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Fat as a Health Food: Benefits & Course Corrections During a Year of Tracking Ketosis

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Ketosis, where the body burns fats in preference to carbohydrates, is being promoted as an approach to weight loss and treatment for chronic diseases. I’ve taken a Quantified Self approach to tracking my experience with ketosis seeing a number of benefits and challenges along the way. One of the conclusions, which I’m testing further, is that the types of fats used to replace carbohydrates may be critical to optimal health in response to a ketogenic diet. These slides are from my March 17, 2015 presentation to the Quantified Self St. Louis Group (www.quantifiedstl.com) at the Cambridge Innovation Center.

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Fat as a Health Food: Benefits & Course Corrections During a Year of Tracking Ketosis

  1. 1. Fat as a Health Food: Benefits & Course Corrections During a Year of Tracking Ketosis Jim McCarter, MD, PhD Entrepreneur in Residence, BioGenerator & Adjunct Professor of Genetics, Washington University Quantified Self St. Louis Tuesday March 17, 2015, CIC
  2. 2. Vilhjalmur Stefansson, Artic Expedition 1913-1918, www.dartmouth.edu/~news/releases/2008/02/26a.html
  3. 3. N=1 Disclaimer • This is my own experience. • We all have different genotypes & phenotypes. • We all respond differently to diet (& exercise, sleep, etc.). • I am not providing medical advice. • As you’ll see, this is a work in progress.
  4. 4. Daily • Work • Sleep • Mood • Exercise • Steps & Stairs • Weight • Heart rate • Food log & photos • Blood glucose • Blood ketones (BOHB) • Exhaled ketones (acetone) What do I measure? Periodically • Body fat & bone density (DEXA) • Blood Pressure • Blood Chemistry … – Complete blood count with differential – Comprehensive metabolic panel – Fasting glucose, HGB A1c, HS CRP, TSH – Lipid panel (TG, HDL, LDL) – NMR Lipoprofile (LDL subfractions) – Blood fatty acid profile (Ω 3 & 6) • Gut Microbiome
  5. 5. In One Generation, U.S. Obesity Has Tripled and Diabetes Has Increased 9-Fold
  6. 6. Working Hypothesis: Carbohydrate Over-Consumption is a Driver of the “Diseases of Civilization” Slide From: Prof. Tim Noakes, “Medical Aspects of the Low Carbohydrate Lifestyle” https://www.youtube.com/watch?v=fL5-9ZxamXc
  7. 7. Carbs Result in a Glucose & Insulin Roller Coaster (Post-breakfast munchies, Post-lunch food coma) Slide From: Prof. Jeff Volek, “The Many Facets of Keto-Adaptation” https://www.youtube.com/watch?v=GC1vMBRFiwE
  8. 8. Meta-Analysis Does Not Support a Connection Between Saturated Fat and Cardiovascular Disease Am J Clin Nutr 2010; 91:535. Ann Int Med 2014; 160:398.
  9. 9. Bad Dietary Advice is Everywhere. Fat Does Not Make You Fat. http://www.extension.org/pages/63813/what-are-triglycerides#.VQOx9-E6994 This web site says that for Homer to lower his high blood triglycerides he should stop eating fat and eat more fruit & non-fat dairy. This is just wrong. If Homer has high triglycerides (a dyslipidemia which goes along with low HDL and high levels of small dense LDL) the single most effective thing for him to do is to reduce sugar & starch in his diet. Note: I’ve doubled my fat consumption while cutting my body fat in half & reducing my blood triglycerides.
  10. 10. What is Nutritional Ketosis and What Makes it Desirable? - Benefits of ketosis include - decreased hunger & fatigue, easier weight loss - increased endurance (access to 80,000 kcal “fuel tank” of body fat versus 2,000 kcal glycogen store) - Improved lipid profile – decreased triglycerides, increased HDL But, ketosis is pretty controversial and challenging to implement. - Ketosis is the production of ketone bodies from stored or dietary fat. Ketones are a marker of fatty acid metabolism. - Ketones are naturally occurring and increase when fasting or when carbohydrates in the diet are limited (e.g. breast feeding, certain hunter gatherers). - Ketogenic diets are used in the treatment of epilepsy and are being tested for treatment of chronic diseases. - A ketogenic state occurs after adaptation to fat burning (~3 weeks after carbohydrate restriction). - Nutritional ketosis is not ketoacidosis which occurs in diabetes with high glucose levels & a lack of insulin. - During fasting, ketones can provide 60% of brain energy needs (the remaining glucose provided by gluconeogenesis).
