Dr. Carrie Diulus: Whatever diet we need to get you on so that you feel good, so that you’re able to go out and be active and live an active life, is the ideal diet for you.
Dr. Mark Hyman: Welcome to The Doctor’s Farmacy. I’m Dr. Mark Hyman. And that’s Farmacy with an F, F-A-R-M-A-C-Y. A place for conversations that matter. If you’ve heard about ketogenic diets and intermittent fasting and the benefits or the harms, this conversation is going to matter to you. Because it’s with two of the most informed, intelligent, and articulate people on this subject. Which is a very slippery subject for many people. For our first guest is Carrie Diulus. She’s a orthopedic spine surgeon. She’s a good friend of mine. Has helped me with my back and many of my friends with their backs. She’s the vice chief of the medical staff and director of the Spine Wellness Center at the Crystal Clinic in Akron, Ohio. She was a spine surgeon at the Center for Spine Health at Cleveland Clinic for many years, and medical director of their IT department. Not only is she-good with the body, she’s good with computers. She’s gotten her MD from Northeast Ohio Medical University and did pathology residency. She was also on the US national team for the duathlon and competed in the world championships. Quite a lady. I could go on and on.
Dr. Carrie Diulus: Yeah, you don’t have …
Dr. Mark Hyman: One of the most interesting things about Carrie is that she developed Type 1 diabetes actually since I met her. We worked together early on in it. She’s one of the few diabetics I know who’s Type 1 who uses very, very little insulin, almost no insulin really. It’s pretty impressive. We’ll talk about how and why that is and what she’s discovered about her own body. And what it means for the treatment of diabetes in general and Type 1 diabetes. Our next guest is Dr. Ethan Weiss, who’s an Associate Professor of medicine at the University of California, San Francisco. A principal investigator in the Cardiovascular Research Institute. He’s got his MD from Johns Hopkins School of Medicine where he also completed his internship and residency, and completed his cardiology training at UCSF. He’s a cardiologist focused on prevention and lipids, and the emerging intersection of endocrinology and cardiology with a specific focus on prediabetes and Type 2 diabetes. Which I call diabesity. Which are main risk factors for heart disease and how to treat those with diet.
Dr. Mark Hyman: In fact, how to treat those with extremely high fat diets, which seems like a crazy thing for a cardiologist to be recommending. But it’s true. His research is really focused on why that works. Looking at the mechanisms of how we gain weight and obesity, fatty liver and diabetes. I think what’s increasing clear in cardiology is that it’s not just about plumbing, it’s about the immune system. It’s about the hormone system and the endocrine system. He’s has an active program in clinical nutrition exploring things like time restricted eating, which many people refer to as intermittent fasting. Although that’s something else. He’s the principal investigator in grants funded by the National Heart, Lung, and Blood Institute and the National Institute of Diabetes. He serves on many scientific advisory boards. He’s a co-founder of an incredible new company called Keyto, K-E-Y-T-O. Which is based in San Francisco. It helps people use heart-healthy ketogenic diets for weight loss. A heart-healthy diet is 70% in fat and saturated fat. It doesn’t seem like healthy for most of us who grew up in the ’80s and ’90s when fat was the enemy number one.
Dr. Mark Hyman: But welcome, Carrie, and welcome, Ethan.
Dr. Ethan Weiss: Thanks Mark.
Dr. Carrie Diulus: Thanks Mark.
Dr. Mark Hyman: Okay. Let’s get right into it. Everybody hears in the news, ketogenic, ketogenic is hottest new diet trend. I wrote my book, Eat Fat, Get Thin, a few years ago before that hit. But I could see it coming and went into the science of why our thinking about fat is pretty wrong. Why our guidelines for eating lots of carbohydrates and very low fat diets led to a massive epidemic of obesity and diabetes. What’s been fascinating over the last few years is to watch how science is shifting and actually opening up the doors to understanding how to shift metabolism through using different types of eating patterns. Whether it’s time restricted eating, or it’s different days of fasting ,or diets that mimic fasting like low calorie diets or even ketogenic diets. Which sort of mimics fasting, it’s what it does to the body. Let’s start with you, Carrie. You are a Type 1 diabetic.
Dr. Carrie Diulus: True.
Dr. Mark Hyman: You certainly don’t identify as a sick person with an illness. You actually are, like I would say, an Olympic-
Dr. Carrie Diulus: No.
Dr. Mark Hyman: … kind of … No, you didn’t let me finish. You’re sort of an Olympic biohacker who has Jerry-rigged her blood sugar monitor so she can adjust her insulin and regulate her sugars. Knows exactly what’s happening every minute in her body and has been her own guinea pig in terms of diet. And had an incident where she had to switch her diet to not just being a keto diet that was including animals, but one that was vegan. Which most people are sort of perplexed that because we think keto is bacon and cheese and butter and coconut oil. That it doesn’t have to be including animal products. Tell us about how you kind of came to realize you should be as a Type 1 diabetic not eating a lot of carbs and eating a ton of fat. Actually how you switched to then be a vegan keto, which most people don’t even think it’s a thing.
Dr. Carrie Diulus: It’s a thing, yeah. It is a thing. I have a plant-based bend in that when I was 12, I first gave up meat just because I didn’t really like it. I have a lot of obesity in my family and it seemed like the thing to do at the time. There was the Pritikin diet. Over the years I was mostly plant-based throughout that. I struggled with my weight at varying times and-
Dr. Mark Hyman: That’s putting it mildly. You were 100 pounds-
Dr. Carrie Diulus: I was 100 pounds-
Dr. Mark Hyman: … more-
Dr. Carrie Diulus: … heavier-
Dr. Mark Hyman: … than-
Dr. Carrie Diulus: … than I was in college.
Dr. Mark Hyman: If you see her on the video, you’ll see she’s a petite little lady who was 100 pounds more.
Dr. Carrie Diulus: It’s true. I lost it. I mean, I lost it in the traditional ways of calorie restricting and exercising a lot. That’s when I got into doing all of the multi-sport stuff and competing. As I got into my 30s, it was sort of harder to keep weight off and I struggled with some of the things with the plant-based diet. I went to the gurus of it and many of them said, “Well, you’re doing it wrong.” Or, “You’re eating too much.” At that point I felt like I could win a Olympic medal in calorie counting and it just wasn’t working. At that point I sort of shifted to-
Dr. Mark Hyman: Wait, you were on a low calorie vegetarian diet and still not losing weight?
Dr. Carrie Diulus: Yeah. I gain weight very, very easily. It was just not working well. I ended up shifting at that point to … I had gained weight with each of my pregnancies and I was trying to lose that weight. I ended up shifting to a very low carbohydrate diet. That at the time there was sort of the South Beach thing, but really it was low carb. I was getting into ketosis most likely looking back on what I was doing at the time. And-
Dr. Mark Hyman: Was it before you got diabetes?
Dr. Carrie Diulus: This was before. Then I sort of shifted back to plant-based for a while. Had done some different things with really whole food plant-based, a lot of greens and things like that. It worked well. I was out actually speaking in the orthopedic and surgical community about how we modify patient’s metabolic risk factors when they’re orthopedic patients to impact surgical outcomes in their musculoskeletal health. I went for-
Dr. Mark Hyman: Meaning if they’re overweight and sick, they do better if they get their-
Dr. Carrie Diulus: They do better.
Dr. Mark Hyman: … metabolism fixed?
Dr. Carrie Diulus: Right. We get better surgical outcomes. I went for an executive physical and my A1C was elevated. I was like, “No, that’s …”
Dr. Mark Hyman: That’s your average blood sugar.
Dr. Carrie Diulus: Average blood sugar, yeah. I was like, “No, that’s not a thing.” I had some room that I could clean up some things in my diet and focus on stress and sleep and all those things.
Dr. Mark Hyman: But you weren’t eating bags of chips and hot cookies?
Dr. Carrie Diulus: I was not.
Dr. Mark Hyman: No?
Dr. Carrie Diulus: I was not. Then I ended up trying to control my blood sugars. I got a glucose monitor and I started paying attention to what spiked my blood sugars. I slowly started working on, okay well I can’t eat that or my blood sugar goes up really high. At that point they sort of thought I was going to be Type 2 which didn’t really make sense. I don’t have a family history despite the obesity history. But I do have a family history of Type 1 on my mom’s side. Long story short, I was really super low carb and was able to stay off insulin for a while. Then I got sick and it became clear that it was Type 1 diabetes at that point. That’s when I went on insulin. Initially, I did the things that you’re told to do when you go on insulin. Which is you have to eat a-
Dr. Mark Hyman: Carbohydrates.
Dr. Carrie Diulus: … certain number of carbs per meal so that you can dose insulin so that … I gained 15 pounds almost immediately doing that. [crosstalk 00:08:52]-
Dr. Mark Hyman: Well, insulin makes you gain weight. That’s what it’s job is partly.
Dr. Carrie Diulus: It does. If I want to gain 10 pounds, I just do any of the many [crosstalk 00:09:01]-
Dr. Mark Hyman: You just look at a bagel.
Dr. Carrie Diulus: I look at a bagel and take insulin. But even stress will do it. I mean, lack of sleep, stress. Anything that increases my need for insulin will lead to increased weight for me. I shifted back to low carb at that point because I was like, “I can’t figure out … I have degree in biochemistry and I can’t figure out how much insulin to give for an apple not to …” My blood sugars throughout the day were anywhere between 400 and 40, and it was not sustainable as a surgeon.
Dr. Mark Hyman: 40 and 400, you mean?
Dr. Carrie Diulus: Right. Yeah. I mean I would bounce between the two of them. Which is, it was a roller coaster. I was miserable and it felt awful. So I was chasing blood sugars around. I just said, “I’m just going to stop eating carbs and go back to what I was doing before.” Because that seemed to make-
Dr. Mark Hyman: It worked.
Dr. Carrie Diulus: … the most sense. There’s not a lot of guidelines out there. Dr. Bernstein has written a book and we’ve since found that there’s this whole community of people who are Type 1’s who are eating very low carbohydrate diets using very small insulin doses. When you use very small insulin doses, you have less room for error. You don’t have the big peaks and valleys like you would with your blood sugar if you’re eating carbohydrates. Where you’re trying to guess when it’s going to absorb and how high your blood sugar is going to go. Then I got … There was another several years into it, a bad virus going around and I ended up having some issues where with my stomach. I wasn’t able to eat normally for a while and had to sort of get back into where I was adding foods back in. I just really didn’t tolerate meat well.
Dr. Mark Hyman: You had a hard time to digesting it.
Dr. Carrie Diulus: I couldn’t digest it.
Dr. Mark Hyman: Then went in vegan keto.
Dr. Carrie Diulus: It’s-
Dr. Mark Hyman: Which people don’t think it’s a thing.
Dr. Carrie Diulus: Don’t think it’s a thing.
Dr. Mark Hyman: What is vegan keto?
Dr. Carrie Diulus: Yeah. What is it? Initially I was protein powders and things like that because that’s what I could get down. But now it’s been several years now and it’s blossomed into, I eat a lot of the same things that people on a ketogenic diet eat in the sense of the macros and the vegetables.
Dr. Mark Hyman: Like what?
Dr. Carrie Diulus: Lots of non starchy vegetables, broccoli, asparagus, Brussels sprouts, kale, cauliflower.
Dr. Mark Hyman: So the veggie queen.
Dr. Carrie Diulus: All of those with healthy fats like avocado, olives, olive oil, nuts and seeds. Then the protein sources are things like edamame, tofu, black soybeans, Lupini beans. Hemp seeds are a great source of protein. You can make a ton of really delicious things that way. I did it thinking, “All right, I’m going to do this for a little while …”
Dr. Mark Hyman: Yeah. Not only is she an orthopedic surgeon and she a biohacker, but she’s a great chef and makes the most amazing keto foods.
Dr. Carrie Diulus: I did it for a while and a bunch of lab markers that are inflammatory markers and things like that, got better that I’d been struggling to bring down. My high-sensitivity CRP, which is a marker of inflammation, improved. My liquid profile improved. I’ve been sort of riding it at this point where I’ve said, “I will keep doing plant-based low carb until I run into a reason to consider it.” I may. I mean four minutes from now I may add fish back if there’s reason that I want to add fish back.
Dr. Mark Hyman: You supplement with things like fish oil.
Dr. Carrie Diulus: B12 and algae oil for the omega-3’s. In the sense of, I mean a lot of people need to supplement with B12. But anybody who’s fully plant-based needs to supplement with B12.
Dr. Mark Hyman: Yeah. You can’t just get it by eating the dirt on your vegetables like they say in Game Changers?
