resolved area as yet But in the study published in the New England Journal by this group, it's a international research consortium studying lifestyle factors, and health outcomes in a couple 100,000 people in 17 different countries

– sure It's a massive study called the PURE, P, U, R, E, that's the acronym, study And they, rather than asking people how much salt did you eat yesterday, they actually took a urine, got a urine sample from people From over 100,000 people and then looked at sodium excretion at that time point and their subsequent, assuming that the day before they'd eaten their usual, whatever their usual salt intake would be Inaccurate if you were dealing with a few people But when you have 100,000 people it gives you a good measure of range of sodium intake

And then they looked at health outcomes for four years afterwards The total mortality and coronary disease, that is heart attack risk for people was a U shaped curve And the bottom of that curve, where the risk was lowest, was between four and five grams of sodium, not salt Four and five grams of sodium intake per diet When people went down to the value of where the current US recommendations are at 2

3 grams per day, there was actually a measurable increase in risk And under 23 grams, again these are people in multiple cultures, in many different countries But consistently there's a rise when you restrict sodium severely And as one increases sodium intake past six or seven grams a day, then the risk also begins to go up

Now there are some regions and some cultures where people eat a lot more sodium, and there is evidence that that can be dangerous, for instance some fishing villages in Japan, where the sodium intake may be in the 10 to 15 gram per day range, that can be associated with increased risk of stroke and even heart disease So again, this is not a blanket permission to eat vast amounts of salt But keeping, particularly when somebody is on a ketogenic diet which enhances the kidney's ability to clear extra sodium, it appears that the beneficial range for people who don't have significant heart or kidney, already have significant heart or kidney disease, the beneficial range is in the four to five gram per day of sodium intake range – Yeah, I think an important takeaway from this is that it's always in context It's always for an individual person

You have to consider all the different things that they have going on And we can't give a blanket, across the board kind of recommendation But, – If somebody has fluid retention, or hypertension– – Right, have to be much more careful– – Requiring diuretic therapy We get people onto the ketogenic diet and get them keto adapted, and typically we withdraw the diuretic medication Then we then begin to gently add back the sodium to optimize their circulatory reserve, their wellbeing, and their function

So again this has to be individualized, and there aren't, as Dr McKenzie says, you can't give blanket recommendations And we're not doing so here – Alright, our next question is, "Too many calories, and too much fat, "what is your take on these issues, "and the low carb, high fat way of life? "Will hitting your fat macros lead to weight gain?" Hmm, well I'm gonna start with saying, basically what we just said Is that it's very individual, and I would say, what's your goal? Is your goal to lose weight? Is your goal to maintain weight? Is your goal to build strength and muscle? All of these different factors are going to change what your macros may be

At Virta we handle this a little bit differently And we really focus on, you know, it's, we're trying to treat Type II Diabetes We really focus on carbohydrates, getting an adequate amount of protein, and then in terms of the fat, we don't count calories, and we don't prescribe a certain amount of fat We really teach you about hunger and satiety And we encourage people to eat fat to satiety

– So we try to stay away from macros because when somebody comes to us, and they carry extra weight and they wanna lose weight, what's coming in is different than what the body's burning That's how people lose weight And so again, this is as Amy said, we individualize carbohydrate intake to a restricted level where they can get into nutritional ketosis We guide them to eat protein in moderation But enough to maintain lean tissue and function, but not to over eat protein

And then, we counsel people to eat fat, add fat to satiety What that means is to trust your instincts – Yeah – And so often, people, when they're eating a high carbohydrate diet, they don't get that sense of satiety And they're surprised at hey, I, there's still food on my plate and I'm satisfied

And we coach people through that process And one's natural instincts after a significant weight loss is that the body will basically give a person signals, yeah, eat a little more fat But A we don't counsel people to eat a specific amount of fat, and we definitely don't tell people to eat more fat to make your ketones go up because that doesn't work Ketone production is a function of how much carbohydrates you eat, which is the biggest driver Keeping it low enough to maintain the liver in a state where it produces ketones

Not overeating protein Which protein is not a very potent suppressor But it's a moderate suppressor of ketone production And then the other factor that brings ketones up moderately is adding a moderate amount of endurance type activity And if people haven't had the energy level, and they don't have the lower extremity and back problems that prevent exercise, then exercise can be a factor was well

– Yeah, and that's for many of our patients It's been a really successful component, just getting moving in terms of a walk after dinner or something like that Been really helpful for a lot of people – But we don't encourage to purposely add a specific amount of fat to the diet Only to add fat to the point where that meal, that day they have adequate sense of satiety, that they're not constantly thinking about, and obsessing over food

– Yeah, I certainly hear people say, well if I add more fat will my ketones go up But as you mentioned it's not much of a main driver And then if you have that thinking, then you're potentially getting more calories than you really need and potentially stalling weight loss if that's your goal– – Again the process of keto adaptation gives the body permission to burn fat at twice the rate, and at least initially, it doesn't care whether it comes from inside, or from the mind – Alright, now our next question, "Is there a protocol for using the ketogenic diet "as an adjunctive therapy in the treatment of cancer?' Working on this – Again a hot topic

– There's a lot of animal research going on There have been a fair number of human case reports, and small uncontrolled studies have been done There is now a lot of interest in doing controlled, larger cohort studies And again not stealing Dr Volek's thunder, but he has one underway at Ohio State University

But to my knowledge there are no published protocols at this point for treating specific forms of human malignancies or cancer with a ketogenic diet And that you know, hopefully that will be forthcoming, and with high quality research within the next few years – Yeah I think when we were at the Global Symposium for Ketogenic Therapies they were discussing this, and talking about using ketogenic diets in treatment, as an adjunctive therapy for glioblastoma But it was a few case studies, or a case series But yeah

– Again, it takes, as we've discovered, and at Virta, it takes a lot of education and support for people to know what to eat and how to sustain a well formulated ketogenic diet And there's a potential application for vertigo going forwards in providing our continuous remote care to support these kinds of studies – Sure – But, again that's something we look forward to in the future – Alright, so if you're just joining us, we just wanna welcome you to the Virta Facebook live Q and A

We have Dr Stephen Phinney here with myself, Dr Amy McKenzie And if you would like to tune in again, and join our future events, you can follow Virta on Facebook Our next question says, "Many have great concern "about eating protein and fat if they have kidney disease, "or if their doctor warns them that a ketogenic diet "may cause kidney problems, can you address this?" – Yes

– Yes I would say the risk to kidney function from dietary protein intake, is based more on a presumption than on data When protein is eaten in moderation there is very little evidence in, when people have normal, or even modestly impaired kidney function that it will negatively affect the kidney function In our one year data from the IUH study that we published a couple months ago, the commonly used measure of kidney function is something called serum creatinine And that's a product that's produced metabolic in the body and has to be cleared by the kidneys as a waste

And the level of creatinine over the course of a year in people with preexisting Type II Diabetes, so the kidney's are already being challenged by their diabetes The creatinine level went down slightly, but statistically significantly, in the context of a well formulated ketogenic diet So we saw no evidence at one year of any negative effects of moderate protein in the context of carbohydrate restriction and circulating ketones And we will have, hopefully data from two year, that we'll publish from two years as well So again it's, this is not a high protein diet

That, really we have to emphasize that Protein is eaten in, as when we say moderation it's in a range that if you're talking about macros in terms of what the body is burning in a day, we're providing 10 to 15%, at most 20% of the daily energy intake of protein Some people advocate higher protein intakes with carbohydrate restriction, let's say with the Paleo diet And that does not appear to be necessary We don't know whether that's safe or not

But certainly at the levels that we counsel people to do this, we have every evidence of improving kidney function, and no evidence that there's a negative impact on renal health – Alright I'm pretty sure this is a question for the physician "Could diazox– – Diazoxide – "Be helpful to ketogenic dieters?" I have no idea

– It hasn't been studied – Can you tell us what diazoxide is? – It's a therapy that's used in acute care medicine for people with severe hypertension – Okay – It does have metabolic effects that might be beneficial But it's a prescription medication

And I don't know of any evidence that it would be any better than naturally occurring ketone production But again, it's an area where I don't wanna speak from presumption, and I don't know published evidence that would support its use – Okay "Do we need to supplement iodine "since we are using sea salt? "If so, how much?" – So most commercial salt is supplemented with iodine– – Iodized salt – Because if people don't get enough iodine they can have impaired production of thyroid hormone because it has, each molecule that the thyroid makes has to have four iodines on it

In the past, in areas where people aren't close to the ocean where sea food contains a fair amount of iodine, even if sea salt doesn't Iodine depletion can lead to what's called goiter The thyroid gland hypertrophies because it wants to make more But it doesn't have enough of that mineral – Sure

– If somebody eats, takes a standard, basic multivitamin, – Multivitamin That contains plenty of iodine Much of the salt is used in food preparation is iodine supplemented, so again prepared foods will have it, and even if one chooses to eat a version of sea salt that's not been iodine supplemented So we don't have any evidence that folks eating a well formulated ketogenic diet and using sea salt rather than commercial supplemented salt will see an iodine deficiency Theoretically possible

We do counsel people that a seven cents per day, standard, low iron multivitamin is a very, very inexpensive insurance policy that will do no harm and cover some of these basic issues were they ever to become a factor – Sure Our next question is, "What is the maximum limit "grams of carbs for weight maintenance?" This is a very challenging question "What is the maximum limit of grams "of carbs for weight maintenance?" It's a very challenging question to give an answer to broadly I think it depends on the person

– Sure As Jeff and I, I think, if that coined a term, certainly promoted the concept of diabetes as a form of carbohydrate intolerance And diabetes is a disorder of, Type II Diabetes is a disorder of predominately insulin resistance When people reverse that with a well formulated ketogenic diet they can increase their carbohydrate tolerance At the other end of the spectrum, there are people, and we know people who eat a lot of carbohydrates on a low fat diet, and remain very thin, and very healthy

They have a very high carbohydrate tolerance So we range, as humans from very carbohydrate intolerant, that's Type II Diabetes, to those skinny high carb people who seem impervious to even a high intake of refined carbs They're highly carb tolerant So humans vary in a range And then we vary with age

And I would say 30 years ago I was much more carb tolerant than I am now And so you know, for me, 50 grams a day of carbs is about all my metabolism will handle without having health effects But other people can handle 100 to 150, 200, so again, it has to be highly individualized And so we don't have rigid prescriptions And at this point people really have to find through coaching and a bit of trial and error what works for them

