September 1, 2012
[00:00] About Dr. Peter Attia
[01:59] Dr. Attia's Ketogenic State
[06:11] Reason for The Ketogenic State
[13:21] Maintaining One's Intensity in Events
[18:33] Suggestions & Advice from Dr. Attia
[22:42] End of the Podcast
Ben: Hey folks, it's Ben Greenfield, and it's been a few months since we have had Dr. Peter Attia on the podcast. We did an incredibly popular interview with him a few months ago, and I'll be sure to link to that in the show notes for this interview, but when we talked to Peter, we specifically talked about how to fuel an active lifestyle and still be in a low carbohydrate, or even what is called a ketogenic state, and if you want to really lay down the foundation of understanding and go back and listen to that podcast, if you haven't yet, I would recommend you check it out before you listen to this one. But I had the pleasure of hanging out with Peter for a few days over in Boston recently, at the Ancestral Health Symposium, and while we were visiting, Peter mentioned to me that he recently fasted for 24 hours and then he went on, I think it was a five or a six-hour long bike ride with what I think was no fuel, just some sodium, and so I told him I had to get him on the podcast to learn how he's doing stuff like that, how he's tracking it, what some of his tips and tricks are, just because there are a lot of health and fat loss and some really cool fat burning implications when you're in this ketogenic state which we cover in the last podcast that we did. So, Peter, thanks for coming on the call today.
Dr. Attia: Ben, thank you so much for having me. It was awesome to meet you in person, finally after speaking so many times. It's an honor to meet you, and I look forward to chatting about this topic.
Ben: Yeah, and if you've ever seen me or seen Peter, you do know that I win the hair contest.
Dr. Attia: And the height contest.
Ben: Yeah, that's true, but you win the ketogenesis contest, I think. So, let's start there, man, do you actually stay in this ketogenic state all the time?
Dr. Attia: It's a great question, it really depends on how you define it, so if you were to define ketogenesis as having a plasma or serum concentration of beta hydroxybutyrate above 0.5 millimolars, then there are definitely times I dip out of that state. Just for reference, the average person walking around is at zero millimolars. The average person after an overnight fast might be at 0.1 millimolars, so 0.5 is the notional use of the threshold for being in nutritional ketosis, and in my experience, the sweet spot is really when you're about that one millimolar in a fasting, non-exercise state. So yeah, for about almost 18 months now, I have been in nutritional ketosis, but there are definitely days when I slip out, and it's obviously always a result of eating a little too much of something, and its generally over consuming protein, but on occasions, it can be over-consuming certain carbohydrates. For example, you're very, very susceptible to fruit, so overconsuming fruit can easily whack you out of ketosis. Like I said, for me, that sweet spot in protein needs to be below about 120, 125 grams a day, and there's times when I'll go over that and I might get out for a day.
Ben: What's the sweet spot for carbs? How you like it, zero?
Dr. Attia: No, it's very difficult to get in zero. There are a couple of foods I just like too much to eliminate. It's hard for me to get rid of nuts in my diet. What I don't eat really any of this just your routine carbs that most people think of. I don't eat low-carb breads or low-carb bars or things like that, but all of my carbohydrate content really comes in the form of vegetables which I eat quite liberally, and obviously, I don't really eat the big starchy ones, but even making a salad with tomatoes and cucumbers and stuff, you're getting some carbs there. As I mentioned, the nuts, I really like almonds and cashews and walnuts and macadamia, not huge sources of carbs, but especially in the cashew, you got to be careful. Every ounce of those things can come with anywhere from five to nine grams of carbs, so you got to use those liberally. Pardon me, you can't use those too liberally. I really like olives, and I put heavy cream in my coffee and stuff. And again, it's really a numbers game. Over the course of 24 hours, you can very easily get to that 50 level which is probably about the threshold. Although as we'll discuss today, Ben, there's a huge temporal component to when you consume these things.
Ben: And you mean in conjunction with activity levels or time of day?
Dr. Attia: Both, yeah, and the frequency with which you're eating as I'm starting to learn over the past few months.
Ben: How often are you testing with ketone strips?
Dr. Attia: When I first entered nutritional ketosis, I was testing probably three or four times a day, and when I work with people who are transitioning with ketosis, I sort of give them a very simple set of parameters, which is I'd like you to test first thing every morning, I'd like you to test immediately before dinner, and I'd like you to test right before bed. Those are three pretty predictable times in a person's day. When looking at the changes in glucose and beta hydroxybutyrate give me a sense where the struggles are and where they go. Now the kicker is these things aren't cheap, and as one reader on my blog pointed out, probably one of my top 10 comments I've ever got on the blog. They said the new definition of wealthy is with a person who can afford to check their ketone strips all day long. The glucose strips are cheap, the ketones strips are not. Once you're really dialed in, I mean you can move to as infrequently as every couple of days. Although I still check a lot when I'm doing experiments on myself, sometimes I'll go a week without checking and sometimes I'll check seven times in a day.
