Facebook Live: The Power of Ketosis — Why, How, and Everything In Between

In this Facebook Live, Apollo Health’s Chief Science Officer, Dr. Dale Bredesen, and Chief Health Liaison Julie Gregory discuss ketosis, a process whereby your body burns fat and produces ketones as an alternate fuel source for your brain. Researchers have found that a neural fuel deficiency precedes and accompanies Alzheimer’s disease and ketones can help fill this energy gap. Julie G. shares her personal experience with ketosis and how it helped to heal her underlying insulin resistance and achieve metabolic flexibility — the ability to burn both glucose and fat as fuel. 

We’ve included a complete recording of the session and a full transcript below for your convenience.

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Transcript:

Dr. Dale Bredesen: Hi everybody, I hope everyone is staying safe and well. Here today with Julie G, Julie, welcome.

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– Hi, thank you for having me.

– Thanks for being here. So many people talk about ketosis, what is it, why is it important? Is it really an important part of dealing with cognitive decline? Is it important for prevention and reversal? You know, how best to do it, does it mean I’m going to eat a bunch of bacon? And what is a ketone, how do I measure it, do I care about measuring it? There are just so, so many issues, and of course, we’ve heard all sorts of different things about ketosis and different types, is this about eating more meat, is it about eating vegetables, how can you possibly do it? So we thought it would be really helpful to talk about everything from the basic biochemistry, why is this important, why do we think it’s so important? And why, in fact, we’ve even seen the people who have done the best with reversing their cognitive decline typically do get into some degree of ketosis, which is why we recommend it and why we’re so supportive of this. And so let’s just start with the basics of ketones, why do you want them and what are they? These are products of fat breakdown, and the ketones are actually typically synthesized by your liver, and what it’s really trying to do is simply to get something, it’s basically saying, I want to get energy to other parts of the body in the form of acetyl-CoA, so a specific molecule, but there’s no simple way to send that out, so what they do is package these as ketones which then can be shipped to the right places and then turned back into the energy, and it’s a nice way to get energy for brain and muscles and all over the body. But they are particularly important for cognition because, as we find and has been talked about in many different ways by different people, there is a critical shortage, so when you have cognitive decline or risk for cognitive decline, you can actually measure on a PET scan, you can look at the utilization of glucose by your brain, and the characteristic of both Alzheimer’s and pre-Alzheimer’s, and as Julie has pointed out, even in people who are ApoE4 positive, even sometimes into your 20s, you see a change that looks like an L, you see a reduction in utilization in the temporal lobe and the parietal lobe, and that is the hallmark of Alzheimer’s and pre-Alzheimer’s. So we want to be able to bridge that gap, and as Dr. Stephen Cunnane has pointed out and Julie has quoted many times, you can bridge that gap, that energetic gap, with ketones. And there are mainly three ketones, there’s one called acetoacetate which is the one that people measure if you’re measuring in urine, there’s acetone which you’re measuring if you measure in the breath, and there’s beta-hydroxybutyrate which is the one we measure in the blood, and so these are all part of breakdown of fats, and the good news is that your mitochondria in your neurons can use these in your brain to bridge that gap. So when we see patients who have cognitive decline, even early cognitive decline, I consider that an emergency, these are people who don’t have enough support for their brain. So one of the first things we want to, yes, we want to deal with the inflammation, we want to deal with leaky gut and things like that, but one of the very first things is we want to get that energy. And so maybe, Julie, you’ve been through so much of this yourself, tell us a little bit about what happened when you first drove yourself into ketosis, and did you start with exogenous ketosis or endogenous ketosis?

– I wish I knew about ketosis when I was experiencing cognitive decline. As you know, I didn’t have the luxury of your work, so I was sort of figuring things out for myself, but I very slowly made the transition from a sort of healthy version of the standard American diet to eating whole foods, primarily vegetables, clean proteins and generous amounts of healthy fat, but I would say my transition to getting into ketosis actually took months, but once I finally achieved it by using Cronometer and actually measuring my macronutrient ratios, the cognitive clarity that I received was astounding. And on top of that, my entire adult life preceding that period, I’d been on a glucose rollercoaster, I would have the highs followed by the lows, and when I had the lows, which I had very dramatic lows, I would have a huge decline in my cognition and my overall energy, I would become shaky and sweaty and I’d have to eat again and I was just on this rollercoaster, and once I learned how to get into ketosis, I now am bio-energetically stable throughout the day, and I have this wonderful sense of cognitive clarity.

– It’s a really good point because there are several features to this and one of them is, for those of us who have been on a standard American diet for many years, we’re burning glucose, so as you pointed out, we can now get hypoglycemic, and for people who follow their CGM, they can follow with continuous glucose monitoring, you can actually see when you go to sleep at night sometimes you plummet, and people will wake up in the middle of the night not realizing it and then they find out, well, my glucose was 45, I really dropped it down, whereas if you have …

– That used to happen to me, I would wake up in the middle of the night and have to eat a snack, I mean, how ridiculous is that? My blood glucose was so unstable.

