#236 – How keto improves brain health and weight loss and combats chronic disease and disorders such as ADHD | Dr. Annette Bosworth & Dr. Casey Means

The ketogenic diet fuels the brain and makes the body more metabolically flexible. The keto diet drives ketone production, which serves as fuel for energy as well as an antioxidant to combat oxidative stress. Switching from burning glucose to burning ketones has numerous benefits, including for cognitive decline and ADHD. Dr. Annette Bosworth and Dr. Casey Means discuss the intricacies of the keto diet, why it boosts brain health, how to make behavioral changes, and how to encourage kids to eat keto for improved health and well-being.

Helpful links
– Annette Bosworth, MD: https://bozmd.com/
– Any Way You Can: A Beginner’s Guide to Ketones for Life by Annette Bosworth, MD: https://bozmd.com/product/anyway-you-can-a-beginners-guide-to-ketones-for-life-paperback-edition/
– Keto Continuum: Consistently Keto for Life by Annette Bosworth, MD: https://bozmd.com/product/ketocontinuum-consistently-keto-diet-for-life-paperback-edition/
– Annette Bosworth, MD, on Instagram: https://www.instagram.com/drboz_annettebosworthmd/
– Annette Bosworth, MD, on Twitter: https://twitter.com/AnnetteBosworth
– Casey Means, MD, on Instagram: https://www.instagram.com/drcaseyskitchen/
– Casey Means, MD on Twitter: https://twitter.com/DrCaseysKitchen

**14:31 — What we put into our body matters**

The foods we eat and our lifestyle habits all inform biochemical processes in the body.

> One framing that I love, is that, in many ways, the body is a pharmacy in its own right. It can produce things based on stressors and inputs that we put on it, diaphragmatic breath can have you squeeze out some more acetylcholine or get the vagus nerve to make certain things. You can support the microbiome to make more serotonin, etc. And I hear what you’re saying is that you can put conditions around yourself that make your body a producer of ketones, which in an essence is a medicine. It’s a healing chemical. It’s a chemistry force that can be positive for the body, which makes sense from what you’re saying: You can’t do it every three weeks and have a little flash. It wouldn’t work if you were on a medication and took it once every three weeks.
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**16:37 — The value of ketones as fuel**

Ketones can serve as fuel for energy and antioxidants.

> When the glycogen storage or the glucose is empty or is in short supply that it needs to offer another option, this fat molecule can be—think of it as unspun into a fuel called a ketone. When that ketone is in circulation, it does more than just offer a fuel. It is a signaling agent. It is a molecule that talks to other parts of our system and our body that it is an antioxidant. It can grab that rogue electron and destabilize it—take it out of the destructive mode.
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**28:32 — Dr. Annette Bosworth explains her ‘Dr. Boz’ ratio**

By using her ratio, Dr. Bosworth can determine if patient is metabolically flexible, meaning their body can switch from burning glucose to using ketones for fuel.

> You take the glucose divided by the ketones. So when the Dr. Boz ratio would be above a 100, people aren’t losing weight, but when they can flex frequently in a week, that their glucose, is in that 60s, 70s, 80s, maybe 90s, and then their ketones are quick to rescue them, that they’ve got a good ratio, then I know their metabolism is strong and flexing.
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**34:47 — Your body will adapt to ketosis**

The carbohydrate limit to stay in ketosis may change overtime, based on various factors.

> How many carbs can I get away with? Well, the beginner is going to have one answer. A beginner’s phase is really how you are kind of coming up with that chemistry. You’re getting people into this chemistry: a ketosis state. It’s the easiest job ever. They do great. But then your body will adapt and that’s where people say, “I did that keto thing and it worked for a while, but then it didn’t.” The title of the book is Keto Continuum because things change unless you’re going six feet under. You’re going to have to adjust as you age and for different seasons of life.
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**44:49 — Dr. Bosworth shares info from a study on cognitive impairment**

Dr. Bosworth talks about a study looking at medium-chain triglyceride oil and cognitive impairment.

> They  started these mild cognitive impairment patients on like 30 and then 45 grams of oil a day that were these specific chains that they knew would cross the blood-brain barrier . . . Their mild cognitive impairment was statistically back up to a normal rate within one week of doing that, meaning what they postulate—and what I am a believer of—is that as you age a brain in a chemistry of glucose fuel all the time, it becomes resistant. That’s what insulin resistance is: It doesn’t use that glucose as it should. It doesn’t get into the cell as it’s supposed to. And so the cell is starving. It can’t get the fuel it’s supposed to. But it would use a fuel like ketones or a fat if it could get access to it. And so when you flooded the system with it, and across that blood-brain barrier, first of all, their scans—what was dormant, what was not functioning, is back to functioning. And that correlated with their testing that they went from this mild cognitive impairment—which, I don’t want that ever, because the next step is dementia—that mild cognitive impairment went back up to normal functioning within a week. Within a week. I don’t have a med that works that fast.
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**50:41 — Dr. Bosworth shares her experience with getting patients on a ketogenic diet**

Dr. Bosworth uses the state of ketosis as a first line of therapy for mental health issues.

> When patients come to me and they have autism or they have depression or they have bipolar, or they have wet brain—and now dry brain because they’re sober—but they have really had a hit to their brain from substance misuse and other forms of mental health issues . . . And they say, “Well, what would you do?” The answer is I would do what I am doing, which is fueling my brain with ketones every day in a way that I usually can deliver with a diet. Sometimes I will supplement if I’m being human, I’ve not eaten as well as I should, but the reason I do it is because I love what it does to my brain. And I have some of the most incredible experiences with patients.
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**53:07 — Dr. Bosworth shares her wisdom about behavior change**

Being in community with others modeling a behavior can help you mirror that behavior.

> When you grow up in an environment where you don’t see a behavior and now you’re being asked as an adult to use it, the only option—the only way that brain can learn it—is to watch it in another person before they can activate it in themselves . . . If you want to learn a new behavior, you have got to be in relationship with other people who are working on it too. And you’ve got to show up with a little grace for yourself and know that. The grace for others and yourself are always the same. So if you’re being nice to them and you’re not being nice to yourself, you’re lying to one of you.
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**1:13: 31 — Dr. Casey Means describes her experience with metabolic dysfunction**

Dr. Means changed the way she fuels her body and had positive results.

> We put it in the Standard American Diet, and we’re sleep deprived, and we do all this stuff, and this beautiful machine creates what can be such a painful devastating life experience of loss. For me, when I was in my surgical residency and was almost certainly metabolically dysfunctional, what I described to my parents, I was like, “I felt like I was thinking in color and now I’m thinking in black and white.” And I didn’t have creativity and my mood was very just flat. It was an under-fueled brain. It just was. And then once I got out of that and the fuel was better, it comes back, you know. There’s this moral hazard with the health and pharmaceutical industry. I know a lot of really wonderful people in that industry. It’s not that the people are bad. It’s that the incentives are bad, because these are publicly traded companies that are designed to grow. And the only way you grow companies that are making medications for chronic disease is there needs to be chronic disease.
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**1:18:05 — Dr. Bosworth shares her techniques for getting her kids to eat healthfully**

> Yes, it will be a fight. It’s what happens when you withdraw from sugar. They’re going to be crabby. But my son is a perfect example. He’s the youngest and he’s a wrestler . . . This wrestler now needs to make weight. And he doesn’t like sardines any more than the next guy. I would challenge you to call him and say, “What’s in your backpack today?” Not because he likes sardines, but because that mother was around saying what was true. The carbs are going to slow down your brain. The carbs are going to put you to sleep in the period right after lunch.
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**1:21:00  — In general, the food industry’s aim is for profit**

The food industry at large isn’t protecting children from poor health. But parents can step in by modeling healthful eating and lifestyle habits and explain the “why” to their children.

