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Dr. Stephen Phinney on the Safety and Benefits of a Ketogenic Diet (Part 2)

– Nutritional ketosis is a very powerful tool. And it can be used to achieve metabolic health and well-being in people who have diseases associated with insulin resistance or inflammation. Now, there are lots of myths and misunderstandings about ketogenic diets and about nutritional ketosis and I wanna really focus on the scientific evidence around safety and efficacy of this approach to nutrition. And I realize it’s hard for people to commit to this kind of endeavor if people around you are saying, “Oh, this is dangerous so you shouldn’t be doing it.” So you need to be confident that if you undertake this that you’re doing it in a safe and efficacious way.

In study after study, not just ours but others, a well-formulated ketogenic diet when compared to a standard calorie restricted low fat diet has a greater effect on weight loss and particularly loss of abdominal adipose tissue and it’s the adipose tissue or a fat mass within the abdomen that is the most dangerous fat that we carry in our body. For instance, a study that I did with Dr. Jeff Volek and Dr. Cassandra Forsythe, one of his graduate students, we compared a high carbohydrate low-fat calorie restricted diet to a ketogenic diet that people followed where their instruction was to eat to satiety, that is not count calories and don’t restrict calories but eat enough to feel like they had had enough food and they weren’t hungry.

And we ran the study for 12 weeks.

And at the end of 12 weeks, the weight loss in the high carbohydrate low-fat group was about half the weight loss in the ketogenic diet group. Now, some critics will say that well, when you go into a ketogenic diet, a lot of your weight loss is water. But we actually did careful measurements of body fat and the water loss on the ketogenic diet was only about 1/5 of the difference so five kilograms on the carbohydrate rich low-fat diet and 10 kilograms on the ketogenic diet and only about 1/5 of that difference was water, the rest was body fat. More importantly, we used the dual x-ray absorptiometry so called DEXA technique to measure body fat content.

There is a significantly greater reduction in abdominal fat, so it’s not just total fat, it’s not fat from under the skin, but it’s some of the most dangerous fat that is more rapidly mobilized when someone gets the ketogenic diet right.

The next most common effect is for people who have either slightly or markedly elevated blood glucose levels, so either prediabetes or diabetes, a prompt response of the ketogenic diet is a reduction in blood glucose. Now, that makes sense because if you eat less carbohydrate in a diet, there’s going to be less glucose produced by digestion and the level of sugar coming into the blood is gonna be reduced, that’s what we commonly see.

However, in Dr. Forsythe’s study..

. Now, these are people with prediabetes but their blood sugars are still slightly elevated. We saw a marked reduction in blood glucose in the people on the ketogenic diet and no change in blood glucose in the people who were on the high carbohydrate low-fat diet. What’s more interesting is that we also measured blood insulin levels. And insulin a hormone that makes glucose go into cells, so if the blood sugar came down, you’d think that the body was making more insulin to make it go into the cells.

But it was the opposite of what we saw. And that is that insulin level came down dramatically, blood glucose came down. And the only way you can make sense out of that is that the ketogenic diet improves insulin sensitivity, that is the body’s response to any one molecule of insulin is markedly greater.

And that’s a consistent finding we’ve seen across multiple studies and that’s the finding that has led us to the concept that we can actually reverse the root cause of Type 2 diabetes. Another effect of a well-formulated ketogenic diet is to change the blood lipid values that are characteristic of metabolic syndrome.

And, by the way, metabolic syndrome is also referred to as prediabetes.

Typically we’d see with metabolic syndrome a reduced good cholesterol, an increase in triglycerides and a greater proportion of the small dense or bad LDL cholesterol. And when we looked at that in this cohort, we saw that triglycerides plummeted. Now, they went down in both groups but they went down more than twice as much in the patients on the ketogenic diet. And by the way, they were eating more fat, and yet the blood fat levels dropped.

HDL went up about 13% which is greater than any HDL response we can get from any drugs that we have available that we can write as a prescription. So this is a pretty much unique benefit to a well-formulated ketogenic diet. And then the small dense LDL which is the most dangerous didn’t go down. If anything they went down slightly in the group who were eating the high carb low-fat diet and went down sharply in the group on the ketogenic diet. So again, all the lipid changes are going in the right direction in favor of the ketogenic diet.