– Right. And then you pointed out the other piece of this which is that when you’re first starting, you actually, your body is not very good at burning ketones, it’s so used to burning the glucose, so it’s hard to get into ketosis. And as Aida always points out, you’ve got to get, that insulin sensitivity and the ketosis often go together so that you’re now able to burn both, and as you pointed out, in the long run you want to have that flexibility. So now your brain can do, it can go back and forth, so it’s almost like if you’ve got, you know, for houses that have backup power, when your power goes out, boom, you just turn on the backup and no problem, you just continue, but those of us who are not able to burn ketones initially, we’re like the houses where the power goes out, there’s no backup, so suddenly things are not good, you’re not thinking as well, you’re not powered as well, so we want to be able to go back and forth between the glucose and the ketones, and that means not staying with high-carb diet all the time. So then people will often say, “Well, look, I want to get into ketosis, I’m just going to eat a bunch of meat”, okay, which is fine if you’re interested in meat but it’s not the best way to improve your brain, and so, as we find again and again and again, a mildly ketonic, plant-rich, high good fats diet is what’s been published again and again to give best outcomes for people with cognitive decline, and Julie, I think you were really instrumental in getting people to be more interested in a plant-rich ketogenic diet vs. a meat-rich ketogenic diet. So tell us a little bit about your diet, I know you typically do include some fish and some meat and some eggs and things like that, talk a little bit about what you do to stay in ketosis and then we’ll talk about the cycling in and out, which is yet another facet of this.

– Sure, so at this point in my recovery, I generally eat once a day and it’s sort of a feast, it’s a long, extended, relaxed meal with maybe some leftovers or some dessert afterwards, but I use a long daily fast plus exercise to get into ketosis. And when I do eat, my diet is KetoFLEX 12/3, heavily plant-based, whole food, nutrient-dense, I emphasize non-starchy vegetables, organic, local, seasonal, from every color of the rainbow, with an adequate amount of protein which is important, because our body cannot create the protein it needs and will cannibalize muscles if it doesn’t have enough, but it’s really a relatively small amount of protein, so a piece of fish or a grass-fed steak or something, a small amount of protein, and then generous amounts of healthy fat. So in many ways, it’s almost like I do a pescatarian Mediterranean diet without grains, essentially.

– Yeah, that’s a very good point. Now some people will say, “I am already overly thin, and when I tried to get on this KetoFLEX 12/3, I lost weight”, as many people do when they get on a more ketogenic diet, “So how am I going to deal with that and how am I going to keep my weight on and yet still be ketogenic?”.

– Right, it is a relatively common problem, and the reason this happens for many people is that at the very beginning of the diet we ask you to give up certain foods. We ask you to stop eating sugar in all forms, we ask you to stop eating all simple carbohydrates, so this is cakes, muffins, cookies, pretzels, chips, pasta, bread, bagels, we ask you to give up grains, and we ask you to give up dairy, conventional dairy, and we ask you to do this because all of these are inflammatory foods, and when you layer inflammatory foods on someone who’s already insulin resistant and you increase healthy fats, you’re setting the stage for vascular disease, which is not what we want to do. So a lot of these people who lose too much weight, they give up all the bad foods and they increase their intake of non-starchy vegetables, but they’re very hesitant to increase the healthy fat. They are fearful of increasing the healthy fat. The low-fat dogma and the concern about cholesterol is so driven into our brains from decades of hearing this from our physicians, in the medical literature, that people are hesitant to use enough healthy fats. So by and large the people that are losing too much weight, they gave up all the bad food, which is fabulous, but they’re not eating enough healthy fat, and sometimes they’re not eating enough protein, so if you’re underweight, that’s a subset of people that we actually want to eat a little extra protein.

– That’s a very good point.

– Yeah.

– Yeah, and of course, a lot of people, this is, in part, because they have some degree of malabsorption, and so you may, especially if you’re over 45, you may consider looking into some digestive enzymes, that can be helpful for people, you might also find out if you have a leaky gut or if you have microbiome changes that are associated with poor absorption. So for many of us, as we get a little older, we have lesser absorption, we may have an issue with our gastric pH, so we may not be getting enough acid there, so there are several ways that you may actually be not getting the appropriate absorption, and if you were just getting the absorption from the food that you were eating, you’d actually be doing much, much better. So then, people will often say then, “Okay, you’ve asked me to give up a number of things here, and now you’re telling me to eat fats, things like avocado and you’re having oil on your salad and fatty fish and things like that, now, well, you know, if I’m going to do that, isn’t that going to destroy my lipid profile? Isn’t my cholesterol going to go sky high?”. Now interestingly, so, you know, you are an ApoE 4/4, as you’ve pointed out many times, it’s a big issue in terms of lipids, and actually, your lipids have done very, very well on this high-fat diet. Talk a little bit about that, if you will.