> Every other force is going to try and use your child as a profit center. Like, how much processed food can we put in this? How many medications can we put in this unit, this person? And I think when you understand those incentives of the forces that want your child to be sick, dependent, and addicted, your role as a parent is: How can you be that protector?
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Annette (00:00:06):
When that mood is going up and down, and up and down, what you’re really doing is you are stimulating that mitochondria to burn out a bunch of fuel and then it crashes. You don’t have a flexible metabolism, you go to zero, and they starve, and they get crabby and irritable. And that looks just like a non-focused, irritable, attention deficit. So then it’s much easier to label, give it a pill, stimulate the crap out of it, and not fix the problem, but have a prescription that must be the answer. I think it is a tragedy that it is not better educated that your brain prefers ketones, and when you fuel it like that, it works like a superpower. We are the most advanced brain on earth, and when you fuel it correctly, it is quickly recovered.
Ben Grynol (00:00:50):
I am Ben Grynol, part of the early startup team here at Levels. We’re building tech that helps people to understand their metabolic health. And along the way, we have conversations with thought leaders about research backed information so you can take your health into your own hands. This is A Whole New Level.
Casey (00:01:28):
Hello, and welcome to A Whole New Level. This is Dr. Casey Means, co-founder and Chief Medical Officer of Levels, and I am thrilled to introduce Dr. Annette Bosworth, otherwise known as Dr. Boz, to our show today. We are going to be talking about keto diets, of which Dr. Boz is a trailblazer and leader. We’re going to be talking about brain optimization, chronic disease reversal, and exactly how to know if you are reaching a ketogenic state. Dr. Boz is incredible. She was one of the early physician leaders using YouTube and media to get her message out. She’s been making YouTube videos for over 10 years, has 500,000 subscribers on her Dr. Boz YouTube channel, and it is a wealth of information. She is a physician trained in internal medicine. She’s a faculty member, she’s taught at University of Utah and University of South Dakota. She’s written two incredible books, Anyway You Can and KetoCONTINUUM.
(00:02:22):
She’s an author, storyteller, mother, she’s been featured in so many outlets, like CNN, Time, US News, and World Reports. She also speaks all over the community, in churches, in jails. She hosts a support group in a bowling alley. She speaks at universities. She is so passionate about getting the message of metabolic disease reversal out, which is so important. We’re facing a metabolic disease epidemic in this country, and Dr. Boz is really a crusader. She has been successfully reversing type 2 diabetes, obesity, addictions of all kinds for decades now. We are going to talk about how to use continuous glucose monitors in relation to ketone monitors. We’re going to talk about how to do the keto diet and how to know if you’re in ketosis. We’re going to talk about fasting. We’re talking about incredible inspiring patient stories. This is an amazing opportunity to speak with one of the world leaders in the ketogenic diet, and I could not be more excited to have Dr. Boz here. Welcome to A Whole New Level, Dr. Boz.
Annette (00:03:31):
The rest of these slides won’t, but really important for people to say this changes. When people say, “Well, what should it be?” I’m like, “I don’t know. There’s about 10 more questions I need to know before I can answer that question for you.” It is, what is it doing over time that is the most important. Like any data point, if you only have one, we’re not going to get that good of answer for you. But when we have a range of data for you, it really is helpful. So I call this the four-day forecast. So Willie is quite predictable. He has no control over his meals, he’s at an orphanage where it’s rationed and very minimal. There is no snacking at night.
(00:04:08):
And when you follow day one, day two, day three, day four, it’s that solid of a plan. His time spent in ketosis is, well, it’s like half of the day, because when he’s sleeping, he’s got ketones being… in the fear of being a little redundant, this is the zone for the burning fat, and I just want you to put that in your memory to watch what happens when you compare that to an American.
(00:04:32):
So here is our American. We’re going to call our American David. So David is also 10. David is the person that I wrote about in KetoCONTINUUM, but here’s what his “would have been” had he checked. So I want you to notice that his glucose is going up to well above 120 when he eats his meals throughout the day. His ketone level may rise during the evening hours. It’s got a baseline of ketones happening during the day when he is eating glucose, but it is not nearly as robust as what Willie’s was from Honduras. It’s in the zone where those ketones are burning that it is a strong metabolic stimulus for the mitochondria.
(00:05:16):
And if I get to answer what is a ketogenic diet, I’m like, “It’s a workout for your mitochondria to help keep the body low on inflammation.” And if you just burp a few ketones into your circulation, well, maybe you can get rid of, I don’t know, a pimple or something. But if you’ve got metabolic disease, or dementia, or an autoimmune disorder, you got to have ketones around a lot more than that, if you want me to have a chance of being able to crisscross those on the list of diseases that I used to say, “Oh, you’re in no man’s land, that’s not reversible.” Here’s just another look at that. His average blood sugar, unlike the Hondurans, is about 5.1. So that’s about an average of a hundred, so average blood sugar of a hundred. And not terrible, everybody’s going to say, “Good job. It’s great.” But the volume of food that that American is eating is much more processed and at much higher volume.
(00:06:13):
So let’s see what happens when we age. That insulin amount is overproducing and every time you swallow food now, you are making insulin, even though the textbook says, “But it was all fat.” I’m like, “Yeah, yeah, yeah, I know you think it’s all fat, but there’s other stuff in there.” And in that process of eating, just the mastication, the chewing, is now stimulating your parotid gland to tell your brain that here comes a bunch of carbs, because that’s what you’ve done for the last 30 years. But even at 17, we watched to see, yep, he’s making some ketones but not very much. His glucose and ketones turn on and off in a different way. We now have a very low… zero is his baseline in between, whereas before, his baseline was closer to 0.5. So again, there is absolutely no ketones being fueled in the 17-year old who looks lean, who’s very healthy, whose mom says, “We don’t snack at night, so we’re fine.”
(00:07:12):
But his eating window is much larger than it should be, and the time he spends burning carbs versus burning fat, well, there’s just no comparison. After a few years, from his 10-year-old self to now his 17-year-old self, you’re like, “Well, his average sugars aren’t too bad, 115, 5.5, no problem.” Yes, it is. If you want this child to not grow up with an immune system that is crippled, or an insulin system that is resistant to the messages inside itself, it’s too high for a healthy person. Human beings were not designed for that. And when I watch those numbers go higher and higher at an earlier age… I actually had a pediatrician call me probably about two years ago because I had given him the algorithm for how to treat type 2 diabetes, something he didn’t learn in his pediatric years, but he needs to know now.
(00:08:04):
And he called me and said, “Well, what happens when I’ve run out of all your drugs?” And I said, “What do you mean?” “Well, I’ve maxed them all out,” and his blood sugars are still high. I’m like, he needs a different mom. You need to get the carbohydrates out of his life, you got to stop doing this. Because this is what he looks like when he’s 40 years old. Now, we’ve got this man who’s spent 20 years doing… he’s cleaned things up, he only has three meals a day, but his blood sugars go all the way up to 160 when he is eating his meals. And his eating window is more than 12 hours, is probably about 13 or 14 hours, and his blood sugars are now up into that… yeah, 6.1, which, an average blood sugar of 125, often, if you check it 15 times in a row, you’re going to find morning fasting ones that are in the diabetic range.
(00:08:57):
He doesn’t know it. He would never want you to say that out loud, “That’s just not me. I’m sure you’re wrong. I looked in the textbook, it says it needs to be higher than that.” I’m like, “I don’t care. You’re so close to diabetes, you’re just fighting over needles right now.” It’s really not an appropriate antidote for saying, “Oh, I don’t have it.” No, you’ve got a problem brewing deep inside your system. So let me go to what happens when our patient goes to 55 years old, and now have blood sugars that go way up here. So now, you’re above 60. And here’s a couple of things I like to point out, see how this doesn’t get back down to normal in between meals? Well, those sugars, what it really looks like on a CGM is they hang out up here. It’s so close to a flatter line in between the meals that you know they’re doing some damage to their body, and their brain.
(00:09:43):
And the ketones, they’re rare. If you had a ketone continuous monitor, if there was a thing, and I know folks are working on it, but I don’t see one on the market yet, but if you could, it’s this really half a hot minute that you made about five ketones and then your body said, “No, no. Here comes cortisol in the morning, it’s going to rise.” And in the end, that glucose going way up, burning the fuel that is short-acting, that is not an anti-inflammatory or an antioxidant, but is instead a really wasteful but rapid fuel. And with that, comes a whole bunch of reasons you’re going to end up seeing an internal medicine doctor. When I look at those slides, and I’ve done that lecture many times, and really find that, as you watch, well, what do you do to get better? The key component is that you’re going to need a way to recruit those ketones back into your chemistry set.
(00:10:40):
And when patients say, “Well, how many grams of fat should I have?” “Well, how many grams of protein should I have?” I’m like, “I don’t want you counting any of those macros right now. I want you to keeping 20 total carbohydrates in one day. Period. That’s what you focus on.” Now, I want you eating high fat. Some people can do that right out of the gate. Some people bang their head up against the wall and need high protein with low fat and then they feel terrible. And finally, they just say, “Well, here’s what I would recommend, is I would recommend you eat some steak, some sardines, some high fat, we could say ancestral foods, that are filled with fat and that are not laden with a lot of carbohydrates.” And even in my advanced diabetics, I’m injecting insulin. My A1C is in the double digits, which now has a blood sugar of north of 270 at least, and that was in my no man’s land.
(00:11:39):
