Is Keto Safe for Diabetics? (Myths vs Facts) • Dr James McCarter

Is Keto Safe for Diabetics? (Myths vs Facts) • Dr James McCarter


[Music] hello everyone and welcome to biohackers lair but I’m your host Gary Cohen and on today’s episode I have dr. James micarta dr. micarta is currently an adjunct professor of genetics Washington University School of Medicine and is the senior entrepreneur in residence at bio generator in st. Louis he was also the former head of research for Verta health and a previous guest on the bio hackers lab show for episode 44 James thanks for Matt so much for coming on for another episode excellent Gary glad to have the opportunity to speak with you yeah so I’m the reason I’ve got you on is because we’re going to be discussing a recent medium article that’s you shared that I thought was very interesting to read and of course when in a bit viral on Twitter and that was where you got to share the current keto myth-busting evidence front that’s related to research so we’re going to be busting some keto mr. day and sharing what the facts are but before we get on to what those different ones are could you just explain to listeners the exciting news how the a DA changed its guidelines using verticals evidence yeah so you know one of the things as Verta has been working to expand its offering is that we use as part of our intervention of continuous remote care we combine that with nutritional recommendations that use nutritional ketosis to reverse type 2 diabetes it you know in our patients but the a DEA guidelines for the last you know really going back years are silent on low carbohydrate and ketogenic nutrition whereas they used to recommend a low-fat diet that’s largely kind of gone by the wayside but they still recommending Mediterranean and plant-based diets and so they have a cycle of reviewing the information every year there’s a new standard of care and every I believe every four years there’s a new set of nutritional recommendations and so we knew that those committees were meeting and looking at the evidence that was coming out of new publications from not only virtus clinical trial with Indiana University health but also other randomized clinical trials that have been done over the last few years such as the work out of UCSF and a number of other meta analyses of ketogenic nutrition and low carbohydrate nutrition trials for for type 2 diabetes and so we were excited to see that in January of 2019 when the new standards of care came out that they for the first time incorporated low carbohydrate and very low carbohydrate eating patterns into the recommendations around nutrition and then that was confirmed in when the nutritional guide guidance came out the consensus statement on nutrition came out in April both of those in diabetes care and you know it showed basically that citing the verdict trial and citing some of the recent meta analyses that there is evidence that very low carbohydrate eating patterns can lower hemoglobin a1c at the same time that people see removal of glycemic control medications and so what they said I’ll just quote from that they said low carbohydrate eating patterns especially very low carbohydrate eating patterns so that would include ketogenic patterns have been shown to reduce hemoglobin a1c and the need for anti hyperglycemic medications these eating patterns are among the most studied eating patterns for type 2 diabetes so that yeah that was just we were tremendously enthused to see the the a da coming around on that yeah I mean that must be because it’s a historic event for I think diabetics given that option now and because it is a part of the guidelines so it just means that more health care professionals now will have confidence being able to give that option to patients I think around the world well especially in the u.s. yeah exactly so I think and it also included the European Association for the study of diabetes made a similar statement and a joint consensus paper with with a DA that came out and in late 2018 so it’s I think it applies it leads to some practitioners in Europe as well and I think that makes for for patients who want to explore this dietary pattern as a way of treating their diabetes it makes that conversation with their medical provider much more comfortable that and and I think it puts the provider in a better position to that they don’t have to feel that they’re giving guidance that’s outside of the guidelines yeah perfect so yep we’re going to move on to your facts and myths now so if you could take it away with your number one myth-busting one which was is the keto diets unsustainable long term yeah and so this medium post I’d you know rode after our two year outcomes paper for Verta health and Indiana University health the two year trial data came out in in in frontiers in endocrinology in June and so I started looking back at our one-year data and and our two-year data and saying you know what are some of the things that are commonly given as kind of roadblocks to that are thrown up around trying ketosis that we now have a lot of data from clinical trials to suggest that that’s not the case and so one of the most common is sustainability you know can people do this long-term and you know yet we