Carbs vs. Keto Debate with Dr. Eric Westman and Dr. Mike Nelson

Do you need healthy carbs to feel your best?  Or, should you be ketogenic and very low carb?  A case can be made for either so I decided to organize a debate between two experts to represent these respective views.  This was a very fun and interesting conversation I am sure you will enjoy.

Episode Intro

Dr. Michael Ruscio, DC: Hey everyone, welcome to Dr. Ruscio Radio. This is Dr. Ruscio. Today I’m here with Dr. Mike T. Nelson and Dr. Eric Westman. And we’re going to be talking about carbs. And two things I’m hoping to get out of this conversation. What can people doing a very low carb keto type diet do if they’re not feeling well on that diet and what I’ve termed a low carb triage list and then also have a very friendly debate over the merits and potential detriments of lower carb intake versus higher carb intake. And I’m really excited to get the ball rolling and to introduce Dr. Westman. We met at Low Carb U.S.A. and he asked some really challenging questions when we were both down there. So I said, you know what this would be a good conversation for us to have in front of an audience so that we can all learn something. So that is how Eric and I had met. But, Eric, for people who haven’t heard of you before, would you please tell us a little bit about your background?

Dr. Eric Westman:   Sure. I’m a professor of medicine at Duke University. I’ve been at Duke for 28 years now. I’m a clinical researcher. My primary research is in smoking cessation for about ten years, nicotine research and now diet research for about ten years. So I’m still a professor in medicine with students and residents and have a busy clinical practice. After eight years of clinical research, we opened a lifestyle medicine clinic that basically uses a low carb, high fat or keto approach for all sorts of medical issues. So my vantage point comes from the treatment of problems, medical problems mainly in a therapeutic way using diet as – I find – the most powerful tool we have.

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DrEW:   And now I’m blissfully happy in a clinical practice. I do a lot of teaching based on the clinical research we did. I was asked to help write the New Atkins for a New You book that came out about eight years ago now. And I have a couple of other books with Jimmy Moore. Keto Clarity is one that teaches you how to do keto and I have a couple of new companies based on all this. But I’m happy to continue our conversation from Low Carb U.S.A. about keto. And I’m here to learn about the gut, gut microbiome. So, it’s mutual.

DrMR:   Awesome. Well great. I’m very much looking forward to it because I certainly don’t profess to be a low carb expert. And I’m hoping I can learn a few things from one, and conversely hopefully I can shed light on a few mysteries regarding the gut in the microbiota. And I love the fact that you’re both a clinician and a researcher. I think the three of us can boast that same claim. I think this will be a very productive discussion where we all have our heads partially in academia but also in the clinical practice. So we’re attached to the real world and also plugged into the research literature.

Defining Low Carb

DrMR:   So as we wade into this conversation, Mike, before we had started the recording you said, “Well, how are we defining low carb?” And so let’s go through how we might define – I’m assuming maybe the best way to parse these definitions would be – a ketogenic diet, a low carb diet and then a moderate carb diet. If there’s a better system or classification please let me know. But if we were going to use those three to help orient people, what would you guys propose in terms of what the carbohydrate ranges should be to help identify each one of those?

DrEW:   I can start. The definition that we proposed and wrote in a paper in 2007, The American Journal of Clinical Nutrition and I’m the first author on that paper was that the amount of carbohydrate in the diet can define low, medium, high. We did it in terms of total grams of carbohydrates per day. So if you just added up, in My Fitness Pal or some other app all of the carbs you eat for the day, if you’re under 50 grams of carbs a day we define that as 50 grams or less as keto because most people will be in a keto mode, which basically means you have ketone levels that are higher if you weren’t keto, if you’re eating carbohydrates.

DrMR:   Is this total or net? Or are you distinguishing-

DrEW:   Total only total. So that enters in another whole area we can get into about variability because not everyone reacts to carbohydrate in the same way. So I take the worst case scenario that you’re going to absorb all of the net carbs that are subtracted out. So there are individual variabilities. And I guess you have to understand that the people who come to me are the worst metabolic cases in the world that I need to have at work. Under 50 grams is keto, 50-150 grams we define as low carb and then above 150 grams is moderate and then high but no one really cares about those anymore in the low carb world. It’s more how do you define low, moderate low, ultra low. So we said low is 50-150. Keto is less than 50. Now enter in paleo, which really isn’t defined by grams of carbs a day. It’s more loosely defined or primal or hunter/gatherer of you have all these different names and that’s not the science. The science is based on the grams of carbohydrate per day.

DrMR:   Sure. There may be two different items that we’re trying to optimize for with looking a keto and low carb as compared to paleo. And again I’m open to input on this but I think one of the primary objectives of paleo diet is construing is trying to reduce potentially immunogenic and inflammatory foods. That’s the main goal whereas the lower carb and ketogenic, not that it’s not also trying to operate to that end but I would assume the main goal is really the carbohydrate content. Is that a fair kind of summary?

DrEW:   Sure, but there’s big overlap because most of the inflammatory foods are carbohydrate contained foods.

DrMR:   Sure, agreed. Eric as you’re saying that it reminds me of something that I’ve heard you say Mike, which is there’s a metabolic no man’s land. Where you’ve done low carb but you’ve gone low carb enough to potentially be causing some of the detrimental effects some people may experience by reducing their carbohydrate intake but not low enough to get to the beneficial realm of keto. Can you expand upon that? And then Eric I’d be very curious to hear your thoughts on that in response.

Dr. Mike T. Nelson:  Yeah. Generally I’m dealing with people who are a little bit on the spectrum, are a little bit healthier and more performance orientated. So they’re probably more active also. But I find that if you’re in total grams of carbs approximately 50 to maybe 100, maybe 120 that most people just generally just don’t do very well there. You’ve got a limited amount of glucose but those numbers are usually too high for you to have any significant among of BHB or betahydroxybuterate to be considered in more of a ketogenic type state. So usually if I have someone who says for whatever reason, which we’ll probably get into, I’m going to go into 80 or 75 grams of carbohydrates, depending on what they’re doing, I think they may consider doing a ketogenic diet at that point instead of trying to hang out at these extremely low carbohydrate levels. I just find that people, in general, don’t feel very good. Performance generally goes down. They feel more tired, things of that nature.

DrMR:   And you said that was 50-120.

