This Happens When You Quit Carbs [5 Stages] Dr Koutnik

How much weight can you lose in the first 7 days of quitting the carbohydrates?

Most people could lose anywhere between 5 to 10 plus pounds in this window of time. Insulin drops at the very first meal and stays around 33 to 75% lower over a 24-hour window. We actually see that some individuals may actually see 300 to 400% increases in fat burning.

Dr. Andrew Kutnik is a metabolic scientist who has lived with type 1 diabetes for two decades. Today, he's revealing the five stages your body moves through when you quit carbs.

Insulin is the most powerful fat storage hormone in the body. And so, high levels of insulin means higher levels of fat storage.

Sugar-free drinks, for the most part, this I've come up with a list of about a 100 different things that are near equivalent to sugar that are on labels that typically result in blood sugar and insulin spikes nearly identical to sugar.

What is happening in the first 24 hours when you quit carbohydrates?

Basically the initiation of the fat burning phase. We know triglycerides lower 15 to 26%.

If you eat bread, pasta, or even fruit every single day, that is actually the main reason why your body is sick. You see, we've been told for decades that carbohydrates are the foundation of a healthy plate. But my guest today, Dr. Andrew Kutnik, will prove why that is dangerous advice based on new science.

Dr. Knutnik is a metabolic scientist and a type 1 diabetic. He knows firsthand what too many carbohydrates does to the body. And today we're walking through the five critical stages your body goes through when you quit carbohydrates from the first 24 hours to the 6 week mark so that you can finally get the results. And I'm going to make a bold statement. If you follow this advice, you will reverse insulin resistance, lose visceral fat, and lose weight without effort.

And if you want to take control of your health when doctors can't, a really easy step is to hit the subscribe button because next week I'm sitting down with Professor Tim Nos to discuss a new study about carbohydrates and fat loss.

So Dr. Kudnik, my first question, you are a metabolic scientist. You deeply understand the role of insulin and carbohydrates in the body. So do you think that our bodies are designed to run on carbohydrates?

So our bodies have the enzymes and functional machinery to digest carbohydrates and utilize them. The question is when someone has a metabolic uh health issue, a subchronic condition or some other uh uh disease related to metabolism, the question is should they be running on carbohydrates? And that gets into a more nuanced conversation about how diets affect metabolic disease and what are the most evidence-based diets out there that can not only address or manage current disease but potentially even prevent or reverse those diseases. And we know that some of the most effective of evidence-based approaches to doing that are carbohydrate restricted dietary strategies.

So if somebody's coming to this they have very high insulin. Let's try to understand what too many carbohydrates does to the body. What does too many carbohydrates do to fat stores and putting on fat?

Sure. So, I I think it's first important to kind of dissect a part uh fat in general. So, we know that when you digest carbohydrates, they're broken into individual glucose molecules. Those glucose molecules then go into the blood, raise blood sugar levels, and release insulin. Insulin is the most powerful fat storage hormone in the body. And so, high levels of insulin means high higher levels of fat storage. But it we're kind of getting into an important conversation about the type of fat. So when we think about various forms of fat, um people get very concerned when they think about just gaining weight. And it is very true that when people gain weight, uh they uh increase the risk for a number of major conditions or diseases. However, there's a distinct difference between, let's say, fat being stored under the skin called subcutaneous fat or other forms of fat that are stored around the abdominal region, uh, typically, uh, termed visceral fat. And impacts around what people eat and how that might affect ultimately where they store fat is is quite quite important.

So, when it comes to eating these carbohydrates, and people are going to be thinking, well, I don't eat all of that junk, but what is the worst processed carbohydrate that you think people are eating?

I think it's kind of like keto cereal because that is going to be like low carb. Keto cereal, they think it's really healthy because they want to have that crunch.

What do you think is the worst food?

Uh, the foods that cause people to feel hungry after they consume them. I'm going to define it on how people actually feel after they consume the food because that can be a large number of foods nowadays. In fact, I would argue when you go to a grocery store around 70% of the food falls into this category. Um, so when we think of like healthy food categories, you actually mentioned one which is these forms of ketogenic style foods that cause people to have this incredible sugary salt, fat uh context because yes, they may be using uh, you know, healthier forms of sweetness that don't have the sugar spikes, insulin spikes, but that sweetness still triggers a brain response. You combine that with fat, you combine that with things like salt, and you have this very hyper palatable, meaning very high flavor profile food. And that high flavor profile food can have a very powerful effect on the brain, making you want to seek that food again. And so, yes, you can run into issues where foods typically labeled as healthy, uh, some of those are certainly on these ke uh, you know, keto friendly options can be quite problematic. Um, and to also be quite frank, a lot of foods that are labeled as keto friendly are anything but that. They actually contain hitting carbohydrates on the label. So, not only are you not free of a glucose and insulin spike, it actually does not only spike glucose and insulin, but it also has fat and all the other components combined together, which is really a composition of what we call the western diet. It's a combination of high fat, high carbs, um, and other ingredients that make the food nutrient void. So, um, they remove a lot of the important micronutrients within the food, things like even like fiber, which can be healthy in some forms in some diets. Uh, and they're basically removing those from the diet. Uh, and then they have a lot of calories and they taste really really good. So, people over consume them and they're not getting much in return for that consumption.

So, you mentioned like all of these processed foods that people are eating. So, even these like keto foods or like low carb foods that we should be avoiding. You mentioned there's some hidden carbs inside. What are some ingredients that people can look at on the label to say like that's got a carb inside of it?

Uh well, typically if it uh one of the worst offenders is when you look on a label and it says zero sugar because t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t t typically zero sugar. It just means that they removed sugar, specifically sugar. However, when you remove sugar, most companies will attempt to match the flavor profile and they don't typically match it with healthy forms of non-lucose and insulin spiking forms of sweetness. Uh the typical safe ones are alulose, stevia, and monk fruit. However, we know that uh a lot of times they'll replace these with maltitol. Uh they'll replace them with maltodextrin. They'll replace them with uh certain forms of grains, um starches, uh uh honeys, agave, things that are typically framed as healthy carbohydrates, um but yet still spike sugar and insulin all the same. So in those ways, uh the companies are are typically trying to ensure the product has the same flavor profile because people won't come back and buy it. And so a lot of times when looking on a label, the the most notorious offenders are things like uh malitol, malttodextrin, but you can typically look at a label and if you if if you haven't heard of it before, uh doesn't mean that it's in inherently bad, but there are a large number of ingredients that are basically sugar equivalents. In fact, I've come up with a list of about a hundred different things that are equivalent to sugar or near equivalent to sugar that are on labels um that typically result in blood sugar and insulin spikes nearly identical to sugar. For example, we know that high fructose corn syrup most at least most of your listeners will probably know what high fructose corn syrup is is that is a very problematic um uh form of a sugar equivalent. It's very condensed forms of fructose unlike what you consume in a fruit. It's very very dense pure form of fructose. When you consume it, it has not only the blood sugar elevation, insulin elevation, but it also has unique effects, adverse effects on the liver beyond that. And uh those are sometimes it's not labeled high fructose corn syrup, although it should be. It's also labeled HCF S. You know, some people don't even know what that is, right? They'll use these alternative framings to remove the concern that has been presented because someone may hear about it on a podcast like this and say, "Well, that's not good for my health." And the company may hear about that. It gets into the public space. People realize, "Oh, no. I'm consuming something that's not healthy for me." And the companies will adapt, not usually by making it healthier, but typically by just trying to get around the problem uh by reframing the foods that are on the list or swapping them out for things that people are unaware of, of which there's almost a limitless number of those options. And so people can tend to be a little bit safer by avoiding highly processed foods, companies they have that don't have a good reputation for producing products that are actually in fact healthy because yes, there are processed forms of foods that are in fact healthy that provide great options for people uh who are on the go who can't always go to their local market, cook the food, and then eat eat it right on the spot. Sometimes they need something on the go. And so there are healthier options, but um unfortunately some of the bigger companies out there um I won't name any names, but they they're they're notorious offenders for doing things like this. Um I will at least name Reese's Cups because they put zero sugar on the label and they just replace the sugar that was on the label for for alternative ingredients that are sugar equivalents. And so it's just one example, but you can look at all major brands um that are out there and they do something equivalent to this most often.