So again, the concern about eating a high fat diet, eating eggs and meat and dairy which contains cholesterol, the actual, the cholesterol in the blood and the blood lipids are changing all in a beneficial way when one gets this diet right. If you’re eating low carbohydrate and moderate protein, the majority of your dietary calories come from fat. And a lot of the fats that people eat typically come from animal products or from dairy and cocoa butter and things, which are saturated fats.

And so the question is is eating a lot of saturated fat dangerous when you’re on a ketogenic diet? And the reason people propose it as dangerous is that we know that when you measure blood levels of saturated fat, that the higher the blood level of saturated fat, the greater the risk of diabetes, a heart attack and overall mortality.

And so if you assume that eating saturated makes the blood level go up, that would suggest this is dangerous. But people hadn’t ever actually looked at what happens to the blood levels with saturated fat when they’re going on a ketogenic diet, so we did. And what we found was, even though the people on the high fat diet, the ketogenic diet were eating three times as many grams of saturated fat per day, their blood levels of saturated fat actually were lower than the group eating the lower saturated fat intake high carb diet.

And again, this is a head scratcher. It appears that we’ve disconnected intake from blood levels.

And that violates the law that all dietitians tell you that you are what you eat. In actuality, you are what you save from what you eat. And the neat thing about the ketogenic diet is it teaches your body to burn fat more effectively. How effectively? Well, we did a study where we looked at highly trained athletes some of whom were following a traditional high carbohydrate loading diet regimen and the other half of them were following a well-formulated ketogenic diet.

And these people had been following these diets for at least six months or longer, which means that they were fully keto-adapted for the ones on the low carbohydrate or ketogenic diet. And when we looked at the resting rate of fat oxidation, it was about double as much on the low carbohydrate ketogenic diet as it was on the high carbohydrate diet.

So again, highly trained athletes, theoretically, their bodies are highly conditioned to burn fat for fuel during exercise and yet, just the difference of diet doubled the bodies’ ability to burn fat for fuel. And then as they..

. We had them do greater and greater levels of exercise, the people on the ketogenic diet demonstrated remarkable ability to use fat for fuel. The athletes like that because they can run on body fat stores much better than trying to eat and load with carbohydrate which means that when you’re keto-adapted, your body has a capability of getting rid of saturated fat and so the amount you eat is not important, it’s how much your body saves from what you eat. And clearly, the body doesn’t save saturated fat when you’re keto-adapted, which means that saturated fats are not harmful when consumed, if you’re keto-adapted.

Another very important area of current research is in the topic of inflammation because we know that when we measure biomarkers of inflammation, and there have been some that we’ve measured over the last century, like white blood cell count and some that are more recent additions to our ways of measuring inflammation.

That those levels predict the later onset of diseases like heart disease, Type 2 diabetes, Alzheimer’s disease and many of the common forms of cancer. And so in doing the study with Dr. Volek and Forsythe, we actually measured every biomarker we could think of and we came up with 14 different biomarkers of inflammation.

And when we compared them for the people in the high carb diet versus people adapted to the low carb high fat diet, none of the levels of inflammation went down more in the people who were on the high carb low fat diet. In contrast, 7 of those 14 were significantly reduced for the people on the well-formulated ketogenic diet.

That is on average there was a marked reduction in inflammation with the ketogenic diet, indicating that this has a wide-ranging antiinflammatory effect. Now, up until recently, that’s been what we scientists call a phenomenon. We see it’s happening but we don’t know why. And it turns out that there is a particular gene, it’s kind of like a traffic cop gene, it regulates the flow of traffic around inflammation. And this gene is targeted directly by the ketone that we have circulating.


A primary ketone in our blood which is called β-hydroxybutyrate, or BHB. And this is a place where ketones talk to your genes and your genes turn down the heat, if you will, through a regulated series of events to reduce inflammation of the body and that has the likelihood of having very positive effects not just on reducing insulin resistance but also reducing other common chronic diseases, as well. Now we not only know that the inflammation goes down, but we know why it goes down and why it is so effective and even modest levels of ketones, the levels that you achieve just by restricting carbohydrates to less than 5% of total calories and keeping protein moderate.

We’re doing a study with Indiana University Health where we recruited over 260 people with Type 2 diabetes and put them on a well-formulated ketogenic diet.

