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

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

July 16, 2019 53 By William Morgan


– Nutritional ketosis
is a very powerful tool.
And it can be used to achieve
metabolic health and
well-being in people who have
diseases associated with insulin
resistance or inflammation.
Now, there are lots of
myths and misunderstandings
about ketogenic diets and
about nutritional ketosis
and I wanna really focus
on the scientific evidence
around safety and efficacy of
this approach to nutrition.
And I realize it’s hard
for people to commit
to this kind of endeavor if
people around you are saying,
“Oh, this is dangerous so
you shouldn’t be doing it.”
So you need to be confident
that if you undertake this
that you’re doing it in a
safe and efficacious way.
In study after study,
not just ours but others,
a well-formulated ketogenic
diet when compared
to a standard calorie
restricted low fat diet
has a greater effect on weight loss
and particularly loss of
abdominal adipose tissue
and it’s the adipose tissue or
a fat mass within the abdomen
that is the most dangerous
fat that we carry in our body.
For instance, a study that
I did with Dr. Jeff Volek
and Dr. Cassandra Forsythe,
one of his graduate students,
we compared a high carbohydrate low-fat
calorie restricted diet
to a ketogenic diet
that people followed
where their instruction
was to eat to satiety,
that is not count calories
and don’t restrict calories but eat enough
to feel like they had had enough food
and they weren’t hungry.
And we ran the study for 12 weeks.
And at the end of 12
weeks, the weight loss
in the high carbohydrate
low-fat group was about half
the weight loss in the
ketogenic diet group.
Now, some critics will
say that well, when you go
into ketogenic diet, a lot
of your weight loss is water.
But we actually did careful
measurements of body fat
and the water loss on the ketogenic diet
was only about 1/5 of the difference
so five kilograms on the
carbohydrate rich low-fat diet
and 10 kilograms on the ketogenic diet
and only about 1/5 of
that difference was water,
the rest was body fat.
More importantly, we used
the dual x-ray absorptiometry
so called DEXA technique to
measure body fat content.
There is a significantly greater reduction
in abdominal fat, so
it’s not just total fat,
it’s not fat from under the skin,
but it’s some of the most dangerous fat
is more rapidly mobilized
when someone gets
the ketogenic diet right.
The next most common effect is for people
who have either slightly
or markedly elevated
blood glucose levels, so
either prediabetes or diabetes,
a prompt response of the ketogenic diet
is a reduction in blood glucose.
Now, that makes sense because
if you eat less carbohydrate
in a diet, there’s
going to be less glucose
produced by digestion and
the level of sugar coming
into the blood is gonna be reduced,
that’s what we commonly see.
However, in Dr. Forsythe’s study…
Now, these are people with prediabetes
but their blood sugars are
still slightly elevated.
We saw a marked reduction in blood glucose
in the people on the ketogenic diet
and no change in blood
glucose in the people
who were on the high
carbohydrate low-fat diet.
What’s more interesting
is that we also measured
blood insulin levels.
And insulin’s a hormone that
makes glucose go into cells,
so if the blood sugar
came down, you’d think
that the body was making more insulin
to make it go into the cells.
But it was the opposite of what we saw.
And that is that insulin
level came down dramatically,
blood glucose came down.
And the only way you can
make sense out of that
is that the ketogenic diet
improved insulin sensitivity,
that is the body’s response
to any one molecule of insulin
is markedly greater.
And that’s a consistent finding we’ve seen
across multiple studies
and that’s the finding that
has let us to the concept
that we can actually
reverse the root cause
of Type 2 diabetes.
Another effect of a
well-formulated ketogenic diet
is to change the blood lipid values
that are characteristic
of metabolic syndrome.
And, by the way, metabolic
syndrome is also referred to
as prediabetes.
Typically we’d see with metabolic syndrome
a reduced good cholesterol,
an increase in triglycerides
and a greater proportion
of the small dense
or bad LDL cholesterol.
And when we looked at that in this cohort,
we saw that triglycerides plummeted.
Now, they went down in both groups
but they went down more than twice as much
in the patients on the ketogenic diet.
And by they way, they
were eating more fat,
and yet the blood fat levels dropped.
HDL went up about 13%
which is greater than any
HDL response we can get
from any drugs that we have available,
that we can write as a prescription.
So this is a pretty much unique benefit
to a well-formulated ketogenic diet.
And then the small dense LDL
which are the most dangerous
didn’t go down.
