What is Moderate-Carb in a High-Carb Society?

If we were eating what the government actually funded in agricultural supports, we’d be having a giant corn fritter, deep fried in soybean oil. And it’s like, that’s not exactly what we should be eating.
~ Mark Hyman

A couple years back (2018), researchers did an analysis of long-term data on intake of carbohydrates, plant foods, and animal foods: Sara B Seidelmann, et al, Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis). The data, however, turns out to be more complicated than how it was reported in the mainstream news and in other ways over-simplified.

This was an epidemiological study of 15,000 people done with notoriously unreliable self-reports called Food Frequency Questionnaires based on the subjects’ memory of years of eating habits. The basic conclusion was that a diet moderate in carbs is the healthiest. That reminds me of the “controlled carbs” that used to be advocated to ‘manage’ diabetes that, in fact, worsened diabetes over time (American Diabetes Association Changes Its TuneAmerican Diabetes Association Changes Its Tune) — what was being managed was slow decline leading to early death. Why is it the ruling elite and its defenders, whether talking about diet or politics, always trying to portray extreme positions as ‘moderate’?

Let’s dig into the study. Although the subjects were seen six times over a 25 year period, the questionnaire was given only twice with the first visit in the late 1980s and with the third visit in the mid 1990s — two brief and inaccurate snapshots with the apparent assumption that dietary habits didn’t change from the mid 1990s to 2017. As was asked of the subjects, do you recall your exact dietary breakdown for the the past year? In my personal observations, many people can’t recall what they ate last week or sometimes even what they had the day before — the human memory is short and faulty (the reason nutritionists will have patients keep daily food diaries).

There was definitely something off about the data. When the claimed total caloric intake is added up it would’ve meant starvation rations for many of the subjects, which is to say they were severely underestimating parts of their diet, most likely the parts of their diet that are the unhealthiest (snacks, fast food, etc). Shockingly, they didn’t even assess or rather didn’t include carbohydrate intake for all those periods for they later on extrapolated from the earlier data with no explanation for this apparent data manipulation.

To further problemitize the results, those who developed metabolic health conditions (diabetes, stroke, heart disease) in the duration, likely caused by carbohydrate consumption, were excluded from the study, as were those who died — it was expected and one might surmise it was intentionally designed to find no link between dietary carbs and health outcomes. That is to say the study was next to worthless (John Ioannidis, The Challenge of Reforming Nutritional Epidemiologic Research). Over 80% of the hypotheses of nutritional epidemiology are later proved wrong in clinical trials (S. Stanley Young & Alan Karr, Deming, data and observational studies).

Besides, the researchers defined low-carb as anything below 40% and very high-carb as anything above 70%, though the study itself was mainly looking at percentages in between these. This study wasn’t about the keto diet (5% carbs of total energy intake, typically 20-50 grams per day) or even generally low-carb diets (below 25%) and moderate-carb diets (25-33% or maybe slightly higher). Instead, the researchers compared diets that were varying degrees of high-carb (37-61%, about 144 grams and higher). It’s true that one might argue that, compared to the general population, a ‘moderate’-carb diet could be anything below the average high-carb levels of the standard American diet (50-60%), the high levels the researchers considered ‘moderate’ as in being ‘normal’. But with this logic, the higher the average carb intake goes the higher ‘moderate’ also becomes, a not very meaningful definition for health purposes.

Based on bad data and confounded factors for this high-carb population, the researchers speculated that diets below 37% carbs would show even worse health outcomes, but they didn’t actually have any data about low-carb diets. To put this in perspective, traditional hunter-gatherer diets tend to be closer to the ketogenic level of carb intake with, on average, 20% at the lower range and 40% at the highest extreme, and that is particularly ketogenic with a feast-and-fast pattern. Some hunter-gatherers, from Inuit to Masai, go long periods with few if any carbs, well within ketosis, and they don’t show signs of artherosclerosis, diabetes, etc.

The study simply looked at correlations without controlling for confounders: “The low carb group at the beginning had more smokers (33% vs 22%), more former smokers (35% vs 29%), more diabetics (415 vs 316), twice the native Americans, fewer habitual exercisers (474 vs 614) ” (Richard Morris, Facebook). And alcohol intake, one of the single most important factors for health and lifespan, was not adjusted for at all. Taken together, that is what is referred to as the unhealthy user bias, whereas the mid-range group in this study were affected by the healthy user bias. Was this a study of diet or a study of lifestyle and demographic populations?

On top of that, neither was data collected on specific eating patterns in terms of portion sizes, caloric intake, regularity of meals, and fasting. Also, the details of types of foods eaten weren’t entirely determined either, such as whole vs processed, organic vs non-organic, pasture-raised vs factory-farmed — and junk foods like pizza and energy bars weren’t included at all in the questionnaire; while whole categories of foods were conflated  with meat being lumped together with cakes and baked goods, as separate from fruits and vegetables. A grass-finished steak or wild-caught salmon with greens from your garden was treated as nutritionally the same as a fast food hamburger and fries.

Some other things should be clarified. This study wasn’t original research but was data mining older data sets from the research of others. Also, keep in mind that it was published in the Lancet Public Health, not in the Lancet journal itself. The authors and funders paid $5,000 for it to be published there and it was never peer-reviewed. Another point is that the authors of the paper speak of ‘substitutions’: “…mortality increased when carbohydrates were exchanged for animal-derived fat or protein and mortality decreased when the substitutions were plant-based.” This is simply false. No subjects in this study replaced any foods for another. This an imagined scenario, a hypothesis that wasn’t tested. By the way, don’t these scientists know that carbohydrates come from plants? I thought that was basic scientific knowledge.

To posit that too few carbs is dangerous, the authors suggest that, “Long-term effects of a low carbohydrate diet with typically low plant and increased animal protein and fat consumption have been hypothesised to stimulate inflammatory pathways, biological ageing, and oxidative stress.” This is outright bizarre. We don’t need to speculate. In much research, it already has been shown that sugar, a carbohydrate, is inflammatory. What happens when sugar and other carbs are reduced far enough? The result is ketosis. And what is the affect of ketosis? It is an anti-inflammatory state, not to mention promoting healing through increased autophagy. How do these scientists not know basic science in the field they are supposedly experts in? Or were they purposefully cherrypicking what fit their preconceived conclusion?

Here is the funny part. Robb Wolf points out (see video below) that in the same issue of the same journal on the same publishing date, there was a second article that gives a very different perspective (Andrew Mente & Salim Yusuf, Evolving evidence about diet and health). The other study concluded a low-carb diet based on meat and animal fats particularly lowered lifespan which probably simply demonstrated the unhealthy user effect (these people were heavier, smoked more, etc), but this other article looked at other data and came to very different conclusions,

“More recently, studies using standardised questionnaires, careful documentation of outcomes with common definitions, and contemporary statistical approaches to minimise confounding have generated a substantial body of evidence that challenges the conventional thinking that fats are harmful. Also, some populations (such as the US population) changed their diets from one relatively high in fats to one with increased carbohydrate intake. This change paralleled the increased incidence of obesity and diabetes. So the focus of nutrition research has recently shifted to the potential harms of carbohydrates. Indeed, higher carbohydrate intake can have more adverse effects on key atherogenic lipoproteins (eg, increase the apolipoprotein B-to-apolipoprotein A1 ratio) than can any natural fats. Additionally, in short-term trials, extreme carbohydrate restriction led to greater short-term weight loss and lower glucose concentrations compared with diets with higher amounts of carbohydrate. Robust data from observational studies support a harmful effect of refined, high glycaemic load carbohydrates on mortality.”

Then, in direct response to the other study, the authors warned that, “The Findings of the meta-analysis should be interpreted with caution, given that so-called group thinking can lead to biases in what is published from observational studies, and the use of analytical approaches to produce findings that fit in with current thinking.” So which Lancet article should we believe? Why did the media obsess over the one while ignoring the other?

And what about the peer-reviewed PURE study that was published the previous year (2018) in the Lancet journal itself? The PURE study was much larger and better designed. Although also observational and correlative, it was the best study of its kind ever done. The researchers found that carbohydrates were linked to a shorter lifespan and saturated fat to a longer lifespan, and yet it didn’t the same kind of mainstream media attention. I wonder why.

The study can tell us nothing about low-carb diets, even if low-carb diets had been included in the study. Yet the mainstream media and health experts heralded it as proof that a low-carb diet was dangerous and a moderate-carb diet was the best. Is this willful ignorance or intentional deception? The flaws in the study were so obvious, but it confirmed the biases of conventional dietary dogma and so was promoted without question.

On the positive side, the more often this kind of bullshit gets put before the public and torn apart as deceptive rhetoric the more aware the public becomes about what is actually being debated. But sadly, this will give nutrition studies an even worse reputation than it already has. And it could discredit science in the eyes of many and could bleed over into a general mistrust of scientific experts, authority figures, and public intellectuals (e.g., helping to promote a cynical attitude of climate change denialism). This is why it’s so important that we get the science right and not use pseudo-science as an ideological platform.

* * *

Will a Low-Carb Diet Shorten Your Life?
by Chris Kresser

I hope you’ll recognize many of the shortcomings of the study, because you’ve seen them before:

  • Using observational data to draw conclusions about causality
  • Relying on inaccurate food frequency questionnaires (FFQs)
  • Failing to adjust for confounding factors
  • Focusing exclusively on diet quantity and ignoring quality
  • Meta-analyzing data from multiple sources

Unfortunately, this study has already been widely misinterpreted by the mainstream media, and that will continue because:

  1. Most media outlets don’t have science journalists on staff anymore
  2. Even so-called “science journalists” today seem to lack basic scientific literacy

In light of the Aug 16th, 2018 Lancet study on carbohydrate intake and mortality, where do you see the food and diet industry heading? (Quora)
Answered by Chris Notal

A study where the conclusion was decided before the data.

They mentioned multiple problems in their analysis, but then ignored this in their introduction and conclusion.

The different cohorts: the cohort with the lowest consumption of carbs also had more smokers, more fat people, more males, they exercised less, and were more likely to be diabetic; each of these categories independently of each other more likely to result in an earlier death. Also, recognize that for the past several decades we have been told that if you want to be healthy, you eat high carb and low fat. So even if that was false, you have people with generally healthier habits period who will live longer than those who do their own thing and rebel against healthy eating knowledge of the time. For example, suppose low carb was actually found to be healthier than high carb: it wouldn’t be sufficient to offset the healthy living habits of those who had been consuming high carb.
Also, look at the age groups. The starting ages were 46–64. And it covered the next 30 years. Which meant they were studying how many people live into their 90’s. Who’s more likely to live into their 90’s, a smoker or non-smoker? Someone who is overweight or not? Males or females? Those who exercise or those who don’t? The problem is that each variable they used in the study along with high carb, on their own supports living longer than the opposite.

Carbs, Good for You? Fat Chance!
By Nina Teicholz

A widely reported study last month purported to show that carbohydrates are essential to longevity and that low-carb diets are “linked to early death,” as a USA Today headline put it. The study, published in the Lancet Public Health journal, is the nutrition elite’s response to the challenge coming from a fast-growing body of evidence demonstrating the health benefits of low-carb eating…

The Lancet authors, in recommending a “moderate” diet of 50% to 60% carbohydrates, essentially endorse the government’s nutrition guidelines. Because this diet has been promoted by the U.S. government for nearly 40 years, it has been tested rigorously in NIH-funded clinical trials involving more than 50,000 people. The results of those trials show clearly that a diet of “moderate” carbohydrate consumption neither fights disease nor reduces mortality.

Deflating Another Dietary Dogma
By Dan Murphy

Just the linking of “carbohydrate intake” and “mortality” tells you all you need to know about the authors’ conclusions, and Teicholz pulls no punches in challenging their findings, calling them “the nutrition elite’s response to the challenge coming from a fast-growing body of evidence demonstrating the health benefits of low-carb eating.”

By way of background, Teicholz noted that for decades USDA’s Dietary Guidelines for Americans have directed people to increase their consumption of carbohydrates and avoid eating fats. “Despite following this advice for nearly four decades, Americans are sicker and fatter than ever,” she wrote. “Such a record of failure should have discredited the nutrition establishment.”

Amen, sister.

Teicholz went on to explain that even though the study’s authors relied on data from the Atherosclerosis Risk in Communities (ARIC) project, which since 1987 has observed 15,000 middle-aged people in four U.S. communities, their apparently “robust dataset” is something of an illusion.

Why? Because the ARIC relied on suspect food questionnaires. Specifically, the ARIC researches used a form listing only 66 food items. That might seem like a lot, but such questionnaires typically include as many as 200 items to ensure that respondents’ recalls are accurate.

“Popular foods such as pizza and energy bars were left out [of the ARIC form],” Teicholz wrote, “with undercounting of calories the inevitable result. ARIC calculated that participants ate only 1,500 calories a day — starvation rations for most.”

Low carbs and mortality
by John Schoonbee

An article on carbohydrate intake and mortality appeared in The Lancet Public Health last week. It is titled “Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis”. In the summary of the article, the word “association” occurs 6 times. The words “cause”, “causes” or “causal” are not used at all (except as part of “all-cause mortality”).

Yet the headlines in various news outlets are as follows:

BBC : “Low-carb diets could shorten life, study suggests”

The Guardian : “Both low- and high-carb diets can raise risk of early death, study finds”

New Scientist : “Eating a low-carb diet may shorten your life – unless you go vegan too”

All 3 imply active causality. Time Magazine is more circumspect and perhaps implies more of the association noted in the article : “Eating This Many Carbs Is Linked to a Longer Life”. These headline grabbing tactics are part of what makes nutritional science so frustratingly hard. A headline could perhaps have read : “An association with mortality has been found with extreme intakes of carbohydrates but no causality has been shown”

To better understand what an association in this context means, it is perhaps good to use 2 examples. One a bit silly, but proves the point, the other more nuanced, and in fact a very good illustration of the difference between causality and association.

