Keto and Vegetarian? - with Dr. Will Cole | The Empowering Neurologist EP. 76

Hello everyone, welcome to The Empowering Neurologist. I'm Dr. David Perlmutter. You know, there seems to be a bit of a misunderstanding in the world of being on a ketogenic diet or keto diet, uh, that it looks to many people that this is a diet that's just loaded with animal products— meat, eggs, cheese, dairy, you name it. And the reality is you can get into a ketogenic state, be in ketosis, without consuming animal products, or consuming a few animal products if that's your choice. There's a new book out called Ketotarian, and it's a terrific book. It's written by Dr. Will Cole, and that's with whom we will speak today. Let me tell you a little bit about him. He is a functional medicine practitioner His website is drwillcole.com. He's in Pittsburgh, but he does a lot of consultations through the internet. He investigates underlying factors, learns about individuality in terms of patients, in terms of what might underlie their specific health issues, and then he is involved in customizing specific programs based upon that individual's need, which is certainly, I think, in contrast to the standard Western medical model where we— where the goal is to fit the patient into the model as opposed to trying to understand who that patient really is. He's involved in treating thyroid disorders and very much involved in treating inflammatory and autoimmune conditions as well as digestive disorders. And as you might expect, by paying attention to diet, His work has a huge influence on brain health and function. He was named one of the top 50 functional medicine and integrative doctors in America, and as mentioned, he is the author of this new book, Ketotarian. I was delighted to endorse it, and we're going to jump in right now and say hello to Dr. Will Cole. Well, Dr. Will Cole, welcome to our program. How are you doing?

Good. How are you?

Very— I'm doing great. I enjoyed your book, and here it is for all to see. So I want to— you got a great title here, Ketotarian. What do you mean by that? Who's a ketotarian?

Ketotarian is my play on words. It's a plant-based ketogenic lifestyle, and it's this, you know, amalgamation of the best of both ways of eating, and I didn't see it as You know, one side or the other. I think really both can be symbiotic and something that you really can bring both principles of both ways of eating together to amplify one's wellness.

And to be clear, when you say both, you mean both ketogenic type of diet and being mostly vegetarian. I know you have a couple of ideas here that are not necessarily plant-based, but nonetheless, why would a person want to engage both of these? I mean, let's, let's first talk about why would you want to be on a ketogenic diet?

Yeah, and that's something as a functional medicine practitioner that I've seen amazing health benefits, and the science is very exciting. I'm very excited about what's coming out in the scientific literature. But what, what I'm most excited about as far as ketosis is concerned, nutritional ketosis being a fat burner, is the anti-inflammatory benefits that it has. Most of My patients are somewhere on this autoimmune inflammation spectrum and they have these high inflammatory markers on their labs and they feel it too. And beta-hydroxybutyrate, the main ketone that our liver naturally produces, as you know, is a strong anti-inflammatory. That is wonderful, but also we also know that the main metabolic benefits of being a fat burner too, we lose weight. Yeah. more lean and your weight loss is a natural byproduct of being in this metabolic fat-burning state. So that's another benefit of ketosis. And I love the impact that it has on the brain, the fact that beta-hydroxybutyrate can pass through the blood-brain barrier and be clean fuel for the brain, be anti-inflammatory for the brain. And I also love the mitochondrial biogenesis, the fact that ketones can actually produce more Mitochondria and cellular energy. So all of this stuff I love about the ketogenic diet, but what I saw, what was unintentionally going maybe a little bit awry on social media and more of the conventional way of eating the ketogenic diet was avoiding all plant foods because of its carb content, and their main goal was ketosis at all costs, and anything that lowered ketosis, anything, they would want to avoid. And then that left them really eating anything as long as it's high-fat, low-carb, with vats of cheese and bacon all day long. In the short term, I think there's benefits to that. That's better than the standard American diet. They're avoiding carbs and sugar, but long-term wellness is really what I was thinking. People were stuck at plateaus past that honeymoon period of going keto. Where were they going to go sustainably and the impact that could have on the gut microbiome, the impact as far as antioxidants were concerned? Those are— That's why I wanted to kind of fuse that way of being ketogenic with the best of being plant-based, and by plant-based I mean plant-centric. So adding tons of non-starchy vegetables into your life, and in Ketotarian there are many vegan keto options for people who want to be entirely plant-based, but I give the arguments as far as the bioavailability of the omega fats and fat-soluble vitamins. That to open maybe some of the people in the plant-centric world or the plant-based world to bring in some things like eggs or ghee or wild-caught fish. There's many keto vegetarian and keto pescatarian options for people as well. So I wanted to basically bring something new to the conversation. I don't think we need another ketogenic cookbook, and I wanted to kind of recalibrate the keto world and recalibrate the plant-based world too.

