The Dr. Hyman Show - Is It Possible To Be Vegan-Keto? with Dr. Ethan Weiss and Dr. Carrie Diulus

Episode Date: January 22, 2020

Despite what conventional medicine has told us, type 1 diabetes is not a sentence for a heavy reliance on insulin. For many people, a diet that carefully monitors carb intake can dramatically reduce blood sugar swings and reduce the amount of insulin needed.  Keto (or the ketogenic diet) has gotten a lot of buzz lately, and this fat-heavy very low-carb approach to eating is showing some promise for diabetics and many other metabolic diseases as well. With that being said, there is no perfect diet for everyone, and each person needs to find what works best for them. One of my guests on this week’s Doctor’s Farmacy podcast, Dr. Carrie Diulus, has found vegan keto is the best approach for managing her type 1 diabetes and maintaining a healthy weight. We’re also joined by Dr. Ethan Weiss, who’s been steadily in ketosis for about 2 years using a plant-heavy, mostly pescatarian keto approach. This episode is brought to you by Thrive Market and SomniFix.  Thrive Market has made it so easy for me to stay healthy, even with my intense travel schedule. Not only does Thrive offer 25 to 50% off all of my favorite brands, but they also give back. For every membership purchased, they give a membership to a family in need, and they make it easy to find the right membership for you and your family. You can choose from 1-month, 3-month, or 12-month plans. And right now, Thrive is offering all Doctor's Farmacy listeners a great deal, you’ll get up to $20 in shopping credit when you sign up, to spend on all your own favorite natural food, body, and household items. And any time you spend more than $49 you’ll get free carbon-neutral shipping. All you have to do is head over to thrivemarket.com/Hyman. Most of us aren’t getting our best rest. But there is actually a proven solution I’ve found for getting high-quality rest, simply by helping you breathe through your nose instead of your mouth. They’re called SomniFix Strips. Breathing through your nose has so many benefits—it protects against mouth dryness and nasal congestion, boosts oxygen saturation for enhanced focus, and helps naturally produce nitric oxide that kills bacteria and supports immunity. SomniFix is now offering all Doctor’s Farmacy listeners 20% off of your order. Just go to somnifix.com, and use the code HYMAN20 at checkout. Here are more of the details from our interview: -How Dr. Diulu became vegan keto (9:13) -The evolution in thinking about heart disease and heart-healthy diets (22:26) -The idea of “the best diet” (26:36) -Saturated vs unsaturated fats and the ketogenic diet (32:38) -Why fiber is a significant factor and calories still matter with the ketogenic diet (43:58) -Do you need to go in and out of ketosis and can you achieve longevity through diet? (50:55) -Sarcopenia of aging and eating for mobility as you age (1:00:53) -The benefits of testing blood insulin levels (1:12:37) -What you need to know if you want to try keto (1:20:15) -What a typical day of eating looks like for Dr. Diulu and Dr. Weiss (1:31:03) -Learn more about Keyto, which aims to make the ketogenic diet more accessible through a breath meter device and phone app at www.getketyo.com

Coming up on this week's episode of The Doctor's Pharmacy. Whatever diet we need to get you on so that you feel good, so that you're able to go out and be active and live an active life, is the ideal diet for you. Hey everybody, it's Dr. Mark Hyman. Seems like every week there's a new superfood on the market, and then it kind of fades away. But there's one that isn't going to fade away,

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We experienced some audio issues in the first one minute of the episode. It quickly resolves and shouldn't interfere with your listening. Thanks for tuning in. Welcome to Doctors Pharmacy. I'm Dr. Mark Hyman, and that's Pharmacy with an F, F-A-R-M-A-C-Y, a place for conversations that matter. And if you've heard about ketogenic diets and intermittent fasting and the benefits or the harms, this conversation is going to matter to you because it's with two of the most informed, intelligent, and articulate people on this subject, which is a very slippery subject for many people.

Our first guest is Carrie Douglas. She's an orthopedic spine surgeon. She's a good friend of mine. She's helped me with my back and many of my friends with their backs. She's the vice chief of the medical staff and director of the Spine Wellness Center at the Crystal Clinic in Akron, Ohio. And she was a spine surgeon at the Center for Spine Health at Cleveland Clinic for many years and medical director of their IT department. So not only is she good with body, she's good with computers. She's got an RMD from Northeast Ohio Medical University and did pathology residency. She was also on the U.S. national team for the duathlon and competed in the world championships.

Quite a lady. I could go on and on. Yeah, yeah. One of the most interesting things about Carrie is that she developed type 1 diabetes, actually, since I met her. And we worked together early on in it. And she's one of the few diabetics I know who's type 1, who uses very, very little insulin, almost no insulin, really. And it's pretty impressive. And we'll talk about how and why that is and what she's discovered about her own body and what it means for the treatment of diabetes in general and type 1 diabetes.

Our next guest is Dr. Ethan Weiss, who's an associate professor of medicine at the University of California San Francisco a principal investigator in the cardiovascular research Institute He's got his MD from Johns Hopkins School of Medicine where he also complete his internship and residency and complete his cardiology training at UCSF So he's a cardiologist focused on prevention lipids and the emerging intersection of endocrinology and cardiology with a specific focus on pre-diabetes And type 2 diabetes, which I call a diabesity Which are main risk factors for heart disease and how to treat those with diet. In fact, how to treat those with extremely high fat diets, which seems like a crazy thing for a cardiologist to be recommending, but it's true. And his research is really focused on why that works, looking at the mechanisms of how we gain weight and obesity, fatty liver and diabetes. And I think what's increasingly clear in cardiology is that it's not just about plumbing.

It's about the immune system. It's about the hormone system and the endocrine system. He has an active program in clinical nutrition, exploring things like time-restricted eating, which many people refer to as intermittent fasting, although that's something else. He's the principal investigator on grants funded by the National Heart, Lung, and Blood Institute and the National Institute of Diabetes. And he serves on many scientific advisory boards. And he's a co-founder of an incredible new company called Keto, K-E-Y-T-O, which is based in San Francisco. It helps people use heart-healthy ketogenic diets

for weight loss. So a heart-healthy diet at 70% in fat and saturated fat doesn't seem like healthy for most of us who grew up in the 80s and 90s when fat was the enemy number one. But welcome, Kerry, and welcome, Ethan. Thanks, Mark. Thanks, Mark. Okay, so let's get right into it. Everybody hears in the news ketogenic, ketogenic, hottest new diet trend. You know, I wrote my book, Eat Fat, Get Thin, a few years ago before that hit, but I could

see it coming and went into the science of why our thinking about fat is pretty wrong and why our guidelines for eating lots of carbohydrates and very low fat diets led to a massive epidemic of obesity and diabetes. And what's been fascinating over the last few years is to watch how science is shifting and actually opening up the doors to understanding how to shift metabolism through using different types of eating patterns, whether it's time-restricted eating or different days of fasting or diets that mimic fasting, like low-calorie diets or even ketogenic diets, which sort of mimics fasting.

It's what it does to the body. So let's start with you, Carrie. You are a type 1 diabetic. True. You certainly don't identify as a sick person with an illness. You actually are, like I would say, an Olympic kind of. No, no, you didn't let me finish. You're sort of an Olympic biohacker who has jerry rigged her blood sugar monitor so she can adjust her insulin and regulate her sugars and knows exactly what's happening every minute in her body and has been her own guinea pig in terms of diet and had an incident where she had to switch her diet to not just being a keto diet that was including animals,

but one that was vegan, which most people are sort of sort of perplexed at because you know we think keto is bacon and cheese and butter and coconut oil and and that you know doesn't have to be including animal products so tell us about how you kind of came to realize you should be as a type 1 diabetic not eating a lot of carbs and eating a ton of fat and actually how you switch to then be a vegan keto, which most people don't even think is a thing. Is a thing. Yeah. So it is a thing. I have a plant-based bend in that when I was 12, I first

gave up meat just because I didn't really like it. And I have a lot of obesity in my family and it seemed like the thing to do at the time there was the Pritikin diet and so you know over the years i was mostly plant-based throughout that and i struggled you know with my weight at varying times and so that's putting it mildly you were a hundred pounds more than i was if you see her on the video you'll see she's a petite little lady who was 100 pounds yeah more it's true and then i lost it i mean i lost in the traditional ways of like calorie see she's a petite little lady who was 100 pounds more. True. And then I lost it. I mean, I lost it in the traditional ways of like calorie restricting and exercising a lot.

And that's when I got into doing all of the multi-sport stuff and competing. And, you know, as I got into my 30s, it was sort of harder to keep weight off. And I struggled with some of the things with the plant-based diet. And, you know, I went to the gurus of it and many of them said, well, you're doing it wrong or you're, you know, eating too much. And at that point I felt like I could win a, you know, Olympic medal in calorie counting and it just wasn't working. And so at that point I sort of shifted to... So you were in a low calorie vegetarian diet and still not losing weight and i was yeah i gained weight very very easily um and so it was you know it was just not working well and

i ended up shifting at that point to i had gained weight with each of my pregnancies and i was trying to lose that weight and i ended up shifting to a very low carbohydrate diet. At the time there was sort of the South Beach thing, but really it was low carb and I was getting into ketosis, most likely looking back on what I was doing at the time. Was this before you got diabetes? This was before. And then I sort of shifted back to plant

based for a while um and had done some different things with really whole food plant-based a lot of greens and things like that and it worked well and i was out actually you know speaking in the orthopedic and surgical community about how we modify patients metabolic risk factors you, you know, when they're orthopedic patients to impact surgical outcomes in their musculoskeletal health. And I went for... Meaning if they're overweight and sick, they do better if they get their metabolism fixed. Right, right. We get better surgical outcomes. And I went for an executive physical and my A1C was elevated. And I was like, no, that's... That's your average blood sugar. Average blood sugar, yeah.

And I was like, no, that's not a thing. And so I had some room that I could clean up some things in my diet and focus on stress and sleep and all those things. And you weren't eating bags of chips or cookies. I was not. No. I was not. And so then I ended up going, you know, trying to control my blood sugars.