Dr. Carrie Diulus: Oh my God, no.
Dr. Ethan Weiss: I’m the only one who hasn’t seen it.
Dr. Carrie Diulus: What?
Dr. Ethan Weiss: I say I must be the only one who hasn’t seen it.
Dr. Carrie Diulus: You haven’t seen it?
Dr. Mark Hyman: Well-
Dr. Carrie Diulus: I’ve just been doing it.
Dr. Mark Hyman: … for those who are listening who don’t know what that is, that’s a new movie by James Cameron called Game Changers about the benefits of a vegan diet. Which has a lot of valid points, but also a lot of sort of half truths and science misrepresentation. Which you can listen to on Chris Kresser and Joe Rogan’s podcast. Where he discusses for three hours the challenges of the movie. Just to put that out there.
Dr. Ethan Weiss: I haven’t listened to that either.
Dr. Mark Hyman: What?
Dr. Ethan Weiss: I haven’t listened to that [crosstalk 00:13:05]-
Dr. Mark Hyman: Joe Rogan is like the number one podcaster.
Dr. Ethan Weiss: No, I know Joe, but … Yeah.
Dr. Mark Hyman: That’s amazing, Carrie. Your blood sugars had been great. Your A1C, is the average blood sugar, is better than most people who don’t have diabetes.
Dr. Carrie Diulus: Yeah, I range from 4.8 to 5.3.
Dr. Mark Hyman: Yeah. To put it into perspective, most people run around five and a half, six plus more is diabetes. You’re doing better than most people who don’t have diabetes and using-
Dr. Carrie Diulus: The goal for taking-
Dr. Mark Hyman: … how much insulin do you use a day?
Dr. Carrie Diulus: I mean, it depends on what I’m doing. I run a lot and so that impacts how much insulin I use. It can vary anywhere from eight to 12 units per day. Unless I eat carbs, and that can raise it up. Stress will raise it up. I mean, if I’m sick, I may use 35, 40, 50 units a day.
Dr. Mark Hyman: For sure. Most Type 1 or Type 2 diabetics who are using insulin use 30, 40, 50, 100 units who are diabetic Type 1 or Type 2. It’s usually at least 20 is sort of the baseline amount that most people need a day. You’re doing half that and keeping your blood sugars better than average or better than normal. That’s because you’re not eating a lot of the starch and carbs.
Dr. Carrie Diulus: It’s just easier. When your blood sugars do get high, a high blood sugar tends to beget high blood sugar. You tend to be more insulin resistant the higher your blood sugar is. By keeping it in a very low range with very low glucose excursion, so the ups and the downs, makes it easier to manage it. Then there’s much less worry about a low blood sugar. I can say I’ve never had a low blood sugar at a time when it’s critical like in the operating room.
Dr. Mark Hyman: Yeah. Which is amazing because you think that your blood sugars go up and down and you’re at risk of low blood sugar being a diabetic. But by eating the fat, it actually normalizes your blood sugar.
Dr. Carrie Diulus: Right. And by keeping the insulin doses very low.
Dr. Mark Hyman: Yeah. Amazing. Okay. Well let’s get back to you in a minute, but I want to talk to Dr. Weiss for a minute. You grew up in a hospital, your dad was a cardiologist, you had a lot of experience seeing heart patients. You went to the same path as your dad. You had a series of patients in their late 30s and early 40s who had heart attacks. That really didn’t have the obvious risk factors. Those then seemed to inspire you to get into cardiology. What did you learn from those experiences?
Dr. Ethan Weiss: Well, I learned that you can’t fight destiny, I guess. Or that I don’t have very much imagination or creativity.
Dr. Mark Hyman: You mean the destiny of your dad being a cardiologist?
Dr. Ethan Weiss: Yeah.
Dr. Mark Hyman: Not the destiny that you have to get a heart attack.
Dr. Ethan Weiss: I went to college intending to do anything but be a doctor. When I went to medical school, I absolutely didn’t even consider being a cardiologist. I thought I’d be a psychiatrist actually. But I did a CCU rotation when I was a third year medical student. There were all these younger patients coming in with heart attacks and not obvious risk factors. I thought that was interesting. That sort of spurred my interest in trying to understand some of the mechanisms behind cardiovascular disease. Especially these events in younger people. I went and worked on thrombosis, on blood clotting. I did that for the better part of the next 10 or 15 years. Trying to understand sort of what was different about … If you think about the plaque inside of a coronary artery, as I tell my patients, it’s like a zit, a pimple. It’s full of inflammatory cells. It’s full of cholesterol and lipids and fats. But one of the things that happens when it breaks or open, when it ruptures, is that it exposes blood to this substance or series of substances that signal an injury.
Dr. Ethan Weiss: Our body’s response to that is to try and [crosstalk 00:16:46]-
Dr. Mark Hyman: Wall that off.
Dr. Ethan Weiss: … that injury off. That’s why we have this blood clotting system. It senses an injury. It forms a blood clot, and it happens to form a blood clot in the worst possible place. Which is right in the middle of an artery and inside your heart. Therefore, it stops the blood flow beyond that [inaudible 00:16:59]. I wanted to understand what was different about people’s blood clotting system that might lead them to have these events at a young age. Really actually didn’t think about the part leading up to that rupture of the plaque. I didn’t really care at that time in my life. I didn’t care about things that caused development of plaque. So I didn’t care about lipids-
Dr. Mark Hyman: You’re just walking downstream.
Dr. Ethan Weiss: Yeah. I cared about the final event. I thought, “Well, this is …” The reason for that was that there were some old evidence from these pathologists. I don’t know if you remember this British pathologist who was like my hero when I was a medical student, Michael Davies.
Dr. Carrie Diulus: Yeah.
Dr. Ethan Weiss: … had done this series of autopsies in young people that had heart attacks and died suddenly. He went and did this histological analysis and found that it looked like the plaques had ruptured in these people. Not just that one time when they die, but had ruptured several times before and averaged up to seven times. There was this idea that every plaque rupture did not result in a heart attack. That was sort of the question that I started my career. Thinking about what’s different about the one that does cause a heart attack than the previous ones. That’s a long history that continues today.
Dr. Mark Hyman: You got into cardiology. Typical cardiology advice for years was to eat a low fat diet. Still sort of part of the recommendations of American Heart Association. It’s kind of bizarre way that it sort of is and it isn’t. A totally low cholesterol diets, to cut out eggs, to eat lots of carbohydrates. Even in major heart hospitals, they’re still giving post heart attack patients and post heart surgery patients a high carb, low fat diet. Somehow it hasn’t translated. Although the government has changed the recommendations around this. But you’re kind of going to the other extreme now. You’re studying diets that are actually pretty high in fat as a way to treat metabolic disease. For people who don’t know, I think it’s important to explain the change in thinking from heart disease being a plumbing problem to being an inflammatory problem and a metabolic problem. That’s driven by insulin resistance or prediabetes or blood sugar issues. I think not all heart disease is that, but it seems like the majority of current heart attacks and heart disease is because of that. Is that fair to say?
Dr. Ethan Weiss: Well, I think it’s fair to say that we understand and appreciate a lot of the risk factors for a coronary disease, but we also don’t understand all of them. I think the focus in the ’70s and ’80s when I was growing up as a kid was on fat because of the known effects on lipids. When you eat a lot of fat, your blood cholesterol goes up. That was something that had been recognized decades before. As a kid when I was growing up, Carrie is tired of hearing me talk about it, but we didn’t have any fat in our house. We had-
Dr. Mark Hyman: No Fleischmann’s margarine?
Dr. Ethan Weiss: No. Maybe margarine, but we had nothing that resembled fat. But because nutrition is truly a zero sum game, if you don’t have one macronutrient, you have a lot of another. Because we all eat a typical sort of normal amount of protein, we ate carbs like it was literally candy. I mean, I’d come home from school-
Dr. Mark Hyman: Well, it is candy.
Dr. Ethan Weiss: It is. But I remember coming home from school and I would eat through a bag of chips or Doritos or Skittles or whatever the heck-
Dr. Mark Hyman: Health food.
Dr. Ethan Weiss: … it was. It was healthy. It was heart healthy. It took a little while I think for me-
Dr. Carrie Diulus: And all plant-based.
Dr. Ethan Weiss: It was …
Dr. Mark Hyman: Skittles are definitely a colorful plant-based diet.
Dr. Ethan Weiss: They are.
Dr. Mark Hyman: But not the kind we talk about, no.
Dr. Ethan Weiss: That was ingrained, I think culturally and otherwise ingrained in all of us. I mean, particularly me growing up in the home with my dad as a cardiologist. I didn’t begin to think about the metabolic effects. I do remember hearing about the Atkins diet in like the early 2000s and thinking, “God, that’s crazy.” And-
Dr. Mark Hyman: But it worked for people.
Dr. Ethan Weiss: Well, it did work for people in improving their metabolic health, but we didn’t connect the … I mean, I don’t think we a good job, at least in cardiology, we didn’t connect the relationship between metabolic health and sort of cardiovascular health until relatively recently. I think that’s been [crosstalk 00:20:57]-
Dr. Mark Hyman: It’s fascinating because the numbers that really go awry that predict heart disease, even the conventional biomarkers, it’s not the total cholesterol. It’s the HDL ratio, it’s the triglyceride ratio. Those are determined more by your blood sugar control and your insulin levels. That’s something that people don’t understand, I think. People think about cholesterol and they just think about fat. But it’s actually the sugar that makes your body make more cholesterol. [crosstalk 00:21:27]-
Dr. Ethan Weiss: It’s true to some extent. There’s some strong component of genetics as well. But in terms of the things that you can control, and I always talk about this with people, with patients, it’s what are the things that you can control, what are the things you can’t control. In terms of the things that you can control, there are two levers you can pull on. One is the amount of carbohydrate and the other is the amount of fat and particularly saturated fat. I think that’s sort of one of the things that’s different and evolved in the recent past for me and thinking about the ketogenic diet. Is considering sort of saturated fat, which was when I first got into this, was something I didn’t [crosstalk 00:21:59]-
Dr. Mark Hyman: No, it was the enemy number one, right?
Dr. Ethan Weiss: Well, yeah. It was the enemy and then it wasn’t the enemy. Then now I’m not sure, maybe it’s in between.
Dr. Mark Hyman: Yes. I think you’re right because here’s the deal. Everybody hears about the best diet. There is no such thing.
Dr. Carrie Diulus: No.
Dr. Mark Hyman: There’s the best diet for you. Some people, like I’ve had patients who I put a ketogenic diet who’ve had been resistant to weight loss, whose cholesterol is like 300 and their triglycerides are 300 and their HDL is very low. They’re struggling. I put them on butter and coconut oil and they dropped the weight. Their cholesterol comes down 100 points, their triglycerides drop 200 points, their HDL goes up, all their metabolic markers get better, their inflammation comes down. You’re like, “Wow, this is impressive. This is the cure for everything.” Then you have another patient who’s the opposite, who has got these lipid issues and you try to treat them with a higher fat diet and they actually get worse. It’s interesting, there’s a lot of what we call heterogeneity in the population. Genetically, we’re all different, we all respond differently. Some people respond worse to carbohydrates, some people respond worse to fats. It’s very hard sort of for people to figure it out.
Dr. Mark Hyman: I think that universally saying everybody should be this keto, or everybody should be low carb, or everybody should be low fat, just doesn’t make sense. Is that fair to say?
Dr. Ethan Weiss: Yeah, I think so. I think that we all aspire to want to find the perfect diet. I think you’re right, that there probably is no perfect diet. I still hold out some fantasy that there is a best diet maybe. Maybe not perfect, but best. What I mean best, I mean best for most people. I don’t mean … Obviously it’s not going to be best for everyone, but I [crosstalk 00:23:42]-
Dr. Mark Hyman: Okay. You can spill the beans. What is it?
Dr. Ethan Weiss: Well, no. I mean, I think, look I mean-
Dr. Mark Hyman: Don’t keep us waiting.
Dr. Ethan Weiss: I think … Let me step back. I think we all appreciate that the ketogenic diet has done wonders for a lot of people. Particularly the patients that you describe who were overweight and metabolically extremely unhealthy. I think there’s no doubt that the improvements they see are dramatically beneficial. Most of the time, all the improvements go in the same direction. You don’t have to worry about, well 30 markers go in the right direction but one goes in the wrong direction. Those people, I think, there’s very little controversy about, and they can thrive in a ketogenic diet. It’s this other group of people where you see this discordance in the movement of the markers where I think there’s the most conversation. What I’m specifically talking about is, there are some people who will go on the ketogenic diet. All their metabolic markers will move in the right direction. So [crosstalk 00:24:30]-
Dr. Mark Hyman: Insulin and blood sugar-
Dr. Ethan Weiss: Insulin, and glucose, A1C, all that stuff, moves better. Inflammation gets better. But then they see what would give me or my colleagues a heart attack in terms of the movement of their cholesterol. I think what that is-
Dr. Mark Hyman: What happens to their cholesterol?
