Is It Possible To Be Vegan-Keto?

Whatever diet we need to get you on so that you feel good, so that you're able to go out and be active and live an active life is the ideal diet for you.

Welcome to Doctor's Pharmacy. I'm Dr. Mark Hyman and that's Pharmacy with an F, F-A-R-M-A-C-Y, a place for conversations that matter. And if you've heard about ketogenic diets and intermittent fasting and the benefits or the harms, this conversation is going to matter to you because it's with two of the most informed, intelligent and articulate people on this subject, which is a very slippery subject for many people. Our first guest is Carrie Dayles. She's an orthopedic spine surgeon. She's a good friend of mine, has helped me with my back and many of my friends with their backs. She's the vice chief of the medical staff and director of the Spine Wellness Center at the Christo Clinic in Akron, Ohio. And she was a spine surgeon at the Center for Spine Health at Cleveland Clinic for many years and medical director of their IT department. So not only is she good with bodies, she's good with computers. She's gotten her MD from Northeast Ohio Medical University. did pathology residency. She was also on the US national team for the duathlon and competed in the world championships. Quite a lady. I could go on and on. One of the most interesting things about Carrie is that she developed type 1 diabetes actually since I met her. And we worked together early on in it. And she's one of the few diabetics I know who's type 1 who uses very, very little insulin, almost no insulin really. And it's pretty impressive. We'll talk about how and why that is and what she discovered about her own body and what it means for the treatment of diabetes in general and type 1 diabetes. Our next guest is Dr. Ethan Weiss, who's an associate professor of medicine at the University of California, San Francisco, a principal investigator in the Cardiovascular Research Institute. He's gotten his MD from Johns Hopkins School of Medicine, where he also completed his internship and residency and completed his cardiology training at UCSF. So he's a cardiologist focused on prevention, lipids, and the emerging intersection of endocrinology and cardiology with a specific focus on pre-diabetes and type 2 diabetes, which I call diabetes, which are main risks factors for heart disease and how to treat those with diet. In fact, how to treat those with extremely high fat diets, which seems like a crazy thing for a cardiologist to be recommending, but it's true. And his research is really focused on why that works, looking at the mechanisms of how we gain weight and obesity, fatty liver and diabetes. And, you know, I think what's increasingly clear in cardiology is that it's not just about plumbing, it's about the immune system, it's about the hormone system and the endocrine system. He's has an active program in clinical nutrition, exploring things like time-restricted eating, which many people refer to as intermittent fasting, although that's something else. He's the principal investigator on grants funded by the National Heart, Lung, and Blood Institute and the National Institute of Diabetes. And he serves on many scientific advisory boards. And he's a co-founder of an incredible new company called Keto, K-E-Y-T-O, which is based in San Francisco. It helps people use heart-healthy ketogenic diets for weight loss. So a heart-healthy diet is 70% in fat and saturated fat doesn't seem like healthy for most of us who grew up in the 80s and 90s when fat was the enemy number one. But welcome Carrie and welcome Ethan.

Thanks Mark.

Thanks Mark. Okay, so let's get right into it. Everybody hears in the news ketogenic, how does new diet trend? I wrote my book Eat Fat, Get Thin a few years ago before that hit, but I could see it coming and went into the science of why our thinking about fat is pretty wrong and why our guidelines for eating lots of carbohydrates and very low fat diets led to a massive epidemic of obesity and diabetes. And what's been fascinating over the last few years is to watch how Science is shifting and actually opening up the doors to understanding how to shift metabolism through using different types of eating patterns, whether it's time-restricted eating or different days of fasting or diets that mimic fasting, like low-calorie diets or even ketogenic diets, which sort of mimics fasting. It's what it does to the body. So let's start with you, Carrie. You are a type 1 diabetic.

True.

You certainly don't identify as a sick person with an illness. You actually are, like I would say, an Olympic kind of, no, no, you didn't let me finish. You're sort of an Olympic biohacker who has jerry-rigged her blood sugar monitor so she can adjust her insulin and regulate her sugars and knows exactly what's happening every minute in her body and has been her own guinea pig in terms of diet and had an incident where she had to switch her diet to not just being a keto diet that was including animals, but one that was vegan, which most people are sort of perplexed at because we think keto is bacon and cheese and butter and coconut oil. And that doesn't have to be including animal products. So tell us about how you kind of came to realize you should be as a type 1 diabetic not eating a lot of carbs and eating a ton of fat and actually how you switch to then be a vegan keto, which most people don't even think is a thing.

It's a thing, yeah. So it is a thing. I have a plant-based bend in that when I was 12, I first gave up meat just because I didn't really like it. And I have a lot of obesity in my family and it seemed like the thing to do at the time. There was the Pritikin diet. And so, you know, over the years, I was mostly plant-based throughout that and I struggled with my weight at varying times.

So let's putting it mildly, you were 100 pounds more.

I was 100 pounds heavier than I was.

If you see her on the video, you'll see she's a petite little lady who was 100 pounds more.

Yeah. It's true. And then I lost it. I mean, I lost it in the traditional ways of calorie restricting and exercising a lot. And that's when I got into doing all of the multi-sport stuff and competing. And as I got into my 30s, it was sort of harder to keep weight off and I struggled with some of the things with the plant-based diet. And, you know, I went to the gurus of it and many of them said, well, you're doing it wrong or you're, you know, eating too much. And at that point, I felt like I could win a, you know, Olympic medal in calorie counting and it just wasn't working. And so at that point, I sort of shifted to...

So you were in a low-calorie vegetarian diet and still not losing weight.

And I was, yeah, I gain weight very, very easily. And so it was, you know, it was just not working well. And I ended up shifting at that point to, I had gained weight with each of my pregnancies and I was trying to lose that weight and I ended up shifting to a very low carbohydrate diet. That, you know, at the time there was sort of the South Beach thing, but it really, it was low carb and I was getting into ketosis. most likely looking back on, you know, what I was doing at the time.

And... Was it before you got diabetes?

This was before. And then I sort of shifted back to plant-based for a while and had done some different things with really whole food plant-based, a lot of greens and things like that, and it worked well. And I was out actually, you know, speaking in the orthopedic and surgical community about how we modify patients metabolic risk factors, you know, when they're orthopedic patients to impact surgical outcomes in their musculoskeletal health.

And I went for, meaning if they're overweight and sick, they do better if.

They get their metabolism fixed. Right, right. We get better surgical outcomes. And I went for an executive physical and my A1C was elevated. And I was like, no, that's your average blood sugar. That's your blood sugar, yeah. And I was like, no, that's not a thing. And so I had some room that I could clean up some things in.

My diet and focus on stress and.

Sleep and all those things.

When you weren't Eating bags of chips or her cookies? I was not. No.

I was not. And so then I ended up going, you know, trying to control my blood sugars. I got a glucose monitor and I started paying attention to what spiked my blood sugars and I slowly started working on, okay, well I can't eat that or my blood sugar goes up really high. And at that point, they sort of thought I was gonna be type 2, which didn't really make sense. I don't have a family history despite the obesity history. But I do have a family history of type 1 on my mom's side. And long story short, I was really super low carb and was able to stay off insulin for a while. And then I got sick and it became clear that it was type 1 diabetes at that point. And that's when I went on insulin. And initially, I did the things that you're told to do when you go on insulin, which is you have to eat a certain number of carbs per meal so that you can dose insulin. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr.

Dr. Dr. Dr. Dr. Dr. Dr. Dr.

Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr So that, and I gained 15 pounds almost immediately doing that.

Well, insulin makes you gain weight. That's what its job is partly.

It does. And if I want to gain 10 pounds, I just do any of the behaviors.

You just look at a bagel.

I look at a bagel and take insulin, but even stress will do it. I mean, that's lack of sleep, stress, anything that increases my need for insulin will lead to increased weight for me. So I shifted back to low carb at that point because I was like, I can't figure out, I have a degree in biochemistry and I can't figure out how much insulin to give for an apple not to, my blood sugars throughout the day were anywhere between 440 and it was not sustainable as a diet.

40 and 400, you mean?

Right, yeah. I would bounce between the two of them, which is, it was a roller coaster and it was miserable and it felt awful. and so I was chasing blood sugars around. So I just said, I'm just going to stop eating carbs and go back to what I was doing before because that seemed to make the most sense. Dr. Dr.

Right.

And there's not a lot of guidelines out there. Dr. Bernstein has written a book and there's, you know, since found that there's this whole community of people who are type 1s who are eating very low carbohydrate diets using very small insulin doses. When you use very small insulin doses, you have less room for error so you don't have the big peaks and valleys. like you would with your blood sugar if you're eating carbohydrates where you're trying to guess when it's going to absorb and how high your blood sugar is going to go. And then I got, there was, you know, another several years into it, a bad virus going around and I ended up having some issues where with my stomach and I wasn't able to eat normally for a while and had to sort of get back into where I was adding foods back in and I just really didn't tolerate meat well.

You had a hard time digesting it.

I couldn't digest it.

So then you went vegan keto, which people don't think is a thing. So what is vegan keto?

So what is it? You know initially I was doing protein powders and things like that because that's what I could get down. But now it's been several years now and it's blossomed into, you know, I eat a lot of the same things that people on a ketogenic diet eat. in the sense of the macros and the vegetables. So lots of non-starchy vegetables, broccoli, asparagus, Brussels sprouts, kale, you know.

All of.

Those with healthy fats like avocado, olives, olive oil, nuts and seeds. And then the protein sources are things like edamame, tofu, black soy beans, lupini beans, you know, hemp seeds are a great source of protein. And you can make a ton of really delicious things that way. And I did it thinking, all right, I'm gonna do this for a little while.

Yeah, not only is she a big surgeon, is she a biohacker, but she's a great chef and makes the most amazing keto foods.