I got a glucose monitor, and I started paying attention, trying to control my blood sugars. I got a glucose monitor and I started paying attention to what spiked my blood sugars. And I slowly started working on, okay, well, I can't eat that or my blood sugar goes up really high. And at that point, they sort of thought I was going to be type two, which didn't really make sense. I don't have a family history, despite the obesity history, but I do have a family history of type one on my mom's side. And long story short, I, you know, was really super low carb and was able to stay off insulin for a while. And then I got sick and it became clear that it was type one diabetes at that point. And that's when I went on insulin. And initially I did the things that you're told to do when you go on insulin, which

is you have to eat a certain number of carbs per meal so that you can dose insulin. And I gained 15 pounds almost immediately doing that. Well, insulin makes you gain weight. That's what its job is, partly. It does. And if I want to gain 10 pounds, I just do any of the behaviors. You just look at a bagel. I look at a bagel and take insulin.

But even stress will do it. I mean, that's, you know, lack of sleep, stress, anything that increases my need for insulin will lead to increased weight for me. So I shifted back to low carb at that point because I was like, I can't figure out. I have, you know, a degree in biochemistry and I can't figure out how much insulin to give for an apple, not to, my blood sugars throughout the day were anywhere between 440

and it was not sustainable as a surgeon. 40 and 400, you mean? Right, yeah. I mean, I would bounce between the two of them, which is, it was a rollercoaster and it was miserable and it felt awful. And so I was chasing blood sugars around. So I just said, I'm just gonna stop eating carbs

and go back to what I was doing before because that seemed to make the most sense and there's not a lot of guidelines out there Dr. Bernstein has written a book and there's you know since found that there's this whole community of people who are type ones who are eating very low carbohydrate diets using very small insulin doses when you use very small insulin doses you have less room for error. So you don't have the big peaks and valleys like you would with your blood sugar if you're eating carbohydrates where you're trying to guess when it's going to absorb and how high your blood sugar is going to go.

And then I got, there was, you know, another several years into it, a bad virus going around and I ended up having some issues where with my stomach and I wasn't able to eat normally for a while and had to sort of get back into where I was adding foods back in. And I just really didn't tolerate meat. Well, you had a hard time digesting it. I couldn't digest it. So then you went vegan keto, which people don't think is a thing. Don't think it's a thing. So what is vegan keto?

Yeah, so what is it? You know, initially I was doing protein powders and things like that because that's what I could get down. But now it's been several years now and it's blossomed into, you know, I eat a lot of the same things that people on a ketogenic diet eat in the sense of the macros and the vegetables. So lots of non-starchy vegetables, broccoli, asparagus, Brussels sprouts, kale, cauliflower. All of those with healthy fats like avocado, olives, olive oil, nuts and seeds.

And then the protein sources are things like edamame, tofu, black soybeans, lupini beans, hemp seeds are a great source of protein. And you can make a ton of really delicious things that way. And I did it thinking, all right, I'm going to do this for a little while. Not only is she an orthopedic surgeon, she's a biohacker, but she's a great chef and makes the most amazing keto foods. So I did it for a while and a bunch of lab markers that, you know, are inflammatory markers and things like that got better that I'd been struggling to

bring down. So my high sensitivity CRP, which is a marker of inflammation improved, my lipid profile improved. So I've been sort of riding it at this point where I've said, you know, I will keep doing plant-based low carb until I run into a reason to consider it. And I may, I mean, four minutes from now, I may add fish back if there's reason that I, you know, want to add fish back. And you supplement with things like fish oil and B12 and algae oil for the omega threes in the sense of, I mean, anybody, a lot of people need to supplement with B12, but anybody who's fully plant-based needs to supplement with B12. Yeah. You can't just get it by eating the dirt on your vegetables, like they say in Game Changers.

I'm the only one who hasn't seen it. What? I must be the only one who hasn't seen it. You haven't seen it? Well, for those that are listening who don't know what that is, that's a new movie by James Cameron called Game Changers about the benefits of a vegan diet, which has a lot of valid points, but also a lot of sort of half-truths and science misrepresentation, which you can listen to on Chris Kresser and Joe Rogan's podcast, where he discusses for three hours the challenges of the movie. So just to put that out there. I haven't listened to that either. What?

Joe Rogan's like the number one podcaster. No, I know. I know Joe. So that's amazing, Carrie. And your blood sugars have been great. Your A1c is the average blood sugar is better than most people who don't have diabetes. Yeah, I range from 4.8 to 5.3. Yeah.

And to put it in perspective, most people run around 5.5. Six plus more diabetes So you're you're doing better than most people who don't have diabetes How much insulin you use a day? I mean it depends on what I'm doing. I run a lot and so that impacts how much insulin I use It can vary anywhere from eight to twelve units per day Unless I eat carbs, you know, and that can raise it up. Um, stress will raise it up. I mean, if I'm sick, I may use 35, 40, 50 units. So some, most, most type one or type two diabetics were using insulin use 30, 40, 50, a hundred units

who are diabetic type one or type two. And, and it, and it's usually at least 20 is sort of the baseline amount that most people need a day. And you're doing half that and keeping your blood sugars better than average or better than normal. So that's because you're not eating a lot of the starch and carbs. It's just easier. And when your blood sugars do get high, high blood sugar tends to beget high blood sugar. So you tend to be more insulin resistant, the higher your blood sugar is. So by keeping it in a very low range with very low glucose excursion, so the ups and the downs makes it easier to manage it. And then there's much less worry about a low blood sugar. You know, I've, I can say I've never had a low blood sugar at a time when,

you know, it's critical, like in the operating room. Yeah. Which is amazing because you're, you think, you know, your blood sugars go up and down and your risk of low blood sugar, the being a diabetic, but by eating the fat, it actually normalizes your blood sugar. Right. And by keeping the insulin doses very low. Amazing. Okay. Well, let's get back to you in a minute, but I want to talk to Dr. Weiss for a minute. You grew up in a hospital. Your dad was a cardiologist. You, you know, had a lot of experience seeing heart patients. Um, and you, you know, went to the same path as your dad. You, you had a series of patients in their late thirties and early forties who had heart attacks, uh, and then really didn't have the obvious risk factors. And, uh, and those

events seem to inspire you to to get into cardiology So what did what did you learn from those experiences? Well, I learned that you can't fight destiny I guess or that I'm just Not I don't have very much imagination or creativity. So You mean the destiny of your dad being a cardiologist I went to college intending to do anything but be a doctor and when I went to medical school You mean the destiny of your dad being a cardiologist? Not the destiny that you're going to have to get a heart attack. I went to college intending to do anything but be a doctor.

And when I went to medical school, I absolutely didn't even consider being a cardiologist. I thought I'd be a psychiatrist, actually. But yeah, I did a CCU rotation when I was a third-year medical student. And there were all these younger patients coming with heart attacks and not obvious risk factors. And I thought that was interesting. And so that sort of spurred my interest in trying to understand some of the mechanisms behind cardiovascular disease, especially these events in younger people. And I went and worked on thrombosis, on blood clotting. And I did that for the better part of the next 10 or 15 years, trying to understand sort of what was different about.

So if you think about the plaque inside of a coronary artery, as I tell my patients, it's like a pimple. It's full of inflammatory cells. It's full of cholesterol and lipids and fats. But one of the things that happens when it breaks or open, when it ruptures is that it exposes blood to this substance or series of substances that signal an injury. And our response, our body's response to that is to try and wall that injury off. And so that's why we have this blood clotting

system. It senses an injury. It forms a blood clot. It happens to form a blood clot in the worst possible place, which is right in the middle of an artery inside your heart. And therefore it stops the blood flow beyond that. And so I wanted to understand sort of what was different about people's blood clotting system that might lead them to have these events at a young age and really actually didn't think about the part leading up to that rupture of the plaque i didn't really care at that time in my life i didn't care about things that caused development of plaque so i didn't care about this working downstream yeah i cared about the final event I thought well this is and the reason for that was that there were some old evidence from these pathologists I don't know if you

remember this British pathologist who was like my hero when I was a medical student Michael Davies oh yeah had done this series of autopsies and young people had had heart attacks and died suddenly and so he went and did this histological analysis and found that it looked like the plaques had ruptured in these people, not just that one time when they died, but had ruptured several times before on average, up to seven times. And so there was this idea that every plaque rupture did not result in a heart attack. And so that was sort of the question that I started my career thinking about was what's different about the one that does cause a heart attack than the previous

ones. And you know, that's a long history that continues today. So, so you got into cardiology and, you know, typical cardiology advice for years was to eat a low fat diet, uh, still sort of part of the recommendations of American Heart Association. It's kind of bizarre way. This sort of is, and it isn't, um, you know, are told to eat low cholesterol diets to cut out eggs, to, you know, eat lots of carbohydrates. And, you know, even in major heart hospitals, they're still giving post-heart attack patients and post-heart surgery patients a high carb, low fat diet, somehow translated, although the government has changed their recommendations around this. But you're kind of going to the other extreme now.

You're studying diets that are actually pretty high in fat as a way to treat metabolic disease. And, you know, for people who don't know, you know, I think it's important to explain, you know, the change in thinking from heart disease being a plumbing problem to being an inflammatory problem, metabolic problem that's driven by insulin resistance or prediabetes or blood sugar issues right so I think not all heart disease is that but it seems like the majority of current heart attacks and heart disease is because of that is that fair to say well I think it's fair to say that we understand and appreciate a lot of the

risk factors for coronary disease but we also don't understand all of them I think the focus in the 70s and 80s when I was growing up as a kid was on fat, uh, because of the known effects on diet on lipids. So when you eat a lot of fat, your blood cholesterol goes up. And that was something that had been recognized, you know, decades before. And so when I, as a kid, when I was growing up, curious, tired of hearing me talk about it, but like, we didn't have any fat in our house. We had, uh, we had, you know, no Fleischmann's margarine. No, no, no, no. And we had maybe margarine, but, we had, you know, no fleshman's margarine. No, no, no. And we had maybe about margarine, but like we had nothing that resembled fat, but because nutrition is truly a zero sum game, if you don't have one macronutrient, you have a lot of another. And because we all eat

a typical sort of normal amount of protein, we ate carbs. Like it was like literally candy. And so, I mean, I'd come home from school and like like I would eat through a bag of chips or Doritos or you know Skittles or whatever the heck it was and it was healthy. It was heart healthy. And so it took a little while I think for me it was Skittles are definitely a colorful plant-based diet. They are not the kind we talked about and that was you know ingrained I think culturally and and otherwise ingrained in all of us. I mean, particularly me growing up in the home, you know, with my dad as a cardiologist. So I didn't begin to think about the metabolic effects.