Dr. Ethan Weiss: Their cholesterol … When we talk about cholesterol, as you mentioned, that we used to just paying it into the total and then it became this LDL cholesterol. Now I think we’re paying more attention to non-HDL cholesterol. So it’s the total cholesterol minus the HDL. Or really it’s the ApoB … Apolipoprotein B is a lipoprotein that carries around these cholesterol molecules. That one is thought to be the most dangerous one. When those go up, whether it’s LDL or non-HDL or ApoB or LDL particle number, any of those things go up to a large degree that makes people like me nervous.
Dr. Mark Hyman: Yeah. By the way, just to stop. Most cholesterol tests that doctors do are I believe are antiquated. We should be looking at ApoB and ApoA1, which you should ask your doctor for and also looking at, what we call NMR or Cardio IQ. Which are tests to look at particle number and particle size. Which turns out to be more important than just the absolute number you get on your regular cholesterol test.
Dr. Ethan Weiss: Yeah. There’s a ton of controversy even within that world of … There are people who are sort of minimalist who think you can get everything you need out of like the non-HDL, so total minus the HDL. Which I think is a bare minimum. Then there are people who think you have to measure ApoB specifically or people who think you have to do this NMR or even this ion mobility test to look at the LDL particle number and look at the LDL particle size. I’m not going to weight into that controversy. I think most people, 90 plus percent of people, there’s concordance between non-HDL cholesterol, ApoB and LDL particle number. Which are the three markers that I [crosstalk 00:26:13]-
Dr. Mark Hyman: Yeah. Then what happens to these other patients who maybe aren’t really overweight, but want to try a ketogenic diet to lose a little weight or to get healthier or to performance. What happens to these people?
Dr. Ethan Weiss: Right. Those people have this very alarming increase in their bad cholesterol. What we used to call LDL cholesterol. Now non-HDL ApoB. And-
Dr. Mark Hyman: Including the small particles and the total particles?
Dr. Ethan Weiss: Yeah. Although not necessarily the small particles. I think that people on a low carbohydrate diet tend to have more of the larger particles. Again, tons of debate if that matters. But the total particle number is increased. There’s a difference in the pattern. The total particle number is increased. But regardless, the result of that makes some people very nervous. It makes other people less nervous. There’s this sort of resulting debate about, does it matter and does it matter in the context of all the other positive things that have happened? My take on that is, we don’t know if it matters and we probably won’t know if it matters for quite a long time. But we have an enormous amount of evidence supporting the fact that increases in these kinds of cholesterol over the lifetime of an individual does matter. If you want to wait around to figure out if it does matter, you’re going to be waiting a long time and it may be too late.
Dr. Ethan Weiss: My take is, if you could do this diet, which we all love … I’ve been practicing myself for almost two years. If you can do it without the scary looking cholesterol numbers, why wouldn’t you do that? For me, it kind of comes down to a hedge. What we’ve been working on is trying to develop a diet where you can get all of the benefits of this low carb, high fat ketogenic diet, but without that one [inaudible 00:27:54] that bothers-
Dr. Mark Hyman: Is that because it’s plant-based fats versus animal fats?
Dr. Ethan Weiss: Yeah. I mean, there’s evidence going back now 50 years or probably in that range, that increased dietary intake of saturated fats causes an increase in these LDL cholesterol numbers. You can basically … A typical sort of conventional ketogenic diet is rich in butter, bacon, lard, steak, things that are pretty high in saturated fat. You don’t have to do a ketogenic diet with a high saturated fat diet. You can do it with unsaturated fats, a mono or polyunsaturated fats. Whether those come from plants or potentially from animals like fish, really rich in mono unsaturated … Sorry. Omega-3 polyunsaturated fat. Whether you choose to do it entirely plant-based or you do it with plants and fish or plants and other animals that are lower in saturated fat, that’s a choice that any individual can make. But that’s what we’ve been working on is trying to develop options for people who don’t want to wait around to figure out if that cholesterol rise is a problem.
Dr. Mark Hyman: Not all saturated fats are created equally, right?
Dr. Ethan Weiss: No.
Dr. Mark Hyman: They have different effects on fat, on your lipids. For example, my understanding is that the stearic acid, that’s the most common saturated fat in meat actually doesn’t really affect your blood cholesterol.
Dr. Ethan Weiss: That’s right. There are a tons-
Dr. Mark Hyman: Yet-
Dr. Ethan Weiss: Yeah.
Dr. Mark Hyman: … others might. Like coconut oil will but it also increases the HDL more and the size of the particles. There’s such a variable response.
Dr. Ethan Weiss: It becomes head spinning. But again, you have to make a choice. This is a choice that is on the one hand, empowering for people because they don’t have to have a doctor like any of the three of us write a prescription for you. You can do this on your own. But yet it’s daunting for people because they’re confused and frankly, so am I my sometimes. I think it’s a place where we have to be humble and kind of recognize that this is not easy.
Dr. Mark Hyman: If someone wants to be on a ketogenic diet and their cholesterol is up, you put them on a statin?
Dr. Ethan Weiss: Well, what I tell people … Again, this is coming from the perspective of me as a cardiologist trained in the Western world. What I tell people is, you have options. If you love eating the way you eat, and your diet includes a lot of saturated fats, of butter and bacon and lard and stuff like that, and you don’t want to change that, then you have an option. You can take a statin or you can ignore your cholesterol. I would recommend you take a statin or some other cholesterol medication. But if you choose to not want to take a medication, there are other options. You can modulate this with diet and nutrition itself. I’ve had a lot of patients have a lot of success in doing that in taking in replacing all of that. Because I think some people feel like you have to do it. Because the keto diet is so strongly associated with bacon that people feel like, “Oh well that has to be the way it has to be done.”
Dr. Mark Hyman: It’s the gateway food.
Dr. Carrie Diulus: Right.
Dr. Ethan Weiss: Right. But-
Dr. Mark Hyman: It’s like the gateway drug for eating meat.
Dr. Ethan Weiss: … the point, you don’t … It took me a little while to figure that out too. You don’t actually … In fact, because of the way the biochemistry works, it’s actually easier to oxidize unsaturated fats. It’s easier to get into ketosis. It’s actually easier to do the ketogenic diet on a diet that’s predominantly unsaturated fat than saturated fat. This is something that through being introduced to Carrie and other people, it’s been an awakening for me that this is possible.
Dr. Mark Hyman: Ethan, just to sort of go down this rabbit hole a little more, the saturated fat question is sort of sticky. I think it’s so variable how people respond to it. I think there are people who are what we call, Lean Mass Hyper-responders, who do end up with this high cholesterol. It is worrisome because I think there’s increasing data that your lifetime exposure of your arteries to the cholesterol elevations is what matters. It’s sort of a new metric and sort of like life years of LDL or something.
Dr. Ethan Weiss: Yeah. It’s pack years for smoking. Same thing, yeah.
Dr. Mark Hyman: That creates a risk. In the whole field, you’re talking about eating now more of the polyunsaturated fats. I just want to dive a little bit into this rabbit hole of omega-6, omega-3, saturated fat. And I-
Dr. Ethan Weiss: My favorite topic.
Dr. Mark Hyman: Yes. I’ve tried to understand this, I read a lot of the signs myself, I talked to experts. Everybody has got a different opinion, everybody. There’s epidemiologists, there’s trialists, they all disagree. The rest of us are stuck in the middle. We’ve had about 1,000% increase in the intake of soybean oil in this country in the last 100 years. These refined oils were really never part of our diet historically. We had olive oil, we had some oils that were nut and seed oils. But the bean and seed oils that we’re having, what we call plant-based oils, are a relatively new phenomenon and they’re very unstable. They’re easily oxidized. They’re produced in ways that are using heat and solvents to extract the chemicals that are often filled with glyphosate, if it’s soybean oil. That’s a sort of a side point. But how-
Dr. Carrie Diulus: How many rabbit holes are we going?
Dr. Mark Hyman: How do you-
Dr. Ethan Weiss: [crosstalk 00:32:55] there’re a lot.
Dr. Mark Hyman: How do you navigate this controversy between those who say we should be eating way more plant oils and less animal oils and navigate that as a cardiologist? Because when I hear you say eat more like soybean oil or-
Dr. Ethan Weiss: I never said that.
Dr. Carrie Diulus: Wait. We never said that.
Dr. Mark Hyman: I know you didn’t say it but you said-
Dr. Ethan Weiss: I never said that.
Dr. Mark Hyman: But you did say-
Dr. Carrie Diulus: We’re almost sitting here, we’re like …
Dr. Mark Hyman: You did say-
Dr. Ethan Weiss: I never said that.
Dr. Mark Hyman: Okay. But that’s what people are going to be hearing. When you say polyunsaturated fats, people here, okay [crosstalk 00:33:18]-
Dr. Ethan Weiss: [crosstalk 00:33:18]-
Dr. Carrie Diulus: [crosstalk 00:33:18], yeah.
Dr. Mark Hyman: Then they hear all these oils. So I’m glad you don’t agree, but I want to hear your perspective on this. Can you unpack that for us a little bit? For the average listener who is not an expert in lipidology.
Dr. Ethan Weiss: Well, I mean I don’t know how detailed we want to get in sort of the chemistry of fatty acids. But let’s skip that. Let’s just focus on the sort of what. I think-
Dr. Mark Hyman: Well, let me just say quickly. Saturated fats are basically solid at room temperature.
Dr. Ethan Weiss: That’s right.
Dr. Mark Hyman: They’re more stable and less easy to oxidize or damage. Polyunsaturated fats are more fluid, liquid at room temperature and they’re more easily damaged by oxygen or basically various [inaudible 00:33:59] that can create oxidation which causes the damage to the cholesterol.
Dr. Ethan Weiss: That’s right. It has to do with the number of double bonds and it makes the [crosstalk 00:34:07]-
Dr. Mark Hyman: Yeah, it’s the chemistry stuff. But it’s essentially one unstable, one stable, unstable.
Dr. Ethan Weiss: Look, I don’t like processed food at all. There are some people who will make the argument that olive oil is processed food. Olive oil is processed in what seems to me at least to be a pretty normal and natural way. You take an olive and you crush it. I’m okay with that. When it comes to-
Dr. Mark Hyman: Not too many steps. There’s no hexane or solvents or-
Dr. Carrie Diulus: Right.
Dr. Ethan Weiss: No. I think that kind of stuff makes me nervous too. As to the sort of relative effects, you’re not going to get me to bite on the relative potential damage of polyunsaturated versus saturated fatty acids. But you will get me to bite on the processed food bit. I’ll just tell you what I do and it’s probably not that different from what Carrie does. I get my unsaturated fat from a limited number of sources. In terms of oils, Carrie mentioned avocado and olive oil. Those are the only oils I use.
Dr. Mark Hyman: Yes, me too.
Dr. Ethan Weiss: The only oils-
Dr. Carrie Diulus: Same here.
Dr. Ethan Weiss: … I touch, I cook with or use them for salad dressings or sauces or anything else.
Dr. Mark Hyman: You never use ghee or anything like that?
Dr. Ethan Weiss: I don’t use ghee.
Dr. Mark Hyman: Coconut oil.
Dr. Ethan Weiss: I will occasionally … I’ll get killed by a number of people. The other night I made a stir fry for my kids and it called for a tablespoon of sesame oil. Kill me.
Dr. Mark Hyman: Why?
Dr. Ethan Weiss: One tablespoon. I don’t know. It was an-
Dr. Carrie Diulus: Flavor.
Dr. Ethan Weiss: … Asian dish and I wanted the [crosstalk 00:35:23]-
Dr. Mark Hyman: Why would people kill you?
Dr. Ethan Weiss: Because people are nervous about these seed oils because of all these methanes you mentioned. That they think that they’re easily oxidizable and therefore inflammatory and unstable.
Dr. Mark Hyman: You worry about that then?
Dr. Ethan Weiss: No, I don’t really. But [crosstalk 00:35:35]-
Dr. Mark Hyman: Well, then why don’t you eat safflower oil or canola oil?
Dr. Ethan Weiss: Because I don’t like it. I like olive oil and avocado oil and it’s simple and easy.
