Dr. Steven Phinney – Keto-Adaptation

– I'm also a student of history, and I love this slide
because this is a picture of the two people facing
the camera, Inuit women. This is a photograph
taken on the Arctic Tundra in Northern Canada. Taken about 1910. You can see by their
clothing and everything these are people that were following their Aboriginal lifestyle,
with a few exceptions. If you look really closely right here, this is a double barrel shotgun, which wasn't a handmade
native hunting instrument. But the thing they didn't have is, they hadn't been educated. They don't have notebooks and paper and what we don't have is we don't have any written records of what their dietary guidelines were. We have anecdotes from
people who'd watched them and lived among them but
the records are sparse and I want to try and drag
a little bit out of this because there are a couple of things I think they could have told us.

For instance, when they
brought their fox pelts into camp, they've hunted them,
or into the trading posts, they've hunted them all winter long when the pelts were rich and thick and they'd bring these pelts and they'd trade them for things like shotguns and tea and tobacco and sugar and flour. And the anecdotes,
there was a book written by a French explorer,
Her name was Kabloona, which is the Inuit name
for white guys, and this explorer mentioned that when they came into camp and they traded all this stuff, that they took the sugar and flour and stuff and they loaded it on their
sleds and they'd go about five miles outside
from the trading post. Then they'd set up their camp, and they'd spend a week or two there eating all the food and they thought that was intemperate of these people.

They were eating all this food, they should make it last over the course of the year, and he said they were really slothful and then
they'd pack up and leave. And I think what happened was they'd eat the carbs which tasted good,
and it was Kabloona food. And then they'd spend a week or two getting over having
eating, and then go back to their lifestyle, which was
really physically challenging.

So I think that I'm
trying to reverse engineer but I think example that I can find on literature, or one
of the first examples, of Keto Adaptation, which is one of the key things I want to talk about in my segment of this talk. Now this is a pastel, picture that was drawn
and published in the journal of an arctic explorer
named Frederick Schwatka. Schwatka went into the
arctic in late 1870's and he wanted to find a way
to get up to the Arctic Ocean from the western shore of Hudson Bay and find out what happened to a Royal Navy expedition with 129 men and two ships that
disappeared in the Arctic in the 1840's and was
never heard from again, and no one had figured out what fate became of these people.

So rather than take a load of sleds or take boats and try to drag them into the Arctic, which was
what other people had done in many expeditions trying to figure out what happened to the Franklin expedition, and come to grief, he
decided, "I'll just hire "a couple of Inuit families and I'll "let them take me there." And that's what they
did, and you can see he – Oops, wrong button. He does have paper and pencil, and they're writing stuff down, and he kept a journal of that experience. They traveled 3000 miles in about 13 months. They found artifacts and evidence of where this expedition came to grief. But in his journal, he wrote
a really fascinating line.

Now let me put this in context. I discovered this in the spring of 1980. I just finished doing
my study on Bike Racers and I was trying to write it up and I thought I'd come up with the idea of Keto Adaptation. Then I'd come upon this
thing where he says, "When first through wholly upon the diet "of reindeer meat…" by
which he means caribou, which is what they hunted in the winter when they were inland
– "it seems inadequate "to properly nourish the system, and "there is an apparent
weakness and inability "to perform severe arctic journeys. "But this soon passes away in the course "of two or three weeks". What that means is that this
guy scripted me by 100 years. (faint laughing) But he didn't write down what they ate. He just said that they didn't take enough supplies with them to have, you know,
sugar and carbohydrates, for more than the first few weeks. And after that, for about 13 months, they lived off the land and there were no fields of waving grain.

But then this other Arctic explorer, a very controversial person named Vilhjalmur Stefansson,
who was trained in what we would now call anthropology at Harvard, was fascinated in what the Inuit peoples. By his name you can tell that he's of Icelandic origin, but he was born in Canada, and he was interested in first nations, and Inuit
lifestyles, and so on. So he went into the north of Canada and spent the better part of 10 years living among the Inuit. He ended up being put in
a compromising situation where he didn't have
any food or sustenance for winter and so he had actually had to move in with this group of Inuit and when spring emerged – and now the winters there last 9 months – he spoke their language and
understood their culture enough that he could live that lifestyle. And he did that for
prolonged periods of time. He wrote about it in both
scientific papers and in books.

And among those things he said, "I could live on a diet of meat and fat "without any vegetable matter for more "than two years at a time
and I wouldn't get sick." Now if you look at the
timing, between 1914 and 1927 was when all
the vitamins were found. Some of which, like Ascorbate, are said to be only found in significant quantity in vegetable matter. The people who read his writings who knew nutrition and
understood the science of nutrition knew he was lying.