I do remember hearing about the Atkins diet in like the early 2000s and thinking, God, that's crazy. But it worked for people. Well, it did work for people in improving their metabolic health, but we didn't connect the, I mean, I don't think we did a good job, at least in cardiology, we didn't connect the relationship between metabolic health and sort of cardiovascular health until relatively recently. I think that's been.

And it's fascinating because, you know, the numbers that really go awry that predict heart disease, even the conventional biomarkers, it's not the total cholesterol. It's the total to HDL ratio. It's the triglyceride HDL ratio. And those are determined more by your blood sugar control and your insulin levels. And that's something people don't understand, I think. So people think about cholesterol, they just think about fat, but it's actually the sugar that makes your

body make more cholesterol. It's true to some extent. There's some strong component of genetics as well. But in terms of the things that you can control, and I always talk about this with people, with patients, it's what are the things that you can control and what are the things you can't control. In terms of the things that you can control, there are two levers you can pull on. One is the amount of carbohydrate and the other is the amount of fat and particularly saturated fat and i think that's sort of one of the things that's different in evolved in my in the recent past for me and thinking about the ketogenic diet is um considering sort of saturated fat which was when i first got into this was something i didn't know it was the enemy number one, right? Well, so

Yeah, so it was the enemy and then it wasn't the enemy and then now I'm not sure maybe it's In between yes, I think you're right because here's the deal, you know, everybody hears about the best diet There is no such thing. Yeah, there's the best diet for you Mm-hmm So some people like I've had patients who I put on a ketogenic diet, who've been resistant to weight loss, whose cholesterol is like 300 and their triglycerides are 300 and their HDL is very low. Uh, and they're struggling. And I put them on butter and coconut oil and they dropped the weight. Their cholesterol comes down a hundred points. Their triglycerides dropped 200 points. their HGL goes up, all their metabolic markers go get better, their inflammation comes down. And you're like, wow, this is impressive.

This is secure for everything. And then you have another patient who's the opposite, who's, you know, you, you know, has got these lipid issues and you try to treat them with a higher fat diet and they actually get worse. And, you know, it's interesting. There's a lot of what we call heterogeneity in the populations and genetically we're all different we all respond differently some people respond worse to carbohydrates some people respond worse to fats and it's very hard to sort of for people to figure it out so I think you know the universally saying everybody should be this keto or everybody should be low carb or everybody should be low fat just doesn't

make sense is that fair to say yeah I think so I think you know, we all aspire to want to find the perfect diet. And I think you're right that there probably is no perfect diet. I still hold out some fantasy that there is a best diet, maybe, not perfect, but best. And when I mean best, I mean best for most people. I don't mean there's obviously not going to be best for everyone, but. Okay, spill the beans what is it well no i mean look i mean i was waiting i think let me step back and i think you know we both appreciate we all appreciate that the ketogenic diet has done wonders for a lot of people and particularly the patients that you describe who are overweight and metabolically

extremely unhealthy i think there's no doubt that the improvements they see are dramatically beneficial most of the time all the improvements go in the same direction, right? You don't have to worry about, oh, well, 30 markers go in the right direction, but one goes in the wrong direction. So those people I think there's very little controversy about, and they can thrive on a ketogenic diet. It's this other group of people where you see this discordance in the movement of the markers where I think there's the health, the most conversation.

And what I'm specifically talking about is there are some people who will go on the ketogenic diet, all their metabolic markers will move in the right direction. So, you know, insulin, glucose, A1C, all that stuff moves, moves better. Inflammation gets better, but then they see what would give me or my colleagues a heart attack in terms of the movement of their their cholesterol and and I think what happens their cholesterol so their cholesterol and when when When we talk about cholesterol as you mentioned that we used to just pay attention to total and then it became this LDL cholesterol and now I think we're paying more attention to

You know non HDL cholesterol the total cholesterol minus the HDL or really it's the Apo B So a polipe protein B B is a protein that carries around these cholesterol molecules. And that one is thought to be the most dangerous one. So when those go up, so whether it's LDL or non-HDL or ApoB or LDL particle number, any of those things go up to a large degree that makes people like me nervous. Yeah. By the way, just to stop. Most cholesterol tests,

the doctors do are, I believe are antiquated and we should be looking at APO B and APO A1, which you should ask your doctor for. And also looking at what we call NMR or cardio IQ, which are tests to look at particle number and particle size, which is turns out to be more important than just the absolute number you get on your regular cholesterol test. Yeah.

There's a ton of controversy, even in that, within that world of there are people who are sort of minimalist to think you can get everything you need out of like the non HDL. So total minus the HDL, which I think is a bare minimum. And then there are people who think you have to measure APOB specifically, or people who think you have to do this NMR or even this ion mobility test to look at the LDL particle number and look at the LDL particle size. I'm not going to wade into that controversy. I think, um, most people, 90 plus percent of people, there's concordance between non-HDL cholesterol, ApoB and LDL particle number, which are the three markers that I mentioned. So, so then what happens to these other patients who maybe aren't really

overweight, but want to try a ketogenic diet lose a little weight or to get healthier performance What happens to these people right? So those those people have this very alarming increase in their cluster in their bad cholesterol what we used to call LDL cholesterol now Not HDL Apo B and including the small particle. Yeah, and the total particles. Yeah, although not necessarily the small particles I think the people on a low carbohydrate diet tend to have more of the larger particles. Again, tons of debate if that matters, but the total particle number is increased. There's a difference in the pattern. The total particle number is increased, but regardless, the result of that makes some people very nervous. It makes other people less nervous. And there's this sort of resulting debate about, does it matter? And does it matter in the context of all the other positive things that have

happened? And so my take on that is we don't know if it matters and we probably won't know if it matters for quite a long time, but we have an enormous amount of evidence supporting the fact that increases in these kinds of cholesterol over the lifetime of an individual does matter. And if you want to wait around to figure out if it does matter, you're going to be waiting a long time and it may be too late. And so my take is if, uh, if you could do this diet, which we all love, and I've been practicing myself for almost two years, if you can do it without the scary looking cholesterol numbers, why wouldn't you do that? So for me, it's kind of comes down to a head.

So what we've been working on is trying to develop a diet where you can get all of the benefits of this low carb, high fat ketogenic diet, but without that one wart that bothers. And is that because it's plant-based fats versus animal fats? Yeah, I mean, so there's evidence going back now 50 years or probably in that range

that increased dietary intake of saturated fats causes an increase in these LDL cholesterol numbers. And so you can basically, a typical sort of conventional ketogenic diet is rich in butter, bacon, lard, steak, things that are pretty high in saturated fat um you don't have to do a ketogenic diet with a saturated fat high saturated fat diet you can do it with unsaturated fats a mono or polyunsaturated fats and so whether those come from plants or potentially from animals like fish you know rich really in mono, in monounsaturated, sorry, poly, omega-3 polyunsaturated fat. So whether you choose to do it entirely plant-based or you do it with plants and fish or plants

and other animals that are lower in saturated fat, that, that's a choice that any individual can make. But that's what we've been working on is trying to develop options for people who don't want to wait around to figure out if that cholesterol rise is a problem And not all saturated fats are created equally right and and they have different effects on fat on your lipids for example My understanding is it's a stearic acid. That's the most common saturated fat in meat Actually doesn't really affect your blood cholesterol That's right

There are yet others might like coconut oil will, and it, but it also increases HDL more. So, and the size of the particles. And so this is such a variable response. And it becomes head spinning. And so, but again, you have to make a choice. And this is a choice that is on the one hand empowering for people because they don't have to have a doctor like any of the three of us write a prescription for you. You can do this on your own. But yet it's daunting for people because they're confused. And frankly, so am I sometimes. So I think it's a place where we have to be humble and kind of recognize that this is not easy.

So someone wants to be on a ketogenic diet and their cholesterol is up to put them on a statin? Well, so what I tell people, again, this is coming from the perspective of me as a cardiologist trained in a Western world. So what I tell people is you have options, right? If you love eating the way you eat and your diet includes a lot of saturated fats, so butter and bacon and lard and stuff like that, and you don't want to change that, then you have an option. You can take a statin or you can ignore your cholesterol. I would recommend you take a statin or some other

cholesterol medication. But if you choose to not want you take a statin or some other cholesterol medication But if you choose to not want to take a medication, there are other options You can modulate this with diet and nutrition itself so and I've had a lot of patients have a lot of success in doing that and taking and replacing all of that because I Think some people feel like you have to do it because the keto diet is so strongly associated with bacon That people feel like oh well that has to be the way it has to be done. It's the gateway food. Right.

It's like the gateway drug for eating meat. The point is you don't, and it took me a little while to figure that out, too. You don't actually, and in fact, because of the way the biochemistry works, it's actually easier to oxidize unsaturated fats. So it's easier to get into ketosis. It's actually easier to do the ketogenic diet on a diet, on saturated on a diet that's predominant unsaturated fat than saturated fat. So this is something that like, you know, through introduced, being introduced to carry and other people, it's been an awakening for me that this is possible. So, so even just, just to sort of go down this rabbit hole a little more,

you know, the, the saturated fat question is sort of sticky and, and I think it's so variable how people respond to it. And I think there are people who are we call lean mass hyper responders who do end up with this high cholesterol. And it is worrisome because I think there's increasing data that your lifetime exposure of your arteries to the cholesterol elevations is what matters. It's sort of a new metric. It's sort of like life years of LDL or something, you know? Yeah. It's like, it's like pack years for smoking. Yeah. And so that, that, that creates a risk. And in, in, in the whole field, you're talking about eating now more of the polyunsaturated fats. So I just want to dive a little bit in this rabbit hole of omega-6, omega-3 saturated fat And, you know, you know, my favorite topic.

Yes. And I and I try to understand this. I read a lot of the science myself. I talked to experts. Everybody's got a different opinion. Everybody. So there's epidemiologists, there's trialists. They all like disagree.

