Dr. Stephen Phinney on Problem Solving a Ketogenic Diet (Part 3)


– I wanna take a little bit of time to talk about troubleshooting problems that commonly occur on a ketogenic diet. The first problem that people have is that they just struggle with either having low energy after
a few weeks, or longer, so they should be through
the initial adaptation phase and they still don’t have energy or they can’t get their blood ketones up in a desirable range, that
it is above .5 millimolar. The most common cause of that if people are holding their
carbs in a restricted range is that they’re eating too much protein. Now why would people eat too much protein? Well, one thing is, many people refer to a
low carbohydrate diet as a high protein diet,
and that’s a mistake. People should think of this as a moderate protein, high
fat diet, and the second is, that people have been
taught to fear fat so much told that fat
causes heart disease, eating fat makes us fat, blah, blah, blah, that they just have a very hard time putting that much fat on
their plate and eating it. And besides, protein’s much
more expensive than fat and so environmentally and financially getting your protein dose right,
not too high, is important. So what is the right amount of protein? Well when we map this out on a graph where we show carbohydrates
on the vertical axis and protein on the horizontal axis if you look at the Standard American diet we eat about 50% of our
calories as carbohydrate then a minority of our calories are gonna be coming from fat. But when we switch to a
well-formulated ketogenic diet where the carbohydrate intake
is in the five to 10% range, if you hold protein in the
moderate range of about 15% then clearly the majority
of one’s calories have to come from fat. We cannot satisfy our need for energy by holding carbohydrates
low, holding fats slow, and then eating the rest as protein. Protein in moderation, and
the majority of calories, they need to come from fat. Easy to say, but for many
people, that’s hard to do. How would you do that in a practical way? Well this is a menu basically
of what somebody my age, a male my height and
weight would eat in a day. I’m a pretty high activity guy, my daily calorie need is in the range of 27 or 2,800 calories per day. For me, the majority of my calories, probably in the range of
75%, typically come from fat, and I do that by having, maybe, a high fat food for breakfast, some days it’s ham and
cheese, some days it’s eggs. On a typical day it might be
four modest size sausage links, that’s real sausage, not a processed meat that looks like sausage. For lunch I might have a couple cups of chopped green vegetables in a salad with six ounces of poultry,
or meat, in this case, it would be a six ounces
of water packed tuna. And again, we use water packed because we don’t want the fats that tuna is normally packed
in when they pack it in oil, that would be soybean
oil, we don’t want that, and we’ll come back to
that in a few minutes. And then to add the
fat, I add black olives, I may add some cheese, I’ll
typically make a dressing, in this case. it might
be a blue cheese dressing that has a lot of olive oil added to it. So it ends up being a high fat meal with very little carbohydrate. Snacks could be nuts in broth,
nuts being a high fat food, or it could be a couple ounces of cheese spread on some vegetables, and then dinner might
be a cream tomato soup made with homemade broth. A modest amount of
meat, it could be steak, or pork, or fish, and then
two servings of vegetables, both of which are cooked
or prepared with fats, like buttered green beans and mushrooms sauteed with
a little bit of garlic and olive oil. And when one’s in maintenance, that is, you’re trying to eat as many
calories as you’re burning, you can also add fat in the
form of high fat desserts and one can make really
delicious homemade ice cream with heavy cream and
non-table sugar sweeteners, and there are varieties of
those that could be used. And so this gives you the
idea of the range of food someone can have, this
looks like real meals, it’s all made with real food. The other point I make about this menu is it looks like there’s
a lot of protein in here but notice the portion sizes are quite modest for a male my size. But those could be replaced
with more dairy fat, with more eggs, if someone
is a lacto-ovo vegetarian, or they can be replaced
with tofu, nut butters, and other vegetable sources of protein if one wants to do this as a vegan. Doing this as a vegan is
a little more challenging but it’s not impossible,
and it certainly is healthy if in spite of having a
history of being a vegan if you’ve developed type two diabetes this is certainly a reasonable option to achieve metabolic health. The second problem that
is very common for people when they’re trying to make a well-formulated ketogenic diet work is they end up choosing
the wrong kinds of fat. Normal common sense assumption
that we’ve had for decades is that we should avoid saturated fats and eat healthy fats,
including polyunsaturates. That concept is turned upside down when you go on a
well-formulated ketogenic diet because the polyunsaturate fats that we get from vegetable oils that were thought to be good because they, quote, are essential fats, ignores the fact that when
you eat too much of them they can cause harm. You’ve probably heard of
both the Omega-3 fats, the so-called fish oil
