ketogenic diet

meredith:welcome to cellular healing tv. this is episode 104, and i have dr. pompahere, and we have special guest dr. jeff volek on the call. we have an awesome topic for you guys today,and we’re going to be talking about the ketogenic diet. and how it not only can impact disease andimprove our health, but also impact our athletic performance. so that’s a subject we haven’t reallydelved into a lot on the show yet so really exciting topic.

before i introduce dr. volek, i’d like toread his bio, so you guys can learn a little bit more about what he’s doing. so dr. jeff volek is a registered dieticianand professor in the department of human sciences at ohio state university. for the last two decades he’s been performingcutting-edge research elucidating how humans adapt to diets restricted in carbohydrateswith a dual focus on clinical and performance applications. his work has contributed to the existing robustscience of ketones and ketogenic diets, their use as a therapeutic tool to manage insulinresistance, plus their emerging potential

to augment human performance and resiliency. this research indicates that well-formulatedketogenic diets result in substantial improvements in insulin resistance and the myriad of cardio-metabolicbiomarkers associated with metabolic syndrome, cholesterol, and lipoprotein profiles. he’s also performed seminal research ona wide range of dietary supplements that can augment performance and recovery. he’s accumulated an enormous amount of laboratoryand clinical data as it pertains to biomarker discovery and formulation of personalized,effective, and sustainable low-carbohydrate diets.

his team is currently exploring the role ofnutritional ketosis induced by and/or supplements to: 1) reverse type-2 diabetes, 2) alter gutmicrobiota, 3) favorably impact tumor metabolism and help outcomes in women with advanced breastcancer, and 4) extend human and physical and cognitive capabilities in elite athletes andmilitary personnel. dr. volek has secured several million dollarsin research funds from federal sources, industry, and foundations. he’s been invited to lecture on his researchover 200 times at scientific and industry conferences in a dozen countries. and his scholarly work includes 300 plus peer-reviewedscientific manuscripts and 5 books, including

a new york times best seller. so a very impressive bio, and welcome to theshow, dr. volek. thanks so much for joining us. dr. volek:thank you, meredith. pleased to be here. dr. pompa:yeah. yeah. hey, jeff, yeah, and i just want to thankyou myself. yeah, i said years ago, i read this.

we think 2011, 2012, and if you look throughit, oh my gosh, all the notes and the studies. and it was just one of the best studied andreferenced books on low-carbohydrate diets and ketosis that i have ever read. so this is one of many. but thank you so much for the research youdo. i don’t know if i should call you professoror just call you jeff. dr. volek:please do, yes. yeah, first name basis. dr. pompa:okay.

but yeah, jeff, we have a lot in common thati’m on one side teaching doctors around the country to do what we do, and ketosisis a tool that we use in conditions that you study from diabetes, to heart disease, tofixing the gut, which you mentioned the microbiota. we utilize ketosis in so many ways, and soi’m sure we’ve referenced a lot of your research. so with that said, i have to ask you. i mean, that’s been the area of study foryou for the longest time. i mean diabetes and heart disease. speak just a little bit about that.

because i believe that, especially with heartdisease, most people would think a high-fat diet would be the cause of heart disease. jeff, we grew up in the time where saturatedfat was evil, and cholesterol is still evil, and it was a cause of heart disease. your research shows the opposite. dr. volek:yeah, well, first of all, thanksfor having me here, and i’m very pleased that you enjoyed the book. we actually wrote it for physicians so mycolleague and i, steve phinney, and other healthcare professionals, including dieticians,and nurses, and really, any educated folks

that are interested in nutrition. and we wrote it primarily because the ketogenicdiet is not taught in any curriculum and, really, anywhere. so we wanted to give people information aboutthe science and also the art. because it really transcends the science inmany ways when you get into the weeds in how you would actually implement this. so i’m glad you thought it was helpful anduseful. so, yeah, in regards to the issue of diabetesand heart disease, i guess i’d like to start and just talk a little bit about the historyof this problem.

because i think people may be generally awareof where all this started and where we’re at. but just briefly, the first dietary guidelinescame out in 1980, and that really started the low-fat diet-heart hypothesis, and theoffspring of that was, of course, the low-fat diet. and so we’ve now got 35 years of this paradigmthat we have—or experiment, if you will, that we began in the 80s or, really, the 70swith ancel keys prior to the dietary guidelines. he’s the one who wrote saturated fat. dr. volek:exactly.

and so if you think of this as a massive experimentin americans, you look at what’s happened today. two-thirds of adults in the u.s. are overweight. one-third are obese. now this is staggering. fifty percent of adults in the u.s. have prediabetes,and so we just have this massive suffering. and it really extends beyond that. there’s a financial burden on this. we spend about $300 billion today just managingdiabetes alone.

so i think it’s time to stop this experiment. the problem is no one’s really wanting tobe accountable, and we’re still fighting the government, usda, and dietary guidelineswhich are trying to continue to promote this low-fat paradigm and demonizing saturatedfat, demonizing meat, and all the dogma that we’ve been hearing for 35 years, which just,quite frankly, hasn’t worked at all. it’s been an epic failure, and you needto—we need to embrace, really, 15 solid years of research that has been supportingan alternative approach which is really focused more on reducing carbohydrate and findinga—for each person, finding their correct level of carbohydrate that matches their tolerance,and that’s really what we should focus on.