So I did it for a while and a bunch of lab markers that are inflammatory markers and things like that got better that I've been struggling to bring down. So my high sensitivity CRP, which is a marker of inflammation improved, my lipid profile improved. So, I've been sort of riding it at this point where I've said, I will keep doing plant-based low-carb until I run into a reason to consider it. And I may, I mean, four minutes from now, I may add fish back if there's reason that I want to add fish back.

And you supplement with things like fish oil.

B12 and algae oil for the omega-3s.

Yeah.

In the sense of, I mean, anybody, a lot of people need to supplement with B12. But anybody who's fully plant-based needs to supplement with B12.

You can't just get it by eating the dirt on your vegetables, like they.

Say in Game Changers.

I'm not going there.

I'm only one who hasn't seen it.

What?

I must be the only one who hasn't seen it.

You haven't seen it? Well, for those who are listening who don't know what that is, that's a new movie by James Cameron called Game Changers about the benefits of a vegan diet, which has a lot of valid points, but also a lot of sort of half-truths and science misrepresentation. which you can listen to on Chris Kresser and Joe Rogan's podcast, where he discusses for three hours the challenges of the movie. So just to put that out there. Haven't listened to that either.

What?

Joe Rogan's like the number one podcast.

No, I know, I know Joe.

So that's amazing, Carrie. And your blood sugars have been great. Your A1C is the average blood sugar.

Is better than most people who don't have diabetes.

Yeah, I range from 4.8 to 5.3. And to put it into perspective, most people run around five and a half, six is plus more diabetes. So you're doing better than most people who don't have diabetes. The goal is for how much insulin do you use a day?

I mean, it depends on what I'm doing. I run a lot and so that impacts how much insulin I use. It can vary anywhere from 8 to 12 units per day unless I eat carbs. And that can raise it up, stress will raise it up. I mean, if I'm sick, I may use 35, 40, 50 units.

For sure. So most type 1 or type 2 diabetics we're using insulin use 30, 40, 50, 100 units who are diabetic type 1 or type 2. And it's usually at least 20 is sort of the baseline amount that most people need a day. And you're doing half that and keeping your blood sugars better than average or better than normal. That's because you're not eating a lot of the starch and carbs.

It's just easier. And, you know, when your blood sugars do get high, high blood sugar tends to beget high blood sugar. So you tend to be more insulin resistant the higher your blood sugar is. So by keeping it in a very low range with very low glucose excursion, so the ups and the downs makes it easier to manage it. And then there's much less worry about a low blood sugar. I can say I've never had a low blood sugar at a time when it's critical in the operating room.

Yeah. Which is amazing because you think your blood sugars go up and down and your risk of low blood sugar being a diabetic, but by eating the fat, it actually normalizes your blood sugar.

Right, and by keeping the insulin doses very low.

Amazing. Okay, well let's get back to you in a minute, but I want to talk to Dr. Weiss for a minute. You grew up in a hospital, your dad was a cardiologist, you had a lot of experience seeing heart patients and you went to the same path as your dad. You had a series of patients in their late 30s and early 40s who had heart attacks and then really didn't have the obvious risk factors. And those events seemed to inspire you to get into cardiology. So what did you learn from those experiences?

Well, I learned that you can't fight destiny, I guess, or that I'm just not I don't have very much imagination or creativity.

I mean, the destiny of your dad being a cardiologist. Yeah, not the destiny that you're going to get a heart attack.

I went to college intending to do anything but be a doctor. And when I went to medical school, I absolutely didn't even consider being a cardiologist. I thought I'd be a psychiatrist, actually. But yeah, I did a CCU rotation when I was a third-year medical student, and there were all these younger patients coming in with heart attacks. not obvious risk factors. And I thought that was interesting. And so that sort of spurned my interest, spurred my interest in trying to understand some of the mechanisms behind cardiovascular disease, especially these events in younger people. And I went and worked on thrombosis, on blood clotting, and I did that for the better part of the next 10 or 15 years, trying to understand sort of what was different about. So if you think about the plaque inside of a coronary artery as a I tell my patients it's like a pimple. It's full of inflammatory cells, it's full of cholesterol and lipids and fats. But one of the things that happens when it breaks or opens, when it ruptures, is that it exposes blood to this substance or series of substances that signal an injury. And our response, our body's response to that is to try and wall off that injury off. And so that's why we have this blood clotting system. It senses an injury, it forms a blood clot. It happens to form a blood clot in the worst possible place, which is right in the middle of an artery. inside your heart, and therefore it stops the blood flow beyond that. Thanks. And so I wanted to understand sort of what was different about people's blood clotting system that might lead them to have these events at a young age. And really actually didn't think about the part leading up to that rupture of the plaque. I didn't really care at that time in my life. I didn't care about things that caused development of plaque.

So I didn't care about the- Just working downstream.

Yeah, I cared about the final event. I thought, well, this is... And the reason for that was that there were some old evidence from these pathologists, I don't know if you remember, this British pathologist who was like my hero when I was a medical student, Michael Davies, had done this series of autopsies and young people who had had heart attacks and died suddenly. And so he went and did this histological analysis and found that it looked like the plaques had ruptured in these people not just that one time when they died, but had ruptured several times before, on average, up to seven times. and so there was this idea that every plaque rupture did not result in a heart attack. And so that was sort of the question that I started my career thinking about was what's different about the one that does cause a heart attack than the previous ones. And, you know, that's a long history that continues today.

So you got into cardiology and, you know, typical cardiology advice for years was to eat a low fat diet, still sort of part of the recommendations of American Heart Association.

Yeah.

Kind of bizarre way. This sort of is and it isn't. You know, we're told to eat low cholesterol diets, to cut out eggs, to, you know, eat lots of carbohydrates. and even in major heart hospitals, they're still giving post-heart attack patients and post-heart surgery patients a high carb, low fat diet. It hasn't translated, although the government has changed the recommendations around this. But you're kind of going to the other extreme now. You're studying diets that are actually pretty high in fat as a way to treat metabolic disease. And for people who don't know, I think it's important to explain the change in thinking from heart disease being a plumbing problem to being an inflammatory problem, metabolic problem that's driven by insulin resistance or pre-diabetes or blood sugar issues. So I think not all heart disease is that, but it seems like the majority of current heart attacks and heart disease is because of that. Is that fair to say?

Well, I think it's fair to say that we understand and appreciate a lot of the risk factors for coronary disease, but we also don't understand all of them. I think the focus in the 70s and 80s when I was growing up as a kid was on fat because of the known effects on lipid. So when you eat a lot of fat, your blood cholesterol goes up. And that was something that had been recognized, you know, decades before. And so as a kid, when I was growing up, curious, tired of hearing me talk about it. But, like, we didn't have any fat in our house. We had, we had, you know, no Fleischmann's margarine. No, no, no. And we had, maybe margarine, but, like, we had nothing that resembled fat, but because nutrition is truly a zero-sum game. If you don't have one macronutrient, you have a lot of another. And because we all eat a typical sort of normal amount of protein, we ate carbs like it was literally candy. And so, I mean, I'd come home. Oh, it is candy.

It is.

But I remember coming home from school and like I would eat through a bag of chips or Doritos or, you know, Skittles or whatever the heck it was. And it was healthy.

It was heart healthy.

And so it took a little while.

I think, for me to be plant-based.

It was Skittles.

Skittles are definitely a colorful plant-based diet. They are. Not the kind we talk about though.

And that was, you know, ingrained, I think culturally and otherwise ingrained in all of us. I mean, particularly me growing up in the home, you know, with my dad as a cardiologist. So I didn't begin to think about the metabolic effects. I do remember hearing about the Atkins diet in like the early 2000s and.

Thinking, God, that's crazy.

But it worked for people. Well, it did work for people in improving their metabolic health, but we didn't connect the, I mean, I don't think we did a good job, at least in cardiology, we didn't connect the relationship between metabolic health and cardiovascular health until relatively recently. I think that's been.

And it's fascinating because the numbers that really go awry that predict heart disease, even the conventional biomarkers, it's not the total cholesterol. It's the total to HDL ratio, it's the triglyceride ratio ratio, and those are determined more by your blood sugar control and your insulin levels. And that's something people don't understand, I think. So people think about cholesterol, they think about fat, but it's actually the sugar that makes your body make more cholesterol.

It's true to some extent. There's some strong component of genetics as well, but in terms of the things that you can control, and I always talk about this with people, with patients, it's what are the things that you can control and what are the things you can't control. In terms of the things that you can control, there are two levers you can pull on. One is the amount of carbohydrate and the other is the amount of fat, particularly saturated fat. And I think that's sort of one of the things that's different evolved in the recent past for me in thinking about the ketogenic diet is considering saturated fat, which was when I first got into this was something I didn't know.

It was the enemy, number one, right?

So yeah, so it was the enemy and then it wasn't the enemy and then now I'm not sure, maybe it's in between.

Yes, I think you're right because here's the deal. You know, everybody hears about the best diet. There is no such thing. No. There's the best diet for you. So some people, like I've had patients who I put on a keto diet who've been resistant to weight loss, whose cholesterol is like 300 and they're triglyceride. 300 and their HDL is very low and they're struggling. And I put them on butter and coconut oil and they drop the weight, their cholesterol comes down 100 points, their triglycerides drop 200 points, their HDL goes up, all their metabolic markers get better, their inflammation comes down and you're like, wow, this is impressive. This is secure for everything. And then you have another patient who's the opposite, who has got these lipid issues and you try to treat them. with a higher fat diet and they actually get worse. And, you know, it's interesting. There's a lot of what we call heterogeneity in the population. So genetically, we're all different. We all respond differently. Some people respond worse to carbohydrates. Some people respond worse to fats. And it's very hard to sort of, for people to figure it out. So I think, you know, the universally saying everybody should be this keto or.

