Clinical Experience Using Low Carb (Part 1)

A lot of what is written about in this blog probably seems a little abstract. But real, effective results trump all. And real, effective results are what many doctors are getting by using low-carbohydrate, ketogenic, and even all-meat diets for their patients.

This approach can be effective enough to reverse things as seemingly different as diabetes, joint pain, anxiety, and gout.

Here are some brief notes from a recent podcast with Dr. Ken Berry where he describes the results his patients have from adopting a ketogenic way of eating:


Ken Berry HPO Podcast Notes

Book Review: The Alzheimer's Antidote

Alzheimer’s Disease (AD) is generally viewed as an unstoppable disease with a cause that is too complex to understand or prevent. Amy Berger, author of The Alzheimer’s Antidote, counters that AD may not be as enigmatic as commonly believed. Medical literature often refers to AD as “Type 3 Diabetes” and like most chronic diseases, it is related to chronically elevated insulin. Berger is far too nuanced and too practical to claim bulletproof treatment or prevention of this dignity-robbing disease. However, her approach of using a ketogenic diet and other lifestyle modifications is an important step towards improving cognition in AD-afflicted people. Some of the same tactics can also mitigate the risk of developing AD in the first place.

This is the only way I could make the review any more glowing.

Berger postulates that the defining factor of AD is the brain’s inability to properly fuel itself via glucose. The good news is that brains unable to properly metabolize glucose can still metabolize ketones. Ketones are produced by the liver when one eats a very-low-carbohydrate diet, so Berger promotes this ketogenic way of eating (along with other ketone-boosting interventions) to improve cognition in a person suffering from AD.

The book highlights the work of Dr. Dale Bredesen. In contrast to the disappointing results from drug-based AD treatments, Bredesen’s work has been largely successful. His ketogenic approach has allowed many of his severely AD-impaired patients to go back to work and lead their normal lives. Berger shares his quote: “AD is not a mysterious, untreatable brain disease-- it is a reversible, metabolic/toxic, usually systemic illness with a relatively large window for treatment.”

Berger discusses brain health from many angles, and she spends lots of time underscoring the value of cholesterol for a healthy brain. She is highly critical of the idea of cholesterol-lowering medications (statins) and calls out the fact that people who take them have increased risk of brain fog, cognitive impairment, depression, hormonal imbalances, diabetes, low libido, infertility, and memory loss. Furthermore, antacids (e.g. Pepto-Bismol) and proton pump inhibitors (e.g. Prilosec) can lead to brain-atrophying vitamin B12 deficiency. With common usage of these drugs and with common diets being nutrient-poor and insulin-spiking, it is no wonder that we are seeing cognitive decline in people earlier than we used to.

The Alzheimer’s Antidote pushes back against a common idea that beta-amyloid plaques are a driving factor in Alzheimer’s. Rather than disease causes, these plaques are effects: the plaques build up when an enzyme that could degrade them instead is too busy degrading excessive insulin. Long before beta-amyloid plaques show up in the brain, decreased brain glucose metabolism can be detected in PET scans (including in people just in their 30s and 40s). Berger also downplays common concern about the APoE4 gene variant. While APoE4 carriers do have an increased AD risk, focusing on genetics distracts from the root cause of elevated insulin levels.

For AD sufferers, for AD caregivers, and for anyone who cares about maintaining cognitive health, this book is a terrific resource. In a a practical, compassionate, and realistic manner, it teaches the reader how to implement a low-carb diet to improve cognition. It also makes the case for lifestyle practices like exercise and intermittent fasting. Berger’s work gives plenty of “why” and lots of "how" but it ultimately provides something else even more important: hope.

If you want to see a heartwarming real-life example of Berger's approach, see here. That video is what inspired me to finally read this book.

While you will find Berger's name in several of my favorite podcasts, I think one of her best interviews is here on the Peak Human podcast.

The Power of Nutrition

For anyone wondering why someone would become interested in, fascinated by, or obsessed with nutrition, check out this Tweet:

7 months ago my Mom, who has #Alzheimers, could barely walk. Eating #keto, she lost 23 lbs, gained sharpness & mobility. Share this video of my Mom dancing, she'll smile knowing she can give others hope. Tx :- ) @TuitNutrition @DietDoctor1 @tednaiman @Nutradvance @bigfatsurprise pic.twitter.com/c5cYBSV3gq

— 50 Fitty (@50Fitty) January 14, 2019

Things like this are why people like me are so passionate about nutrition. And about the potential of keto. 😃😃😃

This is Your Health on Keto

A well-formulated ketogenic diet (WFKD) improves insulin resistance. Insulin resistance is the condition connected to nearly every chronic disease: from type 2 diabetes to cancer to heart disease to Alzheimer’s and more. Most American adults today are insulin resistant. About 9 out of 10. Therefore nearly everybody could benefit from eating a ketogenic diet. A full description of a WFKD is beyond the scope of this post, but at its essence, a WFKD is a low-carbohydrate diet consisting of whole foods (=/= 50 grams of carbohydrate or less per day, eat until full, no calorie counting).

To highlight what happens to real people when they go on a ketogenic diet, it is helpful to look at a couple interesting cases: (1) the Virta Health study, and (2) dual lab values between twins: one eats the standard American diet, one eats a ketogenic diet.

Virta Health Study

In one year, using the ketogenic diet, the Virta Health program reversed Type 2 Diabetes in 60% of its patients. Yes, that’s right: type 2 diabetes, commonly thought to be chronic and progressive, can be reversed. In the same peer-reviewed study, 94% of patients reduced or eliminated their usage of injected insulin.

