OSU Keto Conference, Day 1

About

I am really fortunate to live in Columbus, OH. For a lot of reasons. Columbus is great. But in this case, I'm specifically fortunate because I live in the same town that hosted the Emerging Science of Carbohydrate Restriction and Nutritional Ketosis conference. Hosted by the Ohio State Food Innovation Center, this conference had a star-studded lineup of doctors, scientists, and researchers from the low-carb world. Being very interested in the topic, I decided to take a couple days off work, shell out $300 and go to this conference. Spoiler alert: it was time and money well spent.

Welcome Reception, Night Before Conference

The welcome reception itself was great. With a few keto-friendly snack foods available, it was great to chat with some of the other attendees. Some people I chatted with were keto enthusiasts, like me. Others were looking for ways to get more involved in the nutrition/keto world (also like me). And others are already highly involved: I got to chat with:

• an NIH researcher
• James McCarter: head of research at Virta Health
• Dave Feldman, creator of cholesterolcode.com
• Brian Sanders, creator of the Peak Human podcast and the Food Lies documentary

Despite all being high on the science and/or keto totem poles, all of these people were willing to talk to a random guy like me. No one looked down on me in the slightest. It reflected well on them all.

Day 1

General Thoughts

Everyone was really nice, very sincere, very engaging. This conference full of medical professionals and researchers could have easily looked down on a random software developer like me, but I was completely welcomed. There was no trace of condescension. It was great to swap stories with doctors, nurse practitioners, chiropractors, naturopaths, health coaches, scientists, and other ketogenic eaters. 

Talking to so many medical professionals, it is clear that the medical system is in rough shape. Thanks to potential lawsuits and medical governing bodies, doctors are pressured to offer medications even in cases where they do not feel medications are the best approach. Many of the clinicians at this conference are looked upon as dangerous or as faddists by their mainstream colleagues for suggesting that low-carb nutrition can have a role in treatment. (Don't think nutrition is important to health? Nutrition changes the way a human's face forms!!! Imagine what it does to the rest of your body.) The food offered at hospitals is obviously a large problem; vending machines are shelling out sodas and junk processed food on every floor. And the food coming from the hospital kitchens is often not much better. These foods are often keeping patients in the hospital longer and impeding patient recovery.

Many of the medical professionals who were there became believers in the ketogenic diet via their own experiences or via the experiences of someone close to them. For instance, one doctor at my table mentioned losing 22% of his body weight in two months from the ketogenic diet. Another doctor at my table referenced losing 120 pounds via the ketogenic diet after weighing 260 pounds while being pregnant with her first child. Lots of powerful anecdotes were shared during breaks, during presentations, and during Q&A throughout the conference.

Below is a quick summary, with some occasional commentary. But it's mainly just what I was able to cobble down in my notes.

Opening

This event, with 275 attendees, was sold out. There was a wait list. The opening speakers did some "show of hands" polls and found that most of the 275 attendees were physicians, there were a few registered dietitians, some other medical professionals, and a decent amount of academic faculty and staff. It helped me realize how lucky I was to be able to attend right in my backyard when we learned that a high percentage of the attendees were from outside Ohio, and lots of the attendees were from outside the United States altogether. Costa Rica, South Africa, Canada, Australia, and Dubai are a few of the countries people traveled in from.

Dr. Morley Stone, Senior VP of research at Ohio State, referenced his background at Air Force Research Labs. He is only two weeks into his job at OSU. He said he was first exposed to keto at a DARPA program for Peak Soldier Performance fifteen years ago. Between this and D'Agostino's work with SEALs and with NASA (mentioned below), it is interesting that many of these high-performing groups are investigating how to gain an edge via ketosis.

Jon Ramsey, PhD: Ketogenic Diet and Aging

Dr. Ramsey discussed how the ketones our bodies generate when eating low-carb ketogenic diet are signaling molecules. Ketone body beta hydroxybutyrate (BHB) is not just a fuel, it also is involved in its own processes in the body. Ramsey's rodent studies showed that compared to control mice and low-carb but non-ketogenic mice, ketogenic mice had fewer tumors, performed better on a "novel object test" (testing learning and memory), better grip strength, better hanging wire endurance (muscular strength and endurance), improved motor function, lower inflammation, and better insulin sensitivity.

For Ramsey's mice, sustained ketosis led to better longevity and healthspan.

The low-carb but non-keto mice did worse in some areas than the control. I found that interesting. It was only rodent research, but it helped establish that ketogenic diets are about more than just restricting carbohydrate-- the endogenous ketones produced by the body have effects on their own.