– Well, I think what I’ve experienced is true for many ApoE4 carriers, we do tend to hyper-absorb dietary fat, but if we prioritize the monounsaturated and polyunsaturated fats from primarily whole food sources, as you mentioned, avocados, nuts, seeds, fatty fish, high polyphenol extra virgin olive oil, we tend to have pretty good lipid profiles, high HDL, low triglycerides, and as long as we don’t go crazy with saturated fat, most of us don’t have sky-high LDL. And I know that some people do, and in that case I think it’s very important to do advanced lipid testing, to check small dense LDL, oxidized LDL, even to do a low radiation calcium scan to get a baseline to see what’s happening inside of your coronary arteries.

– Yeah, absolutely, that’s a good point. And then what about checking, of course, a lot of people will say, “Well, okay, I’m trying to get into ketosis but I don’t really know whether I’m there yet and where it goes”, so let’s talk for a minute about blood testing versus breath testing, so I know you’ve done both. If you do blood testing, what instruments do you typically use for blood testing and what do you typically target?

– Right, so I’m glad you brought this up and I actually want to take a step backwards, because our step one is giving up the bad foods, but step two really is getting a baseline fasting glucose. So we actually want people to start by testing their glucose, and the two systems that we like are the Abbott Precision Xtra, which is the dual glucose/ketone meter, or the Keto-Mojo, and so both of those are terrific. We want the fasting morning glucose, we want you to check that before coffee, tea or supplements, so after you wake up, you know, within the first 30 minutes or hour, check your fasting glucose, and we want that fasting reading to be between the range of 70 to 90 mg/dL, consistently for a few weeks, before you start measuring your ketones. Because our initial goal is to get into endogenous ketosis, so we want our bodies to create natural ketones, endo, the prefix, means coming from inside, and we do this by combining KetoFLEX 12/3 with the long daily fast, and then daily exercise. And so once we’ve reliably reached our glucose goal, then we can begin testing our ketones, and I prefer to do it with finger sticks, so I use the Precision Xtra, and your fasting morning goal is going to be anything above 0.5mM. Then we want you to test again before you break your fast, and at that point or sometime during the day we want you to get as high as 1.0 to 1.5mM, and some people find they need higher levels for that cognitive clarity, most people do fine within that specific range. I also have used BIOSENSE which is measuring breath acetone, which they refer to as a unit of measure called ACEs, and when you’re using BIOSENSE, you want to measure at least three to five times a day, so you want to get that fasting morning reading, you also want to measure before you eat each meal and then again at night. It’s that area under the curve that comes from three to five measurements per day that has a correlation with beta-hydroxybutyrate of about 80%. If you’re used to BHB, the finger stick measurements, it’s also important to know that there’s a lag time, so your acetone’s going to lag behind about 30 minutes to two hours, and if you’re used to BHB, I think ACEs of like 8 to 10 is pretty close to 1.0mM, but it’s not that one reading that you’re chasing, it’s accumulated over the end of the day, and you want that to be above 120.

– Yeah, and I should add that, again, for people who actually have some degree of cognitive decline or are dealing with cognitive decline, at the beginning, it’s fine to use some exogenous ketones, we want to bridge that gap, but as Julie’s saying, over time there are some advantages to getting into endogenous ketosis. So okay, so you’ve now talked about measuring these, as you say, starting with the glucose, getting into the ketosis, do you notice difference and do people report differences to you when they are in and out? Do they notice differences when they’re out of ketosis versus when they’re in? And I know you noticed at the beginning that there was this degree of clarity, and I think, you know, for many of us, just the fasting, we noticed sometimes a degree of additional clarity that can be lost, I mean, let’s face it, we all know when you have this major repast and then you kind of pass out and just, you know, sleep after a huge Thanksgiving dinner or something like that, you know, we’re all a little less aware of things, so I think everyone is recognizing that, but the opposite is true that you do fasting and you do get that sharpness, which we want to use, and to some extent this is because you are burning those ketones. So let’s then talk a little bit about people getting into this and then, are there side effects, do people say, “Well look, this could hurt me if I do the wrong things”? I know we’ve had, there are occasional people who will report a kidney stone, that’s been relatively uncommon. The studies that have been done to suggest kidney stones have mostly been done with the people who are on very high levels for seizures, and, but no question, there is an issue with the keto flu, there is an issue, which is a transient thing, there is an issue with people getting on ketosis and getting a little bit dehydrated. So Julie, what do you recommend to people who are just starting out on ketosis?

– Well, really for people who are starting out, I think the keto flu is one of the, you know, most common symptoms that people do suffer, and as you mentioned, it’s caused by dehydration, so adequate hydration is so important. Increase your intake of sea salt, that provides minerals and electrolytes, while you’re increasing your intake of water. When you give up all this processed food, your sodium intake drops dramatically, and then when your glycogen stores deplete, your kidneys are dumping all this water, so that’s how the dehydration occurs. The dehydration is also driving kidney stones, although they’re very rare, staying adequately hydrated, once again, can help with that side effect as well.