now have evidence of seventy-four percent retention of the hundreds of patients in our clinical trial out out at two years and so all of those individuals nearly all have demonstrated that they’ve been in nutritional ketosis at least for a time but based on their ketone levels by by blood and in terms of what they’re doing out at two years it’s a variety of different things there’s some people who really get dialed in on on a strict ketogenic diet generally less than 30 grams of carbohydrates a day and want to do that long-term and then there are others that as they’ve got better insulin sensitivity are able to kind of expand their dietary choices and so whether they’re still on the relatively low carbohydrate end of the spectrum perhaps less than a hundred grams per day they’re not necessarily strictly staying with with a ketogenic diet long term so it really depends on kind of what’s sustainable for the patient and do they continue to see favourable biomarkers in terms of their blood glucose and their weight and the other changes that are occurring within their health you know and if they’re do they require strict ketosis to sustain those then that’s something they can shoot for if if they do well without being in strict ketosis they can do that as well so but you know it’s that but I think it’s you know to say that ketosis is only something that can be tried for you know a few weeks or a few months is incorrect mm-hmm and now you put the data behind it for type-2 diabetic patients I mean you yourself who you know diabetic but you’ve been in ketosis for several years now – you are coming up on seven years so it’s definitely sustainable for you that’s a that’s a good n equals one there yeah yeah perfect and then what about the second myth which is that being on a ketogenic diet could cause a diabetic ketoacidosis yeah so you know one of the challenges just in terminology is that when a physician or an endocrinologist hears nutritional ketosis or keto they may immediately jump to their medical training around diabetic ketoacidosis and so it’s really this kind of the vocabulary there that these are very distinct metabolic states ketoacidosis is a dangerous event that occurs with very high ketone levels in the absence of insulin together with very high glucose levels and resulting in a metabolic acidosis and and that is not at all what nutritional ketosis is which are ketone levels that are about 1/10 as much with normal physiological control of of glucose and insulin and so we don’t see that being in nutritional ketosis predisposes our patients to transitioning into ketoacidosis that’s just not the case and I guess again you know the the data that we’re referencing here is for type 2 diabetics or people who are diagnosed with a diabetic condition and using a low carbohydrate diet and not entering the state of diabetic ketoacidosis that that’s right and so we’re able to demonstrate in our trial that we’re not seeing ketoacidosis as an adverse event we’re also not seeing metabolic acidosis or what’s called an anion gap in in the in the tracking of our laboratory values for our patients I would add a couple of notes that one thing that we do with the the verdict Linacre practice is that we generally will remove patients from what are called sglt2 inhibitors which were one of the diabetes medications it’s it’s known and been shown in case reports that sglt2 inhibitors predispose patients to ketoacidosis and to what’s known as u glycemic ketoacidosis so they can get a ketoacidosis in the absence of a glucose rise because they’re they’re removing glucose from their blood through the kidneys filtering and disposing of glucose in the urine and and what we want to do is we want to not miss an event like that so we want to avoid somebody having this adverse reaction to an sglt2 inhibitors and so generally we will take our patients off of those medications okay is there any particular name for those as someone would know that they are on them let’s see so invokana is is one jardian so our dziga would be a couple of those yeah yeah perfect yeah so maybe any again it’s just good information for anyone listening to this and the third myth here is that being on a ketogenic diet will cause low blood sugar yeah and so this is something that we also don’t see so you know one of the you know ideas that people have is that as you enter into nutritional ketosis it’s going to drive your blood sugar down not only to to normal but actually below the normal range and and that’s just not the case that the thing to that we were you know careful of in them in the medical practice within Verta is to remove again medications that can cause this and so if if you’re having a high dose of insulin whether you’re in ketosis or not that can predispose you to a hypoglycemic event and then so fond of urea drugs most people don’t need to be on those and then in the case of the clinical trial population we actually removed got a hundred percent elimination of sulfonylureas and so I can I can throw some brand names out there again I don’t I didn’t have that handy I should I’ll I’ll have it for you next next time but but but you know you want you want to kind of get off of the drugs that you no longer need that that are