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

– Hi, I’m Steve Phinney, and I am the main medical officer of Virta Health. This is gonna be the first of four talks I’m gonna be presenting on ketogenic nutritions andhow they are effective and safe in treatmentof various ailments. This first talk will be an introduction to nutritional ketosis. What passed me to this field to begin with was that I’m a recreational cyclist.I like riding a bicycle long distances. I’ve been doing it for over 50 times. And very early on I have found that if when going a bikefor more than an hour or two if I didn’t eat when ridingI would stumble the wall, which is what happenswhen the body runs out of carbohydrates when it’scarbohydrate-dependent. And you feel really lousy, and your accomplishment lowerings. So I very quickly becamea carbohydrate advocate. Interestingly, at thistime 40 or so years ago was when the Atkins dietfirst became favourite. And Atkins said, youknow, you don’t need carbs to feel well and function well. Well, I was a freshly minted young physician, and I was feeling my oats. And I was set out toprove Bob Atkins wrong. And, guess what, proved myself wrong. Now, actually, it wasn’t quite that simple because if you go on aketogenic nutrition for a few weeks, or two weeks, your conduct does drop.My event had been only in short-term limiteds in carbs. So we did a study that lasted six weeks, and by the third weekof the six week study people’s achievement was coming back up. And by 6 to 12 weeks their act was back to or abovewhere they’ve started. The figure becomes capable of burning almost all of its intensity from solid. In my experiment I actually make a habit, sometimes successfully, oftrying to prove myself wrong. And you say wait a minute, why wouldn’t you try to prove yourself right? If you prove yourself wrong that’s how medical advances are made. If you are of the view that something’s right, and you find out it’swrong, you can now change your understanding andchange medical knowledge. And that’s something that I, and my co-founder and collaboratorin this, Dr. Jeff Volek, have made a habit of doingover the past multiple decades. In this process backin 1980 I coined a expression nutritional ketosis, andanother term, keto-adaptation. The first thing you have to consider when listening to someone talk about nutritional ketosisor ketogenic diets is, how are you able trust what they are saying? The rationalization is that they are a lot of self-appointed professionals out there, but very few people in the medical realm have much training in nutrition.And most of them haveabsolutely no develop or investigate experiencein nutritional ketosis. That is most people get their expertise by see what other beings have done. Now, why should you trust me? I convey, I’m an MD, and I cantell you I had no training in nutrition in medical clas back when I went through that process. But after I completed my medical education curiosity drove me back to institution, and I expended four years doing a PhD in nutritional biochemistrybecause I recognise there is indeed a cluster of paradoxesbetween what I was taught to believe and what theevidence seemed to present.After accomplishing that, myPhD, I is to continue to do two years of formal training in clinical nutrition. Since then I published 80 newspapers, I’ve co-authored three records. I’ve been studying and prescribing ketogenic foods for 40 years. The first station I want to compile is that nutritional ketosisis a very powerful tool when properly done, but it’s not simple. It’s not just a matterof cutting out carbs.And the other point isthat particularly in parties that have medical conditions, it’s not always safe. So my goal in presenting this information to you is to share the powerof nutritional ketosis, share the fact that it can reverse, and, or frustrate verysignificant medical cancers. Oftentimes takingaway the prescriptions that are currently beingused for those conditions. With this strength comes probability, particularly as it relates to havingbeing on medication because if you’ve altered the disease, and you don’t take away the remedy, you can have major side effects. The other important time is that this is much more complexthan just taking away carbohydrates, bread, rice, pasta, potatoes, and interesting thing. For a ketogenic food to be safe, it has to be much more wrote than that. Getting the nutrition right in terms of the other nutrients in thediet is somewhat complex.And it’s not somethingthat a simple slide, or even this simple talkis gonna be adequate in order to get it on safely. The other important item is there are some medical conditions where people should not do this type of diet. And I’ll mention thosebriefly in this talk, and more completely in last-minute talks. Let’s discuss what’s a ketone. It turns out that there are two compounds that the body induces from fat. And their own bodies, signifying the liver, stimulates two complexes fromfat which are classified as, and I positioned this in air quotes, ketones. Now, I won’t get into the details of the technicalities of that. Now, these can eitherbe made from body fat, that is fatty we’ve eaten before and stored, or fat that we feed, and that flows through the blood after absorption. Solids that are munched orstored when they circulate through the blood aredifficult to transport.They’re in what are calledlipoprotein particles. And these are the thingsthat you were measuring when we measure cholesterol, and triglycerides, and things like that. And because doctorsworry about these things you might imagine that