A Functional Approach to the Keto Diet with Mark Hyman, MD

Podcast Transcript

Nada Youssef: Hi, thank you for joining us, I'm your host, Nada Youssef, and today I am back with the one and only Dr. Mark Hyman.

Dr. Mark Hyman: Hello.

Nada Youssef: Welcome, and Dr. Mark Hyman is the director of Cleveland Clinic's Center for Functional Medicine. He's also the 11th time, number one New York Times bestselling author, and an internationally recognized leader, speaker, educator and advocate in his field.

And today we will cover a whole hour talking about the ketogenic diet. For those who don't know, it is a strict nutrition plan that is high in fat, moderate and low protein, and very low in carbs.

So before we begin, please remember, this is for informational purposes only, and is not intended to replace your own physician's advice. So thank you so much for coming back.

Dr. Mark Hyman: I'm so glad to be here. Hey everybody.

Nada Youssef: So let's talk about the ketogenic diet, what is it and how did it start?

Dr. Mark Hyman: Well, the ketogenic diet has been around for a long time, and it's typically been used in neurology to treat epilepsy or seizures that don't respond to anything else. So when nothing else works they put children, or adults, on a very high fat diet so the body burns fat instead of carbohydrates. And that's extremely effective for treatment resistant epilepsy.

It's a hard diet to do, and recently it's been increasingly used in other medical conditions. And it's also kind of caught the popular imagination, and people are using it who don't have medical conditions. So there's a whole range of people now using it, and we can talk about the pros and cons of all that.

Nada Youssef: Great, alright. Well, I want to talk about the food pyramids, what we had and how we kind of flipped everything around. So, what are we looking at right here?

Dr. Mark Hyman: Well, you're not looking at us, but we're hiding behind the thing.

Nada Youssef: We're hiding behind here.

Dr. Mark Hyman: The interesting thing was in the 60s, in the 50s, there was a doctor named Ancel Keys who was a scientist who concluded that fat was evil, that it caused obesity, that it had more calories than carbs, and that it actually also led to heart disease.

And so, the research on that was only cause and effect ... I'm sorry, the research on that was only showing correlation, not cause and effect. And so the assumption was made based on relatively weak data that fat was the enemy. And in fact scientists related to him were also in the field at the time, Dr. Hegsted and Dr. Stare at Harvard, were funded by the sugar industry to write a report in The New England Journal of Medicine that said sugar's fine, fat's bad.

And then the guy who was the author of that paper was paid by the sugar industry, he ended up being the guy who ran our first dietary guidelines, which told us to eat less fat and eat more carbs. That turned into the food pyramid, which was looking like this. Fat and oils on [inaudible 00:02:46] except fats and oils were only at the top here, wasn't even that much, it was like a tiny little bit.

So the idea was to eat six to 11 servings of bread, rice, cereal and pasta every day. Now, at this point in our culture we understand that seven or 11 servings of bread or pasta is not a health food, and yet that was what our government told us in the 1992 food pyramid, which correlated exactly with the increase in obesity and type 2 diabetes in America and around the world. 'Cause the whole world took on this dietary guidelines advice.

And that has really led to our current crisis of obesity, and carbs were thought to be helpful and fat was thought to be harmful. And then we now have actually increased the sophistication of our nutritional research. We've had more data, many more studies, and it's really clear that fat is not the enemy. In fact, according the 2015 US Dietary Guidelines, they removed any limit on fat, they used to eat less than 30% of your diet as fat or 35% of your calories as fat and if you were, for example, having heart disease they recommended even greater restrictions. Some people said less than 10% of your diet is fat.

And the US government, based on the advice of experts and the Dietary Guidelines Committee, concluded that the evidence for that was not there, and that the evidence that fat was harmful wasn't there and that we needed to actually change our guidelines. So the new guidelines have no upper limit on total fat in your diet, none.

And they also say to reduce refined sugars and reduce refined carbohydrates. They also eliminated any restrictions on dietary cholesterol 'cause they found it wasn't linked to heart disease. So all of our past advice is still haunting us and there is still many low fat products on the market. There's still low fat yogurt, which basically has more sugar per ounce than a can of soda. And we have this meme where people are stuffing egg white omelets and skim milk, and unfortunately it's not matching the science.

So, this food pyramid has really led to a crisis in our society and a crisis in our economy because of the burden of chronic disease. One in three Medicare dollars are spent on type 2 diabetes. We are seeing one in two Americans, with prediabetes or type 2 diabetes. And 90% of people with prediabetes are not even diagnosed. Maybe up to a quarter of people with type 2 diabetes are also not diagnosed.

So this is a huge problem, and the dietary guidelines have shifted, but I think our beliefs have not. And I think people are still enamored with diets that are low in fat. Now it's changing and there's a whole movement around paleo and ketogenic diets which I think is concerning in some ways because it sort of misses the bigger picture, and we're going to talk about that.

Nada Youssef: And even when you look at the ... our SAD diet, that's what the plate looks like right now.

Dr. Mark Hyman: Yes, this is our new improved guidelines, which I think is an improvement for sure, but it's interesting how it talks about protein, but not carbs or fat, and then it talks about fruit and grains.

Nada Youssef: And dairy, right.

Dr. Mark Hyman: And dairy. And it doesn't say what kind of vegetables, so you could be eating potatoes, you could be eating white flour, you could be eating various kinds of protein, and-

Nada Youssef: Cereal.

Dr. Mark Hyman: -cereal. And it's not really necessarily healthy. In fact dairy, the US Dietary Guidelines tell us to drink three glasses of milk a day as an adult and two glasses as a kid to be healthy. There's no evidence for that. In fact, the government, the Congress, based on the work of a number of people was asking the National Academy of Sciences, gave them a million dollars to review our dietary guidelines process.

And they found that a lot of the recommendations were not based on good evidence. That they ignored large amounts of evidence about, for example, low carbohydrate diets about saturated fat, and that they had undue influence from the industry. For example, the dairy industry is linked in to the dietary guidelines process through various people on the committee who are involved with the dairy industry's consultants around boards or other things.

So, we have a corrupt system, where we're seeing dietary guidelines that actually don't match the science. In fact, those Got Milk? ads, they were funded in part by taxpayer dollars along with the dairy council, and eventually they were taken off the air and out of magazines because the Federal Trade Commission that governs truth in marketing, basically said there is no evidence, Got Proof? instead of Got Milk?

And there was no evidence that it protects against bone loss, that it helps kids grow and be healthy, that it's necessary for all the things that they said it was good for. In fact, it may not be. It may increase the risk of fractures, increase risk of cancer, increase risk of gut issues, autoimmune diseases, and many other things.

So, we are now sort of moving towards a more scientifically whole and scientifically rigorous review of our diet and our guidelines, which hopefully will happen in the 2020 guidelines.

Nada Youssef: And correct me if I'm wrong, you've mentioned if you wean your baby off of breast milk there's no need to go to any kind of milk. Right?

Dr. Mark Hyman: No .... I mean ... there's ... I mean we're the only species that feeds our kids milk after weaning, that's a mammal. In fact, there's no biological requirement for dairy or milk. Some populations do well with it, but the truth is the milk we eat now is not traditional milk. It's not right from the cow, it's not unpasteurized, it's not unhomogenized, it's not raw milk which is traditionally what we've eaten for thousands and thousands of years.