predisposing you to these hypoglycemic events in the first place yeah and I guess anyone listening to this who ought who is on any of these drugs yeah so those so funny areas would be like glipizide and glyburide or two of the most common okay and I guess you know this is the always interesting situation where we’re now seeing that you can use nutrition to try lower the amount of medications we’ll get off chronic medications when you’re a type two diabetic and maybe even in these situations it just shows if maybe you are and some of these medications that you mentioned that can have adverse side effects there hopefully even through nutritional intervention and you’ll be monitored closely by a medical professional that you’ll be able to safely get off these so that you don’t get into one of these event stages right yeah and and you know and with the so funny areas there there are a handful a small percentage of people that have atypical diabetes that doesn’t clearly classify as type 1 or type 2 that actually respond nicely to a sulfonylurea but this is about 1% of the population so there may be patients who are being kept on those drugs for you know for a reason yeah yeah perfect um so myth number four is that being on a ketogenic diet will deprive your brain of glucose yeah and this is one that if you just sort of do it do a search online and you see kind of what it would do you need you know folks with nutrition training kind of throw up there in terms of just things that are complete falsehoods that just kind of get thrown around that this is one of the top ones that’s out there and it’s completely untrue so you know the the body is exquisitely tuned at regulating blood glucose levels and if you for instance are fasting your your liver will be producing glucose by gluconeogenesis that will keep your glucose within you know a normal range and and then in the in in additional point is that for folks that are driving substantial amounts of their energy through nutritional ketosis that the ketones cross the blood-brain barrier and provide an additional supply of nutrients for the brain so the brains being fuelled both on glucose but also on ketones as well and actually in a fasted State really for anyone so let’s just say somebody who’s not even doing a ketogenic diet but goes on a three day fast ketones will provide over half of the fuel for the brain so it’s yeah so it’s not it’s it’s not true that the people will get hypoglycemic it’s also not true that that the brain will be deprived of fuel and in fact ketogenic diets are being looked at to treat neurologic conditions and improving cognitive performance beyond just the treatment of epilepsy for which ketogenic diets have been used for years and I guess I’m you would have seen that in your in your day said that if patients who were following that dietary intervention won’t get enough sugar to their brains that that’s suddenly you would have thousands of people with brain fog not able to function properly not happy but the data is not showing them that’s right yeah yeah cool so miss number five is that the ketogenic diets will cause a cardiovascular damage yeah and this is something that also is not true and we really just but went to a lot of effort to address this in terms of the clinical trial that was conducted by Roberta health and Indiana University health so in addition to looking at glycemic control we looked at at 26 different markers for cardiovascular risk and and so one way to look at that is just at the what’s called the AAS CVD risk score the atherosclerosis core disease risk score from the American College of Cardiology and that combines a number of those risk factors and we saw actually a 12% improvement in the one year AAS CVD risk score or ten year risk score in our patients whereas the score for those in the usual care arm of the trial declined at about eleven percent and then if you start breaking out by all those individual 26 different biomarkers which include markers for hypertension and dyslipidemia and inflammation in fatty liver we see a statistically significant improvement in the intervention group on a ketogenic diet in 22 out of 26 risks fact risk factors whereas we saw we saw zero of 26 improved in the usual care group so you know it’s a these are markers these are not mortality morbidity and mortality statistics which would require much larger sample size a much longer time frame but but they’re the best we can do in terms of monitoring people’s cardiovascular health and and it’s looking like a substantial improvement and did I read also that you did across at intima-media thickness test part of that so you actually did a scan of the carotid arteries that’s right and in what we saw really was no change in either the intervention group or the usual care group at one year and that that’s pretty much as you would expect that it’s going to take you know and quite a number of years for the carotid intima-media thickness to show you know either an improvement in response to a therapy or getting worse over time and you know so in some cases in some ways sort of no change is good news but yeah we didn’t see any kind of noticeable movement of that marker or measurement yeah and that takes me onto myth number six was