DrMN:  Yeah, 50-100/120. If it’s a smaller female she may get by on 100. If it’s a bigger guy it’s probably closer to 120. But I usually find that’s the top end. Well, the low end I guess depending on how you look at it.

DrMR:   And that’s something very interesting because it makes me wonder to some of the conversations that Eric and I had a few months ago. If some of the people that are going low carb and not feeling well and then doing better when they increase their cards. Perhaps they can feel better if they went in either direction: either a little bit lower or a little bit higher. I’m also wondering if the population makes a difference. Eric, it sounds like you’re seeing people with many metabolic – I don’t want to draw too many inferences – so high cholesterol, high blood sugar, diabetes, metabolic syndrome, overweight. And then, Mike, you might be seeing people who have pretty darn good body fat and they’re athletic and they’re trying to optimize and they’re performing at a fairly high level.

Carb Intake And Athletic Performance

So perhaps we should be even more discerning with how we enter into this conversation and noting that the population may skew how long you want to try a ketogenic diet. I’m not sure. Eric, do you have any take on that. Have you seen some athletes who have been more prone to perhaps flounder when going lower carb?

DrEW:   That’s interesting. Mike number two, are your clients having higher ketone levels at that level of carb? Do they measure blood, BHB or urine.

DrMN:  I agree with the 50 gram mark that most have to be under that and especially if they’re trying to get into it for the first time. If they’ve been doing it for a period of years it can be a little bit more lenient. But I usually find that they have to be pretty restrictive. Then I would agree that measuring blood, BHB levels is the best marker to determine that.

DrEW:   I’ve seen some data that we’ve collected in our clinic that the breath, blood, and urine hang together pretty well the ketone measurements. But they measure different molecules.

Time To Adapt To Keto

Getting back to the change in metabolism. There’s an interesting phenomenon called keto-adaptation, where time is required for the body to totally adapt from a carb burning, carb eating, carb burning state to a non-carb eating, fat burning state. And as outlined, there two movies that are still really the best resource of information for this. One called Cereal Killers. Donal, the author of the movie, is in a coffin with Corn Flakes around him to dramatize that cereal is the problem. But Cereal Killers II was the second movie that talks about elite athletes doing keto or LCHF, as they call it in the movie. And it took them six months for these two elite athletes to fully fat-adapt. The method was we’re going to measure these people every week and as long as they start burning fat better we’re not going to put them in the rowboat. Then they rowed from San Francisco to Hawaii, again these are two elite athletes.

So if they had put them in the rowboat after one week or two weeks they wouldn’t have performed as well probably. So if you’re going to conclude that keto isn’t for me as someone who does exercise, you’ve got to give it time to have your body adapt to the keto state. So the Cereal Killers II concludes with these two elite athletes breaking the record of rowing from San Francisco to Hawaii by 15 days.

And the real reason they broke the record in retrospect is that had no requirement for rest days. This is the general theme for those who are elite athletes doing keto is they don’t have the same time required for resting their muscles and soreness. Muscles recover faster. In my clinic, it’s mainly people who are therapeutic that they’re sedentary. They’re sedentary going to running. I can count on a hand how many people in the last six months have done that. But I do have some people who have done half marathons totally keto. If someone’s at that level I refer them to other consultants who are consulting elite athletes and keto diets.

Because there is kind of an art to it of adding making sure that electrolytes, the salt is correct. Making sure that sometimes they’ll add carbs during the race or during the event of whatever they’re doing. So there’s a method to it. Steve Finney one of my teachers says, you can’t fly halfway from San Francisco to Hawaii. If you’re going to do keto, you have to go all the way. Which makes me wonder, Mike Number 2, if some of the clients might do better but they have to go down to 20 grams. They have to really get the BHB going, but even then we don’t know the right level of BHB yet.

 

Mike Number 1, you had the question of keto-adaptation symptoms. If someone isn’t feeling well the first thing I think about is salt, not sugar. People will feel better by eating carbs no question. But adding salt in the form of bouillon or broth will probably make people feel better during that first week of keto-adaptation. So what do you think about the idea that maybe it takes more time for some of your clients? What’s your experience with that?

DrMN:  Yeah, I think it definitely from a research area that’s fascinating to figure out what’s going on. The adaptation period to reach higher end athletics is probably extremely long. If you look at Jeff Bulloch’s faster study, the people he enrolled had been doing it for at least a year. And they did show that they rewrote the book on how much fat you can use during exercise. So from an up-regulation of fat, that was a very massive difference in very good athletes who had been doing it intelligently for a very long period of time.

So we don’t really know how far that goes out but we do know that if your sport is more speed and power based that fats or even ketones can’t quite keep up with carbohydrates from a rate of production. So, I think you can make an argument for a ketogenic diet for more ultra-endurance events, especially if they’re doing an event where you have to carry all your own food or move your own body weight, like in the rowboat if they’ve got supplies or not.

DrEW:   Yeah, they pack a lot.

DrMN:  So if you have to carry everything with you. I think you can make an argument that a ketogenic diet may be extremely beneficial because you can use fat that’s extremely dense, doesn’t weight nearly as much. You may give up a little bit in speed and power but you also have to take into account that you’re not moving as much load either. So from an efficiency standpoint, it may be more efficient.

DrEW:   One of my patients is a hiker. He thought he would never go out to the Boy Scout ranch out west from North Carolina. He has now and he carries about half as much in his pack with the kids carrying all the cooking utensils and all the carbs and they cook them and he’s just sitting there eating butter. Fat is a very efficient way to fuel the body. Steve Finney always talks about if you’re going to really go to space and you want to reduce the weight of the payload, keto adapt your astronaut and then send him up. You’ll get twice the food up there for the same weight. Those are academic exercises.

In your experience and from my general teaching the more exercise you do, the more carbs it seems you can eat and still do well in terms of metabolic issues. And then the younger you are the more you seem to be able to have in carbs. That seems like a general principle here. Probably most the people in your population are younger, healthier and then contrast that where I have to be much stricter if someone is sedentary, postmenopausal, in fact, my clinic is populated with older women mainly, 70% women.

Early Compliance Concerns

DrMR:   I’m picturing clinicians listening to this who are saying, “Gosh, there’s been some people we’ve gone lower carb and they just seem to not really do well.” Again they might be skirting in that metabolic no man’s land range of maybe 50-100. So after a little while, they bring people back up in their carb intake, which is something that I’ve done. And they may be wondering, well, perhaps we needed to go a little bit lower.