Dr. Mark Hyman: But it’s more than just that? You don’t think they’re safe to eat.
Dr. Ethan Weiss: I do-
Dr. Mark Hyman: Otherwise you wouldn’t be-
Dr. Ethan Weiss: I don’t like-
Dr. Mark Hyman: … avoiding them.
Dr. Ethan Weiss: This is good. I don’t like-
Dr. Mark Hyman: I don’t buy that.
Dr. Ethan Weiss: I don’t like … I’m going to bite again on the processed thing. I don’t like … I’m not a food expert. So I haven’t gone to the factory to see how they make these things. But to me it’s very simple to conceive of how they make olive oil and avocado oil. I’m good with that. I love fish. I mean, I’ve done a plant-based experiment for a week and it’s doable. But I-
Dr. Carrie Diulus: You liked it, admit it [inaudible 00:36:14].
Dr. Ethan Weiss: I wouldn’t say that I liked it. I didn’t-
Dr. Mark Hyman: Like what?
Dr. Carrie Diulus: He did a plant-based. We got him to do a fully plant-based week.
Dr. Ethan Weiss: Yeah. It was not nearly as bad as I thought it was going to be. But it was-
Dr. Mark Hyman: Keto? Keto plant-based?
Dr. Ethan Weiss: plant-based [crosstalk 00:36:27]-
Dr. Carrie Diulus: Keto plant-based.
Dr. Ethan Weiss: Yeah.
Dr. Mark Hyman: Yeah.
Dr. Ethan Weiss: Carrie helped me walk through that. As we were launching this, we were launching this program for people who want to do plant-based keto with this company that I’m involved with. I just thought, “Well look, if we’re going to do this, I need to try it and see if it’s actually doable.” It was definitely doable and I think it was a great experiment for me to have done. Again, my diet is 90 plus percent plant-based. The place where I get animal protein is from fish. I mean, I’ll have some chicken and occasionally I’ll have something else. But mostly I would say 90% of the meals that I eat are either plant or plant and fish.
Dr. Mark Hyman: You’re a fish, vegan, keto guy?
Dr. Ethan Weiss: Not vegan. I will eat-
Dr. Mark Hyman: I mean-
Dr. Ethan Weiss: … cheese. I’ll eat some cheese, mostly hard cheeses. Not a ton, but I’ll eat some hard [crosstalk 00:37:16]-
Dr. Mark Hyman: You’re kind of what we call a pegan. Mostly plant-based, but with some animal protein [crosstalk 00:37:20]-
Dr. Ethan Weiss: I like think of it as Mediterranean keto. I think it’s really like a Mediterranean … I mean to me it feels like a Mediterranean keto. It’s like the Mediterranean diet without the bread and the pasta. It’s what I think.
Dr. Mark Hyman: What’s happened to your numbers when you do that?
Dr. Ethan Weiss: My numbers were pretty good to begin with and I haven’t checked them in a year, but they looked really good.
Dr. Mark Hyman: On a keto diet?
Dr. Ethan Weiss: Yeah.
Dr. Mark Hyman: You weren’t one of those Lean Mass Hyper-responders?
Dr. Ethan Weiss: No.
Dr. Mark Hyman: But you weren’t also eating saturated fat?
Dr. Carrie Diulus: But you never did bacon and butter-
Dr. Ethan Weiss: I did it-
Dr. Carrie Diulus: … heavy. Do you?
Dr. Ethan Weiss: … a little bit at the beginning. When I was first experimenting with keto, I did because I thought you had to. I mean, there’s no way to do this unless you eat all this fat and where am I going to find the fat?
Dr. Mark Hyman: As a cardiologist you’re doing this for your patients?
Dr. Ethan Weiss: Yeah.
Dr. Mark Hyman: What are you seeing?
Dr. Ethan Weiss: Well, again it’s the same thing they were all seeing. Some people it’s a no brainer. It’s easy. I should say that for people who go on this diet and they’re eating a lot of saturated fat and their numbers all look good, I have no problem with that. I don’t have any belief that eating saturated fat in the absence of the effects on cholesterol and lipids and other markers that we … If that works for you, then great. Then for the people who have trouble, that’s where we earn our money. That’s where we get to play this game. It’s been great to have options for people, whether it’s plant-based or plant fish or whatever you want to call it. I think that’s what we’ve been focusing on as providing people an option that’s beyond having to take a medicine. Which again, is still out there. Look, there’s a lot of bad stuff written about statins. We’re not going to debate statins here.
Dr. Mark Hyman: No, that’d be fun.
Dr. Ethan Weiss: But it’s-
Dr. Mark Hyman: We’re at the Cleveland Clinic, that could be fun [crosstalk 00:38:49]-
Dr. Ethan Weiss: But I’m a strong believer in the power of statins. I don’t take a statin myself and I know that I probably would do a lot to change my diet before I would take a statin. But I also wouldn’t not take a statin.
Dr. Mark Hyman: Yeah.
Dr. Carrie Diulus: I see it in my patients. I put almost all of my surgical patients on the ketogenic diet of varying forms, depending on where they come to me. I do have some people who are plant-based at the beginning. Probably about 80% of them end up staying on it after surgery because they like-
Dr. Mark Hyman: How they feel.
Dr. Carrie Diulus: … the results of it. The people who I’ve had struggle with their lipids, the vast majority of them … Again, this is anecdotal. It’s not something that I can quantify or that we formally studied. But by making this shift … I actually think we need to talk about the fiber side of it too with the plant-based. Because I think that’s a really significant factor in addition to just the fats. I think the important part is-
Dr. Mark Hyman: Because a lot of times if you’re on a ketogenic diet, it’s hard to get enough fiber.
Dr. Carrie Diulus: Well, and this is one of the criticisms that was in the article that was published earlier this year in JAMA about was that the ketogenic diet was low in fiber. My argument … We have a mutual friend, Danielle [Gallardo 00:40:02] who is a staunch ethical vegan and she did a two week plant-based keto. Her fiber intake was 80 to 100 grams per day.
Dr. Mark Hyman: Okay. That’s like 10 times what most Americans get.
Dr. Carrie Diulus: Right. But her net carbs … We can talk a little bit about that. But this whole argument about the seed oils and things like that … People will frequently, when I say I do plant-based keto, that’s the first thing that they say is, “Well, you’re eating all these seed oils.” I have no seed oils. I have olive oil, some avocado oil, and then occasionally if I’m baking something, I’ll use some coconut oil. But otherwise I eat whole nuts and seeds whole.
Dr. Mark Hyman: Yeah. I think that’s really important, Carrie. I mean, what you’re saying and what you’re saying, Ethan, is that you can eat any kind of oil as long as it’s in its original packaging.
Dr. Ethan Weiss: Yeah.
Dr. Mark Hyman: Eat the nut.
Dr. Carrie Diulus: Eat the-
Dr. Mark Hyman: Eat the seed or eat the bean. Right.
Dr. Ethan Weiss: I mean, Carrie knows I eat, I don’t know, at least a fistful of macadamia nuts a day. I love them.
Dr. Mark Hyman: Yeah, I love that.
Dr. Ethan Weiss: I love them.
Dr. Carrie Diulus: Yeah.
Dr. Ethan Weiss: Yeah.
Dr. Carrie Diulus: I mean, I think those are all options.
Dr. Mark Hyman: Those are like the olive oil of nuts. They have a lot of-
Dr. Ethan Weiss: They’re so good.
Dr. Mark Hyman: [crosstalk 00:41:14] myself.
Dr. Carrie Diulus: Yeah, they’re fantastic. I mean, and that’s the thing. It’s not free either. This is one of the things that calories do still matter and people you know will struggle on the ketogenic diet. They’ll eat too much protein. I think we see that and some of the other studies that are out there with the more traditional ketogenic diet. They found that women in particular seem to struggle if they get too much protein on it. It prevents them from getting into ketosis. I have a lot of patients who are measuring their ketones through the acetone breath meter and that’s what they’re finding. Is that we have to shift them to more of the high fiber, non starchy vegetables, more avocado, more olive oil and dial back whatever their protein source is. Whether it’s a plant-based protein-
Dr. Mark Hyman: Because protein gets turned into sugar in the body. If you take-
Dr. Carrie Diulus: It does.
Dr. Mark Hyman: … too much.
Dr. Carrie Diulus: I mean, through-
Dr. Mark Hyman: It also-
Dr. Carrie Diulus: Yes.
Dr. Mark Hyman: … increases insulin.
Dr. Carrie Diulus: It increases insulin. That’s for sure. I mean, amongst the Type 1 diabetic community people will … There’s this insulin index that was out there that was studied a number of years ago and the vast majority of us have a very different, particularly those of us on a low carb diet, we actually bolus for protein. Which is not something that’s traditionally taught in the-
Dr. Mark Hyman: Meaning you give it extra insulin if you’re eating extra protein.
Dr. Carrie Diulus: Extra protein. But what the protein source is matters. Lupini beans for example, which are an Italian bean, has zero net carbs. I don’t bolus for the carbs that are in them. The protein that’s in there, because it comes along with fiber, I’ll give insulin for about half of that. Fish typically need very little insulin for the protein, the amino acids that are in the fish. But something like steak, almost all Type 1 diabetics that I know will report that they need much more insulin for steak than they do for fish. Then chicken is sort of somewhere in between there. Of course the amount of fat that you eat and things like that matter too.
Dr. Mark Hyman: But it’s interesting though, if you look at people who are Type 1 diabetic, when the pancreas fails, they produce no insulin. They could eat 10,000 calories a day and lose weight because they have no insulin and insulin is required to actually store fat. When you’re eating protein, you’re obviously getting insulin and you’re eating some carbs when you’re on a ketogenic diet. But that’s a really important thing for people understand. Is that insulin is really the key hear. Eating in a way that keeps your insulin low, there’s a lot of ways to get there. Ketogenic is one of them, but there are other ways.
Dr. Carrie Diulus: Fasting, intermittent fasting, things like that. For sure, all of those things can be factors to lower insulin levels. It’s not to say that you don’t need some insulin. Obviously, that’s one of the criticisms people will say, “At what point is insulin … What is the ideal insulin level?” Ultimately for me, it’s where are you at from a performance standpoint? I look at with running, how much insulin do I need to take so that I can run as long as I want to run and be in the perceived exertion that I want to be and at the pace I want to be in. Those are all things that I’m playing with and there’s different people out there who are playing with that. I mean, Zach Bitter just broke the world record for the 100 mile in just over 11 hours.
Dr. Mark Hyman: While on a ketogenic diet.
Dr. Carrie Diulus: Although it depends on what point in his training he’s at. He eats a ketogenic diet. Although because he burns so many calories, he at different times of his training will increase his glycogen stores by adding things like sweet potatoes and things like that. Yet the vast majority of the time he remains in ketosis. I mean, one of the beauties of being in ketosis and doing endurance sports is your body is so efficient at burning fat. I used to do these long races in my 20s and doing them now. You had to carry a carbohydrate along with.
Dr. Mark Hyman: I mean, you used to … This is for people who would understand. Your body can store by 2,500 calories of glycogen and carbohydrate in your muscles. Which you burn through pretty quickly if you’re doing endurance athletes. But you have 30, 40, 50,000 calories of fat on your body, then you can access if you’re on a ketogenic diet. Which gives you a much more sustained energy sources.
Dr. Ethan Weiss: Carrie’s point is that the capacity to burn those fats is increased when you’re fat adapted. Jeff Volek did a study I think in athletes-
Dr. Carrie Diulus: Faster, yeah.
Dr. Ethan Weiss: … a few years ago. It was the capacity for beta oxidation was increased by like three or four fold in these-
Dr. Mark Hyman: You runs a lot faster and you can run a lot further and [crosstalk 00:45:45]-
Dr. Ethan Weiss: Yeah, and you’re better at burning fat. Basically, your body’s adapted to learning how to burn fat.
Dr. Carrie Diulus: You can be … I mean, there are plenty of athletes that use the more traditional model and Volek has talked about this, that there’re very good athletes burning predominantly carbohydrate. But you can burn predominantly fat. One of the benefits of it, if I go out and do a really long run, the difference now is I take along some emergency carbs because I’m a Type 1 diabetic. But otherwise I can run for three or four hours or more-
Dr. Mark Hyman: Which you just did. You just ran a 50 kilometer race, right?
Dr. Carrie Diulus: I did.
Dr. Mark Hyman: That’s impressive. You missed my birthday, but it’s all right. I forgive you.
Dr. Carrie Diulus: I’m sorry. It was on my schedule before … I really wanted to do it.
Dr. Mark Hyman: I said not save a date in the summer.
