Dr. Stephen Phinney – 'Achieving and Maintaining Nutritional Ketosis'

Dr. Stephen Phinney - 'Achieving and Maintaining Nutritional Ketosis'

okay well this isn't supposed to be brief and I will do my best although I do need to point out that one of my graduate students once with maybe a grain of truth in it gave me the nickname of dr. digression so try not to live up to that one so the topic I was assigned for this is okay we talked about the theory what about the practice and so the title is achieving and maintaining nutritional ketosis that and I want to point out that this is the the far end of the low-carb spectrum it doesn't mean that this has to be everybody's destination but as Professor Noakes pointed out in his is the presentation this morning that the more insulin resistance the person is the farther he had they have to go down the carbohydrate intake scale to drop down towards the improved metabolic condition and to get out of the damaging zone from as a result of carb intake so this is not everyone's destination but it is a destination that the more insulin resistant the person is the more likely they need to target that to achieve the best result so I'll show you this diagram that you saw this morning you just point out that robot to point out that the goal here is to achieve ketone values above 0.5 millimolar and most people don't have to worry about going above 3.0 if somebody does a period of a few days of fasting they will go above 3 but if your enough protein to maintain lean body mass almost everybody stays under three so this is the the target range that we defined as nutritional ketosis you don't have to be high in this range to get the benefits and I've had a lot of questions from people today who measure their ketones and they say well you know sometimes I mean below 0.5 and sometimes I'm in this range is that okay we all differ one from another and we still have a lot to learn about how high you you need to get up to change not just the fuel flow but the gene expression things that I mentioned and if you get into that our suspicion is if you get into that range of for say six hours a day you may trigger the benefits that then continue on even if you slide back down into a lower zone so it's sort of sticking your head up and looking around and know where you are you don't have to be looking for where you are all the time and you still don't run into parked cars or parking meters and things like that so again the point here is that the island of safety that we're talking about for the most insulin-resistant people is nutritional ketosis here I'm not saying that paleo is not beneficial certainly coming from the standard American diet cutting coming down to the to the paleo range will can cause considerable benefit but there are some people for whom the final destination needs to be lower and more moderate and protein in order to stay in this place where you will get those ketone values above 0.5 and hopefully above 1.0 millimolar so I want to share with you not just the the the diet composition but how that changes as a person who initiates a low-carb diet how it that changes as they move down the weight-loss curve so what we show here is a diagram which you have four phases of weight-loss starting from the initial adaptation phase all the way down to maintenance and so for just this the kind of a theoretical example we start with at say a woman who starts out Wayne 200 pounds and over the course of many months losses down to 150 pounds when a overweight person first goes on a well-formulated ketogenic diet it's very common that they lose quite a bit of weight quickly and that's because they have markedly enhanced satiety and loss of cravings and they want to lose weight so they consciously restrict calories and or unconsciously restrict them and some people say it's just effortless that weight came off for other people they have to pay attention to it but that person weighing 200 pounds will initially probably have an energy expenditure of something like going on on the order of 2,800 calories per day but if you're eating 1400 calories a day the weight loss will average about 2.8 pounds a week and then as the weight comes down the energy expenditure comes down associated to some degree with that reduction in weight and people tend to eat more and so what we see is that weight loss is steep initially and then it tapers over time but the important point is that at this point where they're eating 28 hours of Boerne 2880 1,400 half of the body fat oxidation comes from body fat so the purple zone here is body fat contribution that's why they're losing weight as one tapers the rate of weight loss increases the dietary fat so if you go from 14 to 18 order calories and very little of that as added carbs and you don't add much protein then what you're doing is they're running fat progressively and as you add that fact progressively there's a smaller and eventually a zero contribution from adipose tissue and a lot of people get confused by this and they say well gee if I'm in ketosis why aren't I still losing weight because we've been many people say well if you're in ketosis you must be burning fat fast enough gain weight or lose weight and that's because whether consciously or or spontaneously when someone gets to maintenance they have to be eating roughly tooked overall the same number of calories as they're burning and so you know I did people say huh how is that and I point out that you know my weights been stable I've been on the ketogenic diet for 10 years my waist been stable for the last nine years and seven months and yet I still have that the level of ketosis and the reason is that I'm being imbalanced by eating over 70% of my calories is carbohydrate and I eat about five percent 70 percent is fat my about five percent is carbohydrate which is what it takes for me to stay in a stable situation and so here's one of the really practical issues of that if somebody's going to get to maintenance and still stay on the ketogenic diet they have to eat a lot of fat and as Professor Noakes said you know people come to this with fat phobia and