havingtoo much of them is a problem. Well, it is about to change thatwhen fattens in the liver are made into ketones you no longer have to worry about lipoproteins because these are water-soluble molecules, and they move through the blood. They move into cellseasily, so it’s a much more efficient fuel for the body to use. Once it’s in the bloodstreamin adequate levels it can feed the intelligence, it is feasible feed your middle, and it is feasible feed your muscles.And as we’ll mention in a few minutes it can do other important things as well. Now, how do we know it can feed the psyche? Well, there are actually some, let’s say dangerous experiments done back in the 1960′ s where patientswho’d been fasting for weeks, so they had quite high ketone levels, were then infused with insulin, which drove the blood sugardown to an extremely low level, to the point where it shouldcause parties to pass out. And as long as there were ketones in the blood the brainfunctioned just fine. So we know that ketones are a very efficient and effective brain fuel. We’ve discovered in thelast 5 year that ketones are a very potent signalthat am talking about our genes. And some of the genes it’s talked to are the genes thatprotect us from things that we announce oxidativestress, or free radicals.And this is really important because these are the root causes ofa number of diseases, including category 2 diabetes, myocardial infarction, inflammatory bowel infection, blood pressure. Also, people with seizuresoftentimes have stunning outcomes when they get in awell-formulated ketogenic diet. And it’s not so much about oil as it is about reducing oxidativestress and rednes. This is a particularly, very important topic in terms of understanding howketogenic foods can be used to markedly improve some chronic diseases. We understand not just what they do, but how they do it at the molecular statu. And this is important in terms of moving this field forwards, and acquiring optimum use of this state we call nutritional ketosis. Where did nutritional ketosis come from, and why did we have todefine that as a period? Over a century ago physicians figured out that when people with what’scalled nature 1 diabetes, the diabetes frequently of younger kinfolks where the pancreas stopsmaking any insulin at all, they can’t use glucose at all for ga, and the body overproduces ketones.The ketones build up to very high levels, and that’s called ketoacidosis. When ketones construct to very high levels you can actually smell them on a person. It’s like a( smells) stink that these ketones, then say, ah, you are familiar with, thisis uncontrolled diabetes. And they “ve realized that” thatchanges the battery-acid stages in the blood, and that’s ketoacidosis. But these are vastlyelevated levels of ketones. So figure let’s say a number of 20 would be a extremelyhigh level of ketones. But if you’re eating awell-formulated ketogenic nutrition your blood tiers are not 20, your blood stages willbe in a range of. 5 to 3. So it’s one-tenth that very high level. Yet if you eat say orangejuice and bagel for breakfast, after breakfast your ketone elevations will not be. 5 to 3, they’ll be. 1 or. 2. So one-tenth, 10 times higheris nutritional ketosis. 10 times greater to that is ketoacidosis. So we define this stateof nutritional ketosis as being a safe blood levelwhere ketones function to feed vital organs in the body when you’re not eating awhole lot of carbohydrate. You has been noted that in the greenzone between. 5, and 3, or 4, that’s what we call theoptimum ketone zone.That’s when ketones havebeneficial effects in terms of feeding the ability andother parts in the body. And as “youre seeing”, if youwere in total famine, which we don’t recommendbecause of negative effects on lean tissue and organ role, total famine ketoneswill go up as high as seven. And you don’t get anywhere near the risk of ketoacidosis untilthe numbers are above 10. These are very distinctstates distinguishing nutritional ketosis fromdiabetic ketoacidosis. So by 1970 all of thisstuff was well-defined, and has occurred in the medical literature. And we kind of assumed that, you know, if we can just tell people thatketones are good for heart, and muscle, and brain thatthat would be a good thing. But really exciting things have happened in the last five years. The rationale we know thatthis is not a rumor, word of mouth, there were somevery solid scientific papers in the medical literaturenow indicating not just that, gee, looks likeinflammation goes down, we actually know precise how.The beta hydroxybutyrate, this primary ketone we have in our blood, realizes swelling and oxidative stress go down, and furnishes optimized authority for some inflammatory cancers. Let’s kind of get to a little bit more practical information. How does one get into nutritional ketosis? People who have reasonto want to have benefit if they have type 2 diabetes, or they’re gravely overweight, or have hypertension, very often those people have what we call insulin resistance.That is their body has begunto lose its responsiveness to this hormone, insulin, which is the hormone that causes blood sugar to go into cells, and too finagles torso fat metabolism. So if you’re insulin-resistantyou probably have to get your daily totalcarbohydrate intake down somewhere between 20 and 50 grams of carbohydrate per daylight. If you want to think about that in terms of macronutrients that’s less than 10%, and oftentimes less than 5% of your total daily energyintake comes from carbs. So that’s very carb-restricted. And the more insulin-resistant the person