fats, and Omega-6 fats. And it is true that we humans need a little bit of each of that category metabolically everyday to
help construct healthy cells but they don’t make good fuel, this is not fat that your
body likes to burn for energy. When you’re eating a high fat diet you naturally will get
enough of the Omega-6s even if you avoid the high Omega-6 oils. You get your Omega-3s by
having fish three times a week, or, if you don’t eat fish, then maybe supplementing
with a fish oil capsule. If you over eat the polyunsaturates, particularly Omega-6
fats, what happens is, that it upsets a person’s
stomach and digestive system and people just don’t
feel well after they eat and I’ve had so many people tell me, “I’ve been following your
diet for a couple months “but I can’t keep on it “because I just can’t tolerate
eating all those fats.” And I say, “Well, what
fats are you eating?” And they say, “The healthy ones, “I get the corn oil margarine, “and I get the soybean oil mayonnaise.” And I say, “No, no, that’s
not what you need to do “when you’re on a high fat diet.” You need to get most of your
fats from monounsaturates, and to some degree, from healthy
sources of saturated fats. Soybean, corn, the older versions of
safflower and sunflower, peanut oil, all are high in
the Omega-6 polyunsaturates and what you wanna do is have… Choose fat sources and oil sources where the great majority of calories come from monounsaturates and saturates. Probably the ideal source of fat for the the human diet is olive oil because that’s very
high in monounsaturates, has relatively little in
the polyunsaturate category. But even if you look at lard, which is relatively high in saturates, but also equally high in monosaturates, and has a low polyunsaturate
intake, again, an excellent fuel source for humans. You can say the same for
beef fat, for butter, and for coconut oil, again,
they’re higher in saturated fats and that causes some anxiety in people. But as we mentioned in the previous video when you’re fully keto-adapted, your body more than doubles its
ability to burn fat for fuel and one of the first fats that
goes into that energy fire is saturated fats, they
don’t accumulate in the body, and they don’t cause harm. Now one of the questions
I get over and over, they say, “Well, Steve
Phinney, you’re a doctor, “you got a good income, and you
can buy that fancy olive oil “but it’s too expensive, “most people can’t afford olive oil.” And I would like to give
you a little simple example of why that’s not true, and that is, if you go do your big box grocery store where they sell stuff in big quantities you can buy olive oil
in a big jug like this and this is good quality olive oil, I’m not gonna tell you
which company it comes from so I’m not showing you this side, but this is true olive oil,
it’s not the extra virgin stuff which has very intense flavor, this is a more mild flavor stuff. And you wanna guess how much
1,000 calories of this costs? 53 cents. That if you pour out
1,000 calories of this and you mix it in, make it
into dressings and stuff, that 1,000 calories in
your diet, in one day, cost 53 cents, where
else in the grocery store can you buy 1,000 calories for 53 cents? I mean this is really good
energy at a very low price. The other point is, people say, “Well that amount would last me 10 years.” No, if I eat 500 calories of this a day this bottle is going to last
me a little over a month. So, it’s not an expensive
source of energy. I have this little bottle,
and in this bottle, I can put 700 calories, and
if I have a salad for lunch, and the dressing is suspect, I don’t know what fat
they put in the dressing, I just squeeze in some lemon juice, pour some of this over
the top, take it home, fill it up the next day. And then the other thing is, if you wanna use fat for frying, and fried foods are really good, as long as you don’t batter dip them, a good source of frying fat
is a high monounsaturate oil and again, you have to be sure
this is a safflower based oil but you have to read the
label, and look down here, and if it says mostly… If the… mostly unsaturates, relatively
few polyunsaturates. This is both a good food
for cooking, you know, ingredients in food, but
also a good oil for frying, or you can use coconut oil for frying, and it’s not expensive, as
long as you buy it wisely, strategically, in bulk. The next problem is, maybe,
the most common difficulty that people have when they’re trying to deal with getting the pieces of a well-formulated ketogenic diet right and that is they feel
light-headed, they feel dizzy, they have a headache,
they try to exercise, and they feel just really
bad and they stop exercising. And, frequently, they have constipation. If you go on the web and look this up it’ll tell you that you have the keto flu. Now I don’t like that
name because it’s not flu, it’s not an infection. This
is just a group of symptoms that occur when people are on a well-formulated ketogenic diet that they’re not eating enough salt. The reason why salt becomes a
problem with a ketogenic diet is that ketosis causes the kidneys to accelerate their excretion of salt. Now if you have… Retain salt, so you’re swollen, or if you have high blood pressure, and you get rid of that extra
salt, that’s a good thing, but if you get rid of too much of it, it impairs your circulation, and you have this group of symptoms. If it inhibits exercise,
