Keto Q&A Part 1
SUMMARY KEYWORDS
cholesterol, ketogenic diet, ketosis, keto, question, ketogenic, keto diet, ketones, heart disease, people, diet, inflammation, evidence, oxidized, heart, state, epilepsy, oxidized cholesterol, called, leads
SPEAKERS
Jack Heald, Dr. Philip Ovadia
Jack Heald
Welcome back, everybody after the excitement of last week's podcast with Brian Keith, Dr. O and I both need to take a breath. Lord, that man has a lot of energy.
Dr. Philip Ovadia
Great to be back with you this week, Jack. And yeah, that was a great episode. I hope everyone's taking a listen. If not, please go back and listen to you last week with Brian Keith. But I think it's a good opportunity for us to take a step back. And we're going to do some topics that have been kind of at the forefront. And we've I've been getting a lot of questions on from followers on social media. So we figured we would do an episode where we would dig in to some of the myths around ketogenic diets.
Jack Heald
Good deal. Well, these are things that I got to admit, I started doing keto diet off and on. I want to say six or seven years ago, and I assure you, I've heard all of these things said to me, I would love to hear a professional insight on the saw if we're short, and we'll form remission.
Dr. Philip Ovadia
Oh, yeah, yeah. Just gonna say before we get to the actual myths, I think one kind of just concept that is important to clear up is ketogenic diets as sort of a term that I think is more used in the maybe healthcare field, versus the popularized keto diet that's out there today. And I think it is important to kind of clarify what may or may not be different about those two. And so from Yeah, from a medical standpoint, from the sort of clinical side of things, a ketogenic diet is any diet that has you primarily burning fat for energy, as opposed to sugar, or glucose or carbohydrates for energy. The standard American diet, being very heavy and carbohydrates has our bodies primarily running on sugar, and primarily burning carbohydrates and sugar for our energy source, or ketogenic diet, which are going to be low in carbohydrates and low in sugar causes your body to switch to burning fat primarily, and a breakdown of fat, or what are called ketone ketones or ketone bodies.
And so that's where the name the ketogenic diet comes from. And the ketogenic diet was actually first described in the early 1900s. As a therapeutic diet for kids who were suffering from epilepsy from seizures, and prior to the discovery of medications to treat those conditions. The ketogenic diet was really the only treatment available to those children. Now, we fast forward to modern times. And it was discovered that ketogenic diets can be useful for a variety of conditions, including obesity. And more recently, I would say, within the past 10 to 15 years, the keto diet has been popularized.
Jack Heald
And so what's the keto diet?
Dr. Philip Ovadia
Yeah, so what happens with the keto diet is basically in an attempt to eliminate sugar and carbohydrates, you increase the fat in the diet, and the keto diet has become popularized for weight loss and lots of other benefits that go along with it. But the problem that I see today, and I talk about this in, stay off my operating table, the book is that we now can go to the supermarket, and we can see a lot of products that are labeled keto. And there's really, first of all, no regulation behind that food companies can literally slap the words keto on anything, and there's no like keto organization that certifies things as keto or says that they really are keto or really or not.
And or what the food companies have done to latch on to this craze is they make basically junk processed food in a ketogenic way. So they take out the traditional sugar and flour and high carbohydrate ingredients and they substitute other things in there like alcohol based products, things like Earth recall other sweeteners, alternative flours like nuts, flowers, or coconut flour, and they label it keto.
And everyone therefore assumes that it's going to get them the benefit of the ketogenic diet. And that likely is not true. So that's what I always caution people about the keto diet is getting on a ketogenic diet, I think can be very beneficial for a number of different conditions. It can certainly help with weight loss, it can help with diabetes control. But you have to be careful about products, processed food products that are labeled as keto and realize that they may not be any better than their full sugar for full carb alternatives, because they're still just a heavily processed food with lots of the other undesirable ingredients.
Jack Heald
This takes us back to what I guess is probably law number one in Dr. Ovadia's "How to Eat:" eat whole real foods.
