OSU Keto Conference, Day 2 (Part 3)

Continued from Day 2, Part 2

Gary Taubes: Quality of Calories (Lunch Keynote)

Gary Taubes, prominent journalist and author of books such as Good Calories, Bad Calories, Why We Get Fat, and The Case Against Sugar, detailed some of his research for his lunch keynote speech.

He talked about meeting with Swiss Re, a global reinsurer, in Zurich. Whereas most of the processed food and pharmaceutical industries have little to gain financially from people improving their health via diet, reinsurance companies do stand to gain from it.

He detailed the state of affairs in the timeframe of 1998-2002. At the time there were maybe a dozen MDs across the country who utilized Low-Carb High-Fat (LCHF) as treatment. [He noted that he has since learned that number might be a little low, but regardless it was nearly unheard of.] Authorities (Gerald Reaven, someone named Flatt) used low-carb to lose weight but it was assumed that low-carb would lead to deadly cardiovascular consequences. Low-Fat diets and Calorie Restriction were dogma.

He then talked about an article written by Malcolm Gladwell in 1998 investigating the obesity epidemic in the Pima Indian tribe on a reservation in Arizona. Gladwell raised some interesting points and questioned the nutritional advice being given by groups with authority, but he also implied that Atkins was B.S. advocated just to make big money.

Taubes referenced the work of Daniel Kahneman (author of a terrific book, Thinking, Fast and Slow) by saying that the whole nutrition and medical industry were under the cognitive bias of WYSIATI (What You See Is All There Is).

Taubes fast-forwarded to the state of affairs now in 2018. He said tens of thousands of MDs now prescribe LCHF worldwide. He referenced that the Canadian Women Physician LCHF Network, a closed Facebook group of Canadian women physicians who prescribe LCHF. This group of doctors is at 3290 members.

He said that the conventional wisdom still says that LCHF is dangerous. He showed a 2018 U.S. News ranking that placed the ketogenic diet in last place of all diets. He said this was decided by a committee of establishment nutritionists using groupthink.

However, the tide is turning. In the media, now the argument is turning to whether Low-Fat is as good as LCHF/Keto. This is progress from where things stood a couple decades ago.

Taubes recalled an anecdote of his trip to Switzerland to point out the changing narrative. After a Swiss customs agent learned Taubes was there for a nutrition meeting, the agent said "I should give up carbohydrates, right?"

Taubes referenced the DIETFITS trial of Healthy Low-Fat vs. Healthy Low-Carb. He noted the progress, as both diets restricted refined carbohydrates.

Taubes said many doctors now prescribe by hypothesis and questioned: what about clinical experience?

He said that energy balance (calories in/calories out, AKA "Eat less, move more") does nothing to predict whether an 18-year-old lean person will continue to be lean or whether they are pre-obese. He said that eating "not too much" is a lean person's diet advice (as in, it worked for the lean person, but they might just happen to be lean. More helpful to have advice of someone who at one point was not lean.)

Taubes then talked about the limitations of nutritional epidemiology. That cannot establish causation. What epidemiology does is looks at what healthy people eat vs. what unhealthy people eat. (And thanks to the unreliable data collection methods, it does not even really do that well.) He said that it's not helpful-- compared it to saying that rich people eat at expensive places and buy fancy cars. . . so if you want to be rich, that's what you should do.

Taubes made reference to the DIRECT Diabetes Remission Clinical Trial. He said during the sustained weight loss phase, there was 2/3 energy intake.

Taubes talked about the hyperinsulinemia phenotype. He talked about the hypothesis that to put obesity and/or diabetes into remission, you need to minimize insulin secretion. He said you need low insulin to get fat out of fatty tissue.

He talked about Insulin Resistance vs. Healthy: he said the more time you spend below the insulin threshold, the leaner and healthier you are. He then referenced carnivory, intermittent fasting, and time-restricted feeding in relation to this idea.

He said the key is commitment. And then he showed a quote from Dr. Eric Westman:

"If you do this, it will work. But I can't make you do it. Word on the street is I'm too strict, but maybe strict is the answer."

He also showed this quote from Peter Foley: "Rather than going to the gym, think about the 84 meals a month you're eating."

Taubes referenced someone named Pennington in the 1950s who noticed his weight loss stopped if he ate a single apple.

Taubes asked about plateaus-- does it have to do with not enough fat? Too much fat? Do we still need caloric restriction? Too little/too much protein?