– Absolutely. And then I know that some people will say, “Hey, you’re talking about high-fat diets, this is a problem”. We’re not talking about, as you said a few minutes ago, we’re not talking about high saturated fats, we’re talking about monounsaturated fats and we’re talking about polyunsaturated fats, and I know you and I discussed this a few years ago, when people actually will take some MCT oil, you know, that is a saturated fat, and so some people would suggest that if you’re ApoE4 positive, then you should use instead some exogenous ketones like ketone salts or ketone esters, and, you know, you can go by your LDL particle number, if you’re still in that 800 to 1,200 sweet spot, you don’t need to worry so much, if you’re sitting up at 1,500 or 2,000 or something like that, then you probably want, you do probably want to stay away from the MCT oil. And again, saturated fats, particularly bad if you have high carbohydrates and if you have no fiber, so what we’re talking about is a high-fiber diet. So Julie, are there other things you want to emphasize before we go and take a few of the questions?

– Yeah, let’s talk a little bit about exogenous ketone supplements, and as you mentioned, you know, when you come to the program and you’re insulin resistant, you’re experiencing cognitive decline, it is a crisis, and if you’re insulin resistant, lots of people have trouble extending that fast, they become hypoglycemic, like I did, and that’s a perfectly appropriate time when you would use an exogenous ketone supplement. And as you mentioned, MCT oil or coconut oil is great if you don’t have lipid issues, and for those folks, you want to start with a low dose, you want to do less than a teaspoon about three times a day in divided doses, so it’s going to supply you energy but it’s going to peak and then fall, the same as glucose, that’s why you need three divided doses throughout the day. You want to work up to around a tablespoon a day, for both MCT and for coconut oil, and if you do have the lipid issues and you decide to go with ketone salts or ketone esters, you know, follow the manufacturer’s label recommendations, I know they’re all different, but start with a very low dose before you work up to what they consider a normal dose, because, I don’t know if you’ve experimented with any of these things, I have and I’ve had some crazy experiences. The first time I did MCT, I stupidly took a tablespoon and I like started shaking and I felt like I had to climb a mountain or run a marathon, I had so much energy, so you want to avoid that. So even when using ketone salts and esters, use a very small amount, let your body get used to it and work up to the recommended dosage, and once again, you’re going to need to take that in three divided doses throughout the day, while healing from insulin resistance and trying to create your own endogenous ketones, and we really would prefer that people use ketone supplements on a transitional basis.

– Yeah, this is a really good point and, you know, this brings up an important part of the consideration for treatment. So when you have cognitive decline, there are people, we talked about earlier, where energetics are the thing that are really limiting you, but there are other people, so there are people where it can be vascular or people where it can be more about getting the ketones, getting the combustible substrates there, so you have to, again, kind of be aware of this because if you have vascular disease, now you’re trying to increase your support with ketones, but if you’re now enhancing the vascular disease with MCT oil or if you’re actually making things worse with your vascular status, then that’s not going to help. On the other hand, if your vessels are good and you’re delivering this and it’s a matter of getting the ketones there, then the MCT oil will be fine, so again, you have to kind of figure out where do you stand here and make sure that you have a good vascular status. So there are some wonderful questions here, let’s start with Deirdre who’s asking, “What about getting enough soluble fiber for someone who has slow motilities?”. So absolutely, and this comes up all the time, fiber is one of the most important things because look at all the great things it does for you. So it does improve your motility, you know, it does address your microbiome, it does improve your glycemic load, it does improve your lipid profile, it does improve your detoxification, so I mean, if you wanted to go out and find something good for cognition, you’d probably find, you know, to develop fiber, it’s one of the best things. And so absolutely, KetoFLEX 12/3 is very high in fiber, we’ve talked before about the fact that, you know, in ancient times, people were probably getting something like 100 grams a day, now people are getting 5 or 10 grams a day, we like people to push up above 30 if they can. And again, you mentioned the Cronometer, it’s a simple, free way to follow where you stand and find out how much fiber you’re getting each day, so absolutely a good thing, and when you track yourself, Julie, how much fiber are you typically getting per day?

– I’m getting, I would say, certainly between 25 and 50 milligrams a day, it’s very easy to do. Although the diet is high in fat, when you look at the plate, it’s 3/4 vegetables, and you eat non-starchy vegetables, so there’s tons of fiber on your plate. So, you know, fat is very calorically dense, and it’s really hidden in the plate because it’s in the form of olive oil, you know, so we use it to season and to finish everything.

– Absolutely, and then, of course, some people will bump up their fiber even further with things like psyllium husk or konjac root or inulin and other things like that. So Laura asks, “What about lower T3 conversion with very low-carb diets, is there a concern for thyroid?”. And certainly there are changes, we’ve talked before about thyroid sensitivity, when you’re doing the right things, in fact, often you get more sensitivity to thyroid itself. So Julie, have you had any issues in terms of thyroid, in terms of T3, T4 is a T3 conversion, which definitely occurs for many of us as we get a little older, the conversion from T4 to T3 can change.