Hospitals cause people to die. Imagine someone saying being in hospital shortens your life span, or increases your mortality. Imagine telling a child going for a tonsillectomy this! Of course people who are admitted to hospital have a higher mortality risk than those (well people) not admitted because they are generally sicker. This is an association, but it’s not causal. Being in a hospital does not cause death, but is associated with increased death (of course doctor-caused iatrogenic deaths and multidrug resistant hospital bugs alters this conversation).

A closer example which more parallels the the Lancet Public Health article, is when considering mortality among young smokers, men particularly. Young men who smoke have a higher mortality risk, mostly related to accidental death. Does this mean smoking causes increased deaths in young men? Clearly the answer is NO. But smoking is certainly associated with an increased death rate in young men. Why? Because these young men who smoke have far higher risk taking profiles and personalities, leading to more risk taking behavior including higher risk driving styles. Using a product that has severe health warnings and awful pictures, with impunity, clearly indicates a certain attitude towards risk. They are dying more because of their risk taking behavior which is associated with a likelihood of smoking. But it’s not the smoking of cigarettes that is killing them when they are young. (When they are older, the cancer and heart disease is of course caused by the cigarette smoking, but at an earlier age, that is not the case.)

The guidelines for “healthy” eating since the late 1970’s (which were not evidence based) have stipulated a certain proportion carbohydrate intake. Guidelines have typically also biased plants as being healthier than animal sources of protein and fat. In this context then, “healthy eating” is understood to be consuming 50-55% of carbohydrates, and having less animal products, and more plants, as general rules. It means those who then choose to ignore these guidelines – hence eat far higher amounts of animal fat and protein – would conceivably be those that are snubbing generally accepted “good health” advice (whether evidence based or not) and who probably do not care as much about their health. Their lifestyles would not unreasonably therefore be expected to be unhealthier in general.

The Lancet Public Health article shows that in the quintile of their study participants having the least amount of carbohydrate intake, they significantly

  • are more likely to be male
  • smoke more
  • exercise less
  • have higher bmi’s and
  • are more likely to be diabetic.

“Those eating the least carbohydrates smoked more, exercised less, were more overweight, and were more likely to be diabetic”

This seems to confirm an unhealthy user bias. Interestingly the authors also note that “the animal-based low carbohydrate dietary score was associated with lower average intake of both fruit and vegetables“. Ignoring conventional wisdom around the health of fruit and vegetables reaffirms the data and conclusion that the low carb intake group lack a certain healthy mindset.

Low, moderate or high carbohydrate?
by Zoe Harcombe

In 1977 the Senator McGovern committee issued some dietary goals for Americans (Ref 1). The first goal was “Increase carbohydrate consumption to account for 55 to 60 percent of the energy (caloric) intake.” This recommendation did not come from any evidence related to carbohydrate. It was the inevitable consequence of setting a dietary fat guideline of 30% with protein being fairly constant at 15%.

Call me suspicious, but when a paper published 40 years later, in August 2018, concluded that the optimal intake of carbohydrate is 50-55%, I smelled a rat. The study, published in The Lancet Public Health (Ref 2), also directly contradicted the PURE study, which was published in The Lancet, in August 2017 (Ref 3). No wonder people are confused. […]

I wondered what kind of person would be consuming a low carbohydrate diet in the late 1980s/early 1990s (when the 2 questionnaires in a 25 year study were done). The characteristics table in the paper tells us exactly what kind of person was in the lowest carbohydrate group. They were far more likely to be: male; diabetic; and current smokers; and far less likely to be in the highest exercise category. The ARIC study would adjust for these characteristics, but, as I often say, you can’t adjust for a whole type of person.

The groups have been subjectively chosen – not even the carb ranges are even. Most covered a 10% range (e.g. 40-50%), but the range chosen for the ‘optimal’ group (50-55%) was just 5% wide. This placed as many as 6,097 people in one group and as few as 315 in another.

This is the single biggest issue behind the headlines.

The subjective group divisions introduced what I call “the small comparator group issue.” This came up in the recent whole grains review (Ref 6). I’ll repeat the explanation here, and build on it, as it’s crucial to understanding this paper.

If 20 children go skiing – 2 of them with autism – and 2 children die in an avalanche – 1 with autism and 1 without – the death rate for the non-autistic children is 1 in 18 (5.5%) and the death rate for the autistic children is 1 in 2 (50%). Can you see how bad (or good?) you can make things look with a small comparator group?

From subjective grouping to life expectancy headlines

For the media headlines “Low carb diets could shorten life, study suggests” (Ref 5), the researchers applied a statistical technique (called Kaplan-Meier estimates) to the ARIC data. This is entirely a statistical exercise – we don’t know when people will die. We just know how many have died so far.

This exercise resulted in the claim “we estimated that a 50-year-old participant with intake of less than 30% of energy from carbohydrate would have a projected life expectancy of 29·1 years, compared with 33·1 years for a participant who consumed 50–55% of energy from carbohydrate…  Similarly, we estimated that a 50-year-old participant with high carbohydrate intake (>65% of energy from carbohydrate) would have a projected life expectancy of 32·0 years, compared with 33·1 years for a participant who consumed 50–55% of energy from carbohydrate.”

Do you see how both of these claims have used the small comparator group extremes (<30% and >65%) to make the reference group look better?

Back to the children skiing… If we were to use the data we have so far (50% of autistic children died and 5.5% of non-autistic children died) and to extrapolate this out to predict survival, life expectancy for the autistic children would look catastrophic. This is exactly what has happened with the small groups – <30% carb and >65% carb – in this study.

The data have been manipulated.

When Bad Science Can Harm You
by Angela Stanton

“Statistical Analysis

We did a time varying sensitivity analysis: between baseline ARIC Visit 1 and Visit 3, carbohydrate intake was calculated on the basis of responses from the baseline FFQ. From Visit 3 onwards, the cumulative average of carbohydrate intake was calculated on the basis of the mean of baseline and Visit 3 FFQ responses…”

WOW, hold on now. They collected carbohydrate information from the first and third visit and then they estimated the rest based on these two visits? Do they mean by this that

  1. The data for years 2,4,5, and 6 didn’t match what they wanted to see?
  2. The data for years 2,4,5, and 6 didn’t exist?

What kind of a trick might this hide? Not the kind of statistics I would like to consider as VALID STATISTICAL ANALYSIS.

“…WWhen Bad Science Can Harm You
Angela A Stanton, Ph.D. Angela A Stanton, to reduce potential confounding from changes in diet that could arise from the diagnosis of these diseases… The expected residual years of survival were estimated…”

Oh wow! So those who ate a lot of carbohydrates and developed diabetes, stroke, heart disease during the study were excluded? This does not reduce confounding changes but actually increases them. That is because the very thing they are studying is how carbohydrates influence health and longevity, that is no diabetes, no strokes, and no heart disease. By excluding those that actually ended up with them completely changes the outcome to the points the authors are trying to make rather than reflect the reality.

Also, if they presume a change in diet for these participants, why not for the rest? Do you detect any problems here? I do! […]

There are 3 types of studies on nutrition:

  1. Bad
  2. Good
  3. Meaningless–meaning it repeats something that was already repeated hundreds of times

This study falls into Bad and Meaningless nutrition studies. It is actually not really science–these researchers simply cracked the same database that others already have and manipulated the data to fit their hypothesis.

I have commented all through the quotes from the study of what was shocking to read and see. What is even more amazing is the last 2 sentences, a quote, in the press release by Jennifer Cockerell, Press Association Health Correspondent:

Dr Ian Johnson, emeritus fellow at the Quadram Institute Bioscience in Norwich, said: ‘The national dietary guidelines for the UK, which are based on the findings of the Scientific Advisory Committee on Nutrition, recommend that carbohydrates should account for 50% of total dietary energy intake. In fact, this figure is close to the average carbohydrate consumption by the UK population observed in dietary surveys. It is gratifying to see from the new study that this level of carbohydrate intake seems to be optimal for longevity.‘”

It is not gratifying but horrible to see that the UK, one of the most diseased countries on the planet today, plagued by type 2 diabetes, obesity, and heart disease, should consider its current general carbohydrate consumption levels to be ideal and finds support in this study for what they are currently doing.

I suppose that if type 2 diabetes, obesity, and other metabolic diseases is what the country wants (and why wouldn’t it want that? Guess who profits from sick people?), then indeed, a 50% carbohydrate diet is ideal.

Latest Low-Carb Study: All Politics, No ScienceLatest Low-Carb Study: All Politics, No Science
by Georgia Ede

Where’s the Evidence?

Ludicrous Methods. The most important thing to understand is that this study was an “epidemiological” study, which should not be confused with a scientific experiment. This type of study does not test diets on people; instead, it generates guesses (hypotheses) about nutrition based on surveys called Food Frequency Questionnaires (FFQs). Below is an excerpt from the FFQ that was modified for use in this study. How well do you think you could answer questions like these?

Provided by Lancet Public Health
Source: Provided by Lancet Public Health

How is anyone supposed to recall what was eaten as many as 12 months prior? Most people can’t remember what they ate three days ago. Note that “I don’t know” or “I can’t remember” or “I gave up dairy in August” are not options; you are forced to enter a specific value. Some questions even require that you do math to convert the number of servings of fruit you consumed seasonally into an annual average—absurd. These inaccurate guesses become the “data” that form the foundation of the entire study. Foods are not weighed, measured, or recorded in any way.

The entire FFQ used contained only 66 questions, yet the typical modern diet contains thousands of individual ingredients. It would be nearly impossible to design a questionnaire capable of capturing that kind of complexity, and even more difficult to mathematically analyze the risks and benefits of each ingredient in any meaningful way. This methodology has been deemed fatally flawed by a number of respected scientists, including Stanford Professor John Ioannidis in this 2018 critique published by JAMA.

Missing Data. Between 1987 and 2017, researchers met with subjects enrolled in the study a total of six times, yet the FFQ was administered only twice: at the first visit in the late 1980s and at the third visit in the mid-1990s. Yes, you read that correctly. Did the researchers assume that everyone in the study continued eating exactly the same way from the mid-1990s to 2017? Popular new products and trends surely affected how some of them ate (Splenda, kale chips, or cupcakes, anyone?) and drank (think Frappucinos, juice boxes, and smoothies). Why was no effort made to evaluate intake during the final 20-plus years of the study? Even if the FFQ method were a reliable means of gathering data, the suggestion that what individuals reported eating in the mid-1990s would be directly responsible for their deaths more than two decades later is hard to swallow.

There are other serious flaws to cover below, but the two already listed above are reasons enough to discredit this study. People can debate how to interpret the data until the low-carb cows come home, but I would argue that there is no real data in this study to begin with. The two sets of “data” are literally guesses about certain aspects of people’s diets gathered on only two occasions. Do these researchers expect us to believe they accurately represent participants’ eating patterns over the course of 30 years? This is such a preposterous proposition that one could argue not only that the data are inaccurate, but that they are likely wildly so.

Learn why we think you should QUESTION the results of the recent Lancet study which suggests that a low carb diet is bad for your health.
by Tony Hampton

1) Just last year, the Lancet published a more reliable study with over 120,000 participates entitled Associations of fats and carbohydrate intake with cardiovascular disease and mortality in 18 countries from five continents (PURE): a prospective cohort study. This study involved participates actually visiting a doctors office where various biomarkers were tracked. Here is the link to this study: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32252-3/abstract In this study, high carbohydrate intake was associated with higher risk of total mortality, whereas total fat and individual types of fat were related to lower total mortality. This is consistent with Dr. Hope and my recommendation to consume a lower carb high-fat diet.

2) Unlike the PURE study, the new Lancet study containing only 15,428 participates entitled Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis used food frequency questionnaires (FFQ) containing 66 questions asking participates what they ate previously. This is not as reliable as a randomized control trial where participants are divided by category into separate groups to compare interventions and are fed specific diets. Using FFQ is simply not reliable. Can you remember what you ate last week or over the last year? FFQ also are unreliable because participates tend to downplay their bad eating habits and describe what they think the researchers want to hear. FFQ are simply inherently inaccurate compared to randomized control trails and allow participates to self-declare themselves as eating low carb in this study.

3) Of the groups participating in the new Lancet study, the lower carb group’s participates were the least healthy of the study participates with higher rates of smokers (over 70% smoked or previously smoked), diabetics, overweight, and those who exercised less. This was not true of the other group’s participates.

4) The so-called low carb group at less than 40% carbs is not really a low carb diet. The participates in this group consuming 35-40% carbs are consuming nearly 200 carbs per day. Many of our patients on a low carb diet are consuming less than 50 carbs per day. So are the participates in this study really on a low carb diet? We would suggest they are not.

5) Declaration of interests: When Dr. Hope and I learned to review research studies, the first question we were taught to ask was: who funded the study. If you click on the study link above and go to the bottom of the study, you will see under the declaration of interest section that there were some personal fees from two pharmaceuticals (Novartis and Zogenix). Pharmaceuticals provide needed resources to fund much-needed research. The big message here, however, is full disclosure. Just as I discussed at the beginning of this post, Dr. Hope and I are somewhat biased towards a low carb high-fat diet. We felt you needed to be aware of this as you read this post. You also need to know who funded the Lancet study we are discussing. You decide how to use that information.