Well, that was a, you know, a really in-depth opening statement, and I would say I'd like to unpack that just a little bit more because you covered a couple of points I think that really need a little bit of a deeper exploration.

Yeah.

You know, one of the— probably the most talked about benefit is that, well, you're switching from burning carbohydrate and basically sugar to burning fat, in this case talking about the merits of burning beta-hydroxybutyrate as a ketone body, but you actually weave that in really quite nicely to the notion of reducing inflammation via amplifying beta-hydroxybutyrate availability by being on this type of diet. And I think that's a really very important point for 2 reasons. First, we recognize that inflammation is a cornerstone of all of our most dreaded long-term degenerative conditions, whether involving the brain, the heart, the physiology in general, things like metabolic problems, diabetes, and even cancer. So to recognize that beta-hydroxybutyrate, which is what you produce when you're in ketosis, is more than just a cool fuel, or as some have called it, a super fuel, but is a signaling molecule, is actually stimulating G-protein receptors on cell surfaces to initiate pathways that reduce inflammation, that augment Immune function, for example, I think is taking it a bit further, and a very important bit further, as I might add. The second thing that you really amplify, and I think it's great that you did this finally, is, you know, people have the notion that being on a ketogenic diet is basically Atkins redux. It's basically, oh, you know, the Perlmutter grain brain, eat meat all day and eggs and butter and hope for the best. And it isn't. And how really grateful we are that you create these recipes that show people, you know, you could be basically vegetarian and be in ketosis. I mean, I know what that's like. And I think you also brought up a really important point that people shy away from fiber-rich vegetables because, yes, fiber is carbohydrate by definition. But recognize that when we're looking, for example, at prebiotic fiber, we're looking at Fiber that is not metabolized and digested by us humans, but is in fact fueling our good bacteria, letting them make wonderful chemicals that, you know, help us be healthy. So this is, though, at its most core level, really about lowering blood sugar and making ketones available, isn't it?

Absolutely. Yeah. So the primary objective here is to lower insulin, lower blood sugar, Lower inflammation and allow ketosis to come up. Allow your body to have that clean fuel. It's akin to a log on the fire. It is a lot more sustainable. It's more slower burning. People are off of the blood sugar roller coaster that many people are on where they're throwing kindling throughout the day. They're having to eat 6 meals, small meals a day because it's kindling after kindling after kindling. We know that there's the dirty kindling of the standard American diet with all its carbs, but then there's so much cleaner kindling of the real food movement and all the healthier snack foods out there, but ultimately they're broken down into carbohydrates and sugar and it's spiking insulin to varying degrees. The cleaner kindling is better, but just because something's better than the standard American diet, it doesn't mean it's optimal for long-term wellness. That's really what I wanted to educate people on in Ketotarian.

You and I both agree this is the ticket to wellness. People watching this video have been thinking about it for a while, and maybe this is what they've needed to move forward, buy your book, and do this. What are some of the setbacks? What are some of the problems, pushbacks that you're hearing from people when they begin to adopt a ketogenic program?