Steve Phinney, MD, PhD and Jeff Volek, PhD: Nutritional Ketosis

Phinney and Volek went through some of the long history of ketosis. Interestingly, ketogenic diets were used to treat diabetes prior to the discovery of insulin in the 1920s.

In the 1980s, Phinney essentially re-opened the study of ketogenic diets.

Their definitions:

Carb burners = 0-0.5 mmol/L ketones in blood

Nutritional ketosis = 0.5 - 5 mmol/L

Starvation ketosis = 5 - 10 mmol/L

Ketoacidosis = 10+ mmol/L

They stated their research shows that keto is better for weight loss vs. low-fat when subjects are eating "ad lib" (e.g. they can choose for themselves how much to eat). Likewise, they find it outperforms low-fat for improving metabolic syndrome. They also find that sustained ketosis outperforms intermittent ketosis for metabolic syndrome.

They emphasize eating whole foods and not eating seed oils in their well-formulated ketogenic diets.

Andrew Mente, PhD: PURE Study

Dr. Mente shared some thoughts about the PURE study, an epidemiological study of communities and diets around the world. He focused a lot on how salt is unfairly maligned.

I agree wholeheartedly that salt is unfairly maligned. However, I am pretty skeptical of data collected via food frequency questionnaires (and therefore I am skeptical of the usefulness of epidemiology for nutrition recommendations), so I didn't take as many notes during this session.

Ron Krauss, MD: Diet, Adiposity, and Atherogenic Dyslipidemia

Dr. Krauss studies coronary artery disease. He detailed two phenotypes, Phenotype A and Phenotype B. Phenotype A has lower risk for heart disease. Normalizing body weight moves most, but not all people, to Phenotype A. And people with Phenotype B have a tougher time losing weight.

Generally, as people eat more fat and less carbs, they move towards Phenotype A.

Krauss was convinced by data to go low-carb. He said that lowering carbs and lowering weight separately improve atherogenic dyslipidemia.

Krauss detailed some mechanisms. But generally, high triglycerides + low HDL cholesterol leads to small, dense LDL cholesterol, which is more ominous than large, buoyant LDL. Large buoyant LDL typically comes with low triglycerides and high HDL. Small dense LDL are more ominous, at least in part, because there is reduced clearance from the plasma, greater artery retention, and they become oxidized faster, making them inflammatory.

A lot of this was over my head, but those were the broad strokes I took away.

Dominic D'Agostino, PhD: KetoNutrition Science: From Science to Application

Dom is the man who brought keto to the people. He's done a million podcasts talking about the ketogenic diet, and those podcasts are likely what helped popularize it. My first exposure to keto was from hearing him and Tim Ferriss discuss it. Dom is the man. (Side note: He once deadlifted 500 pounds for 10 reps on the 7th day of fasting!! Then he lifted 585 for 1 rep. He didn't bring this up at the conference, but it's still really, really awesome.)

D'Agostino, an assistant professor, said USF made him take PTO to attend the conference.

Biggest surprise: at one point, D'Agostino referenced brain slicing techniques and didn't get booed by the low-carb crowd when he said "like a slice of bread".

D'Agostino does tons of research around the ketogenic diet, exogenous ketones, and hyperbaric oxygen. He is helping the Navy research how to keep SEALs safe on deep water dives. He does work for the DOD and for NASA. 

D'Agostino talked about Cahill's fasting studies from decades ago and showed how over time, brain energy comes more from BHB than from glucose. D'Agostino's research for the military has shown that fasting ketosis is effective at preventing central nervous system oxygen toxicity seizures. He has done lots of testing on mental cognition and acuity at 3 atmospheres deep while in ketosis. Basically, keto looks promising for preventing seizures in Navy SEALs. Ketone esters look promising as well. In rats, the control group got seizures in 10 minutes, while rats fed ketone esters were still fine at 60 minutes.

D'Agostino also talked about some of the keto foods he ate while on a NASA NEEMO mission and how he was able to operate without impairment on that mission.

D'Agostino also listed an overview of applications of therapeutic ketosis, separated out into categories of "Strong Evidence" and "Emerging Evidence".