Dr. Philip Ovadia
Exactly. And if you construct a ketogenic diet, so one that is higher in fat, lower in carbohydrates and will get your body into the state of ketosis. If you construct that from whole real food, I think it's going to be very beneficial for most people. But if you're constructing a keto diet out of processed food, you may not be getting any benefit from that
Jack Heald
Seems like there's a market opportunity for a Keto certification, a nonprofit keto certification company, or something that the tests all these things that claim to be ketogenic or keto friendly, or whatever, and maybe grades them or ranks them or something. Surely, there is somebody in our listening audience who's capable of putting that together. I don't have the time myself. Okay, I've got a list of 10 questions people ask about a ketogenic lifestyle or keto diet. I don't think we're gonna get to all 10. Today, will it be okay, if we kind of split this into two different episodes?
Dr. Philip Ovadia
Yeah, I think that will make a great couple episodes. All right.
Jack Heald
Well, if you don't mind, I'd like to just jump into these questions. First question. I've heard it said that you can't stay on a keto diet, it's okay to do it for a little while. But it's not good for you to be on being able to ketogenic diet as a as a lifestyle. True or false? And why?
Dr. Philip Ovadia
Yeah, I think that's generally I think that's false. I know many people who have sustained ketogenic diets consistently for many years, again we go back to the root of the ketogenic diet, treating children with epilepsy, and these children and then into adulthood, maintain these diets for their lifetime, essentially, or most of their lifetime. Out of necessity, we can also go back to our evolution as humans. And prior to the advent of modern agriculture 10,000 years ago, the evidence would suggest that we were probably in a state of ketosis for the vast majority of our time, because carbohydrates and sugar weren't readily available. And there may have been some seasonality there, we may have come out of ketosis for brief periods of time. But the vast majority of our existence, from an evolutionary standpoint, seems to have been in a ketogenic state. So
Jack Heald
That is the most powerful argument in my mind is that up until the advent of agriculture was 10,000 years ago, carbs just weren't readily available. Exactly. I think that's a very powerful argument. Yeah, sorry. I didn't mean to interrupt you there.
Dr. Philip Ovadia
No, I mean, that that really is probably the basis of the discussion for me. It kind of starts and ends there realize that the experiment and all this is the modern diet, and still been a very small part of our existence as humans that we've been on that experiment. Mental diet. And I really see no evidence that people can't stay on ketogenic diets for long periods of time. You know, ultimately, there may be reasons that you want to cycle in and out of ketosis and I think done correctly, that also can be a good strategy and is not necessarily going to be harmful.
I do think we have evidence all around us today that never getting into ketosis. Staying on the high carbohydrate standard American diet for your lifetime, is not beneficial. And again, we go back to 88% of us, of the adult in United States not being metabolically healthy. So I think we can certainly point to the evidence that not getting into ketosis for periods of time is probably harmful. But I have never seen any good evidence that you can't sustain a ketogenic diet, or that there's some danger to sustaining a ketogenic diet over a long period of time.
Jack Heald
Yeah, so we can flip that around and say, there's very clearly danger in never getting into a ketogenic state. We have the evidence all around us. So, hey, do you mind if I follow a brief rabbit trail, Georgia wanted to ask about epilepsy, an old girlfriend was a nurse and she came home one night and talked about this, this young man, I want to say in his 20s, who presented at the emergency room in a with severe seizures, and he never had any history, I'm sorry, when the young man was his father, the young man brought the father and never had any history of, of seizures at all. And he just suddenly started having seizures, and they couldn't figure anything out.
What they ultimately ended up doing was getting him into a state of ketosis, and it seemed to stop the seizures. So I've that was the first time I'd ever run into that particular story. My question, the rabbit trail I wanted to follow is, what's the speculation? Why does being in a state of ketosis help them? Help epilepsy? Do we have any clue?
Dr. Philip Ovadia
Well, yeah, it seems to do again we, our bodies, and all of the organs within our bodies have the capability of running on tool to primary fuel sources, sugar or ketones? Yes, alcohol is also a fuel source, technically, but the primary fuel sources for our bodies are either sugar tea could tea ketones, and they're there continues to be a debate about which one is better, and whether specific organs function better on one versus the other fuel source.