Depending on what the patient's up against when they start that and years of being in this sugar-burning, kindling-on-the-fire metabolic state, they have to make that metabolic transition and sometimes there can be detox-type symptoms because their body, their microbiome is shifting. They're not getting all the sugar and the grains and the carbs that they were depending on for fuel and there can be some Herxheimer or sort of die-off responses for some people because they aren't totally being— filling themselves up with this sugar. Not everybody has this problem. Some people, they feel fantastic right away. But for some people, they have to make that metabolic transition to being a fat burner. So that's definitely something that I write about in Ketotarian so people are— they're aware of what may happen as they're changing the foods that they eat. But this is about sustainable wellness and we have to do something different to see different results. And if someone doesn't like the way that they feel, they have to make those changes. So that's something that can happen. As you start making that metabolic shift, and they can be in a couple of days or they could be in this metabolic purgatory where they're off of all the sugar but their body is not fully fat-adapted yet either. So you can— again, this isn't a—

Let me hold you there. The metabolic purgatory. Take me through that. What does that mean? It doesn't sound like it's fun.

Yeah, metabolic purgatory. It doesn't sound fun at all, but oftentimes when people are depending on every meal having varying amounts of grains and carbs and then they don't eat that anymore, I find that some people, they don't know how to eat more food that isn't those carbs and grains and junk foods. So they just calorically aren't eating enough food, so they're hypocaloric and they aren't fully fat adapted yet, so it's not a fun place to be at. Those people can mitigate this metabolic purgatory by eating more healthy fats. And eating all the clean ketogenic foods that we talk about in the book that are very nutrient-dense, filling, satiating foods. So this metabolic purgatory most of the time happens because the person maybe is in a dieting mentality of, I have to calorie restrict to lose weight, and they are maybe not used to not eating sugar, but they can again focus on these foods until they're satiated, until they're filled to mitigate this metabolic transition of being a fat burner.

So when people are stumbling through it and at the gates of purgatory, do you have them ease into the program?

Yeah, so for every sciencey, more advanced track I put in Ketotarian, I wanted to have some keeping it simple options because as we both know, there are some people that are like, what the heck is this keto thing? And they want to jump in and go 0 to 60, and sometimes that's too fast, too soon for where they're at. So if somebody is starting off on just the standard Western diet and They're not really eating clean. I suggest in ketotarian to just start off with the food list, not worry about ketosis, just focus on the real foods that are ketotarian-friendly, and then from there, I would do that for 30 days, and then from there they can lean into ketosis. That way they've cleaned up their gut a bit, inflammation starts to come down, they've been focusing on these healthy fats for their body. So at that point they've made that metabolic transition so they can gradually just go into ketosis more effortlessly and not go 0 to 60. And then feel like a failure because they try to do all things at once.

So one of the issues that people seem to bring up is, you know, they started going on a ketogenic diet, they don't feel well, they feel fatigued and aren't sleeping well and have brain fog. What do you tell these individuals?

I would first want to check in to see if they are in ketosis or not.

And how do you do that?

So there are a few different ways. I mean, one natural sign of ketosis is, or a list of them, is having more energy, having more brain clarity, losing weight. But if that's not happening, I would check in and test for ketosis. So there's 3 ways to do that. The gold standard is testing for blood. It's similar to a glucometer for diabetics. It's a little prick, it's very painless, and it measures ketones. And that's the gold standard because it's measuring Beta-hydroxybutyrate, and you know at that point that your body's actually burning it and producing it, and it's showing up on the ketone meter. The second way, which I am excited about the research around it and the developments that they're having in technology, is the breath meter. There's the brands like KetoneX and other brands out there too that measure breath acetone, and research shows that breath acetone is a good measurement of beta-hydroxybutyrate. So it's a good way to gauge if your body's producing ketones. And people like the breath meter because They don't have to prick their finger and it's a simple breathing into a tube and it can measure breath acetone. And then the third way is the urine strips, which most people probably are familiar with, and that's measuring acetoacetate. That is okay to use at the beginning because it's a good gauge on, hey, is there some ketones in my urine? But long-term, as you become more fat adapted, you're becoming more of a fat burner, that tends to go lower with time and it's not a good gauge on if you're burning ketones. It's just showing that you're good at peeing out ketones. I want to know, hey, if this person's not feeling great, if they're not getting the benefits of ketosis, I want to know if they're actually burning it. I would probably tell them, hey, let's try testing blood ketones to see what's going on there, because maybe they're not fully keto-adapted yet, and they're staying in this metabolic purgatory a little bit longer than they should, and they need to push their body into ketosis.

