Transcript of Episode 104: Ketogenic Diet Expert Dr. Jeff Volek
With Dr. Daniel Pompa, Meredith Dykstra, and special guest Dr. Jeff Volek.
Meredith:
Welcome to Cellular Healing TV. This is Episode 104, and I have Dr. Pompa here, and we have special guest Dr. Jeff Volek on the call. We have an awesome topic for you guys today, and we’re going to be talking about the Ketogenic Diet. And how it not only can impact disease and improve our health, but also impact our athletic performance. So that’s a subject we haven’t really delved into a lot on the show yet so really exciting topic. Before I introduce Dr. Volek, I’d like to read his bio, so you guys can learn a little bit more about what he’s doing.
So Dr. Jeff Volek is a registered dietician and professor in the Department of Human Sciences at Ohio State University. For the last two decades he’s been performing cutting-edge research elucidating how humans adapt to diets restricted in carbohydrates with a dual focus on clinical and performance applications. His work has contributed to the existing robust science of ketones and ketogenic diets, their use as a therapeutic tool to manage insulin resistance, plus their emerging potential to augment human performance and resiliency. This research indicates that well-formulated ketogenic diets result in substantial improvements in insulin resistance and the myriad of cardio-metabolic biomarkers associated with metabolic syndrome, cholesterol, and lipoprotein profiles. He’s also performed seminal research on a wide range of dietary supplements that can augment performance and recovery. He’s accumulated an enormous amount of laboratory and clinical data as it pertains to biomarker discovery and formulation of personalized, effective, and sustainable low-carbohydrate diets.
His team is currently exploring the role of nutritional ketosis induced by and/or supplements to: 1) reverse type-2 diabetes, 2) alter gut microbiota, 3) favorably impact tumor metabolism and help outcomes in women with advanced breast cancer, and 4) extend human and physical and cognitive capabilities in elite athletes and military personnel. Dr. Volek has secured several million dollars in research funds from federal sources, industry, and foundations. He’s been invited to lecture on his research over 200 times at scientific and industry conferences in a dozen countries. And his scholarly work includes 300 plus peer-reviewed scientific manuscripts and 5 books, including a New York Times Best Seller. So a very impressive bio, and welcome to the show, Dr. Volek. Thanks so much for joining us.
Dr. Volek:
Thank you, Meredith. Pleased to be here.
Dr. Pompa:
Yeah. Yeah. Hey, Jeff, yeah, and I just want to thank you myself. Yeah, I said years ago, I read this. We think 2011, 2012, and if you look through it, oh my gosh, all the notes and the studies. And it was just one of the best studied and referenced books on low-carbohydrate diets and ketosis that I have ever read. So this is one of many. But thank you so much for the research you do. I don’t know if I should call you professor or just call you Jeff.
Dr. Volek:
Please do, yes. Yeah, first name basis.
Dr. Pompa:
Okay. But yeah, Jeff, we have a lot in common that I’m on one side teaching doctors around the country to do what we do, and ketosis is a tool that we use in conditions that you study from diabetes, to heart disease, to fixing the gut, which you mentioned the microbiota. We utilize ketosis in so many ways, and so I’m sure we’ve referenced a lot of your research. So with that said, I have to ask you. I mean, that’s been the area of study for you for the longest time. I mean diabetes and heart disease. Speak just a little bit about that. Because I believe that, especially with heart disease, most people would think a high-fat diet would be the cause of heart disease. Jeff, we grew up in the time where saturated fat was evil, and cholesterol is still evil, and it was a cause of heart disease. Your research shows the opposite.
Dr. Volek:
Yeah, well, first of all, thanks for having me here, and I’m very pleased that you enjoyed the book. We actually wrote it for physicians so my colleague and I, Steve Phinney, and other healthcare professionals, including dieticians, and nurses, and really, any educated folks that are interested in nutrition. And we wrote it primarily because the ketogenic diet is not taught in any curriculum and, really, anywhere. So we wanted to give people information about the science and also the art. Because it really transcends the science in many ways when you get into the weeds in how you would actually implement this. So I’m glad you thought it was helpful and useful. So, yeah, in regards to the issue of diabetes and heart disease, I guess I’d like to start and just talk a little bit about the history of this problem. Because I think people may be generally aware of where all this started and where we’re at.
But just briefly, the first Dietary Guidelines came out in 1980, and that really started the low-fat diet-heart hypothesis, and the offspring of that was, of course, the low-fat diet. And so we’ve now got 35 years of this paradigm that we have—or experiment, if you will, that we began in the 80s or, really, the 70s with Ancel Keys prior to the Dietary Guidelines.
Dr. Pompa:
Yeah. He’s the one who wrote saturated fat.
Dr. Volek:
Exactly. And so if you think of this as a massive experiment in Americans, you look at what’s happened today. Two-thirds of adults in the U.S. are overweight. One-third are obese. Now this is staggering. Fifty percent of adults in the U.S. have prediabetes, and so we just have this massive suffering. And it really extends beyond that. There’s a financial burden on this. We spend about $300 billion today just managing diabetes alone.
So I think it’s time to stop this experiment. The problem is no one’s really wanting to be accountable, and we’re still fighting the government, USDA, and Dietary Guidelines which are trying to continue to promote this low-fat paradigm and demonizing saturated fat, demonizing meat, and all the dogma that we’ve been hearing for 35 years, which just, quite frankly, hasn’t worked at all. It’s been an epic failure, and you need to—we need to embrace, really, 15 solid years of research that has been supporting an alternative approach which is really focused more on reducing carbohydrate and finding a—for each person, finding their correct level of carbohydrate that matches their tolerance, and that’s really what we should focus on. But that doesn’t get reflected in any professional organization, any of their position statements, or any of the Dietary Guidelines. So that’s what’s frustrating from my perspective. Because there’s been a lot of great scientist and researchers publishing work in this area, and it’s being ignored.