Ben: Okay, cool. Well that's probably good. It says when you are talking about experiments that you do on yourself because, like I mentioned, you told me about how you fasted, and then you went a long bike ride. So, before you explain how you did something like that, let's talk about why you would do something like that. What exactly where you trying to achieve when you didn't eat for a day and then went out and did a long endurance training session?
Dr. Attia: That's a great question, it's important to know that certainly wasn't the first time I had done that, and it took me a while to work up into that, and I hope that nobody decide that they're going to go a day without eating and then go for a five or six-hour ride. Took me a while to get there. Basically, in the spring, I wanted to try an experiment to see could I give it an attempt at this intermittent fasting, and as probably your listeners and readers know, there are a lot of different protocols for that out there. There's people who advocate for doing one meal every 24 hours, anywhere from once, twice or several times a week. There are others who talk about it intermittent fasting where you just do all of your consumption within a window of time, call it six hours, sometimes you talk about eight hours. So, going sixteen hours off, eight hours on. Basically, I wanted to look at all these things, and my motivation was really to expand on what I had already learned about my body's ability to utilize its own internal fat stores. I travel a lot for work, and a lot of times I find myself, during travel, not having ready access to the kind of foods that are conducive to the life I want to live, and so just naturally through that process, I found myself fasting quite a bit. It was sort of if my choice is eat the candy covered peanuts that Southwest is giving me or go to Subway and scrape the turkey off the sandwich and eat the turkey.
It's such as you wouldn't eat nothing, and so I began to observe in myself that I had this ability to go longer and longer in between meals if necessary, with no hit in performance. Whereas three years ago, when I was eating a standard American diet, that was simply impossible. I just couldn't function if I wasn't eating constantly. So that was really the genesis for this, and now, specifically for the riding thing, what I wanted to know was if I become metabolically flexible enough that I could access fat stores, even at a relatively high percentage of VO2, it seemed at least theoretically possible that I should be able to go for a long period of exercise without having to intake anything because obviously I still have some glycogen in my liver and my muscles, and it seems that if I provided enough hydration and mineral, I should be able to access fat to provide the majority of my energy requirement, with the exception of those peak periods where power output necessity, it's going to a glycogen past and therefore an anaerobic pathway.
Ben: Gotcha, okay. So basically, you're just trying to, more or less, turn yourself into a fat burning machine?
Dr. Attia: Exactly.
Ben: Cool, so in terms of getting through something like that, you told me that you were using high amounts of sodium via chicken bouillon cubes, and I actually recently wrote an article about some of the things that help you get through a low carbohydrate diet, and I know some of the supplements are the same for a long ketogenic training session, but are you taking in any supplements before or during something like a fast, followed by a long endurance training session, and are you taking in any form of calories at all like medium-chain triglycerides from coconut oil or anything along those lines?
Dr. Attia: That one depends on the experiment, so one thing that I've gotten pretty comfortable with doing, so this would be my standard thing, whereas I would do maybe one meal a day. So, let's say on a Saturday, I would have my one meal, and that might be at five o'clock in the evening, and then the next day, I would wake up, call it at six or seven o'clock in the morning. So, fourteen hours of a fast, I would then consume about three grams of sodium in the form a bullion, usually either chicken or beef stock, and that's a pretty high amount, that's about half my daily requirement of sodium, and then I would load up the bottles with just water, and basically I'm gradually increasing how far I could ride under those conditions. So, the first time I did it, I just went for a thirty-mile ride at a pretty reasonable intensity, and I carried with me what I call my rescue agents, so I carry with me a bag of really salted nuts, usually cashews, some almonds and peanuts, and I got through that thirty-miler, and I came home, and I didn't need to eat. So, I was like okay, great, so the next week, I tried that again and stretched it out to forty miles and then fifty miles, and eventually, I was able to stretch that out. I think my longest ride to date under those conditions was about ninety miles.
By the time, I was doing a ninety-mile ride. That was a pretty hilly ride which probably too close to six hours or five and a half hours, and amazingly when you get home from these rides, of course, I'm always checking my glucose and ketones levels, and that's some of the highest recordings you'll ever find in a ketone because at that point, you really just turn the body over into fat oxidation, and of course, your brain at this point is going to require the ketone because you no longer can supply the hepatic glucose output to meet your brain's requirement fully. So, it wouldn't be uncommon to come from a situation like that and have a blood glucose level in the 50s and a ketone level at three to three and a half millimolars, and so my hopes are kind of familiar with those numbers. Most people with a blood glucose of fifty are not cognitively playing with a full deck of cards, whereas the amazing thing is when you've got to three and a half millimolars of ketone bodies there, you don't actually notice it. So that's what got me thinking. There's an obvious question that begs asking which is my performance improving under that situation? And the reality of it is I would say no, this isn't necessarily a performance enhancing strategy, but one of the things I did want to do this summer was lose ten pounds to try to get a little lighter for some of the climbing, and this was certainly a strategy that facilitated that. This was an easier way to create a caloric deficit, but through still using a ketogenic diet to do it.