Therapeutic Ketosis - Strong Evidence

Weight Loss and Management

Type 2 Diabetes

Inborn Errors in Metabolism (MADD, GSD, PDHD, etc)

GLUT1D Syndrome

Dravet Syndrome

Lennox-gastaut Synrome

Rett Syndrome

Epilepsy

Therapeutic Ketosis - Emerging Evidence

Type 1 Diabetes

Non-Alcholic Fatty Liver Disease (NAFLD)

Polycystic ovary syndrome (PCOS)

Wound healing, inflammation

Motor function

Brain tumors/cancer

Alzheimer's

Parkinson's

Autism

Angelman's

Kabuki syndrome

Anxiety

Neurotrauma

Traumatic brain injury (TBI)

Anesthesia resistance

Operational neuroprotection

Dom talked about both anesthesia resistance rodent studies as well. The ketogenic diet outperformed exogenous ketone esters for anesthesia resistance, but both were effective at establishing resilience against anesthesia.

Tim Noakes, MD, PhD: The Story Behind the Lore of Nutrition

Dr. Noakes thinks the Virta Health team should win a Nobel prize. He said some of us don't see that because we are in the moment, but it is a big deal.

Noakes has a super-interesting history as a widely respected scientist and author. I won't be able to do it justice here. He's got multiple books covering it. But I'll do a quick overview.

Longtime scientist in South Africa, supremely respected

Published book Lore of Running, promoted carb-loading

Lost his father to Type 2 diabetes (his father lost his legs before passing away)

Thought Atkins was a crook

Got diagnosed with Type 2 diabetes himself, =/= 8 years ago

Read Phinney, Westman, Volek's New Atkins book, was convinced

Became proponent of Low-Carb, High-Fat diet (LCHF) (skin in the game)

Started promoting LCHF online

Trumped up charges of non-evidence-based medical advice due to a Tweet he sent

Industry and dietician group found to be colluding against Noakes

Noakes mobbed academically

Noakes credits his wife for staying by his side, keeping him strong. "We were too strong for them."

He and his legal team defended Noakes and science of LCHF in court

Noakes victorious

Noakes has lectures available online

Video of court proceedings also available online

He was a fantastic speaker with a great story. I am looking forward to reading his book Lore of Nutrition, which I just ordered and received within the last couple weeks.

First Q&A

Panel with the first speakers: 

Question about keto & gut microbiome. . . Ramsey was surprised microbiome wasn't changed more in his animal studies. D'Agostino said we don't know the optimal microbiome yet.

Is there a weight "set point" where people no longer continue losing? I think it was Phinney who said that idea exists but it is a phenomenon without biomarkers at this point.

Dr. Richard Feynman asked why there is low general acceptance of ketogenic diets with all the scientific progress being made on them? It was a thought-provoking question. D'Agostino mentioned that it is not taught in med school-- it's taught more as a fad than anything.

Someone asked which animal most closely resembles human physiology. I didn't write anything down here, so I don't think there was a straight answer. 

There was a question about how vegetarian and vegan diets often succeed. Dr. Volek answered that there is no one way, no silver bullet. I really liked the response here. It did not attempt in any way to tear down any other way of eating. It showed that the presenters on the panel are not dogmatic.

Role for keto in Olympic lifting? Volek: acutely no case, but there is a case for longevity in sport, health

The author of Dogs, Dog Food, and Dogma asked if any of this is applicable to pets. They answered that it is tough for dogs because the National Research Council put an upper limit on fat for dogs based on research from the 1940s. And ketosis is tough for cats because they require more protein. They did share an interesting tidbit about how well Iditarod dogs were doing on LCHF diets though.

Someone asked about therapeutic exogenous ketones and the benefit mechanism, whether it would be like something that artificially raised HDL but provided no benefit. D'Agostino replied that they've seen studies where exogenous ketones reduce seizures so there does seem to be benefit. But in that case it is only with both beta hydroxybutyrate (BHB) and acetoacetate (AcAc), no benefit with BHB alone.

An infectious disease doctor asked about keto for wound healing and sepsis. D'Agostino has a student who has found improved wound healing with ketone supplementation. He didn't know for sepsis, but said maybe bugs are feeding off glucose.

A retired food and drug scientist asked about managing anxiety and depression, noting changes in her retiring friends. D'Agostino referenced rodents being calmer with exogenous ketones, spending 30% more time in open arm vs. closed arm of an area. Could there be implications for PTSD?

Jake Kushner, MD: Low-Carb Diets and Type 1 Diabetes

Dr. Kushner provided an overview of Type 1 Diabetes and some of the history behind how it is typically treated. Talked about how difficult it is for T1D patients to keep blood glucose in proper range, and how they inject insulin as the only available treatment. There are major life-threatening complication risks with T1D. There is excess cardiovascular disease in typically-treated Type 1 diabetic population.