Dr. Pompa:
Yeah.
Dr. Volek:
And we need more physicians like you that are challenging the dogma and going against the grain, literally.
Dr. Pompa:
Yeah. Yeah, I mean, it’s interesting you say that because, really, it’s new to humans the amount of carbohydrates that we’re eating. I mean, if you look back at the history of humans and the diets they’ve eaten, I mean, this is a new thing, high-carbohydrate diets. I mean, even the amount of grain or just even grain in the human diet is really a new thing when you look at the evolution of humans. It really is, Jeff. And do you believe that some of the increases in diabetes and heart disease are because of what we’re doing, the amount of carbohydrates we’re eating in a modern diet?
Dr. Volek:
Absolutely. So the diet-heart hypothesis and the low-fat diet was intended to lower cholesterol which in turn was supposed to lower risk for heart disease. But what happened, it really backfired, was that as people were trying to restrict fat, they replaced those calories with more carbohydrate, including a lot of sugar and processed carbohydrates. And so instead of lowering cholesterol and reducing heart disease, what we did is we created an epidemic or, really, pandemic around the planet of prediabetes and diabetes, which in turn is a strong risk factor for heart disease.
So we have this unintended consequence of over emphasizing restriction in fat that has really caused this unintended consequence of metabolic syndrome in diabetes. And so we really need to rethink the whole process and paradigm, and in my mind, it’s overconsumption of carbohydrate relative to a person’s tolerance that is driving almost all chronic disease, including diabetes, heart disease, and probably cancer, and Alzheimer’s, and Parkinson’s.
Dr. Pompa:
Yeah.
Dr. Volek:
And you can really have remarkable effects when you back off on the carbohydrates. How much do you need to back off? That gets into really complex issues, but at least getting that message across to folks I think would do a great deal of benefit for a large number of people, and give them—empower them or enable them to be able to eat more fat and restrict carbs does a tremendous amount of benefit to your health.
Dr. Pompa:
Jeff, when I read—and by the way, folks, this is “The Art and Science of Low-Carbohydrate Living,” and then the other book that I tore up of yours is “The Art and Science of Low-Carbohydrate Performance,” which is the white book that I was digging for. I think I leant it out, and there’s all my notes in there. I better get it back. But anyways, in this book, I remember you stating that some of the criticism with a high-fat, or a keto diet, or even just a low-carbohydrate diet with heart disease I think was the critique, maybe even diabetes, when you looked at the studies and me too of what they called a low-carbohydrate diet, for you and I, it would either be a moderate-carbohydrate diet or even a high-carbohydrate diet. I mean, some of these studies, Jeff, that I saw were looking at carbohydrate diets 180, 200 carbohydrates daily. Now, to me, that’s a high-carbohydrate diet. What’s your take on that?
Dr. Volek:
Oh, absolutely. I think everything’s relative. So if they were eating 400 grams, then maybe they get some benefit by going down to 200. But for many, many folks, 200 is nowhere near low enough to really regain metabolic health. And so most of my work over the last two decades, we’ve been looking at diets that are under 50 grams per day, and for most people, that induces a metabolic state of nutritional ketosis. And we continue to learn more about just incredible health benefits associated with being in a state of nutritional ketosis. And so very few of these studies that you’re referring to had carbohydrate levels low enough to induce ketosis, but the ones that have, the results are just absolutely remarkable in terms of reversal of diabetes, improvements in all sorts of cardio-metabolic risk factors. And as you were alluding to, even on the endurance side and performance side, there’s even evidence now that that may be more optimal for certain athletes.
Dr. Pompa:
Yeah. Talk about some of the improvements that you see with diabetes and heart disease. Because a lot of folks watching our shows, obviously, they have those concerns, and we utilize ketosis as a tool in those conditions and, obviously, others. I mean, we’ve had conversations with Professor Seyfried about cancer. But talk a little bit about those because you’ve studied a lot about diabetes and heart disease.
Dr. Volek:
Well, if you can get a person that has diabetes into nutritional ketosis—and we can certainly do that. I don’t want to trivialize it, but I also want to make the point that a ketogenic diet, although it’s less than 50, probably less than 40 grams for a type-2 diabetic to induce ketosis, that actually has quite a bit of variety in it. It’s not a burdensome diet.
Dr. Pompa:
Yeah.
Dr. Volek:
You’d be absolutely amazed at how much variety and how pleasurable and palatable a ketogenic diet can be. So we can certainly get these diabetics to consume this type of diet, and not just short-term, on a long-term basis.
Dr. Pompa:
Yeah.
Dr. Volek:
And when you do that, we can normalize hemoglobin A1c in blood sugar levels in the vast majority of people with diabetes in three to six months.
Dr. Pompa:
Yeah. I’ve done that as well, Jeff.
Dr. Volek:
So that in and of itself is remarkable, but the other really important part of that is we do that while they’re getting off medication and while they continue to lose weight because most of them are also overweight or obese.
Dr. Pompa:
Yeah.
Dr. Volek:
And that’s exactly the opposite of what happens when you try to really control blood sugar using standard of care, which is to give more medication. And when you give more insulin and more diabetes medications, the side effect is weight gain, and we know that there’s a lot of other undesirable effects of overmedicating to control blood sugars. So there’s really [00:14:35] an incredibly powerful tool that is getting diabetics off medication, allowing them to lose weight, and normalize their condition. So that’s really powerful. I mean, we spend four times as much money managing diabetes as we do cancer, but it doesn’t seem to get the same attention. And just the level of suffering in this country and, really, around the world, this is not something that’s isolated to the U.S. by any means. All developed countries are suffering from increases in diabetes and obesity.