Dr. Carrie Diulus: If I hadn’t signed up for like eight months ago.
Dr. Mark Hyman: All right, I’ll forgive you.
Dr. Carrie Diulus: All right.
Dr. Mark Hyman: I have a question. Historically we would have periods of feast and famine. There’d be scarce times in the winter and we’d have abundance in the summer, et cetera, et cetera. We were in and out of keto historically. Do you think it’s-
Dr. Carrie Diulus: Probably.
Dr. Mark Hyman: … important for people to go in and out? Or is it okay to be on sustained keto your whole life? I mean, how do you guys sort through that?
Dr. Carrie Diulus: I mean, here’s the thing, I think we don’t know the answer to that unless you know of some knowledge that … The human species is incredibly adaptable. I think the problem comes into if you already have a metabolic problem. Do you need to stay on carbohydrate restriction to keep that in check? I mean-
Dr. Mark Hyman: When you spend your life screwing up your metabolism, do you need to stay on it to keep it in check? Because once you’ve kind of got to Type 2 diabetes, it’s pretty far along and you’re kind of on a knife edge.
Dr. Carrie Diulus: Whereas I think the ideal goal, for people who are not already there, is to be metabolically flexible. To where you can go in and out of ketosis without difficulty. You exercise to whatever your particular sport is. Whether it’s endurance or lifting or short bursts of things. I think that’s ideally is to where there is not … I wouldn’t take my kids and put them on a sustained ketogenic diet. I want my kids to be metabolically-
Dr. Mark Hyman: Flexible. That’s called health. It’s called how we age well. Right. What’s your perspective on that?
Dr. Ethan Weiss: I mean, I guess well to be fair, we don’t know or we don’t have a randomized controlled trial over 75 or 100 years.
Dr. Mark Hyman: What’s your gut tell you?
Dr. Ethan Weiss: My gut tells me, and I’ll tell you … I mean my gut … I’ve been in nutritional ketosis mostly almost every day since March of 2018 so almost two years. There’ve been a few times where I … Well, one thing is that being fat adapted means you can expand your intake of carbohydrates and stay in ketosis. I’ll go out and have sushi with my kids with rice at least a couple of times a month and stay in ketosis. I …
Dr. Carrie Diulus: But you’re metabolically-
Dr. Mark Hyman: How do you feel? Do-
Dr. Carrie Diulus: … healthy, right?
Dr. Mark Hyman: … you feel different?
Dr. Ethan Weiss: I don’t if I stay in ketosis. If I’ve had a couple of things like birthdays and stuff where I’ve like said, “Screw it, I’m going to have …”
Dr. Mark Hyman: Eat a cake.
Dr. Ethan Weiss: … “a piece of cake.” I felt … Can I say bad words?
Dr. Mark Hyman: Yes, sure.
Dr. Ethan Weiss: I felt like (beep). I felt so sick that-
Dr. Mark Hyman: Is that [inaudible 00:48:51] now like a medical diagnosis, FLS?
Dr. Ethan Weiss: I mean, I felt the equivalent of like a bad hangover. It really felt awful to me to the point where I was like, “I don’t really want to do this. I don’t feel good doing it. It doesn’t … I’d rather …” I actually enjoy the way I eat. I don’t see any reason not to. Every single parameter I can measure. Most notably my weight size. When I went from … My wife the other day was asking me what I wanted for the holidays. She was talking about … She said, “Remind me again what your waist size is.” And I said, “It’s 32.” She said, ” You know that two years ago you were at 36.” I said, “I forgot.”
Dr. Mark Hyman: Which is one of the biggest determinants of your risk for heart disease is your waist to hip ratio.
Dr. Ethan Weiss: Yeah. I mean, in addition to all the other things that we’ve talked about and I mean, and I feel good. I ski better. There’s everything about it-
Dr. Mark Hyman: You ski better. Well, that’s a good-
Dr. Ethan Weiss: Well, it is. It was … I do. That’s important to me. As doctors, we have the ability to impact people in two ways. We can make them feel better or we can make them live longer [crosstalk 00:49:47]-
Dr. Mark Hyman: Or both hopefully.
Dr. Ethan Weiss: Yes. I hope to be able to do at least one.
Dr. Mark Hyman: Well, let’s talk about the live longer thing. Because I think there’s been so much talk about the varying ways to achieve longevity through diet. Historically, the one thing that’s been proven without a doubt in animal models is calorie restriction. Calorie restriction has a number of things that it does to the body. It actually improves the cleaning up of the waste in the cells called autophagy. It makes you more insulin sensitive, so you’re not insulin resistant. It actually speeds up your metabolism. It increases antioxidant enzymes and reduces inflammation and it helps your neurotransmitter function, your cognitive function, your bone density. It increases stem cell production. It does all sorts of things that actually are very powerful. In fact, I was just reading an article in The New York Times last night about this couple that sort of were lovers in Auschwitz. They sort of lost each other after the war. They survived the concentration camps, but they were pretty starved in there. She died at over 100 and he’s like 93 and still going.
Dr. Mark Hyman: It made me wonder about, wow, was it partly their longevity due to this calorie restriction? But so there’s this whole phenomenon of calorie restriction, but then you don’t want to be starving all the time. We shouldn’t be miserable. I met a guy who was on a calorie restriction program. I’m like, “What did you have for breakfast?” Like, “Five pounds of celery.” I’m like, “No, thanks.” But there are other technologies and other ways of eating that seem to do the same thing. Ketogenic diets, intermittent fasting, which is sort of alternate day fasting or fasting a day a week or a week long fast. Time restricted eating was eating with a narrow window like eight or 10 hour window during the day or ketogenic diets. They all seem to do the same thing. Could you talk about these different approaches and what do we know? You’ve studied this, you looked at the data. Where are we going with all this? How do we use this both for metabolic health, for longevity, for all kinds of illnesses?
Dr. Ethan Weiss: Yeah. I mean, we could probably talk for two hours on this whole subject. I could, I’m sure Carrie-
Dr. Mark Hyman: I think we can. We’ve got a couple of more.
Dr. Ethan Weiss: … could too. Let me just simplify this. I think with all the evidence we have so far on life extension has occurred in animal models. A lot of that has occurred in animals like worms. While we have learned a lot from worms, worms are very different from people.
Dr. Mark Hyman: Although we share a lot of the same DNA.
Dr. Ethan Weiss: We do. Although if you look at the sort of the pathway that seems to be most high … If you were going to do-
Dr. Mark Hyman: Plus mice and other animals.
Dr. Ethan Weiss: Let me turn it to you. If you had to pick one pathway that is the most strongly associated with longevity in animal models, which one?
Dr. Mark Hyman: Well, it’s interesting because I was at a conference on aging when the Dalai Lama and all these scientists. This guy from MIT was Leonard Guarente who has worked with these worms and SIR2 and pathways. I said, “So Leonard, what is the deal with aging? What is the thing here with SIR2? What’s going on?” He says, “Well, it’s really all about insulin resistance and sugar.” It’s like the thing that’s driving it all. I would say the one pathway that it really regulates is nutrient sensing and insulin signaling. I think by fixing that you’re doing a lot to help with aging. Which is what causes … I’ve read about this for decades. Is insulin resistance drives heart disease, cancer, diabetes, Alzheimer’s, depression and more.
Dr. Ethan Weiss: Yeah. I mean, I think that the … Well, you can argue back and forth whether it’s insulin or IGF-1 or growth hormone. It turns out that a lot of animals and the growth hormone itself evolved only in vertebrates. There is no growth hormone and in [crosstalk 00:53:13]-
Dr. Mark Hyman: Worms.
Dr. Ethan Weiss: … in worms. I think what we’re doing is trying to learn a lot from these animal models. The problem with doing aging experiments in people is that none of us are going to be around to see the results. If you do an aging experiment on a mouse, you take a mouse that normally lives to be two years. If you could make that mouse live to be four years, it’s a Nobel prize. But the equivalent in people would be to do a study that makes people go from living [crosstalk 00:53:42]-
Dr. Mark Hyman: 80 to 120.
Dr. Ethan Weiss: No one’s going to be around to see that.
Dr. Mark Hyman: I am. I’m planning on it.
Dr. Ethan Weiss: Look, I think-
Dr. Mark Hyman: I just turned 60. I call it my first 60 years.
Dr. Ethan Weiss: I just turned 50. I think the-
Dr. Carrie Diulus: I’m not there yet.
Dr. Mark Hyman: No way.
Dr. Carrie Diulus: Almost 50.
Dr. Ethan Weiss: She’s [crosstalk 00:54:00]-
Dr. Mark Hyman: No, you’re not.
Dr. Carrie Diulus: I’m 46.
Dr. Mark Hyman: Well, that’s not almost 50. I’m kidding.
Dr. Ethan Weiss: That’s like me saying I’m almost 60.
Dr. Carrie Diulus: Okay. No, it’s not.
Dr. Mark Hyman: All right.
Dr. Carrie Diulus: Okay. I’m on the other side of 40.
Dr. Mark Hyman: There you are.
Dr. Ethan Weiss: Well, anyway, I think what we’re going to be doing at best for the time being is going to be extrapolating. Trying to integrate what we know from the biology, from the animal models as best we can. I always try to stay humble because the work that I’ve done in my laboratory over the years has taught me that we can’t predict a lot of what happens. That biology is super complicated and there’re a lot of feedback loops and feedforward loops and things that-
Dr. Mark Hyman: Right. Like whack-a-mole, you [crosstalk 00:54:38]-
Dr. Ethan Weiss: Yeah, it’s a little hard. I think I try … Again, for my field, the field that I’ve been studying in my lab is growth hormone and growth hormone signaling. That field to me is the best example of this. Because if you go to a growth hormone meeting, you’ll find half the room who believes just religiously that growth hormone is the fountain of youth. That you should be giving growth hormone to prevent aging for longevity. The other half-
Dr. Mark Hyman: [crosstalk 00:55:00]-
Dr. Ethan Weiss: … of the room feels-
Dr. Mark Hyman: It’s the cause of aging.
Dr. Ethan Weiss: Exactly. And I-
Dr. Mark Hyman: I know, “I’m like what the heck?”
Dr. Ethan Weiss: I have my own bias and I’ve interpreted the data how I interpret the data. But I think we have to stay somewhat humble to the fact that it is hard. I mean, it’s a-
Dr. Mark Hyman: Well, it’s interesting. When you’re young, your levels of growth hormone are high.
Dr. Ethan Weiss: Correct.
Dr. Mark Hyman: When you’re old, they go down. I think a lot of people have been using injectable growth hormone as a fountain of youth. But I also see metabolic issues from it.
Dr. Ethan Weiss: Well, it’s true.
Dr. Mark Hyman: [crosstalk 00:55:30] tend to get more weight gain and more diabetes and other issues. Which makes me wonder, maybe it’s not so good.
Dr. Ethan Weiss: Right. I think if you look at the genetics point pretty strongly to the fact that decreased growth hormone or decreased action of growth hormone is probably the single biggest cause of long life. Which doesn’t mean that it doesn’t have other effects. If you don’t have a lot of growth hormone around, you will put on more body fat. You will have more fragile bones and other things like that. But if you’re looking just at how long you’re going to live, I think that answer’s probably pretty clear. That you-
Dr. Mark Hyman: That is.
Dr. Ethan Weiss: That less is more.
Dr. Mark Hyman: Yeah. Back to the original question. You’re sitting in your doctor’s office and you are both sitting there with patients saying like, “I want to live to be 120. How should I eat? Should I intermittent fast? Should I be on time restricted eating? Should I be keto? Should I … Just what should I do?” Because I’m that guy. I’m coming to your office, I’m like, “Okay, docs, you guys know a lot about this. I want to live to be 120. What do I do?”
Dr. Carrie Diulus: I want to go back a little bit and talk about the health span part of it, and put on my orthopedic surgeon hat and bone and musculoskeletal health hat. Because when we’re talking about longevity, we focus a lot on cardiovascular health. But my bias in what I see is that people decline rapidly as their ability to be functionally active goes down. That that then sort of uncovers other problems that they have and compounds them. There’s a phenomenon called sarcopenia of aging. Which is basically where muscle decreases over time. I see it on people’s MRI. I treat people who have trouble walking as a result of nerves being compressed. But we get a lot of back pain, neck pain, even nerve related pain secondary to metabolic disease. It’s not uncommon for people to be-
Dr. Mark Hyman: Metabolic disease, you mean like what? Diabetes?
Dr. Carrie Diulus: Like Type 2 diabetes. It’s not uncommon for people to actually be diagnosed with diabetic neuropathy before they’re diagnosed with Type 2 diabetes.