Nearly all health markers improved for the patients treated with the ketogenic diet. This includes reduced inflammation, weight loss, improved blood pressure, improved liver function, and improved cardiovascular health markers. (Despite the common belief that saturated fat is unhealthy, it turns out that a low-carbohydrate diet with a significant amount of saturated fats is likely very good for heart health.)

That all sounds abstract, but the Virta ketogenic intervention was performed on 218 real people who greatly improved their health by modifying their diet. Many of these people reversed their diabetes and greatly improved their quality of life. That is the power of nutrition; and specifically, that is the potential of a well-formulated ketogenic diet. You can read some of their testimonials here.

Lab Values of Twins (One Keto, One Standard American Diet)

This video details the lab value differences between two 16-year-old twin sisters. One twin eats a ketogenic diet. The other eats something akin to the standard American diet (some meals are ketogenic because the meals eaten with her family are low-carb). They share the same genetics but different diets.

The twins have remarkably similar lab values for most health biomarkers. Even their blood glucose levels were nearly identical. However, the standard American diet twin is significantly more insulin resistant. The keto twin’s fasting insulin is significantly lower than the other twin’s. Likewise, the keto twin’s C-peptide measurement (a proxy for insulin resistance) is significantly lower. As discussed in this post on insulin resistance, elevated insulin levels are an indicator of impending health problems. These elevated insulin levels may appear decades before blood glucose levels rise to prediabetic or diabetic levels.

Measurement	Standard American Diet Twin	Keto Diet Twin	Note
LDL Cholesterol (mg/dL)	61	98	For more on proper context for interpreting LDL-C results on keto diet, visit www.cholesterolcode.com
HDL Cholesterol (mg/dL)	53	57
Triglycerides (mg/dL)	38	42	Both excellent
Glucose (mg/dL)	87	88
Hemoglobin A1C	4.90%	4.80%
hsCRP (mg/L)	0.25	0.17	This is a marker of inflammation. Both have excellent results, extremely low inflammation.
C-peptide (ng/mL)	2.6	1.3	Significant difference-- and generally, the higher the C-peptide, the greater the insulin resistance.
Insulin (uIU/mL)	13.4	4.6	Wow, what a difference. And in the (arguably) most important health marker measurement of the lab results.

Summary

• Most modern people are insulin resistant, which is likely at the heart of most chronic diseases.
• A well-formulated ketogenic diet improves insulin resistance.
• Therefore, eating a WFKD is likely a good way for most people to improve existing conditions related to insulin resistance and to reduce the risk of developing such conditions.
• On a related note, eating a WKFD is likely to lower an individual's inflammation, improve cardiovascular health, and improve liver function.

This post looks at lab values to utilize common objective measurements. However, in real life, subjective experiences are what count. In other words, I don't care if my triglycerides look great on a lab sheet if I feel like crap. For the keto dieters with improved insulin resistance markers, what do you think happened to their moods and energy levels? (If you want a hint, try Googling "keto mood")

The results listed here are a small sample size; they are just from one study and one twin vs. twin comparison. The sample size is small but meaningful. (And remember, you yourself are a small but damn important sample size.) The Virta info is peer-reviewed science carried out in the real world. The twin comparison is a look at two teenagers sharing common genetics but different diets in the real world. I showcase them because they reflect broader truths about what typically happens when people in the real world adopt ketogenic diets. Ketogenic diets improve insulin resistance and therefore they improve people's health, often to an incredible degree.


*Disclaimer: I am not guaranteeing that a ketogenic diet is appropriate for every person, nor that it is the only way to improve insulin resistance. However, the ketogenic diet is so reliable at improving health for the vast majority of the population that it is more appropriate to get that message across as opposed to discussing every rare exception. Focusing on rare exceptions would be missing the forest for the trees. For what it’s worth, Virta Health medical director Dr. Sarah Hallberg says the only type of person she has found that is not a good candidate for a ketogenic diet is someone who has hyperchylomicronemia (1 in 1-2 million people). Regardless, if considering a change, do your own research and always consult a medical professional where appropriate.

References that Dig Deeper

The Ketogenic Diet as a Treatment for Metabolic Syndrome

Complete Guide to Ketogenic Diet for Beginners
Diet Doctor Podcast with Guest Dr. Sarah Hallberg
BioHackers Lab Podcast with Dr. James McCarter
Virta Health
HEAL Clinics (treats Type 2 Diabetes with keto, claims 98% success at eliminating injected insulin)
My Notes (Part 1) on August 2018 Keto Science Conference
My Notes (Part 2) on August 2018 Keto Science Conference
My Notes (Part 3) on August 2018 Keto Science Conference
My Notes (Part 4) on August 2018 Keto Science Conference

Book Review: Tripping Over the Truth

Summary

Tripping Over the Truth is a book about one of the most dreaded words in the world. Cancer. Because we have all known and loved people affected by cancer, it’s not a topic to be brought up in polite conversation. And because we have all known and loved people affected by cancer, it is a critically important topic. Throughout his book, author Travis Christofferson weaves together history, science, personal drama, and level-headed criticisms of the status quo in cancer research. This attention-demanding book is likely to make any reader take a step back and consider viewing the disease differently.



Christofferson suggests that the last several decades of cancer research have approached cancer from the wrong angle. Viewing cancer as a genetic disease has led to billions of dollars (and thousands of research careers) being spent on relatively uninspiring results. Despite many claims of breakthroughs, statistically, cancer rates have barely budged since the 1950s. A gripping anecdote: Senator Ted Kennedy signed the National Cancer Act in 1971, and the nation was optimistic that cancer would soon be overcome. Nearly 40 years later in 2009, despite having access to world-class oncologists, Kennedy died from brain cancer. His treatment induced toxic side effects and provided no life extension.