So this is something that can be employed around the planet to help our colleagues across the sea, and China, now, has 100 million people with type-2 diabetes. India, I think, has similar levels. So this is something that’s affecting over, really, half the population has some level of diabetes, whether that be pre- or full on type-2 diabetes.
Dr. Pompa:
Hey, Jeff, speak a little bit about—because we had a conversation with Professor Seyfried about cancer, and he always says the key is lowering glucose, right? If you don’t lower glucose, people don’t lose weight. If you don’t lower glucose, tumors don’t shrink. So as glucose drops, ketones rise, and I—my doctors and myself, we realize that, and even people that are on a—in a keto diet, if we don’t see a drop in glucose, we seem to see no weight loss. So we have noted that restriction is very important to often times get the glucose down. Some people—most people that are healthy, when they go into a keto diet, they start—their appetite starts to go down as they become more efficient fat burners. But that doesn’t happen for everybody, and therefore, often times their glucose doesn’t drop because they’re still eating, perhaps, too much. What’s your thought on that?
Dr. Volek:
Yeah. I think there’s a lot of, perhaps, holes in our knowledge here, but our experience, when you really get the diet correct and the term I like to use is a well-formulated ketogenic diet, glucose does normalize in most people. A lot of people run into problems when they overconsume protein, and protein can get converted to glucose and actually inhibit ketosis. What we find is, when people are keto-adapted, keto-adaptation is a process that takes at least several weeks. Maybe in certain pathways it may take months or even years to fully keto-adapt. But one of the most profound metabolic adaptations to keto-adaptation is you switch fuel to almost exclusive reliance on fatty acids and ketones. And the corollary to that is you also significantly reduce glucose flux or glucose uptake in the cells. So when we measure, for example, respiratory quotient in people who are keto-adapted, they are at close to .7 or .71, which is an indication that they’re burning 90% plus of their energy from fat, and that implies also that there’s a significant inhibition of glucose metabolism in uptake in the cells. Now a lot of people don’t quite—they flirt with that keto-adaptation, so they’re not quite there, and I think those are the ones where the glucose trickles up.
And they—I would imagine—and we haven’t studied this, and I don’t think there’s a lot of direct evidence. But I would imagine you’re not going to get the full benefits in cancer unless you become fully keto-adapted and reduce that reliance and uptake of glucose in cells, and I think that that’s what Tom has really got his finger on well. That to get the full benefits of ketosis—I mean, we know ketones in and of themselves have a lot of important cellular effects that extend beyond just being an alternative fuel for the brain, which is what the standard function of ketones are. But we know now that they’re having potent drug-like effects or hormone-like effects in cells that are turning on pathways that are related to protection from oxidative stress, for example, that are the same pathways that are upregulated in the studies that have looked at longevity and anti-aging. And so having the ketones is important to get those signaling effects. And then the flip side is having low glucose is equally important, especially for the tumors that are relying on glucose for fuel.
So I do think Tom really has this right where it’s the combination of both. You got to have ketones high, and you got to have glucose low. And how we best do that in people I think we’re still trying to figure out. Because now we have ketone supplements we can give people. There are many different versions of ketogenic diets that people can play with, and which ones are ideal for certain types of cancers and so forth, in humans anyway, we don’t really understand this very well.
Dr. Pompa:
Yeah, we have noted that when we get the ketones up, the glucose down, that’s where the magic does happen, right?
Dr. Volek:
Yeah.
Dr. Pompa:
It’s the ketones turn off bad genes. The ketones down regulate cell inflammation. The ketones do decrease that oxidation, and then, likewise, the lower glucose, same thing. So it’s such a win-win, and I always give three reasons why. If someone’s not getting into ketosis or not losing weight, they could—obvious, they may need to lower their carbohydrates more, right? I mean, everyone’s genetically different. Some people can get in at 50. Some people, I’ve had people get in at 80, for goodness sakes. Some people have to drop it down to 20 or 30. So that’s a factor.
Second factor you mentioned, eating too much protein. Gluconeogenesis, it can turn to sugar. I’ve seen that as a factor. In some people, just consuming too much food. They’re just simply consuming too much food, and Tom talked a lot about that so three reasons for people to look at if they’re not getting the results. And then, Meredith, you had a question. Because gender, right, some women have trouble crossing in, especially in the beginning. Sometimes I have to move them in and out of trying to get into ketosis before they break in. So gender, does gender play a role, Jeff?
Dr. Volek:
Well, I think, yeah, it can. But our experience is it’s more related to the level of insulin resistance.
Dr. Pompa:
Yeah, okay.
Dr. Volek:
So if you have any person, whether male or female, the higher the level of insulin resistance, generally, the more difficult it is to get them in ketosis and the longer it takes to keto-adapt.
Dr. Pompa:
What about the…
Dr. Volek:
Importantly, they eventually do, and that’s what’s really important here. That no matter how insulin resistant you are, you retain this metabolic pathway to adapt to ketosis. It’s so ancient. It’s part of our—it’s just so—a huge part of our human evolution, and it’s almost always perfectly intact, even in the most profoundly insulin resistant people, because burning fat and oxidizing ketones is not dependent on any of the insulin signally pathways. So that’s what’s so really elegant about this tool is it works great in people with insulin resistance. It makes them completely able to have ideal fuel flow, even though they may remain insulin resistant.
Dr. Pompa:
What about thyroid resistance? Obviously, just general hormone resistance but we’ve noted, as physicians doing this, that our thyroid people, like diabetics, have more trouble getting in. However, you said it best. Eventually, they will. But speak to that a little bit.