which is that the ketogenic diet will cause a bad cholesterol profile yeah and so this is kind of a sub part of the cardiovascular risks profile is kind of what happens not only to glycemic control and hypertension and inflammation but to the lipid profile so one of the things that we see that’s that’s really great is a resolution of what’s called a thorough genic dis lipid e meal and that is a state that puts people at risk of cardiovascular disease and it’s best measured by the triglycerides generally high triglycerides and and HDL generally low HDL and we see improvements in both of those the triglycerides are declining getting lower the HDL is rising and therefore the ratio of the two is improving and and so that’s a substantial improvement and and in many cases resolution of atherogenic dyslipidemia and then there’s the LDL profile and so there are a number of different ways of measuring the LDL cholesterol particles in the body one is what’s called what’s traditionally part of the cholesterol panel what’s called LDL C and that’s actually a calculated number by the free wold equation where you derive it by subtracting it from total cholesterol and H you know getting HDL out and accounting for the Assumption around triglycerides and we see that the that the LDL see actually Rises but the metric that’s more important is actually the number of particles not not the total not not the a calculated ldlc and so we measured that a couple of different ways one by what’s called NMR lipo profile we can actually look at the number of LDL particles and in in that case we saw a slight decline in the total number of particles not statistically significant but a decline and then also you can actually look at the protein that’s attached to the the LDL particles it’s called a Bobi and that we also consistently see a decline as well not statistically significant but a decline in the number of particles as measured by a bobeat so you know so that that LDL profile is not worsening so that’s kind of the the situation that we’re seeing with the with the lipid profile because i guess that again that’s always the hot topic is and i think i mean still to this day and i only think that maybe that question will be put to rest with years of data when we have patients who’ve been eating a ketogenic way or very low carbohydrate way and the mortality morbidity rates aren’t significantly worse you know 30 40 years down the line but we just don’t know at that stage but at least people can rest assured a little bit at the moment yes your LDL will go up a little bit it sounds like you know we’ve I’ve had that discussion a lot with people but you know when you when you get into more nitty-gritty aspects of it people are saying it’s it’s it’s a better profile than what it was previously so right so getting into sort of you can use a number of different techniques including an immoral echo profile to kind of look at the distribution of particles and so you see this shift from what are called small dense LDL particles to what are called large buoyant LDL particles that are less thought to be less atherogenic and that’s pretty common to see that kind of shift when people are are undertaking a ketogenic diet and yeah so this is one of the reasons I’d like to see actually the National Institutes of Health get involved as an impartial body with a large potential you know a large source of funding you could enroll thousands of patient and look over you know like a five year window if you enrolled a high-risk population you should be able to design a trial to look at morbidity and mortality so that’s what’s been done with some of the some of the drugs some of the diabetes drugs that have shown survival improvement and and reduced cardiovascular events like geo p1 and sglt2 inhibitors that have Stern’s and encouraging data recently those have generally been two to five year trials in involving on the order of you know five thousand you know or more patients that’s what that’s kind of the randomised trials that that’s kind of the funding level that you would need to in order to see or mitad or morbidity or mortality improvement okay fingers crossed we’ll get that one day yeah that I mean that’s you know you know nutrition trials are very hard to conduct in terms of you’re not just asking people to take a drug you’re actually asking them to alter a sustainable behavior and behavior change is hard asking people to eat a certain way it was hard but that’s why these you know these trials are very difficult to do but conceivably you know that could be done so miss number seven is that the ketogenic diet will cause inflammation yeah and so the the thing that is often comes up is that you know you can part of a ketogenic diet can include eating meat and eating dairy and so people will offer you know make the claim that that meat and dairy will will cause inflammation and this is actually we just don’t see this in our trial outcomes when people are eating a ketogenic diet they show sharp reductions in high sensitivity c-reactive protein a thirty five percent reduction at two years and a seven percent reduction in what I blood cell count and this is to some degree expected based on the the mechanistic understanding of ketones it’s