For the last several decades, cancer research has been conducted under the dominant paradigm of the somatic mutation theory (SMT). The SMT postulates that cancer is caused by DNA mutations. However, in practice, cancer is proving to be more complex than the SMT predicted. Some cancers have no driver gene mutations, whereas the SMT predicted that all tumors require sequential genetic alterations. Beyond that, mutations between different tumors and even within tumors are usually too variable to treat. Targeting specific mutations via pharmaceuticals ends up being like playing “Whac-a-Mole”; as soon as one mutation is targeted and destroyed, another mutation pops up. During this time, toxic side effects accumulate for the patient. With all of these moving pieces and parts, it is no wonder prominent oncologist Bert Vogelstein questioned, “Is it possible to make sense out of this complexity?”

The book is certainly critical of the dominant cancer research paradigm, but it does more than simply criticize the SMT. It provides another view for what causes cancer; in this view, DNA mutations are side effects rather than causes. A small group of scientists have been approaching cancer from this other perspective, based on the research of the late Otto Warburg. Warburg said “the prime cause of cancer is the replacement of the respiration of oxygen in normal body cells by a fermentation of sugar.” His theory states that cancer is a problem related to cellular energy production (metabolism). Cancer cells producing energy via sugar fermentation rather than via aerobic respiration is now known as the Warburg Effect.

After Otto Warburg’s 1970 death, Pete Pederson may have been the only researcher still approaching cancer from this metabolic perspective. Pederson made discoveries and published work consistent with Warburg’s theory. He discovered that tumors form when mitochondria (cellular energy producers) become so damaged that they cannot provide enough energy via aerobic respiration, so they send out a distress signal. This distress signal leads to a retrograde response which tells cells to start fermenting sugar for energy.

Decades into his research career, Tom Seyfried (who holds a master’s degree in genetics and a PhD in classical genetics) discovered that caloric reduction could have antitumor effects. Intrigued by this idea, Seyfried then discovered some of Pederson’s research. He also discovered research from Jerry Shay and Warren Schaeffer. Shay and Schaeffer, completely independently, found that inserting malignant cytoplasms (i.e. damaged mitochondria) into healthy cells led to tumor formation. And inserting a healthy cytoplasm into mutated cells led to mainly tumor-free results (only 1 in 68 mice developed tumors in this scenario). Looking at this research, despite never having heard of the metabolic theory of cancer until the 2000s, Seyfried became convinced that cancer is not genetic, but that it is a metabolic disease. He has since become an outspoken advocate of that view, and he published the 2010 paper Cancer as a metabolic disease and the 2012 book of the same name.

Once the metabolic theory of cancer is accepted, ketosis becomes a potentially therapeutic cancer treatment. If you fast, or if you have a very low intake of carbohydrates, your liver will produce ketones. Your normal cells with healthy mitochondria are fueled by these ketones in the absence of glucose. Cancer cells cannot utilize ketones for fuel, so a ketogenic diet can work to “starve” the cancer cells. At the same time, the ketones help the healthy cells deal with the stresses of radiation. So ketosis has a double benefit in cancer treatment. Because of this, Seyfried (building off the work of many other researchers) has become a major proponent of the restricted ketogenic diet for cancer patients. So far, the ketogenic diet’s success in cancer therapy is relatively small in scope: preclinical experiments, case studies, some trials, and many anecdotes. Many more clinical trials are needed. However, in the meantime, it shows tremendous potential as a non-toxic adjunct therapy. And the ketogenic diet’s early success could help reframe how cancer is viewed. Perhaps cancer could be more effectively battled if viewed as a single metabolic disease and not as one of thousands of indecipherably complex mutations. Nothing is certain; like the book says, “only time will tell.”

The Book's Afterword

This book was initially published in 2014. The version I read is the revised version published in 2017, and with it comes a very enlightening Afterword section. In this section, he provides some tidbits showing that the metabolic view of cancer continues gaining momentum and that the ketogenic diet is currently being used successfully as part of a cancer treatment strategy. But the most interesting part of the Afterword is the story how the author’s mother was diagnosed with endometrial cancer in July 2015, just nine months after the book’s publishing. It is a true “skin in the game” moment: how would his mother choose approach her own cancer treatment? At the age of 73, she underwent surgery to remove her tumor, followed by localized radiation treatment, the adoption of a ketogenic diet, and twice-weekly sessions of hyperbaric oxygen treatment. Christofferson’s mother “felt good and recovered remarkably fast from the radiation.” Actions speak loudly.

Other Topics Covered by Tripping

• The FDA approving drugs based on tumor shrinkage despite that not being correlated with prolonged survival
• History of how cancer came to be known as a genetic disease
• Short history of chemotherapy and details of how controversial it has been to essentially poison cancerous and healthy cells indiscriminately
• The struggle of Pederson’s lab partner Young Hee Ko to bring potential breakthrough cancer drug 3BP to human clinical trials
• The success of chronic myeloid leukemia drug imatinib (Gleevec)
• What it means in the big picture of cancer research
• Whether it truly supports the somatic mutation or metabolic theory of cancer
• The difficulty in getting funding for research of ketosis as a cancer treatment
• The regulatory difficulties impeding the testing of cancer drugs in combination
• The building momentum for metabolic approach to cancer research and treatment even from luminaries like DNA structure discoverer James Watson
• Press-pulse strategy: constant stress on cancer cells (press) via ketosis, periodic acute cancer stress (pulse) via hyperbaric oxygen treatment
• Notes about scientific consensus being overturned including the story of how Barry Marshall went from “quack” to Nobel Laureate by drinking bacteria juice and giving himself an ulcer

My Thoughts

Two concepts were constantly flowing through my mind while reading this book.