Dr. Mark Hyman: That means they have nerve damage from blood sugar.
Dr. Carrie Diulus: Exactly. It can damage tendons and things like that. So people will get a frozen shoulder or they’ll get their iliotibial band, which is the big long fibrous band that runs along your legs. So they’ll have pain when they’re walking. For me, when I’m looking at this question about longevity, all of these things matter. But my perspective on it is how do I keep people moving and active as long as possible? How do we use diet for that? One of the benefits that I see, when I put a patient on a ketogenic diet.
Dr. Mark Hyman: Wait. Just yo stop you there for a minute. People have to understand that your diet plays a big role in the amount of muscle and/or fat that you have or don’t have.
Dr. Carrie Diulus: And degenerative changes. There’s studies that show that advanced glycation end product, which are those sticky molecules get stuck to the discs when people think about disc degeneration. Which are the cushions in between their bones and their spine. That is increased with these advanced glycation end products, which are are byproducts of sugar.
Dr. Mark Hyman: Yeah. The sugar get too high, you create this process called glycation. Which is essentially like the crust on your bread or a cranberry leg crust. That happens in your body when sugars and proteins combine to create this inflammatory process.
Dr. Carrie Diulus: Right. When inflammation is high, those things for varying causes, inflammation leads to more arthritic changes. There are some studies that have shown-
Dr. Mark Hyman: At least the muscle loss, at least the diabetes, at least everything.
Dr. Carrie Diulus: Exactly. There are studies that show that if you decrease it, it doesn’t matter how a knee that has bad arthritis … We talk about bone on bone arthritis. But if you decrease the inflammation, it may still not be a functionally lined up knee. But people actually can have relatively little pain with it. Pain is related to the inflammation. When I put people on a very low carbohydrate diet and they start creating these ketones, not to get into the science of it, but there are pathways where those ketones are anti-inflammatory. That’s one of the things that I hear a lot is people say, “Not only did my back pain get better, but my knee pain and my shoulder pain. I’m able to do more.” That for me is one of the biggest things. I still have to remind people. People will come into the office and they’ll still be on the diet, but they’ll have stopped exercising. I’ll say, “Did you stop brushing your teeth?” They’re like, “Well, no. Why would I stop brushing my teeth?” I’m like …
Dr. Mark Hyman: That’s a good line.
Dr. Carrie Diulus: It’s not not different. You have to keep-
Dr. Mark Hyman: No, it’s true.
Dr. Carrie Diulus: … exercising.
Dr. Mark Hyman: I thing that’s true. I think you can do all the right dietary things, but one of the things that happens as you age is you lose this muscle. That what makes people end up in nursing homes, it’s what actually drives all the hormonal changes. When you have less muscle, you have more cortisol. Which is a stress hormone that causes more diabetes and blood pressure issues. You have lower growth hormone. Which you say is good, but I’m not sure it’s totally good in that situation. You make more insulin. Your cholesterol gets worse, you get more inflammation. The muscle is the biggest organ in your body basically, and we don’t pay much attention to it. It’s actually required to be intact if you’re going to age well. That’s the whole question of protein and how much protein need and should you eat protein, do you need animal protein? It’s another rabbit hole. Because a lot of data show that when you’re younger you actually maybe not do as well if you have more protein.
Dr. Mark Hyman: But if you’re older, if you don’t want a protein, you can’t build the muscles. How do you deal with that?
Dr. Carrie Diulus: Or maintain the muscle. I mean, a lot of that data is emerging. But when we look at things … I follow patients’ bone health. You want to make sure that you’re getting adequate protein. Of course people argue about what is the appropriate amount of protein at different points in your life. I don’t think that that science is settled to where I can tell somebody this is specific. I mean, it’s about-
Dr. Mark Hyman: Yeah. Or saying-
Dr. Carrie Diulus: … a gram per kilogram is the recommendations of lean body mass, not total body mass. But that’s totally debatable. My goal is to-
Dr. Mark Hyman: Wait that seems pretty low, right? One gram per kilo of lean body mass and if you’re [crosstalk 01:01:42]-
Dr. Carrie Diulus: Is the minimum required recommendations for the amount of protein.
Dr. Mark Hyman: That’s like how much vitamin C that you don’t need to scurvy. Like 10 milligrams, not very much.
Dr. Carrie Diulus: Right.
Dr. Mark Hyman: Right.
Dr. Carrie Diulus: And-
Dr. Mark Hyman: It doesn’t mean it’s the optimal amount.
Dr. Carrie Diulus: It doesn’t mean it’s the optimal amount. I don’t know that we know the optimal. The problem is, I’ve even found as I’ve shifted sometimes the more I run, the more weight I gain. The then I have to play with it and go back and forth and do these things. I don’t think that … We’re a long way off from knowing what is the optimal diet and how to dial these things in. My message to my patients at this point is, if you’re benefiting from a low carb diet, we continue that. It’s whole real foods. Whether you include animal products or not into it depends on what markers we’re looking at and are you willing to take medications if you need to. We need to get you active and keep you exercising. The exercising part actually it doesn’t help with weight loss, but it does help with building muscle and maintaining muscle. Because what I see is then the end result of it, which is, people fall, they break their hips.
Dr. Carrie Diulus: The data is clear, once you start getting spine fractures where you sneeze and break your back, or you fall and break your hip, your life expectancy dramatically decreases.
Dr. Mark Hyman: Yeah, right.
Dr. Carrie Diulus: Those are important factors. Whatever diet we need to get you on so that you feel good, so that you’re able to go out and be active and live an active life, is the ideal diet for you at that [crosstalk 01:03:19]-
Dr. Mark Hyman: I mean, people are wondering, back to the sort of ketogenic, intermittent fasting thing. If you say, “Well, I’m just going to do time restricted eating. I’m going to eat in an eight hour window. Is that as good as keto?” Or, “I’m going to fast one day a week. Is that as good as keto?” Or, “I’m going to like do a week long fast once every two months.” Well, there’s all these things that people are recommending out there. How do you compare these different approaches and …
Dr. Ethan Weiss: Well, I think the good news is we’re going to have answers soon. I mean, I think there are a lot of people including us doing trials on time restricted eating. Probably other people doing alternate day fasting. The science will catch up at some point, at least in terms of what we know are the effects on markers that we can measure. Carrie brings up a great point, which is we really have to think about what we want to optimize for. If you want to optimize for total years lived or do you want to optimize for health span, quality of-
Dr. Mark Hyman: Both.
Dr. Ethan Weiss: … life, how you feel. My take-
Dr. Mark Hyman: I want to die young as late as possible.
Dr. Ethan Weiss: Here’s one thing. When I give a talk, I love to talk about the things that I learned from my mom and my grandmother that were wrong and how we can unlearn them. One principle, I think in the meantime, while we’re waiting for the science to catch up on, say, intermittent fasting-
Dr. Mark Hyman: You’re not inviting your mom or grandma to the lecture, I hope.
Dr. Ethan Weiss: No, I’m not. But my-
Dr. Mark Hyman: I bet they wouldn’t go on.
Dr. Ethan Weiss: No, I’m not going there. But I think one thing that I was taught as a kid was to eat all the time and to eat [crosstalk 01:04:41]-
Dr. Mark Hyman: Take three meals and snacks and-
Dr. Ethan Weiss: Yeah, and finish-
Dr. Mark Hyman: … eat before bed.
Dr. Ethan Weiss: … in your plate all this stuff. It was basically like a constant, those Jewish grandmother they’re like, “Eat, eat, eat, eat, eat, eat, eat.” I think what I learned by playing around with fasting myself, was that hunger is not linear. That is that when you start to sense feeling hunger, it doesn’t then continue up on this endless slope to the point where you just die. I mean, Carrie hears me talk about this all the time. I tell my kids, my kids will come in the house and they’ll say, “Dad, I’m starving.” I’ll say, “Are you?” They’ll say, “Yes, I’m starving.” I say, “Well, when do you actually starve to death? When will that happen?” They’re like, “I don’t know. Soon.” I’ll say like, “Well, what’s the longest that anyone’s ever lived without food?”
Dr. Ethan Weiss: They can’t even fathom that there’s a guy that’s lived for 300 and something days and that … Cahill do these experience where people were living for 30, 40, 50 days. I said, “I guarantee you, you, even though you’re tiny, you could live at least 10 days without any food.” I think one of the things that fasting does, is it teaches you to tolerate hunger a little bit more. I think one mistake that we make is eating when we don’t, because calories do matter. Despite all the other things-
Dr. Mark Hyman: Even when we’re not hungry.
Dr. Ethan Weiss: … we’ve talked about, the amount of food you eat will impact your metabolic health and your weight. If you’re not hungry-
Dr. Mark Hyman: It’s more like eating for sport, I shouldn’t do that?
Dr. Ethan Weiss: If you’re not hungry, don’t eat. I mean, I think this is one of the things. This comes to the breakfast thing. We’re doing a randomized trial comparing time restricted eating in an eight hour window to eating three meals a day. The way we designed the study was to skip breakfast because it’s the easiest thing to do in our society. But there’s this dogma out there that breakfast is the healthiest meal of the day. Which may be true, but if you’re not hungry in the morning, should you force yourself to eat? That was sort of one of the things that … That’s one of the principles that I use. I actually think there’s a tremendous interesting synergy between all forms of fasting or intermittent fasting and low carb diets. One of the reasons for that is at least … We’ll get pushback from people don’t believe this. But I believe there’s a very strong effect of the ketogenic or low carb diet on hunger.
Dr. Ethan Weiss: I think that there’s … Personally, I just I’m never hungry I [crosstalk 01:06:48]-
Dr. Mark Hyman: Insulin is what makes you hungry.
Dr. Ethan Weiss: Probably. And that probably it’s the effect of insulin on your brain or the effect of insulin on your fat, then that goes to your brain. But there’s no doubt that I’m less hungry. For me, I had been doing some form of intermittent fasting for five or six years. But when I started doing keto, it just became easy. I mean, I just didn’t even think about it. I was [crosstalk 01:07:07]-
Dr. Mark Hyman: It’s interested. If I don’t eat … I can do an intermittent fast, like an eight hour. If I go longer than that, like 20 hours or something, I start to feel horrible and I can’t recover.
Dr. Ethan Weiss: Really?
Dr. Mark Hyman: Even if I eat something, the rest of the day I just feel out of it. Like brain fog a week. Horrible.
Dr. Ethan Weiss: Yeah. I would say to you if I were your doctor-
Dr. Mark Hyman: I’ve got like 6% body fat.
Dr. Ethan Weiss: … which I’m not. I’m not your doctor. I would say then don’t do it. Because I don’t think there’s … I mean, there’re going to be a whole slew of people who will hate me for saying this. I don’t think there’s evidence yet to support that fasting in any form is going to make you live longer. I think there’s pretty good evidence that calorie restriction probably, if there were anything that would, it would be that.
Dr. Mark Hyman: But these other things mimic-
Dr. Ethan Weiss: But you’d be miserable.
Dr. Mark Hyman: … the same biology, right?
Dr. Ethan Weiss: It does. But again, we get fooled on biology so many times again and again and again. In the meantime, look, my principle is, if you’re not hungry, don’t eat. If you want to be crazy and fast for five days and you do it in a safe way, go for it. But I don’t do that. I’m not going to do that.
Dr. Mark Hyman: I think it’s interesting. People often don’t get the test that matter most. For example, like blood insulin levels, most doctors never measure.
Dr. Ethan Weiss: That you’re absolutely right. It’s something that I probably didn’t do enough of until four or five years ago. If you ask somebody like Lew Cantley, who’s discovered part of the insulin signaling pathway, what the most important hormone is to have low-
Dr. Mark Hyman: To measure.
Dr. Ethan Weiss: Yeah. That it would be insulin. That’s part of the reason why I think … Again, you mentioned that it’s not just fasting or calorie restriction or other things. Keto and low carb diets will also reduce fasting insulin. I think those are all things if you’re going to pay attention to a marker, that’s one that looks good.
Dr. Mark Hyman: The blood tests will say zero to 15. But really it should be less than five. People who are eating well and low carb are like two. I’m about two and I feel good like that. I think that it’s not … Then what’s even more important is what happens after you eat sugar and carbs. We use these now Dexcom that Carrie have is this is basically a 24 hour glucose monitor. But I would like to see a 24 hour insulin monitor because I think that’ll be more reflective-
Dr. Ethan Weiss: There are people working on it.