Everybody should be low carb or everybody should be low fat just doesn't make sense. Is that fair to say? Yeah, I think so. I think the We all aspire to want to find the perfect diet. And I think you're right that there probably is no perfect diet. I still hold out some fantasy that there is a best diet, maybe not perfect, but best. And when I mean best, I mean best for most people, I don't mean there's obviously not going to be best for everyone, but.

Spill the beans, what is it?

Well, no, I mean, I think, look.

I mean, keep us waiting.

I think let me step back and I think we both appreciate, we all appreciate that the ketogenic diet has done wonders for a lot of people. particularly the patients that you describe who are overweight and metabolically extremely unhealthy, I think there's no doubt that the improvements they see are dramatically beneficial. Most of the time, all the improvements go in the same direction, right? You don't have to worry about, oh, well, 30 markers go in the right direction, but one goes in the wrong direction. So those people, I think, there's very little controversy about and they can thrive on a ketogenic diet. It's this other group of people where you see this discordance in the movement of the markers where I think there's the health the most conversation. And what I'm specifically talking about is there are some people who will go on the ketogenic diet, all their metabolic markers will move in the right direction. So, insulin, glucose, A1C, all that stuff moves better. Inflammation gets better, but then they see what would give me or my colleagues a heart attack in terms of the movement of their cholesterol. And I think what happens to their cholesterol. So, their cholesterol and when when we talk about cholesterol, as you mentioned, that we used to just pay attention to total and then it became this LDL cholesterol and now I think we're paying more attention to non-HDL cholesterol, so total cholesterol minus the HDL or really it's the ApoB, so Apo lipoprotein B is a protein that carries around these cholesterol molecules and that one is thought to be the most dangerous one. So when those go up, so whether it's LDL or non-HDL or ApoB or LDL particle number, any of those things go up, to a large degree that makes people like me nervous.

Yeah, by the way, just to stop, most cholesterol tests the doctors do are, I believe, are antiquated and we should be looking at ApoB and ApoA1, which you should ask your doctor for and also looking at what we call NMR or cardio IQ, which are tests to look at particle number and particle size, which is turns out to be more important than just the absolute number you get on your regular cholesterol test.

Yeah, there's a ton of controversy even in that, within that world of there are people who are sort of minimalist who think you can get everything you need out the non-HDL, so total minus the HDL, which I think is a bare minimum. And then there are people who think you have to measure ApoB specifically or people who think you have to do this NMR or even this ion mobility test to look at the LDL particle number and look at the LDL particle size. I'm not going to wade into that controversy. I think most people, 90 plus percent of people, there's concordance between non-HDL cholesterol, ApoB, and LDL particle number, which are.

The three markers that I picked.

Yeah.

So then what happens to these other patients who maybe aren't really overweight but want to try a ketogenic diet to lose a little weight or to get healthier or performance? What happens to these people?

Right, so those people have this very alarming increase in their bad cholesterol, what we used to call LDL cholesterol, now non-HDL apoB and- Including the small particles.

And the total particles.

Yeah, although not necessarily the small particles, I think the People on a low carbohydrate diet tend to have more of the larger particles. Again, tons of debate if that matters, but the total particle number is increased. There's a difference in the pattern, but the total particle number is increased. But regardless, the result of that makes some people very nervous. It makes other people less nervous. And there's this sort of resulting debate about does it matter and does it matter in the context of all the other positive things that have happened? And so my take on that is we don't know if it matters and we probably won't know if it matters for quite a long time, but we have an enormous amount of evidence supporting the fact that increases in these kinds of cholesterol over the lifetime of an individual does matter. And if you want to wait around to figure out if it does matter, you're going to be waiting a long time and it may be too late. And so my take is if you could do this diet, which we all love and I've been practicing myself for almost two years. If you can do it without the scary looking cholesterol numbers, why wouldn't you do that? So for me, it kind of comes down to a head. So what we've been working on is trying to develop a diet where you can get all the benefits of this low-carb, high-fat ketogenic diet, but without that one wart that bothers.

And is that because it's plant-based fats versus animal fats?

Yeah, I mean, so there's evidence going back now 50 years or probably in that range, that increased dietary intake of saturated fats causes an increase in these LDL cholesterol numbers. And so you can basically, a typical sort of conventional ketogenic diet is rich in butter, bacon, lard, steak, things that are pretty high in saturated fat. You don't have to do a ketogenic diet with a saturated fat, high saturated fat diet. You can do it with unsaturated fats, a mono or polyunsaturated fats. And so whether those come from plants or potentially from animals like fish, you know, are rich, really rich in mono unsaturated, sorry, poly, poly, omega-3 polyunsaturated fat. So, whether you choose to do it entirely plant-based or you do it with plants and fish or plants and other animals that are lower in saturated fat, that that's a choice that any individual can make. But that's what we've been working on is trying to develop options for people who you don't want to wait around to figure out if that cholesterol rise is a problem.

And not all saturated fats are created equally, right? And they have different effects on fat, on your lipids. For example, my understanding is that stearic acid, that's the most common saturated fat in meat, actually doesn't really affect your blood cholesterol. That's right. There are tons. And yet others might, like coconut oil will, but it also increases HDL more. And the size of the particles. so this is such a variable response.

And it becomes head spinning. But again, you have to make a choice and this is a choice that is on the one hand empowering for people because they don't have to have a doctor like any of the three of us write a prescription for you. You can do this on your own. But yet it's daunting for people because they're confused and frankly so am I sometimes. So I think it's a place where we have to be humble and kind of recognize that this is not easy.

So if someone wants to be on a ketogenic diet and their cholesterol goes.

Up to put them on a statin? Well, so what I tell people again, this is coming from the perspective of me as a cardiologist trained in a Western world. So what I tell people is you have options, right? If you love eating the way you eat and your diet includes a lot of saturated fats, a butter and bacon and lard and stuff like that, and you don't want to change that, then you have an option. You can take a statin. or you can ignore your cholesterol. I would recommend you take a statin or some other cholesterol medication. But if you choose to not want to take a medication, there are other options. You can modulate this with diet and nutrition itself. So, and I've had a lot of patients have a lot of success in doing that and taking and replacing all of that, because I think some people feel like you have to do it because the keto diet is so strongly associated with bacon that people feel like.

Oh, well, that has to be the way it has to be done.

It's the gateway food.

Right.

It's like the gateway drug for eating meat. and it took me a little while to figure that out too. And in fact, because of the way the biochemistry works, it's actually easier to oxidize unsaturated fats. So it's easier to get into ketosis. It's actually easier to do the ketogenic diet on unsaturated, on a diet that's predominant unsaturated fat than saturated fat. So this is something that like, you know, through introduced, being introduced to Carrie.

And other people, it's been an awakening for me that this is possible. So, so even just Just to sort of go down this rabbit hole a little more, the saturated fat question is sort of sticky and I think it's so variable how people respond to it. And I think there are people who are we call lean mass hyper responders who do end up with this high cholesterol. And it is worrisome because I think there's increasing data that your lifetime exposure of your arteries to the cholesterol elevations is what matters. sort of a new metric. It's sort of like life years of LDL or something.

Yeah, it's like pack years for smoking.

Yeah. And so that creates a risk. And in the whole field, you're talking about eating now more of the polyunsaturated fats. So I just want to dive a little bit in this rabbit hole of omega-6, omega-3, saturated fat. And, you know, my favorite topic. Yes. And I try to understand this. I've read a lot of the science myself. I talk to experts, everybody's got a different opinion. Everybody, so there's epidemiologists, there's trialists, they all disagree, and the rest of us are stuck in the middle. So we've had about 1,000% increase in the intake of soybean oil in this country in the last 100 years. These refined oils were really never part of our diet historically. We had olive oil, we had some oils that were nut and seed oils, but the bean and seed oils that we're having, what we call plant-based oils, are a relatively new phenomena and they're very unstable. They're easily oxidized. They're produced in ways that are heat, using heat and solvents to extract the chemicals. They're often filled with glyphosate if it's soybean oil. That's a sort of a side point.

How many rabbit holes are we going to go down?

How do you navigate this controversy between those who say we should be eating way more plant oils and less animal oils and navigate that as a cardiologist. Because when I hear you say eat more soybean oil or- Wait, I never said that. I know you didn't say it, but.

You said- you- did say- We're both.

Sitting here around the table. You did say, okay, but that's what people are going to be hearing. When you say polyunsaturated fats, people hear- okay, best of all, and then they hear all these oils. So, I'm glad you don't agree, but I want to hear your perspective on this. And can you unpack that for us.

A little bit for the average listener.

Who- is not an expert in lipidology.

Well, I mean, we don't, I don't know how detailed we want to get in sort of like the, but the chemistry of, of fatty acids. But the, let's skip that. Let's just focus on the sort of what I think. Well, let me just say quickly.

So saturated fats are basically solid room temperature. They're more stable and less as easy to oxidize or damage. Polyunsaturated fats are more fluid, liquid at room temperature, and they're more easily damaged by oxygen or basically various insults that can create oxidation, which causes the damage to the cholesterol.

That's right. And it has to do with the number of double bonds and makes the chemistry stuff.

Yeah, the chemistry stuff. But it's still, you know, more one.

Unstable, one stable, unstable. Look, I don't like processed food at all. There are some people who will make the argument that olive oil is processed food. Olive oil is processed in a what seems to me at least to be a pretty normal and natural way, right? You take an olive and you crush it. I'm okay with that. So when it comes to- you- have too many steps.

There's no hexane or solvents.

No, and I think that kind of stuff makes me nervous too. As to the sort of relative effects, you're not going to get me to bite on the relative potential damage of polyunsaturated versus saturated fatty acids. But you will get me to bite on the processed food bit. And so I'll just tell you what I do, and it's probably not that different for what Carrie does. I get my unsaturated fat from a limited number of sources. And so in terms of oils, Carrie mentioned avocado and olive oil. Those are the only oils I use.