And that's what makes the Virta treatment complex, and why it makes it difficult to put it into a standard cookie cutter approach – Yeah, definitely individual to each person what their goals are, what their insulin resistance is Definitely have to work with each person individually Our next question says, "Are there discreet groups of people "who tend to be at greater or lesser risk of losing "muscle mass if protein intake is too low? "How about groups of Type II Diabetics "who react differently to different levels of protein?" Hmm – We do know that people vary in their protein needs

There have been very rigorous studies done in the context in a quote, balanced diet And actually when I was a graduate student at MIT, oh, many decades ago, some of my teachers there were doing studies to measure precisely how much protein the average, normal person needed – Um hmm – I don't wanna cast any spurgeons, at students at my alma mater But they were using MIT undergraduates as their normal subjects, and some people from Harvard might say that those weren't really normal people

Just a little bit of Cambridge politics there, sorry But what they found is that keeping the protein intake very low, down to the point where the people were just hanging on to their existing lean body mass, was a specific number But some people were doing just fine at that And other were losing these tissues So the group average doesn't represent what the individual needs

So there is quite a bit of human diversity in terms of their protein needs We also know that that protein need goes up with aging That older people tend to be less able to maintain lean body mass when protein is restricted And then illness, particularly inflammatory illnesses can increase protein requirements And certain medications will increase protein requirements

So again, there's a lot of variability The number we've chosen to focus on, which centers around an intake of what we call 15 grams of protein per kilogram of reference weight, which is, it basically makes some assumptions about how much lean body mass a person has We pick that number because for the vast majority of people that we've tested that turns out to be a adequate amount of protein, with some buffer But not so much that it suppresses ketone production

And so again, but we, our coaches will work with people if they're struggling to get their ketones up in a good range They can dial back a bit from that level of protein Other people, if they're doing resistance exercise and wanna build lean body mass they can add a bit more, as long as it doesn't compromise ketone levels So again, it's individualized through our biometric monitoring and our coaching – Yeah, one thing that I was really surprised about when I was working clinically was, patients who gained lean body mass once they started doing a ketogenic diet

Can you talk about that a little bit? – Well we've seen that in metabolic work studies That some people come in, perhaps because they have been doing restrictive dieting for an extended period of time And again, when you restrict calories, the body becomes less efficient in the use of protein So people that are constantly restricting, trying to lose body fat may end up also compromising lean tissue – Compromising protein

When we get them on a well formulated ketogenic diet the fascinating thing is satiety goes up They no longer feel like they're restricting But they're eating fewer calories And yet they gain lean body mass And that implies that there is something about the nutritional ketosis that enhances the body's ability to build and recover lean tissue

And we hear that from athletes as well Particularly on the recovery point Again areas that we see evidences there, but we really haven't had the resources to study it rigorously – Our next, who Oh, sorry

We have time for two or three more questions So please ask yours in the comment section under the video "What is the best time to test "for blood ketones to verify ketosis?" we've gotten quite a lot of these, it depends questions today Sorry, this is another one of those it depends questions So I apologize

It really varies between people In general I would say most people have lower ketones in the morning, and higher ketones in the early afternoon, evening, generally kind of in the before dinner, dinner time range But I've definitely seen exceptions to that rule too So I think this is something that it's good to test a a lot of different times and see where you are at different points in the day It's also good to test at different time to understand how your body reacts to food, how your body reacts to exercise, and you can really understand how you work with this

But then ultimately it's up to you, and it's up to you and how your pattern works, and really what you're looking for – In the past we thought that ketones primarily were just a good replacement for glucose to feed the brain Which means you had to have them there all the time, 'cause your brain is burning energy continuously, minute by minute, and so we thought ketone levels should be up in a good range all the time And now it turns out that ketones, particularly beta Hydroxybutyrate has almost a hormone like action signaling various cells in the body to do things, and some of those come through changing gene activity as an apo genetic effect And that maybe something, that if one gets up into it, an effective apo genetic signaling range at some point during the day, the benefits will carry on

And so there's more to be explored here But as Dr McKenzie implied – I can't wait for that People vary at different time points in a day And you know, if you wanna get positive feedback, and see a good quote, you know, a higher level – a higher level

Test yourself typically in the afternoon after it's a half hour, from anything from a vigorous walk to working out in the gym it will probably go up – But if you wanna know your lowest you test at your lowest time point So it depends on what, it really depends on you and what feedback you want to get So our next question is, "Have there been "any updates to the literature around taking "exogenous ketones for general health, "energy, and neurological disorders "since your March blog post?" I don't know if I've seen anything recently– – There really hasn't, I haven't seen anything that enhances what we already know Again there are, this a very active area of research with ketone supplementation

And research being done at Oxford – Yeah – Dr D'Agostino's group at University of South Florida and Jeff Volek at Ohio State University all have active protocols under way And as the range of ketone supplements that can be consumed, the range of formulations is increasingly available, and particularly as the cost comes down we'll– – Yeah that too

– Hopefully have an understanding of how best to marry the exogenous ketone usage with also enhanced endogenous production by appropriately restricting dietary carbs – Our next question is, "How do you address "those doctors who advocated whole foods, "plant based diet to restore insulin sensitivity "and thus control Type II Diabetes, "and also decrease insulin needs for Type I Diabetics? "It seems their way of eating "is the complete opposite of a ketogenic diet" – The answer is, not necessarily One can do a, definitely a low carb, and even a ketogenic diet as a vegan vegetarian It's easier to do as a lacto ovo vegetarian where the majority of one's food is coming from non meat sources, and particularly from plant sources

And I actually was, I participated in a symposium recently in Chicago where there was a advocate of total fasting for a duration of like two or to three weeks, followed by a plant based diet And he presented evidence of reversing Type II Diabetes with that approach The total fasting was done in an inpatient setting This is obviously, would be a very expensive way of using this kind of therapy And his data was impressive in terms of the people he selected to present

But these are people who chose to A, pay the money, and B, go through the fasting And at the end we agreed very collegial that there are some people who are well suited to do it that way And there are many people, and certainly we found quite a few of them in the Lafayette, Indiana area who were able to do it with the Virta program The two are not mutually exclusive And so in the future as, particularly as there are rigorous studies done with the plant based diet, because up til now it's been more anecdotal and ideological than science based

But as people demonstrate what percent of people who are recruited into such an intervention can succeed at that, not just for months, but for years, we'll be able to offer people, basically a menu of options rather than saying this is the way to do it And I don't think there's one carbon, or one cookie cutter approach that fits every human being's metabolic needs – Yeah, and I also think there's preference, and lifestyle choice too, is that you have to, we were talking about doing something sustainable You have to choose something that's going to work for you both in terms of health and your metabolic needs, and your lifestyle, so you have to kind of find the balance between the two And for some people it might be one direction, and for some people it might be a different direction

Definitely have to consider what the patient's goals and values are – Agree – Next question says, "How will I know "if I am no longer insulin resistant?" That is a challenging question to answer We could tell you about your glycemic control You know there's certainly a range of understanding your blood glucose, and how much your blood glucose varies in terms of you know, what is your average blood glucose over a period of time when measured by A1c

In terms of insulin resistance, I guess the gold standard would be the clamp? The glycemic clamp? – There's actually a sign, a research test where you infuse insulin in one arm and you infuse glucose in the other arm and you see how much glucose it takes to overcome the effects of insulin – Sure – The more standard approach is to do either a fasting insulin, and a fasting glucose in the morning and that is a calculation called– – A homeo– – Homeostatic measure of insulin resistance And that's something that can be done by any physician It's a standard test with just one blood test

If you wanna be more rigorous you could do a, and we don't advocate this, have people drink either a 50 or 75 grams of glucose and measure the body's insulin and glucose response over either two hours, up to five hours But the home IR is a pretty good test– – Yeah, it's been validated against– – It's been validated in our, what was the reduction in home IR at one year? Was it like 60%? – I don't remember off the top of my head It was significantly reduced Unfortunately I don't remember the number – It was a very large reduction

– Yeah – And so those are the ways, but if you were taking diabetes medication for Type II diabetes, and you're off those medications, and your blood glucose control is better, and your hemoglobin A1c is down significantly you're markedly, you've markedly improved your insulin resistance That you can know for sure – Definitely So thank you so much for joining us today

If you'd like to have more information on ketogenic interventions and their effect on diabetes and heart health, follow Virta Health on Facebook, and check out our research on virtahealthcomresearch – Thank you

Dr. Sarah Hallberg (Live) on Ketogenic Diets and Diabetes

– Hello Welcome to our Facebook Live question and answer session

I am Dr Sarah Hallberg, and I am one of the medical directors here at Virta Health, and I'm also the primary investigator of our large clinical trial looking at a remote supported continuous care intervention utilizing nutritional ketosis as a treatment for type II diabetes and pre-diabetes And I am thrilled to be here with Dr Catherine Metzgar – Thanks, Dr

Hallberg As Dr Hallberg said, I'm Catherine Metzgar, and I am a member of our clinical team here at Virta, and I work directly with patients during their time in the Virta treatment So please list your questions today in the comments below the video, and we'll try to get to as many as we can in the next hour – It's really important too to note that this is not intended to be individual medical advice

The thoughts that we share today do not replace any advice from your primary care or specialty physicians – So our first question to get started, – So our first question to get started, how does ketosis and Virta's treatment affect heart health and cardiovascular risk? – Well, Catherine, that is a really great question and one we get all the time And the exciting news that I have to share is we recently published a paper on this exact topic So our paper looking at our one-year results and cardiovascular outcomes again was recently published, and I encourage everyone to follow the link and read it for themselves, but let's talk about some of the really important highlights in the trial So Catherine, of all the risk factors that we looked at, and there were 26 altogether, the Virta treatment improved 22 of those

So from a big overview standpoint, that's pretty remarkable But now let's look a little bit more at some of the granular details here about things that patients are asking about So one of the really important things is that patients who have insulin resistance, pre-diabetes or type II diabetes very often struggle with something called atherogenic dyslipidemia, and let's pause for a minute and break that question down or break that term down Atherogenic dyslipidemia means essentially atherosclerosis causing cholesterol And so what is this atherogenic dyslipidemia? What it is is increased triglyceride levels, decreased HDL or good cholesterol and LDL particles that are very small and dense