1. Baseline beliefs and assumptions matter.
2. The Pareto Principle is important.

Baseline beliefs and assumptions matter. I believe that, like other wild animals, humans evolved to be naturally healthy and largely free of chronic disease. The “primitive” populations studied by Weston A. Price did not eat white flour, sweetened goods, or vegetable oils. Those same populations had nearly nonexistent incidence of cancer. (For what it’s worth, other studies of traditionally-living hunter-gatherers also show the same low incidence of cancer.) This makes me skeptical of approaching cancer research in a gene-centric way*. The metabolic theory of cancer just explains the sudden increase in cancer rates upon Westernization better than the somatic mutation theory.

The Pareto Principle is important. The Pareto Principle states that the 80% of benefits come from 20% of causes. Lots of brilliant, caring researchers have dedicated their entire careers to studying cancer. But Tripping causes me to wonder whether many of these researchers are simply looking at the wrong cause. Perhaps DNA mutations are not the cause (as suggested by Somatic Mutation Theory), but the effect of mitochondrial damage (Metabolic Theory). Perhaps focusing more on mitochondrial damage and reversal of the Warburg Effect would be the “20%” that provides “80%” of cancer research benefit. 80/20 probably actually undersells the Pareto distribution in this case, as 95% of cancers are PET-positive. PET-positive cancers are cancers that feed off of sugar, making cancer cell sugar starvation (reversal of the Warburg Effect) a potentially fruitful approach.

All of that being said, I think the ketogenic diet is likely to be a very important non-toxic approach for cancer treatment. It’s a simple idea: cancer cells feed off of glucose, so don’t ingest glucose. Starve the cancer cells while your healthy cells can still feed off of ketone bodies. Your body being in a ketogenic state (via fasting, a ketogenic diet, or a combination thereof) will help mitigate the nausea and weakness brought about by other cancer treatments such radiation and/or chemotherapy. Periodic hyperbaric oxygen treatments could be beneficial as well. Doing this could lead to a more effective and less toxic cancer treatment than standard of care**.

Cancer is often seen as something that just randomly happens to people, based on genetics. I do not share this view***. Seeing how much impact lack of nutrition had in previously healthy peoples in a single generation in Weston A. Price’s studies makes me a firm believer that what we eat is far, far more of a driver of cancer than genetics. (In other words, the people studied by Price were genetically healthy but their diets changed and they became afflicted by chronic diseases. Similarly, every single day I see anecdotal reports online of modern people making radical health improvements via diet. These observations significantly impact my view here.) Diet is not the only environmental factor that can cause cancer, but I find it likely to be the most prevalent one. I also find diet likely to play an important role in treating the disease.

*I am not saying there is nothing about cancer that is related to genetics. As the book says, about 5-7% of cancers are related to germline mutations (passed from parent to offspring). But even those inherited mutations interfere with mitochondrial function, consistent with the metabolic theory of cancer.

**I am not claiming that ketosis will cure cancer, nor that there are no possible negative side effects. Ketogenic diet cancer researchers at the OSU Low Carb conference in August mentioned the existence of a reverse Warburg effect in some types of cancer cells (where cancer is fueled by ketones), so ketosis is not a panacea. But ketosis has a lot of potential for improving cancer treatment in a large percentage of cancer cases.

***I also do not mean to blame anyone suffering from cancer. But I do want to provide the perspective that you don’t need to resolve yourself to the idea that “maybe I’ll get it, maybe I won’t, not much I can do”-- there may be steps you can take to lower your risk (steps mentioned in How to Improve Your Insulin Sensitivity here would be among steps that deserve consideration). And if you do suffer from cancer, perhaps you could find therapeutic benefits from fasting, ketosis, or other treatments targeting cancer metabolism (certainly, there are no guarantees, but it might be worth researching further).

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.

OSU Keto Conference, Day 2 (Part 2)

continued from Day 2, part 1

Day 2, part 2

During this part of the day, the speakers were discussing the effect of ketosis on the brain-- specifically, the effects of ketosis on Alzheimer's and epilepsy.

Stephen Cunnane, PhD: Brain Glucose and Ketone Metabolism (Alzheimer's)

Cunnane talks about how ketones are an essential fuel for infant development. Breast-fed babies spend time in ketosis. There are medium chain triglycerides (MCTs) in mammalian milk.

Glucose is pulled into the brain, while ketones are pushed into the brain.

Alzheimer's sufferers have inhibited glucose uptake into the brain. And glucose uptake deficiency precedes cognitive decline. However, the ketogenic diet shows promise as an Alzheimer's treatment because when brain glucose uptake is impaired, brain ketone uptake is fine.

Cunnane mentioned cerebral metabolic rate. Interestingly, the ketone uptake rate into the brain is not as variable as blood ketone levels. People with Alzheimer's can still uptake ketones!

Cunnane talked about the BENEFIC trial (n=39) where cognitive performance was improved with MCT supplementation (MCTs are easily converted into ketones in the body) ("Conclusion: Ketones from MCT compensate for the brain glucose deficit in AD in direct proportion to the level of plasma ketones achieved.")

The more MCT consumed, the less the brain energy gap there was (glucose was still low, but ketones make up the difference). Also, exercise helps get both glucose and ketones to the brain in Alzheimer's patients. Cunnane noted the difficulty of doing such trials; it took 7 years to get 5 Alzheimer's patients through this protocol.

Summary bullet points (from Cunnane's slides):

• Pre-symptomatic, glucose-specific brain energy deficit.
• Brain energy rescue by ketones is feasible in MCI [Mild Cognitive Impairment] and AD [Alzheimer's Disease].
• Recapitulates role of ketones in infant brain.
• Cognitive benefits and mechanism of action need further evaluation.