You’re never going to get back from this. That’s not reversible, and I have criss-crossed that out. You have to reduce this not for a week, not for 10 days, not for a month and a half, but until your beta cells are not overproducing every time you chew. That’s going to take time. And when I look at the price that people pay, is they often don’t hear this message until… well, until their brain wasn’t working right. That started at 17 for our David. His brain changed. His ability to be resilient, to have the reversal of anxiety, the depth of his sleep, all of that changes when glucose is the only thing that you’re fueling those cells on. That even though he could produce some ketones, and into his 20s and 30s, in the middle of the night, there were maybe an hour or two of ketones, not enough to keep away.
(00:12:35):
What we ask of our brains in this world, which is, you need that depth of sleep, you need the power of a strong source of ketones. And like I’ve said at the beginning, it means that mitochondria cannot get a flash of ketones every third week when you said, “I’m fasting for Lent, or I got a colonoscopy.” There’s some ways that ridiculous human beings skip meals. When they do that, sure, we can wake them up just a little bit. That is not what nutritional ketosis is, that’s a flash of your body’s saving, that one lever that you haven’t been using, and it’s going to try to use it in a moment where you do something different than you’ve been doing. That’s not how you reverse these problems, that’s not how brains get to peak performance. They really do need a journey, or ketones are routinely delivered into the space and glucose comes down, especially, that average glucose comes down.
Casey (00:13:32):
What an incredible overview and explanation. I know that’s going to help so many people, and I just thank you for going through that. If you’ve heard me talk on other podcasts before, you know that I believe that tracking your glucose and optimizing your metabolic health is really the ultimate life hack. We know that cravings, mood instability, and energy levels, and weight, are all tied to our blood sugar levels. And of course, all the downstream chronic diseases that are related to blood sugar are things that we can really greatly improve our chances of avoiding if we keep our blood sugar in a healthy and stable level throughout our lifetime. So I’ve been using CGM now on and off for the past four years since we started Levels, and I have learned so much about my diet and my health. I’ve learned the simple swaps that keep my blood sugar stable like flax crackers instead of wheat-based crackers.
(00:14:36):
I’ve learned which fruits work best for my blood sugar. I do really well with pears, and apples, and oranges, and berries, but grapes seem to spike my blood sugar off the chart. I’m also a notorious night owl, and I’ve really learned with using Levels, if I get to bed at a reasonable hour and get good quality sleep, my blood sugar levels are so much better. And that has been so motivating for me on my health journey. It’s also been helpful for me in terms of keeping my weight at a stable level much more effortlessly than it has been in the past. So you can sign up for Levels at levels.link/podcast. Now, let’s get back to this episode.
(00:15:20):
One framing that I love is that, in many ways, the body is a pharmacy in its own right. It can produce things based on stressors and inputs that we put on it, or conditions that we put on it, like a deep diaphragmatic breath can have you squeeze out some more acetylcholine or whatnot, or get the vagus nerve to make certain things, you can support the microbiome to make more serotonin, et cetera, et cetera. And I hear what you’re saying is that, you can put conditions around yourself that make your body a producer of ketones, which, in an essence, is a medicine, it’s a healing chemical, it’s a chemistry force that can be positive for the body. Which makes sense from what you’re saying of you can’t do it every three weeks and have a little flash. It wouldn’t work if you were on a medication and took it once every three weeks. So how are you going to create a condition in which you’re actually constitutively getting this?
(00:16:13):
And my question for you is, what is it about this molecule, or several molecules, that are beneficial for the body? Is it the way they’re impacting the mitochondrial health? Is it the anti-inflammatory benefit? You talk about how fat fuel outperforms carbohydrate fuel, what is actually happening when you make these ketones that’s positive for our cellular health?
Annette (00:16:35):
Yeah. So when I explain metabolism, it is actually a really advanced discussion. It’s one of those topics that the more I understand, the more I realize, “Okay, I just don’t know anything.” But to give it to patients and say, “Well, how do I help them frame why I’m asking for a different chemistry set?” If you want me to get you off these prescriptions, I know that’s a nice talk, and there’s lots of folks out there saying, “I stopped my meds, I stopped my meds.” I’m like, “How long, and how are the numbers behind the scene?” When you look at what a ketone body does, yes, it can be used as fuel. That is one major component that… we store fuel as strings of glucose called glycogen, and we store fuel as fat. When the glycogen storage or the glucose is empty, or is in short supply that it needs to offer another option, this fat molecule can be, think of it as unspun, into a fuel called the ketone.
(00:17:38):
When that ketone is in circulation, it does more than just offer a fuel, it is a signaling agent, it is a molecule that talks to other parts of our system and our body. It is an antioxidant. It can grab that rogue electron and stabilize it, take it out of the destructive mode of crashing into things, and pull it back into that space of energy. Well, ketones in circulation beget more ketones. They signal that the mitochondria in the liver should be making ketones. As we may or may not have disclosed at the beginning, I started out with a book that I didn’t want to write, and then I tried to reach for products that I couldn’t find in predictable formulas that stayed the same and didn’t have a bunch of fillers in them. So I ended up making a product, and then I made a couple more products.
(00:18:31):
And some of those products are the exogenous ketones that you can swallow, add to the circulation, and they can be used therapeutically. Those exogenous ketones, one of my favorite ways to use them is, if you’ve worked with human beings, they’ll do great for a while and then their old habits show up again. And as much as I would like them all to be the offspring of James Clear and the atomic habit of stacking new habits on the next ones and getting better, they don’t exist in real world, they need to fall off the wagon and get back on, and fall off the wagon and get back on. And what you’ll find is they’re like, “Ah, it’s just so hard to do. I don’t want to do that again.” Well, the truth is, the first time you go keto, there’s an awakening of those mitochondria.
(00:19:18):
They’re kind of rusty, they haven’t used ketones in a while. It could be slow to say, “Are you for real? Are these ketones actually here? Are we going to use them?” And so the mechanics of how to turn it into energy can be a little rusty. But as you stay in ketosis, within three or four days, you really can see a transition in how you feel. And then when I fall off again, those glucose gears are ready and waiting for you to go back to the old way you were doing. So when they carb binge or they have a bunch of booze, or they do some things that would take them out of ketosis, well, they end up with no ketones in circulation. To add them back exogenously before they cut the cord and go back to what they’re supposed to be doing, is a brilliant transition difference that has really helped people get back on the wagon.
(00:20:07):
Just sip ketones for two days, draw a line in the sand that you’re going to go back to 20 total carbohydrates per day on this day. And in the two days prior to that, I need you drinking some ketones, because those ketones in circulation will stimulate the production of ketones out of your mitochondria in the liver. So now you’ve got the mechanics that when you drop the carbs, it’s not going to hurt like that again. The other things that we know, there are histone deacetylase signals that, say, the way you wind up DNA and then wind it back together in its tight little coils that matters, and when you don’t do it well, your body makes mistakes. And so we know that there are some excellent augmentations when a state of ketosis is the chemistry bath that your cells are in when they are replicating, when they are doing things. One of the benefits, dangers, of being on YouTube since 2011 is that, people say, “Boy, you look different than you used to.”
(00:21:09):
I’m like, “Well, I’ve aged.” But what they tell me is, “Well, you’ve aged backwards.” So I think, well, what a great testimony to say when my cells divide, they’re in a bath of ketones most of the time, and my metabolism is closer to Willie’s than it is to David when he was 40 or 50. But I’ve birthed children, so I have a chemistry set that has some hormones in it that make it, I have to be pretty strict at how I eat, how often I eat, and when I eat, in order to keep that good flexibility of turning ketones on and off in my system, in order to gain… Well, do I have any skin cells that are dividing today? Probably. Are they in a bath of ketones or are they in a bath of a bunch of blood sugar?
(00:22:03):
And that inflammatory state versus anti-inflammatory state, well, that kicks the crap out of any acai berry antioxidant, apple cider vinegar stuff that patients say, “I’m sure I’m getting better. I’m having a tablespoon of apple cider vinegar.” I’m like, “You’re totally kidding yourself. It’s not doing anything. You got to change your behavior.” So when I look at a ketone state, I really do look at it, at the best, aging health is that those cells have a constant, at least within a 24-hour period, access to some ketones.
Casey (00:22:41):
That is so interesting. One question that comes up for me is just, you mentioned less than 20 grams of carbohydrates per day, and I’m curious, if people, based on their finger prick readings and their glucose monitor readings, are able to stay with low glucose spikes, so let’s say, pretty much never going above 110 after meals, 110 milligrams per deciliter, and ketones are between 0.5 at baseline, maybe go up higher, above 1, when they sleep or something like that… And I’m asking about myself here actually. So I used to be vegan and I’m not anymore, but I was very focused on a very low glycemic vegan diet that really had fairly low net carbs. I was eating a lot of lupini beans and beans that have very low net carbs, a lot of fiber, and I was able to keep glucose pretty much 24 hours a day under 110.
(00:23:35):
My insulin’s 2-3, triglycerides are 45, just like everything was looking good, but I was definitely eating more than 20 grams of carbs a day. So my main question here… and I was intermittent fasting, or time restricted feeding, not eating late, and sometimes doing more extended fast, if people can keep these numbers with a higher carb diet, slightly higher carb, very thoughtfully chosen higher carb diet, do you think that that’s what really matters? Is the fact that you’re generating the outcome of a body bath in ketones, or is it truly the large percentage of fat in the diet and the very low net carbs that also is important, or is it the outcome? Does that make sense?