This is really the hallmark of atherogenic dyslipidemia, and once again important to stress how very common it is in the insulin resistant patient population So what happened with atherogenic dyslipidemia in our trial? Catherine, the results were really remarkable Triglycerides decreased by almost 25%, HDL or good cholesterol went up by almost 20%, and those small dense particles, what they did is they became large buoyant LDL particles So it's really important also to note that there's no medication that can do this – Pretty awesome

– This is just by changing what? Your eating, can drastically improve something that is a big cardiovascular risk for this patient population But one of the other important things that we get questions about all the time is, I know that my diabetes may be reversed, and all these other improvements may occur, but what's gonna happen to my LDL cholesterol? Well again, we looked at this very specific question in our one-year cardiovascular risk outcomes paper And what happened? Well, LDLC or LCL cholesterol did increase slightly However, and this is really important, when we look at cardiovascular risk factors in a insulin resistant patient population, what becomes a much better marker of risk when it comes to LDL is LDL particle number So how many LDL particles are there? Another term for this is the apoB

This is really looking at how many particles there are that potentially could cause problems with heart disease And what we saw is that these were unchanged through the year, and that is really important So the question that we get asked all the time, I mean the really root question is, I can make all these other things better like my diabetes, like my liver function numbers, but am I making some of my cholesterol worse? And the answer from the paper is no Again, the LDLP or apoB did not change over the year, so that is a really important take home point from the study So that's specifically looking at cholesterol

So what we see is dramatic improvements in atherogenic dislipidemia, no change in those really important LDLP or apoB numbers, and we see a really big improvement in blood pressure, a key risk factor for cardiovascular disease And here's the important point Not only did we get to see patients blood pressure significantly decrease, but they were taking less medication for it So we were making it better while being able to remove medication, so again a critical risk factor The other one that is really important to make note of is inflammation because it is important for everyone to understand that at every phase of the development of cardiovascular disease, inflammation plays a key role

So what happens to the inflammatory markers with any intervention is really important And the best one to look at specifically cardiovascular risk is one called C-reactive protein And Catherine, in this study our patients decreased their C-reactive protein by 40% So again, another really important cardiovascular risk factor made better by the Virta treatment – Awesome, thank you, Dr

Hallberg So our next question, can you point to any clinical So our next question, can you point to any clinical evidence of ketogenic diet's anti-inflammatory benefits? – Yeah, so let's go back to what I was just talking about before, the C-reactive protein, and the dramatic decrease We know that that is an improvement in a cardiovascular risk factor, and then that's an improvement in systemic inflammation overall And we actually have this number supported by a decrease in our study in patients' white blood cell counts because that actually, people think of white blood cells, and they think of elevation in sickness, but the other thing is there can be an elevation in chronic inflammation as well So not only did we see the C-reactive protein decreasing by 40%, but we saw out patients' white blood cell count drop as well

– For our next question, if I'm following a low carb diet, – For our next question, if I'm following a low carb diet, and I start eating carbs again, does that make the fat I've been eating have a negative impact on my cholesterol and heart? – Okay, so what we're talking about really there is, the question is geared towards the past fat that someone has consumed when they're eating a low carb diet, and the answer to that is no, that's not gonna negatively impact their cardiovascular disease risk But what they're talking about doing then is going back to our standard American diet, right? Eating fat and eating carbohydrates, and what we have plenty of evidence for is that that combination is a problem So I would really reframe this a say, okay, I was eating low carb and high fat, and I was doing better Maybe now I wanna add a little bit more carbs into my diet again, but we have to really be cautious about ensuring that those carbs that are added are not exceeding any individual's carbohydrate tolerance, because if you increase carbs over your carbohydrate tolerance and add fat in, what you've done is gone right back to the standard American diet that has failed us for decades – I think that's a really great point, Dr

Hallberg, because it talks about, or it speaks to a little bit how we really try to personalize the Virta treatment to each patient's carbohydrate tolerance levels Thank you for that If you're just joining us, we wanna welcome you to Virta Facebook Live Q&A with Dr Sarah Hallberg Please put your questions in the comments below the video, and to get notified of future Facebook Lives and events, follow Virta on Facebook

So with that, our next question, can you provide any So with that, our next question, can you provide any clinical that the ketogenic diet is helpful in preventing cancer? – So there are a lot of trials ongoing here as a potential adjunct cancer treatment So by adjunct I mean in addition to traditional cancer treatment So in order to answer that question and as a prevention for cancer, there would have to be a really long what we call the hard outcomes trial And I think that honestly we're probably pretty far away from that, but we're not that far away of finding out how a ketogenic die may play a role in cancer treatment, because as I said right now, over the next few years we're expecting many of the ongoing trials in this very area to get published and really help with some insights into this question insights into this question

– For our next question, what are the possible side effects of coming off of insulin when your body does not produce enough C peptide? – Well, let's go back and first talk about C peptide and exactly what is C peptide, because many patients who are getting the Virta treatment may have their C peptide levels checked, and why do we do that? We do that because it gives us a really good idea of how much insulin their pancreas is able to produce So when a patient is first early diagnosed with type II diabetes, on average 50% of the cells in their pancreas that produce insulin have actually died already at the very beginning of the diagnosis because they've been over used for so long They essentially tucker out And so people would initially think okay, look, if I wanna take a look at insulin levels and how much insulin my pancreas is able to produce, we'll just draw a insulin level, and that actually is really problematic in giving us answer to the question of how much insulin is my body able to produce because our insulin levels are very dynamic through the day They're up and down and up and down, so if you're just checking an insulin level, you're not really sure if you're catching a high one or a low one

But they're also metabolized differently So insulin is metabolized in the liver very quickly, but insulin is released along with something called C peptide, and it doesn't have these peaks, troughs and quick metabolism issues that come with insulin So when we're looking at someone's insulin producing ability, what we usually check is a C peptide It tells us how much insulin they're able to produce So how that we understand C peptide a little bit more, let's go back to that question and say how is that going to influence my ability to get off insulin? Well, if your C peptide is zero, meaning your body is not able to produce any insulin any longer, you will not be able to get off of insulin completely

That is a condition called insulin apenia, and it's very similar to type I diabetes where patients aren't producing any insulin It's just that the cause is different In type I diabetes this is an autoimmune process, and in type II diabetes where someone develops low or zero C peptide, meaning they can't produce insulin any longer, it's essentially from pancreas burnout Now people who follow a strict low carb diet who are still producing some insulin, meaning they have maybe a lower but still present C peptide, possibly still have the ability to get off insulin or maybe all but a very small basal insulin Again and that's something that would be very personalized and needs the assistance of a physician

And that is one of the reasons why we have a physician, a Virta physician, assigned to each patient in the Virta treatment, so that we can help patients not only remove medication safely, because that is critical, but also at the beginning take a look in patients who are taking insulin, at the C peptide to give them some realistic expectations about what can be accomplished and potentially at what rate So this is a really important question because C peptide for anyone who has type II diabetes over a long period of time, and has needed exogenous or insulin that's injected, a C peptide can be really helpful in predicting how they will be able to get off insulin, of if – Thank you So our next question, how often is it okay to eat keto So our next question, how often is it okay to eat keto approved fruits and foods containing erythritol or other sugar alcohols? Would you say daily or less than daily? – I would say that it really depends on each individual, and I know that that can sometimes be a frustrating answer, right? Meaning that there's not one simple answer for this, but you know, the fact of the matter is we are all different, and what one person can do does not mean another person is able to do and have the same effect So this is one of the areas where a Virta health coach comes in as a critical piece of the puzzle, because your Virta health coach can help work with you to develop your own carbohydrate tolerance level, and also that can lead over to sweeteners as well because some people, it seems that sweeteners can stall weight loss some, and in other people it seems like they can have quite a bit of sweeteners and not ever have an issue at all

And so it's something that we need to experiment with, and you need to have someone to work with you and support you through trying to figure out what your tolerance is What we can find is that most people, most people can consume at least on occasion sweeteners Other people though, the answer may be that they can have them every day So again, individualized, personalized It's such an important key part of keeping people in good metabolic health and making the lifestyle changes to do this sustainable

– And one of the cases that Dr Hallberg mentioned is the sugar alcohols or erythritol or other sweeteners can stall weight loss So we would be looking at how often are is when including these foods, and how does that impact their other metrics like blood glucose and ketones as well – Absolutely, thanks for saying that That's a really important point

– So the next question comes from an individual So they say I've been following a keto eating plan, but my weight loss has slowed even though I have more to lose I struggle with increasing my calories, and I still believe it's necessary to keep calories on the low end between 1200 and 1500 calories daily Would increasing my daily calorie goal speed up my weight loss? – Increasing daily calorie goals, no, probably not I would say the most important thing is to make sure that you're not hungry because that's that sustainability piece that is key

And if you're not hungry, pushing yourself to eat beyond that would not be a good plan for the long run So a couple of things that I would say to that Number one, a weight stall for a while is very normal So first you have to say, is this truly a plateau or is this just my body's pause period for a little bit? And bodies seem to adjust to a lower weight So we see this in most everyone

So my first recommendation is to be patient on this, and it may take a while for your body to essentially reset So a pause in the weight loss sometimes can be very normal And if you're not regaining weight, I like to tell people think about this What you're doing right now is you're practicing maintenance, and it can be very hard in the long term for people to maintain the weight that they've lost ever more so than to get down to a specific weight So practicing is something that is a really important part of the process for everyone

Now if your stall in weight loss continues on, one of the other things I would do is to go and spend a week really specifically weighing and calculating everything because, and you know I'm guilty of this too, all of us here at Virta who follow the Virta treatment sometimes can fall into these traps where we say oh, that looks like a cup of tomatoes And even people who have been doing this for a long time, I encourage everyone to pause at least every couple of months and spend just a few days literally weighing and counting everything to make sure some things haven't snuck back in And the other thinkg that I would say is has exercise changed? Have you started exercise? Or have you stopped exercise, because sometimes that can impact it Believe it or not, especially in women, what we see often is when they begin exercise, which why wouldn't they? They're feeling better, they've lost that initial weight, they're ready to start moving What happens is that can actually cause a prolonged weight plateau

