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生酮饮食与代谢健康：预防和治疗心血管疾病及脑部疾病

我是一名心脏病专家，多年来我一直致力于帮助患者改善代谢健康，预防和治疗心血管疾病。通过学习和实践，我发现生酮饮食和低碳水化合物饮食在改善代谢健康方面具有显著疗效，这与主流医学的观点有所不同。 首先，代谢功能障碍并非仅仅指2型糖尿病，它始于胰岛素抵抗的早期阶段，表现为超重、脂肪过多以及对胰岛素信号反应不良。餐后血糖飙升并持续一段时间，也是胰岛素抵抗的信号。长期高胰岛素血症会阻碍脂肪燃烧，引发慢性炎症，进而影响血管壁和器官功能，甚至可能加剧胰岛素抵抗，最终导致各种慢性疾病，例如心血管疾病、脑部疾病和癌症。 其次，预防心脏病没有单一的健康饮食，关键在于选择自己能够坚持并改善代谢健康的饮食。对于代谢健康较差的人来说，减少碳水化合物摄入非常重要。虽然减少碳水化合物摄入对于改善代谢健康很重要，但有些人即使碳水化合物摄入量高，也能拥有良好的心血管健康，这取决于他们的生活方式和饮食习惯。低碳水化合物饮食是一个相对模糊的概念，其定义因人而异。我将低碳水化合物饮食定义为每天碳水化合物摄入量少于100克，而生酮饮食则通常少于30克。低碳水化合物饮食不仅要考虑数量，还要考虑食物质量。 再次，生酮饮食并非人人适用，但降低碳水化合物摄入量对改善整体代谢健康有益。对于某些特定疾病，例如脑部疾病，生酮饮食可能更有效，因为它能促进酮体的产生。酮体不仅是脂肪燃烧的副产物，它本身也具有积极的生物学作用，例如降低炎症、增加饱腹感和为大脑提供能量。酮体是脑部细胞的有效能量来源，可以改善脑部功能，并对某些脑部疾病具有显著的治疗作用，例如癫痫、精神疾病和认知障碍。 最后，关于LDL，低碳水化合物饮食通常不会导致LDL升高，反而可能改善其他脂质指标。LDL并非预测心血管疾病的最佳指标，直接检测血管斑块更为准确。虽然高LDL可能增加心血管疾病风险，但这并非必然结果。生酮状态下，LDL升高机制不同，其对心血管健康的风险评估应该与其他情况区分开来。深入了解不同类型的LDL（小而致密、大而蓬松、氧化型LDL）对于评估心血管疾病风险至关重要。氧化型LDL是导致血管斑块形成和心血管疾病的主要因素，其形成与炎症环境有关。改善代谢健康是治疗血管斑块的首要步骤，他汀类药物等其他治疗方法应作为辅助手段。即使代谢健康，也可能出现血管斑块堆积，这可能是由于其他风险因素，例如吸烟或家族史。

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作为一名心脏病专家，多年来我致力于帮助患者改善代谢健康，预防和治疗心血管疾病。我的临床经验和持续学习让我深刻认识到生酮饮食和低碳水化合物饮食在改善代谢健康方面具有显著疗效，这与主流医学的一些观点有所不同。本文将分享我对代谢健康、心血管疾病以及相关饮食策略的理解。

许多医生，包括我早期的培训，都将代谢功能障碍简单地等同于2型糖尿病。然而，事实远非如此。代谢功能障碍始于胰岛素抵抗的早期阶段，表现为超重、体内脂肪过多以及对胰岛素信号反应迟钝。餐后血糖飙升并持续1.5到2小时，也是胰岛素抵抗的明显信号。

长期高胰岛素血症（高胰岛素状态）会阻碍身体利用脂肪储备，导致脂肪堆积。同时，它还会引发慢性炎症，进而影响血管壁、器官功能，甚至可能加剧胰岛素抵抗，形成恶性循环，最终导致心血管疾病、脑部疾病和癌症等多种慢性疾病。

预防心脏病没有单一的“最佳”饮食。关键在于选择一种自己能够长期坚持，并能有效改善代谢健康的饮食。对于代谢健康状况不佳的人来说，减少碳水化合物摄入至关重要。

然而，需要强调的是，一些人即使碳水化合物摄入量较高，也能拥有良好的心血管健康。这取决于他们的整体生活方式、饮食质量以及身体活动水平。他们通常食用本地种植的完整食物，保持活跃，避免久坐，并且不过量饮食。

“低碳水化合物饮食”是一个相对模糊的概念，其定义因人而异。我个人将低碳水化合物饮食定义为每天碳水化合物摄入量少于100克，而生酮饮食则通常少于30克。

低碳水化合物饮食不仅要关注数量，更要注重食物质量。摄入100克饼干、意大利面和面包与摄入100克蔬菜、坚果、水果和种子，对身体的影响截然不同。后者富含纤维，身体对碳水化合物的吸收和利用方式也大相径庭。

生酮饮食并非适用于所有人，但降低碳水化合物摄入量对于改善整体代谢健康确实有益。对于某些特定疾病，例如脑部疾病（包括认知障碍和某些精神疾病），生酮饮食可能更为有效，因为它能促进酮体的产生。

酮体并非仅仅是脂肪燃烧的副产物，它本身就是一种具有生物活性的分子，具有降低炎症、增加饱腹感以及为大脑提供能量等积极作用。酮体是脑细胞的有效能量来源，可以改善脑部功能，并对癫痫、某些精神疾病和认知障碍等脑部疾病具有显著的治疗作用。

关于LDL胆固醇，低碳水化合物饮食通常不会导致其升高，反而可能改善其他脂质指标，例如HDL和甘油三酯。然而，需要强调的是，LDL并非预测心血管疾病的最佳指标。直接检测血管斑块的存在和程度更为准确。

虽然高LDL可能增加心血管疾病风险，但这并非必然结果。在生酮状态下，LDL升高的机制与其他情况不同，其对心血管健康的风险评估也应区别对待。深入了解不同类型的LDL（小而致密、大而蓬松、氧化型LDL）对于准确评估心血管疾病风险至关重要。氧化型LDL是导致血管斑块形成和心血管疾病的主要因素，其形成与炎症环境密切相关。

改善代谢健康是治疗血管斑块的首要步骤。他汀类药物等其他治疗方法应作为辅助手段，而非主要策略。即使代谢健康状况良好，也可能出现血管斑块堆积，这可能是由于其他风险因素，例如吸烟或家族遗传史。

代谢健康处于健康金字塔的顶端，它对多种慢性疾病（包括心血管疾病、脑部疾病和癌症）的预防和治疗都具有重要意义。改善代谢健康能够产生多方面的积极影响，而非仅仅针对某一种疾病。

虽然生酮饮食并非灵丹妙药，但它为改善代谢健康提供了一种有效的策略。对于那些希望改善健康状况的人来说，选择适合自己的饮食方式，并坚持下去，才是最重要的。 切勿被过多的信息和所谓的“健康神话”所迷惑，应根据自身情况，在专业医生的指导下，制定个性化的健康计划。

00:00

Coming up on today's show. Metabolic dysfunction for a lot of doctors and certainly the way I was trained is whether or not you have type 2 diabetes. And if you're short of that, you're okay. Metabolic dysfunction, being metabolically unhealthy, starts at that early stage of insulin resistance when your body tends to be overweight, have too much adipose and not responding well.

00:19

as well as it should to the insulin signals to keep that blood sugar in a steady range. And if your blood sugar is spiking to 170, 180, 200 and staying there for an hour and a half or two hours after your meals, that's a sign your body's not responding well to the food you're eating and that you have this component of metabolic dysfunction and insulin resistance. As insulin is chronically high, it can prevent you from accessing your fat stores and burning your fat stores for energy. So it's a good way to add fat.

00:46

to the body. Second is it can actually trigger a chronic inflammatory state. We can measure the relationship between hyperinsulinemia and inflammation, and they tend to really be correlated fairly closely. Not that everybody needs to be on a ketogenic diet, but the fact that it is such a powerful treatment that contemporary medicine doesn't even talk about is just a crime. I mean, it should be at least a tool in every doctor's toolkit to be used at the appropriate time.

01:14

As a cardiologist, what is the best diet for somebody looking to prevent heart disease? Starting off with a good one. Well, if you walk into any mainstream medicine doctor's office, they're going to tell you it's a plant-based vegan or vegetarian diet. And that simply is not true.

01:35

It's unfortunately true if you focus on LDL as the most important and kind of only important risk factor because that's the diet that can lower LDL a little bit. But once you factor in metabolic health,

01:49

And you factor in how diet isn't like a pill that you can prescribe, but it's something that, you know, involves emotion and enjoyment and pleasure and our, you know, our past, um, and how we see ourselves and our lifestyle, right? There's so many things involved in,

02:05

in a diet that isn't involved in a pill. So I would say there is not one healthy diet for heart disease, but it's the diet that you're going to enjoy and stick with that's going to improve your metabolic health. And I think that's a

02:21

a really important differentiation that metabolic health is really what impacts our risk of cardiovascular disease far more than any other solitary lab test. So I can't answer the question with a simple answer, but you probably knew that when you asked the question would be my guess. But

02:40

But we get into trouble when we try to answer it with one answer. So it's not carnivore. It's not keto. It's not Mediterranean. It's not vegetarian. It's not vegan because people are going to respond differently to those. People are going to define those differently. It's only fair to say that going low carb is part of this because you are a low carb cardiologist. You mentioned keto and carnivore. Sure. Would you not say that somebody needs to at least lessen the carbs to start regaining that metabolic health?

03:11

Well, when you phrase it like that in terms of regaining metabolic health, yes. I think if somebody has poor metabolic health, then lowering carbs is a very important part of that. But there are examples of people eating high-carb diets and having excellent cardiovascular health. Now, they have lifestyles that are very different than ours. Their food is all

03:35

locally sourced whole foods on average. They tend to be physically active and not sitting in traffic and sitting behind desks all day long. And they're not overeating. They're not overweight. They don't have metabolic dysfunction. So it's perfectly possible to live a metabolically healthy life with a high carb diet. It's just exceedingly rare in our current environment in the way our lifestyles are structured in the way our food system is structured.

04:04

So I wouldn't make a blanket statement that everybody needs to lower their carbs. But once you are metabolically unhealthy and have metabolic dysfunction, then lowering carbs can be a very powerful intervention to help remedy that. Low carb is a relatively vague term. It can mean a lot of different things to different people. When you use that term, how do you define it? Yeah, it's a good question.

04:28

You know, when I say low carb, it can be really anything less than about 100 grams of carbohydrates per day. But if you want to talk about a ketogenic diet, which is a version of a low carb diet, right? All keto diets are low carb diets, but not all low carb diets are keto diets. So if you're talking about a keto diet, you're generally talking about less than 30 grams per day of carbohydrates, sometimes less than 50 or so. But that's easy to test, right? You can test if you're in ketosis or not.

04:57

It's the one diet that you can actually prove kind of compliance with and effect with by testing ketones, whereas low carb is much more vague. But I tend to use about 100 grams per

05:09

per day. And, you know, you can talk about quantity, but you also have to talk about quality. If you're eating a hundred grams of, you know, cookies and pastas and bread, you know, you, you fill that a hundred grams up pretty quickly, but your body's going to react differently to that than if you're eating a hundred grams of vegetables and nuts and fruit and seeds and, you know, more whole foods, lots of fiber that your body's going to see those carbs very differently too.

05:34

somebody looking to regain metabolic health, given what you just said about quality of food, we've been talking about carbs, carnivore, keto, low carb. How does somebody begin to determine where along that spectrum of low carb is right for them? Yeah, that's a good question too. I mean, I guess…

05:53

how quickly you want to change things and how, I guess you'd say, how far gone are things already, right? If you are five pounds overweight and have some early signs of insulin resistance, maybe just go on a hundred grams of carbs and you're eating, you know, 300 grams of carbs, standard American diet kind of thing. Then maybe just go on a hundred grams of carbs of whole foods will be plenty.

06:18

If you have type 2 diabetes and you have 100 pounds to lose and very low body muscle, high body fat, that's going to take more of an effort. And especially if you want to see rapid changes, and that's someone who maybe should start with a ketogenic intervention to see if that's going to have a better effect.

06:39

It depends on where you're starting from and what your goals are. I'm a huge fan of ketogenic diets for many, many instances, but I'm definitely not…

06:48

one who says everybody needs to be keto. There are plenty of people who are going to see benefits from reducing your carbohydrates if you're talking about general metabolic health. Now, if you're talking about a specific intervention, especially like a brain-based intervention, whether it's for cognitive decline or whether it's for a bipolar disorder, schizophrenia, that's where it seems the ketones in the brain makes a big difference. So that's when you're not just talking about carbs, you're actually talking about the production of ketones as a therapeutic intervention. So that's a different discussion.