Because you get scurvy
within three or four months if you eat a diet without
vitamin C in it. Right? So, he was called a liar. He allowed himself to be
locked up in Bellevue hospital. That is now in New York City. It is a place for insane people, but it was also a place
where early scientists who studied had set up a
metabolic research facility, and he was incarcerated. I
think Gary, you corrected me. He was only in there for like 5 months and then they let him out on parole. Basically as long as he came in everyday to be checked up on. And he and another of his
arctic explorer colleagues spent a year living on
the diet of meat and fat, and they did not develop scurvy. And they didn't lose
weight, and – they didn't do formal performance testing – but they would take them out, escorted and let them walk or
jog through Central Park and they showed no evidence
of impaired function.

And in his books, Stefansson
did not give you gram weights or macros for what the
diet that he had learnt to eat in the Arctic. But luckily doctors Walter
McClellan and Eugene DuBois did write down what these guys ate in their multiple months of incarceration, and then tracking their
diet as outpatients. And what he ate, what they ate was roughly about 15 to 20 percent of
daily energy requirement as protein, over 200 grams of fat per day. Which is, represents 80 percent or more. And the only carbohydrate
they got was from the glycogen that was in the meat of the animals when they were slaughtered. And as the doctors notes,
and the people who wrote the Real Meal Revolution point out, they ate nose to tail. They weren't just eating
fancy cuts of stuff. Because there are different nutrients in different parts of the body and in different animal sources. And so I looked at that data and said that if these guys are trying to prove that you could live on
a diet of meat and fat, they bet they would be trying to emulate what they did in the Arctic, because they didn't want to get scurvy and they didn't want to prove
McClellan and DuBois right.

So to me, that the best
that I could come up with at what was, represented an Inuit diet. But Stefansson was, and
remained, very controversial even though this was published in the Journal of Biological Chemistry in 1930. And I met people in the 1960's and '70's who told me, you couldn't
believe anything he said because the guy was obviously a liar. And those are scientific people in the metabolism community. And I wanted… I realize that this is a really busy looking
slide but I want to share this with you because
this is where I identify the origins of carbohydrates loading. And this is a paper published in the Scandinavian journal,
Scandinavian archives of physiology in 1939. The title, it was in
German, the title of it is – and I'll slaughter this probably – is Arbeitsunfähigkeit
Unternehrung, which I believe – maybe Doctor Lechner in the audience can correct me – but I think it means work capability and nutrition.

And this is a study
done of three subjects. And they had three arms of the study, and each of them, each
of the three subjects went on either a high
carbohydrates, low fat diet – their normal diet – or a high
fat, low carbohydrate diet. And I put this stuff up here because I wanna point out that this is the high fat diet. So fat diet, and if you look at the calories over here from, of fat, that and this is, you can see that there is very modest amounts of protein. So there's 21 grams of protein, I'm sorry, 21 cal- grams of protein. 576 grams of fat, not
the 200 that Stefansson was reported to have, and
their eating 5000 calories. So this is extremely high
fat, hypercaloric diet that they were feeding, so this wasn't patterned after an Inuit diet. And what they did was they had people, their subjects eat these three diets for seven days each, and the reason they picked seven days to eat the diet was they had them do
it for three days, and it appeared to be too
short a period of time for adaptation, so they figured seven days would be a good period of adaptation.

And when they did that,
and then they had them do exercise on a cycle odometer and that exercise was about 175 Watts. 175 watts, which is a
pretty, pretty good level of exercise for anything other than a professional athlete, and they looked at their endurance time to exhaustion, and the high fat diet, they went just a little over an hour and then quit. On the normal diet – they didn't push them to exhaustion – but they went longer on the normal diet. And then on a high carbohydrate diet you can see the, going to exhaustion, the duration of exercise
was dramatically longer. And so their conclusion and, the other two subjects – this
is just one subject – the other two subjects had
patterns that were very similar.

And the other thing I'll point
out to you, by the way is, one of the co-authors here is "O" Hansen, Owe
Hansen, and if you look at this subject, this subject is subject OH. So this is actually self experimentation. This was not uncommon then, as now, that people do self experimentation. So, I got interested in this topic. I read these things after I got interested in this, and I got interested because as Gary pointed out, in
1972, Atkins wrote a book called "The Atkins Diet" or the "Atkins Revolution," whatever, and said that people would have a lot of energy if they went on a very low carbohydrate, high
fat, high protein diet. And I knew that was wrong, because from my own personal biking experience, if I didn't start eating carbs after that first hour and I
was trying to ride up and down mountains I would
hit the wall within two hours.

So I set out to prove Bob Atkins wrong. I, working with my mentors, Ethan Sims and Ed Horton in Vermont, had the opportunity to do a study. So we took the group of overweight people who wanted to lose weight and, so we made a bargain with them. We'd lock them up in a
metabolic research ward for seven weeks. We'd give them a high carbohydrate diet for one week then exercise them and do muscle biopsies on them to find out what their endurance time was. And then we would put them
on to, not a high fat, but a very low carbohydrate,
very low calorie, ketogenic diet for six weeks.