Eric Kossoff, MD: Ketogenic Diet and Seizure Management (Epilepsy)

Kossoff is the Director of the Child Neurology Residency Program and a Professor of Neurology at Johns Hopkins. He covered the ketogenic diet's (KD) history in its use as a treatment for epilepsy. We are beyond the tipping point using KD for epilepsy. It is now a mainstream-accepted treatment.

Kossoff noted that in Mark 9:14-29, Jesus recommended prayer and fasting for seizure cure.

In 1921, Dr. Wilder at the Mayo Clinic learned that Low-Carb, High-Fat (LCHF) mimics fasting.

Fasting and ketosis work for epilepsy via different mechanisms.

There was an anticonvulsant drug explosion in 1938, then in the 50s, 70s, and 90s, all of which led to decreased usage of the KD for epilepsy; drugs were now an option, seems easier.

Kossoff mentioned that medical marijuana is now an alternative to the KD (he says it probably won't work).

In the early 1990s, the KD was rarely used. It was a last resport. There was no interest in it at the American Epilepsy Society. Then, in 1993, enter the Charlie Foundation (side note: The Charlie Foundation was started by one of the creators of the best movie of all time [Airplane!] when he went outside the mainstream to use the KD to cure his son's epilepsy. He actually teamed up with Meryl Streep for a related movie titled ...First Do No Harm.)

The number of KD studies has gone up exponentially since the late 1990s.

The Cochrane Collaboration, published in 2012, stated that the KD shows good results for epilepsy.

Today, the KD is usually used after 2 drugs have failed. It is one of the 4 major treatments. Mainstream!

Now, in 2018, the Charlie Foundation has been around for 25 years. 2018 will mark the 6th Ketogenic Diet symposium in South Korea. There is something called KetoCollege and KetoUniversity. The American Epilepsy Society, which showed no interest in the KD in 1993, is holding a symposium on the KD in 2018. Furthermore, the international guidelines are being revised!

Kossoff said we need to know how to make the KD easier and safer.

The traditional KD started with a 24-hour fast. 4:1 ratio of fat to other macronutrients. Kids seen every 3-6 months. After 2 years, they try to wean the kids off the KD.

Now. . . they don't need the 24-hour fast to initiate. Kids often don't need admission to the hospital for treatment. Kids can be gradualized in to the KD.

Kossoff detailed 4 ketogenic diets and said they are all equally valid (slight differences in macronutrient ratios-- Ketogenic Diet vs. Medium Chain Triglyceride Diet vs. Modified Atkins Diet vs. Low Glycemic Index Treatment).

Can the KD be replaced with a pill? People are trying. Certainly not definitive. Maybe as a supplement.

History of: "Can KD help infants?"

1963: No. Not helpful.

2002: Yes. Safe and effective.

2015: Yes. Kids under 2 do even better than older kids.

Johns Hopkins started an Adult Epilepsy Diet Center in August 2010 (previously there had been issues where it was tough to get treatment after turning 18 and no longer being eligible for pediatric care). There are now over 300 adults in the clinic. About 20% were already on the KD. 80% were not doing keto; they get put on the Modified Atkins diet (10-20 g carbohydrate per day, approximately 25% protein, 70% fat).

Outstanding questions to look into: How to improve compliance? What are the implications when patients see elevated lipids? Is the diet safe in pregnancy? (He says he thinks it probably is. In the Q&A below, he touches on this further)

Q&A Session, Cunnane and Kossoff

Is there any research on ketosis for Multiple Sclerosis since it may be an inflammatory brain disease like Alzheimer's? Kossoff said there is not much, although he noted there is some work looking at intermittent fasting for MS.

Dr. Scheck asked about people going off the KD. . . why wouldn't the epilepsy symptoms come back after going off the diet? Kossoff said the mechanism is debated. Said there is some evidence that the KD can alter underlying brain. Cunnane said that with AD patients, going off the KD leads to immediately diminished cognition.

Could the effects of ketones partially be an autophagy effect? Cunnane said they are trying to get funding to study just this.

Someone asked about the APOE4 gene allele-- that tends to lead to problems with saturated fat. . . my notes are slightly confused here. What I jotted down was that the APOE4 gene dampened cognitive benefit and metabolic benefit. But his study saw no difference between APOE4 and non-APOE4. So maybe the dampened benefits are what is typically thought, but his results did not support those.

Is there trouble getting trials for kids? Kossoff said institutional review boards (IRBs) are definitely keto-friendly for epilepsy now. But there are pregnancy exclusions for trials (hence, why he listed "Is it safe for pregnancy?" as an outstanding question in his speech). Just can't do pregnancy trials. Cunnane said the problem is that IRBs are scared of ketoacidosis (toxically high ketone levels) in those cases.

A sports medicine physician from Georgia asked about brain blood flow. Cunnane said you can get the acute effect with exogenous ketones. Cunnane then asked whether it is a desirable effect to get increased blood flow. He answered his own question by saying he's not sure that is a requirement.

A health coach from Detroit asked what the mechanism from exercise is for getting increased glucose and increased ketones to the brain in AD patients. Cunnane said he was not sure. Increased ketones because of increased capacity. Increased glucose: open question.

Someone asked abot children with autism (as approximately 30% of autistic children experience seizures). Is there any research of the KD for autism? Kossoff said the autism community is desperate for answers and treatments. He said a 2003 Greece study showed a very modest benefit. A 2017 Hawaii gluten free modified Atkins beneft also showed a very modest benefit. The mechanism is a hot topic. He said there is some work being done in animal models.