– Yeah, I’m sub-clinically hypothyroid that I’m treating with a very low dose of medication, and we do see this with a lot of people that are using our approach. Is it pathological? I don’t think so, I think our engines are just revving at a lower level, but that being said, it is a trophic support, and it needs to be addressed, which is why I’m doing a small amount of medication. The other thing that we should mention is that we recommend sea salt, which doesn’t have the iodine, so it’s important to get enough iodine in your diet, which you can get through seafood and through sea vegetables, so I sprinkle sea vegetables on my vegetables when I cook them and things like that.

– Absolutely. Yeah, and, you know, you can check to see, it’s not just about the thyroid number because it’s really a part of the thyroid function, so you can either go by your symptoms, if you like the room much warmer than everyone else, you probably are a little hypothyroid, but also you can check with a Thyroflex, that’s another way to look, a very quantitative way to look at how well your thyroid is functioning. So it’s not just about the number, it’s also about the function itself. So Donna says, “I hate seafood”. So that’s no problem, Donna, so we talked before, pastured chicken is one way to go, you know, grass-fed beef, and of course, some people just like to be vegetarian, that’s okay, too, as long as you’re getting the appropriate nutrients to get optimal cognitive function. So no problem if you hate seafood, and you know-

– But I would encourage Donna to supplement the Omega-3s, whether it’s with algal oil or with other DHA supplements, it’s very important, and to measure your Omega-3 index, which we want to be somewhere over 8 to 10%, and for ApoE4 carriers, over 10%, so it’s okay not to do it with food but make sure you’re doing it with supplements then.

– Absolutely, and you can also look at your Omega-6 to Omega-3 ratio, and, you know, we’d like to see it down between 1 and 4. If you’re up at 10 to 15, which is typical for American diet, that’s too much Omega-6 and not enough Omega-3, so we want to supplement that and look. So yeah, as Julie says, if you’re not interested in seafood, just make sure that you’re getting appropriate amounts of these things, that includes things like choline and includes things like Omega-3s. Now Donna says, “If you’re ApoE4, how can saturated fat be good?”. Yeah, so we’re not recommending saturated fat, we’re recommending the monounsaturates and polyunsaturates. Di says, “Love your work”, thank you, thank you, Di, for that, “My mother died of MCI ApoE4 zero copy”, okay, and if it’s zero copy from your mother and your father then you’re absolutely right, this means that your four sisters will not have any ApoE4, so because you have to get it from your mother or your father. However, since she did have MCI, then the critical piece is why? And so there are some people who are ApoE4 negative but there are other genes that are involved, Trem2 is another one that you can evaluate, there are about 32 different genes that all can contribute, ApoE4 just happens to be the most common one. And then there are people who are particularly poor at detoxing, so people who have null alleles in their glutathione, GPX or GST, so that’s another one, so the fact that this was in the family, you’ve already shown it’s not ApoE4 related but there’s something out there, so therefore I would recommend, please, for everyone, get on active prevention so that you can end this with your mother’s generation, that’s the key. All right, and then Barbara asks, “I was on a second day fast, all of a sudden my blood sugar level dropped to 64 and started shaking”. Absolutely, so this is such a good point, and this is, again, why you’ve got to be careful. And I know, Julie, one of the things that you used to do a few years ago was actually to have some MCT that you could take when you essentially felt that you needed to do this. Now I know you really don’t need that anymore, but at the time that was something that you used, and yes, if your blood sugar is dropping, what it’s saying is that you’re not able now to come back with this, you’re not able to produce the needed ketones to keep yourself metabolically flexible, it shouldn’t be dropping down, especially into the 40s and 50s, which we see sometimes. So yes, you know, you want to get yourself out, at least short-term, and then you’re going to ease this and you’re going to make it so that it’s much smoother when you try this in the future with a higher fat diet, and that’s, again, one of the good things about here, you should not be getting hypoglycemic, but it’s a very common thing to happen when you’re not used to this, and you’ve got these, and I know, Julie, as you pointed out, you’ve had some very significant hypoglycemic episodes in the past.

– Definitely, yeah, I still can get some really low numbers, but I don’t have the symptoms anymore, but I’m sorry that that happened to Donna and it is scary when it does happen, that’s certainly a sign that it’s time to end the fast. And you know, it’s also a good time for us to talk about, you know, we don’t really recommend those long extended fasts to our group, because we’re actually doing this on a daily basis. So we’re depleting glycogen stores every day, we’re getting into ketosis every day, and I think a lot of people that recommend these long extended fasts, it’s in between the standard American diet, so they’re doing the standard American diet for a few weeks and then they do the long extended fast, I’m not sure that it’s actually necessary with our program and it might represent an additional strain that the body doesn’t need.

– Yeah, that’s a good point. So for Barbara, yeah, hopefully you then dealt with that, with that hypoglycemia-

– Oh, I’m sorry, Barbara, I said Donna, sorry.

– That was, yeah, Donna, I think, was the one who doesn’t like seafood, so.

– Sorry.