And so there’s a couple of questions I’m trying to reconcile. One is will that just be a very hard sell for some people from a compliance perspective and then, two, when do you make the switch? I believe in six months. Because that’s again for a clinician whose got a patient who’s trying to get answers and you’re trying to strike that balance of not trying to give them a goal that feels unachievable. Six months may be a tough sell for a clinician sitting knee to knee with a patient who saying, “I’m feeling tired, I’m feeling foggy.”

DrEW:   I know. It has to be immediate. So, for example, today I’m seeing new patients. I’ll explain that within a day or two your hunger is gone and you won’t crave the foods. It’s a day or two if you take the leap to the 20 gram or less total, not net, it’s really fast. And then, of course, I have to acknowledge the people who have a really tough time don’t come back to me. I don’t have a 100% retention rate. Most people do. And I spend about an hour teaching, going through the initial side effects that you might have. Make sure they know about the extra salt and things like that. But there is a big of a selection bias in my experience because those who just couldn’t not have fruit. Don’t come back generally.

Although I say, please come back I have other tools. Most medicinal doctors in the U.S. use phentermine or some other medication. I can use those too, but I start with the keto diet. So that takes me back to the Low Carb U.S.A. lecture where we did a great lecture. But then in the Q and A there was a response that instead of taking somebody down lower in the carbs you did say, “we’ll everyone needs carbs.” And I think I got up there and was, well, wait a minute. You don’t have to. But the practical aspect of making the pitch, making the sell, it’s really just a day or two of withdrawal and cravings for most people. Occasionally it lasts up to a week. But that’s pretty rare.

DrMR:   So a few days maybe a week. That seems really reasonable. So now the question and the thing that I sometimes grapple with is for some people they do well lower carb for a little while. And then at least according to my clinical estimation, they just tend to kind of burn out. And then we add some carbs back in and we’re not talking about giving them a ton. We take them maybe from doing maybe a keto-type of approach, 50-75 grams per day and then have them go up to 150-175, and then all of a sudden the lights come back on.

Low Carb Triage List

But it sounds to me like there might be a couple of things that a clinician would want to make sure to check before doing that. And that’s this low carb triage list. You said adding salt a moment ago. I’m sure people are wondering, would upping their intake of something like a sea salt work? Or would this need to be an electrolyte/salt combination with a few different things like calcium, magnesium, potassium? What do you find to be the best way to specifically implement that?

DrEW:   I think it’s just sodium chloride that’s all that’s needed and it can be in any form. It can be even the el cheapo salt that you get. Most people use a form of bullion or broth to make it a little tastier. But a couple of things: when you took the carb level from 50 to 75-100. I was gasping in these huge increments. I take people from 20-25. From 25-30 as huge increments in the keto world. It’s really a different appreciation for the metabolic effects of carbohydrates. From my training, there’s on a teaspoon of sugar in the bloodstream at any given moment.

If you went from 50-100 grams of carbs and that’s a huge metabolic change. So when we get someone to near their goal. We can teach people if they want, although a lot of people end up not wanting to because they enjoy all the other foods and you can go up on the carbs but it’s like 5 grams per day per week, and see how it goes. But I do want to acknowledge that there’s a certain art to keeping people on track. I do a lot of work trying to connect people to resources. There’s so much on the internet now – a lot of free information – I try to match people to what their lifestyle dictates. If they’re really busy and they don’t want to cook, there are certain resources for that. If they do want to cook, there are other people who want to watch other people cook now. So there are lots of videos that show you how to do keto products or keto recipes and now there are all sorts of keto products that are available.  And even then if someone wants to eat fast food in a pinch or if that’s your finances, you just stay away from the carbs. So I have to address these kinds of lifestyle things. And that’s part of what happens in the first few months when people come back. Otherwise, they’ll just naturally gravitate back to what they’ve been eating all their life, “I needed to go back to my macaroni and cheese.” Well, no actually you didn’t but anyway. It’s part of the art.

DrMR:   The art of compliance. This is where it’s really nice to see different perspectives and how we navigate those. For me, I’ve tended to be a little more lenient with the carbs ’cause we often times have people with IBS or IBD and they’re already restricting FODMAPS or potentially FODMAPS plus their following the SED diet or low FODMAP plus low histamine diet. Their food list is already shrinking. So I have to pick how many battles we can fight at one time.

And this is also the approach I advocate for in Healthy Gut, Healthy You, which is by starting someone on a healthier diet, whether it be paleo or low FODMAP or alike, you tend to see a decrease in their carb intake. A little bit later on down the road, once you’ve got their gut healthy and you’re done focusing on that, this may be a better time to focus more specifically on their carb intake because you’re right, people only have so much bandwidth. And I appreciate that about your perspective Eric which is there’s only so much you can ask someone to do at one time before they just throw up their hands and say screw it. Everyone’s got a different line. For some people, you take away their mac and cheese and they’re ready to jump ship. So we may want people who are a bit more motivated than that.

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What about other things that people should think about? Salts, electrolytes. Are there some other key changes people can make who are struggling. If they’re struggling with fatigue or with cravings or with brain fog or with insomnia. That’s another one I’ve seen some people really struggle with insomnia. What are some of your other go-tos to help get people out of that situation?

Side Effects

DrEW:   Probably the main thing is where did the information comes from? How did they get the information to do the keto diet? One of the best things to do is just do a food recall or see what people are eating.  The term is a properly formulated low carb, high fat diet because there’s a lot of stuff out there where people are now adding in oils and fats and butters. And they wonder why they’re having nausea and loose stools, something I haven’t seen in ten years in the clinic when people aren’t adding all these different oils.

So I want to make sure people get the proper teaching and proper education. You don’t have to add in all these fats to be keto. It’s just restricting the carbs. Then your body starts burning fat and making the ketones. Probably the most common thing people complain of is they go to the bathroom less often. It doesn’t matter how often you go. I do a lot of teaching about that, even up front in the first class. But if you do have trouble, that’s probably the most common reason people stop. People don’t want to have constipation, meaning hard stools and hard to pass stools.

The remedy I use is milk of magnesia which is a quick way to absorb magnesium. There are also other pills and products that work. The electrolytes I think about is salt in the form of bullion, magnesium in the form of some magnesium supplement if needed. You could make the argument to just give people that at the get-go so they won’t get any side effects like constipation. Muscle cramps is another thing that I’ll see more commonly.