but that doesn’t get reflected in any professionalorganization, any of their position statements, or any of the dietary guidelines. so that’s what’s frustrating from my perspective. because there’s been a lot of great scientistand researchers publishing work in this area, and it’s being ignored. dr. volek:and we need more physicians likeyou that are challenging the dogma and going against the grain, literally. yeah, i mean, it’s interesting you say thatbecause, really, it’s new to humans the amount of carbohydrates that we’re eating.

i mean, if you look back at the history ofhumans and the diets they’ve eaten, i mean, this is a new thing, high-carbohydrate diets. i mean, even the amount of grain or just evengrain in the human diet is really a new thing when you look at the evolution of humans. it really is, jeff. and do you believe that some of the increasesin diabetes and heart disease are because of what we’re doing, the amount of carbohydrateswe’re eating in a modern diet? dr. volek:absolutely. so the diet-heart hypothesis and the low-fatdiet was intended to lower cholesterol which

in turn was supposed to lower risk for heartdisease. but what happened, it really backfired, wasthat as people were trying to restrict fat, they replaced those calories with more carbohydrate,including a lot of sugar and processed carbohydrates. and so instead of lowering cholesterol andreducing heart disease, what we did is we created an epidemic or, really, pandemic aroundthe planet of prediabetes and diabetes, which in turn is a strong risk factor for heartdisease. so we have this unintended consequence ofover emphasizing restriction in fat that has really caused this unintended consequenceof metabolic syndrome in diabetes. and so we really need to rethink the wholeprocess and paradigm, and in my mind, it’s

overconsumption of carbohydrate relative toa person’s tolerance that is driving almost all chronic disease, including diabetes, heartdisease, and probably cancer, and alzheimer’s, and parkinson’s. dr. volek:and you can really have remarkableeffects when you back off on the carbohydrates. how much do you need to back off? that gets into really complex issues, butat least getting that message across to folks i think would do a great deal of benefit fora large number of people, and give them—empower them or enable them to be able to eat morefat and restrict carbs does a tremendous amount of benefit to your health.

dr. pompa:jeff, when i read—and by the way,folks, this is “the art and science of low-carbohydrate living,” and then the other book that itore up of yours is “the art and science of low-carbohydrate performance,” whichis the white book that i was digging for. i think i leant it out, and there’s allmy notes in there. i better get it back. but anyways, in this book, i remember youstating that some of the criticism with a high-fat, or a keto diet, or even just a low-carbohydratediet with heart disease i think was the critique, maybe even diabetes, when you looked at thestudies and me too of what they called a low-carbohydrate diet, for you and i, it would either be amoderate-carbohydrate diet or even a high-carbohydrate

i mean, some of these studies, jeff, thati saw were looking at carbohydrate diets 180, 200 carbohydrates daily. now, to me, that’s a high-carbohydrate diet. what’s your take on that? dr. volek:oh, absolutely. i think everything’s relative. so if they were eating 400 grams, then maybethey get some benefit by going down to 200. but for many, many folks, 200 is nowhere nearlow enough to really regain metabolic health. and so most of my work over the last two decades,we’ve been looking at diets that are under

50 grams per day, and for most people, thatinduces a metabolic state of nutritional ketosis. and we continue to learn more about just incrediblehealth benefits associated with being in a state of nutritional ketosis. and so very few of these studies that you’rereferring to had carbohydrate levels low enough to induce ketosis, but the ones that have,the results are just absolutely remarkable in terms of reversal of diabetes, improvementsin all sorts of cardio-metabolic risk factors. and as you were alluding to, even on the enduranceside and performance side, there’s even evidence now that that may be more optimalfor certain athletes. talk about some of the improvements that yousee with diabetes and heart disease.

because a lot of folks watching our shows,obviously, they have those concerns, and we utilize ketosis as a tool in those conditionsand, obviously, others. i mean, we’ve had conversations with professorseyfried about cancer. but talk a little bit about those becauseyou’ve studied a lot about diabetes and heart disease. dr. volek:well, if you can get a person thathas diabetes into nutritional ketosis—and we can certainly do that. i don’t want to trivialize it, but i alsowant to make the point that a ketogenic diet, although it’s less than 50, probably lessthan 40 grams for a type-2 diabetic to induce

ketosis, that actually has quite a bit ofvariety in it. it’s not a burdensome diet. dr. volek:you’d be absolutely amazed athow much variety and how pleasurable and palatable a ketogenic diet can be. so we can certainly get these diabetics toconsume this type of diet, and not just short-term, on a long-term basis. dr. volek:and when you do that, we can normalizehemoglobin a1c in blood sugar levels in the vast majority of people with diabetes in threeto six months. i’ve done that as well, jeff.

dr. volek:so that in and of itself is remarkable,but the other really important part of that is we do that while they’re getting offmedication and while they continue to lose weight because most of them are also overweightor obese. dr. volek:and that’s exactly the oppositeof what happens when you try to really control blood sugar using standard of care, whichis to give more medication. and when you give more insulin and more diabetesmedications, the side effect is weight gain, and we know that there’s a lot of otherundesirable effects of overmedicating to control blood sugars. so there’s really [00:14:35] an incrediblypowerful tool that is getting diabetics off

medication, allowing them to lose weight,and normalize their condition. so that’s really powerful. i mean, we spend four times as much moneymanaging diabetes as we do cancer, but it doesn’t seem to get the same attention. and just the level of suffering in this countryand, really, around the world, this is not something that’s isolated to the u.s. byany means. all developed countries are suffering fromincreases in diabetes and obesity. so this is something that can be employedaround the planet to help our colleagues across the sea, and china, now, has 100 million peoplewith type-2 diabetes.

