Drs. Stephen Phinney and Jeff Volek on the Basic Science of Ketosis and Keto-Adaptation

What follows is a condensed form of the Transcript of their presentation.

First, Drs. Phinney and Volek discuss the history of the Ketogenic diet.

Dr. Volek introduced the terms used in the diet. Understanding ketone concentration is fundamental.  If you’re eating a normal mixed diet, your ketones are suppressed. So your concentration of ketones in your circulating blood is for most people under 0.2 millimolar.

When you restrict carbohydrates to under fifty grams a day, you normalize ketones into the range of nutritional ketosis, which is between 0.5 to 4.  So that’s an entire order of magnitude higher than you would have on a normal mixed diet but an entire order of magnitude lower than what you see in ketoacidosis.

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When we’re eating a well-formulated Ketogenic diet you’re normalizing ketones into this range. When you do that over a sustained period of time that is keto-adaptation. You double your rate of fat oxidation when you’re in ketosis.

Obese people following a well-formulated Ketogenic diet don’t need to count calories, they will naturally restrict fat intake.

There’s nothing more potent than a Ketogenic diet to lower triglycerides and it also consistently raises HDL cholesterol.

We consistently see decreases in the small LDL particles. There’s increasing evidence that they are the most atherogenic particles circulating. We see improvements in glucose and insulin and measures of insulin sensitivity as well as improvements in hormone sensitivity so we see improvements in greater decreases in leptin.

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We’ve also measured saturated fat levels, we find that despite consuming two to four times as much saturated fat on a Ketogenic diet that levels in the blood actually go down or stay the same.

When you’re eating saturated fat on a Ketogenic diet you’re promptly oxidizing that incoming saturated fat and converting it to co2 and water it. Saturated fat is a preferred fuel when you’re in ketosis. This is very important because elevated levels of saturated fat in the circulation and in membranes is consistently associated with higher risk for heart disease, diabetes even some types of cancer. Half the inflammatory markers we measured in human trials were significantly decreased and the group fed a Ketogenic diet compared to a low-fat diet.  We’re seeing this a potent inflammatory mechanism in some of patients with type 2 diabetes.

A Ketogenic diet essentially reverses all the signs and symptoms of metabolic syndrome. The more carbs you eat the more you have a higher likelihood of developing the insulin resistant phenotype and if that progresses, type-2 diabetes.The more you restrict carbohydrates especially down to levels that induce ketosis, the less likely to develop type 2 diabetes. It’s driven by carbs in the diet. Everybody has a slightly different carb tolerance and it changes over the lifespan but this relationship between carbs and manifestation of insulin resistant phenotype versus keto-adapted phenotype holds true.

Dr. Phinney will talk to you about some of the characteristics of a well-formulated Ketogenic diet.

Blog - Mar.4 -3 Dietary Proteins and carbs by diet type.pngThis is best visual representation we’ve come up with to differentiate the Ketogenic diet from a the standard American diet, the Mediterranean diet and the Paleo diet.

Blog - Mar.4 -4. Formulated Keto diet.png

To achieve nutritional ketosis you have to get under 10% of a 2000-calorie diet, or about 50 grams of carbs. If you take your protein intake too high that protein intake begins to suppress ketogenesis. Your intake should be 20% or less protein. The energy your body burns comes from the 80% of fat.

What Goes into a Well Formulated Ketogenic Diet?    In terms of about a 2,000-calorie per day intake, the fat is eaten to satiety rather than counting calories. When you take the carbs down and get that insulin signalling down,natural instincts drive fat intake.If we restrict carbs, what can you have?

Eating a moderate proteinintake the protein-based carbs might be 5 to 10 grams per day. If you eat 3 to 5 servings of non-starchy vegetablesper day that is in the 10 to 15 to gram range. If you eat 1 to 2 ounces of nuts and seedsper day that’s 5 to 10 grams.

There is a wide range of luscious foods and still stay in the 30 to 50 gram range.. The vast majority of the calories here are coming from fat, but only till they are satisfied.  Dr. Phinney put up a screen that displays a typical menu.

People experience improvement. People with type 2 diabetes, taking a 100 units of insulin a day, have been taken off insulin. We (doctors) can do that when we get the diet composition right for the metabolic needs of each person. The key here is keepingprotein moderate and carbohydraterestricted.

 The best way todetermine your individual carbohydrate tolerance is you get a finger stickglucometer with a ketone testing and measure your ketones.