6) The Lancet study is an observational study. Observational studies only show an association, not causation. Association is weak science and should always be questioned.

7) The moderate carb diet in this study was associated with the lowest mortality. In this study, participates ate a diet with 50-55% carbs. This mirrors the current USDA diet which has been recommended over the last 40 plus years. During this timeline, Americans followed the USDA recommendations and reduced saturated fat while increasing carbs in their diets. This led to the onset of the obesity epidemic. Let us not go back to recommendations which have not worked.

8) Media sensationalism and bias. I know it’s frustrating to keep hearing mixed messages and dramatic headlines but this is how the media gets your attention, so don’t be convinced by headlines. If you are still reading at this point in the post, you won’t be sidetracked by dramatic press releases.

STUDY: Do Low Carb Diets Increase Mortality?
by Siim Land

Here’s my debunking:

  • The “low carb group” wasn’t actually low carb and had a carb intake of 37% of total calories…It’s much rather moderate carb
  • “Low carb participants” were more sedentary, current smokers, diabetics, and didn’t exercise
  • The study was conducted over the course of 25 years with follow-ups every few years
  • No real indication of what the people actually ate in what amounts and at what macronutrient ratios
  • The same applies to the increased mortality rates in high carb intake – no indication of food quality of carb content
  • Correlation does not equal causation
  • Animal proteins and fats contributed more to mortality than plant-based foods, which again doesn’t take into account food quality and quantities
  • It’s true that too much of anything is bad and you don’t want to eat too many carbs, too much fat, too much meat, or too much protein…

Is Keto Bad For You? Addressing Keto ClickBait
by Chelsea Malone

Where Did the Study Go Wrong?

  1. This was not a controlled study. Other factors that influence lifespan like physical activity, stress levels, and smoking habits were recorded, but not adjusted for. The “low-carb” group also consisted of the highest amount of smokers and the lowest amount of total physical activity conducted.
  2. The data collection process left plenty of room for errors. In order to collect the data on total carbohydrate consumption, participants were given a questionnaire (FFQ) where they indicated how often they ate specific foods on a list over the past several years. Most individuals would not be able to accurately recall total food consumption over such a long period of time and were likely filled with errors.
  3. Consuming under 44% of total daily calories from carbohydrates was considered low carb. To put this into perspective, if the average person consumes 2,000 calories a day, that is 220 grams of carbohydrates. This is nowhere near low-carb or keto territory.
  4. This study is purely correlational, and correlation does not equal causation. Think of it like this: If a new study was published showing individuals who wear purple socks were more likely to get into a car crash than individuals wearing red socks, would you assume that purple socks cause car accidents? You probably wouldn’t and the same principle applies to this study.

#Fakenews Headlines – Low Carb Diets aren’t Dangerous!
by Belinda Fettke

Not only was the data cherry-picked from a Food Frequency Questionnaire that lumped ‘meat in with the cakes and baked goods’ category while dairy, fruit, and vegetables were all kept as separate entities (implying that meat is a discretionary and unhealthy food??), they also excluded anyone who became metabolically unwell over the 25 year period since the study began (but not from baseline). […]

Dr Aseem Malhotra took it to another level in his interview on BBC World News.

Here are a couple of Key Points he outlined on Facebook:

1. Reviewing ALL the up to date evidence the suggestion that low carb diets shorten lifespan from this fatally flawed association study is COMPLETELY AND TOTALLY FALSE. To say that they do is a MISCARRIAGE OF SCIENCE!

2. The most effective approach for managing type 2 diabetes is cutting sugar and starch. A systematic review of randomised trials … reveals its best for blood glucose and cardiovascular risk factors in short AND long term. […]

The take-away message is please don’t believe everything that is written about the latest study to come out of Harvard T.H Chan School of Public Health. The authors/funders of this paper; Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis paid $5,000 to be published in the Lancet Public Health (not to be confused with the official parent publication – The Lancet). While it went past an editorial committee it has not yet been peer reviewed.

Low-carb or high carb diet: What I want you to know about the ‘healthiest diet’, as an NHS Doctor
by Dr Aseem Malhotra

1418: Jimmy Moore Rant On Anti-Keto Lancet Study
from The Livin’ La Vida Low-Carb Show

Old Debates Forgotten

Since earlier last year, I’ve done extensive reading, largely but not entirely focused on health. This has particularly concerned diet and nutrition, although it has crossed over into the territory of mental health with neurocognitive issues, addiction, autism, and much else, with my personal concern being that of depression. The point of this post is to consider some of the historical background. Before I get to that, let me explain how my recent interests have developed.

What got me heading in this direction was the documentary The Magic Pill. It’s about the paleo diet. The practical advice was worth the time spent, though other things drew me into the the larger arena of low-carb debate. The thing about the paleo diet is that it offers a framework of understanding that includes many scientific fields involving health beyond only diet and also it explores historical records, anthropological research, and archaeological evidence. The paleo diet community in particular, along with the low-carb diet community in general, is also influenced by the traditional foods approach of Sally Fallon Morrell. She is the lady who, more than anyone else, popularized the work of Weston A. Price, an early 20th century dentist who traveled the world and studied traditional populations. I was already familiar with this area from having reading Morrell’s first book in the late ’90s or early aughts.

New to me was the writings of Gary Taubes and Nina Teicholz, two science journalists who have helped to shift the paradigm in nutritional studies. They accomplished this task by presenting not only detailed surveys of the research and other evidence but in further contextualizing the history of powerful figures, institutions, and organizations that shaped the modern industrial diet. I didn’t realize how far back this debate went with writings on fasting for epilepsy found in ancient texts and recommendations of a low-carb diet (apparently ketogenic) for diabetes appearing in the 1790s, along with various low-carb and animal-based diets being popularized for weight-loss and general health during the 19th century, and then the ketogenic diet was studied for epilepsy beginning in the 1920s. Yet few know this history.

Ancel Keys was one of those powerful figures who, in suppressing his critics and silencing debate, effectively advocated for the standard American diet of high-carbs, grains, fruits, vegetables, and industrial seed oils. In The Magic Pill, more recent context is given in following the South African trial of Tim Noakes. Other documentaries have covered this kind of material, often with interviews with Gary Taubes and Nina Teicholz. There has been immense drama involved and, in the past, there was also much public disagreement and discussion. Only now is that returning to mainstream awareness in the corporate media, largely because social media has forced it out into the open. But what interests me is how old is the debate and often in the past much more lively.

The post-revolutionary era created a sense of crisis that, by the mid-19th century, was becoming a moral panic. The culture wars were taking shape. The difference back then was that there was much more of a sense of the connection between physical health, mental health, moral health, and societal health. As a broad understanding, health was seen as key and this was informed by the developing scientific consciousness and free speech movement. The hunger for knowledge was hard to suppress, although there were many attempts as the century went on. I tried to give a sense of this period in two massive posts, The Crisis of Identity and The Agricultural Mind. It’s hard to imagine what that must’ve been like. That scientific debate and public debate was largely shut down around the World War era, as the oppressive Cold War era took over. Why?

It is strange. The work of Taubes and Teicholz gives hint to what changed, although the original debate was much wider than diet and nutrition. The info I’ve found about the past has largely come from scholarship in other fields, such as historical and literary studies. Those older lines of thought are mostly treated as historical curiosities at this point, background info for the analysis of entirely other subjects. As for the majority of scientists, doctors and nutritionists these days, they are almost entirely ignorant of the ideologies that shaped modern thought about disease and health.

This is seen, as I point out, in how Galen’s ancient Greek theory of humors as incorporated into Medieval Christianity appears to be the direct source of the basic arguments for a plant-based diet, specifically in terms of the scapegoating of red meat, saturated fat and cholesterol. Among what I’ve come across, the one scholarly book that covers this in detail is Food and Faith in Christian Culture edited by Ken Albala and Trudy Eden. Bringing that into present times, Belinda Fettke dug up how so much of contemporary nutritional studies and dietary advice was built on the foundation of 19th-20th century vegan advocacy by the Seventh Day Adventists. I’ve never met anyone adhering to “plant-based” ideology who knows this history. Yet now it is becoming common knowledge in the low-carb world.

On the literary end of things, there is a fascinating work by Bryan Kozlowski, The Jane Austen Diet. I enjoyed reading it, in spite of never having cracked open a book by Jane Austen. Kozlowski, although no scholar, was able to dredge up much of interest about those post-revolutionary decades in British society. For one, he shows how obesity was becoming noticeable all the way back then and many were aware of the benefits of low-carb diets. He also makes clear that the ability to maintain a vegetable garden was a sign of immense wealth, not a means for putting much food on the tables of the poor — this is corroborated by Teicholz discussion of how gardening in American society, prior to modern technology and chemicals, was difficult and not dependable. More importantly, Kozlowski’s book explains what ‘sensibility’ meant back then, related to ‘nerves’ and ‘vapors’ and later on given the more scientific-sounding label of ‘neurasthenia’.

I came across another literary example of historical exegesis about health and diet, Sander L. Gilman’s Franz Kafka, the Jewish Patient. Kafka was an interesting case, as a lifelong hypochondriac who, it turns out, had good reason to be. He felt that he had inherited a weak constitution and blamed this on his psychological troubles, but more likely causes were urbanization, industrialization, and a vegetarian diet that probably also was a high-carb diet based on nutrient-depleted processed foods; and before the time when industrial foods were fortified and many nutritional supplements were available.

What was most educational, though, about the text was Gilman’s historical details on tuberculosis in European thought, specifically in relationship to Jews. To some extent, Kafka had internalized racial ideology and that is unsurprising. Eugenics was in the air and racial ideology penetrated everything, especially health in terms of racial hygiene. Even for those who weren’t eugenicists, all debate of that era was marked by the expected biases and limitations. Some theorizing was better than others and for certain not all of it was racist, but the entire debate maybe was tainted by the events that would follow. With the defeat of the Nazis, eugenics fell out of favor for obvious reasons and an entire era of debate was silenced, even many of the arguments that were opposed to or separate form eugenics. Then historical amnesia set in, as many people wanted to forget the past and instead focus on the future. That was unfortunate. The past doesn’t simply disappear but continues to haunt us.

That earlier debate was a struggle between explanations and narratives. With modernity fully taking hold, people wanted to understand what was happening to humanity and where it was heading. It was a time of contrasts which made the consequences of modernity quite stark. There were plenty of communities that were still pre-industrial, rural, and traditional, but since then most of these communities have died away. The diseases of civilization, at this point, have become increasingly normalized as living memory of anything else has disappeared. It’s not that the desire for ideological explanations has disappeared. What happened was, with the victory of WWII, a particular grand narrative came to dominate the entire Western world and there simply were no other grand narratives to compete with it. Much of the pre-war debate and even scientific knowledge, especially in Europe, was forgotten as the records of it were destroyed, weren’t translated, or lost perceived relevance.

Nonetheless, all of those old ideological conflicts were left unresolved. The concerns then are still concerns now. So many problems worried about back then are getting worse. The connections between various aspects of health have regained their old sense of urgency. The public is once again challenging authorities, questioning received truths, and seeking new meaning. The debate never ended and here we are again, and one could add that fascism also is back rearing its ugly head. It’s worrisome that the political left seems to be slow on the uptake. There are reactionary right-wingers like Jordan Peterson who are offering visions of meaning and also who have become significant figures in the dietary world, by way of the carnivore diet he and his daughter are on. T?hen there are the conspiratorial paleo-libertarians such as Tristan Haggard, another carnivore advocate.

This is far from being limited to carnivory and the low-carb community includes those across the political spectrum, but it seems to be the right-wingers who are speaking the loudest. The left-wingers who are speaking out on diet come from the confluence of veganism/vegetarianism and environmentalism, as seen with EAT-Lancet (Dietary Dictocrats of EAT-Lancet). The problem with this, besides much of this narrative being false (Carnivore is Vegan), is that it is disconnected from the past. The right-wing is speaking more to the past than is the left-wing, such as Trump’s ability to invoke and combine the Populist and Progressive rhetoric from earlier last century. The political left is struggling to keep up and is being led down ideological dead-ends.

If we want to understand our situation now, we better study carefully what was happening in centuries past. We are having the same old debates without realizing it and we very well might see them lead to the same kinds of unhappy results.

Is Ketosis Normal?

Humans are born into ketosis and will remain in ketosis while breastfeeding, whether or not the mother is in ketosis. For hunter-gatherers, breastfeeding commonly lasts for the first couple of years, the most important time for growth and development, especially the brain. So, evolution has created ketosis as a protected state for infancy. But it goes far beyond that.

Unlike other carnivores, evidence indicates humans remain in ketosis even while eating higher amounts of protein. We are capable of gluconeogenesis, a necessary function turning protein into glucose, but we don’t so heavily rely upon it. Under normal evolutionary conditions, humans would spend much, probably most, of their time in ketosis. No other species so easily goes into and remains in ketosis. The human brain, in fact, preferentially uses ketones. And it is probably because of our large, energy-hungry brains that we are so ketosis-prone in the first place. That is likely why babies are born so fat, so that they can have a ready supply of ketones.

It was a trade-off of the human brain growing larger as the gut grew smaller, as it requires a lot of energy to digest plant matter and that energy was needed for the evolutionary development of a larger brain. So, humans turned to eating fat from animals, to replace a digestive system needed to break down fibrous plants to produce fat. Herbivores are forced to spend all day eating vast amounts of plant matter and it is energy intensive work. Ketosis freed humans from this activity and simultaneously freed up immense energy to be used for other purposes, specifically greater neurocognitive functioning and higher thought.