we've got to cure them of that if we're going to be able to give them the opportunity to stay on a ketogenic diet and stay weight stable long term so overcoming fat phobia is extremely important the second point and again like your fat Pete talked about this in his his presentation and in terms of inflammation and that is the we have a choice of fats and oils that we can eat and for the last 40 years we've been told that we need to avoid the saturated fats so the red here is saturated fats and you can see there's a list starting though the one with the least saturate that's most commonly available canola going down to that said about 6 percent going down to coconut oil which is up in the range of 90% of calories coming from saturated fat and the reason is red is that's why stop signs are red the donators because it's Dain when we now know that's not true but the focus has been on saturated fat and the avoidance of saturated fat and then the other point that many of the seed oil companies want to claim is that well he may six men alayich acid is one of the two essential fatty acids and so that's a quote good fat it's also been shown in research in the past that when you feed somebody a high oh maybe six oil content in their diet their total cholesterol goes down and the seed oil companies say well that's good right except it goes down because HDL goes down the good cholesterol goes down and that's why eating a lot of the blue few stuff here supposedly makes you know is good for your cholesterol when in fact it's not it's driving down the beneficial one of the beneficial fractions of total cholesterol and then of course there is the fact that this the omega sixes are the progenitors of arachidonic acid which people like Barry Sears and others have vilified as being extremely dangerous and very inflammatory but the truth is arachidonic acid in in tissue membranes is absolutely necessary for life and it's only pro-inflammatory when is released from the membranes to make into inflammatory compounds so i'ma have to be a little careful about making simplistic blanket comments about arachidonic acid per se I don't want to get too deeply into that but but it turns out that when you do adipose biopsies on humans what's really surprising because basically whether we take a needle to anesthetize the skin and we take a little bit of fat whether from here or here wherever and what we find consistently in people in a variety of locations a variety of countries and for me in a variety of states right throughout the United States that there's a very consistent pattern where something approaching half of the stored fat now what's stored fat that's what you save to burn tomorrow if there's no food available for you tomorrow that half of that roughly is monounsaturated fat and since olive oil is high in monounsaturated a you know under our skin we're all Italian that this is appears to be what the body stores the composition of what it stores for what is going to burn if it has what it's going to burn this mostly fat well what my body is burning in a key to adapt a state where very little carbs and moderate protein is mostly fat and so it appears that the best combination of fats and oils to consume when you're feeding yourself mostly fat should come from either monounsaturated or saturated fats so when you look at it from that perspective if you look at lard here it's about 41% saturates and 47% mono saturates and maybe something like Lord is a a reasonable composition of fat to eat now my wife is Asian and she says of course the best bag is his locker which was it that and peanut oil with the traditional fats that they ate and again I'm really high modernist at repeated or again this is presumption but the message years is avoid the high omega-6 the big I call them the big blues on this diagram here and try to find something which gives a reasonable mixture of saturates and monounsaturated to use and you know over the course of many years seems quite acceptable is to take olive oil and blend it 50/50 with butter and that you can actually blend those two together put it in the fridge and it's like a soft margarine but it doesn't contain the trans fats that you get from margarine and it doesn't have the the omaha omega sixes and it's a very nice fat because you can put it onto fish or meat or whatever and melt it in or on steamed vegetables and it's got a very neutral flavor in a nice mouthfeel and if you've got to eat a lot of fat that's a nice one to have but people say that's way too expensive olive oil is really expensive except when i'm by olive oil at my warehouse shopping center i can buy two three liter jugs of good quality olive oil for $23 in US currency if you do the math on that that's 50 cents for a thousand calories now where else when you go out to eat can you get a thousand calories for 50 cents I asked it and so the idea that this is way too expensive a diet without high fat moderate protein diet is way too expensive a diet I don't mind if you're a clever shopper and you prepare things in bulk and then put them away and you've heard that multiple times today that's a practical solution to making this be relevant expensive diet so if you take four ounces of chicken breast and you grill it and then you put 300 calories of a nice nicely flavored fat on the plate along with some steamed vegetables makes it really really nice on training it's very satisfying and so attention to the composition of that is very important for the ones long-term success on on this type of diet and again if you can't achieve maintenance it's not going to do you you're not going to benefit your health long term so again now that I think all of our books have been sold so I'm not plugging the book because it really plugs itself but in the book there Jeff Pollack and I share kind of 7-day sample menus that you know guys are height and weight would eat you know if you're a 55 kilogram woman you would want to cut the proportions down but this is just one day I'm not going to give you all seven days but our point in doing this is this can be a pretty simple diet to prepare and it can also be really