india, i think, has similar levels. so this is something that’s affecting over,really, half the population has some level of diabetes, whether that be pre- or fullon type-2 diabetes. dr. pompa:hey, jeff, speak a little bit about—becausewe had a conversation with professor seyfried about cancer, and he always says the key islowering glucose, right? if you don’t lower glucose, people don’tlose weight. if you don’t lower glucose, tumors don’tshrink. so as glucose drops, ketones rise, and i—mydoctors and myself, we realize that, and even people that are on a—in a keto diet, ifwe don’t see a drop in glucose, we seem

to see no weight loss. so we have noted that restriction is veryimportant to often times get the glucose down. some people—most people that are healthy,when they go into a keto diet, they start—their appetite starts to go down as they becomemore efficient fat burners. but that doesn’t happen for everybody, andtherefore, often times their glucose doesn’t drop because they’re still eating, perhaps,too much. what’s your thought on that? dr. volek:yeah. i think there’s a lot of, perhaps, holesin our knowledge here, but our experience,

when you really get the diet correct and theterm i like to use is a well-formulated ketogenic diet, glucose does normalize in most people. a lot of people run into problems when theyoverconsume protein, and protein can get converted to glucose and actually inhibit ketosis. what we find is, when people are keto-adapted,keto-adaptation is a process that takes at least several weeks. maybe in certain pathways it may take monthsor even years to fully keto-adapt. but one of the most profound metabolic adaptationsto keto-adaptation is you switch fuel to almost exclusive reliance on fatty acids and ketones.

and the corollary to that is you also significantlyreduce glucose flux or glucose uptake in the cells. so when we measure, for example, respiratoryquotient in people who are keto-adapted, they are at close to .7 or .71, which is an indicationthat they’re burning 90% plus of their energy from fat, and that implies also that there’sa significant inhibition of glucose metabolism in uptake in the cells. now a lot of people don’t quite—they flirtwith that keto-adaptation, so they’re not quite there, and i think those are the oneswhere the glucose trickles up. and they—i would imagine—and we haven’tstudied this, and i don’t think there’s

a lot of direct evidence. but i would imagine you’re not going toget the full benefits in cancer unless you become fully keto-adapted and reduce thatreliance and uptake of glucose in cells, and i think that that’s what tom has reallygot his finger on well. that to get the full benefits of ketosis—imean, we know ketones in and of themselves have a lot of important cellular effects thatextend beyond just being an alternative fuel for the brain, which is what the standardfunction of ketones are. but we know now that they’re having potentdrug-like effects or hormone-like effects in cells that are turning on pathways thatare related to protection from oxidative stress,

for example, that are the same pathways thatare upregulated in the studies that have looked at longevity and anti-aging. and so having the ketones is important toget those signaling effects. and then the flip side is having low glucoseis equally important, especially for the tumors that are relying on glucose for fuel. so i do think tom really has this right whereit’s the combination of both. you got to have ketones high, and you gotto have glucose low. and how we best do that in people i thinkwe’re still trying to figure out. because now we have ketone supplements wecan give people.

there are many different versions of ketogenicdiets that people can play with, and which ones are ideal for certain types of cancersand so forth, in humans anyway, we don’t really understand this very well. dr. pompa:yeah, we have noted that when weget the ketones up, the glucose down, that’s where the magic does happen, right? dr. pompa:it’s the ketones turn off badgenes. the ketones down regulate cell inflammation. the ketones do decrease that oxidation, andthen, likewise, the lower glucose, same thing. so it’s such a win-win, and i always givethree reasons why.

if someone’s not getting into ketosis ornot losing weight, they could—obvious, they may need to lower their carbohydrates more,right? i mean, everyone’s genetically different. some people can get in at 50. some people, i’ve had people get in at 80,for goodness sakes. some people have to drop it down to 20 or30. so that’s a factor. second factor you mentioned, eating too muchprotein. gluconeogenesis, it can turn to sugar.

i’ve seen that as a factor. in some people, just consuming too much food. they’re just simply consuming too much food,and tom talked a lot about that so three reasons for people to look at if they’re not gettingthe results. and then, meredith, you had a question. because gender, right, some women have troublecrossing in, especially in the beginning. sometimes i have to move them in and out oftrying to get into ketosis before they break in. so gender, does gender play a role, jeff?

dr. volek:well, i think, yeah, it can. but our experience is it’s more relatedto the level of insulin resistance. dr. pompa:yeah, okay. dr. volek:so if you have any person, whethermale or female, the higher the level of insulin resistance, generally, the more difficultit is to get them in ketosis and the longer it takes to keto-adapt. dr. pompa:what about the… dr. volek:importantly, they eventually do,and that’s what’s really important here. that no matter how insulin resistant you are,you retain this metabolic pathway to adapt

to ketosis. it’s so ancient. it’s part of our—it’s just so—a hugepart of our human evolution, and it’s almost always perfectly intact, even in the mostprofoundly insulin resistant people, because burning fat and oxidizing ketones is not dependenton any of the insulin signally pathways. so that’s what’s so really elegant aboutthis tool is it works great in people with insulin resistance. it makes them completely able to have idealfuel flow, even though they may remain insulin resistant.