known that beta-hydroxybutyrate is an inhibitor of the nlrp3 inflammasome which is one of the complexes that’s involved in triggering inflammation within the body so we know both from mechanistic studies in cell culture and in animals as well as now this this human trial work that and also not only the work that bird has done but also work that Jeff Bullock’s lab has done at Ohio State looking at metabolic syndrome and monitoring large panels of of inflammatory biomarkers that that you see this improvement in chronic inflammation and again you know if you’re a diabetic patient inflammation is a is a thing you definitely need to get under control for like for vascular damage at a point of view – yes yeah I know it’s it’s likely just as important in terms of the etiology of of of cardiovascular disease as is the lipid profile so myth number eight is that going on a ketogenic will cause hypothyroidism or disrupt your thyroid hormone yeah again we just don’t see this we’re not seeing new cases of symptomatic hypothyroid in hundreds of patients there’s no evidence in the published literature that the thyroid requires dietary carbohydrates which is kind of out there in you know on the Internet but it’s there’s just no evidence to support that the you can see changes in in thyroid hormone levels of what we saw was that means I read hormone t4 was unchanged and you would expect that that if there was hypothyroidism that you would see a rise in TSH as the system tried to crank up to generate more thyroid hormone we actually see a numeric decrease on average in TSH okay and so then when I I just see it often Ceylon do you think kids in certain cases where people are and be eating like it’s a calorie issue that they do that they’re linking this – that’s a good question I I don’t have a good sort of that I know that in in some cases you’ll get changes that are occurring that are largely due to the the adaptation to ketosis that can be accompanied by changes in the handling of assaults and so and I can spend I think it’s probably worth spending a little more time on the changes in electrophysiology but basically people get hyponatremic they have low sodium levels and that can cause fatigue and headache and and those sometimes people will will attribute to the hypothyroid or a problem with the adrenal glands where in fact it’s more a matter of electrolyte intake and and so we should probably spend a little bit time on that I don’t know now it’s time to talk about that or or whether we’ve come back to that yeah maybe that might be up we we could probably have a whole episode about electrolyte balance just for the ketogenic diet a yeah well I’ll do the I’ll be like the 30-second version of it now and that is that basically as you’re getting into nutritional ketosis that’s going to result in lower levels of insulin one of the things that insulin does in addition to its role in glucose metabolism is it signals the kidneys for the retention of sodium and and then water that travels along with that and so as you enter into nutritional ketosis your body will be not reabsorbing sodium to the same degree that had been previously so you’ll be dumping sodium in the urine you’ll be increasing your fluid output in the urine and so if you don’t do anything about that you’ll get you’ll get low and sodium high pony tree mia and lo and overall circulating volume and so you need to replace that salt replace that sodium and and replace that those fluids and and so largely that you can avoid all of those symptoms that are associated with you know what’s called keto flu can be avoided by just increasing daily sodium intake and that can be done by more heavily salting the food or having broth or bullion or you know other other sources of sodium and so that’s gonna move me on to another myth I’m gonna just shift them around a little bit but whilst we’re talking about kidneys does the ketogenic diet harm your kidneys yeah again we don’t see that in our in our clinical trial outcomes we actually see that the glomerular filtration rate the EGFR EF EGFR actually improves and we didn’t see any cases of worsening kidney function one thing that you will see in the early weeks if you do a blood panel as you’re first going through keto adaptation you can see a rise in uric acid that will then return to normal values very quickly and so the uric acid levels were unchanged at one in two years that’s thought to actually have to do with competition for transport between uric acid and the ketone bodies and so there’s actually again a sort of a change that occurs likely in gene expression and the kidneys during physiological adaptation to ketosis that results then in a return of uric acid levels to normal it’s a diabetic patient who also suffers with gout but they so would they maybe have an increase in count symptoms in the initial phases of of going through Kido genic David right so we did not see that in our trial we did accept patients who who had gout but it would be something to monitor closely with with your physician or care provider and just be aware of that you’re gonna see this you know transient increase in uric acid and just to you know make sure you’re not going off of a galvan medication you know at the same time or just