Dr. Mark Hyman: Thank God. I’ve been talking about that for 10 years. Because I’ve been measuring insulin levels and post glucose tolerance test insulin levels for 25 years. It’s just amazing the amount of stuff you learn from that. I see people whose lipids look totally normal and his blood sugar A1C is like five or five and a half. Their fasting insulin might be normal, their fasting blood sugar might be normal. But they have a load of sugar and their insulin goes up to 200. These people can not lose weight. I think that’s a really very important sort of insight that people can look at. There’s a lot of tests you can do to figure out what your metabolic type is and you can see what happens when you eat different diets. Because people are often looking for outside validation of what to do. I say the smartest doctor [inaudible 01:10:01] is your own body. How do you feel? What happens to your weight? What happens to your muscle mass, your body fat, your lipid numbers, your insulin numbers, your blood sugar numbers?
Dr. Mark Hyman: I mean, that’s what you need to focus on. The variation of the population is humbling. As a doctor, “Okay, I found it. It’s ketogenic diet.” Then you’re like, “Oh (beep), it didn’t work for this guy over here. It worked for this one.” But I was like, “Oh no, it’s not one size fits all.”
Dr. Ethan Weiss: But there are probably … If you took the most staunchly pro whatever, pro, let’s say carnivore diet and the most staunchly pro vegan diet, and the most staunchly … If you took all those people and put them in the same room and ask them to agree on nutrition principles, there would be a couple that they would probably agree on, right?
Dr. Mark Hyman: Yeah.
Dr. Ethan Weiss: Well [crosstalk 01:10:43]-
Dr. Mark Hyman: 100%. I mean, honestly, that’s why I jokingly I call it the pegan diet. Because I was like, paleo, vegan, how could you be more different? But actually they agree on absolutely everything except where you get your protein from. They all agree we shouldn’t eat processed food. They all agree we should eat lots of vegetables. They all agree we should eat lots of good fats. They all agree we shouldn’t be eating lots of sugar and starch.
Dr. Ethan Weiss: Added sugar and refined carbohydrates. Right. I mean if you thought just there just processed food [crosstalk 01:11:05]-
Dr. Mark Hyman: They’re more common with the traditional American diet.
Dr. Ethan Weiss: Right. I mean that to me is like, if you want to just step back and say, “Well, that’s probably going to be the future.” We’re all going to agree less added sugar, less refined carbohydrate, less processed food. That’s probably the [crosstalk 01:11:19]-
Dr. Mark Hyman: It’s a safe bet.
Dr. Ethan Weiss: Yeah.
Dr. Carrie Diulus: There was a study that I had just come across this weekend from 2017 that looked at a plant-based processed diet versus an unprocessed plant-based diet, so whole real foods. The people who were on the plant-based processed diet had increased cardiovascular risk. And those-
Dr. Mark Hyman: Like chips and soda.
Dr. Carrie Diulus: Right, exactly.
Dr. Mark Hyman: And Skittles, yeah.
Dr. Carrie Diulus: Chips and soda and Skittles-
Dr. Mark Hyman: Skittles, yeah.
Dr. Carrie Diulus: … are all plant-based. You can eat a crapitarian diet and it’s not going to-
Dr. Mark Hyman: I’m going to use that.
Dr. Carrie Diulus: … increase your-
Dr. Mark Hyman: Crapitarian.
Dr. Carrie Diulus: Right. It’s not going to increase your health span. I think that that’s the thing that we … The people who benefit … This is the other thing that drives me crazy, because I sort of walk between this plant-based world and the keto world. For a long time the plant-based people were like, “Well, you can’t be keto and plant-based. We don’t understand that.” The same thing happened with the keto people where I even had Tim Noakes on Twitter saying it’s not possible to do a ketogenic diet and be plant-based. And I’m like, “Well, I am.” Yeah. I mean, here’s the thing-
Dr. Mark Hyman: Don’t confuse me with the facts. My mind’s made up.
Dr. Carrie Diulus: Well, this is the problem. Is I think that we all get to where we have our thing that we’re comfortable with that works for patients. I really want us to learn from the people who struggle and that that’s where the real gold is. It’s really not with the people who are successful with it. It’s really with the people like, “Why is this person struggling with it when it worked for these other five?” That’s where I think down the road, if we’re going to reverse engineer our way out of this obesity crisis, it’s to really figure out, “So this person who’s struggling, how do we shift their diet?” If they’re on a really plant-based diet and they’re not having the results that they want, or if they’re on a ketogenic diet and they’re not, is there another variation? Is there another factor that we’ve not looked at? That’s where I wish all of these camps would stop being camps and dogmatic, and really work to try and help people dial those things in.
Dr. Mark Hyman: The diet wars.
Dr. Ethan Weiss: Well, it’s silly.
Dr. Mark Hyman: It’s-
Dr. Ethan Weiss: I mean, we all-
Dr. Carrie Diulus: It’s ridiculous.
Dr. Ethan Weiss: … want to work to enable success. I do think that we can agree on … I mean there are other things and places we can agree to. I mean I think one thing is, some people can be very austere with the way they eat. You could probably eat basically tree bark for the rest of your life and [crosstalk 01:13:45]-
Dr. Mark Hyman: Yeah.
Dr. Ethan Weiss: … pretty happy. I can also probably be pretty happy. Other people-
Dr. Mark Hyman: I love food, yeah.
Dr. Ethan Weiss: … that they recognize that they like food that tastes good and rich and decadent. Maybe we can work to find … We’re working on these bars that I think are-
Dr. Carrie Diulus: They’re good.
Dr. Ethan Weiss: … going to be … It’s almost hard. I brought one, I’ll let you try it later. You’re not even going to believe how good this thing tastes. You’re going to think there’s no way this is just almonds and chicory root fiber. There’s just no way this is all …
Dr. Mark Hyman: Right. This is whole foods, right.
Dr. Ethan Weiss: There’s just no way. Yeah.
Dr. Mark Hyman: Yeah. That was interesting. It’s true. I have a friend, Marc David, who has started the Institute for the Psychology of Eating. He’s sort of a shorter stockier guy. He’s not overweight, but he’s just more stocky. I’m sort of this tall skinny guy. Ever since I’ve known him, he eats like a bird. We went out to dinner and we ordered. It was a shared plate thing. I ate three quarters of the food, he ate a quarter of it. He was happy and satisfied and I was like, “I could eat more.” I think my metabolism is very high, he might be slow. Everybody needs different amounts of food. I think and he’s very good at listening to his body. I think that’s what you’re really saying is, see what’s going on for you, what works, what doesn’t work.
Dr. Ethan Weiss: Well, and also we just need to recognize that the world is full of these choices that are not great. Instead of saying, “Just put those away and don’t have them.” Can we replace them with things that are still really good tasting but just are better that adhere to the principles that we all agree on. That’s the-
Dr. Mark Hyman: It would be great to do a study of like keto compared to intermittent fasting, compared to time restricted eating, compared to just low carb but not super keto. It’d be very interesting to see what that all would do metabolically to people. I hope somebody is going to do that study soon. Because I think we’re still on the question mark of it. But they all do similar things when you look at their metabolic effects and their hormonal effects. They’re all shifting you towards less inflammation, more insulin sensitivity, more muscle mass, better bone density, more brain function. It’s interesting. They all are different pathways into the same kind of thing.
Dr. Ethan Weiss: Yeah.
Dr. Mark Hyman: If someone wants to try keto, it’s a little daunting. Like, how do you do it and not kill yourself? Should you have to talk to your doctor first? Should you need to get to checkup? Should you get your labs done before? How do you do it? How does it work?
Dr. Ethan Weiss: Well, we can both-
Dr. Carrie Diulus: Yeah, we can both-
Dr. Ethan Weiss: … take turns on this one. You want to start?
Dr. Carrie Diulus: Yeah. I mean for somebody, obviously if you have medical problems and you’re on medications and there is a randomized controlled trial that’s about to be underway in Type 1 diabetics for using the low carb diet. There’s a lot of people who are using it. But as physicians, I always sort of hedge and say, “You need to partner with somebody to do it.” To do it safely [crosstalk 01:16:37]-
Dr. Mark Hyman: But if you’re basically a healthy person and you’re just overweight-
Dr. Carrie Diulus: If you’re basically a healthy person, you can do it. I mean that’s what I do in my clinic is, I see patients, I know the medications that they’re on. And I give them a handout and/or since we’ve been working on these meal plans, the app to be able to follow it. Do you need to get labs done before? No, not necessarily. I will frequently do labs inpatients so that we at least understand what their hemoglobin and A1C is at minimum. Most people have already had a lipid profile at some point, and then we check it later to see what happens with that. I mean, there’s a ton of resources out there. It gets controversial. There’s this whole carnival movement. I tend to find people do better in general. I mean, to me, I think the carnivore diet probably is a really good elimination diet and that’s why some people do well with it. I worry about longterm the gut microbiome and things like that with not having the-
Dr. Mark Hyman: You need some [inaudible 01:17:33] with it is fine.
Dr. Carrie Diulus: The fiber sources. Right, yeah. I mean, I think in the phytonutrients in that, that are in plants, I think people benefit from. For me, it’s about eating whole real foods. There’s a ton of sources out there that will help people start ketogenic programs. I think one of the things that I found with patients is that, understanding whether they’re in ketosis or not. Because if you’re doing low carbon and you’re not in ketosis, for some people that’s this sort of metabolic in between no man’s land. They don’t feel good and they’re not getting the benefits from it. Knowing if you’re in ketosis. I use it to inpatients for some very specific reasons. Where from neurologic standpoint, we want to get their ketones to a certain level. I found that those patients who are measuring and tracking their ketones in some way, which you can do it through urine, breath or blood, that they are more successful with it. That, that mechanism of tracking whether you’re actually in ketosis is positive from a behavioral standpoint. But it also is a return on investment in that they feel better faster in general.
Dr. Mark Hyman: Yeah. Let’s talk about that. You’ve got this new company you’re working with called Keyto, K-E-Y-T-O which tests breath for aminoacetone. Which is a ketone body. There’s blood tests for beta-hydroxybutyrate. That you can use the finger stick, a [inaudible 01:19:00] monitor. Urine, ketones may not be as reliable and it’s hard to quantify. For people who want to sort of check, how do they begin to think about what’s the right approach? Do they just use a finger stick, a breath test? What-
Dr. Ethan Weiss: I think it depends on what you want. We designed this thing to be a tool to help enable people to be able to do this diet. Whether their goal is for weight loss or improve their metabolic health. That was the purpose. Carrie mentioned that this sort of, one of the benefits of this diet is that it provides you a biomarker. It’s probably the only diet, unless I can-
Dr. Mark Hyman: That you can you’re on it.
Dr. Ethan Weiss: Well, yeah. Where you have a thing that you can track other than your weight on a scale. Which is a really bad way … I mean, we all know that weight fluctuates a lot. Whether … Especially in women, it fluctuates a lot. It’s not-
Dr. Carrie Diulus: 10 times in a month. It’s eight to 10 times [crosstalk 01:19:46]-
Dr. Ethan Weiss: It’s not a great way to know if you’re doing well. We designed the program to be able to give people the information about whether they’re doing it. In addition to the information about what they should and shouldn’t do in terms of eating or not eating. I mean, there’s plenty of places you can get resources on the internet about how to do a ketogenic diet. It’s not entirely intuitive. The purpose was, give people the information about what to do, give them the information about how they’re doing, which will help enable the behavior change. Then the last part, which I sort of touched on before, is that it’s also going to be really important that we give them the opportunity to find the food. It’s not easy, especially traveling or when you’re [crosstalk 01:20:24]-
Dr. Mark Hyman: Yeah.
Dr. Ethan Weiss: … to eat to be able to … Last night we went out to dinner and I ordered salmon. On the plate with salmon was fingerling potatoes and I just asked if they could put vegetables. They served it over asparagus. That’s sort of something that wouldn’t have been intuitive to me before.
Dr. Mark Hyman: To do a swap.
Dr. Ethan Weiss: Yeah. Or if you’re in the airport and you’re starving, you want a quick something to eat. Where are you going to go? Dunkin’ Donuts, are you going to buy a Clif Bar, or what are the options there? I think [crosstalk 01:20:52]-
Dr. Mark Hyman: I go for the nuts.
Dr. Ethan Weiss: Well, and that’s a good place to [crosstalk 01:20:54]-
Dr. Mark Hyman: They actually now have grass fed jerkies and all kinds of stuff.
Dr. Ethan Weiss: They do. I’ve seen these like cheese crisps and stuff. I think it’s … I’ve seen a few keto bars and at least in the San Francisco Airport. I think it’s coming. But that’s one area that we’ll as a company be focusing on in the future. Is trying to provide people, not just the insights they get from the device, advice that we give them through the app. Lastly is to give them the opportunity to get food.