The benefits and advantages of ketosis are amazingly numerous. It protects against or improves epilepsy, along with other neurocognitive disorders and mental illnesses, from bipolar disorder to ADHD, not to mention much more serious diseases such as Alzheimer’s. It also shows benefit for autoimmune disorders, cancer, and trauma. There is no health condition I can think of, besides type 1 diabetes, that would be worsened by ketosis. And if one were on a ketogenic diet in the first place, one would be unlikely to develop type 1 diabetes and so that is moot.

One would be forgiven for thinking that ketosis might be the natural state of the human species. Still, whatever one thinks of evolutionary arguments, no one can deny that ketosis is a far healthier state to be in, or at least there is no evidence to the contrary. That said, one doesn’t have to be in constant ketosis to see many of these benefits. Even in epilepsy, after a period of healing, some patients can stop a ketogenic diet and stay free of seizures. There are many mechanisms for this healing power of ketosis, such as the related autophagy, but the general anti-inflammatory effect might be more important considering inflammation is found in so many diseases.

* * *

By Amber L. O’Hearn:

Babies thrive under a ketogenic metabolism

Optimal Weaning from an Evolutionary Perspective

Ketosis Without Starvation: the human advantage

I’d love to see this question approached systematically, but the survey does at least suggest that protein levels above our minimum needs based on positive nitrogen balance still support ketosis. […]

Obligate carnivores are always on very low carb diets, so you might think they are always in ketosis, but that’s not at all the case. In fact they are specialised at gluconeogenesis, that is, getting all their energy needs met by converting protein into glucose. Protein needs tend to be high.

Cats have much higher protein needs than omnivores and surprisingly, they don’t adapt well to reduced protein or fasting [Cen2002]. They don’t seem to have good mechanisms to compensate for the various amino acid and vitamin deficiencies that develop, so they suffer from ammonia toxicity, methylation problems, and oxidative stress. They do produce ketones fasted, but they don’t seem to use them in a productive way. and they actually accumulate fatty acids in the liver when fasted; the opposite of what humans do, Because they are still producing glucose, they become like human type two diabetics.

Dolphins are particularly interesting because they have really large brains, and they eat a diet that would be expected to be ketogenic if fed to humans. However, they don’t seem to even generate ketone at all, not even when fasting. Instead, they ramp up gluconeogenesis [Rid2013].

They keep their bodies and their brains going by increased glucose.

When faced with this observation that humans use ketosis even when they don’t have to for glucose production, one obviously wonders how this happens from a mechanistic standpoint. I have never seen the question raised in the literature, let alone answered. If I were to take a guess, I’d say it probably happens somewhere in this process.

CPT1A is a kind of gatekeeper, transporting fatty acids into the mitochondria for oxidation. This is normally a necessary step in the creation of ketone bodies. The coenzyme malonyl-CoA inhibits CPT1A [Fos2004]. The functional reason it does that is because malonyl-CoA is a direct result of glucose oxidation and is on the path to de novo lipogenesis. It could be inefficient to be both generating fat and oxidizing it. So this is a convenient signal to slow entry of fat into the mitochondria.

However, its action is not stictly linear. It uses hysteresis. Hysteresis is a way of preventing thrashing back and forth between two states at the threshold of their switch. For example, if you set your thermostat to 20°C, you would not want the heater to be turned on when the temperature drops to 19.999 and turned off again at 20. This would result in constant switching. Instead, a thermostat waits until the temperature drops a little lower before activating the heater, and heats it a little more than required before deactivating it.

Hysteresis is implemented in CPT1A by its becoming insensitive to malonyl-CoA when levels of it are low [Ont1980][Bre1981][Gra1988][Gre2009][Akk2009]. That means that once CPT1A becomes very active in transporting fatty acids, it takes time before the presence of malonyl-CoA will inhibit CPT1A at full strength again. That means that fluxuations in glucose oxidation, or small, transient increases in glucose oxidation don’t disturb the burning of fatty acids or the production of ketones.

It could be the case that humans develop more insensitivity to malonyl-CoA under ketosis than other species do, allowing them to metabolise more protein without disturbing ketosis. Among humans, this is case in populations such as some Inuit with the Artic variant of CPT1A. That mutation slows down CPT1A activity immensely. This was permitted by their diet which was very high in polyunsaturated fats from sea mammals. Polyunsaturated fats upregulate fatty acid oxidation by a large proportion compared to saturated fats [Cun2002][Fra2003][Fue2004], so this mutation would not necessarily have been disruptive of ketosis in that population when eating their natural diet [Lem2012]. But a second effect of the same gene further decreases the sensitivity of CPT1A to inhibition by malonyl-CoA. That means they are less likely to be knocked out of ketosis by high protein intake. […]

But it’s not just epilepsy that ketosis is good for. Epilepsy is just the condition with the most research, and the widest acknowledgment.

Other conditions for which at least some evidence supports improvement via a ketogenic diet include neurological disabilities in cognition and motor control [Sta2012]; the benefit here may have to do with the proper maintenance of brain structures such as myelination (Recall phases: tear down damage, rebuild)

Survival after brain damage, the hypoxia of stroke or blows to the head is improved in animal models [Sta2012]. There is even animal evidence that brain damage due to nerve gas is largely mitigated by being in a state of ketosis during the insult [Lan2011]. Again, this suggests a structural support and resilience provided by a ketogenic metabolism. Resilience comes in part from not being as susceptible to damage in the first place, and that could be from reduced oxidative stress when using ketones for fuel.

Ketogenic diets as a treatment for cancer are controversial, but some of the best evidence in support of it comes from glioblastomas. See e.g. [Zuc2010][Sch2012]. This could be due mostly to the hypoglycemia stalling the rate of tumour development.

And to venture into an area less well studied, but of critical importance given the epidemic that would be more apparent were it less taboo, there is preliminary evidence in the form of case studies that ketogenic diets may be promising treatments for many psychiatric illnesses too, for example, [Kra2009][Phe2012]. Given that anticonvulsants are also used to treat bipolar, and the solid results of ketogenic diets on epilepsy, this may not be surprising. Additionally, the enhanced availability of AA and DHA may play a crucial role Because these fatty acids are critical for the brain, and dysregulation in their flux has been associated with bipolar disorder and schizophrenia. See e.g. [McN2008] and [Pee1996].

I would almost like to call a ketogenic diet a brain-growth mimicking diet.

The question of how and why humans are so ketosis prone may lead to interesting new insights about us as a species. We seem to avoid giving up ketosis as long as possible. only halting it when we take in so much glucose exogenously that we have to store it.

It seems likely that it facilitated the evolution of our brains, that organ that makes us so different from other animals that we sometimes forget we are animals.

Coffee and Cream, Ketosis and Autophagy

On Twitter, Jerry Teixeira (JT) declared his love of cream in coffee. It led to a long thread where the joys and benefits of creamy vs black coffee were argued.

An interesting side discussion formed over the issue of fasting, ketosis, and autophagy. I must admit that my understanding was always a big hazy about the relationship between the latter two, both of which can be results of fasting. Despite common factors involved in both processes, I didn’t think there was a causal link.

I guess there is a connection, after all (Camberos-Luna et al, The Ketone Body, β-Hydroxybutyrate Stimulates the Autophagic Flux and Prevents Neuronal Death Induced by Glucose Deprivation in Cortical Cultured Neurons.). Even so, that still leaves other benefits of fasting, such as downregulating mTOR (vitamin D3 and Autophagy).

* * *

Patrice Bäumel
My number one reason for drinking black coffee in the morning is to not interfere with IF, which cream does.

Rob W. James
The benefits of IF are overstated in my opinion. Most of the benefits come from calorie restriction, which a splash of milk isn’t going to make much difference too

Patrice Bäumel
The main benefit is clearing out damaged cells. It’s an anti-aging hack. You lose that benefit by breaking fast.

JT
Coffee is still a xenobiotic, you are breaking a fast by drinking coffee and you are breaking a fast by drinking 2 tbsp cream. Regardless, autophagy is stimulated via ketogenesis, neither coffee nor cream Inhibit ketogenesis.
https://www.ncbi.nlm.nih.gov/m/pubmed/26303508/

Tell
Autophagy doesn’t really hit significant levels until 48hrs though. So benefits are mininal if any during IF

Tell
This is not to say autphagy isn’t present until 48hrs, rather it hits full scale around 48hrs.
And if autophagy is why you “fast” an extended fast.. past a normal IF, is necessary to achieve what you’re after.

JT
Autophagy happens downstream via BHB regardless, when you are on a ketogenic diet you have these elevated BHB levels at that point for long periods, where fasting takes 48 hours to get you where a Keto diet keeps you

JT
So if you are IF and eating plenty of carbs I totally agree. It takes longer to get to the higher BHB levels because BHB and carbohydrate are inversely proportional

Tell 
This is such an important point I don’t see anyone talking about.
That’s why I was talking about fasting a few weeks ago.
No one is talking about needing to be in ketosis to be fasted. So most of these guys doing IF are basically just TRE.. Which is a good enough reason to IF

Tell 
The contents creators aren’t talking about this though and selling false promises of autophagy and fountain of youth.

Dave
I read an article about IF that showed signs of arteriole smoothing with a 16:8 diet. If this is true then autophagy at 48 hours isn’t necessary for sole benefit and daily fasting does have vasculature anti-aging properties.

JT
There are benefits for every hour you fast according to Salk institute researchers . What we will need to see is calorie matched studies between TRE/ IF and CR. But to say there is zero additional benefit if you are healthy is wrong. The amount of benefit is arguable

JT
Beta hydroxy butyrate is an HDAC inhibitor and downstream via that action increases autophagy. Cream doesn’t matter. The longer you fast for the higher the bhb. Or a ketogenic diet can increase the bhb. Ketogenic diet mimics fasting and vice Versa.

JT
They are not synonymous. Of course, however elevated BHB levels are a common thread and a little cream in your coffee is not going to matter at all in that regard.

JT
Myriads research over the last two years and mixing more underway showing the mechanisms by which you still see these benefits from BHB weather or not you fast. I am compiling all the links and will sends them over when done if you would like

Erik
Hell, coffee alone (even decaf) induces autophagy.
https://t.co/2KcTpGZur0?amp=1

JT
Yeah, I saw some research that it increases ketogenisis

What causes health?

What causes health? It’s such a simple question, but it’s complex. The causes are many and the direction of causality not always clear. There has been a particular challenge to dietary ideology that shifts our way of thinking. It has to do with energy and motivation.

The calorie-in/calorie-out (CICO) theory is obviously false (Caloric Confusion; & Fung, The Evidence for Caloric Restriction). Dr. Jason Fung calls it the CRaP theory (Caloric Reduction as Primary). Studies show there is a metabolic advantage to low-carb diets (Cara B. Ebbeling, Effects of a low carbohydrate diet on energy expenditure during weight loss maintenance: randomized trial), especially ketogenic diets. It alters your entire metabolism and endocrine system. Remember that insulin is a hormone that has much to do with hunger signaling. Many other hormones are involved as well. This also alters how calories are processed and used in the body. More exercise won’t necessarily do any good as long nothing else is changed. The standard American diet is fattening and the standard American lifestyle makes it hard to lose that fat. Even starving yourself won’t help. The body seeks to limit energy use and maintain energy stores, especially when it is under stress (NYU Langone, Researchers Identify Mechanism that May Drive Obesity Epidemic). All that caloric restriction does is to slow down metabolism, the opposite of what happens on carbohydrate restriction.

We associate obesity with disease and rightly so, but that isn’t to say that obesity is the primary cause. It too is a symptom or, in some cases, even a protective measure (Coping Mechanisms of Health). The body isn’t stupid. Everything the body does serves a purpose, even if that purpose is making the best out of a bad situation. Consider depression. One theory proposes that when there is something wrong we seek seclusion in order to avoid further risks and stressors and to figure out the cause of distress — hence the isolation and rumination of depression. It’s similar to why we lay in bed when sick, to let the body heal. And it should be noted that depression is a symptom of numerous health conditions and often indicates inflammation in the brain (an immune response). Insulin resistance related to obesity also can involve inflammation. When the cause of the problem is permanent, the symptoms (depression, obesity, etc) become permanent. The symptoms then become problems in their own right.

This is personal for me. I spent decades in severe depression. And during that time my health was worsening, despite struggling to do what was right. I went to therapists and took antidepressants. I tried to improve my diet and exercised. But it always felt like I was fighting against myself. I was gaining weight over time and my food cravings were persistent. Something was missing. All that changed once I got into ketosis. It’s not merely that I lost weight. More amazingly, my depression and food addictions went away, along with my tendencies toward brooding and compulsive thought (The Agricultural Mind). Also, everything felt easier and more natural. I didn’t have to force myself to exercise for it now felt good to exercise. Physical activity then was an expression of my greater health, in the way a child runs around simply for the joy of it, for no other reason than he has the energy to do so. Something fundamentally changed within my body and mind. Everything felt easier.

This touches on a central theory argued by some low-carb advocates. It’s not how many calories come in versus how many go out, at least not in a simple sense. The question is what is causing calories to be consumed and burned. One thing about ketosis is that it forces the body to burn its own energy (i.e., body fat) while reducing hunger, but it does this without any need of willpower, restraint, or moral superiority. It happens naturally. The body simply starts producing more energy and, even if someone eats a high-calorie diet, the extra energy creates the conditions where, unless some other health condition interferes, increased physical activity naturally follows.