07:16

But depending on where you start with and where your goals are, for some, reducing carbs and focusing more on whole foods is enough. All right, we're going to get to the brain, get to ketones. But before we do, let's define metabolic dysfunction. Talk about what that is and then the process that somebody goes down as they're heading that way.

07:38

Yeah. So, metabolic dysfunction for a lot of doctors and certainly the way I was trained is whether or not you have type 2 diabetes. And if you're short of that, you're okay. And it sounds simplistic, but that's really how…

07:51

A lot of us were trained and practiced, but it's far more than that. And if you wait for type 2 diabetes, you've had metabolic dysfunction for years, if not decades. And it's really this concept of insulin resistance, right? So if you're looking just at blood sugar, our body has a pretty good system to try and keep blood sugar in check and keep it in a normal range. And that relies heavily on insulin. So

08:17

we can require, we can use more and more insulin to keep blood sugar stable as our bodies become insulin resistant. So if we, you know, needed X number, X amount of insulin, when we're healthy, as we get less healthy, maybe we need two X insulin, but we can keep that glucose in the same level. And then eventually three X insulin, four X insulin, and then glucose is going to start to creep up. And then eventually you can't produce enough insulin. So

08:42

So metabolic dysfunction, being metabolically unhealthy, starts at that early stage of insulin resistance. When your body tends to be overweight, have too much adipose, and not responding as well as it should to the insulin signals to keep that blood sugar in a steady range. And sleep can affect that. Lack of exercise can affect that. Chronic inflammation can affect that. And of course,

09:06

High carbohydrate, high sugar, high calorie diets can affect that, especially when you're overweight and have too much adipose tissue. All right, you gave a nice explanation there, the fact that insulin is going to rise over time, maintain blood glucose, which alludes us to the fact that we can't rely on blood glucose over these years that we're becoming more and more metabolically unhealthy. You talked about the fact that people will become overweight as they're heading in this direction. Yeah.

09:37

But what other things can people look at without testing? I want to get to testing after, but subjectively to determine how far down they've gone towards type 2 diabetes. Yeah, I mean, there are a number of different things you can do. I mean, your waist to height ratio is a very simple one.

09:57

And you want that waist to height ratio to be under 0.5 to suggest less likely to be metabolic dysfunction, where if it's above 0.5, more likely to be metabolic dysfunction and insulin resistance. It's kind of a crude measuring tool, but it's actually fairly accurate considering how easy it is. Body composition test is another big one.

10:22

Um, you know, how much visceral adipose or VAT, um, tissue do you have? Um, you know, what's the body fat percentage and then, and then lab tests like fasting insulin levels, um, you know, hemoglobin A1C, um,

10:36

And certainly a HOMA-IR, which is a calculation using a fasting glucose and a fasting insulin or a glucose to triglyceride index, right? There are lots of different tests that you can do. And we actually have a guide on this at metabolicmind.org and on…

10:53

our YouTube channel that goes through sort of the diagnosis of insulin resistance because it's not your standard blood test, right? It's not your standard fasting blood sugar, which is unfortunately one of the least helpful tests that is very popular to use

11:09

to diagnose metabolic dysfunction, but it's so unhelpful. Um, and you know, even something like a CGM is, is far better, uh, because it tells you how your blood sugar is responding to your meals. And if your blood sugar is spiking to, you know, one 70, one 80, 200, and staying there for an hour and a half or two hours after your meals, that's a sign. Your body's not responding well to the food you're eating and that you have this, uh,

11:32

of metabolic dysfunction and insulin resistance. You gave a number of tests there. Somebody right now who's feeling like they're a bit overweight, they're likely insulin resistant or further down this path. What one test would you recommend if they want to definitively test to see if they're metabolically unhealthy? Yeah, what one test? Because you gave a few there and people, I don't want them to feel overwhelmed and they

11:59

It's already going to be a stretch for a lot of people when they go ask their doctor for some of these more quote unquote obscure tests. Yeah. What can they take to their doctor and get done to see where they're at?

12:10

I think if you're going to ask for one thing, it would be a fasting insulin because everybody's going to get a fasting blood sugar. But the most important thing is what level of insulin is required to maintain that level of blood sugar. So if you get a fasting insulin level, which is a separate blood test that's not routinely done, unfortunately, that in and of itself is a helpful test. But then put together with your fasting blood sugar, you can calculate a HOMA-IR. And that's not a separate test. That's just a calculation that's done by the lab or by your doctor that

12:38

That is a fairly sensitive marker for insulin resistance. So I think that's probably the one thing you can do. But remember, you also standard blood tests tend to get triglycerides and tend to get glucose. So that's another one you can easily do because most people are

12:54

already have the data. They're just not putting it together to look at the ratio or the index. Just make sure it's a fasted test, which is important for both the blood sugar and the triglycerides. So those are ones that are easy to do without an extra blood test. And like I said, as long as you can get that fasting insulin, that's a really good place to start. And there are others that you can do, but that's a good starting point.

13:17

Okay, coming back to the story, the piece of the story, blood glucose is trying to go up, insulin's going up and keeping that at bay. What's happening in the body physiology wise as that's happening? Destruction that people might not tell anyone.

13:36

as it's happening until it goes further down towards, say, type 2 diabetes. Yeah. As insulin is chronically high, it can prevent you from accessing your fat stores and burning your fat stores for energy. So it's a good way to add fat to the body. You know, insulin is…

13:52

it's signifying a fed state. You know, if you think about evolution, it's like, okay, we've got a lot of calories. We've got a lot of energy. We've got high insulin. So we can actually start storing some of this because there's probably going to be a time later when we don't have it and we'll want to burn it.

14:06

Problem is in modern society, you frequently don't get to that stage where there isn't the energy around, so you don't get to access your fat stores. So the first is you're building fat stores, not burning fat stores. The second is it can actually trigger a chronic inflammatory state. You can measure the relationship between hyperinsulinemia and inflammation, and they tend to really be correlated fairly closely. And chronic inflammation is something that really has multiple different

14:33

cascades of what it can impact, whether you're talking about the vessel wall, whether you're talking about organ function, right? It can impact a number of different aspects of your body. And

14:43

theoretically can even worsen insulin resistance. So it's almost like a circular effect there. And then if the blood sugar does start to go up, then you can, or even before it starts to go up, if it's, you know, sort of sustained at a higher than average level or higher than normal level, I guess you can say you get a glycated end product. So you get glucose is deposited on more proteins or more cells, which can then also cause those to sort of

15:12

or misfunction, I guess you could say, is a simple way to do it. So there's a whole cascade of things that happen. And that's why you can read the literature and see insulin resistance, metabolic dysfunction is associated with mental illness, with cognitive decline, with cancer, with heart disease. And you can say, how can one thing be either causative or related to so many different things? And it's because of this sort of general cascade that it can start

15:39

Okay, you quickly touched on heart disease, damage to vasculature, and coming back to again, you being a cardiologist, this is your bread and butter. Let's talk about more detail in this realm. Somebody that's becoming metabolically unhealthy, why this is going to increase risk for things like heart attack and stroke.

16:00

So one thing is as insulin increases, as metabolic health worsens, it can affect blood pressure. That's a perfect example. Your body tends to retain more fluid and sodium in that standpoint. And more adipose tissue is associated with higher blood pressure. Those go in conjunction with each other frequently. And higher blood pressure is going to increase that stress on the arteries with every beat of the heart.

16:27

If it's pumping out at 160 millimeters of mercury in the vessel as opposed to 110, that's a big difference for every single time your heart beats and every single time the blood goes through your vessels. So that's going to create an environment where there can be more damage done to the blood vessels.

16:42

I mentioned about the glycated end products, the glucose being on the proteins. Well, if that's on the vessel wall, that can help injure the endothelium and have the endothelium, the inner lining of the blood vessel not function as well. Combine that with the increased stress and all of a sudden you've got more trauma on the vessel wall. That's certainly one example of how it can happen. Throw inflammation, chronic inflammation on top of that and you've got yourself a good nidus for developing atherosclerosis. Now,

17:10

Would I pretend to know every mechanism? No, there are probably others. And as common as heart disease is, it actually is interesting to recognize that we don't really know everything about how plaque forms and all the different factors that are in play. Certainly we know a lot, but not everything. Let's bring LDL into the picture because as somebody goes lower carb,

17:37

Traditionally, if not always, LDL tends to go up at least for a period of time. How do you look at LDL when it comes to heart disease?

17:46

Well, first I would push back about saying traditionally, if not always, it goes up because it actually usually does not go up. The literature that looks at ketogenic interventions for type 2 diabetes and for weight loss is pretty clear that on average, LDL does not change. And I think that's really important. Now, there is a subset of people usually who are leaner, fitter, more metabolically healthy where LDL will go up.

18:11

But that's the exception, not the rule. And the majority of people, LDL does not change. And instead, you see HDL go up, you see triglycerides go down, obviously blood sugar and insulin go down, inflammatory markers go down. So you usually see a significant improvement in labs, including lipids. And that's something that I think is really important because there's this assumption that LDL goes up.

18:32

Even if it's a high saturated fat, low carb diet, it doesn't mean it's going to affect LDL. But if LDL does go up, then it's something that needs to be taken individually. It can mean different things for different people. But I think the key is that LDL is a relatively poor predictor of the presence of plaque in heart disease.

18:53

The best predictor is the presence of plaque and heart disease, right? We can actually measure whether or not you have plaque. We don't need to use LDL as a surrogate. So for me, you know, in my practice, when I see patients who are low carb or if they're keto and they have high LDL,

19:10

My first question is, do you have heart disease? Let's get a calcium score. Or if that's a little abnormal, maybe a CT angiogram. There are so many better tests we can do, carotid ultrasounds, CIMTs, so many better tests we can do to look for the presence of vascular disease rather than looking at LDL. LDL is not the disease. The disease is plaque in your vessels. So

19:32

So can higher LDL increase that risk? Yes. In large population studies of the general population, there is a small increased risk, not nearly as big as type 2 diabetes or even markers of insulin resistance, but there is a small increased risk. But that does not mean you're going to get it. Even if you look at familial hypercholesterolemia,

19:58

genetic disorder that people are born with where their LDL receptors don't work as well and their LDL levels are very high in the you know 200s or even 300s for the majority of their lives and

20:12

You would think that would be a 100% death sentence the way we talk about LDL, but it's not. It's not. You could say in some studies up to half the people do not even get any vascular disease. Well, how is that possible with LDLs that high if LDL is the causative factor of vascular disease? So there's definitely more to the story. And certainly when you talk about people who are metabolically healthy,

20:36

And in ketosis, we are now learning that that is a very unique situation that probably deserves to be evaluated as such, right? Not evaluated the same as everybody else. And this is where, you know, citizen scientist and engineer Dave Feldman and his colleagues, Dr. Matt Budoff, Dr. Nick Norowitz, and Dr. Adrian Sotomoto, who have published in the medical literature quite a bit about this topic, have

21:01

is really helping us sort of reframe how we see LDL, especially within the context of metabolic health and with a reason for that LDL being elevated. If you're in ketosis and need to traffic more fatty acids for fuel, that can lead to a rise in LDL. So it's saying, oh, wait a second, the mechanism is different.

21:20

the baseline condition and metabolic health is different. The vascular health is different. Maybe we shouldn't see it the same. So that's sort of a long winded answer to your, to your short question about how I see LDL. Well, it's interesting. You brought up the fact that it's not common for LDL to go up. I thought that was pretty common knowledge in our world that that is going to happen. And to arm people with that knowledge, if they go get blood tests done with their conventional doctor, um,

21:49

that this can be a normal response to that dietary change. So this is news to me. Yeah, yeah. I mean, if you look at…

21:57

A number of different published studies and even meta-analyses, most of them show on average no change in LDL. And there was one that actually showed a reduction in LDL particle number. Now, those tend to be the studies that are treating type 2 diabetes or using ketosis for weight loss. When you're talking about thinner cells,

22:19

healthy individuals, that's where you're more likely to see the rise in LDL. So there is a difference based on who you're looking at. And again, Dr. Adrian Sotomoto published a paper looking at a number of these studies showing that the rise in LDL correlated with body mass index and really didn't correlate with saturated fat intake nearly as much, which is

22:41

Again, sort of surprising because a lot of people think you eat saturated fat, your LDL will go up, period, end of story. And that is not the case. But that is what's believed by a number of people in mainstream medicine. And, you know, nothing really bothers me more than somebody saying either you shouldn't start a ketogenic diet because your LDL could go up.