A functional registered dietician asked what may change after long-term KD adherence. Kossoff said only 5% of patients use the KD for > 2 years. He said there are very few long-termers. He said the results of long-termers have been "not great but not bad". He referenced that bone density and bone fractures have been issues. Growth has been an issue. He has seen good lipids and good GI results.

A family doctor from Canada asked about Alzheimer's studies with Metformin, as it can sometimes be helpful with insulin resistance. Cunnane said there are two schools of thought with Metformin. One says it is beneficial because it decreases insulin resistance. The other says it increases the risk.

A neuroscientist asked about nasal insulin as an AD treatment. And about nasal ketones. Cunnane said getting ketones to the brain is the goal. Unknown for both, but I thought Cunnane seemed skeptical.

OSU Keto Conference, Day 2 (Part 1)

continued from Day 1

Day 2, Part 1 (Ketosis, Clinical Applications for Cancer)

I was excited heading into Day 2. . . the first five speakers were all going to speak towards ketosis as a potential cancer treatment.

Also, in case I don't get back around to mentioning it. . . the food at this conference was phenomenal, and all keto-friendly. Eggs and bacon for breakfast one day (and some kind of dairy/berry combo), eggs and sausage the next day. Salads with protein and dressing options for lunch. Delicious. Many people at my table agreed that it was the best conference food they'd ever been served. Also, I wasn't even the only one at my table who brought their own salt! (I brought Redmond Real Salt, someone elese brought pink himalayan salt.)

Other note: I was surprised that a couple people at the conference still balked at mentions of the carnivore diet. I thought the keto crowd would be all on board for it! Most people I talked to were on board, but a couple people seemed thrown off by the idea.

Colin Champ, MD: Dietary Recommendations for Cancer

He didn't call this out, but if you want to read more from Dr. Champ on cancer, check out his website. Specifically, on keto and cancer.

Champ is a clinician and researcher at the University of Pittsburgh. He founded and runs the Cancer Prevention Project. Warburg metabolism was discovered 70 years ago-- this is where cancer cells rely on sugar. This is why ketogenic seem promising for (some) cancer treatments (no sugar for the cancer cells to feed on). This has something to do with faulty mitochondria.

With increased glucose, there is increased cancer cell growth, and with that there is increased fatality.

In a pancreatic cancer study, people who showed blood glucose levels > 200 had low survival. As blood glucose goes up, survival at 2 years decreases.

A 2014 study of ketogenic diets on glioblastoma showed that the ketogenic diet brought blood glucose down.

Exercise, fasting, carb restriction, ketosis are all ways to activate AMPK which decreases cancer growth.

Champ discussed a study where women who formerly had cancer had higher recurrence when eating a high-carb diet when compared to a low-carb diet. This may have something to do with IGF-1 stimulation.

Champ referenced a 1913 (yes, 1913!!!) study published in the Journal of Medical Research that showed a lack of carbohydrates leading to resistance to tumor growth in animals.

Champ said the ketogenic diet is not a miracle cure. He said it is often effective before cancer. And that it can be effective during treatment-- the ketogenic diet works synergystically with radioactive treatment, not by itself.

Interestingly, Champ mentioned a study about statins improving survival in pancreatic cancer patients. (Interesting because low-carbers often are anti-statins for other conditions)

Excess adipose tissue has been shown to be associated with increased cancer recurrence.

Champ, from Pittsburgh, took some pot shots at Cleveland and Cincinnati sports teams. Then he related that to the competition between low-carb and low-fat diets. Out of 57 studies, he found 29 ties, Low Carb won 28, Low Fat won 0.

Champ mentioned that hospital vending machines are a big problem. Lots of people talked about this at the conference-- it isn't something that was on my radar previously. But hearing from these doctors dealing with patients in the real world. . . that is be a huge problem!!

Eugene Fine, MD: Ketogenic Diet and Cancer Treatment

Dr. Eugene Fine was presenting to talk about glucose-avid metastases.

He talked about a 10-patient study he was part of called RECHARGE, where all ten patients had advanced PET+ cancer, and they treated those patients with a very low carbohydrate ketogenic diet (VLCKD), where carbs make up <= 5% of total energy intake. In that study, the patients whose cancers stabilized had 3x higher ketosis. (I have a photo of the chart and the Y-axis shows Dietary BHB / Baseline BHB. I don't have a full understanding, so I am going off of the description of said chart: "Ketosis is 3-fold higher among stabilizers"). Links to information about this study are here, here, and here. The ten patients in this study completed without adverse side effects (note: the patients were specifically chosen because they had glucose-dependent tumors).

For new work, he is working on a 65-patient human randomized controlled trial on patients with breast cancer. A previous study showed that the drug Metformin dropped Ki-67 protein (a prognostic marker for breast cancer, marker of cellular proliferation) in three weeks. The ketogenic diet is usually better than Metformin at controlling glucose and insulin levels, so with that knowledge and the RECHARGE trial vouching for its potential, the keto diet was cleared to be attempted in this 65-patient trial.

They only have data back from their first patient.The patient's Ki-67 (and therefore the patient's health) got worse. That patient was randomized to. . . the ketogenic diet. So the keto diet did not stop this patient's cancer from progressing. Dr. Fine was straightforward about this, and admitted that he was surprised. This was unexpected. He did say that from looking at the patient's tracked BHB levels, the patient was not in nutritional ketosis (BHB too low). He said he, the other researchers, and the doctors take the blame for that. It was interesting. And though obviously sad and painful for the anonymous patient, it was refreshing to see Dr. Fine own up to being surprised by the results. He did not try to sugar-coat things.

Fine went on to talk about how researchers in mouse imaging now think they can trace BHB circulating in the body. He also mentioned ongoing research of rapamycin as a potential anti-cancer drug, as it down-regulates mTOR (but does it cause counter-regulatory effects?).