And the rest of us are stuck in the middle. So we've had about a thousand percent increase in the intake of soybean oil in this country in the last hundred years. These refined oils were really never part of our diet. Historically, we had olive oil. We had some oils that were nut and seed oils, but they're the bean and seed oils that we're having. What we call plant based oils are a relatively new phenomena and they're very unstable. They're easily oxidized.

They're produced in ways that are our heat using heat and solvents to extract the chemicals. They're often filled with glyphosate if it's soybean oil. That's sort of a side point. But how do you navigate this controversy between those who say we should be eating way more plant oils and less animal oils and, and, and navigate that as a cardiologist. Cause when I hear you say eat more like soybean oil or but that's what people are going to be hearing. When you say polyunsaturated fats, people hear all these oils. So I I'm glad you don't agree, but I want to hear your perspective on this.

And can you unpack that for us a little bit for the average listener who is not an expert in lipidology? Well, I mean, we don't I don't know how detailed we want to get in sort of like the chemistry of of fatty acids, but the let's skip that. Let's just focus on the sort of what i think well let me just say quickly so saturated fats are basically solid room temperature they're more stable and less it's easy to oxidize or damage polyunsaturated fats are more fluid liquid and room temperature

and they're more easily damaged by oxygen or um basically various insults that can create oxidation which causes the damage to the cholesterol. That's right. And it has to do with the number of double bonds and makes the... Yeah, it's a chemistry stuff. But it's basically, you know, one unstable, one stable, unstable. Look, I don't like processed food at all. There are some people who will make the argument that olive oil is processed food. Olive oil is processed in what seems to me, at least,

to be a pretty normal, natural way, right? You take an olive and you crush it. I'm okay with that. So when it comes to- Not too many steps, there's no hexane or solvents. And I think, you know, that kind of stuff makes me nervous too. As to the sort of relative effects,

you're not gonna get me to bite on the relative potential damage of polyunsaturated versus saturated fatty acids. But you will get me to bite on the processed food bit. And so I'll just tell you what I do. And it's probably not that different from what Carrie does. I get my unsaturated fat from a limited number of sources. And so in terms of oils, Carrie mentioned avocado and olive oil. Those are the only oils I use. Yes, me too. The only oils I touch.

I don't, I really, I cook with or use them for salad dressings or sauces or anything. You never use ghee or anything like that? I don't use ghee. I will occasionally, and I'll get killed by a number of people. The other night I made a stir fry for my kids and it called for a tablespoon of sesame oil. Kill me. Like one tablespoon. I don't know.

It was an Asian dish and it wanted the... Why would people kill you? Oh, because people are nervous about these seed oils because of all the things you mentioned. They think that they're

easily oxidizable and therefore inflammatory and unstable. So you worry about that then? No, I don't really. Well, then why don't you eat safflower oil or canola oil?

Because I don't like it. I like olive oil and avocado oil and it's simple and easy. But it's more than just that. You don't think there are safety. I don't like avoiding them. This is good.

I don't like I don't know. I don't buy that. I don't like I'm going to bite again on the process thing. Like I don't like and I haven't gone. I'm not a food expert. So I haven't gone to the factory to see how they make these things. But to me, it's very simple to conceive of how they make olive oil avocado oil. So I'm good with that. I'd love Fish, I'm not I mean I've done a plant-based experiment for a week and it's doable

But I liked it admit I don't wouldn't say that I liked it. I think what he did a plant-based We got him to do a fully plant-based week yeah and it was not it was not nearly as bad as i thought it was going to be yeah but it was keto keto plant-based yeah carrie helped me walk through that as we were launching this we were launching this program for people who want to do plant-based keto with this company that i'm involved with and uh and so we i just thought well look if we're going to do this i need to try it and see if it's actually doable. And it was definitely doable. And I think it was a great experiment for me to have done. And again, my diet is 90 plus percent plant-based.

The place where I get animal protein is from fish. I mean, I'll have some chicken and occasionally I'll have something else, but mostly I would say 90% of the meals that I eat are either plant or plant and fish. So you're a fish, vegan, keto guy. Not vegan. I will eat cheese.

I'll eat some cheese. Mostly, you know, hard cheeses. Not a ton, but I'll eat some hard. You're kind of what we call a pegan, you know, mostly plant-based, but with some animal protein. I like to think of it as Mediterranean keto. I think it's like a, it's really like a Mediterranean. I mean, to me, it feels like a Mediterranean keto. It's like the Mediterranean diet without the bread and the pasta.

And what's happened to your numbers when you do that? My numbers were pretty good to begin with, and I haven't checked them in a year, but they looked really good. On a keto diet? Yeah. So you weren't one of those lean mass hyper responders? No, no. But you weren't also eating saturated fat't also you never did bacon and butter I did it a little bit at the beginning when I was first experimenting with keto

I did because I thought you had to I mean, you know There's no way to do this unless you eat all this fat and where am I gonna find the fat and as a cardiologist? You're doing this for your patients. Yeah, and what are you seeing? Well again, it's the same thing. They were all seeing so some people it's a no-brainer It's easy. And I should say that for people who go on this diet and they're eating a lot of saturated fat and their numbers all look good, I have no problem with that. Like I don't have any belief that they're eating saturated fat in the absence of the

effects on cholesterol and lipids and other markers that we, if that works for you, then great. And then for the people who have trouble, that's where we get to, like, that's where we earn our money. That's where we get to play this game. And so, um, you know, it's been great to have options for people, whether it's plant-based or plant and fish or whatever you want to call it. I think that's what we've been focusing on, uh, as providing people an option that's beyond having to take a medicine, which again is still out there. And I'm not, you know, look, uh, there's a lot of bad stuff written about statins.

We're not going to debate statins here. No, that would be fun. We're at the Cleveland Clinic. I'm a strong believer in the power of statins. I don't take a statin myself. And I know that I probably would do a lot to change my diet before I would take a statin. But I also would not take a statin. Yeah. And I see it I probably would do a lot to change my diet before I would take a statin, but I also wouldn't not take a statin.

Yeah. And I see it in my patients. So I put almost all of my surgical patients on the ketogenic diet of varying forms, depending on, you know, where they come to me. I do have some people who are plant-based at the beginning and probably about 80% of them end up staying on it after surgery because they like the results of it. And the people who I've had, you know, struggle with their lipids, the vast majority of them. And again, this is anecdotal. It's not, you know, something that I can quantify or that we formally studied. But by making this shift and I actually think we need to talk about the fiber side of it, too, with the plant.

Because I think that's a really significant factor in addition to just the fats. Yeah. And I think the important part is... Because a lot of times if you're on a ketogenic diet, it's hard to get enough fiber. Well, and this is one of the criticisms that was in the article that was published earlier this year in JAMA about was that the ketogenic diet was low in fiber. And my argument, and we have a mutual friend, Danielle Bellardo, who is a staunch ethical vegan, and she did a two week plant-based keto and, you know, her, her fiber intake was 80 to a hundred grams per day. Okay. That's like 10 times what most

Americans get. Right. And her, but her net carbs. So we can talk a little bit about that, but you know, this whole argument about the seed oils and things like that. And people will frequently, when I say I do plant-based keto, that's the first thing that they say is, well, you're eating all these seed oils. I have no seed oils. I have olive oil, some avocado oil, and then occasionally if I'm baking something, I'll use some coconut oil um but otherwise i i eat whole nuts and seeds whole yeah i think that's really important carrie i mean what you're saying and what you're saying even is that you can eat any kind of oil as long as it's in its original packaging like eat the nut eat the seed eat the bean right i eat uh i mean carrie knows, I don't know, at least a fistful of macadamia nuts a day.

I love them. Yeah, I love that. Yeah. Yeah. And so, you know, I mean, I think those are all options. I just like the olive oil of nuts. They're so good. Yeah, they're fantastic.

I mean, and that's the thing. It's not free either. This is one of the things that calories do still matter. And people, you know, will struggle on the ketogenic diet. They'll, you know, eat too much protein. I think we see that in some of the other studies that are out there with, you know, the more traditional ketogenic diet, they found that women in particular seem to struggle if they get too much protein on it, it prevents them from getting into ketosis. I have a lot of patients who, you know, are measuring their ketones through the acetone breath meter. And that's what they're finding is that we have to

shift them to more of the high fiber, non-starchy vegetables, more avocado, more olive oil, and, you know, dial back whatever their protein source is, whether it's a plant-based protein. Protein gets turned into sugar in the body. It does. If you take too much. I mean, true. It also increases insulin. It increases insulin. That's for sure.

I mean, amongst the type 1 diabetic community, people will, you know, there's this insulin index that was out there that was studied a number of years ago. And the vast majority of us have a very different, particularly those of us on a low-car carb diet, we actually bolus for protein, which is not something that's traditionally taught. Yeah. Maybe you give extra insulin if you're eating extra protein. Extra protein. But what the protein source is matters. So lupini beans, for example, which are an Italian bean, have zero net carbs. So I don't bolus for the carbs that are in them. The protein that's in there, because it comes along with fiber, I'll bolus for, I'll give insulin for about half of that. People, you know, fish typically need very little insulin for the,

the protein, the amino acids that are in the fish, but something like steak, almost all type one diabetics that I know will report that they need much more insulin for steak than they do for fish. And then chicken is sort of somewhere in between there. Um, and of course the amount of fat that you eat and things like that matter too. But it's, but it's interesting though, if you look at people who are type one diabetic, um, when they pancreas fails, they produce no insulin. They could eat 10,000 calories a day and lose weight right because they have no insulin insulin is required to actually

store fat so when you're eating protein you're obviously getting insulin and you're eating some carbs when you're on a ketogenic diet but that's a really important thing for people understand is that insulin is really the key here and eating in a way that keeps your insulin low there's a lot of ways to to get there. Ketogenic is one of them, but there are other ways. Fasting, intermittent fasting, things like that. Um, for sure. All of those things can be factors to lower insulin levels. And it's not to say that you don't need, you know, some insulin, obviously, you know, that's one of the criticisms people will say, you know, at what point is insulin, what is the ideal insulin level? Um, and ultimately

it's, for me, it's where are you at from a performance standpoint? Like I look at with running, how much insulin do I need to take so that I get, so that I can run as long as I want to run and be in the perceived exertion that I want to be in at the pace I want to be in. And those are all things that I'm playing with. And there's different people out there who are playing with that. I mean, Zach Bitter just broke the world record for the hundred mile in, you know, just over 11 hours on a ketogenic diet. He eats the, although he's, it depends on what point in his training he's at. He eats a ketogenic diet, although because he burns so many calories, he, at different times of his training, will increase his glycogen stores

by adding things like sweet potatoes and things like that. And yet, the vast majority of the time, he remains in ketosis. I mean, one of the beauties of being in ketosis and doing endurance sports is your body is so efficient at burning fat. I used to, you know, do these long races in my 20s and doing them now. You had to carry carbohydrate along with it. I mean, just for people who would understand, you know, your body can store about 2,500 calories of glycogen carbohydrate in your muscles, which you burn through pretty quickly if you're doing endurance athletes But you have 30 40 50 thousand calories of fat on your body that you can access if you're on ketogenic diet