dr. pompa:what about thyroid resistance? obviously, just general hormone resistancebut we’ve noted, as physicians doing this, that our thyroid people, like diabetics, havemore trouble getting in. however, you said it best. eventually, they will. but speak to that a little bit. dr. volek:well, in general, what we’ve seenis that sensitivity to many hormones increases when you’re keto-adapted. dr. pompa:right, correct.

dr. volek:that’s clearly the case with insulin. you often improve the insulin sensitivityin folks. we’ve also seen that with leptin. that leptin goes down markedly in folks, andit’s disproportional to the fat loss. so to me, that’s suggesting an improvementin leptin sensitivity. and then we also see a consistent drop inthyroid hormone, and i think there’s been a lot of misinterpretation and misinformationpropagated around the thyroid hormone responses because we see absolutely no functional evidencethat there’s any signs or symptoms of hypothyroidism. so metabolic rate doesn’t go down, and peoplearen’t cold and dry skin and all these types

of things. so to us, that is an indication that peopleare just more sensitive to the thyroid hormone. so they can get by with having less circulatingt3, and still maintain their metabolic rates. so i think in those three examples, they allpoint to more efficient hormonal regulation of cellular processes. so you don’t need to have as much hormonearound. dr. pompa:jeff, i couldn’t agree more. i believe hormone sensitivity is the key. we have most people walking around, even non-diabeticsor even not even diagnosed as pre-diabetic,

still having to many insulin and glucose spikes,which decrease the sensitivity of hormones. in vogue today is giving more hormones, whetherit’s thyroid, whether it’s estrogen, testosterone. that’s in vogue. but i always say it’s like shouting at thekids. eventually, they start hearing you less. so giving more hormones often times is needed. however, most often, it’s not the answer. the key is becoming more hormone sensitiveat the cell, and that’s what i just heard you say.

dr. volek:yeah, absolutely. i think we’re entirely on the same pagethere. i really appreciate that. so meredith, i know that you’ve had someother questions, and i do want you to speak a little bit about some results about heartdisease. because i think there’s a misconceptionthat these diets are potentially bad for heart disease, but meredith, you had a questionon that before we leave that topic. meredith:well, i don’t know. actually, i don’t think i did.

i have a lot of questions about the impactof the ketogenic diet on athletic performance. so i think once we shift over into that, ifyou want to speak to your results on heart disease, dr. volek, that’d be wonderful,and i’d like to have a conversation on how it impacts our athletic performance too. dr. pompa:yeah, great. dr. volek:sure. well, a lot of our work over the years hasfocused on understanding cholesterol and lipoprotein metabolism. and that is extended into looking at fattyacid composition, and that’s gotten us into

looking at saturated fat metabolism when aperson is keto-adapted. and what i can say is that almost every biomarkerof cardiovascular risk improves on a ketogenic i agree. dr. volek:and you can just go down the list. triglycerides plummet. hdl goes up in most people, or in some, itstays the same. but it’s still a more potent tool than exerciseand weight loss or any drug, really, in terms of the triglyceride decrease and hdl increase. so those are obviously positive.

as the inflammatory markers get better, it’sa potent anti-inflammatory diet. oxidative stress goes down. now the one response that gets a lot of physiciansnervous and anxious is the ldl cholesterol response. dr. pompa:i was going to ask. dr. volek:and we spent a great deal of timestudying this. the reality is if you look at ldl cholesterol,i mean, i think, in general, we’ve overstated the importance of ldl cholesterol, and that’slargely been driven by greedy drug companies that want everybody to be on a statin.

dr. pompa:yes. dr. volek:but let’s just assume for a secondldl cholesterol may carry some increased risk of heart disease. what you’d see, though, is about half thepeople show an increase in ldl, and the other half show a decrease. dr. pompa:that’s right. dr. volek:but there’s probably about 10-20%of individuals who show quite a marked increase in ldl cholesterol. dr. volek:saying over 50 milligrams per deciliter,some people even higher, and that really alarms

people. and i get emails every day almost from people. should i go on a statin? my doctor’s going crazy. so this brings us to an important topic aroundldl cholesterol in that we now have very good evidence that ldl cholesterol is a heterogenicparticle. meaning there’s a lot of different typesof ldl cholesterol that range in size and range in density and composition. dr. volek:and we have very, very good evidencenow that the small ldl particles are the ones

that are most atherogenic, and these—it’smany reasons. they have a longer residence time in the circulation. they are more prone to oxidation. they can probably penetrate the arterial walleasier. and a low-carb ketogenic diet is more potentthan anything, including statins, at decreasing these small atherogenic particles. so even if you’re one of these people thatyour total cholesterol and ldl went up quite a bit, almost all cases, your small ldl particlesalmost surely went down, and so that’s a really important fact that is going to berelevant in terms of cardiovascular risk.

dr. pompa:now, jeff, i’m one of those uniquepeople. when i—and i’ll explain why in a minute,but in the summertime, i actually go into ketosis. in the wintertime, i actually move out, andthat’s for performance reason, which when we get there i’ll talk a little bit about. but i’m one of those odd people that myldl does go up. my triglycerides dramatically go down. all of my glucose, inflammation markers, dramaticallylower for the better when i’m actually in however, my particle number of ldl actuallyraises.

now, my smalls don’t change. so my smalls are normal., but my particlenumber goes up. now you and i agree. total cholesterol doesn’t matter. even high ldl, i don’t think it matters. however, the particle number and the particlesize, those two things lead to more oxidation. so now what about the particle’s numbergoing up and not the size? what’s you’re feeling on that? dr. volek: well, part of that particle numberis driven by the total concentration increase.