But again, most of the evidence that I have seen is that the brain in particular favors ketones as its energy source. And that getting into a ketogenic state, can be beneficial for brain health in general, as well as for these seizure states. And again, we have very good evidence when you go back to the early days of epilepsy management, there were some pretty remarkable improvements with ketogenic diets at a time when there was no other option available. And now in modern times where we do have medications available, kids that remain kids that are resistant to the medication treatment will oftentimes improve with ketogenic diet strategies.
Now you could look at that and say, why don't we try the diet first, that gets into the whole rabbit hole of pharmaceuticals and our food environment. Just it's difficult to keep kids on a ketogenic diet these days with their food environment, unfortunately, but all of the evidence seems to point to the brain does work better in general, on ketones as its energy source as its primary energy source, and especially for people with seizures. This seems to be a beneficial state to be in.
Jack Heald
I could follow this one down a deeper, deeper rabbit trail because it's just fascinating to me, but we're gonna move on.
Dr. Philip Ovadia
We might need to find a maybe a neurologist to bring on a future episode to really go into the mechanisms there.
Jack Heald
That would be really cool. I would love that. I've heard this one too. This is this is question number two. And I have heard this one. If you if you go to keto, if you if you start eating keto regularly, it'll cause a diabetic ketoacidosis. Now, I personally had to ask what the heck's diabetic ketoacidosis? So, I guess my question is two things. What is that? And is that true? Is that a serious concern?
Dr. Philip Ovadia
Yeah, no, it is not a concern at all. So and it really just comes from the confusion that the words are close to each other ketoacidosis has keto in it. But ketoacidosis is a unique sort of physiologic event that happens with diabetics, when their blood sugar gets very high. And they then end up with an excessive amount of ketones in your bloodstream that can't be properly metabolized and broken down, and you become acidotic, your blood pH becomes abnormal. But that is a completely different situation than people going into ketosis.
And just as I said, ketosis just means that your body is primarily burning ketones for fuel, as opposed to glucose. But there is no it's not that one leads to the other, certainly not that dietary ketosis is going to lead to Kido acidosis. So, it just, it's a it's a common misconception, even among healthcare practitioners, to be honest. But it's just a mis. It's really just a misunderstanding of those two words being closely related to each other.
Jack Heald
Oh, my God. It's because when you guys go through the college with your science degrees, they don't send you through enough literature courses. That's gotta be what it is.
Dr. Philip Ovadia
Okay, like classics.
Jack Heald
This question number three, of all the question I read all 10 of these, and most of them, I had had people warn me about this one I didn't ever hear. But this is apparently fairly common. keto will cause hypoglycemia. What's the story there?
Dr. Philip Ovadia
Yeah, so um it is true that when you go into a state of ketosis, and your body is primarily burning fat for fuel and running off of ketones, it has less need for glucose. And that can, that can, and in most cases, does lower your blood sugar, which is a good thing. I know people I've personally experienced when I am in sort of deep ketosis, my blood sugar will run at what are considered to be exceedingly low levels down into the 50s, even into the 40s sometimes, but I am not experiencing any of the symptoms that typically go along with low blood sugar, what's called hypoglycemia in the medical speak.
And, again, it's just that the body doesn't need the sugar around because it's using the ketones for energy. And so it will allow your blood sugar to get lower than it normally would when you are not in a state of ketosis. So having very low blood sugar can be very problematic. If you're not in a state of ketosis, and you're running off of blood sugar for energy, but the low blood sugar that we see in people on ketogenic diets is not necessarily a bad thing. And this is why the ketogenic diet is so effective as a therapy for diabetes because it lowers blood sugar. Now, you do need to be very careful. If you're a diabetic and you're considering a ketogenic diet, you need to work with your physician because being on medications to lower your blood glucose can be very dangerous in that situation.
So you want to work with a knowledgeable physician, if you're diabetic and you're considering a ketogenic diet, but I do know many diabetics now who successfully manage their condition both type one and type two diabetics with dietary ketosis, and I know type one diabetics who do dietary ketosis and they have a much lower need for insulin and are able to run normal blood glucose as normal hemoglobin a one sees and are quite successful with that strategy. But again, they're not doing it on their own. They're working with a physician who's knowledgeable about this and can help them understand that.