It’s not merely that being in ketosis leads to changed activity that burns more energy. Rather, the increased energy comes first. And that is because ketosis allows better access to all that energy your body already has stored up. Most people feel too tired and drained to exercise, too addicted to food that trying to control it further stresses them. That is the typical experience on a high-carb diet, mood and energy levels go up and down with the inevitable crashes becoming worse over time. But in ketosis, mood and energy is more balanced and constant. Simply put, one feels better. And when one feels better, one is more likely to do other activities that are healthy. Ketosis creates a leverage point where health improvements can be made with far less effort.

In the public mind, diet is associated with struggle and failure. But in its original meaning, the word ‘diet’ referred to lifestyle. Diet shouldn’t be something you do so much as something that changes your way of being in and relating to the world. If you find making health changes hard, it might be because you’re doing it wrong. Obesity and tiredness is not a moral failing or character flaw. You aren’t a sinner to be punished and reformed. Your body doesn’t need to be denied and controlled. There is a natural state of health that we can learn to listen to. When your body hungers and craves, it is trying to tell you something. Feed it with the nutrition it needs. Eat to satiety those foods that contribute to health. Lose excess weight first and only later worry about exercise. Once you begin to feel better, you might find your habits improving of their own accord.

This is a challenge not only to dietary belief systems but an even more radical challenge to society itself. Take prisons as an example. Instead of using prisons to store away the victims of poverty and inequality, we could eliminate the causes and consequences of poverty and inequality. We used to treat the mentally ill in hospitals, but now we put them into prisons. This is seen in concrete ways, such that prisoners have higher rates of lead toxicity. As a society, it would be cheaper, more humane, and less sociopathic to reduce the heavy metal poisoning. Similarly, studies have shown the prison population tends to be extremely malnourished. Prisons that improve the diet of prisoners result in a drastic reduction in aggressive, violent, anti-social, and other problematic behaviors. A similar observation has been made in studies with low-carb diets and children, as behavior improves. That indicates that, if we had increased public health, many and maybe most of these people wouldn’t have ended up in prison in the first place (Physical Health, Mental Health).

We’ve had a half century of unscientific dietary advice. Most Americans have been doing what they’ve been told. Saturated fat, red meat, and salt consumption went down over the past century. In place of those, fruits and vegetables, fish and lean chicken became a larger part of the diet. What has been the results? An ever worsening epidemic of obesity, diabetes, heart disease, autoimmune disorders, mood disorders, and on and on. In fact, these kinds of health problems were seen quite early on, following the fear toward meat that followed Upton Sinclair’s 1906 muckraking journalism on the meatpacking industry in The Jungle. Saturated fat intake had been decreasing and seed oil intake had been increasing in the early 1900s, in the decades leading up to the health epidemic that began most clearly around the 1940s and 1950s. The other thing that had increased over that time period were grains, sugar, and carbs in general. Then the victims who followed this bad advice were blamed by the experts for being gluttonous and slothful, as if diet were a Christian morality play. We collectively took the hard path. And the more we failed, the more the experts doubled down in demanding more of the same.

Do we want better lives for ourselves and others? Or do we simply want to scapegoat individuals for our collective failures? If you think we can’t afford to do the right thing, then we really won’t be able to afford the consequences of trying to avoid responsibility. The increasing costs of sickness, far from being limited to healthcare, will eventually bankrupt our society or else cause so much dysfunction that civil society will break down. Why choose such a dark path when an easier choice is before us? Why is the government and major health institutions still pushing a high-carb diet? We have scientifically proven the health benefits of low-carb diets. The simplest first act would be to change our dietary guidelines and all else would follow from that, from the food system to medical practice. What are we waiting for? We can make life hard, if we choose. But why not make it easy?

* * *

I’ve long wondered why we humans make life unnecessarily hard. We artificially construct struggle and suffering out of fear of what would happen if people were genuinely free from threat, punishment, and social control. We think humans are inherently bad and must be controlled. This seeps into every aspect of life, far from being limited to demented dietary ideology.

We are even willing to punish others at great costs to ourselves, even to the point of being highly destructive to all of society. We’d rather harm, imprison, kill, etc millions of innocents in order to ensure one guilty person gets what we think they deserve. And we constantly need an endless parade of scapegoats to quench our vengeful natures. Innocence becomes irrelevant, as it ultimately is about control and not justice.

All of it is driven by fear. The authoritarians, social dominators, and reactionaries — they prey upon our fear. And in fear, people do horrific things or else submit to others doing them. Most importantly, it shuts down our ability to imagine and envision. We go to great effort to make our lives difficult. Struggle leads to ever more struggle. Suffering cascades onto suffering. Worse upon worse, ad infinitum. As such, dietary ideology or whatever else pushed by the ruling elite isn’t about public good. It’s social control, pure and simple.

But let all of that go. Let the fear go. We know from science itself that it doesn’t have to be this hard. There are proven ways to do things that are far simpler and far easier and with far better results. We aren’t bad people who need to be punished into doing the right thing. Our bodies aren’t fallen forms that will lead us into sin. What if, instead, we looked to the better angels of our nature, to what is inherently good within us?

Here is some of what I’ve written before about the easy versus the hard, about freedom versus social control:
Public Health, Public Good
Freedom From Want, Freedom to Imagine
Rationalizing the Rat Race, Imagining the Rat Park
Costs Must Be Paid: Social Darwinism As Public Good
Denying the Agency of the Subordinate Class
Capitalism as Social Control
Substance Control is Social Control
Reckoning With Violence
Morality-Punishment Link
Unspoken Connection: Fundamentalism and Punishment
What If Our Economic System Conflicts With Our Human Nature?
An Invisible Debt Made Visible

About imagining alternatives, I’ve been reading Edward Bellamy’s Looking Backward. It’s a utopian novel, but in many ways it isn’t all that extreme. The future portrayed basically is a Nordic-style social democracy taken to the next level. That basic model of governance has already proven itself one of the best in the world, not only for public good but also wealth and innovation.

In reading about this fictionalized world, one thing stood out to me. The protagonist, Julian West, was put into trance to aid his sleep. He was in a sealed room underground and apparently the house burned down, leaving behind an empty lot. As a leap of imagination for both author and reader, this trance state put him into hibernation for more than a century. His underground bedchamber is discovered by the Leete family who, in the future world, lives on his old property although there house was built on a different location.

The father is Doctor Leete who takes particular interest in Julian. They have many conversations about the differences between the late 19th and early 21st centuries. Julian struggles to understand the enormous changes that have taken place. The world he fell asleep in is no longer recognizable by the world he woke up in. When he questions something that seems remarkable to him, Doctor Leete often responds that it’s more simple than it seems to Julian. The contrast shows how unnecessarily difficult, wasteful, and cruel was that earlier society.

The basic notion is that simple changes in social conditions can result in drastic changes in public good. The costs are miniscule in comparison to the gains. That is to say that this alternative future humanity chose the easy path, instead of continually enforcing costly punishment and social control. It’s quite amazing that the argument I make now was being made all the way back in 1888 when Bellamy began writing it. From the novel, one example of this other way of thinking is the description of the future education system in how it relates to health:

I shall not describe in detail what I saw in the schools that day. Having taken but slight interest in educational matters in my former life, I could offer few comparisons of interest. Next to the fact of the universality of the higher as well as the lower education, I was much struck with the prominence given to physical culture, and the fact that proficiency in athletic feats and games as well as in scholarship had a place in the rating of the youth.

“The faculty of education,” Dr. Leete explained, “is held to the same responsibility for the bodies as for the minds of its charges. The highest possible physical, as well as mental, development of everyone is the double object of a curriculum which lasts from the age of six to that of twenty- one.”

The magnificent health of the young people in the schools impressed me strongly. My previous observations, not only of the notable personal endowments of the family of my host, but of the people I had seen in my walks abroad, had already suggested the idea that there must have been something like a general improvement in the physical standard of the race since my day ; and now, as I compared these stalwart young men and fresh, vigorous maidens, with the young people I had seen in the schools of the nineteenth century, I was moved to impart my thought to Dr. Leete. He listened with great interest to what I said.

“Your testimony on this point,” he declared, “is invaluable. We believe that there has been such an improvement as you speak of, but of course it could only be a matter of theory with us. It is an incident of your unique position that you alone in the world of to-day can speak with authority on this point. Your opinion, when you state it publicly, will, I assure you, make a profound sensation. For the rest it would be strange, certainly, if the race did not show an improvement. In your day, riches debauched one class with idleness of mind and body, while poverty sapped the vitality of the masses by overwork, bad food, and pestilent homes. The labour required of children, and the burdens laid on women, enfeebled the very springs of life. Instead of the these maleficent circumstances, all now enjoy the most favourable conditions of physical life ; the young are care fully nurtured and studiously cared for ; the labour which is required.of all is limited to the period of greatest bodily vigour, and is never excessive ; care for one’s self and one’s family, anxiety as to livelihood, the strain of a ceaseless battle of life, all these influences, which once did so much to wreck the minds and bodies of men and women, are known no more. Certainly, an improvement of the species ought to follow such a change, In certain specific respects we know, indeed, that the improvement has taken place. Insanity, for instance, which in the nineteenth century was so terribly common a product of your insane mode of life, has almost dis appeared, with its alternative, suicide.”

* * *

Bonus Article:
Here’s What Weight-Loss Advice Looked Like Nearly 100 Years Ago
by Morgan Cutolo, Reader’s Digest

I’m throwing this in for a number of reasons. It is showing how low-carb views are basically the same as dietary advice from earlier last century. Heck, one can find advice like that going back to the 1800s and even 1700s. Low-carb diets were well known and mainstream until the changes at the AHA and FDA over the past 50 years or so.

The return of low-carb popularity is what inspires such articles from the corporate media. Reader’s Digest would’t likely have published something like that 10, 20, or 30 years ago. Attitudes are changing, even if institutions are resistant. Profits are also changing as low-carb products become big biz. Corporate media, if nothing else, will follow the profits.

Here is what really stood out to me. In the article, two major dietary experts are quoted: Dr. Jason Fung and Dr. Robert Lustig. Both of them are leading advocates of low-carb diets with Dr. Lustig being the most influential critic of sugar. But neither of them is presented as such. They are simply used as authorities on the topic, which they are. That means that low-carb has become so acceptable as, in some cases, to go without saying. They aren’t labeled as low-carb gurus, much less dismissed as food faddists. No qualifications or warnings are given about low-carb. The article simply quotes these experts about what the science shows.

This is a major advance in news reporting. It’s a positive sign of changes being embraced. Maybe we are finally turning off the hard path and trying out the easier path instead. Some early signs are indicating this. The growing incidence of diabetes might be finally leveling out and even reversing for the first time in generations.

Diabetic Confusion
Low-Carb Diets On The Rise
American Diabetes Association Changes Its Tune
Slow, Quiet, and Reluctant Changes to Official Dietary Guidelines
Official Guidelines For Low-Carb Diet
Obese Military?
Weight Watchers’ Paleo Diet

“Is keto safe for kids?”

“Can my kids do keto too? Yes, kids can do keto. In fact, ketogenic diets were first tested on children that had epilepsy, and it was found to be safe and effective.”
~from Ruled.me

How come no one ever asks if sugary breakfast cereal, grape juice, and white bread with margarine is “safe for kids?” We have entered bizarro world when we’re asking if it’s safe for kids to not eat sugar or carb-load like they’re about to run a marathon. As I explain here, there is nothing — no vitamin, mineral, or other essential nutrient — that you can get from high-carb foods that you cannot get from LOW-carb foods.

He feels people don’t understand that carbohydrates are not a food. Carbohydrates are a highly neuroactive drug that we’ve now placed in our food system and we’ve told our population that this highly neuroactive drug is healthy for them. People don’t have a relaxation methodology. Babies are weaned onto carbohydrate rich foods so they’re getting this wonderfully neuroactive euphoria that is satisfying even before they know they’re human. And so they develop this euphoric relationship with a drug called carbohydrates. They seek it in their diet and society gives it to them. Society condones it.
from LowCarbUSA, Keto For Kids, Autism and ADHD

Ketosis for ChildrenKetosis for Children
from Perfect Keto, fact checked by Dr. Anthony Gustin

As far as nutrition on the ketogenic diet, there are some specific ways ketogenic foods are beneficial for kids:

Infants, toddlers, and growing children need a good amount of iron [*] and fat [*] in their diet for proper growth. Healthy ketogenic foods provide plenty of both. These are important for brain development and growth as well as absorbing and using fat soluble vitamins and building nerve tissue [*].

With refined, high-carbohydrate foods widely available and affordable, it’s unfortunately no surprise that one in six U.S. kids and teens are obese and type 2 diabetes is now seen so commonly in children. The connection between the intake of these foods and high blood glucose and insulin resistance is reason enough for parents to show concern about the high-carb foods their children are consuming.

If you look at these foods’ labels, you’ll see they’re fortified with vitamin and minerals for this exact reason—on their own, they’re very nutritionally poor.

Our Kids Are In Ketosis
by Angela A Stanton

We can see that glucose is not the primary fuel because babies are born in ketosis(1) and mother’s milk is low carbs high fat (LCHF), which keeps the newborn in ketosis all through nursing. Milk gets more glucose as it matures, and at full maturation, its nutritional content per cup (8 oz) is 10.77 gr fat, 2.53 gr protein, 16.95 gr carbohydrates (in the form of lactose) and total energy of 172 kcal; it also contains 87.5 gr water. Subtracting the water and looking at the macronutrient ratios only, this glass of mature nursing milk is 55.5% fat, 5.57% protein, and 38.71% carbohydrates (in lactose so not free sugar). In terms of fatty acid composition: 4.942 gr saturated fat, 4.079 gr monounsaturated fat, and 1.223 gr polyunsaturated fat, which in percentages: 48.24% saturated fat, 39.82% monounsaturated fat, and 11.94% polyunsaturated fat(2). One must agree that babies are not fed poison by their mothers and that Nature didn’t provide nursing milk such that it is toxic. In fact, we can see that babies grow very rapidly by nursing milk and we know from studies that babies who are nursed, have a better chance for survival, grow healthier, faster, and their brain develops better.