luscious so if you're rushed in the morning you want to have you know something quick for breakfast you just cook for sausages you know like not hot dogs but real sausage is made with real meat and a cup of coffee and that can be very satisfying breakfast and get you through till lunch for lunch you can have a salad that's simply made it out of some water packed tuna a couple cups of greens and people ziwei about water packed tuna why would I have a lot of I want to have fat well the problem is that most tuna is packed in soybean oil and you don't want the soybean oil so you get the water packed tuna and you put the oil in your dressing and so I make a blue cheese dressing which is I make with yogurt in olive oil and why do I use yogurt rather than mayonnaise way most mayonnaise is high soybean oil and the second is that yogurt is not in emulsion so you can make a batch of this dressing a large batch and freeze it and because it's not emulsion when you freeze it it doesn't come apart so when you thaw it out you still have a consistent dressing and the recipe for that is in the in the book and so I make 10 or 10 or 20 servings of this at one time and put it in the freezer so I take out a half a cup serving in a little ziploc bag put it in the bowl along with the lettuce when I'm rinsing the lettuce off and it thaws out and you know it takes me half a minute per serving to make the dressing and so this is really simple quick marinade the snacks would be a couple of ounces of mixed nuts maybe some soft cheese and some celery we advocate having two cups of salty broth per day whether it's homemade broth or the soup little bouillon cubes not the ones that have lots of start to stuff in them and the reason for taking the salt is that when your keto adapted your kidneys excrete salt quickly if you don't replace the salt you're going to have lightheadedness dizziness fatigue headache and constipation and in the states that's what's casually called the Atkins flu because most people who casually went on the Atkins diet would have these symptoms and they say well I just feel bad all the time I'm losing weight so I'm going to put up with you don't have to put up with it all it takes is 2 grams of sodium added to a lightly salted diet so it's not a high-salt diet it's the mono salt diet those symptoms all go away and then dinner can be I make homemade tomato bisque from the tomatoes I grow in my garden is our summer right now so that's top of my menu moderate to size piece of state beans mushrooms and you can have homemade ice cream we don't get to have commercial ice cream it's good to slow carb it's possible to make homemade ice cream in batches put it away so I make it once a week or once every two weeks and you know if I want to have a 1/2 cup or 3/4 cup serving of that it's there in the refrigerator and and ready to go and that's how you can you know strategize overtime to have the right kinds of fats available and simple to make for a satisfying meal so again I'm going to make this simple because there's actually a lot of sophistication to this this is why Jeff and I wrote a book of how to do this because there isn't a single soundbite that will tell you exactly how to do it so the kind of the key steps is it's moderate protein it's not high protein more protein is not better and it certainly is more expensive and if you want to make it sustainable for the planet we don't want to have to have large servings of animal protein and this protein doesn't have to come from animals it can include tofu when some of the protein comes from nuts it can come from eggs the next is to have enough energy because if you don't eat enough of the fat you're going to you know when you get to a lean weight your body's going to say go eat something and it'll be nonspecific you'll need anything if you're you know if day after day you're trying to eat five thousand or five five hundred calories less than you're taking in as I just emphasized the right kind of fat is critical and then something that's often neglected and very important is mineral management and one of those is just simple salt by the way if you're really really anxious about salt being dangerous and you don't want to take it in I suggest you read the New England Journal of Medicine from two weeks ago there are pair of papers from McMaster University in Ontario Canada and it's now is going to be the definitive study of over a hundred thousand people and they showed that the optimum range for sodium intake for humans not on a ketogenic not just on all diets is between four and six grams a day by the way right now the US American American Heart Association wants us all to cut down to two point three grams per day if you take the McMaster data and look at two two point three grams per day what happens is you had on there you have a 50% increase in cardio ask Euler disease and a 50% increase in all cause mortality when you go from four grams a day down to two point three so this whole thing about demonizing sodium is about to be flipped upside down just like the pyramid is now being flipped upside down so if you're dizzy I'm sorry but you know get used to it it's going to change and then again not being too flippant if things don't seem to be going quite right and you've got to figure out what should I do to clean things up this first rule of thumb is eat less carbs don't eat more carbs the next is if in doubt things don't seem to be going quite right eat more fat than eat less fat yeah this is all sounds counterintuitive but this actually works and the final is and you've heard this from other speakers there has to be pleasure and satisfaction in your life and one of the things that we do more often than anything else that gives us pleasure is not sex but eating three times a day it should taste good it should be satisfying you should walk away from your meal saying I've had enough and the confidence that you're not going to be plagued and until the next time you come to the your next meal and with that I'll end with my welcoming slide come visit me sometime I'll put you up in my Inuit bed and breakfast thank you very much