be be aware of that but it’s it’s not something we’ve seen in terms of an uptick in gout cases you know it’s you know when you mentioned that it just gets me thinking of other situations so the next than is wool the ketogenic diet hum you liver yeah and this kind of goes back to some rat studies where if you formulate high-fat diets in certain ways you can actually increase the stored fat in liver and rats but actually in fact as you implement a ketogenic diet in humans and we’ve shown this other groups have shown this as well is that you actually decrease the amount of fat in the liver and the liver and that you can look at that not only by by imaging that other studies have done but by scores there’s a liver fat score the NL FS score and then the liver fibrosis score the NFS score and both of those showed substantial improvements we’ve published a paper on the one-year outcomes in in BMJ open and and then also followed that up with including those scores in our in our two year outcomes paper in frontiers and under chronology and and those showed substantial improvements as well so you know people you know if a patient has non-alcoholic fatty liver disease and is looking for a nutritional intervention you know that that using a ketogenic approach can be a very favorable way of treating that disease and again this is just shame you know some of some of your major organs I actually get better when you go in a kit again it died is what I’m hearing here that’s right yeah so next myth here is that eating a kid a giant diet will cause muscle loss yeah so and I can talk about kind of the next two together muscle loss and people also worried about bone mineral density and so we did as part of the trial DEXA scans dual energy x-ray absorptiometry scans which has used a low amount of x-ray to look at the sort of fat mass lean lean tissue mass and bone mass within within the body and the changes were favorable so we see that most of the weight loss our patients on average in the first year lost about 30 pounds that about 80% of that is is loss in fat mass as you would expect that’s been shown in other studies and then you’re losing a you know a small amount of lean mass that’s associated with you know carrying around less weight and so that that is you know very much as would be expected so that you you are retaining lean body mass you’re losing mostly fat mass and then the bone mineral density looked excellent so we didn’t see any change in average spine bone mineral density at both one year and two years and when we’re talking about patients here these are patients who are on the vertical diet so the and when I was looking at it you go through different phases through their progress is most of these people then on the maintenance phase or were they from day one when they were diabetic and then they started the diet and they went through all the phases and then eventually by a year two they were on the maintenance phase with because I was seeing a difference in calorie intake between the different phases and I just got just would be interesting to know like which cohorts of patients were in this data right so let me talk a little bit about the trial design and then we can talk about kind of you know kind of calorie intake and what that might look like so that the the vertical trial included four hundred and sixty-five patients that were enrolled in 2015 and 2016 in central Indiana that included two hundred and sixty two people in the intervention group with type-2 diabetes it’s another 116 with pre-diabetes that will be published in a separate paper and then another 87 people with type 2 diabetes that were in a usual care group and so we followed up all of these individuals over the course of initially a 70 day and then one year and and and then two years and so the usual care group was following a recommendations from a registered dietician using the ad a guidelines for 2015 and 2016 and was you know so the verdicts were not involved in their care and then the verdicts were supporting the people in the intervention group and providing not only nutritional recommendations but a whole series of online nutritional educational videos interaction with a health coach and access to a team of health coaches that provided around-the-clock coverage interaction with a with a physician as well as an online community and then biometric feedback so there was it was it wasn’t just you know services a series of nutritional recommendations there actually was an entire support process called continuous remote care and then in terms of the the dietary intervention that was occurring over that time frame it was highly individualized so the idea of Verta is that you know these nutritional recommendations are difficult to do you know if everybody could read a book and get better you know we wouldn’t have to do anything you know you know diabetes would be cured but that’s not the case people need a lot of support and they need a lot of individualization and so what the software and the health coach are doing are taking sort of these general nutritional guidelines and then individualizing them so that it works for somebody in any really any life circumstance whether somebody’s you know working the nightshift and