Hard to inject exactly right amount of insulin, and kids are getting recommended high amounts of carbs; for instance, males 14-18 are recommended about 300 g/day of carbohydrate. This can lead to blood sugar rollercoaster.

Kushner got into low-carb treatment for T1D out of desperation. He heard about Dr. Bernstein's book (Bernstein is a type-1 diabetic, and an engineer-turned-doctor) from a friend who had T1D.

Friend of Kushner's with T1D: "I always thought I'd die from T1D. Now, with low carb, I might be able to live a normal life."

Low carb = much less of blood sugar rollercoaster.

There may be opportunities to implement low-carb with automated insulin delivery in the future-- Kushner referenced AdrianLxM, a developer for Android APS (diyps.org)

Kushner referenced a new paper about managing Type 1 with a Very Low Carbohydrate Diet. It got results the mainstream thinks are impossible. The New York Times wrote about it.

The ADA has softened their fat-is-bad language, allowing for some wiggle room to allow for low-carb Type 1 "individualized" treatment.

Kushner referenced the need for better nutritional guidelines that will make it less of a barrier to implementing low carb diets.

Kushner looks forward to greater access to continuous glucose monitoring and BHB monitoring. He also showed a low-carb Type 1 potluck to tie it back to real people positively impacted by implementation of Low Carb for Type 1.

Sarah Hallberg, MD: Type 2 Diabetes Reversal

Dr. Hallberg opened up by referencing a 2015 JAMA article detailing that as of 2012, over half of Americans have diabetes or prediabetes. (It makes one wonder what the findings would be if more people were getting their insulin checked, as insulin resistance can show up decades before it shows up in the blood sugar levels, which is what that article uses)

She talked about how expensive it is. In 2012, diabetes cost America $245 billion; by 2018 it will be over $300B. So the incidence and cost is rising way too fast.

DIABETES IS REVERSIBLE

3 clinically proven ways to reverse Type 2 Diabetes

• Bariatric surgery
• Low-calorie diet
• Low-carbohydrate diet

As one of the lead doctors on the Virta Health team, she would focus on the low-carb approach.

In a one-year Indiana University study (through Virta), 60% diabetes reversal was achieved!!! 94% of patients reduced or discontinued meds. A1C average dropped from 7.5 - 6.2 (and it dropped below 6.5 in about 70 days, which is a psychological win for the patients going through this). 57% of the prescription meds these patients were using were discontinued. At one year, the pharmaceutical costs were reduced by 46%. There was 83% retention for this ketogenic diabetes treatment-- that's better than the adherence you would get for prescription pills! 22 of 26 cardiovascular risk biomarkers were improved! 12% improvement in 10-year ASCVD score. Liver functions improved at 1-year mark.

Standard of care: Diabetes is a "chronic and progressive disease"

Virta Study: Diabetes is reversible

Standard of care: 0 of 26 cardiovascular risks improve

Virta Study: 22 of 26 cardiovascular risks improve

Did the Virta patients actually eat keto? Well they could actually track it, via monitored BHB. . . and they did! Patients complied.

Biggest criticism: not a randomized controlled study (was controlled, but not randomized).

Question: How to support sustainable behavior change?

3 ways to reverse diabetes: we need to give the patients a choice.

Q&A Session

A weight loss doctor asked about High Protein vs. High Fat. Panel asked if patients were in Nutritional Ketosis.

A NY physician helped a Type 1 Diabetic drop their A1C from 6.6 - 4.9, but their LDL shot up. Should they be concerned about that? [Dave Feldman of cholesterolcode.com smiled]

Some dialogue about fiber and gut microbiome. Discussion talked about how keto typically has some fiber. Also discussed whether the gut gets fed BHB (fiber produces butyrate)

Ketoacidosis is legitimate risk for Type 1 Diabetes, patients should be using continuous glucose monitors.

Why does BHB drop below 0.5 mmol/L after 120 days on well-formulated ketogenic diet? Didn't know, but seems to still be some benefit below 0.5

Dr. Mente did not recommend extra sodium intake for keto people (question was asked because keto/low-carb typically causes subjects to excrete more sodium). The Salt Fix (great book) did recommend more sodium for low-carbers.

Dr. Mente said that PURE's data showed more benefit from fruits than from veggies and from raw veggies than cooked. Epidemiological.