Let's now understand what happens when you drop the carbohydrates to 50, 30 or zero. In the first 24 hours, Dr. Knutnick, this is called the rapid, the switch. What is happening in the first 24 hours when you quit carbohydrates?

Yeah. So to break down what happens, there's kind of five key stages to keto adaptation. And I'll I'll kind of summarize those very quickly and then go into each one a little a little more detail. The the first phase typically within the first 24 hours as you mentioned is what you can term you know metabolic switch phase. Your body is really switching from burning carbs to now switching to burning fat. We also know that insulin drops and that insulin drop is what is the key facilitator of increasing fat burning. It's basically the initiation of the fat burning phase. We know that the second phase is day 1 to 7 which is what we call kind of fat burning kickstart phase. This is when the fat breakdown and ketone production starts to really warm up. Rapid water loss occurs and appetite starts to shift. Phase three, which is week one to week three, is really when you have the fat adaptation building. Okay, build phase. Your body begins to burn get better at burning that fat. Uh energy energy use becomes more stable and we know that the early signals uh of changes within the gut and the microbiome are observed. Now we have phase four which is typically around the fourth week where we see and I call it stabilization phase. Energy performance and appetite tend to normalize ketone and and blood sugar levels level out and now you're in this uh phase of what we call keto adapted. But we know there's a fifth phase called the long-term optimization phase where there's these deeper long-term changes that occur in lipids, muscle fuel, and gut health over time.

Now to back up for a minute to really describe in more detail what happens within this phase one or this first 24 hours. It's this really we term it the metabolic switch. The kind of the rapid initiation of metabolite changes, insulin enzyme shift. What occurs is when you lower your carbohydrates at the very first meal, blood sugar levels begin to uh normalize. They're not spiked as a result of that meal. And what we see is a is a reduction in blood sugar levels. When blood sugar levels are reduced within the blood, insulin drops at the very first meal and stays around 33 to 75% lower over a 24-hour window. Now, what happens when you drop insulin is this switch in metabolism. Okay, that drop in insulin now facilitates elevations of molecules called glucagon and catakolamines. Okay, um now catakolamines are typically what we describe as adrenaline molecules. Okay, but glucagon and catakolamines are really counterregulatory or they work in antagonistic to insulin and this really has this effect on your central nervous system, your hypothalamus, your sympathetic nervous system ultimately uh and facilitating changes in your adrenal glands and we know this increases uh adrenal output of key molecules like epinephrine and norepinephrine. When glucagon and catakolamines elevate as as a result of lower insulin, the process of lipolysis initiates. So lipolysis is a process where fat breakdown occurs. The liiosis means breakdown, lipo means fat. And we know that reduced insulin and increased glucagon and calicodamal means uh mobilized fat into circulation. Now after that occurs, we know that key enzymes within the liver begin to change. Low insulin allows for molecules that allow for fat fatty acid breakdown and ketogenesis pathways to increase. So now you have key changes within the liver which is really the metabolic hub of your body. Now at around 18 hours after the first drop in carbohydrates, the first meal where you drop carbohydrates, we see a noticeable measurable difference in elevation in ketoon levels typically to around.3 millmer or higher. And we know that the body begins to use some of its initial liver glycogen stores uh to maintain normal blood sugar levels until ketone and fat oxidation compensates sufficiently. Okay. Now these are the key changes that happen within phase one within the first 24 hours. But the second phase is really this fat burning kickstart which is 24 hours to 7 days.

Let me ask you a question about that first 24 hours. Do you think that somebody needs to supplement with electrolytes, sodium, potassium, and magnesium?

Typically, that's a good idea because the body will begin to reduce their water. So, this is something that happens within phase 2. So, that within the 24 to 7-day window, this kind of fat burning kickstart, we know that the drop in insulin causes less sodium to be retained. This is where you start to see water body, not only a reduction in body weight, but also reduction in the amount of water the body retains. So, a lot of people get on these diets and they'll see these rapid reduction uh in weight and they start to look better in the mirror and they say, "This is amazing." Because it's not just a drop in overall body weight, but also they're they're holding less water. And that loss of water and sodium retention initiates after insulin is dropped. Now, there's this effect called keto flu, which is a non-scientific term to describe the symptoms that people get when they have, let's say, reduction in minerals within the body. uh and in order to facilitate or offset some of these predictable and preventable pitfalls of initiating the ketogenic diet uh is to make sure you have sufficient amount of sodium. So, typically most people want to consume somewhere between 3,000 to 5,000 uh milligrams of sodium throughout the day. And that might mean for most individuals, they may need to supplement initially uh within the first two weeks or more um with maybe a gram to three grams of sodium on top of their traditional diet to ensure they're getting adequate sodium because the body is now going to release it uh over a uh 7 14 or more day window.

That's really important because I see so many people that start ketogenic diet and they're like I feel like crap because they need electrolytes and they need sodium. So about a teaspoon, a teaspoon and a half. If people can use that with extra high quality salt in their meals and in their water, that's really going to help. So let's move on to the next phase, which is 24 hours to 7 days. Do people lose a lot of weight? How much weight can you lose in the first 7 days of quitting the carbohydrates?

It really depends on the person, but a pretty pronounced amount. You know, some people can lose anywhere between uh you know, on the smaller end, maybe you know, some people may lose uh no initial weight if their calories are retained. and they weren't holding that much water in the first place. But most people, especially if they're he overweight or obese um and you know holding a lot of water because they're consuming a lot of carbohydrates would could lose anywhere between 5 to 10 10 plus pounds in this window of time. Now that isn't going to be everyone but uh some people can see that much weight loss that has been observed before. And what's really happening as we spoke about is as insulin dropped, the body is now not storing more sodium within tissues like the muscle, fat, and other places. And so your body's not holding this excess weight in water. Okay? When that happens, um you'll start to see precipitous weight loss for weeks, okay, until ultimately insulin levels begin to normalize. And we'll talk a bit more about this in the next few phases of when that actually happens. But we see that beyond just the initial body weight and water loss that happens within the the um 24 to 7day window. We also see this changes precipitous changes of adaptation within the fat tissue in the liver tissue. We know that fat breakdown again termed lipolysis accelerates. It begins to uh increase to higher and higher levels. We know that the liver increases further uh the processes of fat breaking called fatty acid oxidation and ketogenesis. Now there's also some key changes that happen in circulating lipids as a result of this. Things like triglyceride, HDL and LDL begin to see changes. So for example, we know that within this window of time, we know triglycerides lower 15 to 26%. Uh because uh we know that metabolically speaking, carbohydrates are linked to higher triglyceride levels. So the second you drop uh carbohydrates, triglycerides almost instantly lower within the first 7 days. We know that HDL begins to elevate because of the increase in healthy forms of fat. And we now start to see a shift from small to large dense LDL which you know small dense LDL has been linked to higher levels of cardiovascular disease and large dense LDL holds a lower risk. Okay so that's important and we also know that in general if you consume more saturated fat within the diet LDL can begin to elevate which you can you know work to offset if you wanted to by reducing or shifting saturated fat to other forms of fat. um and uh you know changing things around like maybe you can increase your fiber intake or begin to exercise which improves basically all lipid levels but that's just a side note because we know LDL elevates and some people have concerns around that which we can talk more about about later but one of the most uh important changes for individuals when they initiate this is they'll begin to initiate a new diet and they'll struggle because they're used to these prior foods they were consuming but within the first seven days we know that appetite actually sees a noticeable change okay around things like hunger and how full you are and response to these meals. And that's key because some people will will start within first two days and they really struggle, but they don't realize that within the first seven days the appetite is shifting. Okay, their hunger for cues and how full they would be in response to meals sees noticeable changes and that's critical because that persists for quite a period of time until it begins to normalize further down uh in in phase four.