Yeah there were risks for that, and you got all kinds of diseases, which is why Louis Pasteur developed pasteurization. That's been a good thing in some ways, but it's clear that our current milk is not the milk it used to be.

There was a study, for example, done in the UK, where they looked at milk that was homogenized versus milk that was not homogenized. And you think, what's the difference? It's just not separated. But in fact, the homogenized milk had really bad effects on cholesterol, whereas the unhomogenized milk did not.

Which is fascinating 'cause it's the same amount of milk, it's milk, it's the same thing. But the way it's processed and refined in a way that's sort of changed the structure of the milk, has a profound effect on your metabolism and your biology.

So, I think we kinda have to think about these dietary guidelines, this sorta my plate as an improvement but not necessarily what we need to get to.

Nada Youssef: I want to talk about cheese, 'cause I know cheese is a big thing with ketogenic diet. Is cheese okay to eat with the ketogenic diet?

Dr. Mark Hyman: Well cheese is not necessary ... is not necessarily essential for a ketogenic diet. You can do a vegan ketogenic diet, you can do a dairy free ketogenic diet. A lot of the fat may come from dairy in some ketogenic diets, but it's not essential, and I don't think it's a good idea in most cases to use a lot of dairy, especially our modern dairy which is full of hormones, pesticides, antibiotics, and it's not necessarily a health food.

So I think you can use healthy dairy, and if you can use grass-fed dairy, great. If you can use dairy without hormones and antibiotics, great. If you can use goat and sheep, probably even better. And there's certain goat and sheep cheese that are better. I think those are fine, you can use raw milk cheese from sheep or goat. Those are allowed.

Nada Youssef: Okay. Now, I want to jump in and talk a little bit about ketosis, what it is and how to get there.

Dr. Mark Hyman: Okay, so what is this whole thing about ketosis. Why is it relevant? Well, biology is very smart. So we as humans have adapted to starvation. We have hundreds of genes that help us adapt to starvation. And historically what would happen is we would have periods of abundance and periods of scarcity. So we're really good at that.

So if we found a patch of berries or a bunch of wild fruit we would just munch down on that stuff, we'd store it all up for the winter, and then we would put it in our bellies and have belly fat, and that was a good thing. And then we would go through periods where there were kind of lean times, and there wasn't enough food. And so our bodies can shift from carbohydrate metabolism to fat metabolism. So you have two fuel sources, you have a backup fuel source. So it's like having a Prius, you have your gas engine and you have your electric engine. Right? So we can adapt.

Now, when we went into ketosis, a whole series of things happened that were pretty interesting. They were all about increasing health. So they sort of effected your body in a beneficial way. When you see the body switch from burning glucose to burning ketones which is what fat produced in the body, a number of interesting things happen.

One, your metabolism speeds up. Two, your hunger goes away. Three, you turn on the ability of a fat cell to release fat, and burn fats, which increases fat burning, whereas carbohydrates actually shut off carbs, carbs shut off fat burning. It literally locks the fat in your fat cells.

And when I mean carbs, I don't mean like broccoli which is a carb. In fact, the truth is that even if you're on a ketogenic diet, a lot of your diet can be carbs, which is vegetables, all vegetables are carbs. Right? So, it depends on the quality and the type of carbohydrate that matters.

So when you look at your diet, you have a ketogenic diet it actually increases muscle mass, it increases fat burning, it cuts your hunger, it may stimulate all kinds of beneficial effects of the body to reduce inflammation. So, there's really profound benefits to it. In fact, it's the opposite of what you'd think. If you're eating a diet that's 60, or 70, or 80% fat, it actually should worsen your heart disease risk profile.

But it turns out it doesn't, in a revealed study looking at over 200 I think 60 patients, they found that out of 26 cardiovascular risk factors, 22 out of 26 improved the type of cholesterol you have, your triglycerides, your HDL, your blood sugar, your blood pressure, your insulin, your inflammation levels, all those things improved, whereas the control group, none of them improved. So it's actually contradictory in your mind, because most people think of fat as causing worsening heart disease, worsening cardiac risk factors, and so it's really important to think about that.

Nada Youssef: Yeah. Okay, now with ketosis, how long does it take to get to ketosis if you start a ketogenic diet?

Dr. Mark Hyman: Well when you switch, and what it is essentially is a 60 to 70 to 80% fat diet, probably 5% of carbs or less, and 20 or so percent protein, it's not a high protein diet. People think of Atkins and paleo. If you eat a lot of protein, protein can convert to sugar in the body, which is not necessarily what you want. So it's mostly fat.

In fact, a ketogenic diet was the diet developed by Joslin, Dr. Joslin, for which the Joslin Diabetes Center of Harvard is named. And his approach to treating diabetes was 70% fat, basically 25% protein, and 5% carbs. That was the treatment of the day before there was insulin, 'cause they couldn't ... these people had a disease of carbohydrate intolerance for diabetes. So it's very powerful.

And I think the ketogenic diet helps you to switch into a different type of metabolism which helps protect against diabetes and other things.

Nada Youssef: Now, when you do the ketogenic diet, there's a lot of-

Dr. Mark Hyman: And your question is; how long does it take to adapt to it?

Nada Youssef: Yeah, so yeah.

Dr. Mark Hyman: It could take up to about three or four weeks to really switch over, you've really got to switch your engine over. And if you do it right, and if you don't do it right, you'll end up with what they call the keto flu, which is you feel weak and tired and dizzy. It's because when you stop eating a lot of starch and sugar, your insulin levels drop, which is a good thing, and insulin makes you retain water and retain salt. And so you lose a lot of water, a lot of salt. You could get low blood pressure, you can get dizzy, you can get achy, you lose magnesium. So making sure you have plenty of salt, plenty of water, lots of magnesium can help prevent that.

Nada Youssef: Good, good. Now when we do the ketogenic diet, there's a lot of talk about macros. Can you tell me what they are and why they're needed?

Dr. Mark Hyman: Sure, but I think it might be good to go back a little bit and talk about who this isn't good for.

Nada Youssef: Oh yeah, definitely.

Dr. Mark Hyman: Because I think right now it's a popular craze in the culture if you look on Amazon, the top books are all ketogenic diets in terms of diet books, and everybody's doing it. This is a therapeutic diet, it's not for everybody. It's for very specific indications, and it can be extremely beneficial for those indications, but it's not for everybody.

So what are those reasons that you would think about doing a ketogenic diet? One is if you are a type 2 diabetic there's great evidence that you can reverse up to 60% of type 2 diabetes in a year. The average weight loss in the study where they looked at this was 12% or 30 pounds. They had a 100% of people get off the main diabetes medication which was called the oral hypoglycemics, and 96% got off insulin or dramatically reduced their insulin.

So this is a powerful intervention for type 2 diabetes. Now there are other therapies that can work. There are other diets that can work, for example calorie restricted diet, protein sparing modified fast and other things can be helpful. But those are not easy to sustain. You're on a calorie restricted diet, it's not fun, you're on a protein modified fast which is just shakes, you're not gonna live on that your whole life. So there's real indications for a ketogenic diet and metabolic disease.