I'm still thinking about the metabolic purgatory. My gosh, I may have to take that one from you. When people are entering into ketosis early on and don't feel well, oftentimes there's a discussion that they need more electrolytes of one form or another. How does that work?

So when you're becoming fat adapted, one of the benefits of ketosis is you're losing inflammation, you're losing intracellular fluid, you're losing edema and water weight basically. So your body's more lean and you're losing all this excess fluid that your body's holding Yeah. But because you're losing that excess fluid and fat, your body can lose the electrolytes in that fluid, namely sodium, potassium, magnesium, calcium, these electrolytes. So you want to make sure that you're optimizing your electrolytes when you are eating ketogenic or ketotarian. But in ketotarian, because we're focusing on all these nutrient-dense foods with Sodium and potassium and magnesium and calcium, that is mitigated because you're eating these nutrient-dense foods with electrolytes. With that said, some people, even if they're eating these clean plant-based ketogenic foods, they may still want to supplement with different electrolytes. You can use sea salt, you can do something called Sole water, which is basically higher concentrated salt water, and you can just have a Teaspoon, tablespoon of that throughout the day just to rehydrate your body with electrolytes.

And what about constipation? That seems to be a fairly common complaint early on.

Yes, and that's also due to the loss of water and staying hydrated is super important for anybody, but especially when you're becoming a fat burner and you're making that metabolic transition. Stay well hydrated. Again, eating all the fiber that is in ketotarian at least, that typically isn't a problem because they're eating such good fibrous foods that helps for healthy gut function. I do see that problem more with the conventional ketogenic diet where they're having lots of dairy and meat and not enough fiber. That constipation is more problematic for the conventional keto diet.

I think that's a very, very important point, you know, because constipation across the spectrum of individuals going on a ketogenic diet is, is pretty common, and I think you Yeah. I think you hit the nail on the head that, you know, again, people think I'm going to be eating meat and dairy and eggs all day and it's going to be good for me. Well, if you're constipated, it's telling you a couple of things. A, your digestive system isn't working appropriately, and B, you're probably not catering to your microbiome appropriately for the reasons you just stated, that you're not getting those fiber-rich vegetables, so you're not giving your microbiome the nutrients that it needs and providing the bulk in your gut To allow appropriate digestion, assimilation, etc. So it's a common problem, I think. And that's again, you know, one of the very strong points of finally seeing your book, which is talking about eating more vegetables and bottom line, eating food and enjoying food. I think a lot of people think, well, if fasting is important on the ketogenic diet, then it means I'm not going to be eating very much. And, you know, I love to eat. I love it. You know, I look forward to it every single day. And that's what's great about what you've written is your recipes are— they're over the top and you can enjoy food. You're not standing at the gates of metabolic purgatory anymore. You're enjoying life. So that said, tell us about some of your favorite recipes.

Yeah, so in Ketotarian, there's over 80 different vegan keto, vegetarian keto, and pescatarian, or what I call in the book Veggiequarian, another play on words, but these wild-caught fish with lots of vegetables as well. Keto recipes. There are a lot that I love. Some that I love for breakfast, which I love it just because a lot of people don't think you can have them when you're eating a keto diet, are smoothies. I don't think— I love fasting in the morning. I eat when I'm hungry and I'm typically not hungry in the morning, so I typically would just have some Earl Grey tea. In the morning and eat at lunch, but many people enjoy breakfast. It's the art of breakfast, and I want people to enjoy it, as you said. I don't think that wellness should be arduous and this sort of gritting your teeth just to get through the day. If you enjoy breakfast, you can eat breakfast. There's a lot of keto smoothies in the book that are all real food, and people like the simplicity of it. They're about to get out and go to work in the morning. They don't want to spend a lot of time in the kitchen. They can just throw— Some great healthy fats in like coconut oil, almond milk, coconut milk, and good green leafy vegetables, some fruit. They can add some MCT oil on if they want and blend it right up. There's a many— there's a whole recipe section in Ketotarian devoted to smoothies and breakfast ideas. For lunch, I love this zoodle bowl, this pesto zoodle bowl that is made with Zucchini noodles, zoodles, and with good pesto sauce, with avocado dressing, it's really delicious. Then for dinner, I like 2 things. There's an albacore tuna salad with grapefruit and avocados, and I also like the eggocada, which is a version of that, is actually the COVID of Ketotarian. It's an egg in an avocado.