– As many people don’t. All right, Gloria says, “I’m very underweight, type 1 diabetic, I do you have trouble staying off some gluten-free bread, some rice, taking insulin when necessary, I have a great diet when I’m on a healthy keto diet”, great, “My brain is sharp, I have energy, but as you said, I have trouble keeping on the weight, 85 to 90 pounds eating grains but can go down to 82 pounds”, wow, yeah. So yeah, we need to make sure you have got more, you know, more energy here and more volume, we’re going to have to get some more calories for you, presumably through the fats and some protein. “So how much protein and good fat should I be eating? I love veggies, avocado, chicken, olive oil, also being diabetic, when I’m keto my blood glucose is great, very stable.” So great point, and actually, you know, making it so that you’re not pushing because you’re not able to make that insulin, so that you’re not pushing it so hard is going to be fantastic, you’re putting less stress and strain on the pancreas which is already not able to make that insulin. So yeah, we’re typically looking at, and we talked about this, Julie talked about this in the book, “The End of Alzheimer’s Program”, somewhere around 70% calories from fats, and then adequate protein, which is typically coming in around 15% or so, we’re looking at something like one, if you’re one gram per kilogram. If you are in the middle of, you know, if you’ve got a lot of toxicity going on you may need more, if you’re working out with weights you may need more, if you’re a little older you may need more, for any of those things. But Julie, I know you followed yourself, as you said, on Cronometer, but what are you typically coming up with for fat percentage in terms of calories versus protein versus carbohydrates?

– That’s a great question because it actually changes over time, and I encourage everyone to get our book, “The End of Alzheimer’s Program”, in chapter 12 we actually walk you through the steps of how to figure out your ideal macronutrient ratios, and we go through the math of doing a 130-pound woman, who at the beginning, needed a high amount of dietary fat, and I think her macros worked out to be around 75% fat, I think 10% protein based on her body weight, and 15% in carbs. So it’s going to be a little different for everyone, you need to work out the math, but that’s wonderful that she’s a type 1 diabetic and doing so well, but being underweight also puts you at risk for cognitive decline, so just like we think this neural fuel insufficiency is a crisis, I think being underweight is a crisis as well. For someone like that I probably wouldn’t recommend the long daily fast, you can still fast three hours before bed but if you’re hungry in the morning, by all means, eat breakfast. Increase the healthy fat, avocados, nuts, seeds, food like that. Also, if you’re insulin sensitive, you can use resistant starches like colored potatoes, turnips, parsnips, legumes food like that as well, in small amounts.

– Yeah, that’s a great idea, and you know, she should probably be going to three meals a day instead of trying to do a long fast and you need to think about

– Agree, and increasing protein, when you’re underweight you’re going to want to do 1.1 to 1.2 grams per kilogram, and you’re going to want to base that not on your current weight but on your ideal body weight, so you increase the protein, we want the muscles strong and your weight stable.

– Yeah, very good point, you want to stay away from sarcopenia. All right, and then Karen says, “As Julie just said, ApoE4 fat hyper-absorber”, and she said, “I did the Boston Heart Diagnostics, plant sterols, lathosterol, desmosterol, beta-sitosterol and campesterol, presumably from the avocado, nuts and other health foods were all too high, so when it comes to keto and all the healthy fats concerned, this really stumped me”. So this is a good point. Now, have you done a Boston Heart, have you looked at those particular ones, and how did that look with your high-fat diet?

– Oh, my sterols were high as well, the plant sterols, but I wasn’t overly concerned because my overall profile was very good, and just as she mentioned they’re high because of the foods I was eating, I’m sure.

– Yeah, I mean having a high plan diet is not such a bad idea, again, and of course, people take plant sterols to reduce their lipids.

– And that’s not something we recommend for ApoE4 carriers, to do that as a supplement, you know, get it from actual vegetables instead.