Ben: Right, and I think that certainly some of the most important to harp on is that there is that health-slash-performance tradeoff, but of any of the folks who have spoken with so far who are endurance athletes or athletes and who are still staying very low carb or ketogenic, you seem to have cracked the code quite a bit here in terms of allowing yourself to go relatively hard in a state of ketogenesis. So, I think this is good information, so what if somebody wants to maintain as high an intensity as possible? Let's say somebody wants to go out and do something like this, go as low carb as they can but also burn a few matches, get up to max power, pass some guys during an Ironman triathlon, be able to run at close to lactate threshold during a marathon, following a hundred and twelve-mile bike. I mean, do you think that there are things that should be added into the mix to help folks along or have you experimented with any of that stuff?
Dr. Attia: Yeah, I've definitely done a lot of that, and certainly if you're going to go out there and do an Olympic course, and you want to break two hours, if you're going to go out there and run the Ironman, you're going to need some supplemental energy, and the reason I say that is anybody who's doing an Ironman, you're talking about even the winners are going to be in that nine-hour range, and your average super fit person is going to be known ten to twelve, I'm assuming. Very difficult to not need to burst to get to the point where you're going to not require going through your entire glycogen store. Now, it's complicated pathways because, obviously, a lot of the glycerol that you're breaking down from fat go through gluconeogenesis, so your tank is not completely depleted, but nevertheless, it's just not the most optimal way to get your performance. So, the other product, and I think we have spoken about this in the last podcast, but I've also been using this, and in fact, for the past two weeks, I've been bringing it back into my training a lot more as the super starch product by generation, you can, and the reason I'm just such a huge fan of that product is it's like the best of both worlds because it is a starch.
It's a pure starch, it's a hydrothermally-treated amylopectin, and amylopectin is just plant glycogen, but you hydrothermally treat it. You turn it into a molecule with a molecular weight that's probably two thousand times that of maltodextrin, and when you're ingesting this stuff on the bike or in the water or in the weight room or whatever, you're basically giving yourself a super, super slow release, time release, glycogen store, but you're doing it without the insulin spike that turns off lipolysis, and right now, what I'm doing with super-starch primarily is using it post-fasted ride as a means to very quickly get glycogen back in the tank, and that's just because of where I am right now and what I'm training for. I want to be able to go into each workout the next day, even though I'm going to be largely fasted, having at least a glycogen tank that's readily full, and by readily, I mean probably two-thirds full. It's obviously very difficult to complete the ketogenic diet to be walking around with a full tank of glycogen.
Ben: Gotcha, have you experimented with anything else, in terms of even supplements like caffeine or creatine or anything of that nature, in conjunction with a good hard session in a ketogenic state?
Dr. Attia: Yeah, I mean I've definitely gone through a lot of those things, so I mean I'm a caffeine consumer. I typically don't consume any caffeine while exercising, but it wouldn't be uncommon for me to have a large cup of coffee along with my cup of bullion before I go out for a ride. As far as other things that I use, I'm just not really a fan of any of the commercial products, and certainly I find the maltodextrins, the high fructose corn syrup products just to be really counterproductive, both on the gastrointestinal tract and also in terms of the amount that they secrete insulin, even during exercise, though to a much lesser extent during strenuous exercise than when you're sitting on a couch, but nevertheless, they really do inhibit fat lipolysis, and there's obviously data showing that, so for me, really on the bike, it's very simple. My supplement regimen off the bike is, I'm sure, more complex. We talk about sodium. I also supplement magnesium, use a probiotic. I do use MCT oil as well and a lot of fluid, believe it or not. I mean it sounds obvious, but you'd be amazed how much your demands for fluids are there when you're doing this kind of work, and so I actually just did a 24-hour urine analysis the other day, and so for a day, I had to keep track of everything that I was drinking, and obviously voiding, and I was amazed. I mean I drank seven liters of water in a day, which is probably more than I would have guessed if someone had asked me how much I drink.
Ben: So, you actually prefer the MCT oil to doing something like coconut oil?
Dr. Attia: Yeah, I do cook with coconut oil, so I'm actually getting MCTs, both when I cook with coconut 'cause I really only apply heat to either coconut oil or butter or lard, but sometimes in the morning, it's just quicker and easy, and if I'm going to use a supplement to just a couple piece bins of straight MCT oil out of a jar.