The insomnia is something that I don’t really see a lot. I don’t have people complaining a lot. They might tell me they sleep less, but that they still get restful sleep. To me, it doesn’t really matter how many hours there are. Unless they’re on a different medication that might become too strong, that’s another concern in a clinical population. People might be on all sorts of medications and insomnia is one of the most common side effects of a popular drug for weight loss. But, that’s not one of the most common things that I see.

If you’re not eating a food you’ve been eating, you may crave it. But they go away pretty fast. Really just a day or two and that’s where I acknowledge that there’s a use for sugar-free things. I don’t restrict Splenda, Nutrisweet, Stevia, any of these things. In my area, it’s hard to get the really high-quality other sweeteners than sugar so I just have people hit the sugar-free jello or sugar-free jello pudding. You can get higher qualities of it if it’s available but that works pretty well. Mostly people have a sweet tooth and they crave sweets.

If you crave pasta, then you hit the shirataki noodles, the spaghetti squash, the zucchini noodle maker kind of concept. There are a lot of substitutions. I guess I also teach the first visit a very popular thing to do which is to make cheese crisps in the microwave or in the oven, so people have a quick snack that’s crunchy. That’s another kind of observation. Some people miss something crunchy. They don’t want celery. Anyway, those are kind of the main cravings and the electrolytes that I’ll use. But I usually wait until someone has a side effect before using electrolyte supplementation. You could argue to use it at the beginning as well.

DrMR:   Are there a few good resources where people can read more? You were saying you try to steer them to a good resource or are there a few books or websites that you find particularly helpful?

DrEW:   There again, it depends on how much reading or what kind of, how deep a dive you want into the information.

DrMR:   Let’s start with the simple ’cause I’m assuming there’s a fair number of clinicians listening to this who are also focusing on digestive maladies. The people probably that they’re working with have somewhat of a limited bandwidth.

DrEW:   Yeah, one of the reasons for a very quick and easy sort of thing came from our popular video and I mentioned. By the way, I’ll send you page four if you ask for it. A lot of people asked me for page four even though they’re not my patient. You can now get page four from healclinics.com, which is one of the companies I’ve helped to start to get the information out. And I can treat you at a distance if you don’t have a medical problem or we can treat you in one of the clinics if you do have a medical problem. So that’s Healclinics.com

And then adaptyourlife.com is a product company that I’m involved in that have truly low carb products. I did a video and have a teaching program at Adapt Your Life and that’s designed for people who don’t have medical problems as well. If you wanna read books, then “Keto Clarity” is a quick, down and dirty read that Jimmy Moore, he wrote and I helped. He has a great way of writing very simply.

Then if you want the best diet ever written, best book ever written on diet, then going through proteins and fats, I think that’s “The New Atkins for a New You” and that’s not because I wrote it. I’m an author on it. It’s because Steve Phinney and Jeff Volek are the co-authors and we worked for about a year at writing that book. It starts with protein comes first, fat is your friend and talks you through the different carb levels but that’s a book you would actually have to read. Most of my patients don’t wanna read a book. They just want, “tell me what to do.”

Benefits

DrMR:   I completely get it. I think the benefits of a lower carb diet are probably fairly apparent, but in case anyone is not privy to those, could you give us a quick list of what you feel the primary benefits of a, to be technical, a ketogenic diet is?

DrEW:   Most people stay on a keto diet because they feel better. They have more energy. They don’t have brain fog. They don’t fall asleep in the afternoon. There’s kind of a self-fulfilling, self-directed… People just keep following it even if they’ve lost 50 pounds or staying on it. People just feel better. Then when they start eating carbs again, they get the carb hangover. They get hungry again. I guess another great point of a keto diet is that you’re just not hungry. So, if you like to work, you like to be active, and you don’t wanna be burdened by food, you can episodically fuel yourself without the constant need of sugar if you’re burning sugar.

It’s kinda like being, taking your wood fireplace. You have to go out there, get wood, put it in there. But now you’re heating your home with oil and the furnace so that you just turn the thermostat on and you don’t have to go out and get the wood anymore. Most people find that it’s just kind of easier. There is some deprivation initially of certain types of foods.

Fortunately, the replication of those or substitution has come a long way and over the last year, I’ve gone to several keto fairs. There’s Keto Fest, Low Carb USA, all these and there are these new companies coming out with really tasty products that substitute for what people thought they needed in the keto way. But, I kind of look at the real food uncomplicated keto diet as a subgroup of the paleo, primal, hunter/gatherer. It’s just real foods without a lot of processed additives. Pasta’s actually a processed food, right Have you ever seen a pasta tree? Pasta bush?

Of course, in the clinical setting, just motivating someone to say, “Did you know that you don’t have to have diabetes? You don’t have to take insulin.” It’s huge. I’m the first doctor often that’s ever mentioned that. The current diabetes mindset is that you have this, it’s lifelong, incurable, manageable, and that’s just not accurate. If you’re actually fixing a medical problem, then that’s just another great incentive to add on to feeling better.

Fasting

DrMR:   Sure. I’d be curious to get both your take, Eric and Mike, on using fasting to achieve some of the same metabolic benefits that one would achieve with either a lower carb diet or a ketogenic diet. But for someone who, for whatever reason, isn’t able to go all the way to especially a ketogenic diet and to bring kinda Jimmy Moore as the connecting point in here, I’ve been recently reading Jimmy Moore’s book with Jason Fung which I believe is, it might be entitled “Fasting Clarity” and I’m blanking on the name now. But it’s an excellent book on fasting. It’s co-authored by Jason Fung and Jimmy Moore. I have to really credit Jason for bringing to my attention that there have been some comparative studies looking at people who…

Mainly it looks like these studies are for either diabetes or for weight loss and who have seen results doing low carb and again, you might be able to criticize some of this for being low carb and truly not ketogenic, but there may have been some studies looking also at ketogenic. But essentially, it would sum it up as saying studies looking at lower carb intake showing benefit for diabetes, showing benefit for weight loss. But, some people hit these plateaus and that’s where adding in fasting seemed to work even better than the dietary approach. Wondering how do you see the application for people who maybe can’t fully commit to keto, using some type of intermittent fasting protocol in its place. What are your thoughts, Eric? And then Mike, I’d be curious to hear your thoughts also.