Annette (00:24:17):
I hear what you’re saying. So what I hear you saying is, let’s see if I’ve got the story straight, during the time when you’re eating, there’s more than 20 carbs per day, but your continuous glucose monitor stays 120 or less.
Casey (00:24:30):
Yeah, I’m basically saying there are people who are going to be able to get to ketogenesis potentially on higher carbs, which they can find because they’re wearing a CGM and using a ketone monitor, and maybe blending it with really good food, timing, and whatnot. And so is it more the outcome that you’re looking for in a patient, like the actual generation of ketones in the body that you can prove on a monitor, and keeping glycemic variability low and average glucose low? And if that may be on a slightly more liberal diet with carbohydrates, is that okay in your mind, or is it the keeping carbohydrates below 20 that actually, in its own right, is also important? Or have you had patients who have used technology to see what’s going on and they’re actually like, “Oh, I can actually tolerate 100 or 150 grams of carbohydrates a day,” and still keep these outcomes, ketone production, and low glucose, and low insulin?
Annette (00:25:28):
So let’s answer the question specific for your metabolism. So have you ever had a weight problem? Have you been, let’s say, outside of pregnancy, 50 pounds overweight for more than six months?
Casey (00:25:38):
I actually have, yeah. I was tipping the scales over 200 when I was in eighth grade, I was a very overweight child. Yeah.
Annette (00:25:45):
Okay. So then when did the weight come off?
Casey (00:25:48):
The weight came off when I was 15. I got really into nutrition and dropped the weight and became an athlete, and then I actually gained weight again when I was in college and then dropped it again in my early 20s. And then I’ve basically been a stable weight since I was 22. And now I’m 35, and have not had kids.
Annette (00:26:05):
Okay. Okay. So give me the weight gain in college. So the metabolism at that peripubertal tells about some stress and some changes that you reset. You can do some life predictions at that point. So now, tell me what happened in college? How high did the weight go and how long was it on the-
Casey (00:26:22):
It went back up to probably about 50 pounds overweight both times, and then dropped it twice, and learned about metabolic health and basically was able to keep it. But it’s definitely work. I’ve devoted my life to this field and really focus my diet on making sure that the glucose readings stay low, and that my insulin always stays low, and that I’m generating ketones that I check my ketones almost every day. So that is now what dictates my diet.
Annette (00:26:52):
What I’m doing is reverse engineering what the chemistry is going on in the background. So in your baseline ketones, what numbers do you usually find first thing in the morning?
Casey (00:27:00):
First thing in the morning, if I’m really dialed, they’re usually around… and again, my diet is not vegan, but I would say, 0.9 to 1.5.
Annette (00:27:11):
So that’s a perfect number. And then what was the glucose when that happens?
Casey (00:27:15):
75 to 85.
Annette (00:27:16):
Okay. So now, go to a less than perfect season.
Casey (00:27:21):
If I’m on vacation and not doing a great job with… like just drinking a little bit more, and eating more restaurant food, my ketones will be 0.1 or 0.2.
Annette (00:27:31):
And then how high does morning fasting glucose go?
Casey (00:27:34):
If everything is off the rails, it can get up to the high 90s. When all my stuff is dialed in, it’ll be 75 to 85.
Annette (00:27:42):
Right. So ever wake up with a triple digit morning fasting sugar? Never, ever, ever? Okay. So that’s a huge predictor for where I separate insulin resistance. When they dial it in, you can make anybody who is in good health… I mean, their mitochondria will rescue them, they will give the good numbers, they will have, I call it Dr. Boz Ratio. Again, I did not come up with that, but it’s stuck and it’s very helpful. When I was teaching my mom how to do this calculation of what is her GKI, she had chemo brain, she couldn’t think that well. And she’s a brilliant woman, like, “Oh, god, woman, what do you mean take it to one… Too much.” So I said, “Okay, mom, divide the big number by the little number and I’ll do the rest of the math for you.” Well, that’s the Dr. Boz number.
(00:28:31):
So you take the glucose, and that’s in milligrams per deciliter, and then you take the ketones, which is in millimoles per liter. So it’s dirty math, you take the glucose divided by the ketones. So when the Dr. Boz Ratio would be above 100, people aren’t losing weight, but when they can flex frequently in a week that their glucose is in that 60s, 70s, 80s, maybe 90s, and then their ketones are quick to rescue them, that they’ve got a good ratio, that I know their metabolism is strong and flexing, it’s doing what Willie did.
(00:29:08):
When they have a history of insulin resistance, you’ll see them dial in, and of course, they always want to show me great numbers. And I’m saying, “Yeah, but what happens when I’m not looking? Go to the numbers. When you’re doing normal stuff, and especially when you go on vacation, when you’re not thinking about your metabolism, how high does the blood sugar go?” Because we know that the ketones is going to go into the pot. But if that glucose in the morning stays in the double digits and doesn’t go to triple digits, well, then I know we’re in a healthier metabolism. And so your question was, “Well, how many carbs can I have?” And I said, “The answer is, enough to keep your morning numbers with a Dr. Boz Ratio of 80 or less. It says, you’re not building chronic disease, you’re not putting on weight.” That they say, “Well, am I doing that today?”
(00:29:59):
I’m like, “I don’t know. Check.” So that Dr. Boz Ratio is really this day-to-day data point. I know you mentioned insulin, I’ve actually fallen away from checking people’s insulin because it’s expensive, they need me to do it, and the two molecules that are most impacted by insulin, glucose and ketones, and I don’t need one point of data. There’s a great study out there looking at all the different ways that you can raise somebody’s morning fasting insulin, and one of them is, have a car ride. What do you think they’re going to do to get to the lab? Have a bowel movement, have a restless night’s sleep. “Well, okay. Just the number was so ridiculous.” Okay, what do you think my patients are doing? They’re doing all of these things. So what is the real insulin? Oh, you sat in the lab for an hour and a half and the lady took two pokes to get your blood drawn.
(00:30:53):
You’re like, “Okay, you just screwed it up, so quit it.” And then you do a Kraft insulin test. Now, I haven’t actually personally tried to order this in a couple of years, but the last time I did this, they charged my patient $2,500 for the glucose, yeah, for the glucose, and then you have to do the insulin with it. So it’s a two-hour glucose tolerance test plus the insulin. But what it really was is, they needed… I mean, I don’t deny that their bill was justified because they needed a dedicated person with a timer to say, “You cannot wait an hour and a half. That screws this up. I needed it at this time.” And without the formula, I can’t make sense of this. So instead, well, let’s let the patient keep track of it, let’s let them show us what the numbers are, and well, let’s teach them on YouTube about this ratio, which is really a GKI, saying, “You got to have glucose and ketones, and they both need to have, in this range, that will predict is Casey going to gain weight in the pattern she’s eating?”
(00:31:55):
I don’t know. Check her Dr. Boz Ratio for a couple of weeks, and do it when you’re being real. You don’t have to show me, you don’t have to show the doctor. I don’t… I mean, I care, but I don’t care. You care. And you’re like, “Okay, if you’re telling me that I need to give up that three o’clock meal every day because I’m now not 36, I’m 46, and my body aged.” Well, nobody told you, but now, we need to do this differently. And so I look at the process of how I walk patients through the steps needed. You want to get better? Let me show you how I do this for patients.
Casey (00:32:31):
So I just wanted to make sure just for the take home for people listening, for the Dr. Boz Ratio, it’s fasting glucose over fasting ketones, so first thing in the morning, and you’re looking for that to be under 100.
Annette (00:32:44):
Under 100 says you’ve got a good metabolism, you’re finding the churn… If you’re trying to reverse things, which is what most of the people coming to see me, if I look at a Dr. Boz Ratio of 80, that number, they can lose weight. If you’re trying to lose weight, you got to hit that number. Now, there are exceptions when people do that and they’re not losing weight. We can explore that if you want to. If I’m looking to reverse a serious medical problem like an autoimmune disorder, like, I hate this word but, leaky gut, so irritable bowel, or gut permeability, so it’s leaking stuff back and forth, which is leaky gut, everybody understands it, you got to have a good chemistry set to do that. It’s not so much your microbiome, it’s what the cells on the inside need to do to repair you.
(00:33:30):
So if I’m looking at one of those serious medical problems, you got to get to a 40 or less, and you got to hold that first thing in the morning every day, every day, every day. That’s hard to do without some of the things that you offer and that we offer. When I’m working with a seizure patient, or a cancer patient, I get their Dr. Boz Ratio down to 20 or less, and that would be essentially a glucose ketone index of one-to-one. So if you’ve looked into that, that’s hard to do, but it is where you heal. So I wrote this book that my husband baited me with, and then all these patients wanted help. And I said, “Well, I can’t see them all.” And so I’m back to this problem where YouTube was going to fix my problems. I was just going to educate them on YouTube.
(00:34:21):
But the book really has a workbook, and a very important part of the process is you understanding you. So as they go through this, you’ll see here there’s a beginner’s phase. And so when you ask that question of, “Well, how many carbs can I get away with?” I’m like, “Well, the beginner is going to have one answer.” Beginner’s phase is really how you are… coming up with that chemistry, you’re getting people into this chemistry, and once they hit a ketosis state, dang, it’s the easiest job ever, they do great. But then your body will adapt. And that’s where people say, “I did that keto thing and it worked for a while, but then it didn’t.” So the title of the book is KetoCONTINUUM because, well, things change. Unless you’re going six feet under, you’re going to have to adjust as you age, and as different seasons of life, if you birthed a child, there’s a different rule set afterwards that you’re just going to have to be more strict if you want to be lean.
(00:35:20):