There was a question about the challenge of acute health events for keto patients. The panelists agreed that is a challenge, as hospitals can be the worst place for keto patients (due to the high-carbohydrate diets fed to them there, and the standard of care to provide insulin to diabetics)

Then I got to ask my question! I asked about the podcast between Peter Attia and Rhonda Patrick where they both estimated that 10-20% don't respond well to keto. They specifically reference C-Reactive Protein (measure of inflammation) going up in such patients. I asked Drs. Hallberg and Kushner if they see that in their patients, and if so, what they do about it. Dr. Hallberg indicated she has seen universally good responses to keto. Kushner seemed to indicate the same. They said they don't know what is happening with Attia's/Patrick's patients/people, but they would have to speculate that maybe there is a lack of adherence. Hallberg mentioned a rare condition, hyperchylomicronemia (one-in-a-million people have it)-- those people cannot do keto. In her experience, everyone else can.

For what it's worth, a couple other people stopped me to chat about my question. A naturopathic doctor has seen CRP go up after putting someone on keto. She had a theory as to what was behind it. Unfortunately I do not recall what it was :/ A health coach wondered if the clientele is much different between Attia/Patrick and Hallberg/Kushner. Attia and Patrick's people are probably looking to optimize, whereas Hallberg and Kushner's people are trying to get a healthy baseline. So maybe keto would be an improvement even if not optimal. Interesting discussions, anyway.

The naturopathic doc asked about iodine-- Dr. Mente said iodized salt is still important because people are still getting iodine deficiencies. (I was walking back to my seat as this was being discussed so I didn't hear much of it)

Then, one of the most interesting moments of the conference came as Dr. Noakes started talking about Low-Fat diets leading to heart disease and how the hazard ratio for cholesterol is 1.2 for cholesterol (so, statistically, nothing). He talked about familial hypercholesterolemia. . . anyway, eventually Dr. Krauss jumped in and they got into a spirited disagreement on statins and cholesterol (Dr. Krauss: "you're on thin ice"). Interesting to see two presenters disagree and debate in real time in public.

A physician from Dubai referenced the need to use Joseph Kraft style Oral Glucose Tolerance Tests. And he questioned whether cholesterol and statins were the greatest scam in history.

Someone asked about Steven Gundry and lectins-- no response

Dr. Mark Cucuzzella talked about the need for improved foods at hospitals. He has some experience in making improvements in that space.

Dave Feldman, whose presence loos large in any cholesterol discussion, talked about the need for science, not advocacy. He referenced lean mass hyper responders. He said we all need to stay skeptical, even of ourselves and of one another.

Nina Teicholz: Seed Oils (Vegetable Oils)

Nina gave a great keynote speech about the history and danger of seed oils (vegetable oils/plant oils). They are highly processed foods that are somehow actually recommended by dietary guidelines (the "logic" is that saturated fat is bad and these fats are polyunsaturated, not saturated).

She detailed how saturated fats are more stabilized. She talked about how much processing it takes just to generate these "foods".

In 1911, Crisco was sold as a food for the first time by Procter and Gamble (a soap company!). An ad said "Economical" and "Digestible". (Talk about damning with faint praise)

PUFA = polyunsaturated fat (high amounts of PUFAs are in veggie oils like corn, soybean, canola, linseed oil)
P&G has a lot of economic history with the AHA (which recommends these PUFAs).

PUFAs lower cholesterol but not mortaility.

Lots of trials have shown bad results from these PUFA-ridden oils. Especially LA Veterans trials (higher cancer deaths with higher intake of these oils, despite lower cholesterol)

These oils are like a "varnish"

1940s animal studies showed horrible PUFA side effects (growth issues, diarrhea, enlarged livers, ulcers, heart damage, premature death).

A 1972 symposium found that heated soybean oil produced compounds highly toxic to mice. Columbia U study showed liver damage, heart lesions.

These oils started coating the walls of fast food restaurants. There were cases of fast food uniforms spontaneously catching on fire.

Linoleic acid breaks down to aldehydes (and other things). Aldehydes are very chemically reactive. They are toxins. These PUFA oils are made of large amounts of linoleic acid. Linoleic acid breaks down into aldehydes like 4-HNE. Bad bad stuff.

It's dangerous because they are in all processed foods (cheap) and all restaurants use them.

Doctors are often not allowed to teach outside nutritional guidelines (which support using these relatively toxic oils), so we need evidence-based guidelines. We need to make Low-Carb not taboo.

I hope to detail some of the Day 2 topics later!