DrEW:   I think intermittent fasting can be useful. The science is not clear on how long you can go with total fasting. That’s where the keto and low carb community is still like, you gotta publish some studies with modern scientific measures to show that you’re not losing muscle mass when you do total fasting more than three days. What I see in my clinic is most everyone is doing intermittent fasting but it’s within the context of a keto diet ’cause they’re just not hungry. But now, some people need to have in their minds, well, I know I can’t eat now ’cause I’m intermittent fasting.

They eat less and that’s a fine way to have people eat less if it’s constraining the hours of the day. But I don’t like the idea if someone’s really pushing through hunger and ignoring hunger. My teaching is that you wanna have just a little something to eat to satisfy that hunger and then it’ll fade away on its own rather than ignore it. I think intermittent fasting can be helpful and it’s used all the time in my clinical setting under the context of being keto. Some studies are done using higher carb and intermittent fasting but my clinical sense is that among people who come to me, it’s not gonna work well. Because for most of my patients, it’s like quitting cigarette smoking, quitting carbs. Letting someone have intermittent smokes is not a way to quit smoking. Maybe Mike, number two, in your population it might work.

DrMN:  Yeah, what I generally find is, compared to a ketogenic diet, I find people do much better with intermittent fasting. I’ve used it off and on for probably 10 years now, I think, going back to when Brad Pilon put out his first book, “Eat Stop Eat“. Shout out to him. At the time, I thought this is a horrible idea. All your muscle’s gonna fall off. I bought the book to basically try to rip it apart and I was like, oh, there’s some actually interesting research.

A lot of it, I think, even now is a lot of animal work. I think the human work is still a lot of theoretical. But for the population that I work with, if they’re on a higher carbohydrate diet for performance, especially with weight training and exercise, things of that nature, if they have one day or even two days of being ketogenic, it tends to kinda throw a monkey wrench into things. They’re probably not gonna get to ketogenic state in that short of time period unless they’re really advanced and have been doing ketogenic for awhile.

Also, if they were doing ketogenic and they have a large amount of carbohydrates say before an event, their glycogen stores can be pretty replete. If we stuff a needle in their leg, we can see pretty good glycogen, but the enzyme PDH, which is kinda the gatekeeper to glycolysis actually will down regulate. Down-regulation can start as fast as even a couple days on just a very high fat, low carbohydrate diet. When you give them back a bunch carbohydrates trying to keep their performance up, they can’t access them as well as they could before. They’ll see a loss of, single digits, one to maybe eight, nine percent in speed and power.

But if they’re very high-level performing athlete, that’s a big difference, where if they do a day of fasting… By fasting a day that they work up to where they’re not consuming any food. For example, I did one today for 19 hours. I could then have a very high amount of carbohydrates tomorrow, relatively speaking, and I will still be able to access them just as well as I could before. On the fasting day, I can get some of the benefits of lower levels of insulin, possibly up-regulation of fatty acid, use oxidation, usually, I time that with more low to moderate intensity exercise. Then, it’s an easy way for most people to cut out a whole bunch of calories during the week. They can eat a little bit more on other days.

From an adherence and compliance standpoint for most people I work with, it’s relatively easy. But I do have some people that they’d much rather just cut their calories a little bit more if body composition is one of their goals. The research I’ve seen on more long-term studies on it, which again there’s not that many, I don’t think we have any good data at this point to say that fasting is superior. But, it’s limited data and again, the patient population is probably gonna make a pretty big difference, too.

Inflammation

DrEW:   Sure. Are you worried at all about inflammation? This is now in the keto world is that you can run your body as a carb machine, but you may have the downside of more inflammation.

DrMN:  Possibly, but I guess my bias is more on metabolic flexibility. I would agree that there are probably some athletes who- I’ve seen especially some endurance athletes who probably go too far on the carbohydrate end of the spectrum. I think from performance, they’re probably okay. Lead marathon runners are using almost a hundred percent carbohydrate, at least the ones that are winning.

I do wonder about their health. I think your body should be able to use more fat at rest and lower level intensity exercise. We do know that that is pretty variable. Gedecki has one study showing 23 to 93 percent variation in how well people can use fat at rest and low intensity. I’ve often wondered if people who are consuming more carbohydrates and have markers of inflammation, whichever ones we agree upon which is a different topic. I’ve often wondered if they can’t really switch all that well to use fat as a fuel at rest, so that they’re basically spinning carbohydrates when they don’t necessarily need to.

DrEW:   My hope the next five, maybe five, ten years of research now that we can study keto diets, maybe we’ll be able to figure out who will metabolically predict who will do better longer term on one or another. Now we kind of use the crude metabolic syndrome, high triglyceride, low HGL as a metabolic marker for lipids anyway. But in my experience, inflammation goes down across the board. In fact, I see people with inflammatory bowel disease. We have a paper on irritable bowel disease get better frequently. The diet I use is actually a low FODMAP diet because anything that has broccoli is very, very limited.

Of course, there are no simple sugars on a keto diet like I use. But, that’s- And I’m not persuaded yet that inflammation is so great that you outta run your body on fat if you’re otherwise healthy.  I’m not persuaded yet, but wondering what you thought. Thank you.

DrMN:  On that last part, could you just clarify? You said you’re not convinced that you should run your body on fat or did you mean carbohydrates?

Is Keto a Healthier Diet Overall

DrEW:   Well, both. I mean, I think the jury’s out on- Let’s say take someone in your population client group where they’re otherwise healthy, they’re trying to optimize running and they don’t have diabetes, don’t have any metabolic, serious metabolic problem. That research on whether you should be eating and burning carbs or eating and burning fat is in its infancy in terms of would it be healthier for someone to live their life as a carb eater and carb burner or fat eater and fat burner.

But just because I’m asking that question is huge. It’s changed so much in the last 10 years or even last five years that we can now- Mice put on a keto diet in middle age live longer than mice that were eating mice chow. Anyway, I wonder- That’s the kinda study I’d like to see. In otherwise healthy people, see all the metabolic parameters, even just over a year maybe. Some of the changes we see in the research are so big. You don’t need a whole lot of research subjects to find significant facts.

DrMN:  Yeah, we have some data out to 12 years that shows possible changes. TAY has one, T-A-Y, looking at low carb versus high carb diets for type 2 diabetics, which is a randomized control trial. Most of the parameters were pretty similar, although they didn’t really match protein between groups. The lower carbohydrate group did see a little bit better reduction in lipids. Maybe that’s from protein intake. Who knows? We do have some studies-

DrEW:   What about in healthy folks though? It may be different.