– Right, and I think it’s worth pointing out that when people, we’ve seen this repeatedly, when people get on an appropriate diet, KetoFLEX 12/3, they’re doing the exercise, they’re doing these other things, what they find is they no, they typically no longer need antihypertensives, they typically no longer need anti-diabetic drugs, and of course, many groups are now pushing toward doing more of a ketogenic diet for people with type 2 diabetes, and then they find out that they no longer need their statins, so this is people are basically getting back to normal health, and just really showing us how much our current lifestyle and current diet is actually pushing us away from optimal health. And then Di asks, “Insulin sensitivity versus insulin resistance and versus prediabetes, can you put these in order?”, so this is a good point. So as we get exposed, so what happens is that, it does, there’s one thing at a time and we can start to measure these. The first change that you begin to see is if you do a glucose tolerance test, where you’ll take some glucose, you’ll have this huge response with insulin, and so that’s the beginning of insulin resistance, it’s because your insulin has been high because it’s responding to glucose, and now your cells have started to wind down their response to it. You can actually measure the molecular changes in a molecule called IRS1, which is downstream from the insulin receptor, so the insulin receptor signals through IRS1, and you start to see changes where it changes its phosphorylation pattern, essentially telling you, I’m turning off, you’ve got, it’s too high for too long, well, now you’re going to have to now exceed that. So we always make the analogy, you know, if you’ve got a child who’s playing the drums really loudly for years and you start wearing earmuffs and then your spouse comes home and puts on a Brahms lullaby, you’re not going to hear it, and this is what’s happening to people who are getting this insulin resistance. So you go from sensitivity, which is a good thing, to insulin resistance, which is a bad thing, and then typically that will predispose, that’s on your way to type 2 diabetes. Now what happens ultimately after having the high insulin, high end, and so for a while you’ll just see high insulin, your glucose will still be normal, but you’re working overtime to do that. Ultimately your pancreatic beta cells will give out and you cannot make that much, that’s when your glucose is starting to come up, so again, just as you see with Alzheimer’s disease, there is a long pre-symptomatic period, in this case, it’s where you’re putting out this excess insulin. So you are, about a hundred million Americans or so have some degree of insulin resistance, so we always look at HOMA-IR, which is the best way to measure this with simple clinical tests, you’re looking at a fasting glucose, you’re looking at a fasting insulin, and then you’re multiplying these and dividing by 405 and you can get an idea. As you’re drifting above 1.0, you’re getting up to 1.3, 4 or 5, even up to 2 and above, you’re really saying, you know, this is insulin resistance, so you should be down around 1.0 for your HOMA-IR. Kelly then asks, “Can you give an example of what to eat for breakfast, dinner, lunch?”, and I know, Julie, you’ve written about this extensively and you put this in the book very nicely about what you’re typically eating, but let’s talk about today, what did you have to eat today?

– I haven’t eaten today.

– Okay.

– It’s 4 o’clock this afternoon.

– What’s the plan?

– Yeah, I think I’m going to have some eggs and some broccoli and some sweet potatoes, and I’m looking forward to it. But at the beginning, when I did have two meals a day, I would have eggs for my first meal of the day, usually close to noon, and then my plate would be covered with all sorts of other non-starchy vegetables, high-polyphenol olive oil I like to put in a ramekin on my plate with sea salt and fresh herbs, and I dip every bite of my vegetables into that so I can get as much of this olive oil, I love the taste, and it’s so good for you. And then for dinner I’d have a piece of wild-caught salmon, let’s say, and a large salad full of non-starchy, colorful vegetables, maybe an avocado and a handful of nuts and that would be a typical day’s worth of food. But in the book we do go through this, and so, yeah, it’s a terrific question. At the beginning you may start out needing three meals a day, when you’re insulin resistant, and even snacks in between, but the goal is to try to get to two meals a day without snacks in between, I’m to the point where I do fine with one meal a day but that isn’t for everyone and it doesn’t have to be everyone’s ultimate goal, so if we can get to two meals a day, that’s wonderful.

– Yeah, fantastic. And then Di asks, “MCT and coconut oil, don’t they break the fast?”. So yes, and the usual point is that if you get to about 50 calories, you’ve broken your fast, if you’ve got something that’s just a couple of calories, probably not going to make a difference, but, of course, the other piece is, are you getting out of ketosis? So these things will, yes, they break the fast, but they don’t get you out of ketosis because you’re still burning fat in this case. And then Susie asks, “What’s your opinion of Bulletproof coffee, does it help to carry you through the morning, yet stay in ketosis?”. And certainly, Dave Asprey’s done a very nice job with his approach and using some MCT oil with that, and Julie, do you ever like to do coffee with oil? I know you like to have certain things that you put in your coffee, so tell us what you do for your coffee.

– So I take my coffee black and I use SweetLeaf stevia drops, and I’m obsessed with a specific flavor, and I’m trying to think, it’s a toffee flavor, it tastes like caramel, but it’s just one or two drops and it makes the coffee taste delicious. I choose not to do the MCT oil in the morning because I get into ketosis without it, and I would treat Bulletproof coffee with the same parameters that we talked about with exogenous ketone supplements, you know, transitionally it might be a good thing while you’re struggling. For people that are struggling to get into that fat burning mode, you do have a period of time where you’re uncomfortable, I mean, you’re hungry, and if you become hypoglycemic it’s time to break the fast and eat. But you check your blood glucose and if it’s still normal and you’re just uncomfortable, ride it through because within 30 minutes or so you’re going to be on the other side and you can actually measure it, it’s fascinating, you can measure your ketones and glucose and you can see when you get into ketosis and suddenly you feel stable. But for people that are having difficulty with that transitional period, the Bulletproof coffee might be great, or I’ve even done a MCT capsule, you know, that’s very low dose but it gets me over that bump if I feel uncomfortable.