This study will be going on for two years, but I want to show you just the early data from the first 10 weeks of the study. All these people had the diagnosis of Type 2 diabetes. Some were poorly controlled, some were pretty well controlled, some were very tightly controlled. So we divided the biomarker of diabetes control called hemoglobin A1c or HBA1c into high levels, intermediate levels and well controlled levels.

And in all three cases, after 10 weeks, there was a reduction in the level of hemoglobin A1c and this effect was greatest in the people who had the highest levels. So people who had the poorest control of their diabetes got the greatest effect, but all three groups had an effect. And the result was that over half of these people moved from having hemoglobin A1c levels in the diabetes range into the non-diabetes range. What’s really intriguing is normally in medical care diabetes, you get better glucose control by giving people more drugs. In this case, we took away most of the drugs from five of the seven classes of diabetes medications.

And the two most dangerous which are insulin and sulfonylurea, those are the two classes of drugs that are most likely to cause hypoglycemia which is probably the most threatening side effect, short-term side effect of in diabetes management that we either stopped or markedly reduced the majority of those medicines in these patients. And so here, again, we have the paradox, less medication, better control. And the reason we can get better control with less medication is β-hydroxybutyrate in ketones, in general, speak to the genes and change fundamentally how the body functions, including changing how the body responds to insulin so the body can get much greater benefit from far less insulin.

And then as a side effect of this, again, we told people to eat to satiety. It limited carbs, protein in moderation, as much fat as they needed, and again, they can put butter on their meat, they can put butter or dressing on their vegetables and dip with vegetables, things like that.

And so they were eating to satiety, and yet 75% of these patients lost more than 5% of their body weight. And on average, the body weight loss was a little bit over 7%. And that was just in the first 10 weeks. At six months in this cohort, the weight loss went from 7% to 12%. So this is not a short-term quick loss and then regain, but it appears to be a sustained long-term effect.

Because, again, people who are six months into our study are doing the same thing we told them to do at the onset and that is limit carbohydrate, protein in moderation, eat fat to satiety and that gives the body permission to burn a lot of body fat stores because the body has become so efficient in burning fat for fuel. Just to mention other conditions that we’ve seen that show improvement with the ketogenic diet, just general muscle and joint aches and pains.

Irritable bowel syndrome typically gets better. Polycystic ovary syndrome in women. People with migraine headaches mention that either their frequency is down, the intensity is down and some people get complete remission of their migraines when they get the ketogenic diet right.

As we showed from the study of Dr. Forsythe, metabolic syndrome or prediabetes has improved along with that liver fat levels go down which is a side effect of poorly controlled diabetes. And we see improvements in fluid retention and blood pressure, as well. This is a very powerful tool. It can have very beneficial effects on a number of chronic conditions, but when a person’s taking medicines for these chronic conditions, those beneficial effects usually mandate a sharp and rapid reduction in medication.

And that can be dangerous, unless you have the assistance of a physician who understands this type of diet and understands how to manage the medications. This cannot be done in a casual way, you can’t start a diet and go back and see your physician six weeks later and say, “So what do you think I should do with my diabetes medication?” Because typically we have most of the changes in the first six days when people get the diet right. The concern is finding a doctor who understands this and that is sometimes difficult, but we see increasing interest in physicians, so if you look carefully, you can probably find someone who can help you, if you need that kind of assistance when you’re following this type of regimen. So again, for our conclusion a well formulated diet is not only safe but it can be very effective in reversing disease.

These effects are so powerful. However, this has to be started with careful monitoring. Stated in this directly, you have to find a physician who can help you manage your medications in the proper way that this be done where the benefits far outweigh any potential risks involving changes in medication use..

Read More: Dr. Stephen Phinney on Nutritional Ketosis and Ketogenic Diets (Part 1)

Dr. Stephen Phinney on Nutritional Ketosis and Ketogenic Diets (Part 1)

– Hi, I’m Steve Phinney, and I am the chief medical officer of Virta Health. This is going to be the first of four talks I’m gonna be presenting on ketogenic diets and how they are effective and safe in treatment of various conditions. This first talk will be an introduction to nutritional ketosis. What led me to this field to begin with was that I’m a recreational cyclist. I like riding a bicycle long distances.