Now that initially sounds like it could be a problem, but in reality what's happening is they tend to be building muscle And so their body composition is changing, but they're just not seeing it on the scale So believe me, if that's occurring, continue on and embrace that longer plateau, and start to pay attention to things like, wait a minute, my pants fit a little bit differently And you may get cues here that you're doing just fine from things other than the scale – I think those are some excellent tips for getting through that weight plateau and thinking about the perspective from that

If you're just joining us, welcome to our Facebook Live Q&A with Dr Sarah Hallberg If you have any questions, please just add them in the comments below the video, and we'll get to them throughout the hour And to get notified of future Facebook Lives and other Virta events, please follow Virta on Facebook Can a ketogenic diet help fight yeast infections? Can a ketogenic diet help fight yeast infections? – There is not any data on that

We do not have any clinical trials on this You know, yeast infections usually are caused by they can be in warmth, so warm places in the body, you know, people can get them anywhere from underneath their breasts to underneath (mumbling) to vaginally And again, sugar does feed yeast infections So I think that the basic science is there that this may truly be a help, but we cannot promote that because we just don't have rigorous clinical trial evidence for this So what I say is try it if you're battling yeast infections, and see if this is something that helps

– For our next question, how concerned should I be about – For our next question, how concerned should I be about high LDLP numbers if my HDL numbers are in a normal range while I'm in nutritional ketosis? – So LDLP is again going back to what we talked about a little while ago, a much better assessment of cardiovascular risk than LDLC And so if someone has got really great improvements decreasing triglycerides, increasing good cholesterol, but struggled with an elevated LDLP, what do they do? And this is not a solidly certain answer yet We don't, there has been no evidence one way or the other 100% So this is one of those places that you really need to work with your physician on So again, the Virta physicians may ask other questions

What are other risk factors that you may have, and how are those controlled? Or this is another place where we may say let's go ahead and get something called a coronary calcium score to assess is there really any burden of cardiovascular disease already present But once again, this is an individual call, and this needs to be worked out one on one between patients and their physicians And Virta physicians are all very, very expert in this area to be able to ensure that they are doing whatever we need to do to promote cardiovascular risk factor reduction for each and every patient individually – So do you say it's fair that it's not just one number that's driving that you're in bad health or great health? It's really a big picture of everything – Absolutely, it is, Catherine

There's not one biomarker when it comes to cardiovascular health that we can point to and say if this is good or if this is bad, you're in the clear or you're doomed It's not like that You know, what we have is we have a whole bunch of things that we know are associated with increased cardiovascular risks, and we have to look at the larger picture You can't get lost in the forest for the trees So each one of those and taking a look at the whole in each individual patient is really important, and that take personalization

– I think that's an excellent reminder because it's very easy to get caught up on that one number Would you say there are any specific drawbacks or benefits to following a ketogenic diet for post-menopausal women? – So I would say there's a lot of advantages to following a ketogenic diet for post-menopausal women And you know, what we know is that post-menopausal women do tend to struggle more with their weight, and it tends to be central weight And so again, a ketogenic diet can improve things for post-menopausal women just as it can for pre-menopausal women and men of all ages So if someone is struggling with those post-menopausal weight gain, especially in those specific areas, I would really encourage people to consider a ketogenic diet

And as far as drawbacks goes, no, there's no specific drawbacks there I mean this is a great patient population for this to be implemented with – What could be the cause of a strong heartbeat when someone's in ketosis? Are there any suggestions of supplements that might help with that? – A strong heartbeat So I would presume that that just means something that one can feel more, that it's not necessarily a racing heartbeat or a feeling of a skipped heartbeat So if I'm taking that question literally, that it's just something you can feel more, here is the likely cause

Someone has lost weight, and literally they can feel it easier So when people lose weight, and there is actually is truly less there, right, they can be more sensitive to feeling their hear beat So a strong heartbeat per se is probably not a problem Maybe a sign of your success Now if that goes into a racing heartbeat, a skipped heartbeat, again that's something that I would see their physician for

– Thank you If you're just joining us, we have Dr Sarah Hallberg here for our live Facebook Q&A Please put your questions in the comments below the video, and we'll address those throughout the hour today And to get notified of future Facebook Lives and other events, follow Virta on Facebook

So jumping to our next question, do you have any plans So jumping to our next question, do you have any plans or timelines on publishing the two-year results of the Virta Health Clinical Trial? – Ooh, that is a great question, and I'm super excited to answer that because well, let me say something before I answer it, which is we have just had an amazing group of truly pioneering patients who have participated in our large clinical trial I mean we all, all of us, not just at Virta, but people around the country should really pause for a moment, and let's just tip our hats to this group of people who have participated in this trial that I really think is going to be part of a nationwide change So if any of our clinical trial patients are watching, you know a big thumbs up to you True pioneers And we are just wrapping up now the two-year results

So we're having the, by the end of this month we will have gathered all of our data for two years, and so it just becomes actually analyzing that data and writing the paper And that seems like okay, we can do that in a couple of weeks, but let me tell you, it's a process because there is a lot of statistical analysis that needs to take place, and a lot of writing and rewriting, and it actually takes a really long time to get a paper published because they go through a peer review process So what is a realistic timeline? Well, we are very hopeful that this paper can get out before the end of 2018, but don't hold me to a promise on that because again, it's dependent on many variables there that all have to fall into line But we are really excited to get those results out, so we're gonna be doing everything we can to keep that process moving forward I actually can't wait for that day

– Me either – It's going to be fantastic, and I am really excited to share with the world again what's possible when it comes to treating this epidemic – This next question is a very common question – This next question is a very common question I get from patients How should I approach fat bombs? Are they a snack, or are they an addition to a meal? – So again, I'm gonna go back to that frustrating answer first, which is, it depends It can be very individual

And so for some people it's a great snack For other people they can have it as part of a sweet treat right at the end of a meal, but you have to be really cautious, and remember this Fat is fantastic We know that we need to have a larger percentage of fat in our diet, but fat is not a free food So just because something is containing even exclusively fat does not mean more is better

So we have to police things even like a fat bomb So I'd say work with your health coach on this to find out what's going to be the right amount or cadence, like every day, or do I do this every other day? Is this a once a week treat for me, depending on how your body is reacting And then really, you know, how is it best for you? Is it one fat bomb in the afternoon, and I'm great until I can get home and have time to prepare dinner? Because for some people that may be the perfect place to put a fat bomb For other people, they're done with dinner, but they just want that small bite of something sweet, and they make a small fat bomb For that person, that may also be perfect, too

So again, individualized on this, but remember, fat is not a free food – I think that's an important point as well because it's very easy to overdo those fat bombs, and then while you may have amazing ketones, your weight is probably going to stall as well, so they can definitely go a little too far if you're not careful, so that personalization piece is very important Thanks for those tips, Dr Hallberg – Absolutely

And the artificial sweeteners are what's causing diabetes in the first place What would your elevator pitch be to answer these critics? – Okay, so let's go back to the sweetener part first, and then let's talk about the long term aspect of this We've got two questions here, and I think they're both excellent questions, and I wanna make sure that we treat each of them individually So my feeling about sweeteners are honestly we don't know how much sweeteners or the very long impact of sweeteners So I take this in, this is my view on sweeteners

We want to be able to use them as little as possible, and we use them really as a tool to make this intervention sustainable because you know, when it comes to sugar, sugar for anyone with diabetes is going to lead to long term problems And so we want to be able to keep people away from utilizing sugar to make foods palatable But to tell someone who really enjoys sweets that, well this lifestyle intervention, you can never have anything sweet for the rest of your life, that's not going very far, okay? But I'll say a couple of things, which is number one, if when people are early on beginning the intervention, and they spend even a few weeks early on without eating anything sweet, you know, meaning even staying away from those sweeteners for a short period of time at the beginning, their taste for sweet things will change And you know, you have to try it to truly believe that because I get that comment from people all the time I can't believe I couldn't eat X, Y or Z any longer because the sweetness was overwhelming to me

So right there that's gonna enable you to be able to decrease any sweetener use significantly And then I just say use sweetener sparingly to make things sustainable, okay? The long term answers to sweeteners we don't know, but we have pretty good evidence that processed carbohydrates, including sugar and their impact on metabolic health for patients with type II diabetes, pre-diabetes or insulin resistance is negative, so we have to keep both of those things in mind Now long term impact of this, what we know is that long term impact of our typical dietary guideline associated dietary recommendations has been a failure, has made people sicker So we have great evidence on this in ketogenic diet in studies out to 56 weeks already And again, with the improvements in metabolic health, including the huge risk factor for so many diseases, cardiovascular disease, cancer, that is type II diabetes, long term if we are able to reverse people out of that disease pattern, we can say with confidence that they're getting healthier

– Are some artificial sweeteners better than others? – Are some artificial sweeteners better than others? Specifically what are the benefits or the effects of saccharine or glycerine or other artificial sweeteners like that? – So artificial sweeteners, there are many different categories, if you will There's sugar alcohols, and then there's what we call the saccharine These are the chemically created, non-nutritive sweeteners And so let's talk about sugar alcohols first So sugar alcohols end in o-hol

You can always kind of pick them up on a food label xylitol, erythritol, neanotol, sorbitol, those are all examples of sugar alcohols, and they can all actually impact blood sugar a little bit differently And so it's important if you're trying out a new sugar alcohol that you check your blood sugar to see what the reaction is for you But the ones that tend to have the least impact by far on blood sugar, which is key here, are going to be xylitol and potentially erythritol Now with sugar alcohols, especially in higher doses, people can tend to have some GI issues, so that's another thing to keep in mind as well

So experiment with them when it comes to your blood sugar and your individual tolerance of them But we tend to recommend a lot of the sugar alcohols overall because of that, and actually xylitol, let's take a quick look at xylitol itself And that is one of the interesting things that people don't realize is right now everybody who's watching this, Catherine and I, we're making xylitol right now Our bodies make xylitol So again, what we're doing is we're ingesting something that we're also making, and so that's one of the reasons that we recommend that

Our bodies are used to that xylitol is found, erythritol too, a lesser degree, naturally in fruits and even vegetables So again, that's high on our recommendation list, but everybody needs to check out their individual tolerance of them Now the non-nutritive sweeteners, those are ones that have no calories, and they don't by themselves have an impact on blood sugar And that's been shown in multiple studies

So let's take a look at Splenda, for example Splenda doesn't, over a patient population, increase blood sugar Once again I'll always say check your own individual blood sugar, but it tends to not have an impact That being said, it's a chemically created compound So if you're using something like Splenda, I would use it sparingly