If anything they went
down slightly in the group
who were eating the high carb low-fat diet
and went down sharply in the group
on the ketogenic diet.
So again, all the lipid changes are going
in the right direction in
favor of the ketogenic diet.
So again, the concern about
eating a high fat diet,
eating maybe eggs and meat and dairy
which contains cholesterol,
the actual, the cholesterol in the blood
and the blood lipids are
changing all in a beneficial way
when one gets this diet right.
If you’re eating low carbohydrate
and moderate protein,
the majority of your dietary
calories come from fat.
And a lot of the fats
that people eat typically
come from animal products or from dairy
and cocoa butter and things,
which are saturated fats.
And so the question is is
eating a lot of saturated fat
dangerous when you’re on a ketogenic diet?
And the reason people
propose it as dangerous
is that we know that when
you measure blood levels
of saturated fat, that
the higher the blood level
of saturated fat, the
greater the risk of diabetes,
a heart attack and overall mortality.
And so if you assume that
eating saturated makes
makes the blood level go up,
that would suggest this is dangerous.
But people hadn’t ever
actually looked at what happens
to the blood levels with saturated fat
when they’re going to
ketogenic diet, so we did.
And what we found was,
even though, the people
on the high fat diet, the ketogenic diet
were eating three times as
many grams of saturated fat
per day, their blood
levels of saturated fat
actually were lower than the group
eating the lower saturated
fat intake high carb diet.
And again, this is a head scratcher.
It appears that we’ve disconnected intake
from blood levels.
And that violates the law
that all dietitians tell you
that you are what you eat.
In actuality, you are what
you save from what you eat.
And the neat thing
about the ketogenic diet
is it teaches your body to
burn fat more effectively.
How effectively?
Well, we did a study where we looked
at highly trained athletes
some of whom were following
a traditional high carbohydrate
loading diet regimen
and the other half of them were following
a well-formulated ketogenic diet.
And these people had been
following these diets
for at least six months or longer,
which means that they
were fully keto-adapted
for the ones on the low
carbohydrate or ketogenic diet.
And when we looked at the
resting rate of fat oxidation,
it was about double as much
on the low carbohydrate ketogenic diet
as it was on the high carbohydrate diet.
So again, highly trained
athletes, theoretically,
their bodies are highly
conditioned to burn fat for fuel
during exercise and yet,
just the difference of diet
doubled the bodies’ ability
to burn fat for fuel.
And then as they…
We had them do greater and
greater levels of exercise,
the people on the
ketogenic diet demonstrated
remarkable ability to use fat for fuel.
The athletes like that
because they can run
on body fat stores much
better than trying to eat
and load with carbohydrate
which means that when you’re keto-adapted,
your body has a capability of
getting rid of saturated fat
and so the amount you
eat is not important,
it’s how much your body
saves from what you eat.
And clearly, the body
doesn’t save saturated fat
when you’re keto-adapted,
which means that saturated
fats are not harmful
when consumed, if you’re keto-adapted.
Another very important
area of current research is
in the topic of
inflammation because we know
that when we measure
biomarkers of inflammation,
and there have been
some that we’ve measured
over the last century,
like white blood cell count
and some that are more
recent additions to our ways
of measuring inflammation.
That those levels predict
the later onset of diseases
like heart disease, Type 2 diabetes,
Alzheimer’s disease and many
of the common forms of cancer.
And so in doing the study
with Dr. Volek and Forsythe,
we actually measured every
biomarker we could think of
and we came up with 14 different
biomarkers of inflammation.
And when we compared them for the people
in the high carb diet
versus people adapted
to the low carb high fat diet,
none of the levels of
inflammation went down more
in the people who were on
the high carb low fat diet.
In contrast, 7 of those 14
were significantly reduced
for the people on the
well-formulated ketogenic diet.
That is on average there
was a marked reduction
in inflammation with the
ketogenic diet, indicating
that this has a wide-ranging
antiinflammatory effect.
Now, up until recently,
that’s been what we scientists
call a phenomenon.
We see it’s happening
but we don’t know why.
And it turns out that
there is a particular gene,
it’s kind of like a traffic cop gene,
it regulates the flow of
traffic around inflammation.
And this gene is targeted
directly by the ketone
that we have circulating…
A primary ketone in our blood
which is called β-hydroxybutyrate, or BHB.
And this is a place where
ketones talk to your genes
and your genes turn down
the heat, if you will,
through a regulated series of events
to reduce inflammation of the body
and that has the likelihood of
having very positive effects
not just on reducing insulin resistance
but also reducing other common
chronic diseases, as well.