I’ve been doing it for over 50 years. And very early on I discovered that if when riding a bike for more than an hour or two if I didn’t eat when riding I would hit the wall, which is what happens when the body runs out of carbohydrates when it’s carbohydrate-dependent.

And you feel really lousy, and your performance drops. So I very quickly became a carbohydrate advocate. Interestingly, at this time 40 or so years ago was when the Atkins diet first became popular.

And Atkins said, you know, you don’t need carbs to feel well and function well. Well, I was a newly minted young doctor, and I was feeling my oats. And I was set out to prove Bob Atkins wrong.

And, guess what, proved myself wrong. Now, actually, it wasn’t quite that simple because if you go on a ketogenic diet for a week, or two weeks, your performance does drop.

My experience had been only in short-term restrictions in carbs. So we did a study that lasted six weeks, and by the third week of the six week study people’s performance was coming back up. And by 6 to 12 weeks their performance was back to or above where they’ve started. The body becomes capable of burning almost all of its energy from fat. In my research I actually make a habit, sometimes successfully, of trying to prove myself wrong.

And you say wait a minute, why wouldn’t you try to prove yourself right? If you prove yourself wrong that’s how medical advances are made. If you assume that something’s right, and you find out it’s wrong, you can now change your understanding and change medical knowledge.

And that’s something that I, and my co-founder and collaborator in this, Dr. Jeff Volek, have made a habit of doing over the past multiple decades.

In this process back in 1980 I coined a term nutritional ketosis, and another term, keto-adaptation. The first thing you have to consider when listening to someone talk about nutritional ketosis or ketogenic diets is, how can you trust what they are saying? The reason is that they are a lot of self-appointed experts out there, but very few people in the medical arena have much training in nutrition. And most of them have absolutely no training or research experience in nutritional ketosis. That is most people get their expertise by reading what other people have done.

Now, why should you trust me? I mean, I’m an MD, and I can tell you I had no training in nutrition in medical school back when I went through that process. But after I completed my medical education curiosity drove me back to school, and I spent four years doing a PhD in nutritional biochemistry because I realized there were a bunch of paradoxes between what I was taught to believe and what the evidence seemed to present.

After completing that, my PhD, I went on to do two years of formal training in clinical nutrition. Since then I published 80 papers, I’ve co-authored three books.

I’ve been studying and prescribing ketogenic diets for 40 years. The first point I want to make is that nutritional ketosis is a very powerful tool when properly done, but it’s not simple. It’s not just a matter of cutting out carbs. And the other point is that particularly in people that have medical conditions, it’s not always safe. So my goal in presenting this information to you is to share the power of nutritional ketosis, share the fact that it can reverse, and, or prevent very significant medical diseases.

Oftentimes taking away the medications that are currently being used for those conditions. With this power comes risk, particularly as it relates to having being on medication because if you’ve reversed the disease, and you don’t take away the medication, you can have major side effects.

The other important point is that this is much more complex than just taking away sugars, bread, rice, pasta, potatoes, and other things. For a ketogenic diet to be safe, it has to be much more scripted than that. Getting the diet right in terms of the other nutrients in the diet is pretty complex.

And it’s not something that a simple slide, or even this simple talk is gonna be adequate in order to do it safely. The other important point is there are some medical conditions where people should not do this type of diet. And I’ll mention those briefly in this talk, and more completely in later talks. Let’s discuss what’s a ketone. It turns out that there are two compounds that the body makes from fat.

And the body, meaning the liver, makes two compounds from fat which are classified as, and I put this in air quotes, ketones. Now, I won’t get into the details of the technicalities of that.

Now, these can either be made from body fat, that is fat we’ve eaten before and stored, or fat that we eat, and that circulates through the blood after digestion. Fats that are eaten or stored when they circulate through the blood are difficult to transport. They’re in what are called lipoprotein particles.

And these are the things that you were measuring when we measure cholesterol, and triglycerides, and things like that. And because doctors worry about these things you might imagine that having too much of them is a problem. Well, it turns out that when fats in the liver are made into ketones you no longer have to worry about lipoproteins because these are water-soluble particles, and they float through the blood.

They move into cells easily, so it’s a much more efficient fuel for the body to use. Once it’s in the bloodstream in adequate levels it can feed the brain, it can feed your heart, and it can feed your muscles.