And what you'll notice with these non-nutritive sweeteners is that in their liquid form it'll say no carbohydrates, no calories But when you get them in their powdered form, that's a different story Why? Because they had to add something called bulking agents, which are carbohydrates, to make them powdery so that you can use them for example in baking recipes So there's a big difference between the liquid forms of these and the powdered forms And one other sweetener that I'd like to draw attention to that is a non-nutritive sweetener, but is little bit different is stevia

So stevia is just from a stevia plant In other words, it's not chemically created Now that being said, stevia is available under many different names, and some of these the stevia leaves are highly processed and some aren't So a good idea is if you're choosing stevia, you wanna take a look and research what brand that you're buying so that you can get the least processed stevia Or if you wanna be completely natural about it, grow some stevia

Now stevia and utilized straight from the plant can have a little bit of licorice taste to it Some people really enjoy it, and for some people it makes it a little less tolerable So those are my comments about sweeteners Sugar alcohols, put them into non-nutritive sweeteners, but the non-nutritive sweeteners are different in a liquid form than they are in a powdered form And always when introducing any kind of sweetener, check your blood sugar

– If you're just joining us, welcome to our Facebook Live with Dr Sarah Hallberg Please put any questions that you have in the comments below the video, and we'll address those during our last 20 minutes or so And to get notified of future Facebook Live events and other Virta events, make sure to follow Virta on Facebook All right, here's a really good one, All right, here's a really good one, and I think the answer's gonna be it depends, but maybe you can shed a little more light for us, is how do you know what your personal carbohydrate tolerance level is? – So that's a great question, and it depends

No no, but let's answer that with a little bit more detail here, okay? So what I like to say is that people can develop different metabolic flexibilities, okay? So let's just take someone who does not have type II diabetes, pre-diabetes, never had an issue with blood sugar, no family history of it, they obviously have a higher carbohydrate tolerance And now that may not last forever because if they utilize that high carbohydrate and eat lots of sugar and refined carbohydrates, they very well may develop a lower carbohydrate tolerance for insulin resistance But that is at one end of the spectrum of carbohydrate tolerance At the other end of the spectrum of carbohydrate tolerance when it comes to type II diabetes is someone who has had very longstanding diabetes, and as we talked about earlier has overworked their beta cells in their pancreas and truly is unable to produce enough insulin Those people are at the other extreme end of carbohydrate tolerance, so there's a big spectrum here

And where, most people fall in the middle of this spectrum, and where exactly in the middle do you fall? And the first thing I'll say is that may change, okay? So in other words we may find someone who's at the lower end of carbohydrate tolerance, and as they implement a Virta treatment, they improve their insulin resistance, which is very nicely documented in our one-year clinical trial Insulin resistance scores dropped dramatically They may actually shift themselves to having a higher carbohydrate tolerance Now I'll tell you right now anyone who improves their insulin resistance, if they go back to eating a high carbohydrate tolerance, they will develop problems again So this is helping back people out, but it's not curing them, and that's a really important point to make

If we implement the Virta treatment, someone does it just for a while, goes back to a high carbohydrate lifestyle, they will have recurring problems at some point So important to remember that as we think about that sustainability piece But in figuring out exactly where in the carbohydrate tolerance spectrum you are at any given time, keeping in mind that that could change, it's really going to be following your blood sugar And if you have a Virta health coach, they're gonna be key in helping you with that because they're gonna be watching your blood sugar And say you try a new food

What's your body's reaction to it? Are you doing really good, and your blood sugars have been in the 90s, and then all of a sudden you went out to a new restaurant and had a sauce on something, on your dinner plate that night, and all of a sudden the next morning your blood sugar was 180? Whoa! That was over your carbohydrate tolerance And even though maybe the food choices looked good, it was probably something in the sauce that you weren't aware was put in there, and most of the time unfortunately that winds up being sugar So it's just going to be following those blood sugars And you know, I'd like to take an opportunity with this question to point out something that I think is going to be key in the type II diabetes community, and that's going to be the advent of continuous glucose monitors that are now available to the type II diabetes population So continuous glucose monitoring is exactly that, what it sounds like

It's monitoring your blood sugar not when you prick your finger and you check it one, two, even more like four or six times a day, which is helpful, but we've got big parts of the day, including overnight where we are not sure what's happening with your blood sugar We're just checking it at specific points in time during the day And continuous glucose monitors have that available, but they have been so expensive that they've really only been implemented for type I diabetes But now there's a new continuous glucose monitor available called the Libre, and these are very inexpensive And I've been utilizing them in some of our patients who have found them to be incredibly helpful at just this, determining their carbohydrates tolerance because they can watch the line through the day instead of just points on that line to see exactly how they're reacting to certain food

So I think finding everyone's individual carbohydrate tolerance is very important Working with your Virta health coach and following your blood sugars when you eat anything new is going to be a wonderful way to make sure that you are personalizing your carbohydrate tolerance threshold for where you're at right now – Great answer to a great question – Great answer to a great question What amount of dairy or lactose is allowed on a ketogenic diet? – Well, for most people that is a great source of additional fat and often protein, okay? Sometimes we will have patients who have issues with dairy, and maybe the lactose in it

It may be other aspects of the specific proteins in dairy, and so it's one of those things If people are really struggling, if they're having some sort of side effect, which oftentimes is GI, they could try removing dairy for a few days to see if that could be the issue, but I would say that's the exception for most patients instead of the rule So for most patients the answer to how much dairy can you have in a day is how much is it taking to get you full, as long as you're making sure that you're meeting your protein requirements for the day – Our next question, what are your thoughts about upping your carbs to 50 to 100 grams a day after achieving type II diabetes reversal or your goal weight? – So it all depends on what your individual carbohydrate tolerance is, right? – Nice follow up question there – Yes, yes, it's a perfect, thank you very much for this question

So again, let's go back to that spectrum idea, right? So someone started out at the very carbohydrate intolerant end of the spectrum, and they've done a great job with this and they've worked their way up They very well may be at the 50 to 100 range That's totally possible For other people, they're not They're gonna fall maybe at the very low end of that, and they can do 50, but if they go above that, they're gonna run into issues

So you're gonna have to just check your blood sugar, but that is not like unfathomable range for some people Some people can regain what we like to call metabolic flexibility, or they can tolerate higher carbohydrates, potentially even in the 50 to 100 range But the other important thing is if you are one of those people who can get into that 50 or 100 range, you always wanna be asking about the quality of the carbohydrates that you're adding in, because if you're at 30 and doing great, then you moved up to 50, and you're still doing good and we're gonna experiment with going higher, if you're adding those in with refined flours, I mean you're gonna get into trouble quickly If you're choosing to add more carbohydrates by choosing berry fruit or choosing to eat more nuts, those are gonna be foods that are gonna allow you again more flexibility So be cautious not only of what your specific gram number is, but exactly what are the foods that you're choosing to increase the carbohydrates if you're able in your diet

– Do you have any evidence of neuropathy improving – Do you have any evidence of neuropathy improving with diabetes reversal? – Well, we see this anecdotally often in the clinic, and patients will report an improvement, but can I claim that this is absolutely a treatment for this? No, because once again we don't have rigorous data on this So it's one of those other situations where I say look, this is probably good for a lot of things in each individual case that we have good data on Try it out, and if the neuropathy is improving for you, wonderful You don't have to wait for the rigorous clinical data, but to be able to say to the masses you should do this for that specific treatment, we have to wait for the data It's really important to say that we as a company, the Virta treatment is being driven by data

So we are continuously getting more data, but what we are doing we are only gonna be promoting things that we know are truly evidence based And like I said, there may be plenty of good evidence based reasons to try the Virta treatment, and for some people that may also improve their neuropathy, which is fantastic – If you're just joining us, welcome to our Facebook Live with Dr Sarah Hallberg Please put you questions in the comments below the video, and we'll try to get to as many of those as we can today

And to get notified of future Facebook events and other Virta events, make sure to follow Virta on Facebook And we have just about 10 minutes, so we'll try to get to as many questions as we can because I know there are a lot of good ones out there All right, here's another common one that I get All right, here's another common one that I get from a lot of patients So I've noticed I'm losing hair on keto Is this normal, and what can I do about it? – So I can be, and it's very important to say what we should really turn this into because what is much more true is I'm losing hair with rapid weight loss because it probably has nothing to do with the diet itself

It's the fact that the diet is causing weight loss And we do get this question a lot, and here's how I like to explain it to my patients in a way that they can really understand And that is when women have babies, they don't go home from the hospital with hair loss, right? But what they will find is that when that baby is four, maybe six months old, all of a sudden they're starting to lose hair, and that's because giving birth is a big shock to the system, right? I mean it's obviously a good one, we all love it, but it is a big shock to the system Weight loss is the same way It's a big shock to the system

We love it, we wanna have it, but again weight loss is likely to occur four to six months after the beginning of a period of rapid weight loss, and that's because the hair grows in phases So what I tell patients here is be patient Let the phase pass, and then the hair will come back If people are really worried about it I'll say, start taking some B-complex vitamins I mean I don't think there's gonna be any problem with patients doing that

Whether or not that's gonna help, hmm, it might, but the bigger thing is you just gotta give it time and let that phase pass – Next question, what effect can a well formulated ketogenic diet have on osteoporosis? – So I'm gonna say table the answer to this question because we have data on this that we have not analyzed, but we will and intend on publishing, looking at dexa scans in our patients in our large clinical trial So right now the evidence on this is scant to non-existent essentially, and so we have the ability analyze some data right now and put these results out So I'm gonna have to say hold on this because I wanna share, one again ensure that all my answers are evidenced based answers, and we will have the answer to this soon – What does the research tell us about ketogenic diets – What does the research tell us about ketogenic diets for thin people with type II diabetes? Specifically would a ketogenic diet be a good option for diabetes reversal for people of southeast Asian descent? – So the answer to that is yes