23:00

Well, why don't you just test it and find out if it goes up, right? It's not like this is a big secret. You can do it four months, six months, a year, whatever, and test it. Or someone would say, no, the risks outweigh the benefits. Well, what risks? Like you can test somebody for the risks

23:17

And what benefits are you even talking about? Are you talking about somebody putting their treatment-resistant bipolar disorder into remission where nothing else worked? Or somebody putting their type 2 diabetes into remission where they were on multiple medications before? What benefits are you talking about? And what theoretical risks are you talking about that you can't measure and follow to see how they change? So those are two things that really bother me about remission.

23:41

how mainstream medicine sort of talks about ketogenic interventions. Yeah. Riffing off of what you just said there, it's like, for one, does LDL actually go up? And then two, does it actually matter if it does go up? And we need to ask these questions. Yeah. Yeah. Yeah. I mean, you know, there's a documentary that will be coming out called Cholesterol Code and

24:04

And it's about sort of this concept about this study that Dave Feldman and Dr. Matt Budoff and others are doing. But the documentary isn't just about the science because that is important. What happens to individuals if their LDL goes up? Can we measure whether or not their plaque and their arteries increase, but also about the personal stories about the

24:25

people who are transforming their lives with ketogenic intervention. So then how do you factor this in? And you absolutely should not take someone who has changed their life with this type of intervention and be like, oh, but your LDL could go up. So you probably shouldn't do it. To me, that's just not medicine. That's not taking care of the person in front of you. And to add some detail to what you just said there about Dave Feldman and his buddies there, we're talking about lean mass hyper-responders.

24:53

And when I was asking you about LDL going up in a general sense, that wasn't what I was talking about. Yeah. But you clearly define both now. Yeah. Good point. Good point. So you can get small rises in your LDL of, you know, 10%, 15%. Again, on average, there's no change, but some people will see small increases, but

25:13

But what a lot of people think about, certainly where my brain goes when you talk about LDL rising, is this very small subset of people where it dramatically goes up. Where you're maybe at 120 before and now you're at 280 for LDL, right? That's a huge jump. And that freaks a lot of people out. Understandably, it can be very nerve-wracking for a patient and for a physician. And that's what this…

25:34

That's what this documentary and this study is looking at because if you want to really investigate the impact this has, it's going to be hard to investigate the impact if your LDL goes from 120 to 150. That's an increase, but what kind of impact is that going to have? But if it goes from 120 to 280, that's a dramatic change. And that's the levels that we would think would cause rapid vascular damage, rapid plaque damage.

26:02

accumulation if LDL by itself was the concern. So, I mean, it's the perfect subset to sort of study this and answer the question. So yes, that's what Dave Feldman and Dr. Matt Budoff and others are studying. But then you can look at the study published by Virta Health. This was back in like 2018, I think they published a study about their one-year results of using a ketogenic diet to treat people with type 2 diabetes.

26:27

and they found on average LDL went up by 10%. But the ApoB, apolipoprotein B, which you can think of as just a better LDL, it's a more predictive marker than LDL itself, ApoB did not change at all.

26:42

And when you see metabolic health improving like that, you're going to get rid of some of the small dense LDL. You're going to have more of the larger LDL. So that's how LDL in total can go up a little bit. But ApoB or the number of LDL particles isn't going to change. So LDL doesn't tell the whole story. And when you calculate their cardiovascular risk, it actually went down by 12%.

27:05

So LDL went up by 10%, but cardiac risk, calculated risk, went down by 12%. And a lot of that has to do with improved metabolic health and the ApoB not changing. So yeah, we have to differentiate just small increases from the lean mouse hyper-responder. But also if you're talking about the LDL itself going up, you want to dig a little bit deeper and say, what does ApoB do? Or what do your small LDL particles do? And what's your metabolic health doing? Because those are better predictors of cardiovascular risk than just LDL cholesterol.

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Try Maui Nui today. Their mission and their delicious, nutritious meats are going to blow you away. All right, let's talk more about this subset of LDL, the different pieces, the small, dense, large, fluffy. We have oxidized LDL. For you as a practitioner and then as somebody listening as a patient, how valuable is that deeper data?

30:46

Yeah. I mean, look, I think it's incredibly valuable. I think LDL by itself is not very helpful. Certainly you want to…

30:55

interpret LDL in context of your triglycerides and HDL and your metabolic health. But knowing if your LDL is mostly small, dense LDL or larger LDL is helpful. Now, it's not an absolute. And I think that's where we can sometimes get into trouble if someone says, oh, my LDL is large,

31:16

I don't need to worry about it. Well, if you've got plaque, if you've got existing heart disease and your LDL is large, I would still be concerned about it. But if you have zero plaque, calcium score is zero, no plaque on CT angiogram, you're metabolically healthy, and you have almost no small dense LDL, that's not a good thing.

31:32

That's a situation that I'm a little less concerned about. Then you mentioned oxidized LDL, same thing. Oxidized LDL or the LDL that's really inflamed and oxidized, that's the one that's going to cause the damage. That's the one that's going to cause the plaque, especially the angry, inflamed, aggressive plaques that can break off and cause heart disease or cause heart attacks.

31:53

So that's the other part of the cholesterol you want to worry about. And that speaks a lot to sort of the environment in which the cholesterol lives. Is it a high oxidized, high inflammatory environment, which happens with insulin resistance and metabolic dysfunction? Or is it a low oxidized and low inflammatory environment when someone who's metabolically healthy and living a very healthy lifestyle? So those things definitely make a difference. But again, not part of the standard medical tests.

32:18

and you can you know kind of infer from standard medical tests about that if your triglyceride to hdo ratio is very good you're less likely to have small dense ldl if your high sensitivity crp which is a sensitive inflammatory marker is good you're less likely to have oxidized ldl but nothing's 100 it's all sort of a best guess based on those tests but the

32:45

And one of the things that's really cool now that didn't exist so much 10 years ago is people can get their own tests. You got to pay cash for it rather than using insurance. But if your doctor's not, you know, interested in getting these tests or doesn't understand these tests, there are websites out there, ownyourlabs.com and others where you can get these blood tests done on your own. It just unfortunately takes, takes money. If somebody wants to do that and be really comprehensive and they're on their own,

33:12

What are the minimal tests they want to get done to have a comprehensive view of their heart disease risk? Yeah.

33:22

And here, the terminology is tricky because Quest is different than LabCorp, is different than Boston Heart, and so they all kind of have their own thing. But basically, you want some sort of advanced lipoprotein testing. And that sort of encompasses this, you know, small particles, large particles, HDL particles, and then some marker of inflammation, whether it's the CRP or a test called a PLA2 test.

33:49

or just an oxidized LDL test. And then tests of insulin resistance, like you mentioned before, the fasting insulin. Those are sort of basic places to start and you can always dig deeper. And that's one of the things that Own Your Labs has done is they've created

34:09

put together sort of these packages depending on what you're looking at. So there's sort of like prearranged packages for, you know, the ultimate heart disease test or the, you know, the base heart disease test, I forget exactly what they call them. I haven't looked at it in a while, but it's nice to have that sort of structure and that guidance. All right, let's move deeper into plaque. Somebody that wants to get a visual on what's happening in the arteries, what's the best test? And then I know there's soft plaque, hard plaque,

34:38

Let's differentiate there and talk about what's more dangerous. Yeah, yeah. So when you're talking about hard arteries…

34:46

The basic test that pretty much anybody can get is a calcium score. That is a CT scan. It takes about 10 seconds. Your entire appointment probably takes about 10 minutes. It's relatively low radiation. It's about 1 millisievert. And for reference, a mammogram is about 0.5 millisieverts. And just living on Earth at sea level by the equator for a year is 3 millisieverts.

35:13

So, it's one millisievert and it tells you whether you have calcium in your arteries. And that is a very good start. Certainly, if the answer is zero, if the score is zero, that you don't have any calcium in your arteries, studies have shown that you have a very low risk for having a heart attack over the next 10 years.

35:34

It's not zero. And that's, you know, everybody can point to one study that says, look, this person had a zero score and had a heart attack. It happens, but it happens with normal LDL too, right? And people sort of forget to point that one out. But it's very, very good. Now, if it's elevated, it's a different story. And this is where, even though it's a good test, it's sort of a blunt test because it doesn't tell you anything about soft plaque. It doesn't tell you anything about when the plaque was developed or why it was developed.

36:03

So some people can use calcium scores to follow over time to see if you're developing more plaque over time. Again, it's a bit of a blunt instrument. The better test is a coronary CT angiogram, but this is much more involved. So whereas the calcium score, if you have to pay for it yourself, is about $100, some places maybe $75, some places $150 at various places.

36:23

CT angiogram is very different. That's about $1,500 if you have to pay for it, right? So much different. Instead of one millisievert, now we're talking about three, maybe four millisieverts. Now we're talking about IV contrast and iodine-based contrast that's injected into your vein. You know, the whole appointment now is maybe an hour and a half. You have to regulate your heart rate, right? So you can see just by me talking about it, it's a much more involved test.

36:48

But because of that, you get much better results. You actually see the arteries themselves. You see inside the arteries, not just the silhouette or the walls of the arteries. You see if there's soft plaque. You see if there's calcified plaque. You can see exactly where it is.

37:03

You can see if there's any narrowings. So it's a much more advanced test. And now there's a company called Clearly, there may be others soon, but right now Clearly kind of has the corner on the market here that does an additional evaluation on those scans online.

37:20

where it can tell you, it can actually quantify how much calcified, how much non-calcified, and how much low-density plaque, which is really the highest-risk plaque. It can quantify that, show you exactly where it is on your arteries.

37:34

And now you know, and you can say, okay, so here I am at time zero, and this is what I'm going to do to treat this, whether it's a medication, whether it's a diet, whether it's a, you know, exercise program, a supplement, a combination of all those, whatever. And now I have an objective measure to say, am I making progress, right? Am I, uh,

37:52

causing regression? Am I halting progression or is it still rapidly progressing despite what I'm doing? That is so important. That's the information everybody needs. Unfortunately, it's not available for everybody. But gosh, when I use this with patients in my practice, it is just, it's mind blowing how precise, how specific, how much information we can get from that test.

38:14

And I wish it was widely available to everybody. Okay, you say everybody, but what about somebody who is metabolically healthy? I want to get an idea of prevention. I know you're really big on prevention. Somebody who's middle-aged, they're a normal weight. They feel like they're metabolically healthy. We've talked about blood. We've talked about now looking at the arteries.

38:40

what would you say somebody would want to do preventatively to see where they're at? And then how often would they want to monitor? Yeah. I mean, because somebody is metabolically healthy now doesn't mean they always were metabolically healthy as well. So it depends on how old they are and what their lifestyle was like before. That's all really important. But a calcium score is the place to start. And hopefully the calcium score will be zero. And then it's also age-based, you know, calcium score of zero at age 40 is

39:07

different prognostic factor than a calcium score of zero at age 60. It's much more powerful at age 60 to have that zero than age 40 to have that zero. So it

39:17

How often you're going to check depends on what you're doing and what are the risk factors you have and how old you are. If you have a zero at 40, maybe you check it five years later. If you have a zero at 60, maybe you check it 10 years later. Now, if it's not zero, then you're going to want to follow it more closely.

39:37

And again, it's hard to give general recommendations because it depends on the age and the score and what you're doing differently. Some people check them every year. Some people will check every year until sort of you see some sort of stability or very slow progression and then and then space it out every two or three years.

39:54

There are lots of different options there, but I think the calcium score is the place to go. You know, Dr. Matt Budoff, who's one of the, I guess you can call him one of the forefathers of calcium scores, has referred to it as the mammogram of the heart. You know, you don't think twice about getting a mammogram just about every year.

40:09

for most average women. So he would say, you shouldn't think twice about getting a calcium score every year or every other year for most average people. That hasn't quite caught on, but it's an interesting concept because it's such a better measure than an LDL blood test. Because I said it before and I'll say it again, LDL is not the disease. Heart disease is the disease. For somebody that has testing done, they see that they have plaque buildup

40:37

What do they do at that point? They decide to take on what we're going to get into today, become more metabolically healthy. What hope do they have to reverse that plaque? Or is it just about maintenance at that point? Well, I like that you said they're going to become more metabolically healthy because often what happens is, you know, the discussion goes, Oh, your calcium score is 50, a hundred, 200, whatever it is. Here's your statin prescription. And in,

41:05

I like how you said it. They decide to become metabolically healthy because the discussion should go, you have calcium in your arteries. Let's make sure we have a very thorough test of your metabolic health and let's make sure we improve that significantly. Then maybe a statin or maybe treating LDL is part of the discussion, but it's not the only discussion. Metabolic health is first and foremost.

41:28

But there are studies, again, in the general population that show if your calcium score is above 100 and you put half the people on a statin, half the people not on a statin, or actually let me rephrase that. It was an observational study, but for people whose LDL was above 100 and those who went on a statin versus those who didn't, those who went on a statin had a small decreased risk of heart attacks.