Wow. And that's just the first seven days. So let's go to the next uh stage which is called fat adaptation. 7 days to 21 days. Um, do you reach maximum ketosis in this stage?

That's a great question. I would argue you get close to it, but you're not quite at peak levels. Okay. You start to see some initial signals that it's starting to get close to peak levels, but it's not quite there. This is where you're really building up to that max capacity to burn fat and also produce ketone bodies. What happens within this period of time, again, 7 days to the 21 days, is you're really building your fat burning potential to its peak levels. Okay, we know that things like carbohydrate or sugar burning drops by upwards of 50%. Okay, we've seen these in our studies even in athletes. We know that fat breakdown or fat burning will be termed fat oxidation. We know that whole body fat burning rises within the first week, but continues to rise for up to two to three weeks. We actually see that some individuals may actually see increases in fat burning 300 to 400% increases. Okay? Where the average person may be 100 to 150%. We do see upwards of some individuals seeing a three to fourfold elevation the amount of fat their body is now burning. Beyond just the amount of uh sugar and fat the body is burning, we also know that changes like energy expenditure change. Okay, we see increases of somewhere between 50 to 150 calories a day are being expended when shifting on this diet by uh the 3-week time point. This is a study by late David Lewig which showed that shifting from higher carbohydrate to lower carbohydrate uh approach actually just burns an extra 50 to 150 calories a day uh and can help facilitate some additional weight loss. Now, we talked about this before where we talked about weight uh and water. we start to initially see some normalization of water retention. Um, now this is this normalization is occurring because we start to see some normalization of insulin to a a more of a plateau level. However, if individuals retain a caloric deficit, so if someone was obese and they really wanted to continue to lose weight on this diet, they probably would still be in a caloric deficit at the 3we point. Okay? And if that's the case, we still see that people continue to lose weight um as insulin continually drops over time. Okay, insulin will continue to drop as weight loss continues and the the reduction in calories continue with it. Now, we know that again within the first 21 days, the microbiome richness actually initially starts to drop. Now, it's important because someone may hear that and be concerned about that. Okay, I've heard the microbiome richness is good. More diversity, higher quantities of bacteria is good. But what's happening is the body is shifting the type of microbiome it has because initially we do see a drop with a shift in any type of diet away from what you were doing before. But we'll get to this later uh and the the long-term adaptations we actually see that that it goes down but actually initially starts to increase after a period of time.

As we've discussed so far, insulin resistance is at the root cause of most chronic health issues. And the first step to fixing it is to significantly reduce your carbohydrates, sometimes to under 20 grams a day. As you do this, your body goes through a major transition. And you might experience some side effects like headaches, nausea, and even cramping. Now, this is where salt is so important. I want you to be so generous with your salt in every meal and in your water. But if you still feel those side effects, you really need a precise balance of electrolytes, sodium, potassium, and magnesium. And that is why I'm so proud to have Element as a sponsor of today's episode. Now, I personally use the raw unflavored option because it has a sciencebacked ratio with no nasties and no preservatives. I've even started reaching for their new lemonade iced tea in the morning instead of my regular cup of coffee because it uses full black tea extract and electrolytes, not isolated caffeine. And I've noticed steadier energy without the crash. And since the caffeine is bundled with elenine and polyphenols, you get that sharp, clear lift with no sugar and no dodgy ingredients. And right now, Element is offering my viewers this free sample pack on every order. So, you're going to get eight single servings of their most popular flavors to try for free. So, if you want this, just head to drinkelement.com/theprimal podcast.

Wow. Okay. So, that is the fat adaptation stage. That is like up to three weeks. Hopefully somebody does not have a cheat meal. Hopefully they don't have a slice of pizza because okay, look, I have a go carnival community and you've been a guest speaker on there and you know that people don't always continuously drop the carbohydrates to an appreciable level, 50 g of carbs. So just don't have a cheat meal at this time. Um just try to stay on track because you see there's so many different benefits that occur day 7, day 14, day 21. Now 4 weeks, what's happening then?

Sure. Sure. And I also want to comment on what you mentioned because it is true when people get on these diets longterm and get into these long-term stabilization of a sustainable approach with these diets, we see that one or two meals here or there will not destroy their fat burning and ketone potential. But we do know early on it can be much more counterproductive and really hinder their ability to get into a fat burning or or keto adapting phase. In fact, individuals who go on uh let's say they diet during the week like they're going to work and then on the weekends they they get off their diet. That pattern doesn't work. Okay? That pattern doesn't allow people to get into these long-term adaptive changes. You're basically doing 5 days of work and reversing it in two days, doing 5 days of work and reversing in two days. So, people really need to think about how do I sustain this over time to really see these changes in my body occur so I can actually sustain it. And that's that's quite critical. So, you bring up a really important point. But when you ask about the four-week mark, this gets to a critical period because we've done a lot of research on studies looking at various groups and four weeks is kind of this really key window and what we kind of term the stabilization phase or this phase 4 response. [snorts] What we see is that things like physical performance begin to normalize. Initially, when individuals go into these switch from a form of fuel they are burning for years and years and years to a new form of fuel, the body goes through this this change window. as it's changing, it's changing its ability to burn new fuel, not rely on old fuel. And so there might be this initial bump in drop in performance. Typically, we see around 2% reduction in performance, which is meaningless for most people, but for some people that might be meaningful. Either way, around four weeks, all of our studies have consistently shown, as well as others, that athletes begin to normalize their physical performance at this period of time. Four weeks is critical for that. Why is that critical? Because we see key brain energy metabolites like glucose and ketones begin to normalize. So glucose levels see this dramatic drop but they begin to normalize and plateau at the fourth week. Now ketone levels they actually peak right after the 3we mark. So you asked this before you have peak fat burning and ketone ketone potential. We actually see that when individuals uh go on this diet, keep calories, activity, body weight, all these things consistent, at the four-week mark, you see this persistent diet induced peak of ketone levels after the third week. Again, if people retain this diet, continue to lose more and more weight, ketone levels probably only continue to rise and rise over time. Now, we also see changes in the muscle and liver. So things like muscle initially start to see increases what we call nitrogen or increases in and uh nitrogen breakdown which is a marker of muscle turnover. But we know that when ketones elevate and peak around the four week or after the 3 week mark we see this balance in nitrogen normalize. Right? We've I've done a lot of studies in my uh graduate training for over 5 years studying the direct effect of ketone bodies on muscle breakdown. And what we see is that ketones themselves are very anti catabolic to the muscle. Okay, they're very powerful tools to reduce the breakdown of uh of of muscle tissue. Um and so we see that again that the nitrogen balance, okay, this balance of muscle breakdown and nitrogen is just a signal of that begins to stabilize uh at the four-we mark. We also know that liver glycogen appears to normalize likely slightly before the four-week mark, but it just suggests that there's increased glucose stability at this time point. Okay. U now we talked about before that there's this appetite and kind of satiation or fullness response. We see that for most individuals going on this diet, there's these rapid changes within the first seven days. But then we start to see these new um kind of new profile when it comes to appetite and how full you are in response to meal really get to a new normal um at the four-week mark. And so that's critical for individuals because a lot of people who go on to these dietary strategies struggle to initially make this this change. But once they make these change um over time it they're it persistently progresses appetite consistently changes how full you are in response to meal games change um and we really see that reach that kind of stabilization point in these new normals for appetite and fullness in response to meals term society uh around this four-week mark. So this four-we mark is really the point most people are trying to get to because this is when you are have seen most of the major changes. you're starting to see stabilization of key metrics and you're really in this fat burning and keto adapted stage and that's that's really critical for individuals but there's been a lot of um criticism over you know how long does the keto adaptive changes occur well we do know that some changes go well beyond the four-week mark