If you're morbidly obese, if you have insulin resistance without type 2 diabetes, it can be very helpful as a short term strategy to help you reset your metabolism. Doesn't have to be forever. Clearly for epilepsy, it's standard care for treatment-resistant epilepsy.

There are other neurological conditions where they're seeing improvements and benefits. For example, there's research on brain cancer, glioblastoma, and ketogenic diets. There's research on autism, showing it's a very effective treatment for autism. Alzheimer's, I've personally seen many Alzheimer's patients dramatically improve on ketogenic diets.

And so it's not for everyone, but it can be extremely powerful for those who want to use it. And by the way many people may not do well on a ketogenic diet. So it's very individualized. There's no one size fits all diet. It's not like our traditional state for history has been ketogenic. Yes, we would flip in and out of ketosis as hunter-gatherers, but the key is in and out. We're not constantly on this for our life.

Now, there are some people who can sustain it for decades, and I know those people and they do well. There's other people who don't do well on it. So you have to look at your own biology, your own numbers, the way you feel, your metabolism, and really personalize the approach.

Nada Youssef: Sure. Okay, and then back to macros, so I know a lot people start counting macros. So I kind of want to talk about what macros are, and should we be counting them?

Dr. Mark Hyman: Macros are basically protein, fat and carbs, and there's also fiber in food, and calories. Now, the quality is what matters. People want to count carbs, but you could have a great ratio of protein, fat and carbs but it could all be from french fries and refined vegetables that's deep fried in, and gross feedlot hamburgers and potatoes. Right?

So you could have plenty of the right ratios of protein, fat and carb but it could be from very poor quality of food. The key is quality, and if you focus on quality you will get results. If you get rid of the junk, and eat whole foods, if you eat unrefined foods, meaning foods in as natural state as possible. A carb can be a buckwheat grain or it could be white flour, those are both carbs, they're both grains, but they have very different effects on your body.

You can eat a white starchy potato as a vegetable, or you can eat broccoli and have profoundly different effects on your biology. You can eat wild salmon and wild fish and sardines, or you could eat a feed lot beef, which is not great for you and the environment or the animal. So you really want to focus on quality and the right approach.

Now, the number of proteins, fats and carbs you eat really depends on your own health and your own biology. For example, for myself, if I eat no carbs, I will lose too much weight and it won't be good for me. I need a little bit, that's my metabolism. Other people, who for example, are type 2 diabetic, morbidly obese, they do phenomenal on these diets. And we see dramatic results in three weeks or even in three days reversing type 2 diabetes, getting them off their insulin, off their medications. It's very impressive.

So, we have to be smart about how we do it. We have to do it, advisedly, with a doctor or a health professional who understands this, who knows how to follow you and can treat you. But it's a very effective therapeutic diet for many people.

Nada Youssef: Now, can you talk a little bit about blood ketones, is that how you measure ketones in the body?

Dr. Mark Hyman: Yeah, so there's two kinds of ketosis. Most people think of ketosis ... and when I was in medical school you learn about keto acid doses, which is when you have very high levels of ketones. You're a type 1 diabetic, it's a life threatening condition, and it's very dangerous.

However, what we're talking about here is nutritional ketosis, which is a very low level of ketones and that helps to stimulate your metabolism, cut your appetite, release fat from the fat cells, improve your immune system, and it's done by measuring, like a blood sugar stick, a finger stick, what your ketone levels are. And it should be between .5 and 1.5, typically is what you want to get. And you can get those machines at a drug store, and it takes a minute to sometimes get into that for people. But it's a very powerful tool for people who are struggling with any kind of serious metabolic or neurologic conditions.

Nada Youssef: Do you do it right after you eat? Or do you have to be fasting?

Dr. Mark Hyman: You do it in the morning-

Nada Youssef: Oh, you do it in the morning?

Dr. Mark Hyman: You do it in the morning, but you can check it anytime because if you wa- ... and people kind of pop in and out or go up and down depending on what's going on. But in this study that I was talking to you about there was ... in a year, there were 83% of people were adhering to the diet because they measured their ketones, and they were able to corroborate the fact that they were in ketosis. It wasn't just, "Oh, I did the diet," but a lot of people say they do it, they actually don't. And so this is a way of validating that people are able to adhere to it, that it's effective and that they validated their results by measuring.

Nada Youssef: Okay, now I'm going to talk about some kind of confusion with ketos, and myths and things like that. Atkins diet, I hear a lot about the comparison about Atkins, or modified Atkins diet versus-

Dr. Mark Hyman: Atkins is not necessarily the same thing. Atkins is tons of steaks and protein and it has a similar effect in reducing insulin, but high protein levels are not necessarily great for us, and also they're not great for the environment, and also they're not great for animals, and also they transform the protein into glucose in the body, when you eat excess protein. So it's called gluconeogenesis which means making sugar from nothing, basically, and it's making sugar from protein as opposed to from eating carbs.

And so it's not an Atkins diet. Also, Atkins is high, you can have processed meats and bacon and lots of dairy. I'm not a huge fan of the Atkins diet from that perspective. There's a modified Atkins which is a sort of a new and improved Atkins, which is slightly better, but I think it's very different than an Atkins diet.

Nada Youssef: Now you talked a little bit about too much protein. I want to talk about too much excessive fat. So if I'm in absence of glucose, I'm on ketosis, and I'm eating fat. How much of that is too much? Is my body storing, is it first of all, is it burning the stored fat or the dietary, the fat that I'm eating? How do I know how much fat I'm eating?

Dr. Mark Hyman: Well, you have this great graph of the insulin. You want to pull that up because I think even most people don't understand the biology. Now this is just basic biochemistry, and here's the deal. When you eat carbs, you increase insulin. When you eat protein, you can also increase insulin. When you eat fat, insulin doesn't go up. And you need insulin to store fat, you need insulin to store fat.

So for example, if you take a type 1 diabetic, these people's pancreas are completely done. They're not making any insulin. These people can eat 10,000 calories a day, they're starving 'cause the food is not getting in their cells, and they're actually losing weight, eating 10,000 calories a day. Because insulin is required to actually store fat, to store your body fat.

The word for fat in the diet, and the word for fat on your body are the same word, they probably shouldn't be, and they're different. So eating carbs makes you fat, eating fat makes you thin. Which is why I wrote this book called Eat Fat, Get Thin. It's about this biology.

And so when you cut down the carbs and you eat fat, you're not spiking insulin so you don't store fat, and you can't store fat in the absence of carbs and insulin. It's very ... you just burn it, and you burn your own fat, and you burn the fat, it turns into ketones, which is a very effective and efficient metabolic jolt. A very clean burning fuel. Think of it as diesel or a sort of super jet fuel. The ketones are like jet fuel whereas carbs are like dirty diesel.

And I think you basically have to use the biology to understand what's happening here, but getting off of the starch and sugar will help drop the insulin, your fat won't get stored, and honestly if I eat too much fat and not enough carbs I will lose too much weight.

In fact, this one study on animals was fascinating. They put the animals on a very high fat diet, very, very low carb, versus a high carb, low fat diet, and they measured everything. It was fascinating. They had to keep increasing the calories in the high fat group so that they wouldn't lose weight. And then when they opened them up, and they tried to keep them the same weight, when they opened them up ... and I know people don't like animal studies, but it's very instructive ... when they open them up, the ones who were eating the high carb diet, the rats, or the mice, their belly was just full of fat. And the ones who were eating the fat had no body fat, and they had increased muscle mass and a faster metabolism.