And he also showed this interesting quote from Dr. Evelyn Bordua-Roy:

"Many diabetic patients tell me they can't go low carb because they love pasta and bread too much. I say 'Imagine if you were allergic to almonds and could eat them with an epi pen, would you?' They say, 'Of course not.' So why eat pasta and bread when you can eat them only with an insulin shot?"

It was a wide-ranging, entertaining keynote speech, delivered over a delicious lunch (yes, that is steak, bacon, bleu cheese, and salmon on top of that salad).

Tim Noakes, PhD, MD: Sports Applications and Beyond

Day 1's lunch keynote speaker, Dr. Noakes, returned for a more technical speech on LCHF for performance.

He initially wrote a book titled Lore of Running in 1985. It talked about the need for runners to increase their carbohydrate intake. Noakes believed it from his research and utilized that dietary approach in his own life. Then, he was diagnosed with Type 2 Diabetes several years ago (despite lots of exercise). Throughout his career, he had been funded by industry to study carbs. His old goal was to eliminate all fat oxidation.

Noakes actually produced the world's first squeezy. "I apologize for producing that."

Noakes told Paula Newby-Fraser (multi-time world Ironman champion) to use High-Fat diet, but was still studying for High-Carb.

Noakes mentioned something about being able to store 4 days worth of energy in fat, but only 2 hours worth in glucose.

After one Ironman competition, Noakes was hard-pressed to explain (in a High-Carb context) how physiologically someone could run a 2:40 marathon after the other two legs of the marathon. "Ironman impossible" because there would not be enough glucose available. He listed off some statistics of why that would be impossible, including something about how a 2:40 marathon would require 1.15 grams/minute of fat burning. But despite depleted muscle glycogen, those marathoners kept them going. How long could they go?

Noakes said that fat-adapted athletes can oxidize fat at 1.2 g/min during exercise.

He mentioned some research about carb-loading (what his Lore of Running book promoted) not improving performance, which led to Noakes suggesting carb ingestion during exercise.

Other studies came out, and Noakes now promotes a LCHF approach for endurance athletes. (Note: He does not promote it for performance in all forms of exercise.)

His conclusions:

Stephen Phinney, MD, PhD, DSc and Jeff Volek, PhD, RD: Keto-Adaptation and Physical Performance

Dr. Phinney opened up by asking what we can learn from "modern Stone Age peoples". (A great question! As a reader of Weston A. Price's work studying such peoples, it becomes very clear that such peoples have lots of wisdom we can benefit from today. Related posts from this blog: here and here)

Phinney mentioned The Friendly Arctic, which he noted as the first recorded example of keto-adaptation. He talked about how from 1878-1880, Schwatka traveled with two Inuit families. These families survived nearly exclusively off reindeer meat. Initially they had weakness and became exhausted, but this soon passed. Then they had strength and endurance-- this is why he says it was keto-adaptation.

The quote: "When first thrown wholly upon the diet of reindeer meat, it seems inadequate to properly nourish the system and there is an apparent weakness and inability to perform severe exertive, fatiguing journeys. But this soon passes away in the course of 2-3 weeks." (He cited where that is from, but my screenshot was too blurry to read the citation.)

Phinney talked about the work of Vilhjalmur Stefansson (author of the aforementioned The Friendly Arctic). Stefansson was a Harvard anthropologist who claimed, based off his studies of the Inuit people, that you could live healthfully off of only meat and fat. The nutrition establishment called him a liar. He allowed himself to be studied for a year, in which he only ate meat and fat (and he was locked up for the first several months to ensure no foul play). At the end of the year, he was fine. He ate nose-to-tail of the animals, so his diet included muscle meat, organs, and fat. The energy composition of his diet was approximately 15-20% protein, 80% fat, and 2% carbohydrate.

A 1939 study is what led to the expansion of the high-carbohydrate diet. 3 subjects showed increased exercise capacity by consuming high-carb diets.

Keto-adaptation was mentioned in regards to an early Phinney study. It discussed how after one week of the ketogenic diet, performance is diminished. But after six weeks, performance is enhanced. So by the six-week mark, you are keto-adapted (AKA fat-adapted).

Phinney worked on a 1983 study where subjects adopted the Stefansson diet. Four weeks were allowed for adaptation. In those subjects, there was a minor improvement in Time To Exhaustion. Initially energy was provided about 50/50 by carbs and fat. Eventually it was mostly provided by fat.

Between the six subjects in this study, there was variability.