  1. Too bat the graph at 7:26 does not have avocado oil on it. And how old is the graph? I heard Lard has way more PUFA than this shows because they feed pigs an unhealthy feed that changes the fat profile.

  2. I haven't heard Dr. Phinney mentioning eggs as part of a low carb/ketogenic diet.
    I eat a 4 egg omelette each morning with butter, perhaps I should replace it with meat?

  3. THIS IS SO NECESSARY. I find it always baffling how most keto communities advise on a high protein ketogenic diet for people coming from metabolic damage and diabetes without considering that both Carbs and Protein are glucogenic macronutrients. I try every day to explain the science behind keto in layman terms, this video has been invaluable to link to my viewers, thank you!

  4. Sorry to be an editor, Dr. Phinney, but near the end of your lecture that should be "eat FEWER carbs". Otherwise, this was an excellent lecture.

  5. The best for a Fatty Liver ; take 1000 mg. of Chloline with Inositol with each meal you eat . Also take 2000 mg of "stinging nettle" every day to bring down bad estrogen and lose weight . Also Take 800 mg. 2×400 of "Lipoic acid" a day .
    Sleep 10 hour every night sleep helps lose weight control your hormones and release HGH try to be in bed by 9:00 pm and wake up early and exercise for 40 minutes before you eat breakfast …..eat a low low fat and low carb diet , don't fry , don't eat any type of oils ,no salad dressings , NO OILS !! NO FATS ! no sugar , no coffee , no chocolate , no stimulants of any kind , go in the sun 40 minutes a day , Eat no dairy , no bread ,no junk food and drink lots of apple cider vinegar with water .. Eats two lemons a day for vitamin C and detox your liver and kidneys .

    Eat daikon radish every day for healthy thyroid you can buy it at any Korean grocery store . The intermittent fasting diet also helps …. I lost 96 pounds and I no longer have a fatty liver , no sleep apnea, and no more diabetic , took me 5 yrs I am a vegan ..nothing is easy .
    one of my favorite books that will help you lose weight ;
    The Obesity Code: Unlocking the Secrets of Weight Loss Paperback – March 1, 2016
    by Dr. Jason Fung ;www.amazon.com/Obesity-Code-Unlocking-Secrets-Weight/dp/1771641258

    Choline supplementation improves liver function and improves cholesterol

    The liver is our largest internal organ (the skin is technically the largest organ) in our bodies. The importance of a healthy liver cannot be overemphasized. Americans have very unhealthy livers, with epidemic rates of liver disease, including cancer, hepatitis, cirrhosis, and fatty liver (alcoholic and non-alcoholic) among other conditions. It is vital to maintain the health of your liver throughout life.

    The liver has two enemies: 1) fats, and that includes vegetable oils, and 2) alcohol and drugs. Americans eat a 42% fat calorie diet, and most all of these fats are saturated animal fats. Saturated fats harm our bodies the most.The real road to healthy liver function is to eat a low-fat, high-fiber, low-calorie, low-protein diet .Stop eating, or limit, red meat, poultry, and eggs. Take dairy of any kind completely out of your life, including low-fat and no-fat dairy products. Keep your fat intake under 20%, and from vegetable, not animal, sources. Under 20% is the magic number. 10% is the ideal.