Nada Youssef: Really?

Dr. Mark Hyman: Really.

Nada Youssef:   We've been lied to, so I wanna ... yes.

Dr. Mark Hyman: We have been. Not on purpose, they really thought they were doing ... not make anybody sick, but I think we just ... we made assumptions based on weak science, and now we have better science.

Nada Youssef: Yeah, and now we can do better. Now, can I just take ketone supplements to induce ketosis?

Dr. Mark Hyman: So there's a whole market out there now for ketone supplements, or what we call exogenous ketones. So you could take a pill, or a powder and actually boost your ketone levels. I don't think all the data's in on that. I think it does suppress insulin which can help when you lose weight, and help in some ways. But we don't know if having natural ketosis or exogenous ketones really is the way to go. And that would be nice to be able to take a pill.

There is a hack, or trick, for example, using MCT oil, which is a medium-chain triglycerides, a special type of fat, comes from coconut, and it's used in a lot of elemental foods for people who can't digest anything because it goes right into the bloodstream as opposed to into the lymphatic circulation like most fat. And it has to get burned, it stimulates your mitochondria, it increases metabolism, it helps reverse insulin resistance, helps increase cognitive function and brain function, your brain loves ketones.

They say, "Oh you need, 25% of your diet in glucose, goes to your brain." Yes, but it actually works better on ketones, and I see this over and over, whether it's me, or Alzheimer's patients, or autistic patients, or epilepsy patients, their brain just gets much sharper and clearer.

Nada Youssef:   Can we talk a little bit about the side effects. I know we talked a little bit about the keto flu, but what about acetone breath? I've heard ...

Dr. Mark Hyman: Well yeah, you could get bad breath 'cause ... yeah, the acetone breath can happen. The constipation can happen if you're not eating enough fiber. So the problem is when you have too much fat and not enough fiber, which usually comes from plant foods ... and by the way, you can eat a lot of plant foods on a ketogenic diet, and you can be vegan keto too, by the way. And I have a friend who's a type 1 diabetic who's vegan keto, and her blood sugars are better than mine, and she's a type 1 diabetic. It's pretty impressive.

You actually have to regulate your symptoms by doing it in the right way. So for example, you need more fiber, which should be taken as a supplement; resistant starch, things in plantain flour, kasha flour, other flours, other things can be very effective in actually building the microbiome, which you need, which can be damaged sometimes, a very high fat diet.

So having enough fiber, enough plant foods; it's really building the science of how to create a healthy approach to a ketogenic diet, which I think we're still evolving.

Nada Youssef: Okay, I want to talk about some other things that people might be doing, they're on the keto diet, and they're not losing any weight. Like the body actually not being on ketosis, 'cause you said it takes a few weeks, and the carb level has to be really, really low to get on ketosis. Correct?

Dr. Mark Hyman: Yeah.

Nada Youssef: And then eating too much in general, not eating enough. I've heard people that actually fast, or intermittent fast while doing keto. Is that a thing?

Dr. Mark Hyman: There is a ... yeah, you could do intermittent fasting. For example, you can have nothing between ... you can, sorry, eat between an eight hour window, let's say from noon to eight, or eleven to seven. If you fast for sixteen and eat during eight hours. That's a way to also do very similar things to a ketogenic diet without actually having to do a ketogenic diet.

But you have to eat high quality food, you can't just eat whatever you want. So they say, "Oh you can eat whatever you want on intermittent fasting," not necessarily. We see the metabolic effects are not great when you do that. So it's important to eat a healthy whole foods diet if you're doing intermittent fasting. But it can actually achieve a lot of the same benefits, and you can combine them. You could also do cyclical ketogenic, which is where you go in and out of it, and there is some evidence that that might be better, just like we did historically.

But it really is personal. I think you have to really look at what happens when the individual does the program, and who's the right person to do it. It's not for everybody, it's a therapeutic diet, it's a medical diet, I don't recommend everybody go on it. I think it's important for those patients who need it. The truth is, though, many patients and people in America will benefit, 'cause like I said one in two is pre-diabetic or type 2 diabetic, and those are the ideal patients for this.

Nada Youssef: Can you talk a little bit about the cyclical keto diet?

Dr. Mark Hyman: Yeah, so the idea is that historically as hunter-gatherers we would binge and fast, and binge and fast. Right? 'Cause it was just about food scarcity and access. So, typically carbohydrates weren't available a lot of the year.

In fact, you look at the grizzly bears, and I remember visiting Admiralty Island in Alaska, which was fascinating. And it's the highest concentration of grizzlies anywhere in the world. It's kinda scary, these guys walk you around with shotguns, and you stay in this little spot and you watch the grizzlies. And they're ... in the beginning of the season, in early in the year, they're fishing. They're eating all this salmon from the rivers. And they just go in and binging on salmon. They don't gain any weight.

When you look at them towards the end of the summer, they've gained 500 pounds because they binge on berries, the alpine berries in the summer. So they're eating all that sugar, they're binging, they're gaining 500 pounds. They basically become diabetic and hyper tensive, and then they go to sleep, and they don't eat all winter, and then they burn all those stores, and they start again.

So the problem with us, we just keep eating all winter. So cyclical ketosis is the idea of going in and out of ketosis in a cyclical way to help mimic a more natural state, and actually achieve a lot of the same benefits.

Nada Youssef: So-

Dr. Mark Hyman: And there are other diets like the 5:2 diet, which is basically eating whatever you want for five days, and two days not eating, or restricting your calories dramatically, which stimulates all these metabolic benefits.

So, I think in terms of aging, in terms of metabolism, in terms of weight, in terms of cognitive function, this can be a very effective approach. And then you're trying what's the right sweet spot for you. Some people do very poorly on low carb diets. Some people do much, much better on very high fat diets. So it really depends on the individual.

Nada Youssef: Okay, I'm going to ask you one more question, then we're going to go to our live questions. How does a keto diet affect athletes and athletic performance? A lot of people if they want to bulk up they look at keto and they're like, "Oh, there's not enough carbs ... "

Dr. Mark Hyman: Yeah. Well, we all were trained that we should carb load before we go for a run or before we do exercise or before a competition. And the evidence for that was pretty weak, and the truth is you carb load, you can store 2500 calories of carbohydrate in your muscle in the form of glycogen.

But if you're doing a long endurance athlete, and you're doing a long race or something, you're going to burn through that and hit the wall. Alright, that's the wall. Now if your body's burning fat, you probably have 20 or 30 or 40,000 or more calories of fat stored in your body. So if you can burn the fat you are just going to keep, keep going like the Eveready Bunny.

And the other thing that people should know about is that there's a lot of research on this by Doctors Volek and Phinney, they wrote a book called The Art of Low Carbohydrate Performance, which debunks a lot of the myths about athletes and ketogenic diets.

And there was an interesting story of a guy I read recently who was an elite athlete, a mountain climber, guided many, many people up Mount Everest and he never could do it without oxygen. He would always poop out and had to use oxygen. And he decided to try a ketogenic diet, and it turns out that he actually was able to summit without oxygen using a ketogenic diet.