Uric acid competes with BHB (this is interesting to note for anyone with gout curious about the ketogenic diet).

In my notes, I have something about Phinney saying minimum adaptation is 9-12 weeks. . . I'm not entirely sure how that squares with the above mentions of keto-adaptation at 4 and 6 weeks. I'm sure I missed some of the detailed context in my notes.

They discussed the 2016 FASTER (Fat-Adapted Substrate Oxidation in Trained Elite Runners) study.

This was a study of the metabolic characteristics of keto-adapted ultra-endurance runners. They had 10 subjects in keto-adapted group and 10 in a high-carb group; they were well-matched outside of dietary differences. The subjects ran for three hours staring at a brick wall. They took muscle biopsies, blood draws, urine and feces samples of all runners. The glycogen was the same between low- and high-carb athletes. They don't know exactly why. The low-carbers had increased LDL and HDL cholesterol (for LDL, they had increased "large fluffy" LDL particles and decreased "small dense" LDL particles).

They referenced that 71% of young people today are ineligible for military service today, largely due to obesity. They transitioned into a TANK (Tactical Athletes in Nutritional Ketosis) study. n=30. Average ketones of participants were 1.2 mmol/L. Despite this not being a weight loss study, and despite the subjects eating ad lib (e.g. their portions were not rationed out), the keto subjects lost body fat and increased lean mass.

They finished with the following image to display why an athlete might be wise to use a ketogenic diet:

Brianna Stubbs, PhD and Dawn Kernagis, PhD: Role of Ketone Supplements

Dr. Stubbs and Dr. Kernagis came to discuss exogenous ketones. The devil is in the details.

Stubbs was a member of the British international rowing team.

Differences between exogenous (taken externally) and endogenous (produced by body) ketone generation was discussed.

Exogenous ketones have a rapid onset effect, but they require a top-up once the ketone energy begins running out. Exogenous ketones are not fat-burning; they are anti-lypolitic. Low plasma free fatty acids.

The commonality between the Ketogenic Diet (KD) and exogenous ketones is beta hydroxybutyrate (BHB).

There are different types of exogenous ketones: MCT (not technically an exogenous ketone, but readily converted to ketones), ketone salts, ketone esters.

Ketone salts: D- and L- BHB

Ketone esters "taste like jet fuel"

They talked about differences between ketone bodies BHB and acetoacetate.

They talked about GI tolerance of exogenous ketones; they said exogenous ketones get a bit of a bad rap.

They talked about adding exogenous ketones to a carb-filled diet, including a sub-elite athlete study. In that study, muscle mass was spared with exogenous ketones. Intra-muscular fat burning was increased with exogenous ketones.

In a time trial, distance exercised (I don't have notes on whether this was rowing, running, or biking) was increased by 1.3% in the exogenous ketone group.

Carnegis is the co-host of the Florida Institute for Human Machine Cognition's podcast STEM-Talk.

IHMC is DOD-funded work testing ketone esters against military stressors. Can it help with muscle recovery? Inflammation? Core body temperature?

SOCOM-funded: is there protection against hypoxia? Does it help in altitude training? Grip strength? Cognition? Could ketone esters be useful for high-intensity missions?

Results are mixed on exogenous ketones. Below is a summary slide:

Brendan Egan, PhD: Exogenous Ketones and Athletic Performance

Egan, from Ireland, had a lot of information to get through in a short amount of time. I didn't keep up too well with it.

He started off talking about how little separates elite competitive athletes. The difference over 26.2 miles in the 2016 Olympic marathon 1st and 2nd place finishers was less than a 1% difference: just 70 seconds.

He showed the broad spectrum of types of athletes and where different sports fall: aerobic vs. resistance vs. both.

Power is improved a bit more by carbohydrate oxidation compared to free fatty acid oxidation (advantage: high carb)

High intensity exercise runs off carbs, but as you go longer, you start using more and more fat.

We are 50 years under the influence of "carb loading".

In 2015, exogenous ketones for biking were investigated (for the first time, I think). In 2018, seven Tour de France teams use them.

In rats, we see an increased capacity to use ketones with exercise.

Ketone esters improved time trials by approximately 2% in cyclists in one trial.

Ketone salts showed no benefit in repeated high intensity exercise trials.

Ketone diesters lead to gastro-intestinal (GI) problems.

Finger pricks often overestimate blood ketones vs. serum ketones.

Ketone esters for recovery? Maybe.