DrMN:  Possibly. I mean, my guess is that it’ll probably be less of an effect. But, right now, there’s just not that much funding that goes into those questions, which I agree, it’s a really good question. We’ve got epidemiologic data from looking at Eskimos to katavans who have completely different lifestyles to Blue Zones. Everything there gets complicated probably by more social factors than anything else.

DrEW:   We need to solve this by experiments, not by epidemiology. I’m hopeful there’ll be more money for research and I guess the more we can chatter about the need for this kind of research, maybe the more likely it’ll happen.

DrMN:  Yeah, no, I 100% agree because even with fasting in terms of caloric restriction and human longevity, don’t really know. It has been shown to be pretty beneficial in animals. But as you scale up from earthworms to chimpanzees, the effects size seems to drop off pretty fast. I don’t know. Then you look at, what are some of the top markers for longevity that we do know? Lower body strength, aerobic capacity, and grip strength. Those are all kinda functional markers too. Could go too heavy on caloric restriction, you might start eroding some of those things that we know are important factors.

DrEW:   But insulin is a good marker. The lower the insulin, the better.

DrMN:  I think in general for longevity, I think it’s good. What I wonder about though, is what is the shape of that curve? Like most things, it’s probably not linear, right? Once you get under a certain point, do you see most of the benefits then? My gut feeling and, again I don’t have any data that I’ve seen to base this on per se, is that yeah, if it’s lower, you’re probably better. Do you need to drive it ultra low to see an enhanced benefit? I don’t know. My gut feeling is probably not. But again, I haven’t seen any data that’s looked directly at that in healthy populations.

DrEW:   In the clinical research world, I’ve been humbled to be taught things that I thought weren’t gonna happen. Yeah, need to collect more data on that.

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I would like, if we can, talk a little bit about the gut and the gut flora, because I don’t really pay attention to it at all, and people get really better in what I do. So Mike, teach me please. Or do you also cut carbs, and cut sugar? And maybe this could be what some of your patients-

Gut Health

DrMR:   Yeah, for me to get out of the deep end of the pool here and get into the shallow waters where I know the data a little bit better. This is a point I’ve been making for a while, which was in response to what peaked about four years ago maybe, which the audience at this point is probably getting sick and tired of the same old shtick from me. But there was this craze about feeding your gut bacteria with carbohydrates, and prebiotics, and fiber. Mechanistically that looked kind of promising, seeing short-chain fatty acid levels go up and what have you, or observing that sick populations had skewing of their microbiota, often times less diversity. And then trying to reverse engineer, “Well, if healthy people have more diversity,” some of this is contestable, but there does seem to be a general trend. “And if sick people have less diversity and we know that fiber and prebiotics in many of the carb-rich foods they contain could feed those gut bugs.

Could we then take a non-diverse sick person and feed their gut into becoming healthier, and then see a result and change in someone’s systemic health?” As you can tell, there’s a lot of inferences being drawn there, and that’s exactly the trepidation I felt. So I started to cross-reference, what were we seeing in IBS literature? In IBD literature? Because there are not many studies looking at a low FODMAP diet for rheumatoid arthritis, so we’re kind of consolidated to looking at digestive maladies as a proxy. It becomes pretty clear that while yes, there are some cases where you can point to prebiotics, not probiotics, prebiotics improving IBS, or increasing fiber in the diet, decreasing the relapse rate of ulcerative colitis, a subset of IBD. The general trend tends to be that people are more prone to flare when you undergo approaches, either dietarily or supplementally, that feed their gut bacteria. We’re still trying to sort out how all this works, but there are a few things that I think underlie this.

It’s probably an erroneous assumption to think that diversity is a one-way street to health, and I think it’s more likely that the diversity is probably more so a byproduct of the health of the host than it is a result of the health of the host. A sick person likely has more inflammation, and we know that inflammation is poisonous to diversity. What we don’t want to do is do something that’s actually pro-inflammatory, and ironically some studies have shown that a high FODMAP diet tends to provoke inflammation. So even though we’re trying to feed the gut bacteria, that seems to make the person more inflamed. And what I think this boils down to, in part at least, is there are some people that there’s a very non-harmonious relationship between the resident gut bacteria and their immune system.

It’s a very tense relationship, and if you do things to feed the gut bacteria, it trips the immune system into attacking with inflammation. This is probably why we see people improve pretty much across the board with low FODMAP diets, and we see reduction of leaky gut, we see reduction of immune activation via histamine, and we also see reduction of inflammatory cytokines, even though someone’s undergoing an approach that in effect can starve, using that term loosely, gut bacteria. This is why I think I was serving a function at Low Carb USA, of course not being an expert in the metabolic end of this, but looking at it from a gut perspective, I think it’s pretty defensible to say that there are a lot of people who will do better on an approach that doesn’t robustly feed their gut bacteria.

DrMN:  How much of that do you think, like you mentioned, is a two-way street versus a one-way street? Right? So if you have someone who’s super-healthy, we’ll assume that their gut bacteria is probably pretty good. So we have someone who is, “Unhealthy,” can we change the gut environment do you think to make them more healthy? Or if we just make them more healthy by doing other things that the gut bacteria will kind of come along for the ride? Or is it both? Does that make sense?

DrMR:   Yeah, I think it’s definitely a bi-directional relationship.  There are things that you can do for the gut that will improve the health of the gut, improve the bacteria in the gut, and then have a resulted improvement in the health of the host. But there are also things that you can do for the health of the host that will improve the health of the gut and health of the bacteria. If you think about a garden, it’s the analogy I use in my book. You wouldn’t just put healthy bacteria, or as another example, seeds in a garden, and expect the garden to flourish. Right? You would both look at fertilizer maybe as an example. You would both potentially want to put fertilizer into a garden, but also make sure you water it, and that you have shade. Shade would be equivalent to rest, water would be equivalent to I suppose diet. You need to have some sun but not too much sun. And these things are kind of akin to exercise, we know sedentary people who start exercising see an improvement in their gut microbiota.

Some evidence is now showing even that vitamin D improves the gut microbiota. I don’t believe we’ve shown sunlight to do so, but there’s certainly a wealth of data showing that sun exposure improves various parameters from all-cause mortality to various cancers. So yeah, I definitely think it’s a bi-directional relationship where we can see that there are these environmental factors that will help, but then there are also things like a low FODMAP diet, or a probiotic that are gut-directed that will improve the gut. And then for some people can result in less brain fog, or less joint pain, or what have you. So yeah Mike, I definitely think there’s bi-directionality there.