but the fact that your small ldl numbers aren’tchanging or in most people they do go down, even if their total goes up, that is unlikelyto contribute to higher risk in any of the—we don’t have the long-term studies. this is the limitation in most of this researchwhere we’ve followed people long enough where you have heart endpoints. where you’ve looked at mortality or you’velooked at actual heart attacks. so you always have to look at these intermediateswith a grain of salt because none of them are that great at predicting heart attack. i mean, over 50% of people who have heartattacks have perfectly normal ldl cholesterol.

so that tells you right there that this isa pretty weak predictor of actual risk. but this gets into a lot of nuances, and ithink you’ve touched on a few things that make it more complicated than even particlesize. and that’s, ultimately, are these particlesoxidized and are they contributing to pro-inflammatory environment? those are the processes that really contributeto atherosclerosis and plaque development in the arteries, and so if you’ve got alot of cholesterol, even a lot of particles circulating in the plasma, hey, that’s fine. you just don’t want them in the arterialwall.

dr. volek:in fact, having higher cholesterolmay confer some protective effects. dr. pompa:absolutely. dr. volek:i mean, that’s maybe a provocativestatement, but there’s some evidence to support that. so cholesterol in the blood is good, cholesterolin the arteries, not good. what contributes to cholesterol in the arteries? well, not so much the concentration but morethe pro-inflammatory environment, the pro-oxidative environment that contributes to that. and those almost always get better on a ketogenicdiet.

even if you happen to be one of these hyper-responderslike yourself. i’m just the opposite. i’ve been ketogenic for 20 years, and mycholesterol is more than 78, and so i don’t have to worry about it. but i know there’s a lot of people out therethat—and it’s just genetics. we don’t understand how to predict thosepeople, but we certainly see it. and i personally don’t think it’s a contraindicationor something to worry about because it’s an isolated increase, and across the board,you look at every other risk factor, it gets better.

dr. pompa:well, i think you said it best. they’re ignoring the obvious. the glucose, the elevated glucose spikes,even in nondiabetics, and insulin spikes, which drive oxidation, is really the biggerproblem than even the small amount of cholesterol they have is oxidizing. and oxidized cholesterol is the problem. not total cholesterol. and i think we’re in total agreement there. dr. volek:so, yeah, the other piece of thisthat i’d like to mention quickly, it’s

the composition of these particles. so if you have a lot of saturated fat insideyour cholesterol—or your lipoprotein particles, that is a consistent risk factor for bothdiabetes and heart disease and certain types of cancer, and so this becomes a very importanttopic when it comes to heart disease. and it starts to tie back to the saturatedfat paradigm. so it turns out that all the latest evidencethat’s been reviewed in i think, at least, four or five meta-analysis in the last threeyears have shown no correlation between dietary saturated fat and heart disease. dr. volek:so that, i think, puts the nailin the coffin of the low-fat paradigm, the

diet-heart hypothesis. but still, people get very concerned. because on a ketogenic diet, now you’reeating two or three times as much saturated fat as you may have been on a high-carb diet,and so we’re interested in what happens to saturated fat levels in the body on a ketogenicdiet. so in three separate studies now we’ve shownthat, despite eating two to three times the level of saturated fat on a ketogenic diet,saturated fat levels in the blood go down. dr. volek:and again, that’s what’s important. because if you are carrying more saturatedfat in your circulation, in your membranes,

that is highly associated and consistentlyin studies puts you at higher risk for heart disease. so the way—the soundbite we use for thisis, “you aren’t what you eat. you are what you save from what you eat.” and if you’re eating saturated fat, that’sfine. saturated fat itself is very benign and contributesto satiety and pleasure and palatability of food. dr. volek:what’s the problem is if you eatit with carbohydrate. dr. volek:it’s the carbs that you’re eatingthat are setting you up to store it and accumulate

it in cells. but if you don’t eat a lot of carbs withthe saturated fat, you actually burn it. saturated fat is a preferred fuel on a ketogenicdiet, and so it’s not accumulating and causing harm. it’s being oxidized and converted to co2in water, and that’s why you see actual levels go down despite the fact you’re consumingmore. dr. pompa:well, i think, talk it about… dr. volek:you need it. you need the saturated fat on a ketogenicdiet for fuel, and those foods that have saturated

fat are ideal foods on a ketogenic diet. dr. pompa:i love to give the example it burnslike natural gas on your stove. you don’t see smoke as opposed to how glucoseburns. you look at the wood in your fireplace. you need a chimney. that’s glucose. dr. volek:that’s great. i think i’m going to steal that. dr. pompa:you’re welcome.

dr. volek:ketones and saturated fat, they’reclean burning fuel. absolutely and more efficient. that’s why those gas carbs can run a longtime. they’re cleaner and more efficient. dr. pompa:yeah, absolutely. meredith:and i have a quick question too. i love what you’re saying about saturatedfat, dr. jeff, and i eat a very high-diet myself, and my cholesterol is only 180. so i was wondering.