and you feel lousy, you’re not gonna continue
to follow the diet. And so adding enough
salt is the key to having a basically a symptom-free experience. So the next question is, how much salt? And again, with the
caveat, if you don’t have problems with high blood pressure or congestive heart failure where you have to take
medicines for those problems, that number turns out to be
five grams of sodium per day, that’s not five grams of salt,
that’s five grams of sodium. And the distinction is, salt
has chloride as well as sodium and only 40% of the weight
of the salt is sodium. So five grams of sodium per day translates to 12 grams of salt and that means about 2.5
level teaspoons of salt. Now do you have to spoon out almost… Yeah, 2.5 level tea spoons,
and eat that everyday? No, because, most people, when they eat a real food diet to satiety will eat about three
grams of sodium per day. Places where that creeps into
the diet in concentrated form is in dill pickles, in olives, in bacon, and other salty foods. So don’t avoid those, you can include them in
moderation in your diet, and you’ll probably get about
three grams of sodium per day from your diet. And then the way to get to our
target of five grams per day is to add two cups of broth or bouillon. Don’t get the low sodium
bouillon, get the regular one, this is about a gram. And if you make your own homemade broth and you add the proper amount
of salt per the recipe, again, you’ll get about one gram per cup, and that’s not super salty,
and it’s delicious, it’s… You can have it with cheese,
or nuts, or something like that so it fits into your diet as a real food. So the question, then, is, you know, if that avoids all these symptoms but it makes you die
early from heart disease now what’s the rationale in that? You know, how can that be safe? In a study that was
published a couple years ago at a highly reputable medical journal by a really good research team they looked at the salt
intake and salt excretion from over 100,000 people
from 17 different countries and then they followed
them for almost four years to see how their health was
maintained over the four years. In particular, they looked at whether they had a heart attack
or whether people died, so the question is, at what level of sodium intake for these 17 different countries, at what level of sodium intake did they see the lowest mortality? The lowest point in the
mortality curve here is at five grams of sodium per day. If you go down to the point of 2.3 grams, which is where the U.S. government says
we should be eating sodium actually for that… those populations over in
many different countries and different cultures, there’s
a 50% increase in mortality if we were to follow those
government guidelines. If you go the other direction you go much higher than five grams per day mortality goes up, but much more slowly. Now these are people who live in cultures where they typically eat
a lot of carbohydrate. If anything we would benefit
from more rather than less but we find that five grams per day is plenty for most people
to avoid all these symptoms but if they stay at three or go under that they’re gonna have severe
symptoms of fatigue, dizziness, constipation,
things that we’d like to avoid and as a related some problem in that, again, if you go on the web, and you look at people’s complaints
about the ketogenic diet you can find many, many
bloggers who will tell you that if you stay on the
ketogenic diet too long you will develop something
called adrenal fatigue. Now that sounds like a medical diagnosis but nowhere in a medical textbook and nowhere in high quality
scientific literature will you find this problem of
adrenal fatigue as a diagnosis or as a problem of a ketogenic diet. What this adrenal fatigue refers to is the increasing symptoms that occur if people have this keto flu
for weeks or months at a time. So if you follow a low carb diet and you stalwartly limit your salt intake you will have increasing fatigue and maybe even a drop in
blood potassium levels and most of the bloggers will tell you the way to make it go away is eat carbs. Well yeah, that’ll work, just, you know, you make the body stop excreting salt. The simple way is, give
the body just enough sodium that it doesn’t have this
problem with impaired circulation and that’s the secret to
this, it’s not eating carbs, it’s avoiding sodium inadequacy. And again, salt is cheap, it’s harmless, if you don’t have hypertension
or congestive heart failure. And the other important point is it has to be taken consistently. The salt you ate yesterday
or the salt you ate last week isn’t gonna help you today because the body doesn’t
have big reserves of salt, you have to be consistent, so think of salt a little
bit like you think of oxygen or breathing, you know, to have the right amount today,
you gotta consume it today, you can’t rely on what you had yesterday. The next problem is a
little bit more complex and that is, how do you manage the diet composition as you go from starting
on a ketogenic diet where, frequently, people
want to lose weight to progressing through the
phases of a ketogenic diet till they get to long term maintenance? And many people ask me, “Well, so, what should my macros
be when I’m on your diet?” Well, macros means, how
much of the macronutrients, what percent of carbohydrate,