And when we exercised them after one week and six weeks, we compensated
for their weight loss by having them wear a
backpack which contained all the weight they'd lost. So we tried to compensate
for their roughly 25 pounds weight loss
on average at the end of the six weeks, and we had them do no
endurance training during this this weight loss diet period. And what we found at one week was exactly what Christensen and Hansen found. And that was, compared
to baseline, there was a significant truncation
in their endurance time to subjective exhaustion after one week. But after six weeks – and
we shouldn't have done that. We should have stopped at one week, because then my career trajectory would have been very, very different.

(audience laughing) But after six weeks, we put them back on a treadmill wearing the backpack. You can see that they
went dramatically longer. And we were mortified. We could explain part of that, because in spit of the fact that they are wearing the backpack with the weight, their exercise performance
– or their relative percent view to mass – dropped from about 60 to 65%, down to 57%. So all of them became more efficient on the treadmill even though they hadn't trained during this period of time. But our conclusion was that there was a, some recovery process
that was occurring. And even though the relative intensity of performance dropped slightly, this looked like there
was some significant recovery of endurance time to exhaustion. But the problem was A:
These were untrained people. They did not know what exhaustion was. And the second problem was that there was weight loss compounding this.

So we wanted to find a way to put people on a diet who can inhabit ketosis and not lose weight, and so this is when I read the 1929
or the 1930 paper from the Stefansson Experiment, and so we adopted a diet
that was essentially the same as the Stefansson diet, and we recruited a group of bike racers. And these guys who eat
ham sandwiches climbing up mountain sides on bicycles. They have cast iron stomachs. We figured, we could get them to eat this. They could eat 80% fat, and indeed, we worked out a way that that could actually do
that and tolerate that.

Unfortunately I was a beggar,
I didn't have a big grant. This was metabolic research ward study. And so I had to beg for the rooms. And the longest I could
get justified keeping any patient, any of my subjects in the metabolic ward was four weeks. So we picked the four week time point. Not six weeks because of
the financial realities of being able to make use of the limited time available in
the metabolic research ward. And this is a lousy way to show the data but, what I show here is that VO2 max along the top line, which
is five liters per minute on a cycle odometer by the way, which is a quiet prodigious VO2 max, didn't change after four
weeks of the ketogenic diet. When we had them exercise to exhaustion, they went 147 minutes at base line, 151 after four weeks of adaptation.

Those numbers aren't different. So unlike the obese
untrained people, there was no difference of their
endurance time to exhaustion. But if you look at what
happened to fuel use, this is a respiratory
quotient, 0.85 or 0.83 means they're burning
a little bit more fat than carbohydrate, but about
close to a fifty-fifty mixture. But after just four weeks of adaptation their RQ dropped down to almost 0.70, which would be almost all fat. So this is a 90% or more
energy coming from fat. Add an exercise intensity of 65%, which is over 3 liters of oxygen
consumption per minute, translates to over 900 calories of energy expenditure per hour.

This is a much better slide,
with most of the same data. It was made by Geoff
Volac, and he's much better at depicting things than I do. And the key thing on this slide, and Professor Knoke showed you his slide, and that is, these are the times for each individual
subject, and you see that one person was about the same after four weeks of keto adaptation. Two people went up and
two people went down. And I've been kinda
criticized for publishing this data, because, how can
you draw any conclusions about the average
person's response to this? And my point is that people
vary one from another.

And it may not be that, it may be that these people biologically
are just not designed to function on a high fat diet. Or the alternative is,
these two people here required a lot longer period
of time to keto adapt. Because we only had four weeks. And essentially all the other studies that have been done, including
Louise Berk's studies, and she knows about this concern, and she runs studies that
are three weeks duration. So the question is, how long does it take to keto adapt, and this
will be my last slide. And this is my best bio marker for metabolic adaptation
to a low carb diet. It's not changing RQ. It's not the ketones
coming up and stabilizing. It's the fact that renal handling of organic gases is very important for acid based balance in the
body and metabolic balance. And when you take a person and put them on a ketogenic diet, and they have two to three milimolar
circulating ketones, those ketones are an organic acid they, that compete with
other organic acids in the body for excretion and the one that we using test
and are concerned about, because of its participation in the cause of gout, is uric acid.

And uric acid, if you… and this is data compiled
from a bunch of studies that I have done over time. I'm not gonna bore you with the raw data, but typically a normal uric acid levels in the four to seven range, and when you put someone on the ketogenic diet, they'll double their uric
acid in the first week. And it's not because they
make twice as much of it.

It's because they're not excreting it because of competition from the ketones. But if ketones stay
constant, and you follow uric acid over the course
of nine to 12 weeks, they find it come back down, which means that's the duration time in which the body can – at least in the kidney – can adapt for acid-based balance. And if so I had to look
at a minimum number for keto adaptation now it
would be in the range of nine to 12 weeks, not the
two weeks or four weeks or one weeks that have caught
true in most other studies. And with that ill turn this over to Geoff and let him tell you
about the modern science..

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