41:50

Now, if the calcium score was zero, there was absolutely no difference 10 years later. But if the calcium score was above 100, there was a small benefit to being on the statin. So that's where treating lipids can certainly come in to be part of the picture because there's something about having plaque that begets more plaque.

42:10

or something about having plaque that provides the nidus for LDL to then become a little more detrimental. But if there's no plaque, it's a different story. So I think that's important. Now, how does metabolic health factor into that? That's what hasn't been studied because whenever you're studying the general population and the intervention is a statin prescription, not improving metabolic health, you can assume that you're dealing with a metabolically unhealthy population at baseline. So will metabolic health change that? It's certainly possible.

42:39

And I think it's actually probable, but we don't have the strong data to point to that. You know, we can look back and say, okay, if we look at triglycerides and HDL in these old studies, it seems to have…

42:52

be a little more protective or have less of a benefit of treating with medications or less of a risk if your triglyceride to HDL ratio is better. But that's different than saying, okay, we're going to design the study moving forward to look at that. Those studies aren't really powered to look at that, but it's certainly suggestive, certainly suggestive. So, you know, that's where you really got to work with your physician and say like, look,

43:16

I am metabolically healthy. Here are my tests. Here's my lifestyle. And yes, I have plaque, but that could have been, you know, deposited before. So it doesn't mean I actually need, um, a prescription for medication, or does it mean we can follow this moving forward to see if there's progression to see if there's regression. So you brought up that term regression, and this is another tricky one. Um, because when you talk about regression, like I'm

43:41

I don't believe regression of a calcium score is really the main goal. Because if you have soft plaque that you turn into calcified plaque, that's actually a good thing, right? Because calcified plaque is more stable and less likely to rupture and cause a heart attack than soft plaque. So that's actually a good thing. But the calcium score is going to go up, which is kind of thought of as a bad thing, right? So it gets a little more complicated. So again, this is where I really like CT angiograms.

44:08

So when you talk about a CT angiogram with an objective plaque analysis, like with the clearly scan, that's where you can really measure regression. Again, it's not a test that anybody can get, unfortunately, but that's how you measure regression. So that's the only place I would really talk about regression. When you're talking about calcium scores, I wouldn't talk about regression. I would talk about slow progression or lack of progression or

44:33

trying to make sure there are no new areas of plaque. You know, those are a little more nuanced interpretations. But yeah, you know, when people, there are, again, there are cases online and people say their calcium score progressed or went to zero. A lot of the times that might be technical issues. A lot of the times it may actually be true, but I think that's too high of a bar to set for the average person and may not be the right goal.

45:01

So we know metabolic health is connected to heart disease. As a cardiologist, how often would you see somebody come to see you who's been metabolically healthy, is currently metabolically healthy, but yet still has plaque building up? How definite is that connection?

45:23

So they were metabolically healthy and they've been metabolically healthy for years and years and years and now have plaque or they were previously not metabolically healthy. So I want to make sure. Basically other risk factors have come in, say it's smoking or fried foods. I'm just making these up, but.

45:40

Basically, can you assume when you see that plaque that somebody is metabolically unhealthy or they've been metabolically unhealthy? Yeah. So that's tough. Yeah. I mean, it's probably the most common risk factor, but sure. You also get people who smoked, you know, a pack or two a day in their twenties or thirties and they'll come to you with plaque in their, in their forties, you know, and tobacco is a smoking tobacco is a huge risk factor.

46:05

or someone who's got a really strong family history. And that's something that is unfortunate. If your dad had an MI in his 40s, you might have the deck stacked against you. And maybe you're going to develop plaque in your 50s if you're perfectly healthy, otherwise healthy, whereas you would have done it in your 40s before if you weren't so metabolically healthy, right? So you do have to weigh all those other risk factors. And

46:31

That's part of the frustration. A lot of times patients come to me and they say, I want to know why I have plaque in my arteries. I'm like, well, you can't always say exactly why. Did you smoke? Do you have a family history? Did you used to have high blood pressure? Did you used to be metabolically unhealthy? There are lots of things that you have to guess at at someone's past, but those tend to be the big risk factors, especially blood pressure, especially metabolic dysfunction and hyperinsulinemia, and especially family history.

47:01

All right, let's work our way back now. Let's talk from somebody that is metabolically unhealthy right now. They want to make diet and lifestyle changes to work their way back. What's the beginning look like for them? And we've already talked about the low carb, the keto, the carnivore. We know diet's a big piece of this. Let's start there and talk about how somebody would work their way back.

47:25

Yeah, so it really depends on what they're eating right now. You know, and again, this is why I wouldn't say we can't recommend just one diet. You got to recommend a diet that's going to work with someone. But any movement towards predominantly whole foods and lower carb is going to be the right move, right? So that's where I really have a problem with someone with, you know, the dietary guidelines saying eat less red meat. Well, the studies about red meat that are involved

47:54

combined with high calorie, high carb, high sugar, metabolically unhealthy, that's very different from somebody eating a whole foods diet with red meat and vegetables, no ultra processed foods, and otherwise improving their metabolic health. Those are two completely different scenarios. So I just use that as an example that we can't make blanket statements about good food, bad foods, good diets, bad diets.

48:19

It's the diet that's going to help you improve your metabolic health. For most people, that is going to be a whole foods, lower carb type diet. Now, again, the ultimate example of that is a ketogenic diet because that's a very low carbohydrate diet, but not everybody needs to do that. So, you know, if your morning's going to look like,

48:38

Oh, and I should also mention protein. We've also been sort of trained by dieticians in the modern medicine that we actually don't need to eat that much protein, that this 0.8 grams per kilo is perfectly adequate. And that's what you need to prevent protein deficiencies, but that doesn't mean it's optimal for metabolic health.

48:58

and for body composition and that's where you do want to make sure you're getting a good amount amount of protein you know about 1.5 grams per kilogram for for the average person so you know start your day if someone starts their day with one egg and oatmeal

49:16

It's very different than if you're going to start your day with four eggs, with some spinach, and some cheese. One, you're going to get more protein. Two, you're going to be much fuller. You're not going to get hungry as quickly, which is another vital component about a healthy diet. Three, your carbs are going to be lower, your insulin spike's going to be much less, and it's going to get you further down the path towards metabolic health. Then chances are you're not going to be hungry again for…

49:42

at least till lunch, you're not going to snack in between. Whereas if you have, you know, a bagel and banana and a bunch of fruit, you're probably going to be hungry a couple hours later and you're going to snack and your insulin is never going to have time to come down because you're snacking and you're eating, right? So that's going to not move you towards metabolic health as quickly.

49:59

Then for lunch, you have a Cobb salad. Again, it's going to keep you pretty full because it's got plenty of protein, it's got the fat in there, and it's relatively low carb. Then for dinner, you have salmon or chicken or steak or ground beef with a whole bunch of above ground vegetables and some avocado and

50:18

Some people may be in ketosis with that kind of eating pattern. Some people may not, but that is like that type of eating pattern is going to improve your metabolic health. Especially if you find yourself being full, you're not snacking, you naturally reduce your calories. This is one of the most, you know, noteworthy things about, uh, low carb and ketogenic diet trials is if you compare it to a low fat diet and in the low carb diet, and you just let them eat as much as they want. Um,

50:46

almost without fail, the low carb diet, people are going to eat significantly fewer calories because they feel fuller. They're getting their protein, they're getting their nutrients. And, um, and that goes a long way, especially if they're high quality calories, um, that, that are giving you your protein and your nutrients. So it's, it's,

51:03

That goes a long way towards improving metabolic health. So moving in that direction, I think, is the first step. Now, if you want to get more detailed and work with a doctor or a dietician or a coach or someone who can design your macros and design exactly what you're eating when and you can use your app, sure, you can do that. But the general concept is move in that direction and you're going to be healthier. If somebody wants to do this in the most efficient way possible…

51:28

I would assume going keto would be the way to go unless you want to go carnivore. But what I'm getting at here is any reason somebody would want to go low carb versus keto? Or is it just for taste buds and for social situations? Like why wouldn't we go keto if somebody is metabolically unhealthy to get them back?

51:49

Yeah. I mean, there's almost no reason why someone shouldn't go into ketosis. There's some rare medical conditions where you just can't metabolize the fat or utilize the fat well, but they're very rare. But yes, otherwise it is enjoyment,

52:07

um, logistically being able to do it, you know, feeling deprived, um, being able to not feel like you're a social outcast. And none of those things have to be true with a ketogenic diet, but in our society, a lot of people do feel that way. And it's like too much of a step for some people, which is fine. Like, absolutely. You can see benefits by going low carb. Um, so I think that's the key, you know, and especially if,

52:36

Gosh, when you read articles about keto being the worst diet and they're just so off base and your doctor says you can't eat all that fat, keto diets are terrible for you. People have this perception of fat is bad and keto is bad. All right, in that case, let's start you with low carb and maybe you can inch your way towards keto. But those are other reasons why to not go into ketosis, but none of them are really good, sound, physiologic medical reasons. Yeah.

53:05

All right. For somebody going low carb, obviously they're going to bring their blood glucose down overall, bring insulin down overall. The other layer with ketosis is producing ketones in the body. Talk about specifically how you think of those and how they benefit metabolic health.

53:23

Yeah, so it's so interesting to try and tease out what is a benefit from reduced insulin, from reduced calories, from reduced body fat, and from actually having ketones. So you can think of ketones as two ways. One, you could say they're just a byproduct, right? You're burning fat for energy and ketones are a byproduct and so be it.

53:50

Or the research actually shows that ketones are an active molecule. They have actual active benefits and they're not just a byproduct, an innocent bystander. There's one study showing about the

54:04

nlrp3 inflammasone so it can actually ketones can actually directly decrease inflammation um there are some studies suggesting that ketones have an actual um satiety benefit to make you feel um fuller and not as hungry um ketones themselves can be used for energy they're you know an active signaling molecule that can affect uh the the um

54:28

the genes themselves and the, the histone deacetylates. And, and then, and then when we talk about the brain, that's where ketones really thrive because, um, your body can use fatty acids for energy very efficiently. The brain does not use fatty acids as efficiently for energy, but can really efficiently use ketones. So if you're, you know, if your muscles are using the fatty acids and not requiring as much glucose, um,

54:57

You don't want your brain still using all that glucose, but the brain can use the ketones and reduce its use on glucose. Now, it's not 100%. Even some of the early starvation studies suggest maybe 70% ketones, 30% glucose.

55:12

That's still a pretty dramatic effect, especially if the brain is suffering from insulin resistance or poor energy utilization of that glucose. Allowing the brain to use ketones is so effective, and it's been shown for over a century and then for decades with clinical research.

55:31

that it can reduce seizures, especially refractory seizures. Your kids are taking medications and not seeing benefit, but then ketosis can reduce or even eliminate seizure frequency in a number of these individuals. And now we're seeing it with mental health as well, with bipolar disorder, schizophrenia, depression, possibly even anxiety, OCD, PTSD,

55:53

that they can see dramatic improvements with ketosis, a lot likely having to do with the brain energy. And the same with cognitive dysfunction, Alzheimer's disease, even maybe Parkinson's disease. So it's really sort of cutting edge research now that we're learning so much more about the benefits of ketones in the brain and still improving metabolic health can improve all those things.

56:17

But metabolic health without the ketones in the brain doesn't seem to be as effective as with the ketones in the brain. So that's pretty exciting about ketones as a therapeutic potential. Somebody that's gone low carb, not quite ready for keto, but they want some of these benefits from ketones. How do you feel about C8 MCT oil, exogenous ketones? Say going low carb,

56:42

And then adding those as an adjunct to that diet. Yeah. So the easy answer is we just need more research, right? We just need more research to know if that's going to be as effective as a ketogenic diet. But the other thing is, is something you can just test in yourself, right? People can do this on their own to see if they get the benefits or not. You know, there's

57:02

practically no harm to taking MCT oil, to taking exogenous ketones. There's the cost of it. And if you take too much, you might get nauseous or have some GI side effects or diarrhea or something, but you'll learn that pretty quickly and work your way up to it. But yeah, it's definitely worth doing. I talk about the brain benefits from the perspective of treating a

57:25

brain ailment, but there are also people who just say, I think clearer. I have less brain fog. I can concentrate better. There haven't been studies really looking at that, but there have been so many individual reports in people's clinical practices where they see this over and over again. People can see that from exogenous ketones as well. I think there is room for a mix of it.

57:49

Where I'm not so sure the exogenous ketones help is like just for, you know, weight loss or for just for improving metabolic health. I mean, I really think you need the lifestyle and diet, sleep, exercise, et cetera, for that. But for brain-based benefits, I think that's where you could see more benefit from exogenous ketones. The other piece of that that I wonder about is how is that person's metabolism able to utilize that fuel?