eating at a company cafeteria or whether they’re cooking for a large family or traveling on business you have to adapt the nutritional recommendations to work for them and it has to work for you know kind of whatever their dietary preferences are whatever their socio-economic statuses whatever their you know religious practices whatever it might be so thats so high degree of individualization and then one of the things that we did not ask people to do was to keep a food log over that’s really would be onerous over the course of two years and it also those kind of dietary recall data collection methodologies are seriously flawed people generally cannot remember exactly what it is that they ate they tend to underreport calories and and so the utility of that info would be highly suspect and so you know our thought was really what’s much more useful is the biomarker his measuring blood beta-hydroxybutyrate on a daily level it gives us a good you know chance to look at their sort of degree of ketosis that’s much more useful to us and to the patient then you know trying to capture you know a calorie count and a macronutrient count from you know food recall okay yeah so in this case here just thinking you know some people may attribute it that it was the reduction of calories which is like one of the approved methods for diabetic control which is a very low calorie diet but in this case but not this intervention isn’t looking at that since I was like yeah and I would say in terms of sort of the mechanism of action of why are people getting better you know I think some of it is attributed to the weight loss but I think sometimes there is a reversal of cause and effect there’s this assumption that weight it you know that extra weight is is the problem or extra fat mass is the problem when in fact mechanistically you know it’s it’s likely that both the both the diabetes and the extra fat mass are related to the hormone levels of hyperinsulinemia and insulin resistance as a putative kind of underlying mechanism so that they are correlative but not necessarily causal but you may see sort of you know you could have symptomatic improvement because of the loss of of fat mass but the one there was a study that was done again out of Jeff vorlix lab at Ohio State recently just published I believe in July in JCI insight looking at people not with diabetes but with metabolic syndrome and addressing this question directly which is to say hey let’s compare a low carbohydrate and moderate carbohydrate and high carbohydrate diet in individuals with obesity and metabolic syndrome let’s hold the weight constant so will will provide all the food and will shift people between these various diets for a four-week block of time you know on each diet and if people start losing weight will provide more calories that people start gaining weight will provide fewer calories so we’ll try to hold their weight study and what they found in that case is that there was still an advantage to the low carbohydrate eating pattern in terms of resolution of metabolic syndrome and so they saw in in these study of 16 individuals that when they just spent four weeks on a low carbohydrate eating eating pattern that nine of the sixteen no longer met criteria for metabolic syndrome after the end of four weeks nine of 16 with a low carbohydrate 3 of 16 met that criteria with the moderate carbohydrate and only one of 16 met that carbohydrate met that criteria for met about reversal of metabolic syndrome with with high carbohydrate so you can you know bottom line is that a low carbohydrate nutrition pattern can effectively reverse metabolic syndrome even in the absence of weight loss yeah and again that’s as you said you keep you’re trying to keep that more consistent from okay it kind of takes that calorie equation out of it a little bit more there so there’s something else going on there yeah yeah and and I think that you know kind of what’s interesting about that it kind of sounds like you know that people get confused about how can you know you know how can that be the case but I think in terms of the underlying physiology and biochemistry it’s important to remember that you know you are not what you eat you are what you save and make from what you eat and so actually you know when people consume high levels of starch and sugar they rapidly will turn that into fat that’s the kind of you know if you over consume those calories that will get converted into fat whereas just consuming fat won’t necessarily result in an increase in fat so for instance in in in the same study they looked at the fatty acid profile of the blood and they actually saw that for well saturated fat consumption increased in in a low carbohydrate eating pattern the amount of saturated fat in the blood actually declined so it’s it’s it’s counterintuitive mmm well we’ve got through all the myths that were in your medium article and I just wanted to say thank you so much for sharing even more information and if anyone has read that article they’ve got to learn even more about what each point was and probably just as we’re coming to the end of the show here I know that you are begin to quantify itself and do a lot of self testing are you doing anything interesting at the