have you seen genetic differences in perhapsthat some people are more suited to ketogenic diet genetically than others? we were interested in that question aboutten years ago before we had a lot of more sophisticated omix tools. but we did a lot of genotyping in our studies,and there was a lot of hope and belief that genetics would be able to predict how peoplerespond to diets. but we were very disappointed. you can explain a very, very small amountof variability by looking at genotypes in so i’m more interested in measuring nowdynamically changing biomarkers because your

genotype doesn’t change. your snips are the same. what i’m interested in is studying morebiomarkers that are providing almost real time information on how people are processingthe carbs they’re consuming on a real time basis, and that moves us in the directionof someday having some objective markers that would tell us if we’re consuming carbs belowour tolerance or above our tolerance. so yeah, in answer to your question, the genotypinghasn’t really led to any insights in terms of responders or not. i find there’s very few, if any, contraindicationsto a ketogenic diet.

so as we were saying earlier, some peoplemay find it a little more difficult to get into ketosis and keto-adapt, but outside ofsome very rare genetic mutations, everyone can do it. we’re going backwards. dr. volek:you may not need to. if you’re one of the lucky ones and youcan maintain health on a high-carb diet, then you may not need to. but at least you can, and that’s where,if you’re insulin sensitive, you have more options.

you can probably do fine on a higher carbdiet. but if you’re insulin resistant and carbintolerant, you really need to restrict carbohydrates, but pretty much anyone can adapt. dr. pompa:well, everyone can adapt becauseit’s life or death. i mean, every human has the ability to goin and out of ketosis, and i believe it actually makes us healthier just even moving in andout of it. because this is what our ancestors had todo. often times, they were in states of fasting,states where they only had this food or that, and it was forcing them into these variations.

i wrote an article, jeff. you should read it, called diet variation. i think you would enjoy it. it’s on my website. but, yeah, i mean, i agree. jeff, i think that there’s too much todayput on these snips in the genotyping whereas, clinically, i’m just not seeing the value. i think that the snips, the body—we knowso little that the body epigenetically starts to change things and move around these snipsand adapt in different ways.

and i think that even in the alternative world,i think there’s being too much put on that. what’s your opinion on that? i agree totally, and that’s starting togo out of vogue, and epigenetics now is the big thing. which as you were saying, it’s that epigeneticsis really looking at how genes are expressed. and we learned just a couple years ago howpotent ketones are at affecting gene expression. so a ketogenic diet is having very potentepigenetic affects. dr. pompa:yeah, amazing. dr. volek:the primary ketone body, beta-hydroxybutyrate,was just recently discovered.

this was in the science paper published atthe end of 2012. so this is really new stuff, and it givesus a whole different perspective on ketosis. but they showed in very elegant experimentsthat beta-hydroxybutyrate was a potent histone deacetylase inhibitor, and that’s a longfancy term. but that’s a very common and well-studiedtarget of epigenetic modulation of gene expression. and i can tell you a lot of drug companiesare desperately trying to find molecules to develop into drugs that basically target thesame mechanism, and here we have a natural metabolite that elevates when you restrictcarbs that has the same epigenetic effects. so it’s really exciting, and it gives usa whole new perception of how a ketogenic

diet is having therapeutic effects. dr. pompa:i think you said it. a lot of what i teach is turning off thosebad genes. whether you’re a thyroid person, someonewho struggles to lose weight, those can be genes that can get turned on. we know utilizing ketosis and ketones turnsoff and has the ability to turn off those genes. i mean, this is new science, but it’s realscience, and it’s very—it’s really amazing. and i believe that these dietary shifts, whati call diet variation, really lead to a lot

of these bad genes getting turned off. well, anyway, so this is the performance sideof the talk. i mean, you wrote the book, “the art andscience of low-carbohydrate performance.” look, your colleague, stephen phinney, i methim here in park city, and here in park city, we are the endurance capitol, little city,of the world. i always say that people here either do onesport a day or three. so we have people who run in the morning,cycle in the afternoon, and go lift weights somewhere in between. they are the high-carb group here, jeff.

i mean, come on. high-carbohydrate diets and endurance, i mean,this is—how can it be low-carb? it’s a little bit like the world turnedupside down, and it’s interesting that this is going on in parallel with what’s happeningin general consumer nutrition and taking on the dietary guidelines and all of the low-fatparadigm. in parallel, you’ve got sports nutritionover here that’s also for the last 40 years been under the belief that athletes have tocarb load and have to have high-carb diet to perform optimally and recover, and nowthat’s being challenged. dr. volek:and so that is really fascinatingbecause it’s been so reinforced by the sports

beverage industry and economy that we’vegot to have these gatorades and powerades after we—even if we run on the treadmillfor 15 minutes, you got to drink gatorade, and we’re basically cancelling out all ofthe benefits we get. dr. pompa:jeff, i can argue… dr. volek:so there’s paradigm shifting,and a lot of it is happening in the grassroots level. it’s real athletes that have made the decisionto switch their diet and abandon their carb loading, and instead embrace a high-fat, low-carbdiet. and to even my surprise, many of these athletesare not just able to compete and finish races,

many of them are winning and, in some cases,setting course and even national records in ultra-endurance. dr. pompa:what’s the—the western 100,what’s the gentleman’s name? didn’t he win the last three years the 100-milerunning race? he’s in ketosis. correct? dr. volek: yeah. well, tim olson won in 2011, and i had mylab group out there. we were studying a whole bunch of athletesthat were on a low-carb diet, and so tim set

a course record that year, and came back andwon it again in 2012. and i think he’s definitely on a low-carbdiet, whether he’s in ketosis or not may be debated. but there’s no doubt he’s not followingthe high-carb approach, and he’s not the only one. there are many successful ultra-endurancerunners who are clearly abandoning their carb loading and benefiting from a high-fat, low-carbdiet. and we’ve had the opportunity to study manyof these elite athletes in the lab to see what makes them tick, and they are nothingbut extraordinary.