And so patients of southeast Asian descent do tend to develop diabetes at a much lower weight than in many other parts of the world, and so they may not have 100 pounds to lose, but it doesn't mean that changing the content of the diet won't lead to successful diabetes reversal just as it would with any other patient population So I would really encourage people of south Asian descent to consider this as a treatment for type II diabetes, really important – Is a ketogenic diet an option for a patient with – Is a ketogenic diet an option for a patient with a family history of hypercholesteremia? – Absolutely, and like I said again let's go back to the cardiovascular risk paper that we just published, looking at improvement in 22 out of 26 risk factors And so having a family history of hypercholesterolemia does not preclude anyone from participating in a lifestyle change that includes nutritional ketosis But once again, I'm gonna go back to say everyone is different, and this is one of those things that you need to have a physician who is following with you to help make sure that you're able to make personalized choices and treatment plans as you move forward

We at Virta want everyone to have their cardiovascular risks as reduced in all aspects as possible – How often if at all would you repeat a CAC? And can you tell us what a CAC is? – Yes, CAC is a coronary calcium score And so coronary calcium scores are a really great way to help people make decisions, giving them another point essentially, remember we don't wanna miss the forest for the trees, and sometimes that can happen when it comes to cardiovascular risk reduction We wanna be able to have as many data points as we can, and somebody's coronary calcium score can be a very helpful point here So in other words, if someone's had high cholesterol all their life, they go on a lifestyle intervention like the diverted treatment, and their cholesterol stays elevated instead of going down like it does with many of our patients, or potentially even goes up, and they have a coronary calcium score of zero, that's a really different place than someone who has had a lifetime of high cholesterol and has a very, very high coronary calcium score

So a coronary calcium score is a CT scan People go in, they can usually be had for very low prices I know in our area Indiana University Health offers them for $49 It's a very quick test, in, out, and what the CT is looking for is calcium, calcium in the arteries that supply the heart with blood And so what a coronary calcium score should be is zero

In other words, no evidence that heart disease that has developed into coronary plaque or calcium Now anyone who has a positive coronary calcium score, even if it's low positive, using and checking this over time, one of the big things that's going to be a factor there is statin medication use because anyone with high cholesterol who then has a positive coronary calcium score, if they get started on a statin, their coronary calcium score actually has the potential to increase, but that doesn't necessarily mean that that's a bad thing because calcium in that plaque shows us that it's stable And I'm gonna go here and digress just a little bit into coronary artery disease physiology Many people think of a heart attack as a clogged tube, right? So you develop disease in your arteries, and they get smaller and smaller in diameter until one day they close, and that's actually now what happens with heart attacks and coronary artery disease progression to an actual event What happens is there's a degree of disease in an artery, and for whatever reason there becomes a piece of this plaque that's unstable

It gets kicked off, floats downstream, blocks the flow of blood, and that causes the heart disease, excuse me, the heart attack So what we wanna do is someone has any degree of disease is we wanna stabilize it, and when you stabilize it that can actually be seen as an increase in the coronary artery calcium score, but that can be mean in many people stabilization of disease, so that's really important But I love the coronary artery calcium score in people as again an additional data point And we can have a really good discussion together at what that person's individual risk factors are, and what is our next logical step And it's a decision that should always be a shared decision

I think this is so important I will never say here's a prescription, you need to take it because taking a new prescription, that's a really big decision to be made, and it should be made as a team It shouldn't be one person dictating what another person does It should be to say let's put your, let's put all the ducks on the table, if you will Let's talk about your risk factor, and let's come up together with what our treatment path is going forward

– Do you need to be in ketosis for the low carb, – Do you need to be in ketosis for the low carb, high fat diet to be effective? Or can eating keto-ish be acceptable or successful? – Well, that's a great question, and honestly the jury is out I think that what we know about ketones are they can be incredibly important in helping people know that they're doing it right, right? Because if they have ketones, what does that mean? It means that they're using fat for energy, and they've got it They're implementing the lifestyle intervention well If they're doing keto-ish, and they don't have that to judge, I mean it's really a little bit more difficult to say how am I doing today? Was this food choice a good one for me? Or did I just make a choice that's negative on my metabolic health? So I think they can be really important there And we're just beginning to understand the benefits of ketones, so I think more and more data is coming out on this, and I would not be surprised within the next few years if we really get a much more firm stance saying ketones are critical in health

There have been studies recently that came out that show ketones very specifically decrease inflammation Once again, going back to remind everyone, key component of all stages of cardiovascular disease formation, inflammation Some really nice studies showing that ketosis specifically with elevated ketone levels lead to decrease in inflammation In the other one there was even longevity studies that came out, and yes, it was a mouse study, but I think it really opens up questions I mean where is the possibility for ketones to play in so many aspects of disease? And we mentioned it briefly before

Right now there are ongoing a lot of trials with ketones specifically in cancer and in many neurologic diseases For over 100 years in fact, ketogenic diets very specifically needing those ketones present, treats epilepsy So I think that we're gonna find out much more on exactly what else besides metabolic health improvements we may get as a benefit by following a true ketogenic diet and implementing that as a lifestyle – So stay tuned More info to come on ketones over the next couple of years

– Yes, absolutely, absolutely – So we have time for just a couple more questions So with that we'll go to the next one So is it dangerous for someone that's living with So is it dangerous for someone that's living with type II diabetes to do ketogenic diet without measuring all of those biomarkers and just following the basic rules? – It can be That's the really quick down and dirty answer, it can be

It can be very dangerous if you are not working with a physician Why? Because medications that patients take for diabetes are intended to lower their glucose And if you're making lifestyle interventions aimed at lowering your glucose, you can enter into a potentially really dangerous double whammy That's why everyone entering into the Virta treatment plan not only gets their health coach who can help personalize their food choices, but they also have their own Virta physician who is ensuring that they are adjusting those medications appropriately, safely, but also getting them down so that people can successfully reverse their diabetes and get rid of some of their medications So it is so important to have a partner in a physician who's working with you on this

And I can't stress that enough because if we get those blood sugars to drop too quickly because no one is helping with medication adjustment, that can be incredibly dangerous – So thanks everybody for joining us today To get more information, follow Virta Health on Facebook, and check out our research, much of which Dr Hallberg referenced today at virtahealthcom/research

So thanks, Dr Hallberg, for joining us today I learned a lot, I hope everyone else learned a lot, and we'll see you back here next time – Thank you so much for joining us I really appreciate it, and I'll be excited we'll be doing more of these in the future

Doctor Mike on Diets: Ketogenic Diet | Diet Review

What is the "ketogenic diet"? " rapid weight loss" " fats with benefits" "Decrease your appetite " "Ketose

" " butter is healthy!" Explain yourself The ketogenic diet

Let's understand why all this fame I'll tell you what it is, briefly explain how it works and discuss some of the more common statements about it Let's start! Before we talk about the ketogenic diet, let's understand a few basic things about nutrition There are three main groups of macronutrients we will focus on here Proteins, fats and carbohydrates

These are the nutrients you find in the food you eat every day The standard American diet consists of 35% fat, 15% protein and 50% carbohydrates But if the ketogenic diet is analyzed, the numbers are quite different With 75% being fats, 20% being proteins and only 5% being carbohydrates Think about it: they are ten times less carbohydrate than the standard American diet

How it works Let's say you change your normal diet to ketogenic What happens inside your body? Your body handles low carbohydrate intake in two ways First, it enters a state called "ketosis" It changes the body's energy source to come mainly from fats Which basically means that there is the breaking of fats to ketone bodies, read ketosis, and then uses that to generate energy

Simply your body starts burning fat as its main source of energy and avoids the use of glucose, which is a carbohydrate The process of getting into ketosis takes a few days And during those days, people begin to experience some side effects Confusion, irritability, nausea, discomfort Some people call it "ketogenic fever

" "I do not feel very well" The second process used by your body is gluconeogenesis It sounds kind of scary but it really is not

It is in your body to create glucose, because not all cells work with fats alone A curiosity: for reasons of survival, you do not need to consume any carbohydrates unless you are consuming enough fats and proteins Affirmations Now, where did all this fame come from the ketogenic diet? Let's take a look at the affirmations and see what is true and what is not First affirmation: "The ketogenic diet is good for weight loss" Yes! The ketogenic diet is good for weight loss

This is done through two important mechanisms First: Since you are using fat as the main energy source, You're burning too much fat Second: Because the fats are more satiating, they make you feel "full", when you eat something high in fat, you really do not want to eat that much Soon, you end up limiting the amount of calories consumed during the day Many people are surprised that when they start the ketogenic diet, they lose weight very fast

But this is kind of misleading, because most of the weight lost initially comes from the loss of water and not fat loss For those of you who want to lose weight in the long run, the ketogenic diet is not very sustainable It's graduation day, all your friends are going to have ice cream Some will take a milkshake of Cookies n 'Cream (me), and you can not take too because you're doing the ketogenic diet? This is crazy! You have to be very attentive while doing the diet Because carbohydrates have this disgusting habit of simply getting into your food

Ketchup, food with a lot of carbohydrate Apples, bananas, Milkshake by Cookies n 'Cream What's it? I love Cookies n 'Cream milkshake

And this is also worth taking that drink with your friends No alcohol Second statement: "The ketogenic diet is good for the brain" The truth about this is that the jury has not come to a conclusion about it yet Because science did not give us the answer

Research in this area is not yet complete And somehow, some people say they feel more focused or smart with the diet But I also listened to my patients saying they feel more confused and that "ketogenic fever" continues for longer than normal So I do not like to use anecdotes to tell if a diet is good or not I need quality research, which is what I do not have

Third assertion: "The ketogenic diet prevents or controls various chronic diseases" This is a yes and no answer Where the ketogenic diet really calls attention is in Type II diabetes Because when you have Type II diabetes, you have insulin deficiency, you have high blood sugar and research shows over and over that the ketogenic diet for type II diabetes works That! We have to talk about childhood epilepsy because it was where the ketogenic diet really created its roots

We can prescribe the ketogenic diet for children who have seizures of refractory epilepsy and what you notice is that when they enter the state of ketosis, there is a decrease in the frequency of these seizures It works, it's proven They are scientifically based evidence The ketogenic diet has been shown to be promising in the field of oncology, commonly known as cancer She is not ready to be an immediate cancer treatment yet

And research does not fully support it as a preventative method in cancer development But what we do know is that there are promising things and that more research needs to be done Potential Damage Some damage that may occur from following the diet: Nutritional deficiencies by removing large food groups from the diet, increase in LDL (your bad cholesterol), liver problems, bone problems and the increase of some types of cancer when you are consuming too much processed food or red meat My final considerations on the ketogenic diet: I think it's a good diet for weight loss, I think it's better to have short-term weight loss than in the long run So if you have a wedding to go or any other big event that is nearby and you're mostly healthy, I do not think a bad diet to be done

The diet is very complex to be followed by the fact how drastically you need to change your dietary pattern, of the possible damages that can come with the diet And frankly, because of the lack of knowledge and lack of research that we have on its long-term effects and all are questionable, I am encouraged not to recommend this diet for the majority of my patients And neither for you from home I read in the comments that some of you wanted me to test the ketogenic diet

If we can get this video to reach 20,000 likes, I'm going to test the diet and I'll take you with me on this journey As always, stay happy and healthy! We have to talk about childhood epilepsy because was where the ketogenic diet actually created its roots Found its roots

"Start your roots"? Scratching nose syndrome I do not know how to do this (quotes) I do this all the time? I said "ketogenic fever

" "The ketogenic fever" Quiet, Bear Is not it strange how it just pops up in framing?