Yes, me too.

Only oils I touch. I don't, I really, I cook with or use them for salad dressings or sauces or anything. You never use ghee or anything like that? I don't use ghee. I will occasionally, and I'll get killed by a number of people. The other night I made a stir fry for my kids and it called for a tablespoon of sesame oil. kill me, like one tablespoon. I don't know, it was an Asian dish and it wanted the- why would people kill you? oh, because people are nervous about these seed oils because of all the things you mentioned that they think that they're easily oxidizable and therefore inflammatory. so you worry about that then?

No, I don't really.

Well then why don't you eat safflower oil or canola oil?

Well, because I don't like it. I like olive oil and avocado oil.

And it's simple and easy.

But it's more than just that.

You don't think there are safety issues? I do not like- I don't like avoiding them. this is good.

I don't like-- I don't buy that.

I don't like-- I'm going to bite again on the processed thing. I don't like-- and I haven't gone-- I'm not a food expert, so I haven't gone to the factory to see how they make these things. But to me, it's very simple to conceive of how they make olive oil, avocado oil. So I'm good with that. I love fish. I've done a plant-based experiment for a.

Week and it's doable.

But I-- who liked it?

I don't wouldn't say that I liked it. I think what? He did a plant-based, we got him to do a fully plant-based week.

Yeah, and it was not nearly as bad as I thought it was gonna be. But it was keto.

Keto plant-based.

Yeah, yeah. Carrie helped me walk through that. As we were launching this, we were launching this program for people who wanna do plant-based keto with this company that I'm involved with. And so I just thought, well look, if we're gonna do this, I need to try it and see if it's actually doable. It was definitely doable, and I think it was a great experiment. for me to have done. And again, my diet is 90 plus percent plant-based. The place where I get animal protein is from fish. I mean, I'll have some chicken and occasionally I'll have something else, but mostly I would say 90% of the meals that I eat are either plant or plant and fish.

So, you're a fish, vegan, keto guy?

Not vegan. I will eat cheese. I'll eat some cheese. mostly, you know, hard cheeses, not a ton, but I'll eat some.

You're kind of what we call Pegan, you know, mostly plant-based but with some animal proteins.

I like to think of it as Mediterranean Keto. I think it's like a. It's really like a Mediterranean.

I mean, to me, it feels like a Mediterranean Keto.

It's like the Mediterranean diet without the bread and the pasta.

And.

And what's happened to your numbers when you do that?

My numbers were pretty good to begin with, and I haven't checked them in a year, but they looked really good. on a keto diet. So you weren't one of those lean mass hyper responders.

But you weren't also a bacon and butter.

I did it a little bit at the beginning when I was first experimenting with keto. I did, because I thought you had to. I mean, you know, there's no way to do this unless you eat all.

This fat and where am I going.

To find the fat? And as a cardiologist, you're doing this for your patients. Yeah. And what are you seeing? Well, again, it's the same thing that we're all seeing. So some people, it's a no-brainer it's easy. And I should say that for people who go, you go on this diet and they're eating a lot of saturated fat and their numbers all look good, I have no problem with that. I don't have any belief that they're eating saturated fat in the absence of the effects on cholesterol and lipids and other markers. If that works for you then great. And then for the people who have trouble, that's where we get to, that's where we earn our money, that's where we get to play this game. And so, it's been great to have options for people, whether it's plant-based or plant and fish or whatever you want to call it. I think that's what we've been focusing on as providing people an option that's beyond having to take a medicine, which again is still out there. And I'm not, you know, look, there's a lot of bad stuff written about statins. I'm not gonna, we're not gonna debate statins.

No, that would be fun. But we're at the Cleveland Clinic. But it would be fun.

I'm a strong believer in the power of statins. I don't take a statin myself, and I know that I probably would do a lot change my diet before I would take a statin, but I also would not take a statin.

And I see it in my patients. So I put almost all of my surgical patients on the ketogenic diet of varying forms depending on where they come to me. I do have some people who are plant-based at the beginning and probably about 80% of them end up staying on it after surgery because they like the results of it. And the people who I've had struggle with their lipids, the vast majority of them, and again, this is anecdotal, it's not something that I can quantify or that we formally studied, but by making this shift, and I actually think we need to talk about the fiber side of it too with the plant-based diet, because I think that's a really significant factor in addition to just the fats. Dr. Justin:Yeah. Dr. Pompa:Because a lot of times if.

You'Re on a ketogenic diet, it's hard.

To get enough fiber. Well, and this is one of the criticisms that was in the article that was published earlier this year in JAMA about was that the ketogenic diet was low in fiber. And my argument, and we have a mutual friend, Danielle Belardo, who is a staunch ethical vegan and she did a two-week plant-based keto and her fiber intake was 80 to 100 grams per day.

Okay, that's like 10 times what most Americans get.

Right, but her net carbs, so we can talk a little bit about that. this whole argument about the seed oils and things like that, and people will frequently, when I say I do plant-based keto, that's the first thing that they say is, well, you're eating all these seed oils. I have no seed oils. I have olive oil, some avocado oil, and then occasionally if I'm baking something, I'll use some coconut oil. But otherwise, I eat whole nuts and seeds, whole... Dr.

I think that's really important, Carrie. I mean, what you're saying, and what you're saying, Ethan, is that you can eat any kind of oil as long as it's in its original packaging. Eat the nut, eat the seed, eat the bean.

I mean, Kerry knows I eat, I don't know, at least a fistful of macadamia nuts a day.

I love them. Yeah, I love that.

And so, I think those are all options.

Especially like the olive oil of nuts.

They have a lot of, they're so good.

Yeah, they're fantastic. I mean, and that's the thing, it's not free either. This is one of the things that calories do still matter and people will struggle on the ketogenic diet they'll eat too much protein. I think we see that in some of the other studies that are out there with the more traditional ketogenic diet. They found that women in particular seem to struggle if they get too much protein on it. It prevents them from getting into ketosis. I have a lot of patients who are measuring their ketones through the acetone breath meter and that's what they're finding is that we have to shift them to more of the high fiber, non-starchy vegetables, more avocado, more olive oil, and dial back whatever their protein source is, whether it's a plant-based diet or- Dr.

Protein gets turned into sugar in the body.

It does, I mean through- Dr.

It also increases insulin. Dr.

It increases insulin, that's for sure. I mean amongst the type 1 diabetic community, people will, there's this insulin index that was out there that was studied a number of years ago, and the vast majority of us have a very different, particularly those of us on a low carb diet, we actually bolus for protein, which is not something that's traditionally hot.

Dr. Yeah. You give extra insulin if you're eating extra protein.

Extra protein, but what the protein source is matter. So lupini beans, for example, which are an Italian bean, have zero net carbs. So I don't bolus for the carbs that are in them. The protein that's in there, because it comes along with fiber, I'll bolus for, I'll give insulin for about half of that. People, you know, fish typically need very little insulin for the protein, the amino acids that are in the fish. But something like steak, almost all type 1 diabetics that I know will report that they need much more insulin for steak than they do for fish. And then chicken is sort of somewhere in between there. And of course the amount of fat that you eat and things like that matter too.

But it's interesting though, if you look at people who are type 1 diabetics, when the pancreas fails, they produce no insulin. They could eat 10,000 calories a day and lose weight because they have no insulin. Insulin is required to actually store fat. So when you're eating protein, you're obviously getting insulin and you're eating some carbs when you're on a ketogenic diet. But that's a really important thing for people to understand is that insulin is really the key here and eating in a way that keeps your insulin low.

There's a lot of ways to get there. Ketogenic is one of them, but there are other ways. Fasting, intermittent fasting, things like that. For sure, all of those things can be factors to lower insulin levels. And it's not to say that you don't need some insulin. Obviously, that's one of the criticisms people will say, At what point is insulin, what is the ideal insulin level? And ultimately, for me, it's where are you at from a performance standpoint? I look at with running, How much insulin do I need to take so that I can run as long as I want to run and be in the perceived exertion that I want to be in at the pace I want to be in? And those are all things that I'm playing with. And there's different people out there who are playing with that. I mean, Zach Bitter just broke the world record for the 100 mile in, you know, just over 11 hours.

On a ketogenic diet.

He eats, although he's, it depends on what what point in his training he's at, he eats a ketogenic diet, although because he burns so many calories, he at different times of his training will increase his glycogen stores by adding things like sweet potatoes and things like that. And yet the vast majority of the time he remains in ketosis. I mean, one of the beauties of being in ketosis and doing endurance sports is your body is so efficient at burning fat. I used do these long races in my 20s and doing them now, you had to carry carbohydrate along with it.

I mean, just for people who would understand, your body can store about 2,500 calories of glycogen carbohydrate in your muscles, which you burn through pretty quickly if you're doing endurance athletes, but you have 30, 40, 50,000 calories of fat on your body that you can access if you're on a ketogenic diet, which gives.

You a much more sustained energy source. And Carrie's point is that the capacity to burn those fats is increased when you're fat adapted. And Jeff Volek did a study, I.

Think, in athletes a few years ago.

Your capacity for beta-oxidation was increased by like three or four fold in these.

So your engine runs a lot faster. You can run a lot further and faster.

Yeah, you're better at burning fat. Basically, you've adapted your body to learn.

How to burn fat. And you can be, I mean, there are plenty of athletes that use the more traditional model and Volek has talked about this, that they're very good athletes burning predominantly carbohydrate, but you can burn predominantly fat and one of the benefits of it, so, you know, if I go out and do a really long run, the difference now is I take along some emergency I'm a type 1 diabetic, but otherwise I can run for three or four hours or more.

Which you just did.