moment or you found any interesting findings yes so just real quick I’ve you know I was putting off getting an aura ring and I finally broke down and said I really want to play around with one of these and so I went ahead and got one of those back in I think was June and so I’ve been looking at metrics around sleep and and found that to be pretty interesting and then I just for a week or a Dexcom g6 continuous glucose monitor and so probably the most interesting finding and for me was that I saw these low glycemic readings overnight and to the point where actually sometimes the the glucometer was was pinging because it you know I thought I was going too low and my nightly blood glucose I think it pings when it gets below 60 or 65 something like that but I would see kind of every night that there’d be these these dips that would occur I’d go down from the 80s into the 70s or the 60s and it would occur at you know 2 a.m. 3 a.m. 4 a.m. and it roughly correlated with what the ordering said were the the REM sleep patterns the rapid eye movement sleep that occurs largely sort of in the second half of the night is when most of the REM events occur and so that was pretty interesting it’s you know sort of is there increased glucose uptake occurring in the brain during REM sleep that it could could account for kind of these lower blood circulating blood glucose levels and I found one paper in paper and diabetic medicine from 2009 decreasing concentration of interstitial glucose and REM sleep in subjects with normal glucose tolerance it’s very small study of 13 subjects but they saw the same thing is that you do get these overnight dips and blood glucose that coincide with REM sleep so that was kind of cool that is very interesting and in this case here it’s you’re not concerned how low your glucose levels winds during that stage yeah i’m i was asymptomatic and that you know sometimes actually the the the the the Dexcom vomiter is connected to your cell phone and so the cell phone pings with a low glucose alert you know and so it woke me up a couple of times and i felt perfectly fine and ended up kind of moving my phone so that it wouldn’t wake me up yeah and i mean that’s why i type one diabetics particularly they also need that continuous glucose meter especially at night and i had the previous gas carried out since he would tell me that that was why she did an open loop or closed loop I forgot which one it was no but you know to allow it to sleep through the night properly right yeah and I I don’t want to minimize the the seriousness of these alerts that are occurring and folks with with type 1 diabetes or insulin dependent diabetes that’s you know indeed very serious and I know it for children with type 1 diabetes that you know it can cause their parents to get very little sleep as the concern of these hypoglycemic events overnight so I I know means should should those do I mean to minimize those but for somebody you know whose non-diabetic and just as you know wearing a glucometer as a learning process this was kind of an interesting observation yeah that would be because again you know I haven’t had a chance myself to test continuous glucose meter but I mean knowing yes you know you’re a situation like that I’m sure anyone else you may be testing right now just you know trying to get some quantified data they’re completely normal they just want to know what food does to them and what happens over 24-hour period your information is fascinating to say hey just you know you may be may have normal blood sugar levels but maybe it dips like this over night and it’s just when you’re in sleeps kicking in yeah yeah yeah first thing well thanks for sharing that tidbit really loves that James if anyone wants to maybe follow you contact you anyway are there any particular references that you would like to share and social media accounts or anything like that yeah so if folks were kind of interested in what I’m up to I post from time to time on on Twitter and that’s at a JP McCarter also occasionally post on LinkedIn James MacArthur is my account and then if anyone would like to reach out to me with with any questions or thoughts my email address is James P McCarter at gmail.com type of it and I’ll link to those in the show notes for everyone listening but I just want to say thank you so much for expanding again on that interesting medium article with the 12 different keto diet myths and yeah I look forward to finding out more from you done down the line when more research comes out yeah and when time permits I’m gonna do a follow-up to that I actually have right over here on my file cabinet have a bunch of post-it notes and those were the top 12 but there are definitely twelve more there may be 24 more so in terms of things that I have to reach a little bit beyond the vertical health Indiana University Health publications to address some of these things but reaching into other parts of the the clinical trial literature there’s there a bunch of other myths that can be busted okay well you know I’ll end up sharing that on social media when you end up sharing that article – excellent perfect thanks again James oh sure to talk with you thanks Gary you

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