I look at this section, it’s what I call the baseline metabolisms, where it really is time restricted eating, that it is… not 16, 18, this one’s in almost 16:8. Again, 16:8 is what this is supposed to say. But if you look at number four, this two meals a day is what these 16:8 are, the boluses of food. I say that word on purpose because if you go back to David’s eating pattern, when he was 17, he had that thing called a snack, but it sent his glucose up so high that you should call it a meal. And so people say, “Well, I only eat two meals a day.” And then you hear that they chew 15 pieces of gum, and they have a half a handful of Tic Tacs throughout the day, and they do all these things that are stimulating what the body does when you put things in your mouth.
(00:36:16):
Well, it didn’t do anything to David when he was 17, but it would definitely do something to you, it would definitely do something to me, and anybody else who’s been overweight for more than six months. And I don’t mean like five pounds overweight, I mean significantly overweight. So having this time restricted eating with two boluses of food per day. You are an adult, you do not need three meals a day. Period. That is a myth, that is not true. Two meals a day, putting them in a certain period of time, and then as we get down here to a 23:1, this little bitty line where people go from 16:8 to 23:1 doesn’t happen in a little bitty line, it’s a little bit more narrow, a little bit more narrow, a little bit more narrow. And when we get to an advanced level of 23:1, which would still be… my eating window’s probably about four hours in a day, if I had workouts, then I can be a little more generous on my eating window.
(00:37:13):
But if I have a week like this and I’m… Well, some weeks, if I only get a one workout, I should have a tighter eating window if I don’t want to gain weight. That’s the formula. How do I know that formula? I check my chemistry. And I can tell you that if I hop out of that and I do it for three or four weeks in a row, guess what? I’m about five pounds up. And then if I go back, oh, then I’m about five pounds down. And so that’s not just me, that’s patient after patient that taught me, “Oh, here’s what you’re doing.” Yep, I see that. And one of the ways that a physician can see that is these continuous glucose monitors. They really do… It just pulls back the veil.
(00:37:50):
Show me the truth. I don’t care, it’s not shameful. It’s shameful that you’ve spent the last 15 years being told low fat, go exercise, and you’re so stinking overweight and insulin resistant that that was never going to work until we fix this chemistry problem. And your 15 medications are a result of not understanding this metabolism issue. But you’ll notice in here that this part here is stressing the metabolism. So there are many people who cannot tighten up their eating window any further in the social world they have. Meaning, every time I take my eating window down to two hours, my husband gets ticked off, and why don’t you eat with the family? And what are you doing… So there’s social stuff, I want to eat with the family, it’s a very important social time, I can’t put another hour in my day, I didn’t get to a workout. So there’s certain levers that you can push, and one of them is the eating window. But then there’s a time where you can completely remove eating.
(00:38:55):
And so this word fast is one of the metabolism stressors. Now obviously, you can go into a sauna, you can go for a workout, there are other ways to stress your metabolism, but when you’re using food consumption and the timing of it… well, baseline metabolisms is where I ask people to live, and then I ask them to stress their metabolism intermittently. Once they can find the rhythm that says, “All right, if I keep it in this zone, it doesn’t tick off the people I love, I actually can stick to it, but I do have to make a bunch of ketones every once in a while to prove that my mitochondria are in good shape. I have to stress that mitochondria and really get that ketone production high enough that it can carry my health, it can do its antioxidant, it can make those skin cells in the right chemistry set, where the next ones might be in a more glucose, that you can get the outcomes you’re asking for.
Casey (00:39:59):
I think one of the things that’s so amazing about it is twofold, one is that it’s all about the body telling you the answers. It’s like, we can talk all day about, how many carbs can I eat? And is vegan okay? Whatever. But it’s like, what’s the chemistry in the body? I love your focus on measurement, and it really cuts through a lot of the noise, I think. It’s like, what is happening, that is what matters. And so of course, we are believers in that at Levels as well, but I also think that it is strict, it’s like, yeah, no, I mean, just having glucose being 85 and ketones being 0.6, it might not be enough if you have certain goals. So it’s a mix of your biology, your choices, but what are you actually striving towards? And it’s really amazing. So thank you for all of that.
(00:40:53):
I’m shifting gears a little bit. One of the things that so many of our Levels members are motivated by in terms of improving metabolic health, and the doorway that leads them to the metabolic health world is, concern about healthy aging, and specifically, about the brain, and Alzheimer’s dementia. We’re having so many simultaneous brain health epidemics rising right now across neurodegenerative disorders, neurodevelopmental disorders, and mental health disorders, that all seem to be going up at the same time, which of course, if you look at the newspaper, it’s like, “Huh, why is this happening? It’s so strange.” And obviously, we are focused on the metabolic trunk of that tree that has, unfortunately, not made it to the mainstream yet.
(00:41:40):
But I’d love for you to talk specifically about the ketogenic diet as a tool for brain disorders of all kinds. Just generally, how can ketones help the brain, and how are these conditions related? And is there data that’s suggesting that this can be a tool to help prevent or reverse some of these issues across the brain spectrum? So very broad question, but I’d love for you to speak to it because I know you’ve produced so much amazing content, and even publications, on this.
Annette (00:42:12):
Yeah. Again, my tapestry was to offer peak brain performance for patients. And when I wasn’t really using the metabolic… I mean, I could tell them they needed better sleep, and I knew that was really important, and I knew that being overweight was a predictor of their brain aging too fast, that their A1C, the higher it got, the more likely they were to have a brain disorder. But I didn’t put this as the baseline for all of my brain patients. Well, if you have a brain, you should first have ketones in circulation if you’re trying to age it without those dementia risks.
(00:42:54):
And it doesn’t mean zero, but it means the best way we know to control that is that, even in people with mild cognitive impairment, which you remember that 30 point test where you have the patient draw a clock, and you ask them all these questions, and then you say, “Okay, if you’ve got 25 or above, you’re going to have normal. But if you get 25 or below, we start to call it mild cognitive impairment. And as soon as it’s even a few more points under that, we call it dementia.”
(00:43:26):
Well, when they studied people looking at, well, they’re aging, but they are right on the edge of that mild cognitive impairment, and they added medium chain triglycerides. Now, they did this knowing that there are two specific chains of fat, one that’s eight carbons long, and one that’s 10 carbons long, so medium-chain triglycerides, C8, and medium-chain triglycerides, C10, and those readily cross the blood-brain barrier and become fuel options for your brain cells, for the astrocytes, and oligodendrocytes. These metabolism fuel sources are not limited in many ways like the glucose is. Ketones are also able to cross that blood-brain barrier without limitations, or different limitations than what a glucose molecule would have.
(00:44:23):
So the people in this study, they were glucose dependent, and they were pretty naive to the medium-chain triglyceride oils. And they started these mild cognitive impairment patients on, I think, it was 30 and then 45 grams, which is a lot, of oil a day that were these specific chains that they knew would cross the blood-brain barrier. Well, they had to get past the third day without so much diarrhea that they gave up. So there was a big fallout rate when you start eating a bunch of fat and your body’s not ready for it. But for the people who made it, their mild cognitive impairment was statistically back up to a normal rate within one week of doing that, meaning, what they postulate, and what I am a believer of, is that as you age a brain in a fuel chemistry of glucose fuel all the time, it becomes resistant, it doesn’t use that glucose as it should. It doesn’t get into the cell as it’s supposed to.
(00:45:32):
And so the cell is starving, it can’t get the fuel it’s supposed to. But it would use a fuel, like ketones, or a fat, if it could get access to it. And so when you flooded the system with it and it crossed that blood-brain barrier… first of all, their scans on SPECT scans, what was dormant, what was not functioning is back to functioning. And that correlated with their testing, that they went from this mild cognitive impairment, which I don’t want that ever, because the next step is dementia. That mild cognitive impairment went back up to normal functioning within a week. I don’t have a med that works that fast. The next question or what most physicians would be asking is, “Is it safe? Is it safe to do this?”
(00:46:15):
I’m like, “Let’s go to the kids whose brains were riddled with seizures,” so much that they put them in the hospital and says, “You failed Depakote, you failed lithium, we’re going to have your whole family admitted to the hospital, and you’re going to be known as the ketone kids, that you had to be on a ketogenic diet.” And they were really compliant because in a state of ketosis, this section of kids stopped having seizures. And as soon as that chemistry shift changes, and I’d like to say it in a different way, as soon as the fuel that was the anti-inflammatory, that was the readily available, was missing in their brain, they seized. And if you’ve ever seen one of these EEGs, they have hundreds of seizures a day. How are you counting all that? There’s so many seizures in a day that one seizure destroys a bunch of brain cells.
(00:47:10):
How do you recover from a hundred of them in a day for two years? So these kids have just rotten luck that their brains were that destroyed, and then they get on the ketogenic diet and they stop having seizures. And of course, they’re not perfect at first, but they get to the point where, dang, straight, I did not go off this diet because I have a seizure, I pee my pants in front of my friends and life is not good for another two weeks because I… post concussive. Okay, so now, they age. And when I wrote my book in 2015, there had been a couple of autopsies put into the literature of the brains of the people at autopsy that were the ketosis kids. They had gotten into their 80s, or 90s, whatever it was, and died. And they were in this study, the kind of study that I like, which is not run by a drug company, and is not funded by this person, it’s not corrupted by that person.