is the lower they haveto go to initially get into a territory of nutritional ketosis.In addition to restricting carbs, this is not a high protein diet. Protein, like carbohydrates, provokes insulin creation, and worsens insulin opposition. So it ought to have moderate in protein, enough protein to maintainhealthy function of our parts, but not so much better that itraises insulin positions. Then the other key point of awell-formulated ketogenic diet is this is not a calorie-restricted, stop dining when you eatx-number of calories per epoch. This is a diet when is doneright is ingested to satiety. That is when you finish a snack you should be satiated, and you shouldn’t be hungry until it’s time for your next meal. And the space you do that if you’re eating very little carbohydrateand moderate protein is the majority of your dietary calories have to come from overweight. And we’ll come back to thesafety issues around, is it okay to eat that much fatty if it’smore than half my calories? And the answer is yes, and hopefully I can persuade you of that later on.The other thing that is very important in a well-formulated ketogenic nutrition is getting enough veggies, specify enough minerals, perhaps fiber to provide satiety. Preferably than coming from capsules it should come from fresh real menu. So we suggest three to five functions of non-starchy vegetables per date. Now, realize this is just an overview, it’s not a prescription. Don’t just say, okay, I know how to make love, I’m gonna go do it. So this is something where you need to understand the helping sizings, that we adjust the proteinto the size and gender. So a small woman’s gonna need little protein than a very tall guy.There are variations in thisthat require individualization. So this is not a cookie cutteror one size fits all nutrition. I want to point out that thereare lots of low-spirited carbohydrate food strategies outthere, but not all of them are either ketogenic orinvolve keto-adaptation. For instance, a paleodiet, or a primal diet, or a low-toned carbohydrate, Mediterranean, and certainly not periodic fasting. Those do not allow for keto-adaptation. Either they’re not sustained enough or they have too much protein. So if you look at this slither here where on the verticalaccess it’s the amount of carbohydrates this percentage per daytime, and the horizontal is protein.You has been noted that thestandard American diet, I contemplate SAD, you are familiar with, sadis a good word for that, which is high in carbohydrate, moderate in protein, and relatively low in overweight, is route above the low-spirited carbohydrate degree. If you trimmed some carbs out of the food, and included more overweight, that wouldbe a Mediterranean diet, but it’s still not low-pitched carb. But as a general rule most people in the nutrition orbit willcall anything under 30% of calories as carbohydrate, a low-spirited carb diet. So a paleo food typicallyis about 30% protein, about 20 to 30% carbohydrate, and exclusively 50% or less solid. So it’s not that high in overweight. But the combination of thecarbohydrate and protein are enough that it preventsthe body from making ketones. So that doesn’t fall intothe ketogenic food series. So you can see that to get to a well-formulatedketogenic diet it’s kind of a small island of keepingprotein in moderation between roughly 10 to 20%, continuing carbohydrates under 10%. So if you’re 20% protein and 10% carbs, and you’re grip your value stable, that is after a reporting period, you’re in weight maintenance, that means that 70% of your energyhas to come from fat.That can be pretty scary, but that’s how one does a ketogenic food. And that can be done notjust for weeks or months, that can be done for years and decades. And the best way to measure it is to, you are familiar with, be tough, prickyour digit like people with category 2 diabetes, ordiabetes to measure blood sugar. And there are special strips for ketone meters thatcan actually measure your blood ketones, andthey’re very accurate. And you don’t need to do that forever, it is required to do that longenough just to know what level you get to if you’re eatinga certain range of foods. One of its most important to success here is you have to be sure that this is safe. If you do this, and do itin a way that’s not safe, then you’re not gonna be successful. You’re either not gonna feel well, or it’s gonna establish you ill, or actually carry significant danger. So as a general rule, evenif you’re otherwise healthy, and you just want to lose some weight, or improve your vigor degree, you should let your doctorknow what you’re doing.If “youve had” type 1diabetes, which is a case where the body is not ableto see fairly insulin, you’ll need specialized medical carry. There are some people who advocate working this type of dietwith type 1 diabetes. But it takes a specially civilized physician who knows how to do this to guide you. And this is something that has to be done with very close supervision.The same is true with sort 2 diabetes, but oftentimes with nature 2diabetes we can get people off of some, or most of their drugs. And, again, that has tobe done by a physician, but then the supervision doesn’t have to be quite so close becauseyou’re no longer taking the drugs that carry risk. The third statu where you would need careful medical subscribe, and have your doctor be directly involved in what you’re doing, is if you have high blood pressure andyou’re on medication. Because, again, oftentimes we need to withdraw those drugs. If you have a heart condition, or if “youve had” substantial liver