    At the famous Mayo Clinic (Expert Opinion in Pharmacotherapy) people with non-alcoholic fatty liver were given TMG with impressive results. This is intimately related to the epidemic of diabetes and other blood sugar problems we now suffer from. Many people have fatty liver disease, but simply don't know it. The same results were found at the famous Stanford University (Review of Gastrological Disorders). Later at the Mayo Clinic (Best Practices in Research in Clinical Gastroenterology) doctors successfully treated non-alcoholic steatohepatitis. Anyone with hepatitis should do this program for two years. Please read the article on hepatitis in our library Hepatitis-C.

    Doctors at the University of Virginia (Current Treatments in Gastroenterology) gave TMG to people with non-alcoholic fatty livers. They suggested this as a superior treatment to drugs, along with better food choices. Fatty liver leads to far more serious conditions including early death. The same results were found at Loyola University (Nutrition Reviews).

  6. This is the best diet that has ever worked for me, not just for weight loss. I have IBD and possibly Chron's disease. it has so far controlled my symptoms and next to no flare ups. The standard North American diet causes me major flare ups and has landed me in the hospital.

  7. My grandparents ate lard sandwiches during the great depression. My mother would always tell me to be thankful that we had butter instead of lard like her parents. Turns out lard is ok!

  8. as i tried many diets before im gonna give it a try and see if how my performance goes with it.however i dont trust people who drink coffe and use apple products

  9. There are so many great benefits to nutritional ketosis. I have seen fantastic results! Here to help if anyone needs it!

  10. Salt, like oils, is not all the same. Instead of over-processed table salt – which usually contains harmful flow agents, and is heated to over 1,200 F – get natural, unprocessed salt. The high temperature changes the salt, making it less beneficial. Himalayan salt is a well known unprocessed salt with high trace mineral content – but Redmond's Natural Trace Mineral salt from Utah is also excellent. It has fewer food miles, and is more affordable, too. Both Himalayan and Redmond's salt taste great, too!

  11. Plastics, especially flexible types like in freezer bags, transfer a number of harmful synthetic chemicals to whatever food or beverages are in contact with them. Instead, try freezing in glass. We've been freezing food in glass, including canning jars, for decades, and only had a couple crack. KEY: do not fill completely, especially when filling with liquids. Flour, nuts, etc keep better when frozen but do not expand like liquids do.

  12. Love his videos. But I can't find answer to this question in them: If ketones test consistently between 3 and 5, what's the proper course of action? More calories keeping the proper ratios, or more carbs?

  13. how long does it take, on average, to get back into ketosis, if you are keto adapted but eat more carbs than you should and are thrown out of it?

  14. Ketosis does nothing more than curb your appetite, you eat less and thus lose weight. I did it strict for 7 months, less than 20 grams a day carbs, bought a ketone and blood glucose meter. Hit the gym 6 days a week. I lost 40 pounds in 5 months and then stalled. Sometimes you would go 5 weeks without loosing a pound. I started tracking my calories and i had to consume roughly 1500 a day to lose any weight. If i ate 1500 kcals a day on a healthy diet with carbs i would have lost the same amount of weight. I did like the stable energy levels, you never get hungry or crave foods so it's easy to consume less food. I weigh 210 pounds and pretty fit. This is not a quick fast fix, requires alot of pre planning, meal preps and dedication, the diet is difficult to stick to as you end up eating the same few meals every day. I went months lifting my ass off at the gym and wasn't getting any stronger because the muscle needs insulin to grow, plain and simple. I started eating cabs again and immediately noticed strength and muscle gains in the gym.

  15. Wow this talk has so much useful information that I am gonna take screenshots of the slides for future reference. Maybe I'll even print them off and stick them on my wall. I have been doing keto for a couple of weeks, but have hardly lost any weight and am feeling tired. I think I have done a pretty good job of cutting carbs, but I am probably still eating too much protein and not enough fat. I think I also have a bit of keto flu, so I will buy that vegetable juice in the stores that I have been avoiding cos they put 0.5g of salt in every 100ml.

  16. I read the book and I did the ketogenic diet. I felt great for the first couple weeks or something. I felt high energy and euphoria after maybe a week into it, but I remember a while after that I felt like crap and low energy and couldn't train at all. I was getting enough calories, though I know better sources now. I did it for 6 months and was not feeling well or having any benefit. I saw no fat loss and couldn't train. I was doing something wrong. I had very high ketones up to 7mg/dl sometimes. I recently learned about intermittent fasting and carb cycling and suspect one or both of those things are the missing part of the puzzle.

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