As babies grow, they retain metabolic flexibility, meaning they stay in ketosis for periods time, which changes by age and how often they are fed, and they may temporarily enter the carbohydrate metabolic process when they eat (1,3,4). […] Note that babies are born with 0.5 mmol/L or higher level of BHB and remain in ketosis until they are fed. In the case of infants, the needs for energy arises very quickly, as shown in Figure 1, and in approximately 20 minutes after feeding the baby is back in ketosis.

Thus ketosis, in one scenario, is a state into which our metabolism reverts to when food is not immediately available on demand — this is labeled “starvation”. However, studies on the fetus in utero show that the fetus, which is never under nutritional duress, is also in ketosis time to time(5,6) and there are ketones in the placenta(7). Therefore, it is very difficult to suggest that ketones are a backup fuel of any kind if even the fetus is in ketosis time to time in the womb. Clearly, being in ketosis provides some benefits that are not possible to achieve using the glucose metabolic process. The ketogenic and the glucogenic metabolic processes have distinct functions, each specialized to benefit us in some way.

Children in Ketosis: The Feared Fuel
by Angela A. Stanton

And here is the important part. The human body is a smart one. It had millions of years in which to figure out the order via evolution. It picks based on an order of urgency, and priority will be given to the most dangerous of fuels, which have negative consequences if they remain in the body for long. The body will use the dangerous fuel first over fuel that can be stored without negative consequences.

So what will the order of preference be in burning the 3 fuels?

Alcohol, glucose, and then fat (aka ketones).

And this is in order of urgency and not based on which is primary.[…]

In the original article, you will find discussion on Cahill’s landmark article (1), which you may or may not be familiar with. His work is focused mostly on ketosis during starvation. By starvation, understand “fasting” in modern terms. Babies, for example are in ketosis all through their early teenage years–as per Cahill–even 20 minutes between feeding initiates starvation responses in babies. But there are articles showing that the fetus is also in ketosis in the womb, where there is no starvation, and babies remain in ketosis even after eating–clearly no starvation there. So there is more to ketosis than meets the careless eye. […]

With all due respect, I disagree with glucose as the primary human fuel. Glucose is not primary or secondary or any-ary. It is a fuel that is urgent to be used up as fast as possible and so it gets used first (after alcohol) but not because it is primary but because we need to get rid of it faster than fat.

If Ketosis Is Only a Fad, Why Are Our Kids in Ketosis?
by Angela A. Stanton

I have had the opportunity to evaluate the 5-hour blood test results of children of all ages—I think the youngest was 5 years old and the oldest 16, so far. I have yet to see a blood ketone test of a child anywhere in this age group that is not showing ketosis both before and after a meal—even if the meal has fruits and dairy in it.

I suppose ignorance is bliss. Few doctors or researchers have the same opportunity I have in being able to measure the blood ketones of various ages of children for five hours postprandial plus fasting and premeal measures, therefore, most don’t realize just how much our kids are in ketosis.

Thus, while today in most countries around the world any type of food is just a short walk/drive away 24/7, and we need not experience hunger and starvation, our children are still in ketosis 24/7. Shouldn’t that tell us something about the importance of ketosis?

Why babies need animal fat
— and are born on the ketogenic diet.
by Maria Cross

As well as needing fat for fuel, a baby’s brain requires specific fat for normal cognitive development and intellectual skills. Without that specific fat, there is the serious risk of developing brain dysfunction.

There are two fats that are essential for optimal brain function in the developing foetus and the newborn baby: the omega-3 fatty acid DHA (docosahexaenoic acid) and the omega-6 fatty acid ARA (arachidonic acid).

Both these fats form part of each cell membrane, and control what passes in and out of each nerve cell. They help develop the central nervous system. They are involved in communication between nerve cells, the firing of neurons, the regulation of neurotransmitters and the development of cognitive skills. […]

What happens without enough of these two fatty acids?

Only two mammalian species have disproportionately large brains and advanced cognition — humans and bottlenose dolphins. Both depend on DHA for that cognition.

Children who lack DHA are more likely to have increased rates of neurological disorders, in particular attention deficit hyperactivity disorder (ADHD), and autism.
“It is our contention that the movement in the 19th to 21st centuries away from traditional use of sea foods and increased emphasis on land based food supply is a likely cause in the rise in brain disorders including mental ill-health, stress, and other psychiatric disorders.”(Crawford et al 2014).

Today, ADHD is the most frequently diagnosed neuro-behavioural disorder of childhood, and it is becoming increasingly prevalent. In 2014, the Centers for Disease Control and Prevention confirmed that there had been a 42% increase in the number of children diagnosed with the condition since 2006. In America today, 11% of children aged 4 to 17 live with ADHD.

There is a growing body of evidence to suggest that ADHD may be preceded by low DHA in the womb.

The link between dietary fat and autism is also strong, and low levels of both DHA and ARA have been found in children on the autistic spectrum. In a study published in 2015 in International Journal of Molecular Sciences, the fatty acid profile of 121 autistic children, aged 3–7, was analysed and compared with children without the condition. The autistic children were found to have levels of ARA and DHA that were “particularly decreased”, compared to the non-autistic controls.

* * *

Bonus Information:

This reminds me of the case, in South Africa, brought against Tim Noakes. He recommended a low-carb diet to a pregnant woman. Public officials considered it to be a crime against humanity that must be harshly punished. After the first attack on him failed, he was forced to endure a second trial. The government spent millions of dollars persecuting him and he not only proved his innocence but proved that the low-carb diet was scientifically valid. It was the greatest boost for the low-carb diet since Ancel Keys led his crusade against it.

Tweet that landed Noakes in hot water ‘scientifically correct’ – lawyer
by Alex Mitchley

Tim Noakes Found Not Guilty Of Misconduct Over Advising Mother To Get Her Baby Onto The Banting Diet
from Huffington Post

Professor Noakes Found Innocent (Again)!
from Nutrition Coalition

Lore of Nutrition
by Tim Noakes & Marika Sboros
pp. 32-34, Introduction by Marika Sboros
(see more at: The Creed of Ancel Keys)

This is the story of a remarkable scientific journey. Just as remarkable is the genesis of that journey: a single, innocuous tweet.

In February 2014 , a Twitter user asked a distinguished and world-renowned scientist a simple question: ‘Is LCHF eating ok for breastfeeding mums? Worried about all the dairy + cauliflower = wind for babies??’

Always willing to engage with an inquiring mind, Professor Tim Noakes tweeted back: ‘Baby doesn’t eat the dairy and cauliflower. Just very healthy high fat breast milk. Key is to ween [ si c ] baby onto LCHF.’

With those few words, Noakes set off a chain of events that would eventually see him charged with unprofessional conduct, caught up in a case that would drag on for more than three years and cost many millions of rands. More difficult, if not impossible, to quantify is the devastating emotional toll that the whole ordeal has taken on him and his family, as critics attacked his character and scientific reputation at every turn.

At the time, it was open season on Tim Noakes. Doctors, dietitians and assorted academics from South Africa’s top universities had been hard at work for years trying to discredit him. They did not like his scientific views on low-carbohydrate, high-fat foods, which he had been promoting since 2011 . His opinions contrasted sharply with conventional, orthodox dietary ‘wisdom’, and the tweet provided the perfect pretext to amp up their attacks and hopefully silence him once and for all.

Within 24 hours of his tweet, a dietitian had reported him to the Health Professions Council of South Africa for giving what she considered ‘incorrect’, ‘dangerous’ and ‘potentially life-threatening’ advice. To Noakes’s surprise, the HPCSA took her complaint seriously.

Noakes is one of the few scientists in the world with an A 1 rating from the South African National Research Foundation (NRF) for both sports science and nutrition. In his home country, he has no equal in terms of expertise in and research into LCHF. Few can match his large academic footprint – quantified by an H-index of over 70 . The H- or Hirsch index is a measure of the impact of a scientist’s work. Noakes’s impact is significant. He has published more than 500 scientific papers, many of them in peer-reviewed journals, and over 40 of which deal exclusively with nutrition. He has been cited more than 17 000 times in the scientific literature.

Yet, remarkably, the HPCSA chose to back the opinion of a dietitian in private practice over an internationally renowned nutrition research scientist. They charged him with ‘unprofessional conduct’ for providing ‘unconventional advice on breastfeeding babies on social networks’ and hauled him through the humiliating process of a disciplinary hearing.

The public quickly dubbed it ‘the Nutrition Trial of the 21 st Century’. I’ve called it Kafkaesque. The HPCSA insisted that it was a hearing, not a trial, but the statutory body’s own conduct belied the claim.

At the time of Noakes’s tweet, I wanted to give up journalism. After more than 30 years of researching and writing about medicine and nutrition science, I was frustrated and bored. People were growing fatter and sicker, and the medical and dietetic specialists I wrote about weren’t making much difference to patients’ lives. Neither was my reporting.

Then I started investigating and writing about the HPCSA’s case against Noakes. The more questions I asked, the more walls of silence came up around me, and from the most unexpected sources. There’s an old saying that silence isn’t empty, it is full of answers. I found that the silence was loudest from those with the most to hide. I could not have foreseen the labyrinthine extent of vested inter ests ranged against Noakes, or the role played by shadowy proxy organisations for multinational sugar and soft-drink companies in suppressing and discrediting nutrition evidence.

It took a US investigative journalist to join many of the dots I had identified. Russ Greene’s research led to the International Life Sciences Institute (ILSI), a Coca-Cola front organisation. In an explosive exposé in January 2017 , Greene showed how the ILSI has worked to support the nutrition status quo in South Africa, as well as the health professionals and food and drug industries that benefit from it. It has opened a branch in South Africa and has funded nutrition congresses throughout the country. It has also paid for dietitians and academics opposed to Noakes and LCHF to address conferences abroad . *

Of course, it might be coincidence that so many doctors, dietitians and academics with links to the ILSI became involved, directly and indirectly, in the HPCSA’s prosecution of Noakes. Then again, maybe not.

The HPCSA’s conduct throughout the hearing and since its conclusion has been revelatory. To a large extent, it confirms the premise of this book: that those in positions of power and influence in medicine and academia were using the case to pursue a vendetta against Noakes. The trial highlighted the inherent perils facing those brave enough to go against orthodoxy.

Tim Noakes: The Quiet Maverick
by Daryl Ilbury
pp. 166-172

Into this turgid culture of food and identity stepped Tim Noakes on 5 February 2014, when he replied to a question posted two days earlier on Twitter, addressed to him and Sally-Ann Creed, a nutritional therapist (and co-author with Noakes of The Real Meal Revolution ). It was from a breastfeeding mother, Pippa Leenstra: ‘Is LCHF eating ok for breastfeeding mums? Worried about all the dairy + cauliflower = wind for babies??’ Noakes’s reply was the following: ‘Baby doesn’t eat the dairy and cauliflower. Just very healthy high fat breast milk. Key is to ween [ sic ] baby onto LCHF.’

It’s neither an offensive tweet by any stretch of the imagination, nor does it fall foul of any media law – it’s not libellous and there’s no encouragement of harm to others. People could disagree with him and had a voice to do so; that’s the point of social media: it is a platform for public discussion. And people did disagree, quite vocally, and there were others who supported his advice, equally vocally. Importantly, the question demanded a public, not private, response, which the person asking the question was free to accept or reject. And, as a medical doctor, Noakes didn’t cross any ethical boundaries in replying on a public platform. He didn’t publish any confidential patient information or dispense a diagnosis for a specific patient without seeing that patient; he simply provided generalised nutritional advice based on scientific evidence. Breast milk is high in fat, and there is scientific evidence to support the benefits of an LCHF diet. There is also evidence to the contrary, but, as we’ve realised, that’s science for you. The secret in making sense of science is context, and this is where it clashes with social media.

The character limitation of Twitter is one of its selling points; it demands concise expression, a sub-editor’s dream. It also means that tweets can be short on context, unless accompanied by click-through links to supporting evidence. Therefore tweets can be open to interpretation. However, this misses the main point of the brevity of Twitter messages: they are designed to encourage debate. Whether Noakes should have said ‘Key is to wean a baby …’ as opposed to ‘Key is to wean baby …’ is a matter for retrospective semantic debate. The fact is he provided a broad opinion on a public platform as a scientist and researcher of human nutrition.

Importantly, in her original tweet, to which Noakes replied, Pippa Leenstra never referred to herself or her baby. She spoke of ‘breastfeeding mums’. She was doing the media equivalent of asking a question in a town hall where the discussion was around LCHF. At that moment, Leenstra was a media consumer of medical or health information.

Not everyone saw it that way. One of those was Claire Julsing-Strydom, who at that time was president of the Association for Dietetics in South Africa (ADSA), the professional organisation for the country’s registered dietitians. Julsing-Strydom’s reaction was to register a complaint with the Health Professions Council of South Africa. It was a decision that would effectively threaten to destroy Noakes’s career, and make Julsing-Strydom the focus of a social media witch-hunt.

According to its website, the HPCSA provides the public with the right to request an investigation of any registered health practitioner whom they believe has acted unethically or caused harm. The site includes a downloadable form and an email address for Legal Med, the department within the HPCSA that handles complaints. To make sure that no health professional is a victim of a truculent member of the public with a hefty doctor’s bill in one hand and an axe to grind in the other, there is a due process of investigation and assessment before any measure of disciplinary action is followed. Only the most serious cases demand a professional-conduct committee hearing, which is what Tim Noakes would be called before.