Steve Tashjian: LCHF in Soccer (for the Columbus Crew)

Tashjian is the High Performance Director for the Columbus Crew (Columbus' Major League Soccer franchise).

"When we all think alike, no one thinks very much." -Albert Einstein

We need to be willing to live in the margins, make mistakes, and learn from them.

Soccer players need a robust aerobic base with repeated sprintability. How could the volume of available energy be increased? How to more quickly resynthesize energy? Enter LCHF.

In the preseason, the Crew get 6 weeks for fat adaptation. Their players and staff eat 40-80 g carbohydrates per day. They do it as a team together and bond over it. The staff participates alongside the players in glycogen-depleted bike sessions.

They do this for wellness, lifestyle, and performance.

Players and coaches are now taking low-carb back to their families.

The team eats approximately 60% fat, 25% protein, and 15% carbohydrate. Their lipid panels are monitored.

Anonymous surveys find that compliance is pretty good but not perfect. On training grounds, compliance is 93%. At home, 80% (although 98% if you average it out over player minutes). When eating out, 88% comply with LCHF.

Since adopting this in 2015, the team's distance covered has increased each year. Anecdotally, players want less and less carbs even on match day. They are seeing intermittent ketosis from voluntary keto dieting.

In 2015 (the last year the MLS released all team's data), the Crew led the league in distance covered.

A subjective soreness rating two days removed from match day shows lowered inflammation and increased recovery from LCHF.

2014 (pre-LCHF) = 6.5

2015 = 4.8

2016 = 5.1

2017 = 4.4

Players are eating approximately 70 g carbs per day, down from approximately 400 g per day a few years ago.

A new Crew player: "I just feel better. I can't tell you why."

Peter Brukner, OAM: What Should the Team Be Eating?

Brukner, author of A Fat Lot of Good, is from Melbourne, Australia.

He has experience with Liverpool soccer. He was their Head of Sports Medicine and Sports Science.

He said LCHF for high-intensity interval sports has only anecdotal evidence.

Initial studies showed high-carb better for soccer distance covered. He now promotes "train low, compete high" (low and high related to carbs).

He said there is no one diet. He sees three general scenarios with low-carb athletes:

1) athlete full-time LCHF diet

2) Athlete LCHF/keto during week, top up carbs on match day or heavy training day

3) Athlete generally low carb

Advantages of LCHF/Keto: weight loss, which increases power:weight ratio. Metabolic health: what are the long-term effects of high carb? Recovery. Reduced inflammation. Reduced need to refuel during activity. Increased fat oxidation.

Anecdotally, endurance athletes' performance is enhanced. Anecdotally, high intensity athletes' performance may be diminished. There are responders and non-responders.

Q&A Session, Physical Performance Speakers

Finally, there was a Q&A session.

The first question was about epidemiology. A study had just been released, making headlines saying low-carb was dangerous. How do the panelists respond to that? They say it is based on flawed epidemiology. Epidemiology cannot establish causation. There have been lots of very valid criticisms of that study.

How accurate is the Ketonics breathalyzer vs. Precision Extra? No data on breath meters, but blood meters are typically more accurate. Stubbs said that the higher ketones get, the less accurate breath meters typically are.

Dave Feldman, software engineer extraordinaire and creator of cholesterolcode.com, asked about LDL in Columbus Crew players. He and Tashjian talked lipid values for a little bit. Tashjian said they take lipid panels very seriously and worry more about making sure Triglycerides are going down and HDL up, and on "large" LDL rather than "small dense" LDL (as opposed to focusing on total LDL count). Dave said he would love to get a hold of player data; I'm sure he would like to see how many fit his Lean Mass Hyper Responder profile.

A Type 1 Diabetes researcher from USF asked a question but I didn't follow it unfortunately. I think it was above my head.

Dr. Mark Cucuzella got up to give some of the reasons the aforementioned "low carb is dangerous" epidemiology is not very useful: at baseline, the "low-carb" subjects of said study were overweight, diabetic smokers who didn't exercise. So it's no surprise that they would have increased mortality.

A team physician at a small Boston school asked how he should go about implementing Low Carb at his school. I think it was Tashjian that responded saying it would have to be incremental.

A Michigan grad student asked if fat adaptation sticks around once carbs are consumed again. The panel didn't know.

And with that, I've exhausted my notes from the conference! It was a very enlightening conference. I learned a lot, had a lot of good conversations, and met a lot of great people.