Dr. Volek:
Well, in general, what we’ve seen is that sensitivity to many hormones increases when you’re keto-adapted.
Dr. Pompa:
Right, correct.
Dr. Volek:
That’s clearly the case with insulin. You often improve the insulin sensitivity in folks. We’ve also seen that with leptin. That leptin goes down markedly in folks, and it’s disproportional to the fat loss. So to me, that’s suggesting an improvement in leptin sensitivity. And then we also see a consistent drop in thyroid hormone, and I think there’s been a lot of misinterpretation and misinformation propagated around the thyroid hormone responses because we see absolutely no functional evidence that there’s any signs or symptoms of hypothyroidism. So metabolic rate doesn’t go down, and people aren’t cold and dry skin and all these types of things. So to us, that is an indication that people are just more sensitive to the thyroid hormone. So they can get by with having less circulating T3, and still maintain their metabolic rates. So I think in those three examples, they all point to more efficient hormonal regulation of cellular processes. So you don’t need to have as much hormone around.
Dr. Pompa:
Jeff, I couldn’t agree more. I believe hormone sensitivity is the key. We have most people walking around, even non-diabetics or even not even diagnosed as pre-diabetic, still having to many insulin and glucose spikes, which decrease the sensitivity of hormones. In vogue today is giving more hormones, whether it’s thyroid, whether it’s estrogen, testosterone. That’s in vogue. But I always say it’s like shouting at the kids. Eventually, they start hearing you less. So giving more hormones often times is needed. However, most often, it’s not the answer. The key is becoming more hormone sensitive at the cell, and that’s what I just heard you say.
Dr. Volek:
Yeah, absolutely. I think we’re entirely on the same page there.
Dr. Pompa:
Yeah. I really appreciate that. So Meredith, I know that you’ve had some other questions, and I do want you to speak a little bit about some results about heart disease. Because I think there’s a misconception that these diets are potentially bad for heart disease, but Meredith, you had a question on that before we leave that topic.
Meredith:
Well, I don’t know. Actually, I don’t think I did. I have a lot of questions about the impact of the ketogenic diet on athletic performance. So I think once we shift over into that, if you want to speak to your results on heart disease, Dr. Volek, that’d be wonderful, and I’d like to have a conversation on how it impacts our athletic performance too.
Dr. Pompa:
Yeah, great.
Dr. Volek:
Sure. Well, a lot of our work over the years has focused on understanding cholesterol and lipoprotein metabolism. And that is extended into looking at fatty acid composition, and that’s gotten us into looking at saturated fat metabolism when a person is keto-adapted. And what I can say is that almost every biomarker of cardiovascular risk improves on a ketogenic diet.
Dr. Pompa:
Yeah. I agree.
Dr. Volek:
And you can just go down the list. Triglycerides plummet. HDL goes up in most people, or in some, it stays the same. But it’s still a more potent tool than exercise and weight loss or any drug, really, in terms of the triglyceride decrease and HDL increase. So those are obviously positive. As the inflammatory markers get better, it’s a potent anti-inflammatory diet. Oxidative stress goes down. Now the one response that gets a lot of physicians nervous and anxious is the LDL cholesterol response.
Dr. Pompa:
I was going to ask.
Dr. Volek:
And we spent a great deal of time studying this. The reality is if you look at LDL cholesterol, I mean, I think, in general, we’ve overstated the importance of LDL cholesterol, and that’s largely been driven by greedy drug companies that want everybody to be on a statin.
Dr. Pompa:
Yes.
Dr. Volek:
But let’s just assume for a second LDL cholesterol may carry some increased risk of heart disease. What you’d see, though, is about half the people show an increase in LDL, and the other half show a decrease.
Dr. Pompa:
That’s right.
Dr. Volek:
But there’s probably about 10-20% of individuals who show quite a marked increase in LDL cholesterol.
Dr. Pompa:
Yes.
Dr. Volek:
Saying over 50 milligrams per deciliter, some people even higher, and that really alarms people. And I get emails every day almost from people. Should I go on a statin? My doctor’s going crazy. So this brings us to an important topic around LDL cholesterol in that we now have very good evidence that LDL cholesterol is a heterogenic particle. Meaning there’s a lot of different types of LDL cholesterol that range in size and range in density and composition.
Dr. Pompa:
That’s right.
Dr. Volek:
And we have very, very good evidence now that the small LDL particles are the ones that are most atherogenic, and these—it’s many reasons. They have a longer residence time in the circulation. They are more prone to oxidation. They can probably penetrate the arterial wall easier. And a low-carb ketogenic diet is more potent than anything, including statins, at decreasing these small atherogenic particles. So even if you’re one of these people that your total cholesterol and LDL went up quite a bit, almost all cases, your small LDL particles almost surely went down, and so that’s a really important fact that is going to be relevant in terms of cardiovascular risk.
Dr. Pompa:
Now, Jeff, I’m one of those unique people. When I—and I’ll explain why in a minute, but in the summertime, I actually go into ketosis. In the wintertime, I actually move out, and that’s for performance reason, which when we get there I’ll talk a little bit about. But I’m one of those odd people that my LDL does go up. My triglycerides dramatically go down. All of my glucose, inflammation markers, dramatically lower for the better when I’m actually in ketosis. However, my particle number of LDL actually raises. Now, my smalls don’t change. So my smalls are normal., but my particle number goes up.
Now you and I agree. Total cholesterol doesn’t matter. Even high LDL, I don’t think it matters. However, the particle number and the particle size, those two things lead to more oxidation. So now what about the particle’s number going up and not the size? What’s you’re feeling on that?
