Book Review: The Big Fat Surprise

“If saturated fat is healthy, why doesn’t xxxx say so?” The Big Fat Surprise provides the answer to that question, whether xxxx is “my doctor,” “the government,” or “the American Heart Association.” Author Nina Teicholz provides a detailed explanation of how a weak hypothesis has led to low-fat diets dominating nutrition discourse in the American public, government, and academia for the last several decades. She details the confluence of factors that helped demonize historically prized saturated fats such as those found in dairy foods and beef. These factors include cherry-picked data, charismatic and bullheaded scientists, vegetarian leanings, industry financial influence, groupthink, institutional inertia, and the well-intentioned act now attitude of a politician and his team.

America’s fear of animal fats started in the early 1950s with the work of scientist Ancel Keys. Using epidemiological data from just six countries, he published a paper showing an association between dietary fat intake and heart disease. With that, the diet-heart hypothesis (alleging that dietary fat causes heart disease) was born. There were many problems with the study and it was only powered only to show correlation (not causation). Nevertheless, Keys promoted his hypothesis strongly. Keys had a strong and persuasive personality, and he responded to critics with vigor. Despite many scientists’ disagreements, Keys’ hypothesis persisted. Despite twenty-two countries showing an at-best nebulous link between fat intake and heart disease, Keys’ hypothesis persisted. Despite ample evidence of healthy populations (Inuit, Masai, and Navajo) eating high-fat diets, Keys’ hypothesis persisted.

The American Heart Association (AHA) got its first big infusion of finances in 1948, so it saw a great deal of growth in the 1950s. This coincided with the timing of Keys’ popularization of his fat-fearing hypothesis. Keys was close to leaders in the AHA and the organization adopted this diet-heart hypothesis as a guiding truth. Over time, the hypothesis evolved to include concern about serum cholesterol levels, which are often elevated by saturated fat consumption. By 1961, the AHA recommended polyunsaturated fats (PUFAs) from industrially processed seed oils as part of its otherwise-low-fat “prudent diet” because of their cholesterol-lowering tendencies. Despite evidence that high triglycerides were more indicative of cardiovascular issues than high cholesterol, the AHA promoted the prudent diet. Despite evidence that high HDL cholesterol (raised by saturated fat) was actually protective, the AHA promoted the prudent diet. Despite a 1967 Indian study showing Southern Indians getting heart disease at 7 times the rate of Northern Indians while Northerners ate 8-19 times more fat, the AHA promoted the prudent diet.

The diet-heart hypothesis remained entrenched in the AHA’s recommendations and in the minds of the American public. In 1977, a small government committee led by Senator George McGovern met to investigate the link between diet and heart disease. McGovern’s team issued Dietary Goals for America that were in line with the AHA’s prudent diet. The central diet-heart hypothesis remained unproven, but the well-intentioned report stated that its authors “cannot afford to await the ultimate proof”. Three years later, those goals were built into the Dietary Guidelines for Americans. Similar logic (“What are the risks associated with eating less meat, less fat, less cholesterol?”) was used to dismiss criticism from a nutrition task force prior to issuance. The idea that saturated fat could be replaced by something worse was not considered realistic. The low-fat diet was assumed right (for everybody) until proven wrong. By 1980, this assumption suddenly had the backing of the AHA, the processed food industry, and the American government. Despite a growing chronic disease epidemic, these same groups continue to promote a similar diet today.

On top of going into detail on the history of America’s dietary guidelines, Teicholz covers many interesting topics, including:

• the history of American red meat consumption
• a fascinating comparison of animal-food-eating Masai vs. geographically similar plant-based Akikuyu
• the dangers of PUFA consumption 
• cases of the AHA historically supporting and promoting foods now known to be harmful
• trans fats
• hard candy, sugar, syrup
• breakfast cereals getting stamped with AHA "heart-healthy" sticker (for a fee) 
• PUFA-laden industrial seed oils (the AHA still recommends these) 
• potential impacts of low-fat diets for children
• the misleadingly-defined Mediterranean Diet
• a history of trans fats
• science and history showing the healthfulness of low-carbohydrate, high-fat diets

Readers of The Big Fat Surprise will learn a great deal about the history, the personalities, and the organizations that shaped America’s dietary guidelines. By spending a decade of her life investigating the issue from every angle, Teicholz masterfully shows that the diet-heart hypothesis emperor has no clothes. Her passionate work demonstrates that saturated fat has been wrongly vilified for the last fifty years. Above all, The Big Fat Surprise teaches that an idea can become widely accepted for a diverse set of reasons that does not include truth.

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

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!