Jack Heald
Okay, so what I'm hearing is, when you measure blood sugar, the number that you come up with can be either good or bad. There are other factors to be taken into account. If a person is not in a ketogenic state, low blood sugar numbers can be a warning sign of serious problems. However, however, the identical measurement in a person who is in a ketogenic state is basically just normal, natural, the body's doing what it's supposed to do nothing to worry about. That right. Yep. Okay. All right, very good. We're plowing through here.
Question number four. And God, I can't tell you how many times I have heard this one. I'm not a doctor. I've just I've just done keto off and on for six years. And my experience says this is not true. But I want I want the doctor's opinion. Here's the question. Won't keto deprive your brain of glucose?
Dr. Philip Ovadia
Yeah, so again like we kind of talked about on the epilepsy topic, your brain, as with most organs in your body can run off of glucose, ketones or both. And when you're in the ketogenic state, yes, your brain is using less glucose. But that never gets to it. You know, that's not a danger. It doesn't get to a dangerous point. And I have almost universal. One of the first things that people notice with a ketogenic diet, is they describe their mental fog clearing, they describe a sharpness and alertness that goes along with being in ketosis.
So again, it's this, the true myth, the true myth, misconception here is that the brain requires glucose requires high levels of glucose to function. Well, and again, the opposite seems to be true. And we can go back to evolutionary history. Or we can just look at the modern experience now of the millions and millions of people who have benefited from ketogenic diets, and are not running into any sort of issues related to low brain glucose levels.
Jack Heald
Yep. Okay. Well, that's been my experience. I've I, that one just always struck me as if it was causing problems. I really think I would know, I think I'd feel it in the it's actually the opposite. That's been my experience is when I'm in a state of ketosis. It's subtle, but everything in the skull here just feels like it's working more efficiently. faster, less effort. I don't know. It's cool. All right.
We are at question number five. And this, this is both one that if it's true, is pretty damn scary, and is right up your alley. I think you're the guy who we really do need to know about this. Need to get this get this question answered there. Here's the question. Will being in ketosis impair heart function, and or cause vascular damage? What's the story there?
Dr. Philip Ovadia
Yeah. So again, similar to the brain, there is no evidence that being in ketogenic states is harmful to the heart. And to the contrary, there is some evidence that it may be beneficial, specifically for people who have heart failure. So they already have poor heart function. There have been some studies now that have shown that ketosis, whether that's achieved through dietary means or supplementation with ketones can actually be beneficial to heart function, and can help to improve heart function in that situation. And the reality is, is that I have no idea where this myth even comes from.
Jack Heald
Well, that was gonna be my question where yeah,
Dr. Philip Ovadia
I'm really not sure where this one like this one is one of those that seem to have just been made up out of the just pulled out of someone's mind that wanted to discount discourage the ketogenic diet because I have never seen any evidence that it can be damaging to heart function. And to the contrary, in certain situations, it seems to be beneficial altered cardiac function.
Jack Heald
Okay, I'm going to follow up on that, because and it's not that I doubt you. I'm actually fully on board with this. However, I do think there's a legitimate question behind the this heart function makes sense. I'm going to totally trust you there. The second part of the question was vascular damage. And what I've had nonbelievers say to me is, aren't you worried about all that meat and all the car all the cholesterol that you're going to have built up in your arteries from all the cholesterol from all the meat and fats that you're eating? And my answer is always, no, I'm not worried. However, given the last 40 years of history, I don't think that's an unreasonable fear. Yes. Could you address that?
Dr. Philip Ovadia
Yeah, exactly. So there is this concern that ketogenic diets being higher in fat, and lower in carbohydrates are going to lead to heart disease or vascular disease. And specifically, there are concerns around increased saturated fat, primarily from animal based proteins, leading to increased blood cholesterol and increased heart disease. And this goes back to the whole diet heart hypothesis, and understand that this was a how I a hypothesis that was put forth, starting around the 1950s. It was primarily advanced by a scientist by the name of Ancel Keys. And he was a firm believer, or at least he purported that increased consumption of dietary saturated fat leads to increase blood cholesterol levels, specifically what we call LDL cholesterol or bad cholesterol.