or kidney illnes that needsto have careful evaluation to see if you have enough function of those parts in order to be able to manage the adaptationof this food successfully. Most doctors aren’t coached how to do this.Some of them will read books, hopefully our volumes, andunderstand how to get it on. But beware of physicians who don’t have the experience in doing this. The final spot aboutsafety is this is not, as I said , not justabout restricting carbs, and retaining protein moderate, but going adequate minerals. The important minerals include sodium. If you don’t have enough salt, or sodium, in your food you’llhave a bunch of manifestations, which include lightheadedness, dizziness, tirednes when activity, and constipation. Those are not side effectsof nutritional ketosis. Those are side effects ofnot having enough salt. It just so happens that whenyou’re in nutritional ketosis your kidneys get much moreefficient at getting rid of salt. And you have to provideit on a procedure basis in order to maintain your well-being and function on this type of lifestyle. An additional mineralthat’s very important, particularly for heart andmuscle function, is potassium. And you get that from broth, you get that from veggies, and you get that fromeating unprocessed meats. We don’t usually have to supplement that. If you get the vegetables, flesh, and hopefully oblige your own homemade broth in order to maintainadequate potassium intake.A third mineral we deal with a lot, particularly in peoplewith diabetes is magnesium. This is a mineral that mostAmericans don’t get enough of. And it seems that people with diabetes have a significant problemmaintaining suitable sums. A major clue of magnesium depletion or defect is muscle cricks, whether after exerciseor appearing at night. And that’s easily managed if someone is knowledgeable on howto supersede magnesium. But don’t simply countenance convulsions as a required effect of this. That’s easily managed by someonewho knows how to do this. Other minerals includecalcium, which is necessary for bones, and nerve, and muscle perform. That’s maintained by adequate veggies, dairy, and cheese, likewise, from homemade broth. We rarely have tosupplement calcium people when they have the normal food intake that’s appropriate fora well-formulated diet.And vitamins are sometimes a concern because people say, well, I’m not eating return, or I’m not eating fairly return, and where are my vitamins gonna collected from. It is about to change that vegetablesare an excellent source of the vitamins that you wouldnormally attribute to fruit. So we find that beings don’t need additional vitamins with this. But if one wants to takea standard multivitamin it’ll do no harm, butprobably not necessary. To wrap up, a well-formulatedketogenic diet and nutritional ketosis is ahealthy ordinary metabolic district. This is not something that is abnormal. This is not something thatyou should only do for a week or two at a time because longer is hazardous. No, this is something one can do for months, times, and decades. It’s achieved by reducing sugar, and refined carbohydrates, and most starchy nutrients. But in the meantimeyou’re eating real foods, and batch of menus, andeating those nutrients to satiety.This is as I mentioned a very effective disease reversing highway of living. And if you have diseasesthat can be altered with this you need medicalsupervision, peculiarly if you’re taking medicationsfor those infections. Because the good news isyou have to take them apart. The bad news is if youdon’t take them apart it can have serious side effects. So it has to be monitored bya knowledgeable specialist. To do this right it arises in improved well-being and function. And the nifty thing is this is not a calorie-restricted approach. You don’t have to go awayfrom the table hungry, and you don’t have to count calories. You let your natural instinctsempower you to succeed when you do a well-formulatedketogenic diet.This is a graphic that weuse when we try to explain to physicians all the developing things that happen when one goesinto nutritional ketosis. In all the regions of the surpass on the left-hand side are fat cadres where we store energy. That force can bereleased by the fat cells, run through the blood, do taken up by the liver. Made into ketones, and theketones feed the brain. We didn’t employed the heart on there. The other interesting thing, it appears to feed the digestive arrangement, which is intriguing, andreduces rash. And that appears to be whyinflammatory bowel disease oftentimes to do better on awell-formulated ketogenic diet. Clearly, ketones and fatscan feed the muscles. But the committee is also abbreviates irritation, including numerous parties with asthma notice that their manifestations to be all right. There’s rising science , not on beings, but in little worms grown in test tubes, and in mice grown in cages, that a well-formulated ketogenic diet actually improves longevityby reducing oxidative stress. Then, countless competitors now, especially fortitude players who go beyond marathon intervals, like triathlons, orlonger interval ranging, and more extreme duration athletics, they’re turning to the question of a ketogenic nutrition because the body can run principally on fat.Then the person doesn’t run out of energy and doesn’t hitting the wall. So, again, this has a multitude of effects, many of them beneficial. But I want to get acrossthe idea it always has to be done with adequate information and adequate supervision to be safe. Thank you ..

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