Which gives you a much more sustained energy source and Kerry's point is that the capacity to burn those fats is increased when you're fat adapted so right like and Jeff Bullock did a study I think in in athletes a few years ago and it was the Capacity for beta-oxidation was increased by like three or four fold in these. So your engine runs a lot faster. You can run a lot further and farther. Yeah, you're better at burning fat. Basically, you've adapted, your body's adapted to learning how to burn fat. And you can be, I mean, there are plenty of athletes that use the more traditional model, and Volick has talked about this, that they're very good athletes burning predominantly carbohydrate,

but you can burn predominantly fat and one of the benefits of it. So, you know, if I go out and do a really long run, the difference now is I take along some emergency carbs because I'm a type one diabetic, but otherwise I can run for three or four hours or more. You just did. You just ran a 50 kilometer race, right? I did. It's impressive. You missed my birthday, but it's all right. I'm sorry. It was on my schedule before I really wanted to do it. I said I had to save a date in the summer. If I had signed up for like eight months ago. I'll forgive you. I'll forgive you. All right. All right. So I have a question. So historically, we would have periods of feast and famine

and there'd be scarce times in the winter and we'd have abundance in the summer, et cetera, et cetera. So we were in and out of keto historically. Do you think it's important for people to go in and out or is it okay to be on sustained keto your whole life? I mean, how do you guys sort through that? I mean, here's the thing. I think we don't, we don't know the answer to that unless you know of some knowledge that, know the human species is incredibly adaptable i think the problem comes into if you already have a metabolic problem yeah do you need to stay on carbohydrate restriction to keep that in check whether you spend your life screwing up your metabolism do you need to stay on it to keep it on in check because you know once you've kind of

got to type your diabetes it's pretty far along and're, you're kind of on a knife edge. Whereas I think the ideal goal, you know, for people who are not already there is to be metabolically flexible and to where you can go in and out of ketosis without difficulty. You can, you know, exercise, you know, to whatever your particular sport is, whether it's endurance or lifting or, you know, short bursts of things. And so I think that's ideally is to where there is not, you know, I wouldn't take my kids and put them on a sustained ketogenic diet. I want my kids to be metabolically flexible. That's, that's called health. It's called how we age well, right? So what's your perspective on that? I mean, I, I guess, uh, well, to be fair, we don't, we don't know, we don't have a randomized

controlled trial over 75 or a hundred years. What's your gut tell you? My gut tells me that I'll tell you, I mean, my gut, so I've been in nutritional ketosis mostly almost every day since March of 2018. So almost two years. And there've been a few times where I, well, so one thing is that being fat adapted means you can expand your intake of carbohydrates And stay in ketosis. So I'll go out and have sushi with my kids with rice at least a couple times a month and stay in ketosis I You feel different I don't if I stay in ketosis if I if I I've had a couple of things like birthdays and stuff where I've like said

Screw it. I'm gonna you know, have a a couple of things like birthdays and stuff where I've like said, screw it, I'm going to, you know, have a piece of cake. And I felt can I say bad words? Yes, sure. I felt like I felt so sick. Is that like a medical diagnosis? Yeah. I mean, I felt the equivalent of like a bad hangover. Like it really felt awful to me to the point where I was like, I don't really want to do this. I don't feel good doing it. It doesn't, I'd rather like, I actually enjoy the way I eat. I don't see any reason not to every single parameter I can measure. Most notably my waist size, right? I went from my wife the other day was asking me what I wanted for the holidays. And she was talking about, but she said, remind me again what your waist size is. And I said, it's 32. She said, you remember,

you know, that two years ago you were 36. Wow. And I said, I forgot. Which is one of the biggest determinants of your risk for heart disease is your waist to hip rate. Yeah. And I mean, in addition to all the other things that we've talked about, and I mean, and I feel good, I ski better. I there's everything about it. You ski better. Well, that's a good. Well, it is. I do. And that's like, that's important to me. Like, I think I, I, you know, as a doctor, we, as doctors doctors we have the ability to impact people in two ways, right? We can make them feel better. We can make them live longer Both hopefully. Yes. I hope to be able to do at least one Well, let's talk about the live longer thing because I think you know, there's been so much talk about

the varying ways to achieve longevity through diet and historically the one thing that's been proven without a doubt in animal models is calorie restriction. And calorie restriction has a number of things that it does to the body. It actually improves the cleaning up of the waste in the cells called autophagy. It makes you more insulin sensitive. So you're not insulin resistant. It actually speeds up your metabolism. It increases antioxidant enzymes, it reduces inflammation. It helps your neurotransmitter function, your cognitive function, your bone density. Uh, it increases stem cell production. It does all

sorts of things that actually are very powerful. In fact, I was just reading an article in New York times last night about this couple that sort of was, were lovers in Auschwitz and had, and, and they, and they were still, and they sort of lost each other after the war. They survived the concentration camps, but you know, they were pretty starved in there and she died at over a hundred and he's like 93 and still going. And I, you know, it made me wonder about, wow, was it partly their longevity due to this calorie restriction? But so there's this whole phenomena of calorie restriction, but then you don't want to be starving all the time because you're going to be miserable. I met a guy who was on a calorie restriction program. I'm like, what do you have

for breakfast? I have like five pounds of celery. I'm like, no thanks. You know, but there are other technologies and other ways of eating that seem to do the same thing. Ketogenic diets, intermittent fasting, which is sort of alternate day fasting or fasting a day a week or a week long fast and time restricted eating. Was it eating with a narrow window, like eight or 10 hour window during the day or ketogenic diets, they all seem to do the same thing. So could you, could you talk about these different approaches and, and what do we know? And, and you, you know, you've, you've studied this, you looked at the data. Where, where are we going with all this? How do we use this both for metabolic health, for longevity, for all kinds of illnesses?

Yeah, I mean, we could probably talk for two hours on this whole subject. I could. I think we've got a couple more. So let me just simplify this. So I think all the evidence we have so far on life extension has occurred in animal models. And a lot of that has occurred in animals like worms. And while we have learned a lot from worms, worms are very different from people. Although we share a lot of the same DNA.

We do. Although, you know, if you look at the sort of the pathway that seems to be most high, like if you're going to mice and other. What's the one? Let me turn it to you. What's the one if you had to pick one pathway that is the strong, most strongly associated with longevity in animal models, which one? Well, it's interesting because I was at a conference on aging with the Dalai Lama and all these scientists, and this guy from MIT was Ed Leonard Guarte,

who has worked with these worms and sirtuin pathways. And I said, so, Leonard, what is the deal with aging? Like, what is the thing here with sirtuins? I said, what's going on? He says, well, it's really all about insulin resistance and sugar. It's like the thing that's driving it all. So I would say the one pathway that it really regulates is, is, is nutrient sensing and insulin signaling.

And I think by fixing that you're, you're doing a lot to help with aging, which is what causes, you know, and we've, I've written about this for decades is insulin resistance drives heart disease, cancer, diabetes, Alzheimer's depression, and more. Yeah. I mean, I think that, uh, you can argue back and forth whether it's insulin or IGF-1 or growth hormone. Uh, it turns out that a lot of animals and the growth hormone itself evolved only in, in vertebrates. So there is no growth hormone in, in, in worms. So, um, I think what we're doing is trying to learn a lot from these

animal models. And, um, um uh the problem with doing aging experiments and people is that none of us are going to be around to see the results right like you know if you do an aging experiment on a mouse you take a mouse that normally lives to be two years and if you can make that mouse live to be four years you've like you know it's a nobel prize um and but the equivalent in people would be to do a study that makes people go from living 80 to 120. No one's going to be around to see that. I am. I'm planning on it.

Look, I think, I just turned 60. I called my first 60 years. I just turned 50. I think the, no way. Almost 50.

No, you're not. I'm 46. Oh, that's not almost 50. That's like me saying I'm almost 60. No, it know from the biology, from the animal models as best we can. I always try to stay humble because the work that I've done in my laboratory over the years has taught me that we can't predict a lot of what happens. The biology is super complicated. Yeah, a lot of feedback loops and feed forward loops and things. Right. That like whack them.

Yeah, it's a little hard. And so I think I try and again, you know, for my field, you know, my the field that I've been studying in the in my lab is growth hormone growth hormone signaling and that field to me is the best example of this because if you go to a growth hormone meeting you'll find half the room who believes just religiously the growth hormone is the fountain of youth that you should be giving growth hormone to prevent aging right for longevity right so the other half of the room feels it's the cause of aging it exactly and you know I'm like what I have my own, you know bias and I've interpreted the data how I interpret the data

But I think we we have to stay somewhat humble to the fact that it's hard I mean, well, it's interesting when you're young your levels of growth hormone are high correct when you're old they go down Yeah, and so I think a lot of people have been using injectable growth hormone as a fountain of youth yes but i also see metabolic issues from it well that's trying to get more weight gain and more diabetes and other issues right which makes me wonder maybe it's not so good right and i think you know if you look at the genetics uh the genetics point pretty strongly to the fact that decreased growth hormone or decreased action of growth hormone is probably the single biggest cause of long life, which doesn't mean that it doesn't have other effects. So if you don't have a lot of growth hormone around, you will put on more body fat.