next one then is beyond 6 weeks you call this optimization what is happening in the body long-term adaptation

sure so for a long period of time. We thought, you know, the key metrics of keto adaptation were okay, reduction in glucose, reduction in insulin, increase in ketone levels, and increase in fat burning potential. Uh well, most of those uh peak or normalize around the four week within the four-week window. And so, most people thought, okay, I'm that's most of the changes that we're going to see with keto adaptation. But we see a lot of individuals who report persistent changes that go well beyond that. Okay. And there have been numerous studies that have confirmed that this is in fact the case. In fact, there was this one study uh that looked at you highfat diet intakes and they actually looked at them in twins. So two individuals that have the same genetics but maybe have different lifestyle habits. And they showed that individuals who are consuming maybe higher fat intake actually show changes in specific liver species that continue to shift beyond six weeks. They call it lipidelmic. So the idea of taking plasma blood samples or the the blood in your body and doing this deep analysis of the type of uh species of lipids that are floating around in the blood and we see that they continue to change at least up to 6 weeks after the diet showing that the type the body is still undergoing persistent changes after initiating uh ketogenic style diets. uh and we know this is uh uh also occurring in even disease populations because this study was actually in a group of patients with multiple scerosis. So this isn't just for healthy individuals. We know that these changes appear to be ubiquitous across biology uh regardless of someone has a disease or not a disease. Now that's the overall lipid changes when the blood again a key signal the body is still shifting its use of partic particular type types of fat even beyond or up to or beyond 6 weeks. But we also know there's this molec called uric acid. Uric acid was something that people were originally concerned about because uh it it can be linked to certain um disease processes. We know that initially the body under goes these rapid changes when it comes to uric acid metabolism. But around six to up to 24 weeks uric acid appears to either one stay neutral or increase initially depending on the individual. And this includes individuals with uh who are healthy or people with type two diabetes. But we know that within the first uh four to eight weeks or beyond the first four to eight weeks, we see a progressive decline in uric acid for up to 24 weeks. So we see either it stays neutral or it might go up slightly initially in the first weeks, but then it drops precipitously for up to the 24 weeks because this wasn't a concern that was raised by a number of individuals in this community saying, "Okay, well if uric acid elevates, we're concerned." But now we have analysis up to 24 weeks on the diet showing that actually uric acid levels on long-term adapted individuals on a ketogenic diet if they're healthy or have type two diabetes are below baseline well below baseline and progressively decrease uh up to 24 weeks. And in fact this study actually didn't show a plateauing of uric acid. We don't know when that uh plateau would even begin to occur but um um you know we'll see we'll see uh maybe some more analysis will look even beyond 24 weeks and and tell us when that plateau may occur but this is what we know up to this stage. So we see again circulating lipid levels species change. We know uric acid changes uh uric acid metabolism changes. We also know that things like muscle glycogen, there has been no study that has actually showed a normalization in in muscle glycogen, particularly in athletes, which is where you most often look at muscle glycogen levels for uh its relationship to performance uh until after 12 weeks. Every study that has been conducted has showed consistently a drop in muscle glycogen levels that slowly starts to increase for up to uh the 12week mark. The only study that has really showed any normalization in uh muscle glycogen levels was a study conducted by Jeff's group at Ohio State University where they had long-term adapted uh elite level athletes and they had been adapted to the diet for 9 months to 36 months. So, we know that muscle glycogen may not be as important as we used to think for performance, but we do still see changes in how the body is storing glucose in key tissues like the muscle. again showing there are persistent changes over time that go well beyond just the 4-we mark. Okay? And that's not just the liver species, uric acid, but also muscle glycogen levels. Now, where it gets really interesting is we talked about before how when you first initiate this diet, the body shifts and adapts uh the microbiome to what it's it's observing, right? We know that if you interact with someone you've never met before, it can change your microbiome species. If you eat a new dietary strategy, it changes the microbiome of the gut. All these these things change the microbiome. So initially when you go on a diet, you're seeing this drop of the microbiome that was adapted to the prior diet. However, we know that there's now uh studies that show up to 24 weeks that initially the micro uh microbial bacteria within the gut concentrations and diversity drops because you're not exposing it to the the the food it was seeing before that that developed that colony or species array of species to the prior diet. But we know it actually recovers at the 12-week mark. And at the 24 uh week mark on a ketogenic diet, the microbiome richness actually exceeds the baseline level. Meaning that the the richness of the microbiome actually improves beyond what it was before on the prior diet on these ketogenic diets up to 24 weeks. At least we now have uh evidence to show this. So you know when we really think about this, there's again these five key stages. Again, first phase 0 to 24 hours, which is the metabolic switch. This is the quick adaptations that occur in metabolites. you you're starting to see the initial drop in uh burning carbs, increasing fat burning because of a drop in initial insulin. That drop in insulin facilitates phase two, day one to uh day one to day seven, which is the fat burning kickstart phase, which increases fat burning, ketone production starts to ramp up, water loss occurs, and appetite starts to shift. We also know at the phase three, which is that 7-day to 3 week mark, that that fat burning increases more and more and more. your body, your energy levels become more stabilized because you're becoming more reliant on on fat, less reliant on sugar, carbohydrates, and you also see initial gut and microbiome based changes. Now, phase four around the four-we marks of the stabilization phase, we know that the energy performance and appetite normalizes, ketone and blood sugar levels begin to level out and you're now in this keto adapted phase. And again, this final phase is really what you can term this long-term optimization phase where we know we see changes that go as far as 24 weeks. deep changes in your metabolize or your lipid levels, species in the blood, uh how your body stores glucose within the muscle and ultimately how your body is now adapting uh its its microbiome species and ultimate diversity to this new form of diet. And that's really how I look at the five phases of keto adaptation and how we've evolved our thinking beyond the adaptation phases, 5 days to 21 days. But now we know that the the most of the major changes happen within 4 weeks. But there are actually changes that are being observed beyond that point that go beyond 6 weeks and up to 24 weeks in duration.

You also published a landmark 2024 expert consensus paper that actually proves this is not just about weight loss. So in this adaptation phase, the five phases, we talked a lot about fat burning, weight loss, and the metabolic changes that happens. But if somebody's coming to this and they say, "Dr. Knut, I have fatty liver disease. I have a thyroid condition. I have XY Z problem. How can a ketogenic diet be a therapeutic option to treat a disease?