(00:48:00):
The guy dies, and we look at an autopsy, and the people who start the study, well, they’re dead because they started it when they were in their 60s and then they pass it along, and now, these people are dying and we get to look at their autopsy. And I am reading this report and saying, “Well, I have brain envy,” and I don’t have brain envy very often. Look at that, there is no neurofibrillary tangles, they do not have the divots and missing fat components, that nicely insulated neurons are everywhere. And this isn’t like a 30-year-old, it’s a 90-year-old. And in that story, you can hopefully read between the lines that what was happening through the years but constant state of ketosis is. Well, these kids really did well. There were other side benefits found in the next several autopsies, but when it pertains to brain health, the safety data, you have to look no further than putting these kids on it.
(00:49:05):
And they were there for a lifetime. And we have autopsies at the end of their life saying, “Pristine, beautiful brains,” and there’s many more of them that have added to the files since 2015. As you look at that understanding though, when patients come to me and they have autism, or they have depression, or they have bipolar, or they have wet brain, now dry brain because they’re sober, but they have really had a hit to their brain from substance misuse, and other forms of mental health issues that turn into a rotten looking brain, and they say, “Well, what would you do?” And the answer is, “I would do what I am doing,” which is, fueling my brain with ketones every day in a way that I usually can deliver with a diet. Sometimes, I will supplement, if I’m being human and I’ve not eaten as well as I should.
(00:50:04):
But the reason I do it is because, well, I love what it does to my brain. And I have some of the most incredible experiences with patients that… Let’s take the article that I shared with you, Chris Palmer, a psychiatrist from Harvard, he and I had been on stage a few times, and again, it was one of those places where I was so comforted by somebody else saying what I was doing. And I was like, “I’m not going to be first again, somebody else said, “I’ll be first.” And when he did, I was like… And then if you’ve ever been to one of these conferences, the people storm around me, and they storm around him, so we get these two minute blurbs. And then a year later, we’re on stage and then we get on a two-minute blurb. And finally, I cornered him and said, “I just want to tell you about this case.”
(00:50:49):
So I am a big proponent of support groups. This comes from the data in my private clinic where I took care of lots of brain people, but some of the most difficult stories and the saddest funerals were the brains that didn’t make it out of substance abuse. And from mothers, to grandmothers, to teachers, that just couldn’t kick the habit, it became this place ride… Anything I could do to do better, that was… The pain of those funerals still haunts me. Could I have done better? Could we have done something different?
(00:51:32):
So I have my own electronic medical record and I’m very data-driven. And so I go back to see who are the people that made it five years sober, and what medication was I using? Did I give them a Vivitrol shot for six months, or did I do it for 18 months? Was it this antidepressant? Was it that? Was it TMS before the six month, or was it after? I was looking for something like I was going to cut down the line. And I found it. Oh, my gosh, look at the outlier. Look at that every single one of the people in the five-year mark of sober, they did. And the answer was, not me, it was, they attended the support group. They looked in the eyes of other people and said, “Yeah, I screwed it up. Here’s how I got back on the wagon.”
(00:52:29):
They were in relation. They were triggering mirror neurons, which are the cells in our brains that copy behavior. And when you grow up in a environment where you don’t see a behavior, and now you’re being asked as an adult to use it, the only way that brain can learn it is to watch it in another person before they can activate it in themselves. And the group was the number one separator, it was not even close. It makes it look embarrassing that they even came to me. They should have just gone to group. If you want to learn a new behavior, you have got to be in relationship with other people who are working on it too. And you got to show up with a little grace for yourself, and know that the grace for others and yourself are always the same.
(00:53:21):
So if you’re being nice to them and you’re not being nice to yourself, you’re lying to one of you. That joy of improvement and sharing outtrumped everything we were doing. I host a support group, and you can say it’s selfish, because how do you get a support group of keto people? But it also came out of a little bit of desperation. When I was living in South Dakota, I had a wonderful Brazilian woman who was a little bit crazy one day and wanted to become my patient. And this was at the time where I could not take on one more patient, my staff would kill me. We were so far behind. I needed a helper, and like anybody ever needed a helper. And it was just in a season where that wasn’t in the budget, and how do I keep going? And she wanted to see me for a ketogenic diet.
(00:54:10):
And I’m like, “You don’t need to see me for a ketogenic diet. Just read the book.” And she goes, “You need to teach a class, and I’ll be your first student.” And there was something about that, where if you’ve ever had these moments in life where you know you should say no, but there is just something where God takes over and makes you say yes. And so I said, “Okay, I’ll lead a support group for keto.” And by golly, well, that’s where David showed up. David actually never saw me as a patient, he was only a person who came to the support group. So I start the support group when I moved to Tampa. And this lady drives two and a half hours to come to the support group that starts at eight o’clock on a Tuesday morning at the bowling alley across the parking lot from here.
(00:55:00):
And she is just so thankful that she can come and ask questions. And she’s got this daughter who has Down syndrome, and her daughter has lost over a hundred pounds at this point on a low-carb diet. Well, if you’ve ever taken care of Down syndrome, it’s like their brain ages metabolically like three times the rate the rest of us do. And especially, most of my Down patients have had an obsession of some sort. I remember the first one was, they were obsessed with eating carrots, and the mother’s like, “No, no, no.” She said, “Why do you think my son is orange?” And her son is like a 35-year-old Down syndrome patient, or patient with Down syndrome. And I’m like, “I don’t know why your son is orange. Come back next week. I got to look it up. I have no idea.”
(00:55:53):
A month into practice, and I’m looking, I’m looking, I’m looking. And I call her and say, “Does he eat carrots?” And she goes, “Oh yeah, if I don’t lock the front door, I’ve found him down the street at the grocery store eating the carrots out of the grocery store.” And I tell the story because it’s this obsession, it’s like an addiction, where they have to eat it, they have to eat it. And once they get in the cycle, they’re going… It’s like, you got to lock the fridge. So fast-forward, her daughter has Down syndrome and has deteriorated significantly. She has been diagnosed with Alzheimer’s. She was I think 42 years old at the time, and a few years prior, when the diagnosis was on the edge of, and going from mild cognitive impairment to dementia. Now, it is absolutely Alzheimer’s, you can’t reverse this, she’s going to die with this.
(00:56:52):
Full-time care had gone from living in the house, doing the family chores, being a functional part of the church and the home life of the family, to now really ornery, just the mood shift that comes with Alzheimer’s. And it’s a really sad story. And that the caregiver exhaustion was everywhere. So mom had resources built around and had gone on the ketogenic diet, lost about 80 pounds herself, and needed to lose probably another… I don’t know if it was 30 or 40 pounds, but she comes to the support group for that. And she does what I tell her, and she loses the weight, and within a couple of weeks, she goes, “Do you think my daughter could do this?”
(00:57:32):
She told me this story and I said, “If she does it, you have got to check her fingers. You have got to check her numbers and keep track of things.” Well, she is nothing if not methodical and did that. And within six weeks, this woman who had already lost a hundred pounds on low-carb, so that means there weren’t ketones around, maybe sporadically, but nothing like what we were measuring, “I need you to measure her ketones every day. I need you to measure her glucose every morning. This is not a negotiation. You have to do this if I’m going to help you with this.” And six weeks of persistent and documented ketosis. And she goes back into her doctor to be tested for some level of something, and she was back to testing at her baseline. She was off of the antidepressants, she was off of the memory medications, at six weeks, because her continence came back, her ability to interact with people came back.
(00:58:30):
It’s like she reversed age and was back to her baseline Down syndrome. And then her mom says, “But it’s even better, my daughter has never used a three syllable word. It’s not in her brain to do that.” And I asked her the other day, “Do you get it? Do you get it?” And she replied, “I understand.” And the mother wept. She goes, “Her brain has never worked this well.” And so I told Chris this story, Chris Palmer, the psychiatrist, and he’s like, “You have to write that up.” I’m like, “I need that like I need a hole in the head. That’s a nightmare of a job. I’m not doing that.” And he goes, “Yes you are. I’ll do it with you.” I’m like, “Oh, I’m a sucker.” So he helped me just get connected. And there were a couple of people in the editing process that were really nice to me saying, “You can’t do that in the paper. You got to use this, and you got to do that.” I’m like, “I don’t know.”
(00:59:30):
So anyway, we got this published and it really did turn out well. It forced me to read through her file and confirm all of the things that were happening before I ever met her. And then I got a Christmas card from her this past year. And mom still comes to group probably once a month, so I get updates on her. But the patient wrote me this letter, and it’s probably a third grade writing, but she wasn’t even able to do that for years. Not only has she continued to stay on the better side of a brain function, but her cognition has continued to improve. But it is based on a mother who loves her daughter and makes sure she’s in ketosis, they check their numbers together every morning.
(01:00:16):
And mom says, “You don’t know what it’s like to have your daughter disappear into this body and out come the monstrous version of her that’s got emotions, and it’s got dysfunction, and it’s got anger. And no one can praise and love like a mother, but I’m struggling, and she’s back and she’s better than ever. So I’m in ketosis for life.” Such a heartwarming story that if there’s ever a brain story that needs to win the most shared brain story, that should be it.
