Rhonda: Something that I...like, in my mind that I'm not exactly certain about is that nutritional ketosis. So eating a high-fat diet and, of course, there's, okay, what types of fat are you eating? Are you eating more polyunsaturated, you're eating more saturated? You know, how much protein are you eating? What types of carbohydrates? Are you getting fiber? I mean, there's so many diets, very complicated. But there is no doubt that there are interesting therapeutic effects from nutritional ketosis. I am interested in the the actual end product, which is ketone bodies and these signaling molecules like beta-hydroxybutyrate being able to get those maybe even without having to eat a high-fat diet, you can get them from fasting, from intense exercise, right? Also, you can achieve...

Dom: Post-exercise ketosis.

Rhonda: Post exercise.

Dom: Absolutely.

Rhonda: So, I guess, the, kind of, the question I had for you with nutritional ketosis besides having to define it was, what do people eat to obtain that? How do you get blood ketone levels between one and three millimolar? Like, what do you have to eat? What do you not have to eat?

Dom: Okay, that is a good question and it varies depending on who you talk to and what's optimal. I think a good way to approach it would to be describe what has been used classically and how the diet has evolved over the last two to three decades, I think, with some of the work with Eric Kossoff at Johns Hopkins has, kind of, advanced the idea of using a modified Atkins diet or modified ketogenic diet. And I can, kind of, talk a little bit about strategies that I use, I think, and others that I know use to achieve that state and sustain it for optimal performance in health, I think.

So in taking a step back, the classical ketogenic diet would be like a 4:1 or 3:1 diet, and that's, kind of, the ratios of the macronutrients. Four being fat and one being a combination of carbohydrates and protein together. So a pretty protein-restricted diet. And the ketogenic diet is not a high-protein diet. It's actually moderate to low protein diet. And most people don't understand that, they think, especially in the fitness community, if they go on a ketogenic diet...if they say they've been on a ketogenic diet, what they will describe to me would be a very low-carbohydrate, high-protein, moderate-fat diet, but the ketogenic diet as it is used classically for drug-resistant epilepsy, the original was, like, 90% fat, like 85% to 90% fat and maybe about 10% protein, typically, and 8% to 10% protein, and a very minimal amount of carbohydrates, and it was heavily based upon the used of dairy fat.

So dairy was the primary, kind of, vehicle, yeah, to get calories into you. And we know that the use of dairy especially in some people, dairy protein in particular, but even sometimes dairy fat, too, can have negative consequences for some people. So there's a wide variety of, kind of, ketogenic diets out there and they, the ketogenic diet has been defined by this ratio of macronutrients. But what we're learning now is that it's more than just macronutrients to optimize the diet, especially for individuals. The sources of the macronutrients, the fatty acid profile, the type of protein, it allows for some amount of carbohydrates, and the types and quality of the carbohydrates as it relates to gut health and gut microbiome, I think, is really important. I think it's really important to optimize the diversity of carbohydrate sources in the form of raw vegetables, and I think that it can optimize the diversity of the gut microbiome, too. I think those two are linked, the diversity of the foods in your diet and the diversity of your gut microbiome. I've seen that just through feedback. It's not really studied, but it's something everyone knows and it should be studied.

So the classical ketogenic diet is very strict to follow. There's a few studies showing that it can influence a lipid profile in a negative way, meaning a high elevation of LDL. And in kids, I think, that follow the diet, they had a high level of triglyceride. There was one study that's often referenced in regard to the ketogenic diet being atherogenic the triglycerides are really high in some of the kids.

Rhonda: It's probably a very complex gene-nutrient interaction, as well.

Dom: Absolutely, yeah.

Rhonda: There's some, I'm not sure if you're familiar with any of this work. It's something I'm getting into recently is this nutrigenomic field and particularly, there is PPAR-gamma and PPAR-alpha, which is important for ketosis and polymorphisms that are associated with not being able to respond well, so it's very likely that some of these people that don't respond well or may have that polymorphism.

Dom: Yeah, undoubtedly, because there are some people that really have a negative effect, but I would it's, kind of, few and far between...maybe as high as 20% in some circles, but generally speaking, if you have a dietitian that's pretty savvy and has worked with enough people, I really emphasize experience because there's no substitute for experience. So you could know as much...yeah, you could know the biochemistry behind nutritional ketosis, all the pathways, whatever, but working with a dietitian, I always stress that in people that want to try the ketogenic diet to start off with a good dietitian. They can tailor and tweak the diet for your specific needs and I find that, for me, personally, a diet that's low in dairy is really essential because I just don't do good with dairy, and nuts have been a staple for some people for the ketogenic diet and I have, like, a mild nut allergy. So that's another food that I've, kind of, had to eliminate. But despite that, I have been following what I call a modified ketogenic diet and I think it's pretty similar to the modified Atkins diet that Eric Kossoff has been using at Johns Hopkins. He's at Johns Hopkins, mainly a neurologist, but has a team of dietitians working with him and has done an incredible job advancing, sort of, the use of the ketogenic diet. You know, he follows in the steps of John Freeman, who was really a pioneer in getting the neurology world to recognize a ketogenic diet as a viable metabolic therapy for drug-resistant epilepsy. And he did a lot of work with The Charlie Foundation and worked with them to help promote awareness of the diet, education of the diet.

So some work that Eric Kossoff has been doing over the years and publishing on is showing that the modified Atkins diet has much of the therapeutic potency of the strict classical 4:1 ketogenic diet. So instead of 90% fat, the modified Atkins diet is roughly 65% to maybe 70% fat which is, kind of, what I follow now, and about 20% to 30% protein, with the balance being still very low on carbohydrates, like no more than 5% or 10% carbohydrates. But it's more liberal in the use of protein. And it's also, advocates the use of medium-chain fatty acids, can be incorporated into that. So by following a diet that's more liberal with the protein and less not restrictive, and less in of a need of a such a high-fat content, I've been able to maintain a moderate state of ketosis as do many of the therapies or many of the patients that are benefiting from this therapy for a wide range of disorders.

So I think that makes the diet more accessible to people, and I think the biggest hurdle now is just compliance. So people know the benefits of the diet, some of them are a little concerned with the side effects of the diet as far as lipid profiles being altered.