58:16

If they haven't trained it. So they're a carb burner, sugar burner, and they're putting those in their body. Isn't used to those.

58:25

Can they utilize them the same? Just a thought experiment. Yeah. And it's fascinating. I think from a, like from a evolutionary perspective, like this is the one time in evolutionary history that we can have high glucose, you know, glucose utilization and high ketones. Like when would that ever, ever exist previously? It couldn't have, it just seems like physiologically impossible. So who knows what's going to happen?

58:51

The other tool that fits nicely into this part of the conversation is fasting. So intermittent fasting, longer fasts, obviously that's even more extreme than carnivore bringing no food in and allowing the body to metabolically heal during that phase and also potentially produce ketones. So talk about how you feel about fasting. Yeah. Fasting can be a really powerful technique. Um,

59:16

But it's important to define what are we talking about with fasting, right? For some people, not eating for 12 hours is considered fasting. And for some people, not eating for five days is considered fasting. So time-restricted eating, not eating all day long, eating in an eight-hour window or a six-hour window, fasting.

59:34

I think can be really beneficial. Interestingly, the science is a little split and a lot of it depends on the study structure. And this is a great example on how you can't just sort of use one study and extrapolate it to everyone.

59:48

I remember there was one study looking at time-restricted eating versus not. And the people in the time-restricted eating window actually ate more calories, ate more calories. And they didn't see as many benefits. And okay, maybe that's not such a surprise. And they didn't really regulate the quality of food. So I think if you're eating high-carb, high-calorie, high-refined-carb processed foods,

01:00:11

maybe it's not going to do a whole lot, but if you can use it as a tool in your otherwise healthy diet, um, and use it as a sustainable way to reduce your calories and give your body more time where, where nutrients aren't coming in and your insulin level can go low and stay low. Um, yeah, then definitely can be benefits. Now,

01:00:32

It's not for everybody. Absolutely no question. It's not for everybody. Some people do get sort of this rebound hunger or just a psychological feeling that you need to eat more because you didn't eat for that period of time. I've got a number of people in my practice who I try time-restricted eating and that's their response. And I just say, forget it. It's not for you. You know, not everybody needs to do it.

01:00:54

And what's interesting though, is as people go low carb or keto, a lot of people will naturally tend towards that way. You know, if you're used to breakfast at seven, snack at 10, lunch at noon, snack at three, dinner at six, all of a sudden they go, wait, I haven't had my snack yet. And I just missed lunch. And I kind of didn't even think about it. And it's like revolutionary for them to think that way. Well, a lot of people experience that when they're in ketosis. And I think that's just

01:01:18

you know, sort of a natural healthy response as long as you're getting enough protein, as long as you're getting enough nutrition. And so that's something to definitely pay attention to. Now, the longer fasting, you know, the three to five day fasting,

01:01:32

That also has a place. I guess from my personal standpoint, I think it's miserable. I don't think it's any fun whatsoever. I hate doing it. So if I'm going to do that personally, I better be pretty confident I'm going to get some benefits out of it. But this is where the whole longevity field, sure, it can help with weight loss. Sure, it can help with metabolic health. I think there are better ways to

01:01:53

to do that the one the main benefit i think for longer fast like that is the potential for this longevity research for you know stem cell regeneration for reducing the size of organs you know some a lot of the surrogate type um data that suggests it may be good for longevity again not doing it very often though because you're going to lose some muscle mass you know you're not you need to make sure you're getting adequate protein before and after um

01:02:22

you know, it can come with some negatives, but for, for some people it can be really be beneficial. I just don't think it's necessary for the majority of people. Now you look at someone like, um, you know, Dr. Jason Fung and he's developed like a whole clinical whole practice around, um, extended fast to help people with their type two diabetes, to help people lose weight. And they've got a protocol that works. So for those people who really want to do it and it works for, and are committed to it by all means, I just don't think it's necessary for everybody.

01:02:48

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01:03:03

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01:03:30

who is overweight, even type 2 diabetic or anywhere along that continuum of insulin resistance all the way to type 2 diabetes, what would you say to them to not overwhelm them are the best tools to at least experiment with in the beginning to help them start on this pathway?

01:03:52

Yeah. Yeah. And you know, like we talked about with the diet, going lower carb, going whole foods, going higher protein, and then stop snacking, right? That doesn't mean fasting or time restricted eating, but stop snacking. Like it's so on the one hand, sort of hilarious. And on the other hand, incredibly frustrating to think that we were teaching people for so long, you got to eat six meals a day, small frequent meals to get your, keep your metabolism up. And

01:04:19

There's really not much science behind that and that's not the healthy way to eat, but so many people believe snacking is perfectly innocuous and something important to do. But eliminate snacking first and doing that by helping people feel fuller with their meals by higher protein meals.

01:04:36

whole foods, lower carb meals. So that's a great first step. And exercise is another perfect example, right? If someone feels like they need to go to the gym and pump iron five days a week, and that's what they have to do for exercise,

01:04:50

A lot of them aren't going to start. It's just a non-starter. So in the beginning, just move your body, right? Everybody's got a smartphone now that tracks your steps. Whatever steps you're doing now, you know, get 3,000 more. And then after that, get 3,000 more after that. And just make sure you're moving your body so you're not sitting. And then maybe eventually you can start talking about a more structured exercise program that has some resistance training, that has some dedicated cardio, maybe with some interval training. But if you start there…

01:05:16

you're going to overwhelm people and lose a lot of people. So first just start moving your body and then graduate to the exercise program and sleep. I mean, we often don't talk about sleep nearly enough, you know, make sure you are in bed eight hours a night. Um,

01:05:31

May not be asleep the whole time, but if you're only in bed six hours a night, you're really giving yourself a barrier to start with. And people think, yeah, yeah, yeah, you know, sleep is the one thing that people can really blow off and think is not that important. Like, I don't need sleep. I do fine. Well, you may feel fine, but you don't know what's going on inside you when you're not sleeping well. And insulin resistance, chronic inflammation have been associated with poor sleep.

01:05:58

And poor decision-making. There's one study that actually I really liked. There was one group that was sleep-deprived for, I think it was, oh gosh, I got to revisit this. I think it was three days versus one group that wasn't. And they took a cognitive test and reaction test

01:06:14

And they felt, they both felt like they did very well. Like when you asked them how they did, it was almost equivalent. But the sleep deprived group did terrible. They did not do well at all, but they felt they did just as well as the other group. And that, to me, that really shows how sleep deprivation and not getting adequate sleep can really sort of mess with our bodies and our brains. I want to add a little bit to that snacking piece for people that feel like I couldn't go more than two hours without a snack. And you touched on this earlier.

01:06:43

When you start to change what you're putting in the body, that's going to become easier. If you're continuing to eat the junk food, the high carb, naturally you're going to be hungry every couple hours. That's only normal for that fuel going into the body. So it's hard probably for a lot of people to understand that until they try and increase the fat and the protein.

01:07:04

and then start to see the way their metabolism's changing. Absolutely. Oatmeal with brown sugar and raisins, I guarantee you, you are hungry two hours later. No question.

01:07:14

you know, four eggs with cheese, avocado and some vegetables, you're probably not hungry for six hours, right? Like there's a huge difference. So yeah, what you eat makes a very big difference. I want to come back to the brain. And this is an area you're passionate about. You know a lot about as the director of Metabolic Mind.

01:07:35

For somebody that feels like right now, for whatever reason, whether it's dementia or mental health, you mentioned both of those before, they want to experiment with ketosis as a tool to help with prevention or even to help reverse that. How do they know how deeply to go into ketosis to get benefits? Because there's ketosis and there's ketosis. There's quite a spectrum even within that.

01:08:05

So from your experience, what level of ketosis do we need to get to before we really start to notice the difference with the brain? Yeah. You know, it's questions like these where I really, really love my position at Bazooki Group and Metabolic Mind because I get to interact with so many experts on a daily basis, whether they're clinician experts or experts by experience with their own personal experience. And

01:08:31

One of the lessons is it varies, right? Now, in general, it looks like most people are going to see the highest brain effects in the 1.5 to 3 millimole range, but that's going to be different for everybody. So actually at Metabolic Mind, we're launching Think Smart, which is going to be a

01:08:51

a community-based tool basically for people to share their experience so we can learn from the community, right? And, you know, someone like Lauren Kennedy West, you know, her ketones are in the four, fives, and sixes. And when they come down to two, she doesn't feel good. She notices her psychiatric symptoms come back.

01:09:10

Other people can be at a 0.5 to 1 and feel great and have complete resolution of their psychiatric symptoms. So I wish I knew why there was such variation, but it's clear there's variation. But I think on average, we can say probably in that 1.5 to 3 range for brain-based benefits, but don't take that as a hard and fast rule.

01:09:31

you got to experiment. You got to do your own experiments. You got to test. You got to see how you feel and respond appropriately. But I think once we launch this Think Smart program, we're going to learn a lot more. Just, you know, community source it and learn from other people's experience. It's going to be really exciting. You talked about one specific patient there that when she dropped down from, I think it was five or six to around the two range, her mental health symptoms would come back on. Right.

01:10:00

Is there a certain period of time that you find, and obviously this can depend on the person and their situation, but that somebody needs to go on a ketogenic diet, create ketones for the brain, fix their metabolism, and then over time can maybe introduce more carbohydrates and be more flexible over time? Yeah.

01:10:23

Yeah, great question. And the answer is yes for some. So other examples, and of course, these are personal examples. We're going to learn more through research. But at Metabolic Mind, I have the pleasure of working with Hannah Warren. And she had mentioned to me how in the beginning of her ketogenic journey, she needed higher ketone levels, right? Like three, around three

01:10:44

to keep her symptoms away. And now she's perfectly fine at one or below. And so that changed over time. There's another gentleman who in the beginning needed to be in strict ketosis and now actually is in ketosis Monday through Friday and Saturday and Sunday, you know, kind of

01:11:01

gets a lot more lax with the family and comes out of ketosis and does just fine and picks it up again on Monday. Now, if he stretches it to, you know, out of ketosis to Monday and Tuesday, he'll start to see symptoms come back, but he's worked it out for him where he knows where his level is. And, but it wasn't like that in the beginning. So there are, there are examples of that.

01:11:22

you know, is that going to be the same for everybody? No, it's not. There's going to be a lot of personal variety. And, and look, the research is exploding in this area. And in the next couple of years, we're going to have so much more data because there are, I don't know, I think there are like 15 clinical trials going on right now or about to start enrolling. And,

01:11:42

So there's going to be a lot more to answer these questions. In the meantime, that's why we want a resource to create a resource like Think Smart so we can sort of crowdsource the learning and people can learn from each other as we're getting more of this research evidence come in. For somebody that's deep in ketosis, they're finding benefit there, say for mental health, but it's been like a year or two and they're starting to Google online and hear people say, ketosis long-term, you can't do that. You start to run into health problems. Right.

01:12:12

What's the research showing with that?

01:12:14

Yeah, so we did a video on our Metabolic Mind YouTube channel about this specifically. Well, can I do keto long-term? And basically, anybody who says there's evidence that long-term ketosis is dangerous is simply wrong. There isn't evidence that long-term ketosis is dangerous. Now, there isn't evidence that long-term ketosis is safe because it hasn't been looked at, right? It just simply hasn't been looked at. But anything to suggest it's dangerous is just simply wrong.

01:12:44

And a lot of the problem is when you look at the studies, they'll look at, oh, see, this study shows low-carb. The people who are low-carb have a higher incidence of heart disease or dying prematurely. And there are observational studies, nutritional epidemiology, which are very low-quality studies to begin with. But then they define low-carb as 40% of your calories from carbohydrates. That's far

01:13:06

40% of your calories from carbohydrates, where a keto diet is like 5% usually. So you're talking about, you know, 20 or 30 grams per day versus 200 grams per day. Those are not even in the same ballpark. So to assume one equates to the other is just wrong. But that's, those are the studies most often cited when saying you can't do keto long-term. And the other is the heart disease concern. You know, it's going to raise your LDL. It's going to give you heart disease.

01:13:32

not proven whatsoever right and so um there's no evidence for that and if you're using it to improve your metabolic health and you know to to improve your your brain function and your mental health like where's the concern there so no there's absolutely no evidence that long-term ketosis is is dangerous um and and the evidence people cite is just doesn't apply really so um

01:13:57

Yeah, so it's something that you just need to follow for yourself. How is your health responding? How is your metabolic health responding? How is your cardiovascular health responding? We can test for these things. We don't have to guess. For most people, when they adopt a ketogenic diet or even low carb, they're going to tend to include more animal products and more saturated fat, which you've brought up a couple times. But I want to go deeper on that because that is a fear that

01:14:25

that could be a potential roadblock for a lot of people who over the years have heard saturated fat is going to cause, you know, heart disease, heart attack, strokes. Let's talk more about saturated fat specifically and put people's minds at ease. And again, as a cardiologist, you're the perfect person to do this. Mm-hmm.