And as we’ll mention in a few minutes it can do other important things as well. Now, how do we know it can feed the brain? Well, there are actually some, let’s say dangerous experiments done back in the 1960’s where patients who’d been fasting for weeks, so they had quite high ketone levels, were then infused with insulin, which drove the blood sugar down to an extremely low level, to the point where it should cause people to pass out. And as long as there were ketones in the blood the brain functioned just fine. So we know that ketones are a very efficient and effective brain fuel.

We’ve discovered in the last five years that ketones are a very potent signal that talks to our genes. And some of the genes it’s talked to are the genes that protect us from things that we call oxidative stress, or free radicals.

And this is really important because these are the root causes of a number of diseases, including type 2 diabetes, heart disease, inflammatory bowel disease, high blood pressure. Also, people with seizures oftentimes have dramatic results when they get in a well-formulated ketogenic diet. And it’s not so much about fuel as it is about reducing oxidative stress and inflammation.

This is a very, very important topic in terms of understanding how ketogenic diets can be used to markedly improve some chronic diseases.

We understand not just what they do, but how they do it at the molecular level. And this is important in terms of moving this field forwards, and making optimum use of this state we call nutritional ketosis. Where did nutritional ketosis come from, and why did we have to define that as a term? Over a century ago doctors figured out that when people with what’s called type 1 diabetes, the diabetes typically of younger folks where the pancreas stops making any insulin at all, they can’t use glucose at all for fuel, and the body overproduces ketones.

The ketones build up to very high levels, and that’s called ketoacidosis. When ketones build to very high levels you can actually smell them on a person. It’s like a (sniffs) smell that these ketones, then say, ah, you know, this is uncontrolled diabetes. And they realize that that changes the acid levels in the blood, and that’s ketoacidosis. But these are vastly elevated levels of ketones.

So figure let’s say a number of 20 would be a extremely high level of ketones.

But if you’re eating a well-formulated ketogenic diet your blood levels are not 20, your blood levels will be in a range of .5 to 3. So it’s one-tenth that very high level. Yet if you eat say orange juice and bagel for breakfast, after breakfast your ketone levels will not be .

5 to 3, they’ll be .1 or .2. So one-tenth, 10 times higher is nutritional ketosis. 10 times higher to that is ketoacidosis.

So we define this state of nutritional ketosis as being a safe blood level where ketones function to feed vital organs in the body when you’re not eating a whole lot of carbohydrate.

You can see that in the green zone between .5, and 3, or 4, that’s what we call the optimum ketone zone. That’s when ketones have beneficial effects in terms of feeding the brain and other organs in the body. And as you can see, if you were in total starvation, which we don’t recommend because of negative effects on lean tissue and organ function, total starvation ketones will go up as high as seven.

And you don’t get anywhere near the risk of ketoacidosis until the numbers are above 10. These are very distinct states differentiating nutritional ketosis from diabetic ketoacidosis. So by 1970 all of this stuff was well-defined, and has been in the medical literature. And we kind of assumed that, you know, if we can just tell people that ketones are good for heart, and muscle, and brain that that would be a good thing. But really exciting things have happened in the last five years.

The reason we know that this is not a rumor, word of mouth, there were some very solid scientific papers in the medical literature now indicating not just that, gee, looks like inflammation goes down, we actually know precisely how.

The beta hydroxybutyrate, this primary ketone we have in our blood, makes inflammation and oxidative stress go down, and provides optimized control for some inflammatory diseases. Let’s kind of get to a little bit more practical information. How does one get into nutritional ketosis? People who have reason to want to have benefit if they have type 2 diabetes, or they’re severely overweight, or have hypertension, very often those people have what we call insulin resistance.

That is their body has begun to lose its responsiveness to this hormone, insulin, which is the hormone that causes blood sugar to go into cells, and also manages body fat metabolism. So if you’re insulin-resistant you probably have to get your daily total carbohydrate intake down somewhere between 20 and 50 grams of carbohydrate per day. If you want to think about that in terms of macronutrients that’s less than 10%, and oftentimes less than 5% of your total daily energy intake comes from carbs. So that’s very carb-restricted. And the more insulin-resistant the person is the lower they have to go to initially get into a state of nutritional ketosis.