Sure. So, what's interesting and I want to I want to reframe this question because uh when we often think about people talk about they always lead these conversations around like okay well what could go wrong with a diet or what's what you know the ketogenic diet you have to be cautious about it. But I want to reframe that for a second because we've known this diet has been around in medical textbooks for preventing and reversing diabetes since 19 or sorry 1797. Okay, this is over 220 years ago. It was standard of care for both type 1 and type two diabetes um since the 1920s. We know that in 1864 was the first report that carbohydrates could reduce and reverse obesity. We know that from 1900s to 1920s, numerous reports were utilized that showed that carbohydrate- restricted diets were utilized in individuals with type 1 diabetes prior to discovery of insulin to extend the life of patients sometimes up to years. Okay, where patients were usually doomed within days to months to die. They could actually get to years sometimes by doing carbohydrate restricted based approaches. We also know in 1921, okay, over a century ago, that ketogenic diet was used to reduce seizure frequency and and epilepsy. uh again showing that it was actually an effective treatment for neurological disorders. Um but what's fascinating is spite of being utilized for obesity, diabetes, and neurological disorders, there's been published texts all the way back to 200 years that the ketogenic diet was actually since 1920s was considered a contra indication for things like type 1 diabetes even though it used to be standard of care, which is quite ironic because it's almost like we have forgotten what was done for centuries as a medicinal tool. um and raised these new concerns around that hypothetical risk and ignored the fact that it would been utilized for two centuries. And so what does that mean? We know that a ketogenic diet is a viable strategy for obesity not only for its prevention but in management but also reversal of obesity. We know that now what was once considered a relative contraindication. So a contraindication means something that means that an therapeutic strategy is not appropriate for an individual and can be harmful. That was how ketogenic diets were defined for type 1 diabetes abs to almost a decade ago. But we now know it's a one of the most effective strategies for managing type 1 diabetes. In fact, the American Diabetes Association in a landmark 2019 consensus report on nutrition indicated that the ketogenic diet was the most evidence-based uh dietary strategy for things like weight loss, glycemic control, blood pressure management, and type 2 diabetes. We know again it's been utilized for epilepsy and now it's considered an appropriate standard of care use in many scenarios for children and adult with epilepsy. But we have all this emerging evidence over the last 100 years with randomized control trials or pilot studies in things like Alzheimer's. We have a three-month study in Alzheimer's on a ketogenic diet. We have multimate initial pilot reports in cancer because there's been tons of work in animal models uh in and cell culture models which I was a part of uh going back over 15 years ago. We know that now has emergent evidence for its use as a bipolar in schizophrenia and there's actually been meta analysis in major journals uh for its potential use as an adjunct for depression um or psychiatric condition but there's been systemic reviews looking at its use for pain and inflammatory conditions. And so it's important to acknowledge that the ketogenic diet is a powerful therapeutic strategy for numerous diseases ranging from obesity to neurological disorders. But there are predictable and preventable and predictable pitfalls of any approach which always must be considered. Um, which is actually led us to do kind of a uh a a very long-term report over 10 years in duration looking at the ketogenic diet. uh published um uh some of the work was published last year and two other pieces of reports were published in 2013 and 2014 on the longest larger reports on the safety and efficacy of the ketogenic diet to date.

So let's talk more about that. Um first I want to understand so we understand we should not eat carbohydrates so many of them we went through the five stages of quitting carbohydrates. Now people are going to want to know how can I increase my ketones getting to ketosis. So, how would you measure ketosis? What do you use?

Sure. So, you can do that with blood finger measurements. A old school approaches were just peeing on a urine stick and it would give you a color out read telling you how much ketones you had in your urine. But, we know that over time as you become more keto adapted that you you start releasing less ketones through the urine. So, it's not really an accurate measurement of long-term ketosis. Uh, I recommend using one of these finger sticks. There's companies like Keto Mojo that produce um ketone meters that are reasonably cost where you can get glucose and ketone meters and you can track both those key measurements over time. And so I think a a capillary blood um blood glucose and ketone measurement is probably the way to go to actually confirm your level of ketosis.

Okay. And how long have you been on a ketogenic diet for?

Almost 15 plus years.

What are your ketones?

So it ranges. So it depends on what my goals are at the time, but somewhere between.3 and 1.5 millmer depending on uh what I did that day, when my first meal is, things like that.

Okay. What would you say to somebody that is coming to this and they're like, "Dr. Cutnick, I'm doing keto, ketogenic diet for like four weeks. My ketones are like absolutely nothing. 2.3, they're not increasing. What are your tips to increase the ketone levels?"

Well, you have to pay attention to a number

of factors, right? So, if someone's doing the ketogenic diet and they're trying to do it because they want to uh increase their fat burning, then yes, you want to get ketone levels higher. That's your surrogate measure that you can measure at home for the level of fat breakdown that you have going on in the body.

Typically, people when they go on these diets have to think about how they formulate the diet. They want to do it in a very knowledgeable approach, and they want to be conscious of not consuming excess amounts of of various foods, which by the way, is very hard to do on this diet. This is why people uh almost valitionally lose weight on these diets because they're not consuming a lot of these processed forms of carbohydrates that cause them to over consume.

So, for most people going this approach, if they're not conscious of it, they're probably going to reduce their caloric intake, um and that helps them uh lose weight beyond just the water weight, right? The fat fat mass they're trying to reduce. But to further increase ketone levels, they have to be conscious of that first. Okay. Are they over consuming on this diet?

Uh because that would at least blunt um some of the ketone production. Because we know that it's not just carbohydrates that release insulin. We know that protein, but at a much lower level (2.5 times less), uh insulin is released from protein, but it still has some. So, if you are consuming a huge amount of protein, it may blunt, okay, not aviscerate, but blunt the level of ketones within the body.

And for individuals who are consuming excess amounts of fat, okay, what I mean by this is someone who's actually going out of their way to consume more fat, uh, which is probably not a good idea in general, regardless of what diet you're on, to do excess amounts of anything, okay, not just fat, not just carbohydrates or protein. Um but uh that we know that ex insanely high levels of fat within the blood, which you don't typically see on a ketogenic diet. The irony there is that you actually burn more of the fat and you actually typically have less circulating lipids in various forms. Um but if you're consuming excess amounts, um then you will have elevated circulating levels, and we know that one of the certified ways to induce insulin resistance in a laboratory setting is to infuse super physiologic levels of free fatty acids. Again, that's well beyond the normal levels, not not what we see with the ketogenic diet. We actually see people see reductions in specific types of lipids on the ketogenic diet.

But again, for individuals who are trying to elevate their ketone bodies, they want to look at their the their overall diet, make sure they're not consuming any anything in excess, okay, which again, is hard to do on this diet. And you can also look at things like if people are actually doing this appropriately, um okay, is is protein levels higher than it needs to be? Because ketone levels can uh higher protein levels can blunt ketone levels marginally.

But this really gets to a different question, though, because ketone levels don't always predict. They are associated, but they're not always a measure of how much weight someone's losing. Okay? Or if it's achieving their goal. Like in type 1 diabetes, the goal is glycemic control. Ketone levels don't dictate glycemic control. They're just a measure of how much the body shifted towards fat-based metabolism. But someone for type 1 diabetes may be doing this diet because they just want to normalize glucose levels, lower insulin levels, get long-term overall metabolic health. And ketone levels are not an obligate part of that. They're a byproduct of it, but they're not an obligate part of it.

Someone who's lowering um or trying to get away from a lot of these processed forms of food, and maybe they shift not just to a lower carbohydrate approach, but maybe a carnivore style diet. Well, carnivore style diets are typically protein focused and fat focused, right? And so, if they have a little bit more protein and their ketone levels aren't as high, is that a huge concern? Well, not if all their health biomarkers are moving in the right direction and losing weight; that's obviously a net positive. In fact, we know this because almost any intervention that helps someone lose weight if they're have obesity or overweight improves metabolic health biomarkers, regardless of what you're doing. Okay?

And so, in that way, I don't always focus on ketone levels, but if someone is looking at it, it is associated with higher fat breakdown and typically associated with weight loss. So, if they want to focus on that, it is something they can pay attention to. But I'll give caveats because I don't want someone to think, "Oh, if my ketone levels aren't 1 millolar, I'm not doing it right." No. What's your waistline? How do you look in the mirror? How do you feel? These are other key metrics beyond ketone levels that are obviously much more important for a lot of people.

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So, somebody's coming to this. They're like, "Right, I need to measure my ketones. I'm going to do that through a blood pick test." Keto Mojo. Um maybe you don't even have to test your ketones because um if you want to lose weight, you need to just be managing your insulin, dropping the carbohydrates, and then the ketones will actually follow. It doesn't have to be as high, like one or two, to actually reach that fat burning. So, my question for you is, if somebody wants to do a well-formulated ketogenic diet, how would you see the balance of protein and fat, because that seems to be the two things that people need to be eating?

>> Yeah. So, uh the way I approach this typically is from a practical perspective for most individuals, right? So, if someone's focused on their muscle mass and trying to optimize their muscle mass outcomes, they may think about this. I I want to get, you know, one gram per pound of body weight of proteins. Do they need to get that? No. They can maybe get away with half that. Um but that's optimal for muscle mass and recovery from exercise and muscle mass retention. But you start with your typically with a protein source, right? You start with that foundation of getting sufficient amounts of protein.