what’s the—phinney was involved in themovie called “running on fat,” right? and the gentleman and his wife rode from californiato hawaii in ketosis, and that was the movie. were you part of that at all, jeff? dr. volek:well, i know sami inkinen and merdithloring who are married and did row; i think it was 2,000 miles from california to hawaiiunsupported. and they really did that to show that it couldbe done without a lot of sugar and carbohydrates. so they were keto-adapted and did a phenomenal,unbelievable performance. setting a record, actually, and beating outsome three and four-man teams that they were competing against so just an enormous featof endurance done with very little carbohydrate.

what’s the name of the movie? dr. volek:it’s “fat chance run,” wasit? dr. volek:or no. dr. pompa:i forgot too. dr. volek:actually, i’m blanking on theexact title now. dr. pompa:yeah, me too. i’m with you. it was all about this paradigm shift in athletesswitching from high-carb to low-carb diets and experiencing widespread benefits in termsof their health and performance and recovery

abilities. it was remarkable. well, meredith, you had a lot of questionsregarding performance because that little girl’s quite the athlete, and she performson a very low-carbohydrate diet in ketosis often times so, meredith. meredith:oh, well, i don’t know if i’dconsider myself too much of an athlete, but ketosis has massively impacted me in a lotof positive ways. something, first of all, what constitutesa ketogenic diet for athletes that you think would be well-balanced and well-formulated?

can you walk us through a day of what thatwould look like? dr. volek:well, yeah, i think i could probablydo that easier for a ketogenic diet where—i don’t know if these athletes, all of themanyway, are truly in ketosis or if they’re introducing enough carbs around exercise. there’s no standardized approach all theseathletes are taking. they’re figuring out what works for them. so it is varied from athlete to athlete. but in general, what i consider a well-formulatedketogenic diet. obviously, getting the carbs low enough toinduce ketosis is kind of straightforward

but, also, the protein. so this is not a high-protein diet, but it’snot a low-protein diet either. so you really need to get protein in the rightrange where it’s low enough, you induce but it’s not so low that you’re goingto be in the negative nitrogen balance. that’s muscle loss, the lean body mass loss. it’s kind of this goldilocks state for protein,and that’s really important. beyond that, other things that people don’talways appreciate which can often result in side effects or suboptimal responses; oneis the type of fat. so because carbs and protein are limited,this is a very high-fat diet, especially if

you’re not restricting calories. so if you’re one of these athletes who’strying to eat enough energy to maintain your training, this is an extremely high-fat dietand the type of fat becomes very important. because the main function of fat is for fuelon a ketogenic diet.â  dr. volek:and the best fuels are the monounsaturatedand the saturated fats. the polyunsaturated fats are important. they’re the essential fatty acids, but youonly need very small amounts of these to meet your essential requirements. so they’re more like vitamins and mineralsin my mind, and they’re not tolerated at

high levels. so you can run into a lot of problems. dr. pompa:okay, jeff, for our viewers, letme just put that in perspective. so we don’t need as much fish oil, right? there’s benefits to those polyunsaturatedfats, and vegetable oil, we don’t like anyway. but what you’re saying is, hey, we needmore grass-fed butter. we need more of those types of saturated fats,and then of course, olive oils and other oils can have some other affects as well. so putting them in…

dr. volek:yeah, the natural foods that—naturalanimal-based foods that are higher in fat naturally have low pufa levels. where people run into problems is with soybeanoil, and corn oil, and safflower oil, and peanut oil. and so it’s easy to not buy those, but whereyou end up seeing those is in salad dressings and mayonnaise. so it’s very difficult to find versionsof those that don’t have soybean as the first ingredient. you’re now starting to see them pop up alittle more.

but that’s really important because it willmake people nauseous if you eat a lot of soybean oil or a lot of mayonnaise that has soybeanoil in it. so the types of fat’s important. the other area is in mineral balance whereyou can run into a lot of serious problems if you don’t understand how to manage sodiumon this diet. so a lot of people are afraid of salt. because we’ve been told we eat too muchsalt, and we need to reduce it. it turns out that science doesn’t supportthat and it actually refutes that. if you restrict sodium, it may actually increaseyour risk for heart disease.

but we won’t go down that path right now. but definitely, when you’re in ketosis,the kidneys go through a very profound adaptation where they excrete more sodium, and it’scalled the natriuresis of fasting or, in this case, the natriuresis of ketosis. and if you excrete sodium, you also lose fluidwith that, and so that manifests in a contracted plasma volume or a reduced blood volume. and that’s what a lot of people feel as—andthey call it the atkins flu, or they feel lethargic or tired. they may get dizzy and faint when they gofrom a seated to a standing position.

some people, they get headaches, even constipation,and in most cases, they blame it on the lack of fiber or lack of carbs in their diet. but nine times out of ten, it’s the lackof accounting for that extra sodium that’s lost. dr. volek:and you have to eat an extra gramor two of sodium on a ketogenic diet to maintain plasma volume, and if you’re an athlete,that’s especially important because it’ll affect your cardiac output and performance. and i won’t go into all of the nuances ofthis, but if you don’t address this, it’s not just those inconvenient symptoms.