You just ran a 50 kilometer race, right? I did. That's impressive.

You missed my birthday, but it's all right. I forgive you. I'm sorry.

It was on my schedule before.

I really wanted to do it.

I said not to save a date in the summer. If I had signed up for like eight months ago. I'll forgive you. I'll forgive you. All right. All right. So I have a question. So historically, We would have periods of feast and famine and There'd be scarce times in the winter and we'd have abundance in the summer etc etc so we were in and out of keto historically. Do you think it's important for people to go in and out or is it okay to be on sustained keto your whole life? I mean what how do you guys sort through that?

I mean here's the thing I think we don't we don't know the answer to that unless you know of some knowledge that you know the human species is incredibly adaptable. I think the problem comes into if you already have a metabolic problem problem.

Yeah.

Do you need to stay on carbohydrate restriction to keep that in check?

Well, if you spend your life screwing up your metabolism, do you need to stay on it to keep it in check? Because once you've kind of got to type 2 diabetes, it's pretty far along and you're kind of on a knife edge.

Whereas I think the ideal goal for people who are not already there is to be metabolically flexible.

Yeah.

And to where you can go in and out of ketosis without difficulty. and exercise to whatever your particular sport is, whether it's endurance or lifting or short bursts of things. And so I think that's ideally is to where there is not, I wouldn't take my kids and put them on a sustained ketogenic diet. I want my kids to be metabolically flexible.

That's called health. It's called how we age well. What's your perspective on that?

I guess, to be fair, we don't know. We don't have a randomized controlled trial over 75 or 100 years.

What's your gut tell you?

My gut tells me, I mean, my gut, so I've been in nutritional ketosis mostly almost every day since March of 2018, so almost two years. And there have been a few times where I, well, so one thing is that being fat adapted means you can expand your intake of carbohydrates and stay in ketosis. So I'll go out and have sushi with my kids with rice. at least a couple times a month and stay in ketosis.

And how do you feel? Do you feel different?

I don't if I stay in ketosis. If I've had a couple of things like birthdays and stuff where I've like said, Screw it, I'm gonna eat a cake. Piece of cake. And I felt, can I say bad words?

Yes, sure.

I felt like. I felt so sick.

Is that like a medical diagnosis?

Yeah, I felt the equivalent of like a bad hangover. Like it really felt awful to me to the point where I was like, I don't really want to do this. I don't feel good doing it. It doesn't, I'd rather, like I actually enjoy the way I eat. I don't see any reason not to. Every single parameter I can measure, most notably my waist size, right? I went from, my wife the other day was asking me what I wanted for the holidays and she was talking about, but she said, remind me again what your waist size is? And I said, it's 32. She said, you remember, you know that.

Two years ago you were 36. Wow. And I said, I forgot.

Which is one of the biggest determinants of your risk for heart disease is your waist to hip ratio. Yeah. And I mean, in addition to all.

The other things that we've talked about.

And I mean, and I feel good, I ski better. There's everything about you- you- see better.

Well, that's a good- well, it is.

I do. And that's important to me. I think as a doctor, as doctors, we have the ability to impact people in two ways. We can make them feel better, or we can make them live longer.

For both, hopefully.

Yes. I hope to be able to do at least one.

Well, let's talk about the live longer thing. Because I think there's been so much talk about varying ways to achieve longevity through diet. and historically the one thing that's been proven without a doubt in animal models is calorie restriction. And calorie restriction has a number of things that it does to the body. It actually improves the cleaning up of the waste in the cells called autophagy. It makes you more insulin sensitive so you're not insulin resistant. It actually speeds up your metabolism. It increases antioxidant enzymes. It reduces inflammation. It helps your neurotransmitter function, your cognitive function, your bone density. It increases stem cell production. It does all sorts of things that actually are very powerful. In fact, I was just reading an article in the New York Times last night about this couple that sort of were lovers in Auschwitz and they sort of lost each other after the war. They survived the concentration camps but they were pretty starved in there and she died at over 100 and he's like 93 and still going. And it made me wonder about, wow, was it partly their longevity due to this calorie restriction? So there's this whole phenomena of calorie restriction. and you don't want to be starving all the time because you're going to be miserable. I met a guy who was on a calorie restriction program. I'm like, what do you have for breakfast? I have like five pounds of celery. I'm like, no thanks. But there are other technologies, in other words, ways of eating that seem to do the same thing. Ketogenic diets, intermittent fasting, which is sort of alternate day fasting or fasting a day a week or a week-long fast, and time-restricted eating, was it eating with a narrow window, like eight or 10 hour window during the day, or ketogenic diets. They all seem to do the same thing. so could you talk about these different approaches and what do we know? And you've studied this, you've looked at the data. Where are we going with all this? How do we use this both for metabolic health, for longevity, for all kinds of illnesses?

Yeah, I mean, we could probably talk for two hours on this whole subject. I could.

I think we got a couple more.

So let me just simplify this. So I think with all the evidence we have so far on life extension, has occurred in animal models. And a lot of that has occurred in animals like worms. And while we have learned a lot from worms, worms are very different from people. Although we share a lot of the same DNA. We do, although if you look at.

The pathway that seems to be most.

High, like if you were going to- Like mice and other animals. What's the one, let me turn it to you. What's the one, if you had to pick one pathway that is the most strongly associated with longevity in animal models, which one?

Well, it's interesting because I was at a conference on aging with the Dalai Lama and all these scientists and this guy from MIT was Dr. Leonard Guarente who has worked with these worms and sirtuin pathways. And I said, so, Leonard, what is the deal with aging? What is the thing here with sirtuins? I said, what's going on? He says, well, it's really all about insulin resistance and sugar. It's the thing that's driving it all. So, I would say the one pathway that it really regulates is nutrient sensing and insulin signaling. and I think by fixing that, you're doing a lot to help with aging, which is what causes, you know, I've written about this for decades, is insulin resistance drives heart disease, cancer, diabetes, Alzheimer's, depression, and more.

Yeah, I mean, I think that you can argue back and forth whether it's insulin or IGF-1 or growth hormone. It turns out that a lot of animals, and the growth hormone itself evolved only in vertebrates, so there is no growth hormone in worms. So I think what we're doing is trying to learn a lot from these animal models.

And.

The problem with doing aging experiments in people is that none of us are going to be around to see the results. Right? Like, you know, if you do an aging experiment on a mouse, you take a mouse that normally lives to be two years, and if you can make that mouse live to be four years, you've like, you know, it's a Nobel Prize. And, but the equivalent in people would be to do a study that makes people go from living 80 to 120.

80 to 120.

No one's gonna be around to see that.

I am. I'm planning on it.

Look, I think-- I just turned 60.

I call it my first 60 years.

I just turned 50. I think-- I'm not there yet.

No way.

Almost 50.

But you're not.

I'm 46.

Well, that's not almost 50.

Yeah, I think me saying I'm almost 60.

Okay. I'm on the other side of 40.

So, anyway, I think what we're going to be doing best for the time being is going to be extrapolating, trying to integrate what we know from the biology, from the animal models, as best we can. I always try to stay humble because the work that I've done in my laboratory over the years has taught me that we can't predict a lot of what happens. The biology is super complicated. There's a lot of feedback loops and feed forward loops and things. Right. That makes me like whacK-A-Mole. Yeah, it's a little hard. And so I think I try, and again, you know, for my field, you know, my, the field that I've been studying in the, in my lab is growth hormone and growth hormone signaling. And that field to me is the best example of this. Because if you go to a growth hormone meeting, you'll find half the room who believes just religiously that growth hormone is the fountain of youth, that you should be giving growth hormone to prevent aging for longevity.

The other half of the room feels.

It'S the cause of aging. Exactly. And, you know, I know, I'm like, what the hell? I have my own, you know, bias and I've interpreted how I interpret the data. But I think we have to stay somewhat humble to the fact that it's hard.

I mean, it's-- well, it's interesting. When you're young, your levels of growth hormone are high. When you're old, they go down. And so I think a lot of people have been using injectable growth hormone as a fountain of youth. But I also see metabolic issues from it. Well, that's true. You tend to get more weight gain and more diabetes and other issues, right? Which makes me wonder, or maybe it's not so good. Right.

And I think if you look at the genetics, the genetics point pretty strongly to the fact that decreased growth hormone or decreased action of growth hormone is probably the single biggest cause of long life, which doesn't mean that it doesn't have other effects. So if you don't have a lot of growth hormone around, you will put on more body fat, you will have more fragile bones and other things like that. But if you're looking just at how long you're gonna live, I think that answer is probably pretty clear. That less is more. Yeah. So back to the original question, you're.

Sitting in your doctor's office and you are both sitting there with patients. They're like, I want to live to be 120. How should I eat? Should I intermittent fast? Should I be on time-restricted eating? Should I be keto? Should I just, what should I do? Because I'm that guy. I'm coming to your office. I'm like, okay, docs, you guys know a lot about this.

I want to live to be 120. What do I do? I want to go back a little bit and talk about the health span part of it and put on my orthopedic surgeon hat and bone and musculoskeletal health hat because when we're talking about longevity, we focus a lot on cardiovascular health. But my bias and what I see is that people decline rapidly as their ability to be functionally active goes down. and that that then sort of uncovers other problems that they have and, and compounds them. So there's a phenomenon called sarcopenia of aging, which is basically where muscle decreases over time. And I see it on people's MRI. So I treat people who have trouble, you know, walking and, you know, as a result of nerves being compressed, but we get a lot of back pain, neck pain, even nerve-related pain secondary to metabolic disease. It's not uncommon for people to- Metabolic disease, you mean like what?

Like type 2 diabetes, right?

So it's not uncommon for people to actually be diagnosed with diabetic neuropathy before they're diagnosed with type 2 diabetes.

That means nerve damage from blood sugar.