01:14:47

Yeah. Well, and the first thing I always have to start with is a keto diet is not one diet. It's any diet that lowers carbs enough to get you into the state of ketosis. You can do that with a vegan diet. You can do that with a vegetarian diet. You can do that with a Mediterranean diet, all low saturated fat. So by no means does it have to be a high saturated fat diet. Now,

01:15:07

the way it's frequently thought of and probably the majority of the people who practice a ketogenic diet do eat higher than recommended amounts of saturated fat. But again, you got to go back to what is the quality of the evidence that either red meat specifically or saturated fat is harmful for cardiovascular health. And if you're talking about general population studies,

01:15:27

Those studies that are observational studies that just follow people over 10 or 20 years, and they do a food frequency questionnaire one, two, three times at most during that 20-year period, right away you know you're dealing with very low-quality evidence. And then how do they define saturated fat? Well, there's saturated fat in cookies and cakes and baked goods. There's a burger, which includes the burger patty.

01:15:56

but also the bun and also the ketchup and usually associated with French fries and a sugary drink. So lasagna is a saturated fat with so high sugar in the sauce and in the noodle. So it is the messiest data you could possibly have.

01:16:14

So to try and take that quality of data and then say the outcomes are meaningful, especially when there's also this concept of healthy user bias, which means when you look at the people who eat more saturated fat compared to less, the people who eat more exercise less, they tend to be less educated, um,

01:16:32

They tend to smoke more, drink more alcohol, more likely to be overweight, eat more calories total. And it's not that saturated fat caused them to be less educated or to not exercise. It's just how they are, right? So you factor in that bias that exists before the study even starts.

01:16:53

So for any of that to have a meaningful outcome, there has to be a very significant difference in the cardiovascular outcome, in the who lives or dies early type of results. So people say, well, what about smoking? All those things are true about smoking. Yeah. And the hazard ratio and odds ratio, meaning sort of the effect size seen in the studies for smoking was like 15 or 20.

01:17:19

And when you talk about red meat and saturated fat, it's 1.2, 1.3. Compare that to smoking 15 or 20. So when you talk about all those problems with the studies in this very thin margins,

01:17:35

it's essentially meaningless um so now we're talking about someone who's eating whole foods low carb they're metabolically healthy they're eating saturated fat or red meat do we have any evidence that that's harmful whatsoever the answer is no we just don't have evidence that that's harmful in that type of situation now the one caveat is if you look at saturated fat and you say okay it

01:17:59

LDL goes up significantly with saturated fat. That is one area where there is a higher risk of cardiovascular disease, still not near the 15 or 20 from smoking. But again, now we have to say, okay, in a metabolically healthy individual,

01:18:14

um does that make a difference but again you can measure for that and in the majority of the people who start a ketogenic diet high saturated fat or not ldl does not go up in the majority of those people so we don't we should not assume that it's harmful so as you peel away the onion um you start to see that really there's there's not much there now

01:18:34

I don't know, would that take me five minutes to explain as opposed to saying saturated fats, dangerous, boom, move on, right? It's a lot harder to kind of go through the nuance and talk about the details and the specifics. But when I'm seeing a patient in front of me,

01:18:48

I want to know what's the effect for that person. What's going to happen to that person? Not what a, you know, a hundred thousand person population study shows that does not apply to this individual sitting in front of me at all. I want to know about the individual in front of me or me as an individual, right? Like I,

01:19:04

I've certainly done a lot of my homework on this. I have no problem eating saturated fat. My metabolic health is excellent. My calcium score is zero, right? My blood pressure is perfect. These are the things I'm following, not some perceived threat from saturated fat when there are things I can measure. And I know the data about saturated fat has nothing to do with me as an individual. All right, well, let's add another layer onto saturated fat, carnivore diet. Somebody totally eliminating plants,

01:19:33

likely saturated fat is going to be at another level. How do you feel about that diet in general? Yeah. Yeah. That's a good question. And this is somewhere where I've definitely evolved. I mean, I, gosh, I wrote a book, I don't know, 10 years ago, eight years, five years ago, somewhere around there. I don't even remember. But, and when I wrote the book, I was sort of like, yeah, you know,

01:19:56

you shouldn't be carnivore. There's, you know, you got to have half your plate full of vegetables and, um, still low carb. Right. But, but I was not a fan of the carnivore diet. And, and, but when I stopped to think about it, I'm like, well, why? Why?

01:20:11

You know, why am I concerned about the carnivore diet? It's just because I've been taught forever. You need your fruits and vegetables, right? I got over the point that you need your healthy whole grain. So can I get over the point that you need your fruits and vegetables? And it's the same concept. Like there's not one diet for everybody. Some people react very poorly to vegetables. That is true.

01:20:30

I definitely stop short of saying everybody needs to avoid vegetables. Sure, you can talk about phytates and anti-nutrients, and those are all true to a degree, but that doesn't mean they're going to affect everybody. In large population studies showing healthy populations eating plenty of fruits and vegetables shows it can't be that bad if they're…

01:20:53

of subsisting on those foods and still living healthily. But that's very different than saying everybody needs them and a diet without them is unhealthy. That is a different statement. And to see people change their lives on carnivore diets, whether it's abdominal bloating and just GI symptoms or whether it's an actual inflammatory bowel condition or mental health, there are some people who went keto and saw some benefit but didn't really thrive until they went carnivore

01:21:22

Like, all you have to see is a few examples of this and be like, wow, there's something there. Is it the elimination diet? Is it the, you know, the more meat and the nutrients and the protein? You know, certainly we don't know because it hasn't been studied all that well. But there's clearly, clearly an area where a carnivore diet can be very beneficial for people. And

01:21:44

And very healthy. I mean, you know, again, you don't have to assume if it's going to be healthy or not. You can follow, you know, people's blood sugar and their insulin and their triglycerides and their calcium scores and their mental health and their, you know, body composition. And there are so many objective things you can follow to say, is this healthy for me or not? You don't have to guess. Well, one area we got to dive into while we're talking about carnivore is the microbiome.

01:22:13

Obviously, this diet, no fiber. One of the big things in conventional dietician realm, medical doctors, is to eat the rainbow, get a lot of fiber. It's good for the microbiome, good for the gut. How do you think about that? Yeah.

01:22:31

I think when it comes to microbiome, our recommendations are far ahead of what we truly know from a science standpoint. I had a good interview with Dr. Jack Gilbert, who's a researcher here in San Diego, is a microbiome expert. We've got it on our podcast. And, you know…

01:22:50

He gets so excited about the microbiome because he, and this is his life and he studies it, but even he sort of admits, you know, we're not quite at the point where we know everything about it, right? Like it's still in his early stages of research.

01:23:03

And how do you explain someone who's carnivore, who put their type 2 diabetes into remission or completely resolved their bipolar disorder or feels the best they've ever felt by eating a diet that quote unquote is supposed to destroy their microbiome, right? So there's a huge disconnect.

01:23:21

So the microbiome is one piece of the puzzle. And I'd even say it's a really small piece of the puzzle because is it the chicken or the egg? Is it the leading factor or the responding factor, right? Are we healthier because we have a healthy microbiome or is our microbiome healthier because we're healthier, right? I don't know that the research is really strong enough to be able to figure that out. Now, you know, microbiome transplants are super interesting. Fecal transplants are super interesting, right?

01:23:48

You can do those now when it comes to something called a C. diff infection, which is totally different. But there's also like in mice and some suggestions that for weight loss, a fecal transplant and changing the microbiome can help with weight loss.

01:24:03

But then also you have to go back to, okay, well, what kind of lifestyle is that person doing? Is it high carb? You know, is it exercise, et cetera, et cetera. Once you take all those other factors into consideration, I think the microbiome is going to have much less of an impact than we think. So yeah, you know, I was under the impression that we all needed to eat our fiber and we needed to eat the rainbow and have a healthy microbiome and microbiome diversity is key.

01:24:30

But then how do you explain these people eating a carnivore diet and thriving and looking very healthy from all objective parameters? You can't, other than to say, well, maybe in some situations it's not as important as we think it is. Given your answer there, I think I know where you're going to go. But how do you feel about fermented foods, probiotics?

01:24:49

Yeah, look, I think it can be helpful. If you like them and you think they're having an impact on your health, then absolutely. I'm in favor of them. Do I think you need to have them? No, absolutely not. There's no need for them. Yeah, you know, a lot of the, and to talk about fiber, you know, the majority of the data on fiber comes from high-carb diets. And there's no surprise that if you're eating a high-carb diet that

01:25:16

the diet with more fiber is going to be better than the diet with less fiber because whole foods, natural foods have the fiber and processed, ultra processed and more of the junk foods don't have the fiber. So you can also say it's just sort of a surrogate for how healthy the diet is, whether in a high carb diet, whether there's high fiber or not. But once you get rid of the carbs, then how important is the fiber? You can see the same thing for the fermented foods, right? Once you get rid of the carbs…

01:25:43

How important is the fermented foods? That's a unique situation that we're learning so much more about. But if you're talking about a high carb diet, absolutely. You want more fiber, you want more fermented foods, you want to, you know, microbiome probably plays a role there in a high carb diet because that's what's been studied and looked at. So supplements we brought up, probiotics, C8 MCTO, we could consider that a supplement, exogenous ketones, and the realm of metabolic health and beyond.

01:26:12

What supplements do you like to recommend for people? You know, I think most people won't need supplements. The majority of people won't need supplements. If you're eating a whole foods diet from animals and plants and most people won't need supplements at all. Now,

01:26:27

You can see magnesium. Our food is… Studies have shown that our food is deficient in magnesium. Our soil is deficient in magnesium. Supplementing with magnesium is probably a good idea for a lot of people. If someone's eating fish, they probably don't need omega-3s. Some people hate fish, in which case I think it's good to supplement with omega-3s. Vitamin D is…

01:26:52

It's hard to get exclusively from food. So if someone's not getting a lot of sunlight, you know, vitamin D supplements can be good. Although I think sunlight is probably the better way to get it. Gosh, what else? Anything else is I think would be directed based on someone's lifestyle. If they're, you know, not eating certain foods or deficient on things on their blood tests or whatever, but other general supplements, I'm not sure that are necessary. What about creatine?

01:27:20

I'm hearing a lot more about creatine for the brain lately. And obviously that's one of your interests. Yeah. Have you looked at that research? You know, I haven't looked at creatine very much, although my teenage son is certainly asking a lot about it to bulk up and see if it's a good thing for him. Um, but I need, I need to learn more about creatine in the brain for sure. That's something that I haven't looked a lot into. Um,

01:27:42

I generally think for the average person from a muscle standpoint, if you're getting adequate protein and doing resistance training, creatine's not necessary for muscle development. Now, if you want to be a bodybuilder or something, maybe that's different. So I wonder if the same thing applies to the brain. I don't know. But I think you start with high quality protein, making sure you're getting enough of it, make sure you're exercising and doing resistance training. And that's going to take care of the majority of what you need for metabolic health.

01:28:11

As we talk about different nutrients and supplementing, this brings in the discussion of different qualities of food and different qualities of food are going to have different nutrient profiles. How do you look at that for yourself and for patients? Things like grass-fed, grass-finished, organic, there's all different certifications now and different qualities of the health foods.

01:28:38

So how do you look at that? Yeah. One, it can be really confusing. So I certainly empathize with patients who get confused by all this, but there's certainly different levers or layers, I should say. Um, and I don't want, you know, the feet, the thought that everything has to be grass fed beef, wild salmon, uh,

01:28:58

organic regenerative vegetables, if that's the barrier to entry, we're going to lose a ton of people. You know, if you want to eat your McDonald's patties instead of your high carb, high processed food, you're going to probably do better than you were on a metabolically dysfunctional, you know, high carb, ultra calorie, ultra processed foods, right? So,

01:29:22

I think we need to lower the barrier of entry for people to eat lower carb, more whole foods. Now in a perfect situation where we can afford it and have access to it. Yeah. I want to get my beef from a grass fed regenerative ranch. Um, I want to eat organic vegetables, um, and berries. Um,

01:29:42

If I can access it and afford it, sure. But by no means is that necessary. I mean, because when we talk about such a poor quality diet, the standard American diet that we're starting with, any improvement from that is going to improve our metabolic health.