Then I typically think, okay, if you're going to do a traditional form of ketogenic diet, which has things like spinach and cauliflower, other forms of diets like this uh that have um carbohydrates, but they're not sugary starchy carbohydrates. They're fibrous forms of carbohydrates with very low net carbohydrate uh content. Has very minimal or almost undetectable levels of glucose impact in the blood and almost no impact on insulin whatsoever. So, if you're having those forms of carbohydrates, I typically say, okay, you know, for most individuals, shooting for around 15 or less net carbohydrates from those form of fibrous vegetables.

Now, it doesn't mean, "Oh, I'm going to go eat 15 grams of Skittles." No, I'm not eating 15 g of bread. You're eating 15 grams from a fiber source of carbohydrates that has phytonutrients and fiber in it. That's the second component of it. Okay? Now, some forms like carnivore, they're not doing that. But if you're doing a traditional ketogenic diet, you do include that.

The last phase is the fat phase. Now, if you're eating whole food forms of animal, plant, uh fish, etc. forms of protein or dairy, um then fat usually takes care of itself. You don't usually need to think about adding excess amounts of it. Um it usually just comes along with these natural uh healthy forms of whole foods, protein sources. But fat's the last component, right? But if you're eating very lean forms of protein, uh then yeah, you're probably going to need to add additional forms of fat calories to, let's say, your salad or some type of dressing to those lean protein sources. Or you can just have the fattier form of that protein if you so choose, which is already going to come with that protein source.

So again, this is broken down into a practical side of things of, you know, typically between 0.6 to 1 gram of protein per pound of body weight. There's no real benefits going beyond that, at least for muscle health and function. Um it's kind of tapped out of that point. Is it problematic to have more than that? No, not unless you're on dialysis. So, most people aren't. So, you could have more. Uh, but at there's nothing, there's no net effect or net negative effect, but there's no additional benefit.

Now, uh, for fibrous carbohydrates, if you're having them, again, we're talking about green leafy vegetables with high fiber and phytonutrients, not Skittles, not bread, not rice, not potatoes, not a cupcake. Um, that can make up around 15 or less net carbohydrates. You have to determine on your own what that number is for yourself based on things like ketone levels.

Then you consider the fat, which typically comes around with a whole protein source. Uh if it's a healthy form of, let's say, uh fish or animal based protein or uh dairy or uh plant-based protein, all those things are typically going to have some form of fat with them, some more so than others. And and so you don't necessarily need to add excess amounts of fat. Well, that's what you get your essential fats and your energetic calories from. So, that's typically how how practically someone can make up one of these dietary strategies.

>> Wow. And if in doubt, meat, seafood, and eggs, and some fibrous carbohydrates if you can tolerate it. I have a question. What do you think are four foods, healthy foods that people should never eat on a ketogenic diet?

>> Um, it's a simple one. Uh, cupcakes, donuts, cookies. Um, you know, those are obvious, right? Like uh I think I think what you're getting at is what are some foods that people would frame as ketogenic which may be less ketogenic than they realize?

>> That are really going to destroy their results, basically.

>> Yeah, that's a really tricky one because it's context dependent. Like we know in type 1 diabetes, things like protein powders uh because they're digested so much quicker, they actually cause a quicker elevation in glucose and insulin than most other forms of protein. And that can be a little challenging in managing glucose levels and type 1 diabetes. That doesn't mean that other people can't consume protein powders on a ketogenic diet. They certainly can. It just means that protein powders are digested quicker and can be problematic for certain conditions who are doing this approach for therapeutic reasons like type 1 diabetes.

Um another thing is that uh similar to that is also things like yogurt. Oftentimes yogurt have, you know, fat focused and protein focused macronutrients, but also contain sugar. But the form of protein that's in these yogurts are also uh rapidly digested, kind of whey uh protein uh sources. Again, not problematic for a lot of people, but again, if you're in a condition where you're really having to manage glucose control, it can introduce problems like in type 1 diabetes.

There's also, um and I'm a big fan of these by the way, but again, this is where you get into a nuance situations. I'm not recommending against these, but there's things that people need to be conscious of, um are things like uh uh chia seeds. I've noticed in a lot of individuals with type 1 diabetes that the macronutrients look phenomenal, but they do elevate blood sugar levels faster and more robustly than other forms of kind of the uh low carbohydrate superfoods, so to speak. And a lot of this is very individualized to the source of food, right? These aren't inherently bad foods. I think anyone with type two diabetes, if they had a diet that's ketogenic and they had chia seeds as a part of it, would it be a problem? Absolutely not. If they had protein in the form of uh a protein powder after a workout, is that a problem? Absolutely not. Not in my opinion.

But that said, um I think for most people, what they could do or smart strategy is when you do this diet, the biggest problem is these hidden forms of sugar and food that are rapid and on the go, or when you're eating out of a restaurant thinking that they're not adding sugar to certain types of food, and they do. Most dressings often do. Um most types of, let's say, someone goes and eats peanut butter. Well, peanut butter is a nut. You're assuming, "Okay, that's ketogenic." Well, they typically add sugars to these. Most bacons on a traditional grocery shelf have sugar added to it. And so, you just got to be very careful about the labeling of these foods.

So, there isn't four specific foods per se. Okay? Okay, I just mentioned a few that you might be careful about if you have certain conditions like type 1 diabetes. But and you can manage them if you know how to, right? But they're not necessarily problematic. They're context. They're problematic in context. But what I would say is you can take those four foods and and put them into a single thing, which is paying attention to the labels of these foods because a lot of these foods had hidden sugars in them, which makes them problematic. For the most part, if it is a ketogenic friendly food, it has it's protein focused, fat focused, and minimal net carbohydrates, which means total carbohydrates minus the fiber, then it's pro probably going to be just fine. Okay? Rare exceptions to that that I already discussed earlier.

But when you get into issues is people will eat these, and this is notorious in protein bar land, okay? Okay, there's like 28 major protein bars um out on the market and all of them minus one spikes blood sugar levels. Okay, spikes blood sugar levels through the roof. Even though they're they're framed as healthy. "Oh, it's protein focused. Look, these are great for you." When in reality, they're they're littered with sugars or malitols or other things like that. Um that spike blood sugar levels uh and and I can I've looked I've looked at some of the most health focused protein bars on the market and there are rare exceptions to this. Most of them either plainly add sugar, okay, like Cliff Bars or things like that, or they frame it as a very low glucose and insulenic based foods, but will actually have a lot of hidden forms of sugar.

So, when you ask that question, I would be very conscious of labeling. Things like protein bars are notorious offenders um for spiking glucose and insulin and hiding sugar-based ingredients in them. Uh and I'm sure there's many others like sugar-free drinks. For the most part, that's [ __ ]. Okay. When people say, "Okay, they're sugar-free." Is it okay? Is it zero sugar or is it no sugar added? Because if it's a fruit drink with no sugar added, that's because all the sugar was already in the fruit to begin with. They didn't need to add any. Why would they add anymore? Okay. Sometimes they even add more on top of that, which is insane.

But it that that's the things you got to be careful of is like these these protein bars that are framed as health is not. These these drinks that say no sugar added or um are are framing as healthy and they're there zero sugar. You know, I have type 1 diabetes. I've had type 1 diabetes for it maybe 20 years in June. And you cannot hide from sugar. You So a lot of these foods that frame as zero sugar um you know, "Oh look, uh minimal glucose and insulin impact," I can't hide from that. It's metabolically and physiologically impossible for me not to see the effects of food on glucose and insulin. And so for me, um I've seen all these things firsthand. And I will tell you that uh uh I typically avoid the overwhelming market of protein bars until someone creates a good one. Um uh I avoid um in contact certain types of rapid acting forms of protein that make glycemic control management more difficult unless you know how to manage them. I avoid most sugarf free drinks because honestly if they make it sugar-free and they add all these other ingredients into it, it it's not necessarily a free pass, right?