As I said at the beginning of this book, I am not going to go into the trial in detail; instead, I will focus on the following: the complaint, the charge that resulted, two key components in the case against Noakes, and the unexpected outcome of the hearing. The main focus will be on how this was all covered in the media.

By now you know that whereas content is king, context is King Kong, and in this case the context behind the complaint makes for interesting reading, for two reasons: firstly, it shows that Noakes’s tweet was judged in isolation, and, secondly, it suggests that the complaint may not have been thought through.

What most people may not know is that directly after Noakes’s reply on Twitter to Pippa Leenstra, someone else entered the discussion: Marlene Ellmer, a paediatric dietitian and someone well known to Julsing-Strydom. Ellmer tweeted the following: ‘Pippa, as a paeds dietician I strongly advise against LCHF for breastfeeding mothers.’ Leenstra replied by posing the following question to both Noakes and Ellmer: ‘Okay, but what I eat comes through into my milk. Is that not problematic for baby and their winds at newborn stage?’ Ellmer responded by tweeting another message with her email address, encouraging Leenstra to contact her directly. Noakes didn’t do this, which is important to note, as we shall soon see. Leenstra tweeted to Ellmer that she would contact her, and after the discussion played out further with various people providing input, Leenstra tweeted: ‘Thanks, but I will go with the dietician’s recommendation.’ This she did, rejecting Noakes’s LCHF suggestion.

Let’s summarise: at that point Leenstra had posted a question on a public forum, received different opinions, including from two health professionals – one of them a registered dietitian – and been provided with the contact details of one of those professionals with an invite to get hold of her. Leenstra was free to choose which one to follow up with, and she agreed, publicly, to contact the registered dietitian. Theoretically, things could have stopped there.

However, the day after Ellmer’s invite for Leenstra to contact her, Julsing-Strydom entered the discussion and reacted with a tweet directed to Noakes, written thus: ‘I AM HORRIFIED!! HOW CAN YOU GIVE ADVICE LIKE THIS??’ For those unfamiliar with the idiosyncrasies of social media, the use of uppercase letters is normally reserved to express a strong feeling of annoyance, displeasure or hostility. On its own, Julsing-Strydom’s use of uppercase in a tweet is perfectly acceptable; it shows how she must have felt reading Noakes’s tweet, and there are possible reasons for that. Firstly, she had a four-month-old daughter she was breastfeeding, so she had a personal as well as a professional interest in the topic under discussion. Secondly, as she would later testify, she had had a strongly worded engagement the previous month with Noakes over what she saw as his dispensing nutritional advice to breastfeeding mothers during a talk. It’s easy to imagine that for Julsing-Strydom the tweet was the last straw, and so she submitted her complaint, including screenshots of Noakes’s tweet, to Legal Med. The accompanying email read:

‘To whom it may concern. I would like to file a report against Prof Tim Noakes. He is giving incorrect medical [nutrition therapy] on Twitter that is not evidence based. I have attached the Tweet where Prof Noakes advises a breastfeeding mother to wean her baby on to a low carbohydrate high fat diet. I urge the HPCSA to please take urgent action against this type of misconduct as Prof Noakes is a celebrity in South Africa and the public does not have the knowledge to understand that the information he is advocating is not evidence based. It is specifically dangerous to give this advice for infants and can potentially be life-threatening. I await your response. Claire Julsing-Strydom.’

The wording is a little breathless, and the reason for that would emerge in the hearing.

The complaint contains many factors that Legal Med would have considered, but five pertain to focus points covered so far in this book: the limits to the public’s understanding of science, in this case that of human nutrition; the complexity and unreliability of academic research behind that science; the media profile of Tim Noakes, and the idea that he is a ‘celebrity’; that the complaint related to something said within a disrupted media environment; and the suggestion that nutritional advice is a clear-cut case of right or wrong.

What the legal department would have known when they received the complaint was that the complainant was another health professional; this wasn’t just someone with a beef about their proctologist having cold hands. This meant that the complainant would have understood the potential outcomes of submitting her complaint, especially one claiming that an act by a fellow health professional was ‘life-threatening’. The fact of the matter is that Legal Med saw sufficient seriousness in the complaint to investigate.

However, inconsistencies in Julsing-Strydom’s complaint soon came to light. She supposedly submitted it on behalf of ADSA, and yet didn’t make that clear in the complaint. When questioned in the HPCSA hearing that her complaint triggered, she replied that it was the first time she had registered a complaint, saying, ‘I was not aware that this email would actually be, you know, used at this level.’

Now, after 30 years of interviewing people for the media, if there’s something I’ve learnt it’s that the most honest comments are usually unconsidered – made as an aside, when thoughts are wandering, or if a little flustered. Perhaps, I thought, Julsing-Strydom hadn’t really thought through what was going to happen once she submitted the complaint.

Furthermore, a forensic analysis of Twitter timelines and the submission date and time of the complaint shows that Julsing-Strydom publicly expressed her horror on Twitter on 6 February 2014 at 07:48, and sent her email to Legal Med less than an hour later, at 08:47. It’s fair to say that Julsing-Strydom was upset when she wrote that email.

Based on the findings of a preliminary committee of inquiry, the legal department of the HPCSA sent a letter to Noakes on 28 January 2015, saying that he was to be summoned before the Professional Conduct Committee of the Medical and Dental Professions Board. The charge against him was attached to the letter, and it makes for puzzling reading: ‘That you are guilty of unprofessional conduct, or conduct which, when regard is had to your profession is unprofessional, in that during February 2014, you acted in a manner that is not in accordance with the norms and standards of your profession in that you provided unconventional advice on breastfeeding babies on social networks (tweet).’

It is so badly written that it would send any sub-editor reaching for a stiff shot of whisky, so it was invariably presented in the media thus: ‘charged with providing unconventional advice on social media to breastfeeding mothers’.

When I first read the charge, that part about ‘social networks’ intrigued me the most. Providing advice on a public social media platform is an ethical catch-22 for any clinician: if they provide generalised information, they can be accused of not taking into consideration the specifics of the patient; yet if they ask for specifics, they risk encouraging the sharing of confidential information on a public platform. There’s also the ethical conundrum that if they open a consultative dialogue with someone other than a patient, they can be charged with supersession, essentially ‘stealing’ a patient; and for the HPCSA, that is grounds for discipline. How is that for irony?

I sensed confusion in the poorly worded charge. On a hunch I contacted the HPCSA and asked for a copy of their guidelines for how registered health practitioners should engage with the public on social media – if the HPCSA were charging Noakes because of his use of social media, they’d obviously have the necessary guidelines in place. I received the following reply: ‘Kindly note that the HPCSA doesn’t have guidelines around how registered health practitioners should engage with the public on social media.’ The HPCSA was clearly in unfamiliar territory. I thought it didn’t bode well for a speedy, clear-cut course for the hearing; and I was right.

What started on 4 June 2015, and was supposed to be wrapped up in little over a week, would drag on for almost two years, and if its aim was to deliver a swift, unsparing and public reprimand of a dissident scientist, it failed.

Dietary Dogma: Tested and Failed

There were two recent studies that looked at diets. One compared the 2010 Dietary Guidelines against the typical American diet. The other compared multiple dietary interventions: Mediterranean diet, low-fat diet, and low-salt diet. This covers the main diets advocated most often by doctors, nutritionists, dieticians, and health officials. Yet neither study found a significant overall benefit to any of the recommended diets. That is shocking, when one considers how official experts and major institutions have pushed these diets for decades. The low-fat diet has been a favorite among dietary technocrats for about a half century (The Creed of Ancel Keys).

What these studies didn’t bother to consider is the benefits of traditional foods diet (Weston A. Price & Sally Fallon Morrell), paleo/hunter-gatherer diet, low-carb high-fat diet, ketogenic diet, carnivore diet, etc. Nor any of the related but less well known diets like ketotarian, pegan, etc. Nor related dietary strategies such as fasting, either intermittent or extended, along with calorie restriction. With a narrow focus, the comparisons were limited. Still, it is a powerful judgment that none of the diets that were tested stood out as being all that impressive. What is being brought under doubt represents the key message of authoritative opinion on diet and nutrition. These diets tested (official Dietary Recommendations, Mediterranean diet, low-fat diet, and low-salt diet) are among the best that the collective wisdom of mainstream thought has to offer.

Here is an intriguing point. The first study looked at the 2010 Dietary Guidelines as separate from weight loss, to determine what were the results of the diet itself (besides, even including weight loss, the low-fat diet is one of the worst, as studies show few people drop body fat when adhering to it — see meta-analysis by UK Public Health Collaboration, Eat Fat, Cut The Carbs and Avoid Snacking To Reverse Obesity and Type 2 Diabetes). This officially trumpeted dietary regime, a fad diet that hasn’t been around long by the way, had no noticeable affect on glucose homeostasis, fasting lipids, or type 2 diabetes. Let’s consider another study, as a comparison and to clarify a point (Parker N. Hyde et al, Dietary carbohydrate restriction improves metabolic syndrome independent of weight loss). As with the above mentioned study, body weight was carefully maintained so as to control for that potentially confounding factor. What were the results?

“Despite maintaining body mass, low-carbohydrate (LC) intake enhanced fat oxidation and was more effective in reversing MetS [metabolic syndrome, including type 2 diabetes], especially high triglycerides, low HDL-C, and the small LDL subclass phenotype. Carbohydrate restriction also improved abnormal fatty acid composition, an emerging MetS feature. Despite containing 2.5 times more saturated fat than the high-carbohydrate diet, an LC diet decreased plasma total saturated fat and palmitoleate and increased arachidonate.”

Interestingly, these particular two studies demonstrate that obesity by itself is not necessarily the problem. Rather, it is a symptom of the problem. Obesity can even be an attempt by the body to compensate in preventing something even worse (Coping Mechanisms of Health). The fundamental problem is the metabolic syndrome itself and the insulin resistance behind it, and any diet that doesn’t directly deal with that will be ineffective. Only some variation of a low-carb diet can accomplish that end.

It’s time to rethink dietary recommendations and guidelines. There are signs this is already happening. The public is already turning toward low-carb diets (Low-Carb Diets On The Rise). And slowly but surely the official position is shifting in this direction (Obese Military?, Weight Watchers’ Paleo Diet, American Diabetes Association Changes Its Tune, Official Guidelines For Low-Carb Diet, & Slow, Quiet, and Reluctant Changes to Official Dietary Guidelines). The evidence keeps accumulating. These recent two studies add to the growing pile. It’s getting harder and harder to ignore the obvious.

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A randomized controlled-feeding trial based on the Dietary Guidelines for Americans on cardiometabolic health indexes
by Sridevi Krishnan et al

To our knowledge, this is the first controlled-feeding trial to test the effect of a food-based dietary pattern following recommendations of the DGA [2010 Dietary Guidelines for Americans]. We measured cardiometabolic disease risk factors in an at-risk female cohort, while maintaining body weight, with the use of foods that are accessible and acceptable to the consumer. The higher quality of the DGA diet relative to the TAD [typical American diet] was confirmed by HEI scores of 98 and 62, respectively. We found that, in the absence of weight loss, consuming a diet based on recommendations of the DGA did not change glucose homeostasis or fasting lipids in our cohort. The 2015 DGA Advisory Committee report concluded that there was moderate evidence for reduction in type 2 diabetes risk associated with nutrient-dense diets (2); however, the results from our short-term intervention trial did not align with this evidence. By design, the intervention did not lead to significant weight loss, and because changes in body weight and body fat can play a role in the pathogenesis of type 2 diabetes (31), this may also explain why improvements in blood sugar control were not observed despite the improvement in diet quality.

Supplements and Diets for Heart Health Show Limited Proof of Benefit
by Anahad O’Connor

When Dr. Khan and his co-authors looked at various diets recommended for cardiovascular prevention, they found a similar lack of solid evidence.

That was certainly the case for low-fat diets, which health authorities have recommended for decades as a way to lower cholesterol and heart disease risk. Dr. Khan and his colleagues found that the most rigorous randomized trials provided no evidence that eating less fat, including saturated fat, had an impact on mortality or cardiovascular outcomes. Low-fat diets have largely fallen out of favor among health authorities in recent years, though the federal government’s dietary guidelines still encourage people to limit their intake of foods rich in saturated fat, such as butter, meat and cheese.

One diet that remains highly touted by health authorities is the Mediterranean diet, with its abundance of whole grains, beans, nuts, fruits and vegetables and olive oil. While clinical trials have found that it reduces cardiovascular risk, some of the major ones have been flawed, and experts who have scrutinized the evidence for the diet have urged caution.

One of the largest and most publicized Mediterranean diet trials, called Predimed and published in 2013, found that it reduced heart attacks and strokes. But last year it was retracted because of methodological problems. The Predimed authors published a new analysis of their data, claiming their conclusions had not changed. But other Mediterranean diet trials have been embroiled in similar controversies. After analyzing data from all the relevant trials, Dr. Khan and his colleagues found that “the totality of evidence did not favor the Mediterranean diet for cardiovascular outcomes.”

“It’s not favorable or harmful,” he added. “It’s just a neutral diet from a cardiovascular perspective.”

The one dietary intervention that seemed to have the most support from randomized trials was lowering salt intake, though the researchers graded the evidence only as having “moderate certainty.” And there was nuance. Low-salt diets reduced mortality from all causes only in people with normal blood pressure. Among people with hypertension, lowering salt intake reduced deaths from heart disease but not from other causes.