01:29:56

how much further you want to go, that's going to be different for everybody. But access is the big problem there. So, I mean, that's how I see it. So I never have that discussion in the beginning with my patients. I might eventually get to that discussion, but almost never in the beginning. You got to set the bar lower to work on someone's metabolic health. And

01:30:16

you know, so-called dirty keto or fast food keto, or, you know, even fast food, fast food, low carb is generally an improvement from what a lot of people are doing in the standard American diet. Talk about your story, getting into low carb metabolic health, because the way I understand it, you were conventionally trained as a cardiologist. And I believe at the beginning of your career, you were conventional. What brought you into this, this new realm?

01:30:42

Yeah, it was luck having the right friends. So I was conventionally trained. In fact, I was trained in a Dean Ornish style cardiology program. We had this great preventive cardiology program where people would exercise together and get community support and stress reduction. And we could really be hands-on and cooking classes for a vegan, very low-fat diet.

01:31:10

Um, that's how I was trained. Um, and then of course, when the hospital and the cath lab and, and all the other aspects of cardiology, but then I got out into regular practice and, um,

01:31:21

Didn't take long for me to get pretty disillusioned and pretty frustrated with the lack of effect I was seeing on my patients. Like so many people just couldn't stick to lifestyle recommendations, didn't want to stick to the lifestyle recommendations, weren't getting better. And I was a pill popper. I mean, I was just saying, all right, here's your medicine. You can't do it. Here's your medicine.

01:31:42

And it took me longer than I would have liked, but shorter than most, I guess, to say something's wrong here. Something's broke in this system. If every patient can't do it, maybe the problem is me. Maybe the problem is what I'm suggesting here.

01:31:58

and not the patient. And, you know, we would see just the revolving door of people coming into the cath lab and getting their stents and getting hospitalized. And it's like, clearly something's broken. So I started a wellness center with a friend of mine who is an amazing health coach and personal trainer. And I was just very lucky that he knew about ketosis and ketogenic diets. And so for some of our more challenging patients,

01:32:24

Initially, he suggested to me, why don't we try this person on a keto diet to help them lose weight and, you know, reverse their type two diabetes or improve their type two diabetes.

01:32:32

And at first I thought he was crazy. I'm like, no, I can't do that. I'm a cardiologist. But luckily he said, have you looked into it? Have you read any studies about it? And I had to think about it. I'm like, no, I guess I haven't. So he challenged me to do that. And once I did, I was shocked. I'm like, oh my God, people have actually studied this and shown that you can treat type 2 diabetes with a ketogenic diet and that their blood work improves so much and that you can improve their metabolic health and

01:32:57

And so once I started to go down that rabbit hole, I'm like, yeah, let's try it on the patients and I'm going to start eating this way. And then that changed everything. I mean, once you see it, you can't unsee it. And again, not that everybody needs to be on a ketogenic diet, but the fact that it is such a powerful treatment that contemporary medicine doesn't even talk about is just a crime. I mean, it should be at least a tool in every doctor's toolkit to be used at the appropriate time. But that's where I almost felt

01:33:25

I don't know, I felt like cheated or I felt like lied to. And that's why I really sort of made it my life's purpose to say more people need to know about ketosis as a medical intervention. Absolutely, people, I need to shout this from the rooftops so that everybody learns it. And fortunately, the community is growing. More physicians are doing it. More physicians are shouting it from the rooftops and patients are starting to understand it. And then we're learning so much more about specific conditions

01:33:54

specific interventions like with brain-based disorders, like with mental illness, where it can be so effective. It's just growing and growing from here. You talked about this pivot in your diet along the journey when you started to learn about this. What does your diet look like these days? Given what you know about keto, are you typically in ketosis? I would say I typically am. In the beginning, I would test and make sure and try and stay in ketosis.

01:34:21

For me personally, I don't pay attention to that anymore. You know, I don't have type 2 diabetes. You know, luckily I don't have a psychiatric diagnosis. I don't have something I need to treat.

01:34:33

So for me, it's just the right way to eat. You know, I'll either not eat breakfast or I'll have, you know, three or four eggs with cheese and avocado and leftover vegetables. Um, lunch, I sort of gave this example earlier and I was sort of talking about me lunch. I almost frequently have a Cobb salad or just leftovers from dinner again, which are going to be a number of different vegetables and some sort of protein.

01:34:54

And then dinner, I'll have steak, ground beef, salmon, chicken thighs, again, cooked with cauliflower and broccoli and zucchini and…

01:35:05

you know brussels sprouts and an avocado and that's what i eat it's it's kind of boring and i don't care because i love it i think it's delicious it keeps me full and keeps me happy and keeps me healthy so i don't i don't really need to eat anything different but that's very different for someone who needs to use ketosis to treat a medical condition and improve their health and you know monitor their ketones and and so forth have you ever played around with the carnivore diet

01:35:32

I started to, and I actually really missed vegetables. I gotta be honest. I love roasted cauliflower and roasted broccoli and roasted Brussels sprouts and zucchini. And I mean, I really love it to me that like adds to my meal and to sit down and have a big old steak with nothing else just felt like I was missing something. So I played around with it for a little bit, but not for very long. Um, you know, so maybe I'll go back to it and try it again for a longer period of time and see how I feel.

01:36:01

For somebody that this is all new to, they're going to embrace a keto diet for, say, a mental health challenge. How important do you feel testing is? Because there are strips you can pee on, blood tests, certain testing kits I know you can breathe into. So how important is testing?

01:36:24

And then talk about the different methods. Yeah. So again, it depends on what you're doing, right? If you just want to become metabolically healthy and lose weight, maybe you don't even need to test, or maybe a urine strip is good enough to say, am I in ketosis? Am I in light ketosis, moderate ketosis, et cetera. But if you're using it to treat a brain-based disorder, that's where I think finger prick blood tests, like a Keto-Mojo type device are crucial.

01:36:47

um because you really want to know that specific amount and if you're you know one thing i like to say for ketogenic therapy rather than just eating a keto diet you actually want to know what your target ketone level is you want to define a target level and try and get there and it may change over time um it's going to be different for each individual but that you can only really get by the finger stick test the breath tests are getting better i guess um

01:37:13

They don't tend to be quite as accurate, but they are improving. And for that type of specificity, the urine tests I don't think are helpful at all. What's really cool is there are continuous ketone monitors that exist, just like a CGM.

01:37:29

they're not widely available in the u.s um you know in asia and europe you can get them i'm not sure even how widely available they are there um but i've got i've been fortunate enough to be able to play with them a little bit they're really cool and that i think is going to kind of take things to the next level for saying what level of ketosis should someone be in we're going to learn so much more you know if you're checking your ketones once in the morning

01:37:54

We know it's going to be very different, you know, before dinner or before bed. You know, your ketones are going to change during the day. But I do think it's important to check on a regular basis and try and figure out when are you at your highest, when are you at your lowest, and maybe check at those times during the day to get a gauge of where you're at and then correlate that with your symptoms or your disease improvement and then take your target. One of the things I want to highlight here as we wrap up

01:38:23

is good news within all of this is that metabolic health is at the top of the pyramid. And we've talked about a lot of different conditions under it, whether it be mental health, dementia, we could put cancer under there, basically all chronic disease. So when you work on what we're working on today, it has a trickle down effect in so many different areas of your life.

01:38:48

So it's not like you need to be on this keto diet for this one condition, but then take this other supplement and switch into this diet. It sounds like a lot, but if this is new to you, this is a lifestyle and diet that when you have it locked in, it's going to reap so many different benefits in so many different areas of your health.

01:39:11

Yeah, I think you're absolutely right. And that's what can create a number of skeptics, right? Because people can be like, no way, this is snake oil. How can something improve your diabetes, improve your bipolar disorder, reduce your risk of cancer and improve your heart disease? There's like, you can't take a pill that's going to do all that. So how can something do that?

01:39:31

And it's because of this constellation of effects that can happen with metabolic dysfunction. And it's not just one thing. It can impact so many different aspects of your health. So treating that and reversing that can therefore benefit all these different aspects of your health. So the uninitiated and the skeptic is going to use that as a detractor. But really, it just shows the importance of metabolic health and the importance of lifestyle and how poisonous our standard lifestyle has become.

01:39:59

Brett, I think this is a great place to wrap up. Really appreciate you. Thank you for coming on the show. We're going to link up your YouTube, your website, your social media. Thank you. Great. My pleasure. Thank you for having me on. It was great discussion. Now that you're finished with the episode, head on over to ultimatehealthpodcast.com for detailed show notes, including links to everything we discussed. Thanks for listening and have a great day.

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D:2025.07.09<markdown>

在许多医生看来，代谢功能障碍通常被等同于是否患有 2 型糖尿病，只要未达到糖尿病标准，就被认为是健康的。但实际上，代谢功能障碍、代谢不健康始于胰岛素抵抗的早期阶段 —— 此时身体往往超重、脂肪过多，对胰岛素调节血糖稳定的信号反应不佳。例如，餐后血糖飙升至 170、180、200，并持续一个半到两个小时，这就是身体对所吃食物反应不佳、存在代谢功能障碍和胰岛素抵抗的信号。胰岛素长期处于高位，会阻碍身体获取和燃烧脂肪储备供能，容易导致脂肪堆积；还会引发慢性炎症状态，高胰岛素血症与炎症的相关性很强。酮食作为一种有效的治疗手段，却未被现代医学提及，这实在是一种遗憾，它至少应成为医生工具箱中适时使用的工具。

若走进主流医学医生的诊室，他们很可能会推荐植物性素食或纯素饮食。但这一观点并不准确，其依据主要是这类饮食能略微降低 LDL（低密度脂蛋白），而若仅将 LDL 视为最重要甚至唯一的风险因素，才会得出这样的结论。然而，饮食不同于药物，它涉及情感、享受、个人过往和生活方式等诸多因素。因此，预防心脏病并没有一种绝对健康的饮食，关键在于选择自己能享受并坚持、且能改善代谢健康的饮食。代谢健康对心血管疾病风险的影响，远超过任何单一的实验室检测结果。不能简单地说荤食、酮食、地中海饮食、素食或纯素饮食哪种更好，因为不同人对这些饮食的反应不同，对其定义也不同。不过，对于想要恢复代谢健康的人来说，减少碳水摄入是重要的一环。

“低碳水” 是一个相对模糊的概念，通常指每天碳水化合物摄入量少于约 100 克。而酮食是低碳水饮食的一种形式，所有酮食都是低碳水饮食，但并非所有低碳水饮食都是酮食，酮食通常每天碳水化合物摄入量少于 30 克，有时也会少于 50 克左右，且可以通过检测酮体来确认是否处于酮症状态。除了数量，碳水的质量也很重要。100 克来自饼干、意大利面和面包的碳水，与 100 克来自蔬菜、坚果、水果、种子等全食物且富含纤维的碳水，身体的反应会大不相同。

这取决于个人想要改变的速度以及身体的初始状况。如果只是超重 5 磅，有早期胰岛素抵抗迹象，原本遵循美国标准饮食（约 300 克碳水），那么每天摄入 100 克全食物碳水可能就足够了。但如果患有 2 型糖尿病，需要减重 100 磅，肌肉量低、体脂高，尤其是想要快速看到变化，可能就需要从酮食干预开始。对于某些特定干预，如针对认知衰退、双相情感障碍、精神分裂症等脑部问题，酮体在大脑中的作用至关重要，这时就不只是减少碳水，而是将酮体产生作为一种治疗手段。

许多医生和传统医学培训中，仅将是否患有 2 型糖尿病作为判断代谢功能障碍的标准，但若等到 2 型糖尿病确诊时，代谢功能障碍可能已经存在数年甚至数十年了。代谢功能障碍的核心是胰岛素抵抗。健康时，身体只需一定量的胰岛素就能维持血糖稳定；随着胰岛素抵抗出现，身体需要越来越多的胰岛素（2 倍、3 倍、4 倍）来维持血糖，最终胰岛素分泌不足，血糖开始上升。代谢功能障碍始于胰岛素抵抗早期，此时身体往往超重、脂肪过多，对胰岛素调节血糖的信号反应不佳。睡眠不足、缺乏运动、慢性炎症，以及高碳水、高糖、高热量饮食（尤其是超重和脂肪过多时），都会影响代谢功能。

除了超重，腰围与身高比是一个简单的判断方法，该比例低于 0.5 时，代谢功能障碍的可能性较低；高于 0.5 时，可能性较高。身体成分测试也很重要，比如内脏脂肪含量、体脂率等。实验室检测包括空腹胰岛素水平、糖化血红蛋白，以及利用空腹血糖和空腹胰岛素计算的 HOMA-IR（胰岛素抵抗指数）、血糖与甘油三酯指数等。连续血糖监测（CGM）比标准空腹血糖检测更有效，若餐后血糖飙升至 170、180、200 并持续一到两个小时，就表明存在代谢功能障碍和胰岛素抵抗。