There was another guy who ... a very successful entrepreneur, decided he was ... he sold his business and was going to become an elite athlete, and he rowed his boat literally from California to Hawaii. And he would use all these carb loader things. These sweet things, and he ended up doing blood tests after his thing, and the doctor told him he was pre-diabetic and here's an elite athlete who's being told he's pre-diabetic and he's doing all this exercise, and it's not working. It turned out it was because of the high starch diet.

Another guy I knew, it was another elite athlete, a doctor, Peter Attia, and you can read his stuff, he's got a great blog online. And he tried to write his own story where he was another elite athlete. He would swim from LA to Catalina Islands, which is miles and miles and back. And he was overweight, he had extra body fat, and he was an elite athlete, and again he used all these sort of carb loading things for his performance.

Turned out he went to the doctor again and was pre-diabetic. And he changed his whole view and shifted to a diet that was super high in fat and was able to fix his diabetes, lose 30 pounds, and actually become an even better athlete. So, I think there is evidence for short term sprinting, you might need a little carbs, but for most people I think you don't need to be on a high carb diet to be an athlete.

Nada Youssef: Great, are you ready for some questions from our audience?

Dr. Mark Hyman: Sure.

Nada Youssef: So I have Pauline, "Is the ketogenic diet safe long term?"

Dr. Mark Hyman: I think there are long-term studies in epilepsy and looking at what happens to cardiovascular risk factors and other things. I think my view is probably not known yet. I think we still don't have enough people doing it over a long enough time to really say that it's effective and safe over 20 or 30 years. I do think as a therapeutic diet, in other words, if you're 300 pounds, if you're diabetic, it can be very effective to get your systems unstuck from the metabolic crises it's in and put it in healthier state.

And I think that's really where I would see using it. I think in Alzheimer's patients, I don't really worry about long-term. I worry about how they're doing in the moment, and if they're functional, if they're engaged, if their memory is better, if they're actually to be able to sort of improve their quality of life. I don't worry about long term. But I think it's really important to realize that this is a therapeutic diet.

In other words, if you are on blood pressure medications and your blood pressure's high but then you change your diet and you exercise, you lose weight, you fix everything and your blood pressure's normal, you don't need to keep taking the medication. You stay in this optimal state that's created by living in a healthy way.

Nada Youssef: Okay great, and just a reminder, I just wanted to thank anybody who just joined us right now. Remind you that this will also be recorded and will be posted afterwards on Facebook and YouTube. Nancy wants to know, "Is it possible to live a ketogenic diet and be a Presbyterian?"

Dr. Mark Hyman: Oh for sure, you can be a vegan-keto, you could a pesco-vegan-keto. I think the challenge with fish is that most of the fish we have today in the world is contaminated. Fish is nature's perfect food except that we've polluted it all. It's got microplastics, heavy metals like mercury, PCBs. So I would encourage people to eat small fish, I call it the SMASH fish, which is wild salmon, mackerel, anchovies, sardines and herring.

Now they may not be your favorite foods, I like those fish particularly, but they are extremely helpful and I think safe to use and I think you just want to track your mercury levels and see what's going on. But, it's tough, we live in a polluted world and it's pretty frightening when microplastics now in fish.

Nada Youssef: Yeah, now Carolyn's been on keto since April and she started having hives and she's itchy, could it be related?

Dr. Mark Hyman: It could be, I mean I think they're changes in your gut microbiome that happen if you're not eating enough fiber. If you are maybe not eating a lot of dairy that you're not used to, you might become allergic. So there's reasons why.

Nada Youssef: Okay, and then Trisha wants to know if it's safe to be on keto while breast-feeding.

Dr. Mark Hyman: Great question, no one's ever asked that before. But I think it can be, sure. I think it absolutely can be if you look at someone who's breastfeeding who's type 2 diabetic, or who's variance resistant or pre-diabetes, or diabetes and pregnancy, then it probably is a good idea. Because the more insulin resistant you are, the worse outcome for the baby, particularly while pregnant, and then after breastfeeding, less of an effect, but I think it's important to keep yourself healthy.

Nada Youssef: Sure, and on Bethany, "How do you know if you're in ketosis, and what are the best tips to not get kicked out of ketosis?"

Dr. Mark Hyman: So, again, using not the urine ketone strips, but the blood strips, which is like a finger stick, is the best way to know you're ketosis, and there are ranges that you can tell if you're in nutritional ketosis. To not get kicked out of it is really dependent on your carbohydrate load.

Nada Youssef: Good. I'm gonna just read a nice comment from Janice, she says, "Dr. Hyman and functional medicine saved my life, it has saved my heart, kidneys, and no more diabetes too. I am no longer on medication, I have a new lease on life, and I'm recommending this program to everyone I meet."

Dr. Mark Hyman: Amazing. Well, we actually had a woman come in to our Functioning for Life program, and we have a functional keto program, which is great. It's a way for people to do this under medical supervision, the programs are filling up like crazy, and people are having great experiences.

But we had a woman come the other day who was morbidly obese, she had heart failure, with what we call an ejection fraction of 35%, it should be 50 or more, and under 50 is not great. She had type 2 diabetes for decade, more, on insulin, she was hyper-tensive, and she did this program and she came back and shared her story. She started in March, and then this was in July, she shared her story.

She not only lost 43 pounds, which was, I think, secondary, but her heart function improved. Her ejection fraction went to 35% to 54% which is medically unheard of, even with the best medical care, treatment, drugs. She had reversed, lowered her diabetes, she got off insulin in three days.

Nada Youssef: Three days, wow!

Dr. Mark Hyman: Three days. She normalized her blood pressure, and she got off all her cardiac meds. She also had liver problems, fatty liver in all her liver function tests, and also kidney function problems. She had renal insufficiency, and she reversed her renal insufficiency, her kidney issues. They went back to normal, her liver went back to normal, and she got off all her cardiac and kidney and diabetes medication.

So, it's pretty remarkable what happens when you apply this to the right person in the right situation.

Nada Youssef: That's amazing. Kelly, "How about diet sodas? Do they hurt if you are doing the keto diet?"

Dr. Mark Hyman: That's a great question. I think there's a lot of debate about this issue now in the literature. But I think there's enough of a smoking gun around the role of artificial sweeteners in harming your microbiome and increasing insulin resistance, increasing inflammation, and increasing appetite, that I would really stay away from these artificial sweeteners. A little stevia might be okay, but I would be very careful.

Nada Youssef: What about, what is it called, monk fruit?

Dr. Mark Hyman: Monk fruit is a Chinese fruit that has no calories, and it has a sweet taste, and that may be okay as well.

Nada Youssef: Good, great.

Dr. Mark Hyman: But again, these are things to use in moderation, not like "I'm gonna have monk fruit cake every day."

Nada Youssef:   Right. Trisha, "Is keto a good option for someone who has had their gallbladder removed?

Dr. Mark Hyman: It could be challenging if you're ... had your gallbladder removed, and you might need to take digestive enzymes. But there are ways to actually do a ketogenic diet if you have a gallbladder removed.

Nada Youssef: Okay, great. And then Julie, "I've been semi-strict with keto for 16 weeks, I lost 16 pounds. Although I love it, why am I not losing more? Some at eight weeks have lost twice as much, I don't exercise, but started at 15 to 30 carbs. Could it be I'm not getting enough fats?"