I know we’re kind of at time here, maybe a few over, but there are one or two studies I’d love to get your guy’s take on briefly. There was the Diet Fits Study by Christopher Gardner, and he did not get people onto a ketogenic diet, but he did look at a lower-carb diet compared to a higher-carb diet, and they tried to use various genetic markers to predict who should be on each respective diet. It was interesting to see that the diet didn’t seem to make a difference, or the diet guided by genes didn’t really seem to make a difference. As long as you followed some of the foundational tenants of a healthy diet, reducing processed food, reducing sugar. He also made sure that people that were doing the higher-carb diet weren’t eating as I believe it was Jimmy Moore termed it, crapitarian carbs, where they weren’t eating a bunch of breads, and cereals, and they were focusing on vegetables, and fruits, and starches, and such, that there was a real benefit. I think that was one of the nice things about Gardner’s study where … And I think rightfully so, he makes a criticism that some of the diets that compare lower-carb to higher-carb, sometimes the higher-carb diet doesn’t specify to focus on healthy forms of higher-carbs. So he wanted to try and adjust for that. But Eric, Mike, any comments on Gardner’s Diet Fits Study?

DrEW:   Yeah, it’s a quick one for me, it wasn’t low enough in carbs, it wasn’t keto, so it really doesn’t inform the space we’re in. Actually, the method said we started people at 20 carbs or less, but then we let people choose the amount of carbs to which they thought they could sustain the program. If I had someone come back to me and they said, “I miss my fruit.” I’d say, “No way, I’m not giving you fruit. You can have fruit flavored things.” I’m a little disappointed, I like Christopher, and I’ve known him for a while, but why didn’t he ask for help in designing the study? And as a researcher, going back, I went to visit Dr. Atkins, and I said, “What do you do?”

No one else asked. And I understand you want to be an academic, and be pure, and independent. But why not, jeepers, ask someone who’s done it and knows about it? So anyway, it really didn’t help, and it almost reminded me of the Frank Sach study, which helped my fall out of academia, where they basically had three different levels of carbs all about in the 35 to 45 carb range. And because there wasn’t any difference they concluded it doesn’t matter if you change the carbs. They didn’t even go down to 20%. So anyway, people are seeing what they want to see, you can’t possibly … No one can sustain it. Well, that’s just not true. So anyway, I was a little disappointed in that study.

DrMN:  I really liked it, I thought it was awesome. I mean, in terms of the trial size, I liked that quality was actually emphasized. Because a lot of times it’s not. I mean, they tried to make protein similar. And while the trial was primarily designed to look at genetic markers and then sort of predict what diet would be best for you, and they did have some pretty interesting data to make those hypothesis on. So it actually didn’t kind of match what they originally hypothesized, which I always find interesting too. I mean, overall you don’t see much difference between the groups in terms of changes. And I agree that it was not a ketogenic diet, but it wasn’t really designed to be that, it was designed to be a lower-carb versus higher-carb intervention. But it’s not a prediction of genetics.

DrEW:   But it didn’t even end up to be that. In the intervention arms, if you don’t have a spread of carbs, or whatever nutrient it is, you’re not going to be able to predict across the wide range of what humans do, especially a keto level of carb. So yeah, I’m sure a lot of great information will be gleaned from it for those people who want to eat carbs. And I don’t want to.

DrMR:   Eric, do you have in the works any comparative trials? Because as a clinician it would be fantastic to see a comparative trial looking at a moderate carb diet next to a ketogenic diet, because that would really help solve some of this quandary for me. Is there anything there that’s in the works?

DrEW:   Yes. We have a study in progress at the veteran’s affairs hospital here in Durham, and it’s a two-site study, but it’s among people with diabetes. So our research has really been in clinical populations with obesity, diabetes, LVAD, heart failure patients, things like that. But that’s right, we need those kinds of studies. To my knowledge there are one or two people with NIH money, I think the Gardner Diet Fits actually came from nusi.org. And I mean, we just got to get the governmental agencies involved, and push them. I think it’s changing. If someone knows of a study section that might fund a keto diet protocol, I’ll send them a protocol right now. I mean, for the last 10 years it’s been just a big dry spell. No, last 30 years it’s been a dry spell in NIH funding.

DrMR:   And if you guys have to go, let me know, I know we’re going over time here but this is just a fantastic conversation. I guess let me just ask, do you guys have about 10 minutes each to go on?

DrEW:   Sure.

DrMN:  Yeah, no, I’m cool.

Forbidden Foods

DrMR:   Okay. If I may play the devil’s advocate a little bit Eric, because I know people are going to be thinking these questions, and it’s probably better just to voice them and see what kind of rational underlies them. It seems for most people to be keto it’s going to mean essentially no fruit, no potatoes, no squash. Is it a bit extreme to conclude that those foods are damaging and dangerous just given our evolutionary history? Does that seem to be a bit at odds? How do you reconcile that?

DrEW:   Well, actually there’s nothing forbidden, it’s just that if it has sugar you can’t have much of it. Actually, some people are surprised to see in my clinic room a product that has small amounts of berries in it. It’s a yogurt and it has a few berries, but it’s a very small amount. So it’s the total number of grams of carbs, and that’s a common misunderstanding. There’s really no forbidden food. You can have, gosh, there’s a book I have, 100 years ago the treatment of diabetes was a 10 gram carbohydrate per day diet, and they prescribed a potato the size of a hens egg, so a very small amount of potato is fine. How you keep people on it again is kind of an art to itself. You can have those foods, you just can’t have much of it. I’m sorry, what was your second part of the question?

Oh, what was the healthiness of it looking back from an evolutionary viewpoint? I think we can do better than evolution. I’m looking for the techno new diet, absolutely. We can go beyond what evolution told us I believe, to understand the biology, the physiology, that is the undiscovered country. Actually, I get kind of tired of people looking back in evolution, and this, and … Come on, I mean let’s really figure out what the human body needs, let’s optimize it. No, most parts of the world did not have fruit. Sorry, America didn’t have fruit before Johnny Appleseed went around and the fruit was very different. So yeah, I think it’s possible that while extreme from what you are experiencing as the normal diet today in 2018, what the typical American gets is just bizarre in terms of what food is available. It may be that the extreme diets are the answer, the ultra-low-fat camp, they didn’t have much meat, how could they not have much red meat? Evolutionarily we ate meat, you know? That’s the Ornish-McDougall predicament, and maybe the ultra-low carb, the Atkins, the South Beach, maybe it’s the extremes that keep the insulin down. Actually, I want the metabolic evaluation, not what’s on the plate, it really is the end-point.