You will have, you know, more fragile bones and other things like that. But if you're looking just at how long you're going to live, I think the, that answer is probably pretty clear that less is more. Yeah. So, so back to the original question, um, you're sitting in your doctor's office and you are both sitting there with patients. They're like, I want to live to be 120. How should I eat? Should I intermittent fast? Should I be on time restricted eating? Should I be keto? Should I just, what, what should I do? So, cause I'm that guy, I'm coming to your office. I'm like, okay, docs, you guys know a lot about this. I want to be 120. What do I do?

I want to go back a little bit and talk about the health span part of it. Um, and put on my orthopedic surgeon hat and, you know, bone and musculoskeletal health hat, because, you know, when we're talking about longevity, we focus a lot on cardiovascular health, but my bias and what I see is that people decline rapidly as their ability to be functionally active goes down. And that that then sort of uncovers other problems that they have and compounds them. So there's a phenomenon called sarcopenia of aging, which is basically where muscle decreases over time. And I see it on people's MRIs. So I treat people who have trouble, you know, walking and, you know, as a result of nerves being compressed. But we get a

lot of, you know, back pain, neck pain, even, you know, nerve related pain secondary to metabolic disease. It's not uncommon for people. Metabolic disease, you mean like what? Like type 2 diabetes, right? So it's not uncommon for people to actually be diagnosed with diabetic neuropathy before they're diagnosed with type 2 diabetes. That means they're nerve damaged from blood sugar. Exactly. And it can damage tendons and things like that. So people get a frozen shoulder or they'll get their iliotibial band, which is the big, long virus band that runs along your legs.

So they'll have pain when they're walking. And so for me, when I'm looking at this question about longevity, all of these things matter, but my perspective on it is how do I keep people moving and active as long as possible? And how do we use diet for that? So one of the benefits that I see, you know, when I put a patient on a ketogenic diet. So people have to understand that your diet plays a big role in the amount of muscle and or fat that you have or don't have. And degenerative changes. So there's studies that show that advanced glycation end product, which are those stickyions in between their bones and their spine, that is increased with these advanced glycation end products, which are byproducts of sugar. So yeah, so when the sugar gets too high, you create this process called glycation,

which is essentially like the crust on your bread or a creme brulee crust. And that happens in your body when sugars and proteins combine to create this inflammatory process. Right. And when inflammation is high, those things for varying causes, inflammation leads to, you know, more arthritic changes. There are some studies that have shown... At least the muscle loss, at least the diabetes, at least everything. So there are studies that show that if you decrease, it doesn't matter how the knee that has bad arthritis, and we talk about bone on bone arthritis, but if you decrease the inflammation, it may still not be a functionally lined up knee, but people actually can have relatively little pain with it. It's pain is related to the inflammation. So when I put people on a very low carbohydrate diet

and they start creating these ketones, you know, not to get into the science of it, but there are pathways where those ketones are anti-inflammatory. And that's one of the things that I hear a lot is people say, not only did my back pain get better, but my knee pain and my shoulder pain, and I'm able to do more. So for that, for me is one of the biggest things. And I, you know, I still have to remind people, people come into the office and they'll still be on the diet, but they'll have stopped exercising. And I'll say, did you stop brushing your teeth? And they're like, well, no, why did I stop brushing my teeth? It's not different. You have to keep exercising. And I'll say, did you stop brushing your teeth? And they're like, well, no, why would I stop brushing my teeth? It's not different. You have to keep exercising. I think that's true. I think, you know, you can do all the right dietary things, but one of the things that happens as you age is you lose this muscle and that's what makes people end up in nursing homes. It's what actually

drives all the hormonal changes. So when you're less muscle, you have more cortisol, which is a stress hormone that causes more diabetes and blood pressure issues. You have lower growth hormone, which you say is good, but I'm not sure it's totally good in that situation. Make more insulin, you make your cholesterol gets worse, you get more inflammation. So the muscle is like the biggest organ in your body basically. And we don't pay much attention to it. And it's actually required to be intact if you're going to age well.

And that's the whole question of like protein and how much protein you need and should you eat protein? Do you need animal protein? It's another rabbit hole because a lot of data show that when you're younger, you actually maybe not do as well if you have more protein. But if you're older, if you don't have protein, you can't build the muscle. So how do you deal with that? Or maintain the muscle. I mean, a lot of that data is emerging, but when we look at things, you know, I follow patients' bone health. And so you want to make sure that you're getting adequate protein. And of course, people argue about what is the, you know, appropriate amount of protein at different points in your life. And I don't think that that science is settled to where I can tell somebody

this is specific I mean, you know, it's about a gram per kilogram is the recommendations of lean body mass not total body mass but that's totally debatable and You know, my goal is to that seems pretty low Right one one gram per kilo of lean body mass and pure Is the minimum required, you know, recommendations for the amount of protein, that's like how much vitamin C do you need to get scurvy? Like 10 milligrams, not very much. Right. Right. And so it doesn't mean it's the optimal amount. I don't know that we know the optimal. And the problem is, is, you know,

I've even found as I've shifted, you know, I sometimes the more I run, the more weight I gain. And then I have to play with it and go back and forth and do these things. So I don't think that we're a long way off from knowing what is the optimal diet and how to dial these things in. So my message to my patients at this point is, you know, if you're benefiting from a low-carb diet, we continue that. It's whole real foods, whether you include animal products or not into it, depends on what markers we're looking at. And are you willing to take medications if you need to? And we need to get you active and keep you exercising. The exercising part actually doesn't help with weight loss,

but it does help with building muscle and maintaining muscle because what I see is then the end result of it, which is people fall, they break their hips and that the data is clear. Once you start getting spine fractures where you sneeze and break your back or you fall and break your hip, your life expectancy dramatically decreases. Yeah, right. And so those are important factors. So whatever diet we need to get you on so that you feel good, so that you're able to go out and be active and live an active life is the ideal diet for you at that time. I mean, so people are wondering, you know, back to the sort of ketogenic intermittent fasting thing.

If you say, well, I'm just going to do time-restricted eating. I'm going to eat an air window. Is that as good as keto? Or I'm going to fast one day a week. Is that as good as keto? Or I'm going to like do a week-long fast once every two months. Or like there's all these things that people are recommending out there. How do you compare these different approaches?

Well, I think the good news is that we're going to have answers soon. I mean, I think there are a lot of people, including us doing trials on time-restricted eating, probably other people doing alternate day fasting. So the science will catch up at some point, at least in terms of what we know are the effects on markers that we can measure. Kerry brings up a great point, which is we really have to think about what we want to optimize for. Do you want to optimize for total years lived or do you want to optimize for, you know, health span, quality of life, how you feel? So my.

I want to die young as late as possible. Here's one thing. Here's one thing. When I give a talk, I love to talk about the things that I learned from my mom, my grandmother, that were wrong and and how we can unlearn them. So one principle, I think in the meantime, while we're waiting for the science to catch up on say, intermittent fasting, you're not inviting your mom or grandma to the lecture.

No, I'm not. But my. Yeah, I bet that wouldn't go on. Not going there. But I think one thing that I was taught as a kid was to eat all the time and to eat. To green meals and snacks. And it's for bed, your plate, you know, all this stuff. Like it was basically like a constant, you know, eat all the time and to eat. To green meals and snacks. And eat before bed. And finish eating your plate, all this stuff.

It was basically like a constant, this Jewish grandmother, like eat, eat, eat, eat, eat, eat. And I think what I learned by playing around with fasting myself was that hunger is not linear. That is that when you start to sense feeling hunger, it doesn't then continue up on this endless slope to the point where you just die. I mean, Carrie hears me talk about this all the time. I tell my kids, like,

my kids will come in the house and I'll say, dad, I'm starving. And I'll say, are you? And they'll say, yes, I'm starving. And I said, well, when do you actually starve to death? Like, when will that happen? And they're like, I don't know, soon. And so I'll say like, well, what's the longest that anyone's ever lived without food? And they can't even fathom that it's like that there's a guy that's lived for 300 and something days. And that, you know, Cahill did these experiments where people were living for 30, 40, 50 days. And I said, you can, I guarantee you, you, even though you're tiny, could live at least 10 days without any food. So I think one of the things that fasting does is it teaches you to tolerate hunger a little bit more.

And I think one mistake that we make is eating when we don't because calories do matter. Despite all the other things we talked about, the amount of food you eat will impact your metabolic health and your weight. And so if you're not hungry for sport, I shouldn't do that. If you're not hungry, don't eat. I mean, I think this is one of the things like this comes to the breakfast thing. Right. So we're studying. We're doing a randomized trial comparing time restricted eating in an eight hour window to eating three meals a day. And the way we designed the study was to skip breakfast because it's the easiest thing to do in our society. And so,

but you know, there's this dogma out there that breakfast is the healthiest meal of the day, which may be true, but if you're not hungry in the morning, should you force yourself to eat? And so that was sort of one of the things. So that's one of the principles that I use. I actually think there's a tremendous interesting synergy between all forms of fasting or intermittent fasting and low carb diets. And one of the reasons for that is at least, and we'll get pushback from people who don't believe this, but I believe there's a very strong effect of the ketogenic or low carb diet on hunger. I think there, uh, sure that there's, you know, personally, I just am never hungry.