Dr. Mark Hyman: Probably not, if you're checking your ketones. But it could be other things. If you're not exercising, your metabolism is static, you could have microbiome issues, you could have hormone issues like thyroid, you could have access estrogen levels.

There's a lot of other reasons for resistance to weight loss. I've written a lot about them in my book, particularly The Blood Sugar Solution. So looking at other factors that affect weight other than just calories or fat or carbs.

Nada Youssef: Alright, okay. And then Kristan, "I'm using the carb manager app, and have been following-"

Dr. Mark Hyman: Oh, by the way, one other thing.

Nada Youssef: Yes, go ahead.

Dr. Mark Hyman: Sometimes, when people lose weight, what happens is the body stores petrochemical toxins like pesticides, DDT, plastics, flame retards, stores all that in your fat tissue. So when you lose weight, and this has been documented, you release these fat soluble toxins, and that can have a negative effect on your metabolism through many ways.

I've written a number of articles about this, toxins and obesity and how the mechanisms are. And now it's much more well understood. I wrote this article, I don't know, probably 10 years ago, but it's much more understood. And I think we have to be careful, a thyroid can be effected, and many other things. So if you're losing weight, you need to also maybe think about detoxifying, using saunas, gut detoxification, accelerating your own body's natural liver function. And so there's a lot of ways to do that, and we do it in functional medicine.

Nada Youssef: You've mentioned thyroid. Is that a side effect? I've read something about underactive thyroid.

Dr. Mark Hyman: Yeah, if you're on a low thyroid function, it can cause weight gain and resistance to weight loss. And when you lose weight, these petrochemical toxins, we call these persistent inorganic pollutants, they do interfere with thyroid function.

Nada Youssef: Okay, alright. And then I'll go back to Kristan, "I'm using the carb manager app, and I've been following keto strictly for two weeks. I've only seen a three pound difference in weight, and feel very bloated. I'm wondering how to follow the keto diet with less dairy, and what food sources to eat that are higher in fat than protein. Also, I'm concerned about my sodium, cholesterol. Are these adverse future health issues from this diet?"

Dr. Mark Hyman: Now, so many questions, let's see.

Nada Youssef: We need to go back to that.

Dr. Mark Hyman: So the weight issue, again, may be related to some of the things that I mentioned. It could be that you're not in ketosis. It could be that dairy is causing inflammation, and that maybe something you need to stop. I do a dairy-free keto, and there's many books on it, and ways to do it.

I think in terms of sodium, you typically lose sodium when you are in a ketogenic diet. That's why I said before your insulin goes down, and you don't retain sodium, you pee it out with lots of water, so you might need extra sodium.

As far as cholesterol, it's fascinating. You see some people, I put people on basically a butter and coconut oil diet, which is high in saturated fat, and their cholesterol drops a hundred points. Their triglycerides drops 2-300 points, their H2O goes up 30 points. Other people, different effects. Maybe harmful effects.

So, you have to look at your own biology. We all are different. We all have genetic diversity, we all have individuality, biochemically and metabolically. And it's really important to look at what your numbers are, because not everybody responds the same. And so some people genetically don't respond as well to high fat diets, or may not be able to eat saturated fat. They may need more monounsaturated fat, or other polyunsaturated fats, or fish oil.

So, you have to sort of look at how to modify this to the individual.

Nada Youssef: Okay. And then, "Are the keto urine strips an accurate way to know what levels of ketosis we're in?"

Dr. Mark Hyman: No.

Nada Youssef: No, okay 'cause ...

Dr. Mark Hyman: I explained about the blood is a much more accurate way.

Nada Youssef: Okay, great. And then, John wants to know, "What are some tips and tricks to avoid the cravings and withdrawals from avoiding sugars and carbs, if I find this to be my biggest issue? My other question is, how do you live in a home with others who do not follow the diet plan?" And usually you don't, honestly, I mean ...

Dr. Mark Hyman: It's tough. I mean the best tool for changing your lifestyle is peer support, is a group around you who's also doing it, and is encouraging you. If everybody's saying, "Here, have a piece of cake, here, have a cookie, here ... " and it's all in the house, I mean ... I basically make my home a safe zone. Like sure, I like ice cream, and I like cookies, and like everybody else.

But ... and I don't give myself the chance to have that stuff in my house because if it's there, if I'm stressed, or I'm tired, or have something happen, then I might go for it. And so I sort of typically will not do that. And if I want to have chocolate, you know, if I have to drive five miles to get an ice cream, probably not gonna do it.

So I think it's important for people to understand how to create their environment that protects them. Also, if you are not in that space it's really hard to do, so ...

Nada Youssef: Willpower.

Dr. Mark Hyman: Yeah.

Nada Youssef: Yeah, Lisa ...

Dr. Mark Hyman: Another part of the question was?

Nada Youssef:   Uh ... let's see, I kind of missed that one. Well let's see, I have Lisa, "How important is water intake on the keto diet?"

Dr. Mark Hyman: Extremely important. If you don't drink enough water you can get weak, tired, dehydrated, 'cause again you lose a lot of water.

Nada Youssef: And you take in a lot of salt. Right?

Dr. Mark Hyman:Yeah.

Nada Youssef: So you need a lot of water. And then Adam, "I'm a very lean guy. I'm overall pretty happy with my weight. If anything, I'd like to gain a little muscle. How do I know the right amount of carbs to consume for long-term maintenance?"

Dr. Mark Hyman: Well again, it's not how much carbs, it's what carbs. So I always joke and say that the most important thing for long-term health and longevity is eating a lot of carbohydrates. And what I'm talking about is vegetables and some fruit, plant foods.

Not necessarily tons of grains, or tons of beans, which are okay in moderation, but are not staples, because those are full of starch and over time, especially in our current society with everything else can be a pro- ... now there's some people who do well with a lot of that, and have great metabolisms and can eat whatever they want. I mean I know people who can eat all the crap in the world and they never gain weight. They may not be fat, but they may not be metabolically healthy. So it's important to know that.

So I think, yeah, I think I would just check on the kinda carbohydrates you're eating. And again, if you're lean, healthy, and fit, and you look at your metabolic parameters. The ketogenic diet probably isn't right for you, but again I would say that a low glycemic diet is right for everyone. And then what I mean by that is a diet that doesn't raise your blood sugar and insulin. 'Cause that is the single thing that drives heart disease, cancer, type 2 diabetes, Alzheimer's, and much more.

So, it's really important to understand that concept. So you could eat a diet that's a wide variety of starches and carbs, but if it's low glycemic, if it's low glycemic, then it's okay. Some people in the world have diets that are 70, 80% carbs, and have high levels of longevity. Why? Because they're eating whole foods, 'cause they're eating non-starchy carbs, 'cause they're not eating sugar.

You know, a Coca-Cola is a carb, but so is broccoli. They're very different.

Nada Youssef: Yeah, right. So following up, Donna wants to know, what are you drinking?

Dr. Mark Hyman: What am I drinking? I'm drinking a green juice, which is basically celery, cucumbers, spinach, romaine lettuce, kale, lemon, and parsley with no fruit juice, 'cause fruit juice is like having soda. So this is very low in sugar, and it's high in phytochemicals, got 800 milligrams of potassium, and vitamin K, and vitamin C, all kinds of good stuff. So it's ...