Exactly, and it can damage tendons and things like that, so people get a frozen shoulder or they'll get their ileotibial band, which is the big long fibrous band that runs along your leg, so that will pain when they're walking. And so for me, when I'm looking at this question about longevity, all of these things matter, but my perspective on it is how do I keep people moving and active as long as possible? And how do we use diet for that? So one of the benefits that I see, you know, when I put a patient on a ketogenic diet, so people.

Have to understand that your diet plays a big role in the amount of muscle and/or fat that you have or don't have.

And degenerative changes. So there's studies that show that advanced glycation end product, which are those sticky molecules, get stuck to the discs. When people think about disc degeneration, which are the cushions in between their bones and their spine, that is increased with these advanced glycation end products, which are byproducts of sugar.

So, yes, when your sugar gets too high, you create this process called glycation, which is essentially like the crust on your bread or creme brulee crust, and that happens in your body when sugars.

And proteins combine that create this inflammatory process. Right, and when inflammation is high, those things for varying causes, inflammation leads to.

You know, more arthritic changes.

There are some studies that- Muscle loss, at least to diabetes, at least to everything. Exactly. So, there are studies that show that if you decrease it, it doesn't matter how know a knee that has bad arthritis, and we talk about bone-on-bone arthritis, but if you decrease the inflammation, it may still not be a functionally lined up knee, but people actually can have relatively little pain with it. Pain is related to the inflammation. So when I put people on a very low carbohydrate diet and they start creating these ketones, not to get into the science of it, but there are pathways where those ketones are anti-inflammatory, and that's one of the things that I hear a lot is people say, not only did my back pain get better, but my knee pain and my shoulder pain and I'm able to do more. So for that, for me, is one of the biggest things. And, you know, I still have to remind people, people come into the office and they'll still be on the diet, but they'll have stopped exercising. Yeah. And I'll say, did you stop brushing your teeth? And they're like, well, no, why did I stop brushing my teeth?

Yeah, that's a good line. It's not different. You have to exercise. No, it's true. I think that's true. I think, you know, you can do all the right dietary things, but one of the things that happens as you age is you lose this muscle. And that's what makes people end up in nursing homes. It's what actually drives all the hormonal changes. So when you're less muscle, you have more cortisol, which is a stress hormone that causes more diabetes and blood pressure issues, you have lower growth hormone, which you say is good, but I'm not sure it's totally good in that situation. Make more insulin, you make your cholesterol gets worse, you get more inflammation. So the muscle is like the biggest organ in your body, basically. we don't pay much attention to it and it's actually required to be intact if you're going to age well. And that's the whole question of like protein and how much protein you need and should you eat protein? Do you need animal protein? It's another rabbit hole because a lot of data show that when you're younger, you actually maybe not do as well if you have more protein. But if you're older, if you don't have protein, you can't build the muscle.

So how do you deal with that? Or maintain the muscle? I mean that, you know, a lot of that data is emerging but when we look at things, you know, I follow patients' bone health. And so you want to make sure that you're getting adequate protein. And of course, people argue about what is the, you know, appropriate amount of protein at different points in your life. And I don't think that that science is settled to where I can tell somebody this is specific. I mean, you know, it's about gram per kilogram is the recommendations of lean body mass, not total body mass. But that's totally debatable.

And.

My goal is to-- that seems pretty low, right?

One gram per kilo of lean body.

Mass in pure-- Is the minimum required recommendation for the amount of protein?

That's like how much vitamin C do you need to get scurvy? Like 10 milligrams, not very much.

Right. Right.

And so-- Doesn't mean it's the optimal amount. It doesn't mean it's the optimal amount. I don't know that we know the optimal and the problem is, is, you know, I've even found as I've shifted, you know, I sometimes the more I run, the more weight I gain, and then I have to play with it and go back and forth and do these things. So I don't think that we're a long way off from knowing what is the optimal diet and how to dial these things in. So my message to my patients at this point is, you know, if you're benefiting from a low-carb diet, we continue that. that it's whole real foods, whether you include animal products or not into it, depends on what markers we're looking at and are you willing to take medications if you need to. And we need to get you active and keep you exercising. The exercising part actually is doesn't help with weight loss, but it does help with building muscle and maintaining muscle because what I see is then the end result of it, which is people fall, they break their hips. And that, the data is clear once you start getting spine fractures where you sneeze and break your back or you fall and break your hip, your life expectancy dramatically decreases.

Yeah, right.

And so those are important factors. So whatever diet we need to get you on so that you feel good, so that you're able to go out and be active and live an active life is the ideal diet for you at that point.

I mean, so people are wondering, you know, back to the sort of ketogenic intermittent fasting thing. If you say, well, I'm just going to do time-restricted eating. I'm going to eat an hour window. Is that as good as keto? Or I'm going to fast one day a week. Is that as good as keto? Or I'm going to do a week-long fast once every two months? There's all these things that people are recommending out there.

How do you compare these different approaches? Well, I think the good news is that we're going to have answers soon. I think there are a lot of people, including us, doing trials on time-restricted eating, probably other people doing alternate day fasting. So the science will catch up at some point, at least in terms of what we know are the effects on markers that we can measure. Kerry brings up a great point, which is we really have to think about what we want to optimize for. Do you want to optimize for total years lived or do you want to optimize for health span, quality of life, how you feel?

I want to die young as late as possible.

Here's one thing. Here's one thing. When I give a talk, I love to talk about the things that I learned from my mom, my grandmother that were wrong and how we can unlearn them. So one principle I think in the meantime while we're waiting for the science to catch up on satiety and fasting.

You're not inviting your mom or grandma to the lecture, I hope.

No, I'm not. But I bet that wouldn't go over well. We're not going there. But I think one thing that I was taught as a kid was to eat all the time and to eat.

Three meals and snacks and your plate.

You know, all this stuff. Like it was basically like a constant, you know, this like Jewish grandmother like eat, eat, eat, eat, eat. And I think what I learned by playing around with fasting myself was that hunger is not linear. That is that when you start to sense feeling hunger, it doesn't then continue up on this endless slope to the point where you just die. I always Carrie hears me talk about this all the time. I tell my kids, like my kids will come in the house and I'll say, Dad, I'm starving. and I'll say, Are you? And they'll say, Yes, I'm starving. And I said, well, when do you actually starve to death? Like, when will that happen? And they're like, I don't know. Soon. And so I'll say, well, what's the longest that anyone's ever lived without food? And they can't even fathom that it's like that there's a guy that's lived for 300 and something days and that, you know, Cahill did these experiments where people were living for 30, 40, 50 days. And I said, you, can, I guarantee you, you, even though you're tiny, could live at least 10 days without any food. So I think one of the things that fasting does is it teaches you to tolerate hunger a little bit more. And I think one mistake that we make is eating when we don't because calories do matter despite all the other things we're not talking about. Any more things we're not talking about? The amount of food you eat will.

Impact your metabolic health and your weight.

And so if you're not hungry, I like eating for sport. I shouldn't do that. If you're not hungry, don't eat. I mean, I think this is one of the things like this comes to the breakfast thing, right? So we're studying, we're doing a randomized trial comparing time-restricted eating in an eight-hour window to eating three meals a day. and the way we designed the study was to skip breakfast because it's the easiest thing to do in our society. But there's this dogma out there that breakfast is the healthiest meal of the day, which may be true, but if you're not hungry in the morning, should you force yourself to eat? And so that was one of the things. That's one of the principles that I use. I actually think there's a tremendous interesting synergy between all forms of of fasting or intermittent fasting and low-carb diets. And one of the reasons for that is at least, and we'll get pushback from people who don't believe this, but I believe there's a very strong effect of the ketogenic or low-carb diet on hunger. I think there, Sure. that there's, you know, personally, I just.

Am never hungry after.

Insulin is what makes you hungry. Probably, and that probably it's the effect of insulin on your brain or the effect of insulin on your fat that then goes to your brain. But there's no doubt that I'm less hungry. And so for me, I had been doing some form of intermittent fasting for five or six years. But when I started doing keto, it just became like easy. I mean, it was, I just didn't even think about it.

It's interesting, if I don't eat, like I can do an intermittent fast, I can eat, if I go longer than that, like, you know, 20 hours or something, I just start to feel like horrible and I can't recover. And I realize, even if I eat something, the rest of the day I just feel out of it, like brain fog, weak, like horrible.

Yeah. Well, and I would say to you, if I were your doctor, I've got.

Like six percent body fat.

Which I'm not, and I'm not your doctor. I would say then don't do it. Because I don't think there's, I mean, and there are going to be all slow people who will hate me for saying this. I don't think there's evidence yet to support that fasting in any form is gonna make you live longer. And I think there's pretty good evidence that calorie restriction probably, if there were anything that would, it would be that.

But these other things mimic this. This is biology, right? It does.

But again, you know, we get fooled on biology so many times again and again and again. So in the meantime, look, my principle is if you're not hungry, don't eat. And if you want to be crazy and fast for five days and you do it in a safe way, go for it. But I don't do that. I'm not going to do that.

I think it's interesting people often don't get the tests that matter most. For example, blood insulin levels, most doctors never measure.

You're absolutely right. And it's something that I probably didn't do enough of until four or five years ago. And if you ask somebody like Lou Cantley, who's discovered part of the insulin signaling pathway, what the most important hormone is to have low or yeah, that it would be insulin. And that's part of the reason why I think, again, you mentioned that it's not just fasting or calorie restriction or other things. Keto low-carb diets will also reduce fasting insulin. So I think those are all things if you're gonna pay attention to a marker, that's one that looks-- and the.

Blood test will say 0 to 15, but really it should be less than five. five.

Yeah.