Dr. Topol said that in his own clinic he sees a wide range of responses to salt intake. Some people are very sensitive to salt: A small increase in salty foods can have a pronounced effect on their blood pressure. But others can eat salt-laden meals and their blood pressure will hardly budge.

Dr. Topol said he finds diet studies hard to interpret because they rarely take into account the unique way that different people can have markedly different responses to dietary changes, whether it is cutting back on salt or avoiding fat or carbohydrates.

“The problem we have here is that all these studies essentially treat all people as one,” he said. “I think that all these things are going to turn out to be quite heterogeneous. Maybe salt restriction really is beneficial for some, but we haven’t defined the people yet that would drive that.”

Getting Into Ketosis

Here is some information about ketones, ketosis, and ketogenic diets. The focus is on treating Alzheimer’s, although the topic applies to many other conditions as well. Let me begin by explaining the basics.

Ketosis is the primary burning of fat, dietary fat or body fat, to produce ketones that the body uses. A ketogenic diet is sometimes called nutritional ketosis, as opposed to ketosis through other means such as fasting. When ketone levels are high enough, it is called ketosis — the term being used more strictly for medical purposes. The body has two main options for fuel, glucose and ketones. With Alzheimer’s as type 3 diabetes, insulin resistance in the brain decreases the ability to use glucose and so the brain slowly starves. Ketones can mostly replace glucose, especially for brain cells. Some argue they’re the preferred source of energy, since for most of human evolution there were limited amounts of carbohydrates in the diet. This is shown in how, when both glucose and ketones are available, the brain prioritizes the latter. Ketones are a more efficient and steady source of energy because few people have to worry about running out of dietary or body fat to make ketones.

Ketones are a superfuel that allows the brain function at a higher level. In ketosis, not only does metabolism change but so does brain functioning. This is why ketogenic diets have been medically used to treat diverse neurocognitive conditions: epileptic seizures, autism, ADHD, depression, multiple sclerosis, Alzheimer’s, etc. Part of this has to do with inflammation, as ketosis is anti-inflammatory. This is important because inflammation is often involved in problems with brain health and many other problems as well (arthritis, autoimmune disorders, etc). I can vouch for this in my own experience when my depression disappeared after going low-carb. Partly that is because my glucose, insulin and serotonin levels would have stabilized, but cutting back my carbs further to go into ketosis definitely made a difference. I generally feel better.

Immediately below is a chart comparing ketogenic strategies and the resultant increase in ketones. If multiple strategies are combined, ketone levels can be higher still. Ketoacidosis is thrown in the chart below for comparison, but it only happens to diabetics and it is harmful — it’s an entirely separate condition from ketosis, although both involve ketones. People sometimes confuse ketoacidosis with ketosis, but what causes each is separate. As you can see below, ketoacidosis raises ketone levels to a degree that nothing else does. Unless one is diabetic, that isn’t a concern.

Ketogenic Strategy                             —>               Ketone Levels (mmol/L)

Caffeine                                                    —>               0.2 to 0.3

Coconut Oil                                              —>               0.3 to 0.5

Vigorous Exercise                                  —>              0.3 to 0.5

Overnight Fast                                        —>              0.3 to 0.5

MCT Oil                                                      —>             0.3 to 1.0

Branched Chain Amino Acids            —>             0.3 to 1.0

Ketone Mineral Salts                            —>             0.5 to 1.0

Classic Ketogenic Diet                          —>             2 to 6

Starvation/Long-Term Fasting       —>             2 to 7

Ketone Esters (Oral or IV)                   —>             2 to 7 or higher

Diabetic Ketoacidosis                           —>            10 to 25

This chart and most of the other info I share here comes from Mary T. Newport’s book, The Complete Book of Ketones. There is also good info available in Dale E. Bredesen’s The End of Alzheimer’s, Amy Berger’s The Alzheimer’s Antidote, and Bruce Fife’s Stop Alzheimer’s Now. All I’m discussing below is the most basic info. For a more in-depth approach, I’d recommend checking out Dr. Bredesen, the author mentioned above, who is an Alzheimer’s researcher and clinician at UCLA. He has a complex protocol, going beyond ketosis, that requires working with a doctor trained in it. The clinical trial he did is the only confirmed reversal of Alzheimer’s. But back to increasing ketones and suppressing mental loss.

How to get into ketosis:

The most dependable method of entering into ketosis and maintaining it is through diet. Put in the simplest terms, there needs to be strict limits on starchy carbs and sugar (bread, crackers, noodles beans, potatoes, fruit, fruit juice, pop, candy, most processed foods, etc) combined with moderate amounts of protein and lots of fat/oil. Specific details can be found below. It is not necessarily easy, since those are some of the foods we enjoy most. Even so, it still allows a fair amount of diversity. Many foods are low in carbs: non-starchy vegetables, fruits like olives and avocados, most nuts and seeds, etc. The difficult part is that many convenience foods aren’t allowable other than as occasional foods eaten in limited amounts.

Of course, there are simpler methods of increasing ketones. Here are three:

(1) Exogenous ketones can be taken directly and will give a quick mental boost that doesn’t last long, but it is easy for the body to use since it is already in the needed form. A single dose peaks out in 30-60 minutes with the body fully eliminating them in a few hours. Exogenous ketones would need to be regularly taken in smaller amounts throughout the day to maintain higher ketone levels. One thing to keep in mind is that as ketone levels go up blood sugar and insulin levels drop. This can be an issue for people with diabetes or pre-diabetes. There are two options of exogenous ketones: ketone esters and ketone salts. The former are more easily used by the body, but the latter are more available on the market. I haven’t found ketone esters in any local store. They can be obtained online, though. I’d probably stick to the ketone salts, as there is much more research done showing their safety. Exogenous ketones are of more limited use since most people can’t safely handle more than one or two servings a day.

(2) Or one can use MCTs (medium chain triglycerides) which turn into ketones without much effort. MCT oils and powders can be added throughout the day and the body uses them fairly quickly. There are also MCTs in coconut oil and Mary T. Newport found that, in treating her husband’s Alzheimer’s, that coconut oil had a longer lasting effect. She used a combination of all three: exogenous ketones, MCT oil, and coconut oil. This gave a more steady level of ketones throughout the day. Her husband showed improvement despite her not doing anything else initially, not otherwise changing his diet. As a side note, Newport says to use cold-pressed coconut oil for reasons of general health. The main advantage is that greater amounts of MCTs and coconut oil allow the body to produce ketones even when carbs aren’t as restricted, not that one can eat carbs unlimited.

(3) An even simpler way is fasting, although easier still if one is already in ketosis (trying to go from a high-carb diet to fasting can be a challenge). A person is guaranteed to go into ketosis by not eating. Even a full night of sleep is enough to begin increasing ketone levels. Skip a meal or an entire day of eating and ketone levels will keep going up to a much more noticeable degree. If you break your fast with a ketogenic meal of low-carb and high-fat, that will extend ketosis into the rest of the day. Starting your day with fat in your coffee can be even better, as caffeine will also boost ketones (I add ghee and MCT oil to my coffee and mix it up with a battery-powered frother). In fasting for ketogenic purposes, one can do a fat fast by eating only fat, such as drinking fat-filled coffee all day. Without starches and sugar, the body is forced to burn fat and produce ketones. There isn’t anything easier than a fat fast nor as satiating.

The only potential downside is not everyone digests and metabolizes fat equally well. MCT oils, in particular, can require some adaptation. Too much can cause diarrhea for those sensitive to it. It’s best to start off with small amounts (1/2 to 1 tsp or less at a time, once or twice a day) and build up a tolerance (upwards of 1 to 2 tbsp or possibly higher, two to four times a day). If sensitive, take MCT oils with other foods, such as mixing it into cottage cheese or Greek yogurt. Coconut oil is easier for the body to handle, as it is a mix of other fats such as lauric acid that has some of the traits of MCTs. There is evidence that lauric acid works as a ketogenic fat directly in the brain. Coconut oil also helps with the thyroid and Alzheimer’s patients often develop thyroid problems.

By the way, here is what Mary T. Newport writes: “When Steve [her husband with Alzheimer’s took just coconut oil in the morning, his ketone levels peaked at about three hours but had returned to nearly normal after eight to nine hours, just before dinner time. With just MCT oil, Steve’s ketone levels went higher, peaked at about ninety minutes, but were gone within three hours.” So, she used both in a 4:3 ratio (MCT to coconut oil) to maintain stable ketone levels throughout the day. Newport suggests gradually increasing coconut oil (and MCT) intake up to 4-6 tablespoons a day or even as high 8 tablespoons, but gradually is the key part.

If one wants to ensure ketosis, there are ways to measure ketone levels. I’ve never done this, but I keep my carbs so low that there is no way for me to avoid ketosis. Without a ketogenic diet, it will be more difficult keeping ketone levels elevated and stable. Still, any greater amount of ketones is better than nothing when it comes to how the brain is starving for fuel in Alzheimer’s or in relation to many other conditions. If you want to try a ketogenic diet, here are some variations explained in detail and with good visuals about what the macronutrient (carb, protein, & fat) ratios should look like as a plate of food: Diet Plans – Charlie Foundation. Also, keep in mind protein levels, which can be an issue for with diabetes, pre-diabetes, etc: Too Much Protein?

Eating in such a way that ketosis is frequent is not always easy, although it can be the easiest diet in the world. It is not easy for many people because such diets reduce the foods they ‘love’ (sugar and carbs), reduce the foods they know how to prepare, and reduce the food options found in most restaurants. Further, these diets run contrary to the traditional food pyramid that we have been trained on for years. They seem downright unhealthy, when in fact, current research is showing they have been healthier all along. It requires changing how one thinks about food. In short, one must be very intentional. One cannot coast along and provide optimal brain nutrition. The first step for most people is breaking their food addiction, but it’s worth the effort.

A Century of Dietary and Nutritional Trends

At Optimizing Nutrition, there is a freaking long post with a ton of info: Do we need meat from animals? Let me share some of charts showing changes over the past century. As calories have increased, the nutrient content of food has been declining. Also, with vegetable oils and margarine shooting up, animal fat and dietary cholesterol intake has dropped.

Carbs are a bit different. They had increased some in the early 20th century. That was in response to meat consumption having declined in response to Upton Sinclair’s muckraking of the meat industry with his book The Jungle. That was precisely at the time when industrialization had made starchy carbs and added sugar more common. For perspective, read Nina Teicholz account of the massive consumption of animal foods, including nutrient-dense animal fat and organ meats, among Americans in the prior centuries:

“About 175 pounds of meat per person per year! Compare that to the roughly 100 pounds of meat per year that an average adult American eats today. And of that 100 pounds of meat, more than half is poultry—chicken and turkey—whereas until the mid-twentieth century, chicken was considered a luxury meat, on the menu only for special occasions (chickens were valued mainly for their eggs). Subtracting out the poultry factor, we are left with the conclusion that per capita consumption of red meat today is about 40 to 70 pounds per person, according to different sources of government data—in any case far less than what it was a couple of centuries ago.” (The Big Fat Surprise, passage quoted in Malnourished Americans).

What we forget, though, is that low-carb became popular for a number of decades. In the world war era, there was a lot of research on the ketogenic diet. Then around the mid-century, low-carb diets became common and carb intake fell. Atkins didn’t invent the low-carb diet. Science conferences on diet and nutrition, into the 1970s, regularly had speakers on low-carb diets (either Gary Taubes or Nina Teicholz mentions this). It wasn’t until 1980 that the government began seriously promoting the high-carb diet that has afflicted us ever since. Carb intake peaked out around 2000 and dropped a bit after that, but has remained relatively high.

The inflammatory omega-6 fatty acids combined with all the carbs has caused obesity, as part of metabolic syndrome. That goes along with the lack of nutrition that has caused endless hunger as Americans have been eating empty calories. The more crap you eat, the more your body hungers for nutrition. And all that crap is designed to be highly addictive. So, Americans eat and eat, the body hungering for nutrition and not getting it. Under natural conditions, hunger is a beneficial signal to seek out what the body needs. But such things as sugar have become unlinked from nutrient-density.

Unsurprisingly, Americans have been getting sicker and sicker, decade after decade. But on a positive note, recently there is a slight drop in how many carbs Americans are eating. This is particularly seen with added sugar. And it does seem to be making a difference. There is evidence that the diabetes epidemic might finally be reversing. Low-carb diets are becoming popular again, after almost a half century of public amnesia. That is good. Still, the food most American have access to remains low quality and lacking in nutrition.












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Blood Sugar Test: Ezekiel Bread vs White Bread

As with all sugars, all starches, including all grain products, will spike your blood sugar level. It doesn’t matter if bread is white, whole grain, sprouted, etc. Bread is bread, unless it’s keto bread made out of almond flour, coconut flour, or some other low-carb ingredient.

Ezekiel bread, for example, might be healthier in other ways such as nutrient profile, although the nutrient-density is rather meager compared to many other plant foods and animal foods. For certain, it is not healthy if you’re diabetic, pre-diabetic, or insulin resistant (the majority of Americans fall into one of these categories).

I used to eat Ezekiel bread thinking it was healthier. And this was during the time I was gaining weight and probably developing pre-diabetes or at least worsening insulin resistance. Claims of lower glycemic index is mostly bunk, as the following video shows — and the same would apply to glycemic load as well. The net carbs, excluding fiber, are identical in Ezekiel bread and white bread.

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More glycemic index tests comparing foods from Dennis Pollock at his Youtube channel, Beat Diabetes!