Angela Poff, PhD: Non-Toxic Methods of Exploiting Cancer Metabolism

Dr. Poff is a PhD working out of the University of South Florida. She mentioned that in many cancers, there is a direct correlation between blood glucose and tumor growth. She showed a chart from this study (study led by Thomas Seyfriend, author of Cancer as a Metabolic Disease) to show this correlation.

Poff said ketones may have an anti-cancer effect in some cancers. Goes back to work done by Magee in 1979.

The idea is that ketones lead to better oxidative metabolism, lower inflammation, lower HDAC, lower blood glucose.

She said exogenous ketones can inhibit some tumor growth.

Cancer cells have increased free radicals.

Hyperbaric chambers can restore oxygen to tumors. In an animal study, animals with cancer did best with a combination of ketogenic diet, ketone esters, and hyperbaric oxygen chamber treatment.

She then discussed press-pulse metabolic therapy. Where press = a chronic environmental stressor and pulse = an acute event with high mortality. She hypothesized that ketosis could be a press stressor for cancer, while hyperbaric oxygen could be a pulse (acute) distressor for cancer. So I think of it like: jab the cancer with sustained ketosis to keep it on the ropes, then go for the knockout punch with the hyperbaric oxygen chamber.

She also talked briefly about the danger of cancer cachexia (loss of skeletal muscle) and how there is no current standard of care to treat cachexia.

From slide: "Cancer will likely require a multifaceted approach", "Effects will be cell, cancer, and model-type dependent", and "Metabolic therapies often work best as adjuvant and investigated as such, including with standard of care". Poff used very cautious language, but she clearly sees lots of potential for ketosis in certain cancer treatments.

Adrienne Scheck, PhD: Tumor Metabolism and the Ketogenic Diet

In vitro, BCNU (a cancer drug) + ketones are effective against cancer.

A 2017 study by Scheck and others showed glowing tumors in mice. I wasn't sure what the takeaway was here honestly, but I'm also kind of dense sometimes :)

She mentioned an increase in survival for mice fed KetoCal vs. standard diet. Study abstract here-- 9 of 11 mice treated with radiation and fed KetoCal were cured

Ketogenic diet reduces Reactive Oxygen Species

Scheck initially thought the ketogenic diet was snake oil; no longer believes so. (Does she think it's extra-virgin olive oil now?)

In vitro, ketones have great effects separate from glucose restriction. BHB increases histone acetylation, increases DNA damage following radiation, is an inhibitor of HDAC, and BHB + radiation leads to enhanced treatment of glioma cells.

Promising keto/cancer research.

Parker Hyde, PhD candidate: Nutritional Ketosis and Advanced Stage Breast Cancer

While all the speakers were excellent, Parker really stood out. He made all of this research hit home as he told the story of his mother being diagnosed (on her 40th birthday) with breast cancer. He made all the high-level scientific discussion reach a personal level. He has spent the last 20 years trying to figure out how to cure breast cancer. (1/6 or 1/8 women will get breast cancer diagnosis in their life. And median survival for metastatic breast cancer [AKA stage 4 breast cancer] is just 26.9 months)

90-95% of occurrence of metastatic breast cancer (MBC) is due to non-heritable traits.

Over 40% of metastases have PIK3CA mutations, and there are reasons to believe ketosis can help against such mutations.

Hyde took care to say not all breast cancers are the same.

Women with post-menopausal obesity have twofold increase in being diagnosed with breast cancer.

Insulin resistance and obesity are correlated (with one another, and with breast cancer diagnoses, if I recall correctly)

Hyde referenced work by Phinney and Volek, and he stated the hypothesis that nutritional ketosis could help breast cancer outcomes. Because metabolism is important, it would decrease inflammation, mTOR would be inhibited, sleep quality would be improved, and emotional functioning would be improved.

He mentioned ketosis being a hammer and everything else being nails.

Then he dug into his work-- the KETO-CARE study (Keto & Chemo for Breast Cancer). 6 months, non-randomized controlled study. Standard care (20 patients, AKA n=20), keto (n=20). For the first three months, the study would feed the patients everything to tightly control what they ate (test biological effect). Then the next three months would be free living (test feasibility-- can the patients maintain the diet on their own?).

Hyde had some very interesting imaging; it showed that the heart even begins using ketones! 

It also showed improvements for the patients who were getting the ketosis treatment.

(Blurry photo below, sorry for poor cell phone image quality. Still interesting. I forget what the imaging specifically highlights, but it was certainly a good thing that less of it was showing up in the 3-month image than the baseline image. The patient was treated with the ketogenic diet.)

Powerfully, here is one of the KETO-CARE ketosis-treated patient's quotes. Important to remember this impacts real people. A real person:

"I am so glad I participated in this clinical trial. The study team have taught me a new way of eating that is healthier for me in many ways aside from any effects it may have on my cancer treatment. My most recent scans showed that my liver mets have regressed and are almost undetectable! I have lost 20 pounds without trying and am off sugar without any cravings. I never thought that would happen!"

Q&A Session, Cancer Speakers

A nutritionist from Costa Rica asked about something he'd seen: advisees who got hyperglycemia after taking Vitamin C injections. Dr. Poff responded that many blood glucose meters actually measure Vitamin C on accident, so their hyperglycemia may not be real; it may just be a defect showing hyperglycemia when the true cause of the meter's spike is Vitamin C.

Is cancer a metabolic disease? Answered: Yes, and a genetic disease, and an epigenetic disease.