– Yeah, because for sure, you do not want to allow yourself to get into hypoglycemia, that’s not good for your cognition as well. All right, and then let’s see here, Catherine is asking, “What about ketone esters, are they available and what about the quality?”. Yeah, great point, so ketone esters, ketone salts versus ketone esters, the ketone esters typically can get you a little higher levels of ketosis. The big problem with ketone esters has been that they taste horrible, and so for years people worked to make better and better tasting ones. This is why I tend to like something called KE1 because it’s a combination of ketone salts and ketone esters, it’s one way to go, but other people, some people who are into, you know, bicycle racing and things like that really want to pump theirs up, and so they like to use pure ketone esters, so again, you have to figure out what’s best for you. The ketone salts tend to taste much better, they don’t bump you up quite as high, which is, again, kind of why I like the combination. And as Julie pointed out, this is not going to last for too long, it’s going to be a few hours, and so if you’re going to do that in early stages where you want to get an exogenous ketosis you’re probably going to want to do that three times a day to stay into some significant ketosis, as you’re getting yourself then rolling into a more endogenous ketosis. And as far as, yeah, quality, there’s some very good ones out there and you can check things like KetoneAid and things like that have some very good ones. And then, let’s see, Kendra asks, “Will taking psyllium husk fiber supplements take you out of ketosis, would it be considered breaking your fast?”. Yeah, good point, and it should not, it has, you know, it’s very, very low calorically. You are feeding your gut bacteria, but you’re not going to change your ketosis level or you shouldn’t. And I don’t know, Julie, have you ever measured your ketones before and after taking psyllium husk?

– Well, yes, as a matter of fact, and I would take supplemental fiber like that in the evening and I still have no trouble getting into ketosis the very next morning, so it has no effect whatsoever. That being said, I probably wouldn’t do it in the morning during the fasting period, I probably would encourage Kendra to do it in the evening, it tends to work out well.

– Yeah, very good point. All right, and then Nancy asks, “What about people with vascular problems?”. So yes, as we were just talking about a few minutes ago, absolutely, this is critical because, you know, if you’re producing the ketones and you’re getting the combustible fuel there to the brain, but the problem is it’s the transport, it’s not what’s in the blood, it’s the fact that the blood itself, and that we really break this down into four areas. Number one, are you getting the blood flow itself? And this is where the example of, you know, critical to have good vessels and open vessels, and again, this will help you, this actually improves your vascular profile, improves your lipid parameters. And then secondly, is there oxygen in the blood? So this is where people with sleep apnea have a big problem, they’ve got the blood flow, they’ve often got the ketosis, but the problem is they don’t have enough oxygen. You have to think about, at the end of the mitochondria, everything gets handed off to oxygen, so that’s how you make this energy, that’s how you make your ATP. So this is critical, and as people are dropping down, this is why we urge everyone, please check your nocturnal oximetry, your doctor can do it, you can do it, you can get a simple oximeter, as Julie has written about, lots of ways to do it, you can do it on an Apple watch, there are lots of different ways to check your oximetry. Then the third piece of this is the ketones that we’ve been talking about, again, because that’s the fuel itself. And then the fourth part is the mitochondrial function, if you’ve got fuel but you don’t have anything to burn the fuel that’s not going to help either, so you have to have the batteries in there, you’ve got to have the mitochondria themselves. So it’s those four together that are giving you the appropriate energetics to fuel your synapse formation and your synapse utilization. And so, and Julie mentioned earlier, you might consider getting a calcium scan just to see what is the status of your vessels and then follow your parameters. If your hs-CRP is high, you’ve got ongoing inflammation, that’s going to be a problem for your vessels. This is also why we recommend to people, if there’s a question, consider EWOT, you can go, there are places where this is set up, this is Exercise with Oxygen Therapy. And one thing I think that’s important to mention, Julie, you’ve had such great results with KAATSU, and I think this is another example where your periphery is communicating with your brain and people are noticing improvements, even though the KAATSU, you’re not wrapping it around your brain, but nonetheless your muscles are communicating with the rest of your body, so maybe talk a little bit about your results with KAATSU?

– Right, so KAATSU, for people who aren’t familiar, is a Japanese exercise practice where you use these tight bands and you put them on your arms between the deltoid and the bicep, and they’re applied quite tightly, you work out your arms first and then you do legs, and I do it with strength training, I do it every day, and this creates a situation where you’re building up, what is it, Dale, nitric oxide?

– Yeah, you’re building up nitric oxide, absolutely, and you’re also-

– While it, yeah, and, oh, go ahead.

– I was just going to say, other things like PGC-1 alpha and things, you’re basically, you’re communicating between your periphery and your brain.

– Exactly, and by stressing your body, you end up needing to use a lighter weight and you work out for a shorter period of time, but you get amazing results, and we’re also finding that it stimulates BDNF, plasmalogen levels, and lots of things healing to the central nervous system, so it’s really powerful and I’ll link something to your Facebook page so people can learn more about KAATSU but it’s a wonderful form of exercise.

– Yeah, great point. So there are lots more good questions here, we’ll take these, we’ll go back online to take these on the site. Thank you so much everyone for the great questions, thank you, Julie, for your expertise and wisdom as always, and again, everyone, please stay safe. We’ll see you next time.

– Bye bye.