And, you know, people are eating well. Low carb are like two. I'm about two. And I, you know, I feel good like that. And I think that it's not. And then what's even more important is what happens after you eat sugar and carbs. You know, we use these now Dexcom, the carry out. This is basically a 24-hour glucose monitor. But I would like to see a 24-hour insulin monitor because I think that'll be more. There are people working on it. Thank God. I've been talking about that for 10 years because I've been measuring insulin levels and post tested glucose tolerance test insulin levels for 25 years. And it's just the amazing amount of stuff you learn from that. I see people whose lipids look totally normal and their blood sugar A1C is like five or five and a half. And their fasting insulin might be normal, their fasting blood sugar might be normal, but they have a load of sugar and their insulin goes up to 200 and these people cannot lose weight. And I think that's really very important sort of insight. that people can look at. And there's a lot of tests you can do to figure out what your metabolic type is and you can see what happens when you eat different diets because people often looking for outside validation of what to do. I'd say the smartest doctor in the room is your own body. How do you feel? What happens to your weight? What happens to your muscle mass, your body fat, your lipid numbers, your insulin numbers, your blood sugar numbers? I mean, that's what you need to focus on. And the variation of the population is humbling. Like as a doctor, okay, I found it. It's ketogenic diet.

And then they're like, oh, it didn't work for this guy over here. It worked for this one. I was like, oh, no.

There'S not one size fits all.

But there are probably, if you took the most staunchly pro whatever, pro, let's say, carnivore diet and the most staunchly pro vegan diet and the most staunchly, if you took all those people and put them in the same room and asked them to agree on nutrition principles, there would be a couple that they would probably agree on, right?

Yeah. 100%. I mean, honestly, that's why I jokingly call it the Pegan diet, because I was like paleo vegan, how could you be more different? But actually they agree on absolutely everything except where you get your protein from. They all agree we shouldn't eat processed food, they all agree we should lots of vegetables, they all agree we should eat lots of good fats, they all.

Agree we shouldn't be eating lots of sugar and starch.

Lots of sugar, refined carbohydrates.

I mean if you thought just there, just- They have more in common with the traditional American. Right, so that to me is like if you want to just step back and say, well that's probably gonna be the future, right? We're all gonna agree less added sugar, Less refined carbohydrate, less processed food. That's probably a safe bet.

And there was a study that I had just come across this weekend from 2017 that looked at a plant-based processed diet versus an unprocessed plant-based diet. So whole real foods. And the people who were on the plant-based processed diet had increased cardiovascular risk.

Like chips and soda. Right.

Exactly. Chips and soda and skittles. Fats are all plant-based. And so you can eat a crappetarian diet and it's not gonna increase your- Dr. Increase your- Dr. Right, it's not gonna increase your health span. And I think that that's the thing that we, you know, the people who benefit, and this is the other thing that drives me crazy because I sort of walk between this plant-based world and the keto world. For a long time, the plant-based people were like, well, you can't be keto and plant-based. We don't understand that. The same thing happened with the keto people where I even had Tim Noakes on Twitter saying, It's not possible to do a ketogenic diet and be plant-based. I'm like, well, I am. Don't confuse me with the facts.

My mind's made up.

And this is the problem is I think that we all get to where we have our thing that we're comfortable with that works for patients, I really want us to learn from the people who struggle. And that that's where the real gold is. It's really not with the people who are successful with it. It's really with the people like, why is this person struggling with it when it worked for these other five? And that's where I think down the road, if we're going to reverse engineer our way out of this obesity crisis. It's to really figure out, so this person who's struggling, how do we shift their diet? If they're on a really plant-based diet and they're not having the results that they want, or if they're on a ketogenic diet and they're not, is there another variation? Is there another factor that we've not looked at? And that's where I wish all of these camps would stop being camps and dogmatic and really work to try and help people dial those things in.

Dr. Then diet wars.

Dr. Well, it's silly. I mean, we all want to work to enable success and I do think that we can agree on, I mean, there are other things, places we can agree to, right? I mean, I think one thing is, you know, some people can be very austere with the way they eat. You could probably eat basically like tree bark for the rest of your life and be pretty happy. I can also probably be pretty happy. Other people- I love food. To recognize like that they like food that tastes good and rich and decadent and so maybe, you know, we can work to find, like we're working on these bars that I think are Gonna be like it's almost hard. I brought one. I'll let you try it later. You're not even gonna believe how good this thing tastes and you're gonna think there's no way this is just almonds and chicory root fiber. Like there's just no way this is all.

There's just no way. That's right. Yeah. That was interesting. It's true. I have a friend who Mark David who has started the Institute for the Psychology of Eating and you know he's sort of a shorter stockier guy. He's not overweight but he's just like more saki and I'm sort of this tall skinny guy. and you know, ever since I've known him, he eats like a bird. Like we went out to dinner, we ordered it was like, it was a shared plate thing. I ate three quarters of the food, he ate a quarter of it, and he was happy and satisfied, and I was like, I could eat more. You know, I think my metabolism is very high, he might be slow, and everybody needs different amounts of food, and I think, you know, he's very good at listening to his body, and I.

Think that's what you're really saying is see what's going on for you, what works, what doesn't work. Well, and also we just need to recognize that there are, that there is is the world is full of these choices that are not great. And so can we, instead of saying just put those away and don't have them, can we replace them with things that are still really good tasting but just are better, that adhere to the principles that we all agree on?

That's the- so it would be great to do a study of like keto compared to intermittent fasting compared to, you know, time restricted eating compared to just low carb sugar, but not super keto. It would be very interesting to see what that all would do metabolically to people. I hope somebody's going to do that study soon because I think we're still at the question mark of it. But they all do similar things when you look at their metabolic effects and their hormonal effects. They're all shifting you towards less inflammation, more insulin sensitivity, more muscle mass, better bone density, more brain function. It's just interesting, there are different pathways into the same kind of thing.

Yeah.

So if someone wants to try keto, it's a little daunting, like how do you do it and not kill yourself, right? Should you have to talk to your doctor first? You need to get a checkup? Should you get your labs done before? How do you do it? How does it work?

Well, we could both-- yeah, we can both-- take turns on this one.

Dr. Dr. Justin I mean, for somebody, obviously, if you have medical problems and you're on medications and, you know, there is a randomized controlled trial that's about to be underway in type 1 diabetics for using the low-carb diet. So, you know, there's a lot of people who are using it. But as Physicians, you know, I always sort of hedge and say, you know, you need to partner with somebody to do it. to do a blood test. Dr. Justin: But if you're basically a healthy person, you're just overweight. Dr. Justin: A healthy person, you can do it. I mean, that's what I do in my clinic is, you know, I see patients, I know the medications that they're on and I give them a handout and/or, you know, since we've been working on these meal plans, the app to be able to follow it and, you know, do you need to get labs done before? No, not necessarily. I will frequently do labs in patients so that we at least understand what their hemoglobin A1C is at minimum. and most people have already had a lipid profile at some point, and then we check it later to see what happens with that. So, I mean, there's a ton of resources out there and, you know, it gets controversial. You know, there's this whole carnivore movement. I tend to find people do better in general. I mean, to me, I think the carnivore diet probably is a really good elimination diet, and that's why some people do well with it. I worry about long-term the gut microbiome and things like that with not having.

Some sawdust with it, it's fine.

Dr. The fiber sources, right, yeah. So, I mean, I think in the phytonutrients that are in plants, I think people benefit from. And so, you know, for me, it's about eating whole, real foods and there's a ton of sources out there that will help people start ketogenic programs. I think one of the things that I found with patients is that understanding whether they're in ketosis or not, because if you're doing low-carb you're not in ketosis. For some people, that's this sort of metabolic in-between no man's land and they don't feel good and they're not getting the benefits from it. And so knowing if you're in ketosis—and I use it in patients for some very specific reasons where, you know, from neurologic standpoint, we want to get their ketones to a certain level. And I found that those patients who are measuring and tracking their ketones in some way, which you can do it through urine, breath or that they are more successful with it. And so that that mechanism of tracking, whether you're actually in ketosis, is positive from a behavioral standpoint, but it also is a return on investment in that they feel better faster in general.

Yeah. So let's talk about that. So you've got this new company you're working with called Keto K-E-Y-T-O, which test breath, acetone, which is a ketone body, and there's blood tests for beta-hydroxybutyrate that you can use with a finger stick, a urine ketones may not be as reliable, it's hard to quantify. So for people who want to sort of check, how do they begin to think about what's the right approach? Should they just use a finger stick, a breath test?

I think it depends on what you want. We designed this thing to be a tool to help enable people to be able to do this diet, whether their goal is for weight loss or improve their metabolic health, that was the purpose. Carrie mentioned that one of the benefits of this diet is that it provides you a biomarker. It's probably the only diet unless I.

Can-- that you can know you're on it.

Yeah, where you have a thing that you can track other than your weight on a scale, which is a really bad way. I mean, we all know that weight fluctuates a lot, especially in women. It fluctuates a lot.

10 pounds in a month.

It's not a great way to know if you're doing well. So we designed the program to be able to give people the information about whether they're doing it, in addition to the information about what they should and shouldn't do in terms of eating or not eating. I mean, there's plenty of places you can get resources on the internet about how to do a ketogenic diet. It's not entirely intuitive. So the purpose was give people the information about what to do, give them the information about how they're doing, which will help enable the behavior change. and then the last part, which I sort of touched on before, is that it's also going to be really important that we give them the opportunity to find the food, right? It's not easy, especially traveling or when you're out to eat, to be able to, you know, last night we went out to dinner and I ordered salmon on the plate with salmon was fingerling potatoes and I just asked if they could put vegetables and so they served it over asparagus. That's sort of something that wouldn't have been intuitive to me before.

You do a swap.

Yeah. Or, you know, if you're in the airport and you're starving, you want to, you know, quick something to eat, where are you gonna go? Dunkin Donuts? You're gonna, like, buy a Clif Bar.