Actually, I just happened to open the book to that. I mean, it is on the COVID but I was going to just show— I want to show our viewers some of the beautiful photographs. I love picture books. So yeah, look at that. Isn't that just great? Yeah, ever since Cat in the Hat, I've been dialed into picture books, but as well as the text. So one question we get commonly is, where does alcohol fit into the picture in terms of trying to remain in ketosis?

Yeah, so in Ketotarian, I advocate in the book to do this for 8 weeks. Do this plant-centric keto thing for 8 weeks to give your body the The time to make that metabolic transition to being a fat burner, get the anti-inflammatory benefits, get the mitochondrial brain benefits of ketosis, and then from there they can start personalizing it a little bit. So that involves many different things to make it a lifestyle and not a diet, but one of that is bringing alcohol in. So for the 8 weeks, there's— I advise not to have alcohol, not that I'm— I think that it can be fine in a healthy ketogenic lifestyle, but I wanted to have it as clean as possible, give the liver a break there. But actually, if you look at the mechanisms and some studies done on that, and I've seen this in patients too, dry alcohol, specifically wine, can actually increase ketosis for some people. And I saw a study actually, it actually impacts growth hormone levels, and people— when people measure their ketones, they'll actually see the ketones come up. So if they have a glass of wine at dinner, they may see actually higher ketones in the morning compared to when they don't have that glass of wine at dinner. So I think clean wine can be a great part of a healthy ketogenic lifestyle for many people.

And what about caffeine?

Caffeine, I think, could be great too. So the mechanism there is at the beginning cortisol can come up if someone's not used to drinking coffee or Yeah. Their cortisol can go up higher, it can impact their blood sugar a little bit, and they may see that impacting ketosis in the short term. But the studies that I've seen is that with time there's this adaptation that goes on and you don't see the spike in cortisol long-term. And I actually think it's gonna be a great way to increase lipolysis, to increase the metabolic rate, and be a healthy part of one's ketogenic lifestyle. There's a lot of pesticides and spraying that can go on with— when it comes to coffee. So from a wellness standpoint, I'd recommend organic coffee, organic tea. But I think both of those can be a great food, a great drink to focus on.

I think positive remarks about coffee will always gain you friends.

Yeah.

I have learned.

Yes.

Me included. So listen, thank you for joining us today. This is great information. The book Your book is awesome, and we've needed your book for a long time, so I was happy to endorse it. I think you're doing a really great job.

Thank you so much. I just— can I say, like, just thank you so much for your support and kindness to me over the years, and writing the blurb on the front cover of Ketotarian really meant the world to me.

Well, I appreciate that, and I did it from the heart because you really put out some really vital information for a lot of people, so thanks.

Thanks so much.

Interesting information, isn't it? We're hearing more and more about the powerfully health-related benefits of getting on a diet that is powering your body with fat as opposed to carbs. And beyond that, not just from a fuel perspective, but from a signaling perspective, where one of the ketones produced on a diet like ketotarian is called beta-hydroxybutyrate and how beta-hydroxybutyrate actually acts not just as an ideal fuel for our cells and our brain cells in particular, but also acts as a signaling molecule to temper down things like inflammation. So again, here is Dr. Will Cole's exciting new book, Ketotarian. I think it's going to do really well. It's very well written, recipes are top-notch. So I hope you'll take a look at that. Thanks for joining us. I'm Dr. David Perlmutter. Bye for now. Bye.