Obviously, if you're consuming uh even a diet soda versus a full sugar loaded drink, is that a net positive? In my opinion, yeah, you just reduce maybe like 120 calories of pure sugar. That's probably better than if you had those 120 calories. But is water better than that? Yeah, absolutely. Like I don't think there's any question that you're reducing your potential risk if you you shifting away from those to to something like water which, you know, um has zero risk unless you consume it uh like you're drinking a pool, right? And so in that way, that's that's how I would typically think about these things when it comes to uh foods or notorious offenders that kick people out of their diet.

But one simple tool for people is these uh AI based tools are very helpful for people on this journey. Okay, so when most people start this, maybe they heard this podcast like, "Oh, I want to try one of these dietary approaches." Take the foods that you have in your household and just take pictures of them, okay? Take pictures of the label and send it through Chat GBT or one of these AI based softwares. I've used ChatB before. I find it to be pretty reliable. Uh, just take a picture of it and say, "Is this ketogenic?" It will tell you if it is or not. Okay? It'll tell you with actually a high degree of accuracy, in my experience, um, whether it is in fact ketogenic or not. So, if you feel like you don't have the knowledge to understand all the key foods and you're not, you don't have a PhD in nutrition, uh, which frankly you sometimes need, uh, if you walk through a grocery store and try to avoid all these hidden sugars on the label, you can simply use AI tools, take pictures of the foods you have and the labels you have and say, "Okay, is this is this ketogenic? Why or why not?" And then every time you take a picture, it's going to teach you something and you'll learn from it. But I generally think that that's a a safe way to go.

Or you go out to restaurants, take a picture of the menu, send it through AI, say, "What on this menu is actually ketogenic? And if it is not, how do I adjust one of these food options to make it ketogenic?" Okay, what questions do I ask the waiter to ensure there isn't added sugars or other components to some of these food products? You know that there's so many available tools if you know how to leverage them to help maintain this style of eating and go out and eat and utilize a lot of the foods that you were eating on your prior diet, right? Obviously, you probably have to give up some of your prior foods, but you can find out what matches your diet already, keep those, and then the things that don't, you remove them and replace them with things that are equivalent to that and flavor and texture and and essentially you're you're eating what you were before, but in a healthier form.

>> Your tip is excellent. Last question for you. People when they do a ketogenic diet, their blood markers are going to change. There is a lot of talk about high LDL is really bad. Can you discuss when you someone does a highfat diet and low carb and their LDL skyrockets? Is that really bad?

>> So, it's very context dependent. Okay. And some people may hear that a general practitioner who's gone through traditional metal training say, "No, it's not context dependent. Elevated LDL is linked to cardiovascular disease regardless of the level, regardless of the context." Well, let's give some context. But I think it will frame it much differently.

We know that when people go on that higher LDL levels um are linked to in the general population higher levels have been associated with cardiovascular events and that treating higher LDL levels reduces the incidence of cardiovascular events. However, why are we even talking about this? Well, because we talked about various diets that lower carbohydrates. But when you lower carbohydrates, what are you replacing that energetic source with? Typically fat. If you're eating healthy, uh if you're eating real food, whole foods, um typically some of that diet is going to be composed of maybe animal-based fats or uh some form of saturated fat, which even coconuts have form of saturated fat. Even olive oil has a portion of it that has saturated fat in it. That is the ultimate polyunsaturated fat but and plant-based, but it still has some saturated fat in it.

And so why this is important is when you go on these higher fat diets that lower carbohydrates is all these medicinal and therapeutic benefits that occur, the one primary concern is the elevation in LDL which typically rises when people consume more saturated fat. So is that problematic? Well, we actually tried to address that question. We actually um conducted the longest large tunal approach um in uh of a ketogenic diet 10 years on the safety and efficacy but specifically advanced cardiovascular physiology in a patient with high risk cardiovascular disease specifically uh type 1 diabetes.

And why this was so unique addressing this question is that it was a very controlled scenario where things like body weight um confirmed by Adexa which is one of the gold standard techniques for body composition physical activity calories medication over that 10-year window were all controlled. Um there's also confirmed elevation of ketone bodies. So which means that they were following the ketogenic diet. There was no concern about whether they were adhering it to it or not. And removing all these confounders like body composition, physical activity, and calories allowed us to actually assess the key question of if you just shift lowering carbs and elevating fat. Um, what are the long-term implications on safety, things like efficacy, how effective it is, but also long-term cardiovascular disease risk?

Because when we did this intervention over a 10-year period, this high-risisk cardiovascular disease where you have high and variable glucose levels, insulin resistance, we saw that glucose levels normalized over that 10-ear period in a disease where 99% of patients will never see glucose normalization. Okay, that's huge. Okay, average blood sugar levels was right where normal blood sugar levels would be uh for the average individual. Okay, but the concern was that in this scenario over the 10-ear period, LDL levels doubled. Okay.

And so not only do we see an elevation of LDL, um we also saw in concert with that that there was this shift from small dense LDL to large dense LDL. So um consistent with pattern A. But we also know the elevation LL also increases APOB B um LDL uh particle number and consistent um but this is all consistent with elevated LL. We expect those things. But we also saw that like uh LP little a small uh LDLP LDL size um and various other metrics were all within the target range. So the only major thing that changed was this doubling of LDL consistent with that was the elevation B and uh LDL particle number.

So for the average person listening that's like, "Why do I care about that?" Well, those metrics have consistently been associated with cardiovascular events, and we have really no long-term data looking at the cardiovascular effects of these diets because we see all these remarkable medicinal benefits, but it often elevates LDL in patients sometimes to astronomical levels, um, in certain scenarios, although that's very rare. And in those scenarios, the concern is, "Well, I'm seeing all these health benefits and like these various biomarkers, my weight, my blood pressure, my triglycerides, my glycemic control, they all improved."

And we know that if you actually look at these conditions like diabetes, we know that HBA1C or glycemic control is by far the leading risk factor. Okay, so you obvious obviously want to control that. Um we know that triglyceride or sorry blood pressure is the next leading risk factor. And so which is a primary risk factor for cardiovascular disease for for anyone really. Um so that's obviously very important. We know that triglycerides oftent times are a surrogate measure of overall metabolic health status or insulin resistance. Um, and that's a a third modifiable risk factor. Um, we know things like resting heart rate, a measure of overall fitness. These are all key modifiable risk factors in a hierarchal fashion that we see in diseases like diabetes. Um, but we also know that LDL is a risk factor for most of these conditions, but the risk is so much lower than the other things I described.

So, in that context, we have all these potential health benefits that can happen from this dietary strategy. That the one trade-off, like with any medication, there's always some potential trade-off, and that trade-off is that we see people see an elevation in LDL. But in order to address whether that would actually have implications on things like cardiovascular disease, we actually in our analysis did an advanced cardiovascular assessment after someone followed a ketogenic diet, normalized glucose and insulin level, which is the byproduct we often see from a successfully managed uh ketogenic diet in context of high cardiovascular disease like type 1 diabetes. And then we assessed their cardiovascular uh health.

And we saw when we looked at more advanced measures of cardiovascular disease, not just the end product of cardiovascular disease. We wanted to look early on. Do we see these early changes in things like how stiff the arteries are? Are the arteries uh able to adjust to higher pressure levels, what we call endothelial function? We looked at all these things um and they're all early predictors of aththeroscerosis. And when we looked at this, we saw that something called central arterial stiffness, so the stiffness of the arteries through the central part of the body, which is the most critical obviously for cardiovascular disease because they're near the heart, was what we call in the lowest quartortile for adults with type 1 diabetes, but was actually similar to individuals without type 1 diabetes. So these individuals are super high risk cardiovascular disease. They're at 10-fold higher risk. But while doing a diet, the ketogenic diet, and despite having an elevation of uh LDL, doubling of it over a 10-year period, they did not see any indications of worsening arterial stiffness. Again, early early signs of cardiovascular disease. Okay?