Insulin is what makes you hungry. Probably. And that probably it's the effect of insulin on your brain or the effect of insulin on your fat that then goes to your brain. But there's no doubt that I'm less hungry. And so for me, I had been doing some form of intermittent fasting

for five or six years. But when I started doing keto, it just became like easy. I mean, it was, I just didn't even think about it. I was interesting when I, if I don't eat, like I can do an intermittent fast, like an eight hour, if I go longer than that, like, you know, 20 hours or something, I, I just start to feel like horrible and I can't recover. Even if I eat something the rest of the day, I just feel out of it. Like brain fog, weak, horrible. Yeah. Um, well, and I, I would say to you, if I were your doctor, I've got like 6% body fat, which I'm not, and I'm not your doctor. I would say then don't

do it. Cause I don't think there's, I mean, uh, and there are going to be all slow people who will hate me for saying this. I don't think there's evidence yet to support that fasting in any form is going to make you live longer. And I think there's pretty good evidence that that calorie restriction, probably if there were anything that would, it would be that. But these other things mimic the same biology, right? It does. But again, you know, we we get fooled on biology so many times again and again and again. So in the meantime or you know look i my principle is if you're not hungry don't eat and if you want to be crazy and fast for five days and you do it in a safe way go for it but i don't do that i'm not going to do that

i think it's interesting people often don't get the tests that matter most for example like blood insulin levels most doctors never measure you're absolutely right it's something that i probably didn't do enough of until four or five years ago but it's a it's and if you ask somebody like lou cantley you know who's a you know discovered part of the insulin signaling pathway what the most important hormone is to measure low or yeah that it would be insulin and that's part of the reason why i think you know again you mentioned that it's not just you know fasting or calorie restriction or other things. Keto low carb diets will also reduce fasting insulin. So I think those are all things, if you're going to like pay attention to a marker, that's one that looks good. And the blood test will say zero to 15,

but really it should be less than five. And you know, people are eating well and low carb are like two, I'm about two. And I, you know, I feel good like that. And I think that it's not. And then what's even more important is what happens after you eat sugar and carbs. We use these now Dexcom that carry out. This is basically a 24 hour glucose monitor. But I would like to see a 24 hour insulin monitor because I think that'll be more reflective. There are people working on it.

Thank God. I've been talking about that for 10 years because I've been measuring insulin levels and post glucose tolerance test insulin levels for 25 years. And it's just the amazing amount of stuff you learn from that. I, you know, I see people whose lipids look totally normal and his blood sugar, A1C is like five or five and a half. And, uh, you know, their fasting insulin might be normal. Their fasting blood sugar might be normal, but they have a load of sugar and their insulin goes up to 200 and these people cannot lose weight. And I think that's really a very important sort of insight that people can look at. And there's a lot of tests you can do to figure out what your metabolic type is. And you can see what happens when you eat different diets, because people often, you know, looking for outside validation

of what to do. I'd say the smartest doctor in the room is your own body. How do you feel? What happens to your weight? What happens to your muscle mass, your body fat, your lipid numbers, your insulin numbers, your blood sugar numbers? I mean, that's what you need to focus on. And the variation of the population is humbling. Like there's a doctor, okay, I found it.

It's ketogenic diet. And then you're like, oh, it didn't work for this guy over here. It worked for this one. I was like, oh no, it's not one size fits all. But there are probably, if you took the like the most daunchly pro whatever pro let's say carnivore diet and the most staunchly pro vegan diet and the most staunchly if you took all those people and put them in the same room

and ask them to agree on nutrition principles, there would be a couple that they would probably agree on. Right? Yeah. 100%. I mean, honestly, that's why I jokingly call the pegan diet, because I was like paleo vegan, how could you be more different? But actually they agree on absolutely everything except where you get your protein from. They all agree we should be processed food. They all agree.

She's lots of vegetables. They all agree. We see lots of good fats. I agree. We shouldn't, you know, be be, you know, eating lots of sugar and sugar. Refined carbohydrates. I mean, if you thought like just there, just they want to come with a traditional American, right. So, I mean, that to me is like, if you want to just step back and say, all right, well, that that's probably going to be the future, right? We're, we're all going to agree less added sugar, less refined carbohydrate, less processed food. Like that's, yeah, that's probably a safe bet.

Yeah. And there was a study that I had just come across this weekend that from 2017 that looked at a plant-based processed diet versus an unprocessed plant-based diet. So whole real foods and the people who were on the plant-based unprocessed or processed diet had increased cardiovascular risk. Like chips and soda. Right. Exactly. Chips and soda and Skittles are all plant-based. And so you can eat a crappitarian diet and it's not going to increase your health span.

And I think that that's the thing that we, you know, the people who benefit, and this is the other thing that drives me crazy because I sort of walk between this plant-based world and the keto world. And for a long time, the plant-based people were like, well, you can't be keto and plant-based. We don't understand that. And the same thing happened with the keto people where I even had, you know, Tim Noakes on Twitter saying, you can't, it's not possible to do a ketogenic diet and be plant-based. And I'm like, well, I am.

Oops. Yeah, I mean, here's the thing. Don't confuse me with the facts. My mind's made up. And this is the problem, is I think that we all get to where we have our thing that we're comfortable with that works for patients. I really want us to learn from the people who struggle and that that's where the real gold is. It's really not with the people who are successful with it.

It's really with the people like, why is this person struggling with it when it worked for these other five? And that's where I think down the road, if we're going to reverse engineer our way out of this obesity crisis, it's to really figure out, so this person who's struggling, how do we shift their diet? You know, if they're on a really plant-based diet and they're not having the results that they want, or if they're on a ketogenic diet and they're not, is there another variation?

Is there another factor that we've not looked at? And that's where I wish all of these camps would stop being camps and dogmatic and really work to try and help people dial those things in. The diet wars. Well, it's silly. I mean, we all want to work to enable success. And I do think that we can agree on,

I mean, there are other things, places we can agree to, right? I mean, I think one thing is, you know, some people can be very austere with the way they eat. You could probably eat basically like tree bark for the rest of your life and be pretty happy. I can also probably be pretty happy. Other people, I love to recognize like that they'd like food that tastes good and rich and decadent. And so maybe, you know, we can work to find like, we're working on these bars that I think are

going to be like, it's almost hard. I brought one. I'll let you try it later. You're not even going to believe how good this thing tastes. And you're going to think there's no way this is just almonds and chicory root fiber. Like there's just no way this is all like, there's just no way. Yeah. Right. Yeah. That was interesting. You know, it's true. I have a friend who, uh, Mark David, who's, uh, has started the Institute for the psychology of eating. And, uh, you know, he's sort of a shorter stockier guy. He's not overweight, but he's just more stocky. And I'm sort of this tall, skinny guy. And ever since I've known him, he eats like a bird. We went out to dinner.

It was a shared plate thing. I ate three quarters of the food. He ate a quarter of it. And he was happy and satisfied. And I was like, I could eat more. And I think my metabolism is very high. He might be slow. And everybody needs different amounts of food.

And I think he's very good at listening to his body. And I think that's what you're really saying is see what's going on for you, what works, what doesn't work. Well, and also we just need to recognize that there is, the world is full of these choices that are not great. And so can we, instead of saying just put those away and don't have them, can we replace them with things that are still really good tasting, but, but just are better that adhere to the principles that we all agree on. That's the thing. It would be great to do a study of like keto compared to intermittent fasting compared to, you know, time-restricted eating compared to just low carb, but not super keto. It'd be very interesting to see what that all would do metabolically to people. I hope somebody is going to do that study soon because it's, you know, I think we're still in

the question mark of it, but they all, but they all do similar things when you look at their metabolic effects and their hormonal effects, they're all shifting you towards less inflammation, more insulin sensitivity, more muscle mass, better bone density, you know, more brain function. It's just interesting. They're all are different pathways into the same kind of thing. Yeah. So, uh, you know, if someone wants to try keto, it's a, it's a little daunting. Like how do you do it and not kill yourself? Right. Should you have to talk to your doctor first? You need to get a checkup. Should you get your labs done before how do you do it how does it work well we could both yeah we can both take turns on this one you'll start I mean for

somebody obviously if you have medical problems and you're on medications and you know there is a randomized control trial that's about to be underway in type 1 diabetics for using the low carb diet. So, you know, there's a lot of people who are using it. But as physicians, you know, I always sort of hedge and say, you know, you need to partner with somebody to do it, to do it. But if you're basically a healthy person, you're overweight person, you can do it. I mean, that's what I do in my clinic is, you know, I see patients, I know the medications that they're on and I give them a handout and, or, you know, since we've been working on these meal plans, the app to be able to follow it. And

you know, do you need to get labs done before? No, not necessarily. I will frequently do labs in patients so that we at least understand what their hemoglobin A1C is at minimum. Um, and most people have already had a lipid profile at some point, and then we check it later to see what happens with that. So, I mean, there's a ton of resources out there. And, you know, it gets controversial. You know, there's this whole carnivore movement. I tend to find people do better in general.

I mean, to me, I think the carnivore diet probably is a really good elimination diet. And that's why some people do well with it. Um, I worry about long-term the gut microbiome and things like that with not having some side dust with it. It's fine. The fiber sources, right? Yeah. So, I mean, I think in the phytonutrients in that that are in plants, I think people benefit from. And so, you know, for me, it's about eating whole real foods. And there's a ton of sources out there that will help people start ketogenic programs. I think one of the things that I've found with patients is that understanding whether they're in ketosis or not, because if you're doing low carb and you're not in ketosis, for some people, that's this sort of metabolic in between no man's land and they don't feel good and they're not getting the benefits from it. And so knowing if you're in ketosis,

and I use it to in patients for some very specific reasons where, you know, from neurologic standpoint, we want to get their ketones to a certain level. And I found that those patients who are measuring and tracking their ketones in some way, which you can do it through urine, breath, or blood, that they are more successful with it. And so that that mechanism of tracking, whether you're actually in ketosis is positive from a behavioral standpoint, but it also is a return on investment in that they feel better, faster in general. Yeah. So let's talk about that. So, so you've got this new company you're working with called Keto, K-E-Y-T-O, which tests breath for amygdala acetone, which is a ketone

body. And there's blood tests for beta hydroxybutyrate that you can use with a finger stick, a dose monitor, urine, ketones may not be as reliable. It's hard to quantify. So, um, for people who want to sort of check, how do they, how do they begin to think about what's the right approach? Should they just use a finger stick or breath test? Like what? I think it depends on what you want. Um, you know, we designed this thing to be a tool to help enable people to be able to do this diet, whether their goal is for weight loss or improve their metabolic health. That was the purpose. Carrie mentioned that this sort of one of the benefits of this diet

is that it provides you a biomarker. It's probably the only diet, unless I can... But you can know you're on it. Yeah, where you have a thing that you can track other than your weight on a scale, which is a really bad way. I mean, you know, we all know that weight fluctuates a lot, especially in women, it fluctuates a lot. So it's not a great, it's not a great way to know if you're doing well. So we designed the program to be able to give

people the information about whether they're doing it. In addition to the information about what they should and shouldn't do in terms of eating or not eating, right? I mean, there's, you know, plenty of places you can get resources on the Internet about how to do a ketogenic diet. It's not entirely intuitive. So the purpose was give people the information about what to do, give them the information about how they're doing, which will help enable the behavior change. And then the last part, which I sort of touched on before, is that it's also going to be really important that we give them the opportunity to find the food, right? It's not easy, especially traveling or when you're about to eat to be able to, you know, last night we went out to dinner and I ordered salmon on the salmon on the plate with salmon was fingerling potatoes. And I just asked if they could put vegetables. And so they served it over asparagus. That's sort of something

that wouldn't have been intuitive to me before. You do a swap. Yeah. Or, you know, if you're in the airport and you're starving, you want a quick something to eat, where are you going to go? Dunkin' Donuts? Are you going to like buy a Clif Bar? What are the options there? So I think. I go for the nuts. Well, and that's a good place to go now.