Nada Youssef: So besides that, do you usually just drink water, coffees, tea?

Dr. Mark Hyman: I drink water, I drink water. Coffee, water.

Nada Youssef: Black coffee?

Dr. Mark Hyman: I put some of this, put almond milk in it, something to make a bulletproof coffee.

Nada Youssef: Okay.

Dr. Mark Hyman: But yeah, I typically drink water.

Nada Youssef: Water, okay, good.

Dr. Mark Hyman: Filtered water.

Nada Youssef: Yeah, filtered water. And then Tiffany, "What about keto after gastric bypass. Is it safe?"

Dr. Mark Hyman: Yeah. I think, yes. I think many people fail gastric bypass. Half of all gastric bypasses fail because people haven't really changed the way they eat.

I knew a guy who was a doctor who had a gastric bypass, lost 200 pounds, and then decided he could cheat by having M&M's all day long. So, he would just have huge bags of M&M's, and he would eat a little all the time. Instead of having a big meal, which would mess up his stomach, he had M&M's. And he gained back hundreds of pounds.

So yes, it can be very effective for people, for maintenance. And people typically who get that big are carbohydrate intolerant. And there's a large group of the population that is carbohydrate intolerant.

Nada Youssef:   Good, and then Dianne wants to know, "What would a dinner plate look like?"

Dr. Mark Hyman: Well my dinner plate typically is three-quarters vegetables.

Nada Youssef: Okay. What kind of vegetables? 'Cause I know there's high ...

Dr. Mark Hyman: Non-starchy vegetables.

Nada Youssef: Okay, so no corn.

Dr. Mark Hyman: So all the salad vegetables are fine, but not a lot of potatoes and large starchy veggies. So, sometimes a little bit of a sweet potato could be fine. If it's keto, you can have less things like winter squash and sweet potatoes, but green beans, and all the broccoli family, all the lettuce stuff. There's just any ... in any kinda non-starchy vegetable is fine.

And then you have a small piece of protein, maybe the size of your palm, fish, or grass-fed meat, or organic chicken. Or you could use tempeh, which is high in protein, or tofu, if you're vegetarian. And then you would eat a lot of fat with that. For example, you could put a lot of olive oil all over the vegetables. If you're not allergic to dairy, you can have grass-fed ghee or butter over your food.

So I think it's very high in good quality fats. I had MCT, or I'll have a fat shake in the morning. For example. My shake might be nuts and seeds, which are also high in fat. Would have coconut oil, I might put MCT on there, I'll have avocado in there, and I'll put it in with a bunch of berries and make a smoothie. And that's what I call my fat shake, and then I'll have a fat salad for lunch, which would be a lot of salad greens, so I'll use arugula, which I like, but I don't use iceberg lettuce, that's not good.

And I would put on nuts, like pumpkin seeds toasted. I'd put olives, which are full of fat, and pumpkin seeds have fat. I'd put avocados, which have fat. I'd put olive oil, which has fat, and I'd usually have some fatty fish, like sardines or herring or mackerel or salmon. And that would be my fat salad, and that's sort of how you kind of use these whole foods as a vehicle for a different kinds of fats.

Nada Youssef:   Okay, so Aaron's actually talking about the starchy veggies and fruits and carbs, but do they have the same effect on you as grains?

Dr. Mark Hyman: Starchy-

Nada Youssef: These kinda carbs, yep. Mm-hmm (affirmative)

Dr. Mark Hyman: Yeah. You know, if you take an heirloom, Peruvian, fingerling potato, probably okay. If you take a starchy, Idaho, Yukon potato, probably not okay. That's not how potatoes were evolved, and they're super starchy.

Nada Youssef: Yeah, and don't fry it.

Dr. Mark Hyman: Yeah, and the frying is bad, yeah. If you're eating some black rice or buckwheat or quinoa, you're probably okay. But if you're eating too much of that you're quickly will get out of ketosis, 'cause those are high in carbohydrates. But for most people they're fine, and beans the same thing, if you want to be in ketosis it's going to be hard to eat a lot of beans.

But you can have ... if you have metabolically sort of fixed yourself, sure, you can have beans every day, and a half a cup of beans, or cup of beans is okay.

Nada Youssef:   Okay, great. And then again, this is just a reminder for our audience. If you're interested in exploring the ketogenic diet as a treatment option for your medical condition, it's best to consult with your physician.

And then Debbie what's to know, well she says, "Hi Cleveland Clinic, I'm a patient in your functional medicine department," hello, "I need to jump-start again. What do you recommend?" You got the floor.

Dr. Mark Hyman: Well, what's wrong with you, I don't even know.

Nada Youssef: So, I guess, I mean, start a ketogenic diet. Right?

Dr. Mark Hyman: Well, not necessarily. It's not good for everything.

Nada Youssef: Yeah, so what do you say for Debbie? She wants to jump-start.

Dr. Mark Hyman: Well, I think, I've created something called the 10 Day Detox Diet, which is our renewed diet, and that is essentially 50% fat. So it's not ketogenic but it's high in fat, it's very low in carbs, in starchy carbs. It's high in plant foods, vegetables, nuts and seeds, some fruit. And that can be very effective to helping people jump-start their biology.

Nada Youssef: Now, Sophia says, "I've tried the detox diet, it is great, but so hard to keep, especially staying carb free. Any tips?"

Dr. Mark Hyman: Well, what's your goal? I mean, if you're healthy ... I mean you don't have to. I think it's important to sort of get to that sweet spot where you feel healthy, where you're biologically healthy, where you're sort of finding what that sweet spot in your diet is.

Like I said, I don't think most people should stay in a ketogenic diet forever. I think it's therapeutic, and it should be used as a medical treatment, but not for everybody.

Nada Youssef: And then, Sheryl, "Anyone that cannot or should not follow this diet?"

Dr. Mark Hyman: Yeah, of course. If you're a kid, unless you're obviously type 2 diabetic, which many kids are. And if you're very thin, if you have eating disorders, if you have certain metabolic issues, and I think that would make it risky, I would be very careful.

Nada Youssef: Okay, and then, Cathy wants to know, "Any recommendations for fiber, please. How necessary is fiber?"

Dr. Mark Hyman: Fiber is essential, especially in a ketogenic diet. So, I like acacia fiber, you could use resistant starches like potato starch, like plantain starch. There's supplements you could take that are fiber supplements. Glucomannan is a great starch. So these have no calorie source, but they're high in carbohydrate content. So, but they're very low in what we call net carbohydrate content, meaning if you take the fiber, that it doesn't really raise your blood sugar, it doesn't get absorbed. It feeds the good bacteria in your gut.

We need, probably, 30-50 grams of fiber in our diet every day, and we get about eight to fifteen on average. And hunter-gatherers had a 100 to 150. They ate 800 species of plants.

Nada Youssef: Wow, that's amazing. Well, Terry says, "Dr. Hyman, I think you should clarify a keto diet versus functional keto diet. Folks seem to be confusing the keto diet full of cheese and bacon with the functional keto diet which is more about healthy fats."

Dr. Mark Hyman: Yeah.

Nada Youssef: So, no bacon?