protein, and fat should I be eating? And I say, we don’t wanna deal with macros because they’re gonna change over the course of your progression on a well-formulated ketogenic diet. So when I started on a
ketogenic diet and I was… Had gotten to a point where
I had a fair amount of weight and a problem of high
blood pressure to lose. And I ate to satiety, getting
the right amount of protein, I was only eating about
14 or 1,500 calories a day but my body was burning twice that. And the other half of those
calories were coming from here but that didn’t show up
on the macros on my plate. So my point is, the amount of protein
you need from day to day doesn’t change, whether
you’re in the initiation phase or when you’re in the maintenance phase or anything in between, and that should be in
the range of 10 to 15%, at most 20%, of your
daily energy expenditure. You wanna keep carbohydrates
at your personal level that keeps you in nutritional ketosis and that could be in
the range of five to 10% and that probably won’t change much although when people lose a lot of weight and get rid of diabetes their tolerance for carbs may go up a bit, they can add a broader range of food, but not a lot of carbs. And what changes as you go from the adaptation phase to maintenance phase is to get to maintenance, eventually, you’re gonna be eating a lot
more your calories as fat so the macros will change but the protein and carb
intake stays pretty constant and all you do is you
adjust your fat intake just by your perceived
need to achieve satiety, you adjust your fat intake
to the point that you’re going away from your meals satiated and not feeling hungry until
the next time it comes around to meal time. The last problem I wanna talk about is one that has cropped
up in the last year or two and that is, it seems that on the web that people interested
in the ketogenic diet are having a love affair with fasting and that fasting might be
quote intermittent fasting or it might be prolonged
periods of fasting and some people will recommend that if you wanna lose weight
and get your ketones high you might fast for a week or even a month. Now the human body is very well adapted to fasting from an evolutionary
perspective as when… You know, people ran out of food and had to wait a week, or two, or a month till the next harvest, or
the next successful hunt, being able to get by on body
energy stores is a good idea. But the misunderstanding here is that when humans fast beyond one day they don’t just live on body fat they also break down muscle. And sometimes… And some people misrepresent
the muscle loss as being minor but in reality, in the first
month of total fasting, and even in the first
week of total fasting, at least half of the weight loss that you see on the scale
isn’t coming from body fat, it’s coming from lean tissue. This is not new information. There’s been really
top notch research done even 50 years ago that looked at the composition
of weight loss with fasting. And this has been demonstrated
over and over again this is not controversial information, there’s not solid data on the
other side of the argument, but, for whatever reason,
you know, people say, “Well fasting’s cheap and it’s easy, “so why don’t we just do it?” But the issue then is
you lose lean tissue, and as we learned from
The Biggest Loser Study, you know, the group of people
that went on that TV show and did radical amounts of
caloric restriction and exercise, attempting to lose huge amounts of weight, is when they came back and
studied them five years later that extreme combination
of exercise and fasting resulted in a permanent reduction
in resting metabolic rate. So not only did they turn
their thermostat down during the time of privation, years later, even after many of them have regained much of all their weight, they still have a depressed
resting metabolism. So, the solution for this,
from our perspective, is don’t go for short-term
quick weight loss. Nutritional ketosis is by… In and of itself, an
extremely powerful tool, and if you get the
composition of your diet right with moderate protein, low carb, and eating fat to satiety, and you get into nutritional ketosis, and you maintain that consistently so your body is not alarmed
by a famine, you know, being caused by fasting, then that will give you
the greatest benefit over a long period of time
and that’s much more likely to be sustainable in the long term. The other reason not to go
through prolonged fasting is pretty much anybody who’s done it for an extended period of time when they’re told,
“Okay, you can eat now,” there is a very strong propensity
to binge on carbohydrates. And carbohydrate binging after
fasting leads to, oftentimes, major episodes of fluid retention if you shut off the
kidney’s salt excretion, and in some cases, it can
lead to something called Refeeding Syndrome, which
can be fatal, and therefore, is something that we would advise people to be very careful to avoid. Again I want o emphasize that
this is not just my opinion but this is data from
many well-done studies, some of them going back
as far as 50 years, and study after study
demonstrates that, yes, weight loss was fasting as rapid, but, the cost in terms of losing lean tissue is too great for this to become something which is scientifically
or medically defensible. I hope those answer some
questions you might have and helps you avoid problems
going forwards, thank you.

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