Dr. Mark Hyman: Are there people who shouldn’t do a keto diet?
Dr. Ethan Weiss: I don’t know of anyone that I would say not to. People always talk about kids and I say, “Well, we have the actually the most experience with children on the ketogenic diet.” Because for 100 years there’ve been kids with epilepsy who’ve been on a ketogenic diet and they’ve done well. I don’t think they’re … I can’t think of anyone. There probably is, if you push me hard enough, that I could think of it.
Dr. Carrie Diulus: I mean, even in pregnancy if you have gestational diabetes, the low carb diet is one of the ways that they manage gestational diabetes. There’re some reports in women who are breastfeeding of this starvation ketoacidosis. I think it’s pretty rare. But if you have a calorie demand because you’re feeding another human and you’re losing a lot of weight … Especially if you’re not getting enough calories for your own metabolic needs. I think it potentially puts you at some risk. But there are plenty of people out there anecdotally who are doing just fine with it. I mean-
Dr. Mark Hyman: Like I know if I start to do it and I do too low carb, I drop so much weight. I’m already skinny. I find that I have to have some stuff-
Dr. Carrie Diulus: I’m trying not to hate your [crosstalk 01:22:22]-
Dr. Mark Hyman: … like sweet potatoes
Dr. Ethan Weiss: Yeah.
Dr. Mark Hyman: I’m sorry, Carrie.
Dr. Ethan Weiss: You have a good problem. You fall in the category of good problems to have.
Dr. Mark Hyman: Yeah. But I had to carb up if I want to gain little weight. I had to get a stem cell treatment once and I just had to eat lots of rice noodles and rice.
Dr. Ethan Weiss: As I’m fond of telling some of my partners, you’re not normal.
Dr. Mark Hyman: I am not normal. I am O-D-D, which means I’m odd. That’s really true.
Dr. Carrie Diulus: No, and it changes throughout life and things like that. I mean, I think women in menopause and perimenopause it shifts. It’s definitely a tool that I see more postmenopausal women benefiting from, is getting rid of the carbohydrates. It gets harder at that point to keep weight off. But it certainly is something that they can consider doing. Right now the studies for Type 1 diabetics, it’s still, there’s a lots of us who are doing it. But the RCTs are not out. I think there are some ways that people can get into trouble. We need to better understand those ways. It’s not that a low carb diet isn’t of benefit. We did a study where we looked at the numbers of people, the average A1C was just over 5.6 in this group of Type 1 diabetics who were doing the low carb diet. I think [crosstalk 01:23:41]-
Dr. Mark Hyman: Which is unusual.
Dr. Carrie Diulus: Which is unusual.
Dr. Mark Hyman: I mean, I’ve treated Type 1 diabetes for years and if-
Dr. Carrie Diulus: And there’s a lot of kids.
Dr. Mark Hyman: … you get a seven, you’re excited or a six …
Dr. Carrie Diulus: The target is seven.
Dr. Ethan Weiss: That was normal, right? Yeah.
Dr. Carrie Diulus: Right. The target is seven. To see this and the low amount of insulin that people are using, I think when people have some of these medical conditions, we need to understand how they can get into trouble. That’s where I hedge as a physician to say, “Oh everybody should be doing this.” Is because it’s like the people with the lipid problems or it’s like your experience with the ketogenic diet which is mine. I still really have to be careful with calories. I still really … Even training for the ultra marathon, I put on some weight. Some of it was muscle, but-
Dr. Mark Hyman: All of it was muscle.
Dr. Carrie Diulus: But I’m not where those things are factors. Our body types are different. That’s the thing that I think we need to be careful of. Is some people, their LDL is going to go through the roof. I really worry about these Lean Mass Hyper-responders who have LDLs over-
Dr. Ethan Weiss: You worry about them?
Dr. Carrie Diulus: Yeah. I know. I can’t even imagine what you do.
Dr. Mark Hyman: I’m one of them actually.
Dr. Carrie Diulus: Yeah. I mean if your LDL goes over 300 it, as a orthopedic-
Dr. Mark Hyman: No, it’s not that high.
Dr. Carrie Diulus: … surgeon that gives me Angina, and I can’t even imagine what it does to you.
Dr. Ethan Weiss: Well, and then … But you said it at the beginning. I want to emphasize again. If you have a medical condition, please to do it under the supervision of your doctor. Then there are some … To answer your question, I thought of one. I think if you have Type 2 diabetes and you’re on certain medicines like SGLT2 inhibitors as one example. You probably don’t want to do a ketogenic diet.
Dr. Mark Hyman: Although you won’t need them if you do the ketogenic diet.
Dr. Carrie Diulus: Or if you’re on sulfonylurea. That’s the thing that I-
Dr. Mark Hyman: [crosstalk 01:25:16] to.
Dr. Carrie Diulus: … see is … Because most medicines-
Dr. Mark Hyman: Any drugs that lower your blood sugar-
Dr. Carrie Diulus: You have to be very careful.
Dr. Mark Hyman: … and raise your insulin, you have to be careful. Because you’ll get low blood sugar. I mean, that’s actually … Actually, when I wrote my book, The Blood Sugar Solution, we were getting a lot of people writing in and calling and saying, “Hey, my blood sugar is too low, my blood pressure is too low.” I’m like, “Yeah, the food works better than the drugs. You got to pay for your drugs with your doctor.”
Dr. Ethan Weiss: True.
Dr. Carrie Diulus: You have to be careful on the SGLT2 inhibitors. They can send someone who’s … Typically in a Type 2 diabetic ketoacidosis is not something that you typically see. That tends to be more in Type 1 diabetics. But with the SGLT2 inhibitors and in particular-
Dr. Mark Hyman: What drug would that be for people listening?
Dr. Carrie Diulus: The-
Dr. Ethan Weiss: The [inaudible 01:25:58]. I can’t pronounce them. It’s Farxiga. It’s-
Dr. Carrie Diulus: Farxiga and-
Dr. Ethan Weiss: [crosstalk 01:26:02]-
Dr. Mark Hyman: The ones you see advertised on television for a lot of money.
Dr. Carrie Diulus: Right.
Dr. Ethan Weiss: Which actually are pretty interesting drugs. They’re actually being used mostly now as … Or they’ve been demonstrated to be very beneficial in heart failure. So the cardiologists are all adopting them, just like I do.
Dr. Mark Hyman: Well, it’s fascinating. Yeah, it’s fascinating. But it’s fascinating, when you see patients with advanced Type 2 diabetes who go in a ketogenic diet, they get off all their medications. They get off their insulin, they get … It’s pretty impressive.
Dr. Ethan Weiss: It is.
Dr. Carrie Diulus: I do it in an orthopedic practice. So it’s not something where, we put them on it and patients are … Very carefully people who are on insulin. I mean, I have the ability to talk with them more about it because I obviously use insulin and understand it. But [crosstalk 01:26:40]-
Dr. Mark Hyman: All right. Let’s go through a day of eating of each of you. What’s a ketogenic diet look like? Then we’ll kind of sort of summarize.
Dr. Carrie Diulus: I’m black coffee for breakfast. I mean, I rarely eat breakfast. If it’s a surgery day, I actually won’t eat until I get home. I can operate all day and not need to have any calories at all. Which is very different than in residency where I would have a bagel before and then by lunch you’re-
Dr. Mark Hyman: Starving.
Dr. Carrie Diulus: … starving and can’t get to the cafeteria fast enough between cases. But if I do eat lunch, it’ll be a salad or I will make some smoothies with kale and Brussels sprouts and broccoli and things like that. But I’ll have a salad and I’ll put hemp seeds on it with olive oil and vinegar.
Dr. Mark Hyman: Like extra fat, you’re using a lot of fat?
Dr. Carrie Diulus: Yeah. I mean, I’ll put avocado on it. I’ll put pistachios on it, I’ll snack on macadamia nuts. I put a ton of other vegetables on the salad itself. Protein sources, I’ll either use Lupini beans or black soybeans or hemp seeds on a salad. Then dinner is similar where I’ll roast vegetables or steam vegetables and use olive oil on them or avocado oil. I like to add nutritional yeast to it because I like the flavor. Then again, I’ll choose from those protein sources and have that. Then I have dark chocolate almost … There’s a sugar-free, it’s sweetened with Stevia. And a little bit of erythritol dark chocolate most evenings just because I like chocolate.
Dr. Mark Hyman: Yeah. All right. That’s good. That’s the vegan keto. Okay. How about you?
Dr. Ethan Weiss: Mine’s not too different. I also have black coffee for breakfast. I normally don’t eat anything until about noon. I eat lunch most days. I make my own lunch, bring it with me to work every day. It’s a salad, it’s whatever I have. So some lettuce, some chopped vegetable, usually celery, cucumbers, peppers, something like that. I’ll throw some Lupini. Carrie introduced me to these Lupini beans, which are delicious. I’ll empty a pack of those in there. I’ll put a bunch of nuts in there, chop an avocado every day. I’ll a whole avocado. Then I’ll go back and forth between adding some protein. Whether it’s like a little bit of salmon, some smoked salmon, even some canned salmon in that. Then I keep like 14 bottles of olive oil in my office and I just drown the whole thing in olive oil. That’s lunch. Dinner is usually some-
Dr. Mark Hyman: 14 bottles of olive oil.
Dr. Ethan Weiss: I have a lot, yeah.
Dr. Mark Hyman: Are these like different varieties-
Dr. Ethan Weiss: Yeah, a lot of [crosstalk 01:29:13]-
Dr. Mark Hyman: … they’re like wine? Or is it like-
Dr. Ethan Weiss: It’s basically like I have a collection of olive oil and wine in my office. They’re gifts from patients.
Dr. Mark Hyman: All right, that’s good.
Dr. Carrie Diulus: Yeah. They don’t bring cookies anymore. They bring olive oil. Yeah.
Dr. Ethan Weiss: No, it’s great.
Dr. Carrie Diulus: It’s nice.
Dr. Ethan Weiss: Then-
Dr. Carrie Diulus: Yeah.
Dr. Ethan Weiss: Then the-
Dr. Mark Hyman: That’s what I got for my birthday, a lot of olive oil.
Dr. Ethan Weiss: … dinner’s roasted vegetables and a protein. The protein is usually fish.
Dr. Mark Hyman: All right, fantastic.
Dr. Ethan Weiss: Then I also have this dark chocolate problem at night.
Dr. Mark Hyman: Great. Well this has been an incredible conversation. There’s still a lot we’re learning and there’s a lot we know about actually what can be the benefits of eating a low starch sugar diet, a high fat diet, a keto diet, and some of these other techniques such as intermittent fasting or time restricted eating. You’re studying all these. Stay tuned for what we’re going to know, because I think we’re really on the trail of something really important terms of health, longevity, metabolic health, and honestly part of the solution to our extreme obesity and diabetes epidemic. Which is bankrupting our nation and causing so much suffering for people. You guys are at the forefront of that work. I really appreciate what you guys are doing. If you want to do keto, make sure you know you’re doing. Check it out. You can go to getkeyto, T-O.com. Is that the website?
Dr. Ethan Weiss: Yeah, I think. Yeah. K-E-
Dr. Carrie Diulus: Getkeyto, so getkeyto, K-E-Y-T-O?
Dr. Mark Hyman: T-O.com.
Dr. Carrie Diulus: So get K-E-Y-T-O.com.
Dr. Mark Hyman: And learn more. I mean, there’s a lot of other options out there, but check it out. If you loved this conversation, we’d love to hear from you. Share a comment. Please share with your friends and family in social media. Sign up wherever you get your podcasts and we’ll see you next week on The Doctor’s Farmacy.
Dr. Carrie Diulus: Thanks, Mark.
Dr. Ethan Weiss: Thank you, Mark.
Dr. Mark Hyman: Hi everyone. It’s Dr. Mark Hyman. Two quick things. Number one, thanks so much for listening to this week’s podcast. It really means a lot to me. If you love the podcast, I’d really appreciate you sharing with your friends and family. Second, I want to tell you about a brand new newsletter I started called Mark’s Picks. Every week I’m going to send out a list of a few things that I’ve been using to take my own health to the next level. This could be books, podcasts, research that I found, supplement recommendations, recipes, or even gadgets. I use a few of those. If you’d like to get access to this free weekly list, all you have to do is visit drhyman.com/picks. That’s drhyman.com/picks. I’ll only email you once a week, I promise. I’ll never send you anything else besides my own recommendations. Just go to drhyman.com/picks. That’s P-I-C-K-S. To sign up free today.