Casey (01:00:53):
I have shivers. That is so, so, so beautiful. It’s incredible because I think a lot of doctors who will go their entire career without ever having an experience like that or a story like that. A true reversal. Most of us, I think the best we can hope for is management of a current level of health. And even that is sometimes wishful thinking, or a slower progression of decline, that’s like winning in the medical system, or I feel like how we’re trained, and so this is incredible. And I’m imagining you see this type of thing all the time.
Annette (01:01:36):
Yeah. That’s an extreme case of somebody who said, “You’re on my no list. You have Alzheimer’s, we can’t reverse that.” And then it’s in a patient with Down syndrome. And-
Casey (01:01:47):
Wonder if you could speak to, we covered… that’s a beautiful example of the neurodegenerative part of the spectrum, what have you seen in terms of more the mental health focus? So depression, anxiety, maybe bipolar, things like that, and then also the neurodevelopmental. I saw one of your videos on ADHD, and I think it’s really interesting to hear about, maybe both in relation to children and adults, if you’ve had just any thoughts on dietary interventions as first line foundational treatment for mental health and neurodevelopmental. I think for a lot of people, this might be the first time they’d ever even thought about that or heard of that. So what kind of results have you seen? What’s the science say?
Annette (01:02:36):
Yeah. I think, as a practicing clinician, you love it when you can find a study that comes and supports what you’re doing. But many times, in my 20 plus years of seeing patients, there’s something happening in front of you that you’re trying to recognize and then replicate. And I’ve been screening for depression from the first day I left the track of becoming an ICU doctor and said, “I’m going to be home for my kids.” And my husband likes to say, “You went from being one of the highest reimbursed physicians to the lowest and we still have the same medical school bills.” I said, “Yes, but our kids won’t be in rehab as much.” I don’t know if that’s true. But the beauty is that primary care outpatient had so much depression when I got there like, “Oh, my word, look at all this stuff.”
(01:03:32):
Really, I remember thinking at about six weeks, I would do just about anything for an intubated patient, because they couldn’t complain about their mental health, “What the heck? I’m an internist. Why am I doing this?” And what I realized is, I cannot improve their health if their brain is doing this. And I was in a leadership course at the time where it was really empowering us to take control of the things that are the most irritating to us. And it was like somebody gave me permission to help them. I’m like, “Oh, well, let’s do this. Let’s formulate that.” So every patient got a PHQ-9 from that point on. And I think it was 350 of them before I got one that wasn’t severely or moderately depressed.
Casey (01:04:18):
This is just standard primary care practice, just like all comers, and it’s getting worse, these depression rates in teens are just going up astronomically. So you’re seeing fairly universal depressive symptoms.
Annette (01:04:32):
Right. And so then you start throwing Prozac, Paxil, Zoloft, Celexa… all these meds. And you say, “Okay, you’re not going to feel a dang thing for at least 10 days. And then you’re going to come back to see me in a month, and we might be able to see a separation, but everybody else says it’s six weeks before we can see anything. And you’re just going to trust me that I know that this is going to help you.” And of course, the only way it’s helping you is that the PHQ-9 got better, and that means they didn’t have anorgasmia, or whatever else was affecting their body and brain. And then comes the ketogenic diet where I would have girl friends. Okay, so my practice in South Dakota was closed, I cannot take on another patient, my staff will revolt if I take on one more person. And my girl friends would come to me saying, “Would you just write me an antidepressant?”
(01:05:22):
And I said, “I’ll do it, but you should really just peak ketones for three weeks and watch what happens.” So this is where the story started for me personally, where I was like, “Yeah, yeah, yeah,” but I’m seeing something in front of me. And again, this is 2015, I can’t quite make sense of this. I can’t find any good literature of anybody else. I hadn’t met Chris Palmer yet. And what would happen is I’m like, “I know it sucks. Just give up the damn carbs, 20 total or less. Take these ketones strips, pee on them. I’ll a send the script in, but just don’t pick it up for 10 days. Watch what happens.”
(01:05:58):
And they did not pick it up. They’re like, “I can’t believe how much better I am.” I’m like, “Yeah, it was such a remarkable difference.” And again, I’m saying, “Here, write this script. I’ll see you at Christmas. Because it’s going to take a while, and you’re going to have side effects, we’re going to change the dose, and we’re going to change the diet, and you’re going to have a fight with your husband and think it’s the pill’s fault… No, you’re just wasting time. Trust me, peak ketones for two weeks and watch what happens.
(01:06:29):
So that was my first like, “Okay, I need to make a rule that I’m not going to keep writing this unless you are really continuing to, A, come to support group, and I know you’re there because I’m there, and B, continue to get back to a ketogenic state as frequently as you can.” And that’s where exogenous ketones were a place that if they got out of funk, take some until you can get the rules, you can find that rhythm of life again. And we’ve all been in and out of rhythm that it really is, once you get into this habit of, really, this is how I play it, I can keep it, but when you fall out, you’re like, “Okay.” But I need ketones in order to get your brain working right. So trust me on this, don’t get away from that. We can chemically induce your ketones much like I’m going to chemically induce a reuptake inhibition with Prozac.
(01:07:21):
Trust me on this, this is better. And so that was step one. Then the ADHD literature, as adults are profoundly on stimulants, I will not write for them unless they are in a state of ketosis. You find another doctor to play this game because I’m not your girl. I will not write for a stimulant unless you’re in a constant state of ketosis. You are not helping yourself with taking that long-term, unless you’re in a state of persistent ketosis. And I need evidence. I’m not saying, “Yeah, I peak ketones. Look at last week.” No, I need a continuous glucose monitor. I need you all following things. I need you reporting on your Keto-Mojo app that I can see you’ve got ketones in circulation. And really, the number of prescriptions I needed to write became very unlikely. I also am the mother of teenage boys now the youngest is 17, but I have 17, 20, and 22.
(01:08:22):
And so in this last season of watching them and their friends age through that rapid brain development, and especially boy brains doing the most maturity from 16 through 25, it’s been a profound gift for my kids. Our family became a very ketogenic family when my mother was faced with a life or death, “Mom, you’re going to be in ketosis or you’re going to die.” And that story is what anyway you can, it’s about 70% story, 30% science, which is usually just enough for people to stay focused all the way to the end. So my kids by accident have had their deepest brain development in a time… Were they always in ketosis? No, but they are not metabolically ill. They are metabolically strong and healthy.
(01:09:13):
And I feel it’s a gift that I would’ve never done had I just kept seeing patients the way I was and doing what I was doing. Instead, I lost a bet to my husband, taught people about a ketogenic diet, have lived one for myself. And I was the mom who would go in and show, “Here’s what your brain looks like when you drink alcohol and you’re a teenage boy, and this is what it’s four days later. And now, look at my Alzheimer’s patient. You are worse than my Alzheimer’s patient when it comes to drinking alcohol during such rapid brain development.” And then I’ll show them pictures of, “And here’s what happens when you smoke marijuana. Here’s what happens at day two, here’s what day four, and then when you quit, 40 days later, here’s still what’s happening. 80 days later, here’s still what you did. It is a fat soluble molecule that goes into the brain and it stays in the fat cells of your brain for 90 days. Period.”
(01:10:10):
Yeah. So I was that mom, showing brain scans and doing all these educations for my kids, because if their friends heard it, then they heard it. But what was more powerful was, how many of my kids’ friends were suffering? And my kids would recognize, “Boy, mama, all they eat is carbs.” And then their energy goes way up, and then it goes down, and they’re calling it ADHD. They have sugar in their pocket so that every two hours, they can eat. And of course, we’ve seen this as clinicians, that you’re like, “God, you eat all the time. What the heck? You got to stop. And you get up in the middle of the night to eat. There’s a problem here.”
(01:10:52):
And so I was very attracted to, I think it was a psychiatrist, last name is Eads, but I’m forgetting her first name. And she’s connected to Chris Palmer somehow, but maybe it was just about we met on stage at the same time. But her rule as a psychiatrist is, “I will not write a stimulant for a child unless you have put them on a low-carb…” Whether or not she called it keto, I can’t remember, but it was, “Get the processed foods out, get the sugar out.”
(01:11:23):
When that mood is going up and down, and up and down, what you’re really doing is you are stimulating that mitochondria to burn out a bunch of fuel and then it crashes. You don’t have a flexible metabolism. You go to zero, and they starve, and they get crabby and irritable, and that looks just like a non-focused irritable attention deficit. And so then it’s much easier to label, give it a pill, stimulate the crap out of it, and not fix the problem but have a prescription that must be the answer. And so personally, I can’t believe how many of the antidepressants I’ve stopped. I think the drug companies are… I know them, they are wonderful people, I get that they have a job to do, but I think it is a tragedy that it is not better educated that your brain prefers ketones, and when you fuel it like that, it works like a superpower. We are the most advanced brain on earth, and when you fuel it correctly, it is quickly recovered.
Casey (01:12:21):
It’s devastating, the brain stuff, because like you just said, it’s like we’ve been gifted with this miraculous mind and brain, and all at once, is just fuel, so it can create magic for us every day for this beautiful life that we have. It’s just ready, it knows how to create magic, and then we put it in the standard American diet, and we sleep deprive it, and we do all this stuff, and this beautiful machine creates what can be such a painful, devastating life experience of loss… For me, actually, when I was in my surgical residency and was almost certainly metabolically dysfunctional and just a mess, what I described to my parents, I was like, “It felt like I was thinking in color, and now I’m thinking in black and white.” I didn’t have creativity, and my mood was very just flat. It was under-fueled brain, it just was.