you end up with a counterregulatory responsewhere you end up stressing the adrenal glands. because the body wants to try to reabsorbsodium, you secrete aldosterone, and that causes you to retain more sodium at the expenseof potassium. so you end up excreting more potassium. you end up in a negative potassium balance. and it’s impossible to gain muscle and evenmaintain muscle if you’re in a negative potassium balance, and it ends up affectingmagnesium balance as well. so you end up with all these mineral imbalances,and there’s one simple countermeasure. it’s just, have a little extra salt in yourdiet.

so we recommend people consume broth, butit can really be any source of sodium to make up for that loss of sodium. so that’s another big component of a well-formulatedketogenic diet that can trip people up. dr. pompa:yeah, i have—we acknowledge thatfully, and i have something called my 2-2-2 rule. just to get the—make sure they’re gettingthe better fats. two tablespoons of coconut oil a day. two tablespoons of grass-fed butter a day,and two teaspoons of sea salt or some type of salt.

so just to make sure some of those bases arehit. because if you don’t make it simple forpeople, they just simply forget, right, and then they end up going i’m weak. i feel tired. my heart’s palpating. and it’s typically, like i said, one ofthose things, especially the electrolytes and the mineral imbalance, so very well said. jeff, i go into—and i said this earlierin the show. i said i go into ketosis in the summer.

why? well, because i love cycling. i’m an endurance athlete. but when i do that, i lose my muscle veryeasily. i can eat muscle into sugar pretty quickly. however, when i’m in ketosis, i don’t. so two reasons, i keep my muscle, even thoughi do high-endurance in the summer, and i’m “bonk proof.” i can literally get up.

not eat. i am even, partly, later in the day stillnot eating. i can go on a three-hour bike ride, and ido not bonk because i’m fat-adapted. so these athletes that—for me, even justat low-carb, i don’t have that effect unless i’m absolutely in ketosis, fat-adapted. then i can run on fuel. and maybe it was you that said this, and iloved the analogy. look, the average human can store about 2,000calories in stored sugar. however, even as lean as i am, i have at leastprobably 80,000 stored calories of fat that

i’m able to tap into. and when i’m biking for all those hourswithout eating—because i didn’t eat through the night, and i didn’t eat through themorning, and i had went out with a group probably about noon one day. so i had already fasted 15 hours. we went out and rode for three and a half. i had not one bite of food, and i didn’tbonk. and they were astounded because they predictedmy bonk. so despite going, whatever that was, 17 hourswithout food, even when we were done, i was

still fine. that’s the beautiful part of being fat-adaptedin ketosis. you summarized it very well. that ability to be able to access and utilizeyour fat stores is one of the most important adaptations of a ketogenic diet, and that’smanifest in so many positive outcomes for these endurance athletes, including cognitivebenefits. dr. volek:because they become bonk proof,and their brains are able to utilize the ketones. so they remain very lucid, and don’t becomedisoriented at the end of these races, which is very common in the high-carb athletes.

another—i think the bodybuilders and theweightlifters are coming around to this. they usually went high-protein, but they’rerealizing the benefit of being in ketosis. and i do something, jeff, where i [00:56:48]. meredith:dr. pompa, looks like he’s frozenthere. dr. pompa:sorry. i don’t know what happened. my internet blipped out for a minute. anyways, i don’t eat in the morning. i intermittent fast, and i benefit from mybody’s ability to burn fat and keep burning

fat whereas the old adage, i believe it’sold, is eat the five or six meals a day. we never give our body a chance to burn fat. when we’re fat-adapted, man, we want togive our body a chance. and there’s two—and i’m not tellinganyone to do this. because the guys, they drop a lot of f-bombs. but they’re called the hodgetwins, and theseguys are built like houses, right? and they’re in ketosis, and they intermittentfast, and they go 19 hours without eating. and these guys are like, look, we do it withouttaking steroids. i mean, these guys are massive, and they’reboasting that it’s all about being in this

intermittent fasting state in ketosis. and what it does for their growth hormoneand testosterone, and that’s how they’re able to compete naturally. if you want a kick, watch it, hodgetwins,google it. but you better be used to a lot of f-bombsbecause they’re funny. they’re funny guys. i think they’re pretty smart, and it’san act. but they do drop a lot of f-bombs. but they really—they prove the point thatthis raises hormones.

it really makes you more hormone sensitive,even to testosterone. meredith:awesome. well we got started a little bit late. so maybe we can have a part 2 because there’sstill questions. meredith:and there’s so much on this topic. it’s really exciting, and your researchis amazing. so do you want to tell our viewers how tofind out a little bit more about you and your research? dr. volek:well, i’m at ohio state universitynow, and as you mentioned, i have a couple

books. the most recent i wrote with steve phinneycalled “the art and science of low-carb living,” and the companion to that for athletesis “the art and science of low-carb performance.” so those are available on amazon. meredith:awesome, great. well, thank you so much for joining the showand for everything you’re doing. and we’ll definitely have to schedule youfor a part 2, and thank… dr. volek:i’d love to come back. meredith:awesome, awesome.

well, great to meet you. thanks for watching everyone. stay tuned next week. we’re going to be interviewing ben greenfieldon low-carb fueling for athletes. so it’s going to be an awesome follow-upto this topic as well. we’re going to continue to delve more intothis, and to get you guys the information you need. so thanks for watching everyone. have a wonderful weekend, and we’ll seeyou next time.