And they actually have like grass-fed jerkies and all kinds of stuff. They do. And I've seen even these like cheese crisps and stuff. So I think it's, and I've seen a few keto bars, at least in the San Francisco airport. So I think it's coming. But that's a few keto bars and at least in San Francisco airport. So I think it's coming, but that's one area that we'll as a company be focusing on in the future

is trying to provide people not just the insights they get from the device, advice that we give them through the app. And lastly is to get them opportunity to get food. Are there people who shouldn't do a keto diet? I don't, I don't know of anyone that I would say not to. People always talk about kids. And I say, well, you know, we have actually the most experience with children on the ketogenic diet because for 100 years there have been kids with epilepsy who have been on the ketogenic diet.

Yes. They've done well. So I don't think there – I can't think of anyone – there probably is. If you push me hard, I probably can't think of anyone. I mean, even in pregnancy, there are – you know, if you have gestational diabetes, the low-carb diet is one of the ways that they manage gestational diabetes there's some reports in in women who are breastfeeding of this starvation keto acidosis I think it's pretty rare but if you have a calorie demand because you're feeding another human and you're losing a lot of weight especially if you're not

getting enough calories for your own metabolic needs, I think it potentially puts you at some risk. But there are plenty of people out there anecdotally who are doing just fine with it. I mean, like I know if I, if I start to do it and I do too low carb, I dropped so much weight and I'm already skinny. So like, I, I find that like, I have to have some stuff like sweet potatoes. Yeah. I'm sorry. You have a good you have a good problem. You you you fall in the category of good problems to have. Yeah.

But it's you know, I just I really I had to carve up if I want to gain a little weight. Yeah. I had to get stem cell at once and I just had to eat lots of rice noodles. You know, like rice. You're you're not as I'm fond of telling some of my partners, you're not normal. I am not normal. I am ODD, which means I'm odd. That's really true. No. And it changes throughout life and things like that. I mean, I think women, you know, in menopause and perimenopause, it shifts. And so, you know, it, it, it's definitely a tool that

I see more postmenopausal women benefiting from is getting rid of the carbohydrates. And it gets harder at that point to keep weight off, but it certainly is something that they can consider doing. Right now, the studies on, you know, for type 1 diabetics, it's still, there's lots of us who are doing it, but the, you know, the RCTs are not out. I think there are some ways that people can get into trouble and we need to better understand those ways. It's not that a low carb diet isn't a benefit. You know, we did a study where we looked at the numbers of people, the average A1C was, you know, just over 5.6 in this group of people, type one diabetics who are doing the low carb diet. I think, which is unusual, type one diabetes for years years and if you get a 7, you're excited.

Right. And that was normal, right? Yeah. Right. The target is 7. And so to see this in the low amount of insulin that people are using, I think when people have some of these medical conditions, we need to understand how they can get into trouble. And that's where I hedge as a physician to say, oh, everybody should be doing this,

is because it's like the people with the lipid problems, or it's like your experience with the ketogenic diet is fine. I still really have to be careful with calories. I still really even, you know, training for the ultra marathon, I put on some weight. Some of it was muscle, you know, but... All of it was muscle. But I'm not, you know, where I, you know, those things are factors and, you know, our

body types are different. And that's the thing that, you know, I think we need to be careful of is some people, their LDL is going to go through the roof. I really worry about these lean mass hyper responders who have LDLs over... You worry about them. Yeah, yeah, I know. I can't even imagine. I'm one of them actually yeah i mean

if your ldl goes over 300 it as a orthopedic surgeon that gives me angina and i can't even imagine what it does to you and then you know so so and but you said it at the beginning i want to emphasize again if you if you have a medical condition please to do it under the supervision of your doctor and then there are some to answer answer your question, I thought of one, like, I think if you have type two diabetes and you're on certain medicines, like STLT2 inhibitors as one example, you probably don't want to do the ketogenic diet. Although you won't need them if you do the ketogenic diet. Or if you're on a sulfonylurea, I mean, that's the thing that I see is, you know, because- Any drugs that lower your blood sugar and raise insulin, you have to be careful because, because you'll get low blood sugar. And I mean, that's actually a,

you know, I actually, when I wrote my book, the blood sugar solution, we're getting a lot of people writing in and calling and saying, Hey, you know, my blood sugar is too low. My blood pressure is too low. I'm like, yeah, the food works better than the drugs. So you got to taper your drugs with your doctor. You have to be careful on the SGL2 inhibitors. They can send someone who's typically in a type two diabetic. Ketoacidosis is not something that you typically see that tends to be more in type one diabetics, but with the SGL2 inhibitors and in particular, what drug would that be for people listening? The, the, the flow Z glen, I can't pronounce them. It's, um, far Ziga. Farziga. The ones you see advertised on television for a lot of money. Which actually are pretty interesting drugs.

They're actually being used mostly now as, or they're being, they've been demonstrated to be very beneficial in heart failure. So the cardiologists are all adopting them just like they do. Well, it's fascinating. Yeah, it's fascinating. But it's fascinating when you see patients with like advanced type 2 diabetes who go on a ketogenic diet they get off all their medications they get off their insulin they get you know it's like it's pretty impressive

it is and we i do it in orthopedic practice so it's not something where you know we put them on it and patients are very carefully people who are on insulin i mean i have the ability to talk with them more about it because i obviously use insulin and understand it but all right so let's let's go through a day of eating of each of you. What's a ketogenic diet look like? And then we'll kind of sort of summarize. I'm black coffee for breakfast. I mean, that's my, I don't, I rarely eat breakfast.

If it's a surgery day, I actually won't eat until I get home. I can operate all day and not need to have any calories at all, which is very different than in residency where I would, you know, have a bagel before and then by lunch you're like starving and, you know, can't get to the cafeteria fast enough between cases. But if I do eat lunch, you know, it'll be a salad or I will make some smoothies with, you know, brussel sprouts and broccoli and things like that um but i'll have a salad and i'll put hemp seeds on it with olive oil and you know like extra fat you know you're like using a lot of fat yeah i mean i'll put avocado on it i'll put pistachios on it i'll snack on macadamia nuts um and so you know that, I put a ton of other vegetables on the salad itself, protein

sources. I'll either use lupini beans or black soybeans or hemp seeds on a salad. And then dinner is, you know, similar where I'll have, I'll roast vegetables or steam vegetables and use olive oil on them, um, or avocado oil. I like to add nutritional yeast to it because I like the flavor. And then again, I'll choose from those protein sources and have that. And then I have dark chocolate almost there's a, you know, sugar-free it's sweetened with Stevia and a little bit of erythritol dark chocolate most evenings just because I like chocolate.

Yeah. All right. That's good. That's the vegan keto. Okay. And how about you? Mine's not too different. I also have black coffee for breakfast. I normally don't eat anything until about noon. I eat lunch most days. I make my own lunch, bring it with me to work every day. And it's a salad. It's, you know, whatever I have.

So some lettuce, some chopped vegetable, usually celery, cucumbers, peppers, something like that. I'll throw some lupini. Carrie introduced me to these lupini beans, which are delicious. I'll empty a pack of those in there. I'll put a bunch of nuts in there, chop an avocado every day. I'll have a whole avocado. And then I'll go back and forth between adding some protein, whether it's like a little bit of salmon, some smoked salmon, even some canned salmon in that. And then I keep like 14 bottles of olive oil in my office and I just drown the whole thing in olive oil. That's lunch. Dinner is usually 14 bottles of olive oil. I have a lot. Are they like different varieties or like wine?

Or is it like... It's basically like I have a collection of olive oil and wine in my office that are gifts from patients. All right. That's good. Yeah. They don't bring cookies anymore. They bring olive oil. No, it's great. And then, uh, and then that's what I got for my birthday. A lot of olive oil, roasted vegetables and a protein and the proteins usually fish. All right. Fantastic. And then I also have this dark chocolate problem at night. Great. Well, this has been an incredible conversation. There's still a lot we're learning and there's a lot we know about actually what can be the benefits of eating a low starch sugarugar diet, a high-fat diet, a keto diet, and some of these other techniques such as intermittent fasting or time-restricted eating,

and you're studying all these, stay tuned for what we're going to know because I think we're really on the trail of something really important in terms of health, longevity, metabolic health, and honestly, part of the solution to our extreme obesity and diabetes epidemic, which is bankrupting our nation and causing so much suffering for people. And you guys are at the forefront of that work. I really appreciate what you guys are doing. Uh, if you want to do keto, make sure you know what you're doing, check it out. You can go to get keto to.com. Is that your website? Yeah. Um, so get keto, K E Y T O dot com and learn more. I mean, there's a lot of other options out there, but check it out. And if you love this conversation, we'd love to hear from you.

Share a comment. Please share with your friends and family on social media. Sign up wherever you get your podcasts. And we'll see you next week on The Doctor's Pharmacy. Thanks, Mark. Thank you, Mark. Hi, everyone. It's Dr. Mark Hyman.

So two quick things. Number one, thanks so much for listening to this week, everyone. It's Dr. Mark Hyman. So two quick things. Number one, thanks so much for listening to this week's podcast. It really means a lot to me. If you love the podcast, I'd really appreciate you sharing with your friends and family. Second, I want to tell you about a brand new newsletter I started called Mark's Picks. Every week, I'm going to send out a list of a few things that I've been using to take my own health to the next level. This could be books, podcasts, research that I found, supplement recommendations, recipes, or even gadgets. I use a few of those. And if you'd like to get access to

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