Dr. Volek:
Well, part of that particle number is driven by the total concentration increase. But the fact that your small LDL numbers aren’t changing or in most people they do go down, even if their total goes up, that is unlikely to contribute to higher risk in any of the—we don’t have the long-term studies. This is the limitation in most of this research where we’ve followed people long enough where you have heart endpoints. Where you’ve looked at mortality or you’ve looked at actual heart attacks. So you always have to look at these intermediates with a grain of salt because none of them are that great at predicting heart attack. I mean, over 50% of people who have heart attacks have perfectly normal LDL cholesterol. So that tells you right there that this is a pretty weak predictor of actual risk.
But this gets into a lot of nuances, and I think you’ve touched on a few things that make it more complicated than even particle size. And that’s, ultimately, are these particles oxidized and are they contributing to pro-inflammatory environment? Those are the processes that really contribute to atherosclerosis and plaque development in the arteries, and so if you’ve got a lot of cholesterol, even a lot of particles circulating in the plasma, hey, that’s fine. You just don’t want them in the arterial wall.
Dr. Pompa:
Yeah.
Dr. Volek:
In fact, having higher cholesterol may confer some protective effects.
Dr. Pompa:
Absolutely.
Dr. Volek:
I mean, that’s maybe a provocative statement, but there’s some evidence to support that. So cholesterol in the blood is good, cholesterol in the arteries, not good. What contributes to cholesterol in the arteries? Well, not so much the concentration but more the pro-inflammatory environment, the pro-oxidative environment that contributes to that. And those almost always get better on a ketogenic diet. Even if you happen to be one of these hyper-responders like yourself.
I’m just the opposite. I’ve been ketogenic for 20 years, and my cholesterol is more than 78, and so I don’t have to worry about it. But I know there’s a lot of people out there that—and it’s just genetics. We don’t understand how to predict those people, but we certainly see it. And I personally don’t think it’s a contraindication or something to worry about because it’s an isolated increase, and across the board, you look at every other risk factor, it gets better.
Dr. Pompa:
Well, I think you said it best. They’re ignoring the obvious. The glucose, the elevated glucose spikes, even in nondiabetics, and insulin spikes, which drive oxidation, is really the bigger problem than even the small amount of cholesterol they have is oxidizing. And oxidized cholesterol is the problem. Not total cholesterol. And I think we’re in total agreement there.
Dr. Volek:
So, yeah, the other piece of this that I’d like to mention quickly, it’s the composition of these particles. So if you have a lot of saturated fat inside your cholesterol—or your lipoprotein particles, that is a consistent risk factor for both diabetes and heart disease and certain types of cancer, and so this becomes a very important topic when it comes to heart disease. And it starts to tie back to the saturated fat paradigm. So it turns out that all the latest evidence that’s been reviewed in I think, at least, four or five meta-analysis in the last three years have shown no correlation between dietary saturated fat and heart disease.
Dr. Pompa:
That’s right.
Dr. Volek:
So that, I think, puts the nail in the coffin of the low-fat paradigm, the diet-heart hypothesis. But still, people get very concerned. Because on a ketogenic diet, now you’re eating two or three times as much saturated fat as you may have been on a high-carb diet, and so we’re interested in what happens to saturated fat levels in the body on a ketogenic diet. So in three separate studies now we’ve shown that, despite eating two to three times the level of saturated fat on a ketogenic diet, saturated fat levels in the blood go down.
Dr. Pompa:
Yeah.
Dr. Volek:
And again, that’s what’s important. Because if you are carrying more saturated fat in your circulation, in your membranes, that is highly associated and consistently in studies puts you at higher risk for heart disease. So the way—the soundbite we use for this is, “You aren’t what you eat. You are what you save from what you eat.” And if you’re eating saturated fat, that’s fine. Saturated fat itself is very benign and contributes to satiety and pleasure and palatability of food.
Dr. Pompa:
Yeah.
Dr. Volek:
What’s the problem is if you eat it with carbohydrate.
Dr. Pompa:
That’s right.
Dr. Volek:
It’s the carbs that you’re eating that are setting you up to store it and accumulate it in cells. But if you don’t eat a lot of carbs with the saturated fat, you actually burn it. Saturated fat is a preferred fuel on a ketogenic diet, and so it’s not accumulating and causing harm. It’s being oxidized and converted to CO2 in water, and that’s why you see actual levels go down despite the fact you’re consuming more.
Dr. Pompa:
Well, I think, talk it about…
Dr. Volek:
You need it. You need the saturated fat on a ketogenic diet for fuel, and those foods that have saturated fat are ideal foods on a ketogenic diet.
Dr. Pompa:
I love to give the example it burns like natural gas on your stove. You don’t see smoke as opposed to how glucose burns. You look at the wood in your fireplace. You need a chimney. That’s glucose.
Dr. Volek:
That’s great. Yeah. I think I’m going to steal that.
Dr. Pompa:
You’re welcome.
Dr. Volek:
Ketones and saturated fat, they’re clean burning fuel.
Dr. Pompa:
Yeah. Yeah. Absolutely and more efficient. That’s why those gas carbs can run a long time. They’re cleaner and more efficient.
Dr. Volek:
Absolutely.
Dr. Pompa:
Yeah, absolutely.
Meredith:
And I have a quick question too. I love what you’re saying about saturated fat, Dr. Jeff, and I eat a very high-diet myself, and my cholesterol is only 180. So I was wondering. Have you seen genetic differences in perhaps that some people are more suited to ketogenic diet genetically than others?