In addition to restricting carbs, this is not a high protein diet. Protein, like carbohydrates, stimulates insulin production, and exacerbates insulin resistance. So it has to be moderate in protein, enough protein to maintain healthy function of our organs, but not so much that it raises insulin levels. Then the other key point of a well-formulated ketogenic diet is this is not a calorie-restricted, stop eating when you eat x-number of calories per day. This is a diet when is done right is eaten to satiety.

That is when you finish a meal you should be satiated, and you shouldn’t be hungry until it’s time for your next meal. And the way you do that if you’re eating very little carbohydrate and moderate protein is the majority of your dietary calories have to come from fat. And we’ll come back to the safety issues around, is it okay to eat that much fat if it’s more than half my calories? And the answer is yes, and hopefully I can convince you of that later on.

The other thing that is very important in a well-formulated ketogenic diet is getting enough vegetables, provide enough minerals, maybe fiber to provide satiety.

Rather than coming from pills it should come from fresh real food. So we suggest three to five servings of non-starchy vegetables per day. Now, realize this is just an overview, it’s not a prescription. Don’t just say, okay, I know how to do it, I’m gonna go do it. So this is something where you need to understand the serving sizes, that we adjust the protein to the size and gender.

So a small woman’s gonna need less protein than a very tall guy. There are variations in this that require individualization. So this is not a cookie cutter or one size fits all diet. I want to point out that there are lots of low carbohydrate diet strategies out there, but not all of them are either ketogenic or involve keto-adaptation.

For instance, a paleo diet, or a primal diet, or a low carbohydrate, Mediterranean, and certainly not intermittent fasting.

Those do not allow for keto-adaptation. Either they’re not sustained enough or they have too much protein. So if you look at this slide here where on the vertical access it’s the amount of carbohydrates this percent per day, and the horizontal is protein. You can see that the standard American diet, I think SAD, you know, sad is a good term for that, which is high in carbohydrate, moderate in protein, and relatively low in fat, is way above the low carbohydrate level.

If you cut some carbs out of the diet, and add more fat, that would be a Mediterranean diet, but it’s still not low carb.

But as a general rule most people in the nutrition field will call anything under 30% of calories as carbohydrate, a low carb diet. So a paleo diet typically is about 30% protein, about 20 to 30% carbohydrate, and only 50% or less fat. So it’s not that high in fat. But the combination of the carbohydrate and protein are enough that it prevents the body from making ketones. So that doesn’t fall into the ketogenic diet range.

So you can see that to get to a well-formulated ketogenic diet it’s kind of a small island of keeping protein in moderation between roughly 10 to 20%, keeping carbohydrates under 10%.

So if you’re 20% protein and 10% carbs, and you’re holding your weight stable, that is after a period of time, you’re in weight maintenance, that means that 70% of your energy has to come from fat. That can be pretty scary, but that’s how one does a ketogenic diet. And that can be done not just for weeks or months, that can be done for years and decades. And the best way to measure it is to, you know, be tough, prick your finger like people with type 2 diabetes, or diabetes to measure blood sugar.

And there are special strips for ketone meters that can actually measure your blood ketones, and they’re very accurate. And you don’t need to do that forever, you need to do that long enough just to know what level you get to if you’re eating a certain range of foods. One of the keys to success here is you have to be sure that this is safe. If you do this, and do it in a way that’s not safe, then you’re not gonna be successful.

You’re either not gonna feel well, or it’s gonna make you ill, or actually carry significant risk.

So as a general rule, even if you’re otherwise healthy, and you just want to lose some weight, or improve your energy level, you should let your doctor know what you’re doing. If you have type 1 diabetes, which is a case where the body is not able to make enough insulin, you’ll need specialized medical support. There are some people who advocate using this type of diet with type 1 diabetes. But it takes a specially trained physician who knows how to do this to guide you. And this is something that has to be done with very close supervision.

The same is true with type 2 diabetes, but oftentimes with type 2 diabetes we can get people off of some, or most of their medications. And, again, that has to be done by a physician, but then the supervision doesn’t have to be quite so close because you’re no longer taking the medications that carry risk. The third situation where you would need careful medical support, and have your doctor be directly involved in what you’re doing, is if you have high blood pressure and you’re on medication.

Because, again, oftentimes we need to withdraw those medications. If you have a heart condition, or if you have significant liver or kidney disease that needs to have careful evaluation to see if you have enough function of those organs in order to be able to manage the adaptation of this diet successfully.