And not only was it way better than the average person with type 1 diabetes, it was equivalent to individuals who didn't even have the disease at all. That's kind of a huge finding. We also saw that again, the second most important modifiable risk factor for cardiovascular disease in this context, blood pressure, was normalized. Okay, no signs of any form of hypertension. Uh again within the top 18 percentile um with all individuals of type 1 diabetes and totally normal levels of blood pressure.

When looking at things like endothelial function, people often think about this as the inner part of the uh blood vessel wall and how it adjusts to these pressures um that come with high levels of stress or exercise or high blood pressure. When looking at this, we saw that endothelial function was not only better than people with type 1 diabetes, it was better than people even without type 1 diabetes. Okay, this is actually the case for a number of uh uh cardiovascular markers of the the blood vessel and also the heart. We saw that there was no signs of of left ventricular dysfunction which is an early sign or metric that we see change in type 1 diabetes.

And so what we observed was that when individuals even in a high-risisk cardiovascular disease, 10-fold higher risk for cardiovascular disease, we see changes in things like uh blood vessel stiffening uh reduced ability for the blood vessels to change and respond to elevated pressures or stress. We see this within children with this disease, but this individual had type 1 diabetes for over a decade, had been on the ketogenic diet for 10 years, a doubling of LDL, and we saw that they showed no signs of cardiovascular dysfunction. In fact, they showed signs of cardiovascular health that were often better than people without type 1 diabetes in the general population.

So at least lends some piece of evidence that we really need to reconsider how we view singularly the elevation of LDL. Um it's obviously a much more complex and nuanced conversation when it comes to cardiovascular risk. And within the context of these ketogenic diets, the elevation in LDL is almost certainly a byproduct of elevated uh saturated fat intake. It's not an elevation that arises simply because of adverse metabolic health internally. It's a byproduct of the nutrient uh that are being consumed. And so we know that elevated saturated fat intake is not inherently linked to heart disease. This is something that's been a high high level of controversy over the years. But high levels of saturated fat increase LDL. This is where you get to this kind of crux of whether there is a relationship between LDL and cardiovascular disease specifically through the elevation of saturated fat which is what happens in the ketogenic diet.

So obviously it's not as clear-cut as we think it is uh at this stage and there's some investigations that are trying to lend answers to this question but they're far from complete but our analysis over a 10-year period is the longest ever done giving some initial insight into even in a high-risisk cardiovascular disease setting if you control the most important risk biomarkers for cardiovascular disease in this environment despite having 10-fold higher risk for cardiovascular disease in the form of diabetes that even despite a doubling of LDL Well, that the therapeutic benefits across all of the biomarkers led to a remarkable level of cardiovascular health that often exceeded individuals who never had diabetes at all. And that's in my opinion a very interesting and remarkable finding that requires a lot more interest and investigation to explore uh why is that the case? Because it seems a lot more complex than than a simple elevation in a singular biioarker uh and understanding the long-term implications. Things like these powerful therapeutic strategies have been around for over 200 years like a ketogenic diet could have on long-term cardiovascular health.

>> I think that if somebody were to take that and take it to to the doctor that would really help that conversation because I think most people when they do this they're really scared about what their blood markers show and changes that occur which you just spoke about. But we understand that the long-term changes are quite uh beneficial in terms of cardiovascular outcomes. Heart attacks and strokes, dementia, and the things that we really care about. LDL is not to say that it's not important, but as you said, there's other markers that are more important, including HBA1C and your blood glucose.

Let's play a bit of a game. I'm going to ask you a question. You tell me yes or no. Do you think that quitting carbs can help you burn fat?

>> Oh, absolutely.

>> Do you think that quitting carbs can help you reverse insulin resistance? For most people. Absolutely.

>> Cancing carbs increase your sex drive. Oh, absolutely. If it's a fixing uh weight and other issues, 100%. If it's it's going to improve those things just like uh yes, I'll just say it. Yes, it can for individuals if it helps them lose weight, get to normal body uh functions and now they're consuming u fat intake sufficient to support uh adequate hormonal function. And I can tell you even when I was younger and I consumed a higher carbohydrate, very very lowfat style of eating for bodybuilding, that was what was recommended. The second I increased my fat intake and went to a ketogenic diet, my testosterone skyrocketed and I could feel a skyrocket. So, um, everyone may be a little different there, but I'm going to give that a short answer yes to the thing you said.

>> Okay. What if somebody comes to this and they say, "Dr. Knick, I bloody love carbohydrates. I love bread. I cannot give up bread." What should they do?

>> Um, you make bread through almond flour, okay? Or coconut flour. You can you can make bread that doesn't have to spike your glucose and insulin through the roof. Um, and I think that's an important thing that people learn when they do these diets is when they actually have to learn to remaster foods that are just traditionally thrown at them uh throughout their their most of their adult life. Um, when they no longer accept that they have to eat those foods and they realize, "Hey, I want to I want to eat bread. What do I do?" Okay, maybe I'll make it with almond flour and coconut flour. Now I understand that I can do it with almond flour, not coconut flour. So it's not going to have the grains or the spike in blood sugar and has insulin, but maybe I want to have some sweetness or some savoriness. Okay, you can add salt for savoriness. You can add alulose, monk fruit, uh stevia for for sweetness if you wanted to, and it's not going to spike your glucose and insulin levels.

The same thing applies to things like ketchup, okay? If you're going to go eat, this is just very common examples, but this applies universally. If you look at the back of a ketchup label, most ketchups are made with high fructose corn syrup and tomato paste, maybe some spices. Okay? You can remake ketchup at home by just simply taking tomato paste, adding a little bit of liquid to it, and adding something like stevia, alulose, or monk fruit, and just adding the little bit of spices that are typically added to ketchup to give it that flavor. And now you have the same exact flavor of ketchup with virtually zero calories.

So imagine instead of having ketchup and feeling like a terrible person for consuming it, you just make your own and realize that you can remaster nearly every food that's out out there in a healthier format by just paying attention and focusing on reducing the negative impacts of things like sugar, elevated spikes in blood sugar, um, and the resulting elevation in insulin. And I think that this is a incredibly important lesson for most people to understand how to do that because it puts all the power back on you. It gives you the power to understand that, "I don't if I ever want to eat normal foods again, I have to break my diet." No, you don't. That's false. You need to learn how to make the foods you once enjoyed healthier. Because in reality, if the only way to enjoy it is to have something unhealthy, then maybe you shouldn't have it at all. But if you want to retain health and enjoy some of the same foods you had before, this is an educational process that isn't overnight. But with all these advanced tools we talked about before, like AI and otherwise, you can rapidly learn to recreate recipes that you once enjoyed.

Okay. For me, there's pizza. Do I know how to make a low carbohydrate pizza now? Yes. Okay. If for I don't really like cake that much, but uh my wife really loves to do something special and I say, "Okay, well go to, you know, one of these websites that makes uh ketogenic recipes and go for it." And they're amazing. They taste absolutely amazing and they don't spike blood sugar levels. I don't do it because, you know, they're basically like keto candy, right? Like uh it it's you still want to eat healthy. Doesn't mean you should be eating cake every single day, even if it's ketogenic or not. But you can still have virtually all the same foods you enjoyed before and make them healthier by just paying attention and putting in some education and knowledge into yourself, using all the tools we have available to us to expedite that process and start a completely new journey of understanding how to eat healthy and not give up all the things you enjoyed when you did eat the way you did before.

What a great answer, Dr. Knutnick. I love that. I think people can they have options. You're not just bound to meat, seafood, and eggs and vegetables for the rest of your life. It's really important. Dr. Kick, thank you so much for your time. I'm leaving all the links for your studies in the description and your social media because your work is so important to understand that you can have a life of carbs and disease or you can lower the carbs and reclaim your life. Dr. Knick, thank you so much for your time.

>> Appreciate it.

>> I hope you enjoyed this episode. Check out this one with Dr. Eric Berg. It is all about how to fix visceral fat and lose weight for good. [music] I'll see you next week.