Dr. Volek:
Yeah. We were interested in that question about ten years ago before we had a lot of more sophisticated Omix tools. But we did a lot of genotyping in our studies, and there was a lot of hope and belief that genetics would be able to predict how people respond to diets. But we were very disappointed. You can explain a very, very small amount of variability by looking at genotypes in people. So I’m more interested in measuring now dynamically changing biomarkers because your genotype doesn’t change. Your snips are the same. What I’m interested in is studying more biomarkers that are providing almost real time information on how people are processing the carbs they’re consuming on a real time basis, and that moves us in the direction of someday having some objective markers that would tell us if we’re consuming carbs below our tolerance or above our tolerance.
So yeah, in answer to your question, the genotyping hasn’t really led to any insights in terms of responders or not. I find there’s very few, if any, contraindications to a ketogenic diet. So as we were saying earlier, some people may find it a little more difficult to get into ketosis and keto-adapt, but outside of some very rare genetic mutations, everyone can do it.
Dr. Pompa:
Yeah. We’re going backwards. Yeah.
Dr. Volek:
You may not need to. If you’re one of the lucky ones and you can maintain health on a high-carb diet, then you may not need to. But at least you can, and that’s where, if you’re insulin sensitive, you have more options. You can probably do fine on a higher carb diet. But if you’re insulin resistant and carb intolerant, you really need to restrict carbohydrates, but pretty much anyone can adapt.
Dr. Pompa:
Well, everyone can adapt because it’s life or death. I mean, every human has the ability to go in and out of ketosis, and I believe it actually makes us healthier just even moving in and out of it. Because this is what our ancestors had to do. Often times, they were in states of fasting, states where they only had this food or that, and it was forcing them into these variations. I wrote an article, Jeff. You should read it, called Diet Variation. I think you would enjoy it. It’s on my website.
But, yeah, I mean, I agree. Jeff, I think that there’s too much today put on these snips in the genotyping whereas, clinically, I’m just not seeing the value. I think that the snips, the body—we know so little that the body epigenetically starts to change things and move around these snips and adapt in different ways. And I think that even in the alternative world, I think there’s being too much put on that. What’s your opinion on that?
Dr. Volek:
Yeah. I agree totally, and that’s starting to go out of vogue, and epigenetics now is the big thing. Which as you were saying, it’s that epigenetics is really looking at how genes are expressed. And we learned just a couple years ago how potent ketones are at affecting gene expression. So a ketogenic diet is having very potent epigenetic affects.
Dr. Pompa:
Yeah, amazing.
Dr. Volek:
The primary ketone body, beta-hydroxybutyrate, was just recently discovered. This was in the science paper published at the end of 2012. So this is really new stuff, and it gives us a whole different perspective on ketosis. But they showed in very elegant experiments that beta-hydroxybutyrate was a potent histone deacetylase inhibitor, and that’s a long fancy term. But that’s a very common and well-studied target of epigenetic modulation of gene expression. And I can tell you a lot of drug companies are desperately trying to find molecules to develop into drugs that basically target the same mechanism, and here we have a natural metabolite that elevates when you restrict carbs that has the same epigenetic effects. So it’s really exciting, and it gives us a whole new perception of how a ketogenic diet is having therapeutic effects.
Dr. Pompa:
I think you said it. A lot of what I teach is turning off those bad genes. Whether you’re a thyroid person, someone who struggles to lose weight, those can be genes that can get turned on. We know utilizing ketosis and ketones turns off and has the ability to turn off those genes. I mean, this is new science, but it’s real science, and it’s very—it’s really amazing. And I believe that these dietary shifts, what I call diet variation, really lead to a lot of these bad genes getting turned off.
Well, anyway, so this is the performance side of the talk. I mean, you wrote the book, “The Art and Science of Low-Carbohydrate Performance.” Look, your colleague, Stephen Phinney, I met him here in Park City, and here in Park City, we are the endurance capitol, little city, of the world. I always say that people here either do one sport a day or three. So we have people who run in the morning, cycle in the afternoon, and go lift weights somewhere in between. They are the high-carb group here, Jeff. I mean, come on. High-carbohydrate diets and endurance, I mean, this is—how can it be low-carb?
Dr. Volek:
Yeah. It’s a little bit like the world turned upside down, and it’s interesting that this is going on in parallel with what’s happening in general consumer nutrition and taking on the Dietary Guidelines and all of the low-fat paradigm. In parallel, you’ve got sports nutrition over here that’s also for the last 40 years been under the belief that athletes have to carb load and have to have high-carb diet to perform optimally and recover, and now that’s being challenged.
Dr. Pompa:
Yeah.
Dr. Volek:
And so that is really fascinating because it’s been so reinforced by the sports beverage industry and economy that we’ve got to have these Gatorades and Powerades after we—even if we run on the treadmill for 15 minutes, you got to drink Gatorade, and we’re basically cancelling out all of the benefits we get.
Dr. Pompa:
Jeff, I can argue…
Dr. Volek:
So there’s paradigm shifting, and a lot of it is happening in the grassroots level. It’s real athletes that have made the decision to switch their diet and abandon their carb loading, and instead embrace a high-fat, low-carb diet. And to even my surprise, many of these athletes are not just able to compete and finish races, many of them are winning and, in some cases, setting course and even national records in ultra-endurance.
Dr. Pompa:
What’s the—the Western 100, what’s the gentleman’s name? Didn’t he win the last three years the 100-mile running race? He’s in ketosis. Correct?
Dr. Volek:
Yeah. Well, Tim Olson won in 2011, and I had my lab group out there. We were studying a whole bunch of athletes that were on a low-carb diet, and so Tim set a course record that year, and came back and won it again in 2012. And I think he’s definitely on a low-carb diet, whether he’s in ketosis or not may be debated. But there’s no doubt he’s not following the high-carb approach, and he’s not the only one. There are many successful ultra-endurance runners who are clearly abandoning their carb loading and benefiting from a high-fat, low-carb diet. And we’ve had the opportunity to study many of these elite athletes in the lab to see what makes them tick, and they are nothing but extraordinary.