(01:13:20):
Then once I got out of that, and the fuel was better and I was putting better, it comes back. Yeah, it’s just devastating. And this moral hazard with the pharmaceutical industry. And I’m with you, I know a lot of really wonderful people in that industry. It’s not that the people are bad, it’s that the incentives are bad, because these are publicly traded companies that are designed to grow. And the only way you grow companies that are making medications for chronic disease is by… there needs to be chronic disease. And so it’s so interesting, and that’s why, honestly, thinking about things like media, YouTube, podcasts, other ways to get this information out, it’s so important. And it’s not surprising that there’s a lot of your videos that have millions of views, because people are hungry, but it’s not coming through the mainstream. So I just so commend you.
(01:14:12):
So the core demographic of Levels members is actually women, ages 35 to 55, which people think that’s surprising because they’re like, “Oh, I thought it was young biohacker men maybe.” Our primary people interested in the company is that age group, and so a lot of mothers. And I think a big question that people have, I’m sure it comes up with you a lot in your practices, how the heck do I get my kid to eat anyway? Other than the standard American diet, how do we create a culture in the family where people are into this? With kids going off to preschool and they’re serving graham crackers and Fig Newtons and juice, which is, to me, just astonishing that that’s legal. But what would you say to a family who’s listening to this and thinking, “I could never get my kid to eat this way. I could never get my family to eat this way.” What is step one, two, and three for thinking through that element of behavior change in a family?
Annette (01:15:14):
Right. Well, so as one strong woman talking to another strong woman, I would tell the women out there to remember that you’re the matriarch, that across the globe, the matriarch’s rule in a family is to run the food and will be the personality of the family. There is a role for patriarch, and they are a different role. But I think, especially as women, and women that have done some pretty brave things, “I left the family farm, I was not going to do that, I became a doctor.” And I thought, strong women were the ones who, I don’t know, boss people around. And it turns out, I shouldn’t be doing that at home or I’m not going to have a marriage for very long. But I do have absolute authority over the food and the personality of our family. And when you study families, that is a role. It’s not woke, it is truly a traditional model of what happens inside a family unit.
(01:16:22):
And I would encourage women to embrace that. I have a prayer that I say, that I am an 80-year-old woman who does CrossFit so I can play with grandkids, and I’m still married to the same man, and I’m hard to live with. So that prayer is definitely going to take God to do this. But that I also honor what my role is for this family to be the best health it can be, not because I’m a doctor, but because I own the matriarchal roles in a family. Which means, you buy the groceries, you choose the foods. The options in front of your kid don’t involve cereal because you don’t buy that, that you are the mother. The reason you care about this more than them is because you’re the matriarch. It’s designed in you to be passionate about this, and it is your role to lead the family in a way that you need to be empowered by.
(01:17:16):
And yes, it’ll be a fight. It’s what happens when you withdraw from sugar, they’re going to be crabby. But my son is a perfect example, that he’s the youngest and he’s a wrestler. The other two are not wrestlers, they followed their mother’s rules and did debate, no head injuries. But this wrestler now needs to make weight, and he doesn’t like sardines anymore than the next guy. But I would challenge you to call him and say, “What’s in your backpack today?” Not because he likes sardines, but because that mother was around saying what was true, “Look, the carbs are going to slow down your brain. The carbs are going to put you to sleep in the period right after lunch.” And yes, you can’t always control what’s going on in a preschool right now, but you control what happens in your home.
(01:18:01):
And then as those kids age, and you think it’s teenage years and they’re not listening to you, they’re listening and they’re following you. And when they have a mother who pays attention to the label and the processed part of foods, and doesn’t buy the crap that she doesn’t want them to eat, and takes on the fight, takes on the role to say, “You want to know what a strong woman is? She stands bravely and says, ‘This is my role in the family,’ and I’m going to do a good job of it.” That’s what I’d tell women.
Casey (01:18:31):
Wow. I feel like in this day and age, oddly, that’s a very bold statement to make, but I think there’s so much importance to it. And just speaking personally, I don’t have children yet, but I dream of that. Obviously, my life is metabolic health, but it excites me in a way to think about being in that role of this protector of the nutrition of these bodies that you’ve created in your body. And I think a lot about, not to get too off track here, but just this privilege and honor I have to grow these bodies, and what environment is that going to be, and how do I, at 35, prepare for that now and create the best conditions, that chemistry set, for both that growth, and then when they’re out, to continue that through strong, what I would say, moral leadership around food in a family.
(01:19:40):
And there’s a lot of industries and a lot of people… and industries, I would say, that really want us to question that, and to feel like it’s actually wrong to have strong feelings around food, that that’s going to harm your kid in some way, like create disordered eating, or this and that. And I think that the way you position it of like there needs… And Kelly Leveque, one of our advisors, says as well, “There needs to be an adult in the room when it comes to food, because otherwise, every other force is going to basically try and use your child as a profit center,” like, how much processed food can we put in this? How many medications can we put in this unit, this person? And it’s like, I think when you understand those incentives of what are the forces that want your child to be sick, dependent, and addicted, and then as your role as a parent, how can you be that protector in a way?
(01:20:42):
And so it’s complex, but it’s just beautiful how you laid it out, and honestly, very motivating. So it sounds like you mixed some philosophy, some really strength of will, a lot of education with your kids, is what I’m hearing, and then of course, keeping the house environment as clean as possible in terms of food. Are those some of the elements that you think about, or is there anything else in terms of practical strategies for what you do when the kids are going to school or birthday party? Any other pearls that you might recommend to parents? If they’ve got those bases covered, they’re not buying the food, they’re serving healthy meals, they’re educating their kids and they have strong sense of will and leadership around this. Any other tips that have worked well with parents to make a transition to a healthier environment for the family?
Annette (01:21:33):
My favorite advice as a mom is, I was the sergeant. I raised boys. Boys and girls are different, but at the beginning, it was very firm boundaries on what your job was. And I remember, one of my best friends had kids at the same time as me, and she had girls, a boy in the middle, but three kids, and I had three boys, and we meet each other about 10 years into reproduction. And her three kids are sitting lovely, and my boys walk in the room and I’m like, “Sit. Stay. No, don’t touch that.” And she goes to her husband, “I think she thinks they’re dogs.”
(01:22:13):
And I’m like, “You have no idea how hard it is, they’re whirlwinds of energy and if you went up for a second, your house will be destroyed.” So I think everybody’s personality comes into motherhood, and mine was being very authoritative at the beginning. But then the acts of service that you do in your community, your children will copy. So I became that mom and just said, “What do teenagers listen to?” They need humor and they need their peers. Humor, and playfulness, and peers are the ways you make a difference in teen years. And so I tried to find ways into that part of, I can’t be the humor, I can influence their peers by doing some of the things I volunteer to do in my community. And I’ll just tell you that they’re listening, they are listening.
(01:23:13):
The seasons of life, of raising kids, is something I… for the women out there who want motherhood, or in any way they get it, whether it’s adopting the neighbor’s kid because she’s just overwhelmed in a time where they just need a helper, or if it’s your own children, that there’s nothing in my life that’s been more rewarding, but also a time of truly looking at who am I as a woman and as a person.
(01:23:42):
And it’s fun. I see my behavior flaws in all of them now, but also, they did adopt, especially as they left the home. They won’t tell me they’re low-carb, but they intermittent fast. They don’t talk to me about it, they talk to their dad. So I know they’re very mindful, they know what the rules are. And I think it’s just that constant, how do kids learn? They watch their parents. So give them a good example and then have the boundaries that are necessary when it comes to nutrition. You buy the food, dude, keep the options at home clean. You can’t control the world, but this little micro universe called your home, you can, and it makes all the difference.
Casey (01:24:31):
Beautiful. Oh, my gosh. Dr. Boz, I could talk to you all day. As you know, we had a list of questions we had prepared. I feel like we got through just a couple of them, but it was 10 times even richer than I could have imagined. And so maybe if there’s ever opportunity to do another one, this is amazing. But I’m so grateful to you for the work you’ve done, the spirit that you bring to this, just the deep integrity that you bring to this, it comes through so much. And I’m so grateful that you’re also a storyteller. You bring a lot of this alive in a way that I think… We’re not trained to be storytellers as doctors, but that really helps people feel it so differently. So I just really admire you and I’m so grateful for this conversation. Thank you so, so much. And if you would like to share with people how they can find you and get in touch with you, we’ll make sure to put it all in the show notes, but what are the best places for people to continue to learn from you?
Annette (01:25:24):
Best thing that I have put my energy into the most has been YouTube. So find me on YouTube. There are other platforms I’m on, and you’ll find your way there eventually. But start with YouTube and find me. Every Tuesday night live is when I give a live presentation. And if you’re ever in Tampa, there’s a free support group at the bowling alley across the parking lot.