And that then leads to the development of atherosclerotic plaque build-up within the arteries of the heart, and in arteries outside of the heart as well. And really, neither side of that equation has been definitively proven, the relationship between our dietary consumption of fat, and our cholesterol levels in the bloodstream is inconsistent at best, and many would say there's no relationship. And then the relationship between elevated LDL cholesterol and the development of heart disease remains controversial as well. And as I've said many times on this program I say in the book, my take on the situation, is that elevated blood cholesterol levels are only harmful in the presence of inflammation and damage to those cholesterol particles.
So you have to have damage to the blood vessel walls, you have to have abnormal, what we call oxidized cholesterol particles. And that combination then leads to build up of these plaques, that can ultimately lead to heart disease. But if you there is no good evidence that having an elevated LDL cholesterol level without inflammation, and in a non-oxidized environment, that that is dangerous, and that that leads to heart disease. So the whole the whole myth, then that keto is going to cause heart disease is based off of that, and so, if you believe that that eating more saturated fat, and having higher blood cholesterol levels in and of themselves are going to cause heart disease, then you might conclude that ketogenic diets are going to cause heart disease. But again, we have no evidence of that we have plenty of people who have now been doing these ketogenic diets for long periods of time. We do not see rampant heart disease among them.
And to the contrary, I would say that ketogenic diets tend to lower inflammation, lower blood glucose, and lower the overall risk profile for heart disease, even if they raise your LDL cholesterol level. And one other important point, and there was actually a pretty good study that came out on this last year, is that the elevated LDL cholesterol that some that occurs, with going on these low carbohydrate high fat diets is a very inconsistent finding as well. And when you look kind of overall at the population level, you actually can't and demonstrate that a relationship between dietary fat consumption specifically high fat, low carb diets and elevated LDL cholesterol levels. So again, all of this is based on what I consider to be the false narrative of the Diet Heart hypothesis. And I don't have any problem with people maintaining a ketogenic diet, and I have seen no evidence that it leads to heart disease directly.
Jack Heald
Would you expand a little bit on I think you called it oxygenated cholesterol oxidized, so oxygen, oxidized cholesterol, I don't think I'd ever heard anybody talk indicate that there were two different states for cholesterol. And it sounds like what you're saying is there's, there's the normal, healthy state, and then there's a an abnormal, healthy and abnormal state. Expand on that a little bit and talk to me about how that happens, and how to avoid it and all that kind of stuff.
Dr. Philip Ovadia
Yeah, basically oxidation of fatty acids in this case, we I guess we all sort of know what oxidation is Rust is oxidation. It's when oxygen molecules combined with typically bond to something else, yeah, typically bond to something else that they're not supposed to bond to, and it causes damage. Specifically, when we look at cholesterol particles, what happens when they get oxidized is that their configuration changes, and they then...
Jack Heald
Changes the shape on a molecule, right?
Dr. Philip Ovadia
Correct. And they become more likely to basically stick to each other and stick through blood vessel walls. And so and that oxidation, okay, that makes, yeah, tends to go along with inflammation in the body in particular, and inflammation
Jack Heald
over a relationship, or is it just correlated?
Dr. Philip Ovadia
Well, again we were trying to, I would say, we're trying to figure that all out but it does seem to be that you need the combination of elevated cholesterol levels, and inflammation, to ultimately lead to heart disease. And we this is all evolving science. There is ongoing studies to try and better answer the question, the reality is, is that we've never really studied a population that had high cholesterol with low inflammation, because it again, the standard American diet causes high cholesterol with high inflammation. But now we have these ketogenic diets, low carbohydrate diets, and we're seeing more people with this.
I guess let me step back something there is very clearly, well describe what is called atherogenic dyslipidemia, and again, that fancy words for meaning. dyslipidemia, abnormal lipid profiles, abnormal cholesterol profiles. atherogenic means that it promotes and leads to the development of atherosclerosis of plaque buildup in the vessels, and atherogenic. dyslipidemia is characterized on blood testing, by high triglycerides, low HDL, which is your good cholesterol, and high LDL cholesterol, bad cholesterol so but what we see in people who are on ketogenic, low carbohydrate diets is that they get high LDL cholesterol, similar to the atherogenic dyslipidemia, but they have low triglycerides, and high HDL, which is our good cholesterol. So that's an opposite situation there. And the reality is, is that we don't have data to tell us, is that dangerous or not dangerous? There is some data we can pull out of other studies and stuff that would suggest that it's not dangerous.