Dr. Pompa:
Yeah. What’s the—Phinney was involved in the movie called “Running on Fat,” right? And the gentleman and his wife rode from California to Hawaii in ketosis, and that was the movie. Were you part of that at all, Jeff?
Dr. Volek:
Well, I know Sami Inkinen and Merdith Loring who are married and did row; I think it was 2,000 miles from California to Hawaii unsupported. And they really did that to show that it could be done without a lot of sugar and carbohydrates. So they were keto-adapted and did a phenomenal, unbelievable performance. Setting a record, actually, and beating out some three and four-man teams that they were competing against so just an enormous feat of endurance done with very little carbohydrate.
Dr. Pompa:
Yeah. What’s the name of the movie?
Dr. Volek:
It’s “Fat Chance Run,” was it?
Dr. Pompa:
Yeah.
Dr. Volek:
Or no.
Dr. Pompa:
I forgot too.
Dr. Volek:
Actually, I’m blanking on the exact title now.
Dr. Pompa:
Yeah, me too. I’m with you.
Dr. Volek:
Yeah. It was all about this paradigm shift in athletes switching from high-carb to low-carb diets and experiencing widespread benefits in terms of their health and performance and recovery abilities.
Dr. Pompa:
Yeah. It was remarkable. Well, Meredith, you had a lot of questions regarding performance because that little girl’s quite the athlete, and she performs on a very low-carbohydrate diet in ketosis often times so, Meredith.
Meredith:
Oh, well, I don’t know if I’d consider myself too much of an athlete, but ketosis has massively impacted me in a lot of positive ways. Something, first of all, what constitutes a ketogenic diet for athletes that you think would be well-balanced and well-formulated? Can you walk us through a day of what that would look like?
Dr. Volek:
Well, yeah, I think I could probably do that easier for a ketogenic diet where—I don’t know if these athletes, all of them anyway, are truly in ketosis or if they’re introducing enough carbs around exercise. There’s no standardized approach all these athletes are taking. They’re figuring out what works for them. So it is varied from athlete to athlete. But in general, what I consider a well-formulated ketogenic diet. Obviously, getting the carbs low enough to induce ketosis is kind of straightforward but, also, the protein. So this is not a high-protein diet, but it’s not a low-protein diet either. So you really need to get protein in the right range where it’s low enough, you induce ketosis. But it’s not so low that you’re going to be in the negative nitrogen balance. That’s muscle loss, the lean body mass loss. It’s kind of this Goldilocks state for protein, and that’s really important.
Beyond that, other things that people don’t always appreciate which can often result in side effects or suboptimal responses; one is the type of fat. So because carbs and protein are limited, this is a very high-fat diet, especially if you’re not restricting calories. So if you’re one of these athletes who’s trying to eat enough energy to maintain your training, this is an extremely high-fat diet and the type of fat becomes very important. Because the main function of fat is for fuel on a ketogenic diet.
Dr. Pompa:
Yeah.
Dr. Volek:
And the best fuels are the monounsaturated and the saturated fats. The polyunsaturated fats are important. They’re the essential fatty acids, but you only need very small amounts of these to meet your essential requirements. So they’re more like vitamins and minerals in my mind, and they’re not tolerated at high levels. So you can run into a lot of problems.
Dr. Pompa:
Okay, Jeff, for our viewers, let me just put that in perspective. So we don’t need as much fish oil, right? There’s benefits to those polyunsaturated fats, and vegetable oil, we don’t like anyway. But what you’re saying is, hey, we need more grass-fed butter. We need more of those types of saturated fats, and then of course, olive oils and other oils can have some other affects as well. So putting them in…
Dr. Volek:
Yeah, the natural foods that—natural animal-based foods that are higher in fat naturally have low PUFA levels. Where people run into problems is with soybean oil, and corn oil, and safflower oil, and peanut oil. And so it’s easy to not buy those, but where you end up seeing those is in salad dressings and mayonnaise. So it’s very difficult to find versions of those that don’t have soybean as the first ingredient. You’re now starting to see them pop up a little more. But that’s really important because it will make people nauseous if you eat a lot of soybean oil or a lot of mayonnaise that has soybean oil in it. So the types of fat’s important.
The other area is in mineral balance where you can run into a lot of serious problems if you don’t understand how to manage sodium on this diet. So a lot of people are afraid of salt. Because we’ve been told we eat too much salt, and we need to reduce it. It turns out that science doesn’t support that and it actually refutes that. If you restrict sodium, it may actually increase your risk for heart disease. But we won’t go down that path right now.
But definitely, when you’re in ketosis, the kidneys go through a very profound adaptation where they excrete more sodium, and it’s called the natriuresis of fasting or, in this case, the natriuresis of ketosis. And if you excrete sodium, you also lose fluid with that, and so that manifests in a contracted plasma volume or a reduced blood volume. And that’s what a lot of people feel as—and they call it the Atkins flu, or they feel lethargic or tired. They may get dizzy and faint when they go from a seated to a standing position. Some people, they get headaches, even constipation, and in most cases, they blame it on the lack of fiber or lack of carbs in their diet. But nine times out of ten, it’s the lack of accounting for that extra sodium that’s lost.
Dr. Pompa:
Absolutely.