Doctor Mike on Diets: Ketogenic Diet | Diet Review

What is the "ketogenic diet"? " rapid weight loss" " fats with benefits" "Decrease your appetite " "Ketose

" " butter is healthy!" Explain yourself The ketogenic diet

Let's understand why all this fame I'll tell you what it is, briefly explain how it works and discuss some of the more common statements about it Let's start! Before we talk about the ketogenic diet, let's understand a few basic things about nutrition There are three main groups of macronutrients we will focus on here Proteins, fats and carbohydrates

These are the nutrients you find in the food you eat every day The standard American diet consists of 35% fat, 15% protein and 50% carbohydrates But if the ketogenic diet is analyzed, the numbers are quite different With 75% being fats, 20% being proteins and only 5% being carbohydrates Think about it: they are ten times less carbohydrate than the standard American diet

How it works Let's say you change your normal diet to ketogenic What happens inside your body? Your body handles low carbohydrate intake in two ways First, it enters a state called "ketosis" It changes the body's energy source to come mainly from fats Which basically means that there is the breaking of fats to ketone bodies, read ketosis, and then uses that to generate energy

Simply your body starts burning fat as its main source of energy and avoids the use of glucose, which is a carbohydrate The process of getting into ketosis takes a few days And during those days, people begin to experience some side effects Confusion, irritability, nausea, discomfort Some people call it "ketogenic fever

" "I do not feel very well" The second process used by your body is gluconeogenesis It sounds kind of scary but it really is not

It is in your body to create glucose, because not all cells work with fats alone A curiosity: for reasons of survival, you do not need to consume any carbohydrates unless you are consuming enough fats and proteins Affirmations Now, where did all this fame come from the ketogenic diet? Let's take a look at the affirmations and see what is true and what is not First affirmation: "The ketogenic diet is good for weight loss" Yes! The ketogenic diet is good for weight loss

This is done through two important mechanisms First: Since you are using fat as the main energy source, You're burning too much fat Second: Because the fats are more satiating, they make you feel "full", when you eat something high in fat, you really do not want to eat that much Soon, you end up limiting the amount of calories consumed during the day Many people are surprised that when they start the ketogenic diet, they lose weight very fast

But this is kind of misleading, because most of the weight lost initially comes from the loss of water and not fat loss For those of you who want to lose weight in the long run, the ketogenic diet is not very sustainable It's graduation day, all your friends are going to have ice cream Some will take a milkshake of Cookies n 'Cream (me), and you can not take too because you're doing the ketogenic diet? This is crazy! You have to be very attentive while doing the diet Because carbohydrates have this disgusting habit of simply getting into your food

Ketchup, food with a lot of carbohydrate Apples, bananas, Milkshake by Cookies n 'Cream What's it? I love Cookies n 'Cream milkshake

And this is also worth taking that drink with your friends No alcohol Second statement: "The ketogenic diet is good for the brain" The truth about this is that the jury has not come to a conclusion about it yet Because science did not give us the answer

Research in this area is not yet complete And somehow, some people say they feel more focused or smart with the diet But I also listened to my patients saying they feel more confused and that "ketogenic fever" continues for longer than normal So I do not like to use anecdotes to tell if a diet is good or not I need quality research, which is what I do not have

Third assertion: "The ketogenic diet prevents or controls various chronic diseases" This is a yes and no answer Where the ketogenic diet really calls attention is in Type II diabetes Because when you have Type II diabetes, you have insulin deficiency, you have high blood sugar and research shows over and over that the ketogenic diet for type II diabetes works That! We have to talk about childhood epilepsy because it was where the ketogenic diet really created its roots

We can prescribe the ketogenic diet for children who have seizures of refractory epilepsy and what you notice is that when they enter the state of ketosis, there is a decrease in the frequency of these seizures It works, it's proven They are scientifically based evidence The ketogenic diet has been shown to be promising in the field of oncology, commonly known as cancer She is not ready to be an immediate cancer treatment yet

And research does not fully support it as a preventative method in cancer development But what we do know is that there are promising things and that more research needs to be done Potential Damage Some damage that may occur from following the diet: Nutritional deficiencies by removing large food groups from the diet, increase in LDL (your bad cholesterol), liver problems, bone problems and the increase of some types of cancer when you are consuming too much processed food or red meat My final considerations on the ketogenic diet: I think it's a good diet for weight loss, I think it's better to have short-term weight loss than in the long run So if you have a wedding to go or any other big event that is nearby and you're mostly healthy, I do not think a bad diet to be done

The diet is very complex to be followed by the fact how drastically you need to change your dietary pattern, of the possible damages that can come with the diet And frankly, because of the lack of knowledge and lack of research that we have on its long-term effects and all are questionable, I am encouraged not to recommend this diet for the majority of my patients And neither for you from home I read in the comments that some of you wanted me to test the ketogenic diet

If we can get this video to reach 20,000 likes, I'm going to test the diet and I'll take you with me on this journey As always, stay happy and healthy! We have to talk about childhood epilepsy because was where the ketogenic diet actually created its roots Found its roots

"Start your roots"? Scratching nose syndrome I do not know how to do this (quotes) I do this all the time? I said "ketogenic fever

" "The ketogenic fever" Quiet, Bear Is not it strange how it just pops up in framing?

DOES THE KETO DIET KILL? Doctor Reviews Low Carb Diets and Mortality

Hey guys, I'm Siobhan a second-year medical resident Today we're tackling a super controversial issue and that's The Keto Diet The question is – is the keto diet actually making you live longer? or could it be actually killing you faster? The keto diet is a very low carbohydrate diet About 75% of calories come from fat 20% from protein and only 5% from carbs It's become one of the most popular diets online and it's been praised for weight loss, heart health, diabetes management and some even believe it fights cancer

But others think it's probably just a fad diet and it's just gonna come and go Just this week, there was a groundbreaking article from The Lancet which totally changed the conversation It's an article that looked at how much carbohydrates people are eating and if that affected life expectancy By the end of this video you should be able to make an educated decision about what you want to do with your diet And then I'm gonna *urge* you to share this with people you care about because this could actually affect how long they live *violin intro plays* So those of you who've been following my journey in the hospital at the new doctor know that about six weeks ago I started the keto diet and the reason I did that is because Overnight I find they're just so many chips and snacks and candy and

I- This whole year I just feel like I have strayed from my normal habits and so I kind of just needed like a reset and I figured that keto would do that And it did like I lost a couple of pounds I put on last year and I haven't been having sugar cravings It was great

So this week when I was flipping through my computer I saw this article And I figured it was gonna tell me that the lower the carbs you eat the longer you live But that's not exactly what it says So the study started about thirty years ago, when they recruited a whole bunch of adults from four different communities in the US They recruited about 15,000 adults and then had them do surveys and they kept track of their health and they tracked them over about 30 years *okay, that's deep* So let's pretend these skittles represent the people in the study First let's divide them into the amount of carbs they eat in a day The yellow ones the low-carb group And so these people about less than 40% of their calories from carbs

The green ones of the moderate carb group So these guys bought about half of the calories from carbs And the red ones are the high carb group where they got over 70% of their calories from carbs Of course this is a simplified model and in the study they worked with really fancy statistical models to get lots of accurate information So looking at mortality within these groups

It turned out the low-carb (yellow) group and the high-carb (red) group actually died faster than that middle green group So it looked like Goldilocks and the three bears The middle 50% carb group actually lived the longest And you can see that it has this U-shape, and we actually call that a U-shaped relationship They're estimating that in this in the low-carb group and the medium-carb group, That was almost a four-year difference in their life expectancy

That's like high school That's university That's so many life experiences That's huge I mean, we can't ignore that Definitely not what I expected

Definitely a huge shock to hear Question 2* So then the next logical question is if you have lower carbs you're eating more fats and proteins Does it matter what types of fats and proteins you're actually eating? So they went back to the database and they looked at all the people and they wanted to see the group that eats mostly animal products So they're eating meats and cheese, lamb pork, beef, chicken all of that compared to the people who are eating plant-based proteins and fats So they're eating nuts and peanut butters and seeds and they're having lots of vegetables And unfortunately all those meat lovers out there, it was very clear that people eating plant-based proteins and fats were living longer than those who ate the animal proteins and fats

And that's tough for me I actually really love a good steak *pleasure* Ooo boiii <3 owww So you might be thinking : "Hold on Hold on Siobhan I don't live in one of those four communities in the US maybe these results don't really apply to me?" Like me I live in Canada

I don't live in the US But the authors were smart and they thought of this So they did what we call a 'meta analysis' Where they took studies that were similar and had results from all around the world and put it all together to see if those results hold true So when they took the data from other parts in North America, Europe, Asia They found the same results People eating the plant-based diets we're living longer

So I really don't think that we can ignore these results Okay, so after all of this what is the main take-home message? Basically, you probably shouldn't be eating a low-carb diet that's high in meat products because it would seem these people are actually dying faster Is that the end of keto? Well, you know if you choose to do keto the recommendations from this study would be that you should be making it all about plant-based protein So lots of nuts and vegetables and healthy oils That's what you should be getting your protein and your fats from So basically don't make the mistake of thinking that keto is just about bacon and fat and grease Because that's probably not the healthiest thing for you Okay So now that we have the information we need to decide how are we gonna actually change our own behaviors to reflect what we believe