A Virta doctor asked if there are concerns about chronically inhibited HDAC from ketosis. Champ's answer included something about ketones potentially protecting against radiation. Poff answered that inhibited HDAC could actually increase the antioxidant response.

An infectious disease doctor asked about wound care. He speculated that carbohydrates are exacerbating wound problems but that administrative restrictions (e.g. national dietary guidelines as standard of care) keep him from being able to prescribe low carb as a treatment. He asked if micro-RNA could play a role in wound care. They responded that it would make a good clinical trial. Poff cited some work done by Lisa Gould, Shannon Lynn Kesl in a mouse model where exogenous ketones quickened wound healing. She said it is not published yet, but told the doctor he could email Poff for more research. (Here is Poff's Facebook page if you are interested)

Someone from Vancouver asked a question about T-cells, B-cells, immune cells that require glucose, and essentially asked if it is a concern that ketosis could inhibit the work of these glucose-dependent cells. Dr Scheck said she was not convinced glucose would go too low. Champ said glucose lowering does not across-the-board help on its own.

An area physician asked about treating patients with insulin to treat cachexia (to lower blood glucose). Champ cited work from the 1960s and/or 1970s: case reports of two patients whose tumors were reported to have gone away using such a strategy. However, he said after that a clinic opened in Mexico for that kind of treatment and it did not go well.

How do ketogenic diets affect PET scan imaging? Do the ketones affect the imaging itself and that's why colors stop showing up after adopting keto? Champ said the scans are trustworthy. Hyde added in measured language about how the Warburg effect (e.g. starve cancer by starving cancer cells of glucose) is complex.

A researcher from the NIH asked about efficacy of treatment vs. toxicity of treatment and asked about lean body mass of patients. Hyde said they are tracking lean body mass with DEXA scans. Mentioned that gaining weight is typically a contraindication for health. He said they are collecting health information on toxicity. Dr. Fine said most patients lost weight, which was positive since most were overweight (so the weight loss was indication of health improvement). Champ said weight loss is not encouraged by the mainstream (due to conflation with cachexia), so that is a barrier in a lot of people's treatment. (General idea: fat loss = good, skeletal muscle loss [cachexia] or lean body mass loss = bad). Champ says we now see heavier patients doing worse. Dr. Maryam Lustberg (panel moderator) jumped in and said social lives complicate nutritional ketosis adherence. Hyde brought it back to the personal again and said patients face discrimination. Several patients, upon cancer diagnoses, end up losing jobs. Then they drop out of studies (which shows in the dropout rate as if they could not do the ketogenic diet).

An OSU nurse asked about how the panel's dream for how their work could be applied to real time. Hyde said they need more funding so they could get more data. Dr. Fine said cancer is more complex than many people originally thought. Keto diet doesn't always work on its own. Also, the reverse Warburg effect exists (some cancer cells are actually fueled by ketones). Scheck said patients think of diet as "just food". Said dieticians need keto training and cancer training. She also said funding is tough because most comes from pharmaceutical companies (so keto makes no $$ for them). Scheck also talked about the need for biomarkers and the need to find out which cancers keto helps vs. the ones that keto makes worse. Finally, practically, all clinicians would need to be fully bought-in to support patients in this approach (think, hospital food, etc).

An oncologist from Uruguay asked about the importance of keeping the glucose/ketone index (G/Ki) between 0.7 and 1.0 (based on Seyfried's animal study recommendations. Hyde said they have seen promising results with relatively low ketones (0.5-0.6 BHB levels). Said you can get that low of a glucose/ketone index in vitro or in mice but not in reality. Dr. Fine said you can't extrapolate from mouse models for the G/Ki. Scheck talked about one patient she know of with a G/Ki =/= 1 who is doing well. She talked about the concern of telling a patient to "hit this number" which can in turn increase stress and cortisol levels, which is counterproductive. She said they don't even know the ideal G/Ki for epilepsy treatment which has used ketosis for decades.

Someone from a medical college in Georgia asked about ketosis for blood-based cancers. No one knew anything about keto for blood-based cancers.

Dr. Kushner asked what it is going to take to help ketosis become accepted by the mainstream. He said something about there being little communication between scientists and SROs (scientific research organizations??). 

Someone referenced Cantley's article in Nature. I'm not sure for what, but here's a page showing Nature's results for Lewis Cantley Panelists talked about increasing dialogue with NCI, talked about RFAs. Scheck said they need nutrition to be one of the three legs of the stool of cancer care. Champ talked about the difficulty fighting with institutional review boards (IRBs). Scheck said she got into ketosis studying via a high school student group (but I didn't get the name written down, unfortunately). Grassroots. Hyde said they haven't sought traditional grant money-- they need more collaboration. Dr. Fine talked up experiment.com (like kickstarter but for science)-- raised $75K from it, and then 2 weeks after campaign, an anonymous donor gave big $$ to fund their research.

The Uruguay nutritionist asked about BCAA supplementation for cancer patients on the ketogenic diet. Poff said a mouse study did not show a benefit (anything would be speculation at this point)

Someone from Penn who specializes in microbiome asked what the pivotal studies are that need done. Poff said mechanism is important for traditional funding (perfect for drug companies). The ketogenic diet has too many mechanisms so it makes traditional funding hard to come by. Scheck said that whatever study you are doing, you need to collect as much data as you can, whether you know what you need it for or not. The questioner said we need to collaborate and break down silos. Lustberg biopsies taken over time will lead to greater acceptance.

And with that, those are my notes from the first part of Day 2 of the keto conference. . . this doesn't even get us to Day 2 lunch yet! So I'm ending this post for now. More about Day 2 later-- Day 2 would go on to look at the research of ketosis in relation to neurology and performance (with a keynote speech by Gary Taubes in the middle).

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!