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Then what should I be eating?     90 grams of protein and 30 grams of carbohydrate that would be 120 calories of carb and 360 calories of protein and then eat fat to satiety. Most people were under eating total calories. The difference between their expenditure and their intake was basically unseen dietary fat but the dietary fat was coming from internal fat reserves.

The weight loss continues over several months and until people reach a new steady state. We don’t count calories. From day one and in maintenance our dietary instruction are: restrict carbs to 20-50 grams depending on tolerance and proteins to 90 grams and eat fats till satisfied.

Blog - Mar.4 -6 Caracteristics of WFKD.png

There are ten characteristics of WFKD, they are posted at https://blog.virtahealth.com/well-formulated-ketogenic-diet/

First characteristic, sustained nutritional ketosis appears to have better clinical response than the intermittent ketosis in terms of degree of weight loss and improvement in insulin resistance.

Next, it needs to maintain lean body mass and function. A well-formulated Ketogenic diet, when not overeating protein maintains or increases lean body mass.

Next, electrolyte and mineral management, when someone enters the state of nutritional ketosis sodium excretion increases. When you combine a Ketogenic diet where the sodium restricted diet in somebody who doesn’t have obvious need for sodium restriction, (hypertension or congestive heart failure), you’ll cause a decrease circulating volume and that leads to a symptoms and side effects that are oftentimes called the keto flu.It is actually an inadequacy of an essential nutrient called sodium to meet physiological needs. The solution is to add sodium to your daily intake.

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We have data from five published studies. The yellow, the purple one and the green one are all studies that used formula weight loss diets under a thousand calories per day for the roughly the first three to five months and then were followed up from anywhere to a year to two years.

In all of these cases by the end of the first year weight regain is beginning.  The blue line shows a case for type 2 diabetes, where when people are eating fat to satiety from day one. The weight loss is slower but it’s more progressive and that at the end of year one we don’t see what rebound and weight regain.

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Because a chronic condition such as type 2 diabetes isn’t going to be cured in one year, why use something, which is only going to provide transient benefit and then begin to lose control and gain that weight back. A well-formulated Ketogenic diet will have a lasting benefit.

People who are on medications for hypertension or type 2 diabetes have to have real-time medication management through the physician and pharmacist or nurse to avoid the side-effects of too much medication in the context of too little carbohydrate coming in and dramatically improving insulin sensitivity.  

Lastly, a well-formulated Ketogenic diet does not necessarily here to traditional dietary guidelines.

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In the next to last slide the first point is the need to provide adequate sodium. With the exception of hypertension or congestive heart failure or conditions where people have to restrict sodium our experience clinically is we need to provide them with 5 grams of sodium intake per day.(I understand that to be natural salt not processed salt.)

For different cultures the low point in terms of mortality for measured sodium excretion, the optimum intake is about 4 grams per day without people being in nutrition of ketosis?  Add nutritional ketosis 5 is a modest number.

When somebody is in weight maintenance, the average person burning 2,000 calories a day needs to eat about 150 grams of fat per day. Whenyou’re in nutritional ketosis and you’vedoubled your rate of fat oxidation. Itappears that some of the first fats thatget into the pathway for oxidation arethe saturated fats and in spite of higher intake, they don’t build up in theblood and if anything are reduced.  

 Worrying about saturated fats is only associated when you’re combining them with a significant proportion of carbohydrates in your diet. Gettingadequate potassium and magnesium asminerals as those are important, thosecome from leafy greenvegetables and to some degree berryfruits or homemade bone broth.

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In the last slide, ketones are fuel for the brain, heart function, and multiple organ systems and for gut function.

 If you eat dietary fiber and your microbiome makes it into butyrate, an optimal fuel for the gut that’s easily replaced with beta-hydroxybutyrate, a by-product of a Ketogenic diet.

Beta-hydroxybutyrate is a beneficial regulatory hormone that regulates the body’s defence against oxidative stress and inflammation, which has an impact on longevity and lifespan impact on inflammatory diseases and cell signalling and mitochondrial function.

Source: Dr. Stephen Phinney and Dr. Jeff Volek on the Basic Science of Ketosis and Keto-Adaptation

Dr. Stephen Phinney and Dr. Jeff Volek co-authored several books, including The Art and Science of Low Carbohydrate Living and The Art and Science of Low Carbohydrate Performance.

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