Dr. Volek:
And you have to eat an extra gram or two of sodium on a ketogenic diet to maintain plasma volume, and if you’re an athlete, that’s especially important because it’ll affect your cardiac output and performance. And I won’t go into all of the nuances of this, but if you don’t address this, it’s not just those inconvenient symptoms. You end up with a counterregulatory response where you end up stressing the adrenal glands. Because the body wants to try to reabsorb sodium, you secrete aldosterone, and that causes you to retain more sodium at the expense of potassium. So you end up excreting more potassium. You end up in a negative potassium balance. And it’s impossible to gain muscle and even maintain muscle if you’re in a negative potassium balance, and it ends up affecting magnesium balance as well.
So you end up with all these mineral imbalances, and there’s one simple countermeasure. It’s just, have a little extra salt in your diet. So we recommend people consume broth, but it can really be any source of sodium to make up for that loss of sodium. So that’s another big component of a well-formulated ketogenic diet that can trip people up.
Dr. Pompa:
Yeah, I have—we acknowledge that fully, and I have something called my 2-2-2 Rule. Just to get the—make sure they’re getting the better fats. Two tablespoons of coconut oil a day. Two tablespoons of grass-fed butter a day, and two teaspoons of sea salt or some type of salt. So just to make sure some of those bases are hit. Because if you don’t make it simple for people, they just simply forget, right, and then they end up going I’m weak. I feel tired. My heart’s palpating. And it’s typically, like I said, one of those things, especially the electrolytes and the mineral imbalance, so very well said.
Jeff, I go into—and I said this earlier in the show. I said I go into ketosis in the summer. Why? Well, because I love cycling. I’m an endurance athlete. But when I do that, I lose my muscle very easily. I can eat muscle into sugar pretty quickly. However, when I’m in ketosis, I don’t. So two reasons, I keep my muscle, even though I do high-endurance in the summer, and I’m “bonk proof.”
I can literally get up. Not eat. I am even, partly, later in the day still not eating. I can go on a three-hour bike ride, and I do not bonk because I’m fat-adapted. So these athletes that—for me, even just at low-carb, I don’t have that effect unless I’m absolutely in ketosis, fat-adapted. Then I can run on fuel. And maybe it was you that said this, and I loved the analogy. Look, the average human can store about 2,000 calories in stored sugar. However, even as lean as I am, I have at least probably 80,000 stored calories of fat that I’m able to tap into.
And when I’m biking for all those hours without eating—because I didn’t eat through the night, and I didn’t eat through the morning, and I had went out with a group probably about noon one day. So I had already fasted 15 hours. We went out and rode for three and a half. I had not one bite of food, and I didn’t bonk. And they were astounded because they predicted my bonk. So despite going, whatever that was, 17 hours without food, even when we were done, I was still fine. That’s the beautiful part of being fat-adapted in ketosis.
Dr. Volek:
Yeah. You summarized it very well. That ability to be able to access and utilize your fat stores is one of the most important adaptations of a ketogenic diet, and that’s manifest in so many positive outcomes for these endurance athletes, including cognitive benefits.
Dr. Pompa:
Yeah.
Dr. Volek:
Because they become bonk proof, and their brains are able to utilize the ketones. So they remain very lucid, and don’t become disoriented at the end of these races, which is very common in the high-carb athletes.
Dr. Pompa:
Yeah. Another—I think the bodybuilders and the weightlifters are coming around to this. They usually went high-protein, but they’re realizing the benefit of being in ketosis. And I do something, Jeff, where I [00:56:48].
Meredith:
Dr. Pompa, looks like he’s frozen there.
Dr. Pompa:
Sorry. I don’t know what happened. My internet blipped out for a minute. Anyways, I don’t eat in the morning. I intermittent fast, and I benefit from my body’s ability to burn fat and keep burning fat whereas the old adage, I believe it’s old, is eat the five or six meals a day. We never give our body a chance to burn fat. When we’re fat-adapted, man, we want to give our body a chance.
And there’s two—and I’m not telling anyone to do this. Because the guys, they drop a lot of F-bombs. But they’re called the Hodgetwins, and these guys are built like houses, right? And they’re in ketosis, and they intermittent fast, and they go 19 hours without eating. And these guys are like, look, we do it without taking steroids. I mean, these guys are massive, and they’re boasting that it’s all about being in this intermittent fasting state in ketosis. And what it does for their growth hormone and testosterone, and that’s how they’re able to compete naturally.
If you want a kick, watch it, Hodgetwins, google it. But you better be used to a lot of F-bombs because they’re funny. They’re funny guys. I think they’re pretty smart, and it’s an act. But they do drop a lot of F-bombs. But they really—they prove the point that this raises hormones. It really makes you more hormone sensitive, even to testosterone.
Meredith:
Awesome. Well we got started a little bit late. So maybe we can have a Part 2 because there’s still questions.
Dr. Volek:
Absolutely.
Meredith:
And there’s so much on this topic. It’s really exciting, and your research is amazing. So do you want to tell our viewers how to find out a little bit more about you and your research?
Dr. Volek:
Well, I’m at Ohio State University now, and as you mentioned, I have a couple books. The most recent I wrote with Steve Phinney called “The Art and Science of Low-Carb Living,” and the companion to that for athletes is “The Art and Science of Low-Carb Performance.” So those are available on Amazon.
Meredith:
Awesome, great. Well, thank you so much for joining the show and for everything you’re doing. And we’ll definitely have to schedule you for a Part 2, and thank…
Dr. Volek:
I’d love to come back.
Dr. Pompa:
Yeah.
Meredith:
Awesome, awesome. Well, great to meet you. Thanks for watching everyone. Stay tuned next week. We’re going to be interviewing Ben Greenfield on low-carb fueling for athletes. So it’s going to be an awesome follow-up to this topic as well. We’re going to continue to delve more into this, and to get you guys the information you need. So thanks for watching everyone. Have a wonderful weekend, and we’ll see you next time.