Ben: Right, gotcha. Cool. So, in terms of additional advice, any thoughts you have for folks as far as going out and doing this. First of all, do you have any additional recommendations, and parallel to that, is there anything that folks need to be aware of when it comes to people who shouldn't be doing something like this or potential side effects of this approach, anything that could potentially be damaging?
Dr. Attia: Well absolutely, it is important for people to keep in mind that my experience is really reflective an end of one, and I started this after a year of being keto-adapted, a little over a year actually. So, I went through, and I think we may have discussed this in the last podcast, Ben, my first six to eight weeks of ketosis were horrible. So that was a really difficult transition for me, and a year into that, I think it was a much easier transition for me to move to not only intermittent fasting protocol and various intermittent fasting protocols, but also incorporating rigorous exercise. I got to be honest with you, I don't think I could have gone straight to what I'm doing now which is two-hour, really challenging high intensity sessions in the weight room, flipping the tires, doing the jumping pull ups, all the crazy stuff I love doing. I don't think I could have just gone straight into a fasting state of doing those out of the gate, so I think the most important I'd give people is this is a journey, and you've got to start slowly. You've got to listen to your body, so when you're getting light headed when your performance is failing, you've got to slow down, evaluate what's going on. It's obviously really difficult to troubleshoot these things in a broad manner. I think every case is a little bit different. It's challenging, I know when you're running a blog, to want to be able to help everyone, specifically whereas at best, the most you can do is going to help people in general and hopefully give them the tools to ask themselves the questions. Am I getting enough sodium, am I getting enough magnesium, am I getting enough fluids, am I getting enough fat, am I taking too much protein. It really is as Jeff Volek and Steve Finney would say it's probably more art than science at this point.
Ben: Gotcha, cool. Well I've got one last, really important question for you, Peter. When are you going to come to Washington State and race me on the bike?
Dr. Attia: I'd love to. It's so funny I was just on the phone with someone up in Washington State, up at the University of Washington today, and I was asking him if he was going to be down in San Diego or if I was going to have to be up there. You know, Ben, I got to be honest with you. I don't think I'd stand a chance against you on the bike, man. Now that I've seen you in person, the only thing I'd could take you in is if we came up with a contest, it was completely geared toward like things I knew how to do that you didn't. If you would come up with a macro may. Obscure set of things to do, but as your readers probably know, I mean, you're a pretty amazing physical specimen. I'm just an old guy trying to get by.
Ben: Well, I think that if you probably put me into as ketogenic a state as you get into, that you would definitely have the upper hand, especially if we fasted for a day and rode our bikes for six hours.
Dr. Attia: Only if you will have adapted. If you adapted, we'll be on par again.
Ben: Well, I think that was a lot of really good information, and what I'll do is link to Peter's excellent website where he's got some really good blog posts, especially on cholesterol, incidentally, over at eatingacademy.com. I'll also put a link to some of the other things that we talked about, like the U-Can sports drink mix and the link to the previous podcast that I did with Peter a few months ago. So, Peter, thanks for your time today and for coming on the call.
Dr. Attia: Thanks a lot, Ben. It's been my pleasure, always great to speak with you.
A few weeks ago I tweeted about a fasting low carb diet:
Today I talked to guy who hammers through 6hr workouts after 24hr fasts & figured out how 2 do it without bonking. Want me 2 interview him?
– Ben Greenfield (@bengreenfield) August 9, 2012
I received multiple responses of “Yes!”.
The guy I mentioned in that tweet was Peter Attia, who has been on my show before in the episode “Is It Possible To Be Extremely Active and Eat A Low Carbohydrate Diet?”.
As promised, I got him on to talk about how to turn yourself into a fat burning machine by fasting for 24 hours and then going out and doing a monster workout (without bonking), and in today's interview with Peter, I ask him:
-Do you stay in ketogenesis all the time?
-When you do something like fast for 24 hours, then go on a long bike ride, what exactly are you trying to achieve?
-What do you actually take on or before a long ketogenic training session? Any calories at all, or just some kind of supplements?
-What do you think is the ideal protocol for someone during a workout in which they want to maintain as high an intensity as possible, but also burn fatty acids as a primary fuel?
-Do you think there could be potential side effects of this approach, such as a decreased metabolic rate, lower thyroid, immune system deficits, or anything like that?
A few resources Peter and I discuss in this interview are (and by the way, sorry about my ice crunching habit, my mic sensitivity was turned up way higher than I thought!):
-Abbott Diabetes Care ketone monitor – This is the device Peter uses for checking his glucose and beta-hydroxybutyrate (B-OHB) levels (those are his ketones).
-UCAN SuperStarch – a corn based starch fueling product with very low release of insulin and extremely stable blood sugar compared to other gels, sports drinks, powders or bars.