And I swear that is the hardest thing: It's actually changing your behavior So with you guys as my witness, here is my plan : I am gonna be focusing on the sources and the types of foods that I'm eating rather than sort of counting carbs I'm gonna be making sure I'm minimizing the amount of meats and animal products that I'm eating I also need to minimize the huge amount of carbs that I think I was eating before With all those treats in the middle of the night and the sugar and the candy so, you know, a high-carb isn't good either and I'm gonna try to hit that sweet spot of carbs by having lots of vegetables and legumes and all those things that I actually love

But I just need to make sure I prep and plan in advance so that they're ready for me to have in the day What's your plan gonna be? If you want to commit to something write it in the comments below I will read it I'll be your witness And I know it's gonna be a controversial topic

So hit me with your comments I actually want to start a discussion, a dialogue I will read your comments and I want to hear what you have to state And then I want you to send this video to people that you care about Because looking at this evidence, you can see that making changes now could actually save them years on their life

Anyway next week, I'll be seeing you guys from the hospital vlogging So don't forget to subscribe and turn on your notifications if you don't want to miss that Otherwise, I'll be chatting with you guys next week So bye for now <3 #livelonger

DOES THE KETO DIET KILL? Doctor Reviews Low Carb Diets and Mortality

Hey guys, I'm Siobhan a second-year medical resident Today we're tackling a super controversial issue and that's The Keto Diet The question is – is the keto diet actually making you live longer? or could it be actually killing you faster? The keto diet is a very low carbohydrate diet About 75% of calories come from fat 20% from protein and only 5% from carbs It's become one of the most popular diets online and it's been praised for weight loss, heart health, diabetes management and some even believe it fights cancer

But others think it's probably just a fad diet and it's just gonna come and go Just this week, there was a groundbreaking article from The Lancet which totally changed the conversation It's an article that looked at how much carbohydrates people are eating and if that affected life expectancy By the end of this video you should be able to make an educated decision about what you want to do with your diet And then I'm gonna *urge* you to share this with people you care about because this could actually affect how long they live *violin intro plays* So those of you who've been following my journey in the hospital at the new doctor know that about six weeks ago I started the keto diet and the reason I did that is because Overnight I find they're just so many chips and snacks and candy and

I- This whole year I just feel like I have strayed from my normal habits and so I kind of just needed like a reset and I figured that keto would do that And it did like I lost a couple of pounds I put on last year and I haven't been having sugar cravings It was great

So this week when I was flipping through my computer I saw this article And I figured it was gonna tell me that the lower the carbs you eat the longer you live But that's not exactly what it says So the study started about thirty years ago, when they recruited a whole bunch of adults from four different communities in the US They recruited about 15,000 adults and then had them do surveys and they kept track of their health and they tracked them over about 30 years *okay, that's deep* So let's pretend these skittles represent the people in the study First let's divide them into the amount of carbs they eat in a day The yellow ones the low-carb group And so these people about less than 40% of their calories from carbs

The green ones of the moderate carb group So these guys bought about half of the calories from carbs And the red ones are the high carb group where they got over 70% of their calories from carbs Of course this is a simplified model and in the study they worked with really fancy statistical models to get lots of accurate information So looking at mortality within these groups

It turned out the low-carb (yellow) group and the high-carb (red) group actually died faster than that middle green group So it looked like Goldilocks and the three bears The middle 50% carb group actually lived the longest And you can see that it has this U-shape, and we actually call that a U-shaped relationship They're estimating that in this in the low-carb group and the medium-carb group, That was almost a four-year difference in their life expectancy

That's like high school That's university That's so many life experiences That's huge I mean, we can't ignore that Definitely not what I expected

Definitely a huge shock to hear Question 2* So then the next logical question is if you have lower carbs you're eating more fats and proteins Does it matter what types of fats and proteins you're actually eating? So they went back to the database and they looked at all the people and they wanted to see the group that eats mostly animal products So they're eating meats and cheese, lamb pork, beef, chicken all of that compared to the people who are eating plant-based proteins and fats So they're eating nuts and peanut butters and seeds and they're having lots of vegetables And unfortunately all those meat lovers out there, it was very clear that people eating plant-based proteins and fats were living longer than those who ate the animal proteins and fats

And that's tough for me I actually really love a good steak *pleasure* Ooo boiii <3 owww So you might be thinking : "Hold on Hold on Siobhan I don't live in one of those four communities in the US maybe these results don't really apply to me?" Like me I live in Canada

I don't live in the US But the authors were smart and they thought of this So they did what we call a 'meta analysis' Where they took studies that were similar and had results from all around the world and put it all together to see if those results hold true So when they took the data from other parts in North America, Europe, Asia They found the same results People eating the plant-based diets we're living longer

So I really don't think that we can ignore these results Okay, so after all of this what is the main take-home message? Basically, you probably shouldn't be eating a low-carb diet that's high in meat products because it would seem these people are actually dying faster Is that the end of keto? Well, you know if you choose to do keto the recommendations from this study would be that you should be making it all about plant-based protein So lots of nuts and vegetables and healthy oils That's what you should be getting your protein and your fats from So basically don't make the mistake of thinking that keto is just about bacon and fat and grease Because that's probably not the healthiest thing for you Okay So now that we have the information we need to decide how are we gonna actually change our own behaviors to reflect what we believe

And I swear that is the hardest thing: It's actually changing your behavior So with you guys as my witness, here is my plan : I am gonna be focusing on the sources and the types of foods that I'm eating rather than sort of counting carbs I'm gonna be making sure I'm minimizing the amount of meats and animal products that I'm eating I also need to minimize the huge amount of carbs that I think I was eating before With all those treats in the middle of the night and the sugar and the candy so, you know, a high-carb isn't good either and I'm gonna try to hit that sweet spot of carbs by having lots of vegetables and legumes and all those things that I actually love

But I just need to make sure I prep and plan in advance so that they're ready for me to have in the day What's your plan gonna be? If you want to commit to something write it in the comments below I will read it I'll be your witness And I know it's gonna be a controversial topic

So hit me with your comments I actually want to start a discussion, a dialogue I will read your comments and I want to hear what you have to state And then I want you to send this video to people that you care about Because looking at this evidence, you can see that making changes now could actually save them years on their life

Anyway next week, I'll be seeing you guys from the hospital vlogging So don't forget to subscribe and turn on your notifications if you don't want to miss that Otherwise, I'll be chatting with you guys next week So bye for now <3 #livelonger

Keto Diets for Children

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What is the Difference Between Paleo and Keto Diets?

– These days, you'd be hard-pressed to go through a health magazine or scroll through your social feed without coming across something to do with the paleo diet or the ketogenic diet So in case you're wondering how they differ, I'm comparing them in this video and looking at if you should give either one a try

The paleo diet, sometimes called the caveman diet, is based on the principle that eating foods that were available to early humans will promote optimal health One of the fundamental theories behind the paleo diet is that modern food systems, production, and processing techniques are damaging to human health Thus, if you adjust your eating style to mimic that of paleolithic hunter-gatherers, you will better support your body's natural biological function, improving digestion and health And paleo eliminates grains, legumes, processed sugar, and pretty much all forms of dairy The keto, or ketogenic, diet aims to induce ketosis through the calculated adjustments of dietary macronutrients, namely carbs, protein and fat

Ketosis is the metabolic state in which your body uses calories from fat, instead of carbs, to create the energy needed to carry out its normal functions In comparison to a standard diet, the macronutrient distribution of the keto diet is shifting significantly in favor of fat, with moderate protein and very few carbs, like less than five to 10% of calories, or 50 grams of carbs per day Now remember the purposes of achieving ketosis with this diet plan is to induce the metabolic breakdown of fat in your body Thus, it's imperative that your macronutrient intake is tightly controlled, ie

your carbs are very low and your fat intake is very high, otherwise you risk putting your body out of that metabolic state of ketosis These diets have a lot in common Although they are distinct, paleo and keto diets share many characteristics So, here are some of the main ideas that these diets have in common They both emphasize whole foods

So, both keto and paleo diets strongly encourage eliminating all ultra-processed foods and replacing them with whole foods like fresh vegetables, meat, fish and nuts They both eliminate grains and legumes, though for different reasons, they're strongly discouraged for both diets For the paleo crowd, this elimination is largely based on the fact that grains and legumes were not likely part of early human diets And for the keto diet, this is because their carbohydrate content is too high, and that can put you out of ketosis They both eliminate added sugar

Now, for both diet plans, this finding falls shares under their shared message of avoiding heavily-processed foods in general However, paleo diet is a bit more flexible with this rule, as unrefined sugar sources, like honey and maple syrup, are still permitted Now keto, on the other hand, doesn't allow any added sugar sources, refined or not, due to the high carb content of these foods Both diets emphasize healthy fats Yeah, they both recommend moderate to liberal amounts of olive, coconut and avocado oils, nuts, seeds and fish

These foods are known to benefit heart health because of their poly and monounsaturated fat content, coconut oil being the exception there Both may be effective for weight loss Now, this one isn't rocket science, there's no magic, additional fat burning happening Basically, when you don't eat junk food and replace it with more fulfilling whole foods, you consume fewer calories, this leads to weight loss Both diets can help you do that

As for the major differences, well, Paleo still allows carbs from whole food sources such as fruits, some starchy vegetables, unrefined sweeteners On the other hand, the keto diet restricts all of these because it wants to keep the carb content very low On the flip side, the ketogenic diet encourages high-fat dairy foods like cream and yogurt, whereas the paleo diet eliminates dairy foods except for butter, for some reason, butter is allowed Which one is healthier? In a side-by-side comparison, the paleo diet is the better option overall Paleo allows for more flexibility of food choices and more options for obtaining the wide array of nutrients your body needs on a daily basis

Freedom within food choices makes paleo easier to maintain long-term, with less potential to be socially isolating, basically Keto is more difficult to maintain because of the strict compliance needed to achieve ketosis It requires careful planning and can be less adaptable to varied social situations In the end, both diets have the potential to positively impact your health when appropriately planned In saying that, you can also positively impact your health, in the same way or even better, without following all those unnecessary restrictions and diet rules

If we look at people who live the longest, people who in the blue zones, none of those people follow a paleo or keto diet and yet they live long, happy and fulfilling lives Ultimately, the best diet for you is the one that you can stick to long-term Thanks for watching, make sure to give this video a thumbs up if you found it informative Don't forget to subscribe to Healthline's Authority Nutrition YouTube channel by clicking the red subscribe button below this video (calm music)