Now we not only know that
the inflammation goes down,
but we know why it goes down
and why it is so effective
and even modest levels
of ketones, the levels
that you achieve just by
restricting carbohydrates to less
than 5% of total calories
and keeping protein moderate.
We’re doing a study with
Indiana University Health
where we recruited over 260
people with Type 2 diabetes
and put them on a
well-formulated ketogenic diet.
This study will be going on for two years,
but I want to show you just the early data
from the first 10 weeks of the study.
All these people had the
diagnosis of Type 2 diabetes.
Some were poorly controlled,
some were pretty well controlled,
some were very tightly controlled.
So we divided the biomarker
of diabetes control
called hemoglobin A1c or HBA1c
into high levels, intermediate levels
and well controlled levels.
And in all three cases, after 10 weeks,
there was a reduction in
the level of hemoglobin A1c
and this effect was greatest in the people
who had the highest levels.
So people who had the poorest
control of their diabetes
got the greatest effect, but
all three groups had an effect.
And the result was that over
half of these people moved
from having hemoglobin A1c
levels in the diabetes range
into the non-diabetes range.
What’s really intriguing is normally
in medical care diabetes, you
get better glucose control
by giving people more drugs.
In this case, we took
away most of the drugs
from five of the seven classes
of diabetes medications.
And the two most dangerous
which are insulin and sulfonylurea,
those are the two classes of drugs
that are most likely to cause hypoglycemia
which is probably the most
threatening side effect,
short-term side effect
of in diabetes management
that we either stopped or markedly reduced
the majority of those
medicines in these patients.
And so here, again, we have the paradox,
less medication, better control.
And the reason we can get better control
with less medication is
β-hydroxybutyrate in ketones, in general,
speak to the genes and
change fundamentally
how the body functions,
including changing how the body
responds to insulin so the body
can get much greater benefit
from far less insulin.
And then as a side effect of this, again,
we told people to eat to satiety.
It limited carbs, protein in moderation,
as much fat as they needed, and again,
they can put butter on their meat,
they can put butter or
dressing on their vegetables
and dip with vegetables, things like that.
And so they were eating to satiety,
and yet 75% of these patients
lost more than 5% of their body weight.
And on average, the body weight loss was
as a little bit over 7%.
And that was just in the first 10 weeks.
At six months in this cohort,
the weight loss went from 7% to 12%.
So this is not a short-term
quick loss and then regain,
but it appears to be a
sustained long-term effect.
Because, again, people who
are six months into our study
are doing the same thing we
told them to do at the onset
and that is limit carbohydrate,
protein in moderation,
eat fat to satiety and that
gives the body permission
to burn a lot of body fat
stores because the body
has become so efficient
in burning fat for fuel.
Just to mention other
conditions that we’ve seen
that show improvement
with the ketogenic diet,
just general muscle and
join aches and pains.
Irritable bowel syndrome
typically gets better.
Polycystic ovary syndrome in women.
People with migraine, headaches mention
that either their frequency is down,
the intensity is down and some
people get complete remission
of their migraines when they
get the ketogenic diet right.
As we showed from the
study of Dr. Forsythe,
metabolic syndrome or
prediabetes has improved
along with that liver fat levels go down
which is a side effect of
poorly controlled diabetes.
And we see improvements in fluid retention
and blood pressure, as well.
This is a very powerful tool.
It can have very beneficial effects
on a number of chronic conditions,
but when a person’s taking medicines
for these chronic conditions,
those beneficial effects usually mandate
a sharp and rapid reduction in medication.
And that can be dangerous,
unless you have the assistance
of a physician who
understands this type of diet
and understands how to
manage the medications.
This cannot be done in a casual way,
you can’t start a diet and go
back and see your physician
six weeks later and say, “So
what do you think I should do
with my diabetes medication?”
Because typically we
have most of the changes
in the first six days when
people get the diet right.
The concern is finding a
doctor who understands this
and that is sometimes difficult,
but we see increasing
interest in physicians,
so if you look carefully,
you can probably find someone
who can help you, if you
need that kind of assistance
when you’re following
this type of regimen.
So again, for our conclusion is
a well formulated diet is not only safe
but it can be very effective
in reversing disease.
These effects are so powerful.
However, this has to be started
with careful monitoring.
Stated in this directly,
you have to find a physician
who can help you manage your medications
in the proper way that this
be done where the benefits
far outweigh any potential risks
involving changes in medication use.