  11. 11. Benefits & Challenges I’ve Experienced with LCHF & Ketosis 10 Benefits 1. Achieved desired weight & body composition 2. No longer hungry or tired after meals 3. Athletic stamina supports sustained high intensity 4. No longer have symptoms of inflammation 5. No longer get cold & flu symptoms 6. Blood pressure is down 7. Resting heart rate is down 8. Triglyceride is down 9. HDL cholesterol is up 10.LDL cholesterol subclass is favorable pattern A 4 Challenges 1. Warm-up time for workouts is longer 2. Prior sensitivity to cold temperature has increased 3. Cholesterol is higher (likely benign) 4. Fasting glucose is higher L.C.H.F. = low carbohydrate, high fat
  12. 12. Benefits & Challenges I’ve Experienced with LCHF & Ketosis 10 Benefits 1. Achieved desired weight & body composition 2. No longer hungry or tired after meals 3. Athletic stamina supports sustained high intensity 4. No longer have symptoms of inflammation 5. No longer get cold & flu symptoms 6. Blood pressure is down 7. Resting heart rate is down 8. Triglyceride is down 9. HDL cholesterol is up 10.LDL cholesterol subclass is favorable pattern A 4 Challenges 1. Warm-up time for workouts is longer 2. Prior sensitivity to cold temperature has increased 3. Cholesterol is higher (likely benign) 4. Fasting glucose is higher 5. Cramping in calf muscles. Cured by daily bouillon cubes for salt replacement
  13. 13. From A Standard American Diet to a Low Carb High Fat (LCHF) & Ketogenic Diet carbohydrate protein fat U.S. Average Diet (2006 1) My Ketogenic Diet (estimated) 48.7% 15.7% 33.7% USDA Advised US Average Carbs 45-65 48.7 Protein 10-35 15.7 Fat 20-35 33.7 1 Austin et al. Am J Clin Nutr 2011. 93:836. Caloric Intake By Macronutrient Low Carb Hi Fat Ketogenic Carbs 7-14 3 Protein 13-21 13-21 Fat 69-76 80 3% 17% 80% US Averages follow USDA guidelines
  14. 14. Numerous Dietary Plans Claim Beneficial Effects Through the Restriction of Carbohydrates
  15. 15. Slide: Prof. Stephen Phinney, “The Art & Science of Low Carb Living & Performance” https://www.youtube.com/watch?v=GkQYZ6FbsmI
  16. 16. What Do I Eat with a Ketogenic Lifestyle?
  17. 17. What Do I Eat with a Ketogenic Lifestyle?
  18. 18. Ketosis Shopping List No Sugar, No Starch … But this is a diet closer to decadence than deprivation.
  19. 19. Optimal Nutritional Ketosis Slide: Prof. Stephen Phinney, “The Art & Science of Low Carb Living & Performance” https://www.youtube.com/watch?v=GkQYZ6FbsmI BOHB 11/7/14
  20. 20. Tracking Ketosis Thru Daily Blood BOHB mmol/L Beta-hydroxybutyrate Points – days, Line – 7 day moving average AM fasting 2.0±0.9 PM post-meal 0.9±0.6
  21. 21. Travel & Restaurants (Unexpected Carbs) Lower Ketones, Fasting Spikes Ketones Thanksgiving Moving Business Trip
  22. 22. Travel & Restaurants (Unexpected Carbs) Lower Ketones, Fasting Spikes Ketones fasting experiment Juniper Chestnuts Hodak’s Almond Butter Picnic One Market Ketone dips are easier to explain than spikes
  23. 23. Benefits & Challenges I’ve Experienced with LCHF & Ketosis 10 Benefits 1. Achieved desired weight & body composition 2. No longer hungry or tired after meals 3. Athletic stamina supports sustained high intensity 4. No longer have symptoms of inflammation 5. No longer get cold & flu symptoms 6. Blood pressure is down 7. Resting heart rate is down 8. Triglyceride is down 9. HDL cholesterol is up 10.LDL cholesterol subclass is favorable pattern A
  24. 24. 1. Achieved Desired Weight & Body Composition – DEXA Scan (Duel-Energy X-ray Absorptiometry) Verified Date Nov 2001 Feb 2015 Weight (lbs) 191 166.0 % Fat ~21-24 12.0 DEXA Fat (lbs) ~40-46 19.9 BMI 23.9 20.7 Waist (inches) ~34 31
  25. 25. 5 years at 183 8 years at 178 QS & Ketosis to sustained 167±1.7 illness days – blue points 50 day moving average – black line pounds 1. Achieved Desired Weight & Body Composition –
  26. 26. days – blue points 20 day moving average – black line Caloric Restriction LCHF Reduced Hunger Ketosis maintenance LCHF maintenance pounds 1. Achieved Desired Weight & Body Composition –