DrMR:   I think that’s fair, I think it’s helpful to look to our history but not be confined by it exclusively. And a low FOBMAP diet is a great example of that. I’m sure there were no hunter-gatherers who were doing a low FODMAP diet for IBS, but we have to be able to update and adopt what we’re doing, giving a population of people that are shifting over time. And especially as their environment changes, it changes our immune system, it changes our phenotypic signaling. I certainly think that’s plausible. Follow-up question on that. Do you think there could be a large degree of the benefit that someone is seeing when they move in the lower-carb direction that comes from some simple strokes that wouldn’t require someone to go all the way to keto? Meaning they cut out grains, they cut out processed sugar, and they focus mostly on meat, vegetables, and they have some fruits and they have some starches. I’m sure a lot of people are saying, “That seems pretty reasonable.” Do you think that that’s tenable to conclude that for most people, that’s going to get them 80% of the way there? Or do you think most people really do need to go all the way to the keto landscape?

DrEW:   Well, that’s a question that needs to be answered. The diet, which is mainly meat, vegetables, meat meaning meat, poultry, fish, and shellfish, and eggs as a protein source, and then having some fruit and berries. If you’re metabolically adaptable, or you’re not insulin resistant, so you don’t have obesity and diabetes, that can be very healthy. What’s interesting is low-carb, I think, and keto will work for everyone. The low fat higher carb can work for those who don’t have carbohydrate intolerance or insulin resistance. I have a brother who can eat anything because he wasn’t insulin resistant, and I couldn’t. So even within a family you have those differences.

But the perception of how extreme … And in fact, I met someone who said, “Yeah, you can have fruit, no worries.” He said that the first day. Then after two days people just aren’t hungry and they don’t really want fruit after you’re fully keto, most people have almost total appetite suppression, or we call it normalization. But I don’t know. I think there is a role for carbs, just not … The low-hanging fruit to me is sugar, refined sugar in drinks, refined sugar in candy, things like that. That’s just not healthy for anyone I don’t think.

Episode Wrap Up

DrMR:   As we move to a close, are there any closing thoughts that you’d like to leave people with? Or even closing questions for one of you to ask me or the other?

DrEW:   Well, it seems like there’s variability in carb tolerance based on if you’re otherwise healthy, active, or whether you’re using a therapeutic diet for diabetes. That’s kind of a problem with the fire hose of information from the internet, people don’t know if it applies to them or not. I guess my point is that if you’re trying to fix a clinical problem, at the doctor level medical issue, you might want to consider lower keto level carb intake.

DrMR:   Yeah, that seems fair. Mike?

DrMN:  I mean, I would agree with that in that population, because I think we need to be very careful about, and people listening to this, about what population we’re talking about. I think you can make an argument that a ketogenic approach for different pathologies might be a very valid approach from TBI to possibly diabetes. I know Steve Finnian just published a one year non-randomized control trial through Verda Health that’s been published, looking at kind of more of the ketogenic-type intervention.

DrEW:   Can I just add, I’ve been using this for type two diabetes for 12 years in the clinic, definitely, it works for type two diabetes.

DrMN:  Yeah, and I’m just saying in terms of data that we have now. I mean, that’s probably one of the bigger controlled, even though it’s not a randomized trial, but definitely a move in the right direction.

If you start getting into my bias of what is a state of health, my bias is I don’t think a ketogenic diet is the default state we need to be in. I think it can work because humans are just incredibly adaptable. To me it’s more of a backup system to someone who is already healthy, and the fact that Joe-Bob who is very overweight, borderline type two diabetic, has never had a blood level of ketones ever, can fast or do a ketogenic diet and get into a ketogenic state that the body will maintain that machinery even though it’s never really been accessed his entire life, to me is kind of mind-boggling from how survival-wired that we are. But if you get into more, like you said, athletes, or even people who are healthy, then I think carbohydrates can serve a fuel for performance and things of that nature. The question I get all the time, people are like, “Should I do a ketogenic diet?” I’m like, “Well, what are you trying to do?” Because I think it’s very much context-specific. Pretty much like most things in physiology, it kind of depends on what are you trying to do? What are you like? Are you trying to be, “Healthier?” You trying to increase performance? Or are you working with a physician to try to treat frank pathology? Those are completely different things.

DrEW:   Well, now that there’s research going on, I don’t know. Children are born into ketosis, this is just … Everyone knows they don’t find it anything to talk about. And then now that there are animals that have knockouts in terms of the ketone genetics, it’s interesting. It may actually be the default mode to be in ketosis. We’ll see. I think you can live a healthy, long life eating lots of different ways. We might be talking about an incremental benefit of, I don’t know, a few percent. I’m not sure. But wow, this has been great, I really appreciate the chance to talk to you guys.

DrMN:  Yeah, thank you very much for setting it up, I really appreciate it.

DrMR:   Yeah, this worked out really well guys, I’m glad we had a chance to do this. Eric and Mike, if you come across any research that you feel is really important and you wanted to have another part to this conversation, please keep me abreast. I’m sure the audience would definitely appreciate that to stay tuned in. Eric, is there a website or a book that you’d like to refer people to if they wanted to learn more?

DrEW:   Yeah, to try to scale up, to make more available this information, we have two new companies. I’m helping with HealClinics.com and also AdaptYourLife.com. Those are great resources.

DrMR:   Awesome. And Mike, on your end?

DrMN:  Yeah, the main part is the website, which is just MikeTNelson.com, they’ll be a little thing at the top where you can hop on the newsletter, that’s where most of my content goes out right now. The other one is just FlexDiet.com, which is a certification that I do using the concepts of metabolic flexibility, and everything from we talk about some ketones, and fasting, more on the nutrition, lifestyle, recovery side of what you can do to enhance body composition and performance.

DrMR:   Awesome. Well guys, thank you both very much again, I really appreciate it. Have a good rest of your day.

DrMN:  Awesome.  Thank you.

DrEW:   Thank you.

What do you think? I would like to hear your thoughts or experience with this.

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