What are the options there?

So I think I go for the nuts.

Well, and that's a good place to go.

And they actually have grass-fed jerkies and all kinds of stuff.

They do.

And I've seen even these, like, cheese crisps and stuff. So I think it's. And I've seen a few keto bars, at least in the San Francisco Airport. So I think it's coming. But that's one area that we'll, as a company, be focusing on in the.

Future, is trying to provide people.

Not just the insights they get from the device, advice that we give them through the app, and lastly is to get them opportunities to get.

Are there people who shouldn't do a keto diet?

I don't know of anyone that I would say not to. People always talk about kids and I say, well, you know, we have actually the most experience with children on the ketogenic diet because for 100 years there have been kids with epilepsy who have been on the ketogenic diet. They've done well. So, I don't think I can't think of anyone, there probably is if you push me hard, I probably can.

And even in pregnancy, if you have gestational diabetes, the low-carb diet is one of the ways that they manage gestational diabetes. There's some reports in women who are breastfeeding of this starvation ketoacidosis. I think it's pretty rare, but if you have a calorie demand because you're feeding another human and you're losing a lot of weight, weight, especially if you're not getting enough calories for your own metabolic needs. I think it potentially puts you at some risk. But there are plenty of people out there anecdotally who are doing just fine with it.

I mean, like, I know if I, if I start to do it and I do too low carb, I drop so much weight.

Yeah.

And I'm already skinny. So, like, I, I find that, like, I have to have some stuff, like sweet potatoes.

Yeah.

I'm sorry, you.

You have a good problem. You fall in the category of good problems to have.

Yeah, but it's, you know, I just were, I really, I had to carb up if I want to gain a little weight. I had to get stem cell therapy once and I just had to eat.

Lots of rice noodles, you know, like rice. You're not, as I'm fond of telling.

Some of my partners, you're not normal. I am not normal.

I am ODD, which means I'm odd. That's really true. No, and it changes throughout life and things like that. I mean, I think women, you know, in menopause and perimenopause, it shifts. And so, you know, it's definitely a tool that I see more postmenopausal women benefiting from is getting rid of the carbohydrates. And it gets harder at that point to keep weight off, but it certainly is something that they can consider doing. Right now, the studies on, you know, for type 1 diabetics, it's still, there's lots of us who are doing it, but the the RCTs are not out. I think there are some ways that people can get into trouble and we need to better understand those ways. It's not that a low-carb diet isn't of benefit. We did a study where we looked at the numbers of people. The average A1C was just over 5.6 in this group of type 1 diabetics who were doing the low-carb diet.

Which is unusual. Which is unusual. I've treated type 1 diabetes for years and you get a seven, you're excited. You're at six.

It's like, that's normal. Right.

Target is seven. And so to see this in the low amount of insulin that people are using, I think when people have some of these medical conditions, we need to understand how they can get into trouble. And that's where I hedge as a physician to say, oh, everybody should be doing this, is because it's like the people with the lipid problems or it's like your experience with the ketogenic diet is fine. I still really have to be careful with calories. I still really even in training for the ultra marathon, I put on some weight. Some of it was muscle, you know.

But- All of it was muscle.

But I'm not where I, you know, those things are factors and, you know, our body types are different and that's the thing that, you know, I think we need to be careful of is some people, their LDL is gonna go through the roof. I really worry about these lean mass hyper responders who have LDLs that are- you- worry about that? Yeah, I know. I can't even imagine.

I'm one of them, actually.

I mean, if your LDL goes over 300, as an orthopedic surgeon, that gives me angina. And I can't even imagine what it does to you.

Well, and then, you know, so, but you said it at the beginning, I want to emphasize again, if you have a medical condition, please do it on the supervision of your doctor. And then there are some, to answer your question, I thought of one, I think if you have type 2 diabetes and you're on certain medicines like STLT2 inhibitors as one example, you probably don't.

Want to do the ketogenic diet.

Although you won't need them.

You should do the ketogenic diet.

Or if you're on a sulfonylurea, that's the thing that I see is, because.

Any drugs that lower your blood sugar and raise insulin, you have to be careful because you'll get low blood sugar. And, I mean, that's actually a, actually when I wrote my book, the Blood Sugar Solution, we're getting a lot of people writing in and calling and saying, Hey, my blood sugar is too low. My blood pressure is too low.

I'm like, yeah, the food works better than the drugs. So, you got to taper your drugs with your Dr. True. You have to be careful on the STL2 inhibitors. They can send someone who's typically in a type 2 diabetic ketoacidosis is not something that you typically see that tends to be more in type 1 diabetics. But with the STL2 inhibitors and in particular- what drug would that be for people listening?

The Flozyglan, I can't pronounce them. It's Farziga.

The ones you see advertised on television.

For a lot of money. Which actually are are pretty interesting drugs. They're actually being used mostly now as, or they've been demonstrated to be very beneficial in heart failure. So the cardiologists are all adopting them like they do.

Well, it's fascinating. Yeah, it's fascinating. But it's fascinating when you see patients with like advanced type 2 diabetes who go on a ketogenic diet, they get.

Off all their medications, they get off their insulin, they get, you know, it's like, it's pretty impressive. It is. And I do it in orthopedic practice. So it's not something where, you know, we put them on it and patients.

Are very carefully, people who are on insulin, I mean, I have the ability to talk with them more about it.

Because I obviously use insulin and understand it.

Alright, so let's go through a day of eating of each of you. What's a ketogenic diet look like? And then we'll kind of sort of summarize.

I'm black coffee for breakfast. I mean, that's my, I don't, I rarely eat breakfast. If it's a surgery day, I actually won't eat until I get home. I can operate all day and not need to have any calories at all, which is very different than in residency where I would, you know, have a bagel before and then by lunch you're like starving and you know can't get to the cafeteria fast enough between cases. But if I do eat lunch, you know, it'll be a salad or I will make some smoothies with, you know, kale and Brussels sprouts and broccoli and things like that. But I'll have a salad and I'll put hemp seeds on it with olive oil and you know- so like extra fat.

You're like using a lot of fat.

Yeah, I mean I'll put avocado on it, I'll put pistachios on it, on macadamia nuts. And so, you know, that's, I put a ton of other vegetables on the salad itself. Protein sources, I'll either use lupini beans or black soybeans or hemp seeds on the salad. And then dinner is, you know, similar where I'll have, I'll roast vegetables or steam vegetables and use olive oil on them or avocado oil. I like to add nutritional yeast to it because I like the flavor and then again, I'll choose from those protein sources and have that and then I have dark chocolate almost there's a sugar-free, it's sweetened with stevia and a little bit of erythritol, dark chocolate most evenings.

Just because I like chocolate. Dr. Yeah, all right. That's good.

That's the vegan keto. Okay. And how about you? Mine's not too different. I also have black coffee for breakfast. I normally don't eat anything until about noon. I eat lunch most days. I make my own lunch, bring it with me to work every day. and it's a salad. It's, you know, whatever I have. So some lettuce, some chopped vegetable, usually celery, cucumbers, peppers, something like that. I'll throw some lupini. Carrie introduced me to these lupini beans, which are delicious. I'll empty a pack of those in there. I'll put a bunch of nuts in there, chop an avocado every day. I'll have a whole avocado, and then I'll go back and forth between adding some protein, whether it's like a little bit of salmon, some smoked salmon, even some canned salmon in that. And then I keep like 14 bottles of olive oil in my office and I just drown the whole thing in olive oil. That's lunch. Dinner is usually 14 bottles of olive oil. I have a lot.

Are they like different varieties? Like wine?

Or is it like-- basically like I have a collection of olive oil and wine in my office.

They're gifts from patients. All right.

That's good. Yeah, they don't bring cookies anymore. They bring olive oil. No, it's great. And then-- that's what I got for my birthday, a lot of olive oil. Dinners, roasted vegetables, and a protein and the protein is usually fish. All right, fantastic. And then I also have this dark.

Chocolate problem at night. Great. Well, this has been an incredible conversation. There's still a lot we're learning and there's a lot we know about actually what can be the benefits of eating a low starch sugar diet, a high fat diet, a keto diet, and some of these other techniques such as intermittent fasting or time-restricted eating and you're studying all these. Stay tuned for what we're going to know because because I think we're really on the trail of something really important in terms of health, longevity, metabolic health, and honestly, part of the solution to our extreme obesity and diabetes epidemic, which is bankrupting our nation and causing so much suffering for people. And you guys are at the forefront of that work. I really appreciate what you guys are doing. If you want to do keto, make sure you know what you're doing. Check it out.

You can go to getketo.to.com, is that the website? Yeah, I think.

Yeah.

Keto. Get Keto K-E-Y-T-O. T-O.com.

And learn more. I mean, there's a lot of other options out there, but check it out. And if you love this conversation, we'd love to hear from you. Share a comment. Please share with your friends and family on social media. Sign up wherever you get your podcasts, and we'll see you next week on the Doctor's Pharmacy.

Thanks, Mark.

Thank you, Mark. Hi, everyone. It's Dr. Mark Hyman. So, two quick things. Number one, thanks so much for listening to this week's podcast. It really means a lot to me. If you love the podcast, I'd really appreciate you sharing with your friends and family. Second, I want to tell you about a brand new newsletter I started called Mark's Picks. Every week, I'm going to send out a list of a few things that I've been using to take my own health to the next level. This could be books, podcasts, research that I found, supplement recommendations, recipes, or even gadgets. I use a few of those. and if you'd like to get access to this free weekly list, all you have to do is visit DrHyman.com/picks. That's DrHyman.com/picks. I'll only email you once a week, I promise, and I'll never send you anything else besides my own recommendations. So just go to DrHyman.com/picks. That's P-I-C-K-S to sign up free today.