  27. 27. RELATIVELY EASY HUNGRY ANGRYHANGRY! pounds 1. Achieved Desired Weight & Body Composition –
  28. 28. 2. No Longer Hungry or Tired After Meals 3. Athletic Stamina for Sustained High Intensity • No longer feel the need for an after breakfast snack • No longer feel the need for an after lunch nap • Able to sustain longer periods of intense concentration • Swimming – Able to sustain near sprint pace for long distances • Basketball – Effortless intensity while opponents half my age are winded • but … longer warm-up time required (especially for running) Slide From: Prof. Jeff Volek, “The Many Facets of Keto-Adaptation” https://www.youtube.com/watch?v=GC1vMBRFiwE
  29. 29. • Hip Pain During Long Runs => Resolved • Shoulder Pain During Swims => Resolved • Verified with C-Reactive Protein Test (3/10/15) 4. Reduction in Inflammation Indicated by Resolved Joint Pain & Verified by Low CRP Low Risk <1.0 Mg/L HS CRP Average Risk 1-3 High Risk >3.0 0.4 10th percentile1 Active Infection >10.0 1 Rifai and Ridker. 2003. Population Distributions of C-Reactive Protein in Apparently Health Men and Women in the U.S.: Implication for Clinical Interpretation. Clinical Chemistry, 49:666-669.
  30. 30. 5. LCHF/Ketosis Plus Vitamin C Has Reduced Cold & Flu Symptoms Colds 2010 Colds 2014 3/5 3/6 3/7 3/8 4/8 4/9 4/10 4/11 6/14 6/15 6/16 6/17 10/20 10/21 10/22 10/23 10/24 10/25 10/26 10/27 10/28 10/29 10/30 10/31 11/1 5/21 5/22 5/23 Sore throat Cough, Sneezing, Nasal drip, etc. - Colds initially got worse on LCHF (2013) - Disappeared with Introduction of 2000mg daily Vitamin C in fall of 2013 - Still notice exposure – awake with a tickle in throat, but then resolves 22 days vs. 0 days
  31. 31. 6. Blood Pressure Has Decreased From Pre-Hypertension to ExcellentmmHg May 2009 Nov 2010 Mar 2013 July 2014 systolic 90 136 diastolic 78 127 80 127 Mar 2011 76 130 68 104 120 76 Mar 2015 Keto <20g LCHF (<50g carb) Prior Diet (estimated 300-400g carb)
  32. 32. 7. Resting Heart Rate is Down From 65 to 50-55 Beats Per Minute With Fitbit Surge, 50 overnight, 53 while preparing this slide.
  33. 33. 8 & 9. On LCHF, Triglyceride Dropped 3X and HDL (“Good”) Cholesterol Rose 2X Ketosis (<20g carb) LCHF (<50g carb) Mg/dL January 2010 April 2013 July 2014 March 2015 Prior Diet (estimated 300-400g carb) HDL TG 46 78 99 85 139 75 41 94 “HDL >60 is considered protective of heart disease” “TG <150 is desirable” “TG/HDL Ratio less than 2:1 is ideal” 3.02:1 1.04:1 1:2.41 1.11:1
  34. 34. Benefits & Challenges I’ve Experienced with LCHF & Ketosis 4 Challenges 1. Warm-up time for workouts is longer 2. Prior sensitivity to cold temperature has increased 3. Cholesterol is higher (likely benign) 4. Fasting glucose is higher
  35. 35. HDL TG 3. High LDL But Subclass Shows Favorable “Pattern A” (Large Buoyant) Particles LDL January 2010 April 2013 July 2014 March 2015 Ketosis (<20g carb) LCHF (<50g carb) Prior Diet (estimated 300-400g carb) 98 91 122 182 “Conventional medicine: LDL > 160 is high”
  36. 36. Clinical Practice Has Not Kept Pace with the Evolving Science of Cholesterol and Cardiovascular Disease (CVD) Risk • Cholesterol – lipid soluble molecule essential to animal cell membranes • 1950s – High dietary cholesterol increases blood cholesterol - incorrect • 1970s – High total cholesterol as a CVD risk factor – incorrect • 1980s – Cholesterol & triglyceride carrying particles – Low blood HDL (high density lipoprotein) a CVD risk factor - correct – High blood triglycerides a CVD risk factor – correct – High LDL a CVD risk factor – incorrect (its more complicated) • 1990s – Discovery of LDL subclasses (Ronald Krauss, Children’s Hospital Oakland) – High blood levels of small dense LDL (Pattern B) is a CVD risk factor - correct – Small Dense LDL (Pattern B) is prone to oxidation and vascular invasion following inflammation – Large Buoyant LDL (Pattern A) is not associated with CVD • 2000s – High dietary carbohydrate correlates with low HDL, high TG, high Pattern B LDL – High dietary saturated fat correlate with high Pattern A LDL • 2011s – Liposcience launches clinical NMR Lipoprofile Test for LDL subclasses