Dr. Mark Hyman: I mean it's not at the top of the list of health foods, no. I think we really need to understand quality. So you can have a poor quality ketogenic diet by having refined vegetable oils, deep-fried foods. This is not healthy. And you can eat a bunch of dairy, not necessarily healthy.

So eating a high quality diet is important across the spectrum of any diet, whether it's Mediterranean or low fat or high fat or keto, it's really the key take home message. It's real food, whole foods, fresh food. Frozen's okay, but eating food that's in an unprocessed state is critical.

Nada Youssef: Okay, now Lynnes wants to know about alcohol and keto. What do you recommend?

Dr. Mark Hyman: Well, I think you want low carbohydrate alcohol. If you eat a beer, or I mean drink a beer, we used to call that a barley sandwich in Canada where I went to medical school, it's very high in carbohydrates. If you have wine, less so, but still ... so ten ounces of beer, five ounces of wine, and one once of hard liquor, that's sort of all the same equivalent in terms of its effects.

So I think having one ounce of hard liquor is probably better than having a ten ounce beer, and so tequila, things like that are fine. Again, it's the dose that matters.

Nada Youssef: And then, "So should women going through menopause do keto the same way younger women do?"

Dr. Mark Hyman: Again it depends on the person. I don't think it's the right diet for everybody who goes through menopause, or maybe really a lot of really thin women who are healthy and fit. They don't really need to do that. I think there's really an emphasis here on personalization. So it really is not, "Should menopause women be on keto?" No, the [inaudible 00:54:38] who should be on keto, and when and for what.

Nada Youssef: Okay, and then Leona, "Can you talk about keto drinks and supplements?"

Dr. Mark Hyman: There are keto drinks. You can get keto shakes, for example, that are made of whey protein, MCT oil. There are supplements that we talked about earlier. I think the data's out on these exogenous ketones and how they affect you. The shakes may be more food-based, which are, I think, better. So I think it really depends on what you're looking to do.

Nada Youssef: And then Bard Dujois wants to know, "Is a keto diet, is it harmful for your kidneys?"

Dr. Mark Hyman: No. In fact, like I said, it can help reverse kidney failure. We've seen many patients who have kidney insufficiency who change their diets and really help improve it. High protein diets can be harmful, but keto is not high protein.

Nada Youssef: Okay, speaking of protein. Marnie, "My nutritionist recommended 90 grams of protein after my gastric sleeve surgery. Is this too high, or proper for keto diet?"

Dr. Mark Hyman: Well, it depends. So if you're 500 pounds, 90 grams of protein is probably not enough. If you're 100 pounds it's probably too much. So, really it's depending on what your protein needs are, depending on your level of activity and your overall goal. So, typically we've been told between 0.8 and 1.2 grams protein per kilo. Kilo is 2.2 pounds.

So, for the average person it is about 70 to 90 grams of protein. If you're an athlete sometimes more. So it really depends.

Nada Youssef: Okay, And then Laura, "Can you address what someone who's strict keto and still not losing weight might be doing wrong. I have hypothyroid and a postmenopausal female."

Dr. Mark Hyman: Well, I think that's it. What are the other factors that are going on? Is it your thyroid? Is it hormone levels? Is it your gut flora? Is it environmental toxins? Is it stress? Is it sleep? I mean, there is a lot reasons people don't actually lose weight. For example, if you have sleep apnea you're not going to lose weight.

Nada Youssef:   Right, right, Charlyn, "What's the difference between keto and protein-sparing diet?"

Dr. Mark Hyman: A protein-spare modified fast is essentially shakes that are higher in protein, very low in calories. It's basically a liquid diet that can be profoundly effective in helping people reverse metabolic conditions, but it's not sustainable. You're not going to be on a calorie ... severely calorie restricted shake diet your whole life.

So the question is how do you eat in a way, long-term, that's going to help you. If you go back to eating the way you were before you were on a protein-spare modified fast, you're going to end up in the same metabolic problems. So it's about understanding how to switch to a whole foods diet and a ketogenic diet can often have the same benefit or more. I call it basically having a gastric bypass without the pain of surgery, vomiting and malnutrition.

Nada Youssef: Oh my gosh, okay and Terry wants to know, "Can you discuss fruits, what types of fruit can I eat and should not be eating?"

Dr. Mark Hyman: Well I think it's interesting, I think if you look at the data overall, people who eat more fruit are healthier in long-term and do better, even diabetics. But I think those are population studies and there may be other confounding factors. People who eat fruit are probably healthier in general and they're not having chips, so maybe there are other factors that are causing this.

I have had patients who have continuous glucose monitors, where they have 24/7 track of their blood sugar, and they tell me when they eat certain fruits they see their blood sugar just goes off the chart, like a plum. Who knew? So I think it really depends on the person. If you're highly carbohydrate intolerant, if you're a severe type 2 diabetic, no you can't eat a ton of fruit until you fix your metabolism.

But the goal isn't to be restrictive your whole life. The goal is to get to be metabolic resilient, to fix things so that they work better, so you can function and have more, we call it metabolic degrees of freedom, more flexibility. In other words, if you're a marathon runner you can eat as much as you want, you're not going to gain weight. Right? 'Cause you have ... create a lot of resilience and flexibility.

If you're someone who's fairly carbohydrate intolerant, you look at a bagel and you just think about eating carbs, your insulin goes up. You can literally gain weight. So, you have to figure out how to get to that place of resilience and that's what functionally medicine is. It's a way to help people.

And our functional keto program, for those people who want to try it, is a very powerful set of tools and also instruction. It's a six week program, it's done in a group. People are together helping each other, and it's super powerful, and we only have a few spots left. But in this round, but it's ... and they're filling up fast if you're interested. Give us a shout at the Center for Functional Medicine at Cleveland Clinic.

Nada Youssef: And I'll tell them it is ccf.org/fmketo. So, if they want to sign up now.

Dr. Mark Hyman: Functional Medicine dot org ... Cleveland Clinic

Nada Youssef: Cleveland Clinic, ccf.org/fmketo

Dr. Mark Hyman: Okay got it. That's easy.

Nada Youssef: Just, we're straight there.

Okay, I'm going to give you one more question before I let you go. Maef, sorry if I butchered your name, "What about the rebound effect? If weight loss is quick, weight gain is fast, how does someone keep their weight off after this diet?"

Dr. Mark Hyman: Well, I think again it's-

Nada Youssef: Is there an after?

Dr. Mark Hyman: There is an after, it's probably staying more low carbohydrate, not necessarily keto range, which is less than 30 to 50 grams, but probably less than a 100 grams and having a whole foods, high quality diet. If you go from any diet, and you go back to what you were doing, you're going to create the same metabolic story. So you have to learn how to eat well for the long-term.

Nada Youssef:   Great. Alright, well that's all the time I have for today. But before we go, if you're interested in learning more about the Center for Functional Medicine, Ketogenics Program, download your free guide at CCF.org/ketointro, and anything else you want to end with today?

Dr. Mark Hyman: No, it's great.

Nada Youssef: No?

Dr. Mark Hyman: We'll love to see you at the center. We'll help you out, and there's enough people out there who would benefit from it that it's going to make a big difference.

Nada Youssef: Yeah, and so for the latest Cleveland Clinic news information follow us on Facebook, Twitter, Instagram, and Snapchat at clevelandclinic, one word, and we'll see you again next time.