But I also know that there are a couple of active investigations to try and better answer this question. And I'll put a plug in here as well, that I think that LDL cholesterol and or total cholesterol are not good measures of heart risk and that we need to do more. You know, a deep Per assessment of risk based on both other studies other laboratory studies that we can do that looks at different particle sizes, there's something called an NMR lipid particle lipid panel. So it breaks down the sizes of your lipid particles more than just LDL versus HDL. And then we have the imaging studies, like the coronary artery calcium scans, that can actually show us whether or not people are building up plaque and calcification in their hearts. And, and that's why I think ultimately, we need to get beyond the focus on LDL cholesterol, to really figure out what are the situations that lead to people developing heart disease.
Jack Heald
Because I'm kind of nerdy like this, sometimes, I am fascinated with the chemical reaction that occurs when cholesterol gets oxidized. So an oxygen molecule bonds with the cholesterol molecule, or more than normal, changes the shape of the molecule, I'm guessing changes the size of the molecule, possibly even changes the valence of the molecule. And all of those things go together, all of those factors are at work, that cause cholesterol that normally wouldn't stick to itself, or to the vessels of the of the body, to do just that, to clump together and make blockages. I'm I, do I have that story? Pretty close to right? I don't have to be perfect.
Dr. Philip Ovadia
Yeah, I think you have kind of it good enough, without getting too deep into the weeds here. And the bottom line being that oxidized cholesterol is a damaged form of cholesterol within our bloodstream, that then has leads to the downstream effects that we're trying to avoid of basically clumping of these particles and sticking to the blood vessel walls, and ultimately forming the plaques that cause blockages within these blood vessel walls. And the difficult part is that it's only been pretty recently that we've been able to actually measure levels of oxidized cholesterol, and it's not part of the standard cholesterol panel most physicians...
Jack Heald
That was gonna be my question. Is there a way to measure your percentage of oxidized versus normal cholesterol? Are they just measuring all of it?
Dr. Philip Ovadia
Well, that's the standard cholesterol panel just measures all of it, there is advanced testing that's available. Now, if your physician knows about it, and knows how to interpret these tests, that can show you how much of your cholesterol is actually oxidized, versus non oxidized.
Jack Heald
Okay, we probably spent 10 minutes longer on cholesterol than anybody but me is interested in, but I've got your attention. So I'm going to take advantage of it. Why does our cholesterol get oxidized? What happens? Do we know?
Dr. Philip Ovadia
Well it certainly is. But I would say that people who have high levels of inflammation in their bodies in general in their bloodstream in general have more oxidized cholesterol, the specific things that are causing it there's a, there's increasing evidence that these high poly unsaturated processed oils, the vegetable and the seed oils, are more prone to becoming oxidized. You know, again, outside of the body, we know this is the case, because if you leave those things in your pantry long enough, they become rancid.
Whereas I think we've talked about on previous on a previous episode that our grandparents and our great grandparents used to leave the jar of bacon fat sitting outside by the sink, and it would be good for years and never really become oxidized because it's heavily saturated fat as opposed to these unsaturated fats, the Oxidation occurs at points of unsaturation.
Jack Heald
Exactly! And the lights just came on for me.
Dr. Philip Ovadia
So again, if you're within your bloodstream, we can picture that the same thing happens. Again, inflammation leads to free radicals within the bloodstream and this is part of the oxidation process. So, the bottom line I think the simple take home measure is the more inflammation you have, the more oxidized your cholesterol is going to be, and the more likely it is therefore to lead to heart disease and cardiovascular disease.
Jack Heald
I've actually really enjoyed these last 1012 minutes this has been really good. All right, well, we've gotten through half this list that I have here on my desk. What do you say we pick this up in our next episode?
Dr. Philip Ovadia
Yeah, part two to this will be great.
Jack Heald
Outstanding. All right. Well for Dr. Philip Ovadia, I’m Jack Heald. You can follow Dr. Ovadia on Twitter at I Fix Hearts. And I suggest that you go to his website, IFixHearts.co. He's got a test there you can self-test and see if you are metabolically healthy. Very worthwhile. It could save your life. Until next time, this is the Stay Off My Operating Table podcast.