  37. 37. • While overall LDL is high, subclass shows favorable “pattern A” (large buoyant) particles indicative of high saturated fat diet • Genetics X Dietary changes in transition from LCHF to ketosis could have driven higher LDL e.g. “subjects carrying the apo E4 allele are more responsive with regard to LDL-C lowering in response to dietary fat & cholesterol restriction than subjects carrying the apo E3 or apo E2 alleles” Ordovas et al. Atherosclerosis, 1995, 118:S11-27. • While probably benign, high total LDL with pattern A is less explored territory. Planned upcoming modifications to ketogenic diet may lead total LDL lower while retaining favorable lipid profile. <90 22.1 NMR Lipoprofile Results 3. High LDL But Subclass Shows Favorable “Pattern A” (Large Buoyant) Particles
  38. 38. Blood Glucose Measurements Taken Simultaneous with Ketones mg/dL glucose Points – days, Line – 7 day moving average AM fasting 94.0±8.4 PM post-meal 97.8±10.6
  39. 39. 4. Glucose Has Trended Higher Over the Course of the Ketosis Experiment mg/dL glucose Points – days, Line – 7 day moving average AM fasting 94.0±8.4 PM post-meal 97.8±10.6 AM fasting 89.4 for first 7 weeks AM fasting 96.3 for next 14 weeks
  40. 40. 4. Glucose Has Trended Higher Over the Course of the Ketosis Experiment Hemoglobin A1C of 5.4% Normal Range 4.0 – 5.7 Pre-Diabetes 5.7 – 6.4 Diabetes >6.5% AM fasting 94.0±8.4 PM post-meal 97.8±10.6 AM fasting 89.4 for first 7 weeks AM fasting 96.3 for next 14 weeks - Could be an indicator of insulin resistance
  41. 41. While a Hotly Debated Topic, Some Studies Link High Saturated Fat Diets to Insulin Resistance • Several studies specifically implicate the saturated fat palmitoleic acid (16:0) with insulin resistance • Medium chain triglycerides (MCT) including lauric acid (12:0) & myristic acid (14:0) do not appear to be associated with insulin resistance • Replacement of saturated fat with the monounsaturated fat (MUFA) oleic acid (18:1) was beneficial in some studies Am J Clin Nutr 2001; 73:544-9. Diabetologia 2001; 33:312.
  42. 42. My Mid-Course Corrections – Continue LCHF & Ketosis But Cut Back on the Palmitic Acid 16:0 Less of These More of These Palm Oil – 45% 16:0 Lard – 40% 16:0 Coconut Oil – 11% 16:0 71% 12:0,14:0 Olive Oil – 7-20% 16:0 55-83% 18:1
  43. 43. Personal Conclusions & Next Steps - Health effects of LCHF & Ketogenic Diet have been generally beneficial but with room for improvement - optimal results during LCHF (20-50g carbs) - Able to transition in and out of ketosis without much penalty to ketoadaptation (i.e. retain energy, return quickly to ketosis) - Increasing saturated fats (e.g. palmitic acid) during ketogenic diet may have had unfavorable effect on LDL and glucose - Next steps. Continue to measure while … 1. Test altered dietary fat – MCT & oleic acid for palmitic acid. 2. Test return to LCHF – somewhat higher carbohydrate levels – e.g. more tomatoes, carrots, beets, turnips, parsnips, fruit. 3. Test slow release carbohydrates (e.g. Generation UCAN super starch) as an alternative to saturate fats. - Lots of data still to analyze – food log, gut microbiome, etc. - Data not yet captured – genotype, fatty acid profile, etc.
  44. 44. Broader Conclusions - Dietary changes will be key to reversing the epidemic of obesity, diabetes, metabolic syndrome, & heart disease. - Most Americans could benefit from reduction in consumption of sugar & refined grains. - Determining the calories that can best replace those carbohydrates is critical. - Ketogenic diets may have utility for treatment of chronic diseases. - Proper formulation of ketogenic diets will be important including selection of proper fats (MUFA, Ω3 PUFA, certain SFAs)
  45. 45. The deceptively simple question: what should we eat? Thanks to my family for their patience with daddy’s crazy experiments!