Most doctors aren’t taught how to do this. Some of them will read books, hopefully our books, and understand how to do it. But beware of physicians who don’t have the experience in doing this. The final point about safety is this is not, as I said, not just about restricting carbs, and keeping protein moderate, but getting adequate minerals. The important minerals include sodium.

If you don’t have enough salt, or sodium, in your diet you’ll have a bunch of symptoms, which include lightheadedness, dizziness, fatigue when exercising, and constipation.

Those are not side effects of nutritional ketosis. Those are side effects of not having enough salt. It just so happens that when you’re in nutritional ketosis your kidneys get much more efficient at getting rid of salt. And you have to provide it on a routine basis in order to maintain your well-being and function on this type of lifestyle.

An additional mineral that’s very important, particularly for heart and muscle function, is potassium. And you get that from broth, you get that from vegetables, and you get that from eating unprocessed meats.

We don’t normally have to supplement that. If you get the vegetables, meat, and hopefully make your own homemade broth in order to maintain adequate potassium intake. A third mineral we deal with a lot, particularly in people with diabetes is magnesium.

This is a mineral that most Americans don’t get enough of. And it seems that people with diabetes have a significant problem maintaining adequate amounts. A major sign of magnesium depletion or deficiency is muscle cramps, whether after exercise or occurring at night.

And that’s easily managed if someone is knowledgeable on how to replace magnesium. But don’t just accept cramps as a necessary effect of this.

That’s easily managed by someone who knows how to do this. Other minerals include calcium, which is necessary for bones, and nerve, and muscle function. That’s maintained by adequate vegetables, dairy, and cheese, also, from homemade broth. We rarely have to supplement calcium people when they have the normal food intake that’s appropriate for a well-formulated diet. And vitamins are sometimes a concern because people say, well, I’m not eating fruit, or I’m not eating enough fruit, and where are my vitamins gonna come from.

It turns out that vegetables are an excellent source of the vitamins that you would normally attribute to fruit.

So we find that people don’t need additional vitamins with this. But if one wants to take a standard multivitamin it’ll do no harm, but probably not necessary. To wrap up, a well-formulated ketogenic diet and nutritional ketosis is a healthy normal metabolic state. This is not something that is abnormal.

This is not something that you should only do for a week or two at a time because longer is unsafe. No, this is something one can do for months, years, and decades. It’s achieved by reducing sugar, and refined carbohydrates, and most starchy foods. But in the meantime you’re eating real foods, and plenty of foods, and eating those foods to satiety. This is as I mentioned a very effective disease reversing way of living.

And if you have diseases that can be reversed with this you need medical supervision, particularly if you’re taking medications for those diseases. Because the good news is you have to take them away. The bad news is if you don’t take them away it can have serious side effects.

So it has to be monitored by a knowledgeable physician. To do this right it results in improved well-being and function.

And the neat thing is this is not a calorie-restricted approach. You don’t have to go away from the table hungry, and you don’t have to count calories. You let your natural instincts empower you to succeed when you do a well-formulated ketogenic diet. This is a graphic that we use when we try to explain to doctors all the emerging things that happen when one goes into nutritional ketosis. Across the top on the left-hand side are fat cells where we store energy.

That energy can be released by the fat cells, circulate through the blood, get taken up by the liver. Made into ketones, and the ketones feed the brain.

We didn’t put the heart on there. The other interesting thing, it appears to feed the digestive system, which is intriguing, and reduces inflammation. And that appears to be why inflammatory bowel disease oftentimes gets better on a well-formulated ketogenic diet.

Clearly, ketones and fats can feed the muscles. But it also reduces inflammation, including many people with asthma notice that their symptoms get better. There’s emerging science, not on people, but in little worms grown in test tubes, and in mice grown in cages, that a well-formulated ketogenic diet actually improves longevity by reducing oxidative stress. Then, many athletes now, particularly endurance athletes who go beyond marathon distances, like triathlons, or longer distance running, and more extreme duration sports, they’re turning to a ketogenic diet because the body can run mostly on fat. Then the person doesn’t run out of energy and doesn’t hit the wall.

So, again, this has a multitude of effects, many of them beneficial. But I want to get across the idea it always has to be done with adequate information and adequate supervision to be safe.

Thank you..

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