如果只能选一项检测，推荐空腹胰岛素检测。结合常规检测的空腹血糖，可计算 HOMA-IR，这是反映胰岛素抵抗的较敏感指标。此外，大多数人会进行甘油三酯和血糖检测，只要是空腹检测，通过它们的比值或指数也能辅助判断，无需额外抽血。空腹胰岛素检测是很好的起点，当然还有其他检测项目可供选择。

胰岛素长期偏高会阻碍身体获取和燃烧脂肪储备，导致脂肪堆积，因为胰岛素标志着 “进食状态”，身体会储存能量，而现代社会中能量持续充足，难以消耗储备脂肪。其次，会引发慢性炎症，高胰岛素血症与炎症密切相关，慢性炎症会影响血管壁、器官功能等多个方面，甚至可能加重胰岛素抵抗。另外，即使血糖未大幅升高，长期处于较高水平也会产生糖基化终产物，葡萄糖附着在蛋白质或细胞上，导致其功能异常。因此，胰岛素抵抗和代谢功能障碍与精神疾病、认知衰退、癌症、心脏病等多种疾病相关。

胰岛素升高、代谢健康恶化会影响血压，身体会保留更多液体和钠，脂肪组织过多也常伴随血压升高，较高的血压会增加动脉的压力，对血管造成更大损伤。糖基化终产物会损伤血管内皮，即血管的内层，使其功能异常，再加上血压升高带来的压力，会加剧血管壁损伤。慢性炎症则为动脉粥样硬化的形成提供了条件。虽然并非所有机制都已明确，但这些是主要的影响途径。

多项已发表的研究和荟萃分析显示，平均而言，LDL 不会升高。在针对 2 型糖尿病治疗或利用酮症减重的研究中，多数显示 LDL 无变化，还会出现 HDL 升高、甘油三酯降低、血糖和胰岛素下降、炎症标志物减少等情况，脂质指标显著改善。只有在较瘦、健康的人群中，LDL 才更可能升高。LDL 对心脏病斑块的预测能力较差，直接检测是否有斑块（如钙化评分、CT 血管造影、颈动脉超声等）比依赖 LDL 更有效。对于低碳或酮食且 LDL 偏高的患者，首先要确定是否有心脏病，通过钙化评分等检查来判断。

LDL 本身的参考价值有限，需结合甘油三酯、HDL 和代谢健康状况综合判断。了解 LDL 主要是小而密的还是大的很有帮助，但并非绝对。氧化 LDL 是导致损伤的关键，尤其是引发炎症、易破裂导致心脏病发作的斑块。氧化 LDL 与胰岛素抵抗和代谢功能障碍相关的高氧化、高炎症环境有关。通过甘油三酯与 HDL 的比值、高敏 C 反应蛋白等常规检测，可在一定程度上推断 LDL 类型和氧化情况，但并非绝对准确。现在人们可以通过一些网站（如ownyourlabs.com）自行进行更深入的检测，只是需要自费。

最基础且易获取的检测是钙化评分，这是一种 CT 扫描，约 10 秒即可完成，辐射量较低（约 1 毫西弗），能判断动脉中是否有钙，评分为 0 时，未来 10 年心脏病发作风险极低，但并非为零。不过，钙化评分无法反映软斑块情况，也不能说明斑块形成的时间和原因，是一种较粗略的检测。更精准的是冠状动脉 CT 血管造影，费用较高（约 1500 美元），辐射量约 3-4 毫西弗，需注射含碘造影剂，整个过程约一个半小时，且需调节心率。但它能清晰显示动脉内部、软斑块、钙化斑块的位置等。目前有公司（如 Clearly）能对扫描结果进行额外分析，量化钙化、非钙化和低密度斑块（风险最高的斑块），从而客观评估治疗效果。

代谢健康人群也需考虑过往生活方式和年龄。钙化评分是起点，40 岁时钙化评分为 0 与 60 岁时为 0 的预后不同，60 岁时为 0 更具积极意义。检测频率取决于个人风险因素、年龄和生活方式。40 岁时评分 0，可 5 年后复查；60 岁时评分 0，可 10 年后复查。若评分不为 0，则需更密切监测，可能每年一次，直到斑块稳定或进展缓慢后，可每 2-3 年一次。有人将钙化评分称为 “心脏的 mammogram（乳房 X 线检查）”，认为普通人应每年或每两年做一次，但这一观点尚未普及。

发现斑块后，首先应全面检测代谢健康并显著改善，药物治疗可能是其中一部分，但并非唯一手段。过往研究显示，在钙评分超过 100 的人群中，服用他汀类药物的人心脏病发作风险略有降低，而钙评分为 0 的人群则无差异。代谢健康是否能改变这一情况虽缺乏确凿数据，但有迹象表明可能存在影响，例如甘油三酯与 HDL 比值较好时，药物治疗的获益或风险可能不同。对于斑块逆转，钙评分的降低并非主要目标，因为软斑块转化为钙化斑块是好事，钙化斑块更稳定，不易破裂引发心脏病，但钙评分会升高，这容易被误解为坏事。通过 CT 血管造影结合客观斑块分析（如 Clearly 扫描）才能真正衡量斑块是否逆转，可惜这种检测并非人人可及，但能为治疗提供精准信息。

代谢健康是斑块形成的最常见风险因素，但并非唯一因素。吸烟、家族史、高血压等也会导致斑块。例如，20-30 岁每天吸 1-2 包烟的人，40 岁时可能出现斑块；父亲在 40 岁患心肌梗死的人，即使代谢健康，50 岁也可能出现斑块。因此，斑块形成可能是多种因素共同作用的结果，需综合考虑个人过往的风险因素。

饮食调整需根据个人当前的饮食习惯，向全食物、低碳水方向转变是关键。不能一概而论推荐某一种饮食，而应选择有助于改善代谢健康且能坚持的饮食。对大多数人来说，全食物、低碳水饮食是合适的。关于蛋白质，传统观点认为 0.8 克 / 公斤体重足够预防蛋白质缺乏，但从代谢健康和身体成分来看，并不理想，普通人约需 1.5 克 / 公斤体重。例如，早餐吃 4 个鸡蛋配菠菜和奶酪，比吃 1 个鸡蛋配燕麦更好，能提供更多蛋白质，让人更饱腹，减少饥饿感，胰岛素波动小。午餐吃科布沙拉，晚餐吃三文鱼、鸡肉、牛排等搭配大量地上蔬菜和牛油果，这种饮食模式可能让人进入酮症，也可能不会，但都有助于改善代谢健康，且能自然减少热量摄入。

除了少数无法良好代谢或利用脂肪的罕见疾病，是否选择酮食更多与个人感受、生活便利性等有关，而非生理或医学原因。在社会中，很多人对酮食存在误解，认为脂肪有害，医生也可能不推荐，因此对一些人来说，从低碳水开始逐步过渡到酮食更易接受。

酮体不仅是脂肪燃烧的副产品，还是一种活性分子，具有实际益处。研究表明，酮体能直接减少炎症（如影响 nlrp3 炎症小体），可能有饱腹作用，能为身体供能，还能影响基因和组蛋白去乙酰化酶。对于大脑，酮体尤为重要，肌肉能高效利用脂肪酸供能，而大脑对脂肪酸的利用效率低，但能高效利用酮体，尤其在大脑存在胰岛素抵抗或葡萄糖利用不佳时，酮体可作为能量来源，这在治疗难治性癫痫、双相情感障碍、精神分裂症、抑郁症等脑部疾病方面有显著效果，对认知功能障碍（如阿尔茨海默病、帕金森病）也可能有益。代谢健康的改善本身有助于这些疾病，但结合酮体对大脑的作用，效果更显著。

关于补充 MCT 油、外源性酮体是否与酮食效果相当，还需更多研究，但个人可以尝试，除了成本和可能的胃肠道不适（如恶心、腹泻），几乎无危害。对于脑部益处，补充这些补剂可能更有效，但在减重或单纯改善代谢健康方面，可能不如生活方式和饮食（包括睡眠、运动等）的作用大。从进化角度看，高葡萄糖利用与高酮体同时存在的情况在历史上罕见，其影响尚不明确。

禁食的定义因人而异，12 小时不进食或 5 天不进食都可称为禁食。限时进食（如 8 小时或 6 小时进食窗口）可能有益，但研究结果存在差异，若进食高碳水、高热量、精制碳水的加工食品，效果可能有限；若结合健康饮食，作为可持续减少热量摄入、让胰岛素保持低水平的工具，则有好处。但并非所有人都适合，有些人会出现反弹饥饿感，此时不必强求。随着低碳或酮食的进行，很多人会自然倾向于限时进食，只要保证足够的蛋白质和营养，这是健康的表现。3-5 天的长时间禁食有一定作用，可能与长寿研究、干细胞再生、器官缩小等相关，但不宜频繁进行，否则会损失肌肉，需在禁食前后保证足够蛋白质。有人将其用于治疗 2 型糖尿病和减重，有一套有效的方案，但并非对所有人都必要。

饮食上，向低碳水、全食物、高蛋白质饮食转变，停止零食。通过高蛋白质、全食物、低碳水的 meals 让人更饱腹，减少饥饿感，避免胰岛素持续处于高位。运动方面，初期不必进行高强度训练，从增加日常活动量开始，如利用智能手机记录步数，逐步增加，之后再考虑结构化的运动计划（包括力量训练、有氧运动、间歇训练等），避免因强度过高让人却步。睡眠方面，保证每晚在床上 8 小时，睡眠不足与胰岛素抵抗、慢性炎症相关，还会影响决策能力，即使自我感觉良好，身体内部也可能已出现问题。

不同人所需的酮体水平存在差异，总体而言，大多数人在 1.5-3 毫摩尔范围时能看到最明显的脑部效果，但并非绝对。例如，劳伦・肯尼迪・韦斯特的酮体水平在 4、5、6 毫摩尔时状态良好，降至 2 毫摩尔时精神症状会复发；而有些人在 0.5-1 毫摩尔时就感觉良好，精神症状完全缓解。因此，需要个人尝试、检测，根据自身感受调整。相关社区项目（如 Think Smart）有望通过分享经验，帮助人们更好地了解适合自己的酮体水平。

部分人在长期保持酮症后可以引入更多碳水。例如，汉娜・沃伦初期需要 3 毫摩尔左右的酮体水平来控制症状，后来在 1 毫摩尔或更低水平也能保持良好状态。还有人工作日保持酮症，周末适当放松，只要不超过两天，就不会出现症状反复，但初期并非如此。这存在个体差异，目前研究正在增多，未来几年会有更多数据。社区资源（如 Think Smart）也能帮助人们相互学习。

没有证据表明长期酮症有害，那些声称长期酮症危险的说法是错误的。一些研究将低碳水定义为碳水占热量的 40%，这与通常仅占 5%（约 20-30 克 / 天）的酮食截然不同，不能将两者等同来证明长期酮症有害。关于酮食会升高 LDL、导致心脏病的说法也无依据。判断长期酮症是否适合自己，可通过监测代谢健康、心血管健康等指标，而非依赖没有科学依据的担忧。

酮食并非一定是高饱和脂肪饮食，也可以是素食、地中海式等低饱和脂肪的酮食，只是大多数实践酮食的人摄入的饱和脂肪高于推荐量。关于红肉或饱和脂肪对心血管健康有害的证据质量较低，多为观察性研究，仅在 10-20 年期间进行 1-3 次食物频率问卷调查，且对饱和脂肪的定义模糊，常将其与高糖、高加工食品相关联，还存在 “健康用户偏差”（摄入更多饱和脂肪的人往往运动更少、受教育程度更低、吸烟更多等）。因此，这些研究结果意义有限。对于代谢健康的人，应关注可测量的健康指标（如钙评分、血压等），而非饱和脂肪可能带来的潜在风险，因为相关数据并不适用于个体情况。

对荤食饮食的态度是不断发展的。过去认为不应采用荤食饮食，需保证一半餐盘是蔬菜，但后来意识到这种观点缺乏充分依据。有些人对蔬菜反应不佳，植物中的植酸和抗营养成分对他们有影响，而荤食饮食能改善他们的健康状况（如缓解腹胀、肠道炎症、精神健康问题等）。虽然大规模人群研究显示吃大量水果和蔬菜的健康人群状态良好，但这并不意味着每个人都必须吃蔬菜，也不能说明不含蔬菜的饮食就不健康。可以通过监测血糖、胰岛素、甘油三酯、钙评分、精神状态、身体成分等客观指标来判断荤食饮食是否适合自己。

关于肠道菌群的建议往往超前于科学研究，即使是肠道菌群专家也承认该领域仍处于研究初期。无法解释为何有些人采用荤食饮食后，在糖尿病缓解、双相情感障碍改善等方面表现良好，且各项客观健康指标正常，这表明肠道菌群可能只是健康的一个小因素，其与健康的因果关系尚不明确

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D:2025.07.09

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