  46. 46. Appendix
  47. 47. Here’s one book recommendation if you want to try implementing nutritional ketosis … Start with Chapter 9, fluid & electrolyte management
  48. 48. In My Case, Trend Toward Lower Glucose with Higher Ketones But Correlation is Weak
  49. 49. Fatty Acid Synthesis Pathways palmitic palmitoleic stearic oleic linoleic linolenic
  50. 50. Jim McCarter LCHF (Low Carb High Fat) Shopping list, 3/12/15 Vegetables - LOTS Cucumber, avocado, broccoli, peppers, artichoke, cauliflower, spinach, lettuce (iceberg, bib, arugula, etc.), kale, collard greens, cabbage, parsley, celery, bok choy, green beans, eggplant, radishes, asparagus, Brussel sprouts, onions, scallions (green onions), leeks, shallots, chives, ginger, pea tips, mushrooms – shiitake, porcini, Portobello, etc., squash – zucchini, butternut, pumpkin, bamboo shoots [In moderation - tomatoes, peas, carrots, turnip, parsnip, beets, peas, taro, edamame] Fruits [In moderation] Raspberries, blackberries, strawberries, limes, lemons Grains/Starch (replacements) Ground flax seed (replacement for morning cereal), coconut flour (ingredient for making wraps) Oils/Fats/Oils Coconut oil – (LouAna), Extra virgin olive (high quality brand), grass feed butter (Kerrygold), avocado oil, cuts of pork fat from butcher, duck or goose fat, canola oil
  51. 51. Jim McCarter LCHF (Low Carb High Fat) Shopping list, 3/12/15 continued Protein (meats, seafood) Eggs - LOTS (chicken & quail), meats – many – (choose fatty cuts like pork belly, bacon, pot roast, avoid lean), beef, pork, chicken, turkey, duck, rabbit, etc., liverwurst, pate, corned beef, spam, seafood – many, choose fatty fishes, all shell fish, canned tuna, sardines, anchovies, [In moderation – tofu] Dairy Cheeses – many, feta, mozzarella, Swiss, American, sour cream, crème fresh, cream, half-half. (Avoid processed cheeses with added sugar) Condiments (all unsweetened – read the label) Bouillon cubes – LOTS, sea salt, malt vinegar, horseradish, salsa, ginger, olives, tapenade, capers, sun dried tomatoes, hot peppers, pickles, mustards, lots of herbs & seasonings, [In moderation – unsweetened peanut butter, almond butter, sunflower butter, soy sauce] Nuts & seeds Almonds, walnuts, pecans, pistachios, cashews, macadamia, peanuts, sunflower, hazelnuts, pumpkin seeds, sesame seeds, chia seeds
  52. 52. Jim McCarter LCHF (Low Carb High Fat) Shopping list, 3/12/15 continued Snacks [In moderation] Unsweetened cocoa – ground or bars (85-100%), pork rinds (chicharrone), Cacao bliss Drinks Water (Mendota sparkling, club soda), coffee, tea, [In moderation – wine] Vitamins, minerals & Supplements Bouillon cubes – 2 daily in hot water Magnesium supplements –slow release Mag64 (64mg twice daily) Vitamin C – 1000mg twice daily Omega 3 - DHA & EPA – 1200 mg daily combined from algal sources. Multivitamin – generic equivalent for Centrum Silver, Vitamin D3 Things I avoid – Sugar (table sugar, HFCS, soft drinks, fruit juices, jelly, honey, candy, ‘energy’ drinks & bars), All grains – wheat, oats, etc. (bread, pasta, beer, rice, all baked items, all items using flour – e.g. fried chicken), Potatoes (fries, chips, mashed, etc.). [If LCHF but not ketogenic, could eat sweet potato, yam, white rice, & sweet corn in moderation.] Most vegetable oils with Ω6 polyunsaturated fatty acids (corn, soy, safflower, sunflower, peanut oils, etc.) Vegetable-seed based fats & spreads (mayonnaise, margarine) Most fruit (see exceptions). [If LCHF but not ketogenic, could eat more fruit in moderation.] Most legumes including baked beans, refried beans, soy milk, etc. (see exceptions). Milk, ice cream. [If LCHF but not ketogenic, could eat unsweetened yogurt in moderation.] Artificial sweeteners. (Sugar free protein bars, sugar-free gum, etc.)

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