#62 Ask Dr Boz Part 1


Originally published at: https://ketowomanpodcast.com/ask-dr-boz-part-i-transcript/

This transcript is brought to you thanks to the hard work of Trish Roberts.

Welcome back to the Keto Woman podcast, Annette. How are you doing today?

I am doing great. Thanks for having me back, Daisy. This is a true privilege. I love your audience.

Well it's really nice to see you again and yes, they love you too. And we had such great feedback that we thought we might do a...what's going to turn out, I think, to be a regular episode where listeners can ask Dr Boz their questions, and we can go through them and have a bit of a chat about different things that come up.

I also got quite a bit of feedback when we were on and just had such positive response for explaining what we did with just listening to your story and your headaches, and how important sleep was in the equation of really repairing and resetting a metabolism. So I just want to say thank you for being willing to share your story and how many people it helped by just sharing where you've been, and being a little vulnerable to say life for you isn't perfect, when it isn't for anybody. But when you share it publicly, sometimes it can make people nervous and they shy away. But you were able to just talk through your history and what those headaches had done and how they had evolved, and where the sleep a story came from. And just a lot of great feedback saying I learned so much by listening to that.

It's funny because I did mention in the intro, or the...it was probably the outro actually...I mentioned that I do have a tendency to stay online too late. One of the reasons is, because in the main I'm talking to people in America who are at least six hours behind me. So obviously that's a problem. But I asked people to tell me off if they saw me up past midnight. And people have been very good at telling me off. Unfortunately, I don't always listen, so I feel like we have a bit of a follow-up coming on, so I will have to own up to some of my sliding tendencies.

The beauty of 20 years of practicing is, when people talk about the changes that are made, boy, there's so much that's involved in a behavioral change. It is more than just a doctor saying, the science says, if you don't want dementia, you should get eight hours of sleep and it should match the light versus dark hours. Okay. So there's the science. Now add the humans. And man, we messed that up so many ways for so many good reasons. And I think if you're looking for two mantras that I use and how do you change behavior? The two tested-over-time things I continue to tell myself or encourage a wife who's trying to help a husband, or a son who's trying to help a bro...someone who's trying to help anyone...the two things that have stuck throughout time when you're trying to change behavior is...focus on improving you. And stay connected to the person you're trying to change. So that whole scolding, shaming, belittling people for not making the best choices, that doesn't improve behavior over the long run. You'll get a short term improvement, but nothing that is sustainable. Sustainable acts come from seeing a model behavior, like somebody who is trying to work on something themselves. And then if you want to change somebody and you never speak to them, you're never in their life, it's pretty hard. Stay connected, and keep working on you. So in that aspect, how have you been?

Well I have to say overall that I improved. It had got to a point where it was so bad as I think I said...talking about my sleep, this is...that I was often not starting to sleep until the sun was coming up. So, I'd really set myself up for the worst possible case scenario there. And so I did start pulling it back and I did get very good about getting to sleep. Or at least going to bed - because it can take me a while to get to sleep - but at least being in bed before midnight every day which is a massive improvement for me. And that has slipped, but it certainly hasn't slipped back to where it was, but it's still often...I'll start thinking about it. I'll look at the clock, and it's 11 o'clock and I think, right, I really must start winding down now. I'm not going to start watching another television program or I'm not going to start doing something else. I'm going to start winding down whatever I'm doing with the intention of being in bed by, or before, midnight. And then before I know it, I've got involved on questions or comments in my Facebook group or something like that. And before I know it, I look again at the clock and it's like half past one, two o'clock! And I'm like, oh no. And so then I shut down and I do, right, I'm going to bed now. On average I would say it is more like a half past one, two o'clock, which is a slip, but it's not back as far as it was. I have been aware of that and I have been thinking, yes, I must get good again about bringing it forwards.

I tell you my biggest problem, and that is getting up in the morning. I can remember you saying when we spoke in the first place, I can't do anything about telling your brain when to go to sleep, but I can tell it when to wake up. I tell you the problem. I will have great motivation and resolve when I'm going to sleep. I think, yep, tomorrow's going to be the day that I start getting up on the dot of whatever it is, seven o'clock...it's never going to be seven o'clock...eight o'clock in the morning; at least set myself a time that I might achieve. That's it. Eight o'clock I'm going to be up. I'm going to be out of bed. But when that comes around and the alarm clock goes off, it's like no, it's just not happening and unless I've got somewhere I have to be for a certain time, my resolve and my motivation just completely goes out the window.

And then of course by getting up later...although I am better about pulling myself up and getting up before a certain time, so I don't let it go as long as it used to...then I've slept too long, which of course then makes it more difficult to get to sleep at a decent time the next night when I should be asleep. So it just keeps having that knock-on effect because I am one of these people who ideally does like a nice solid eight hours sleep. And so just do the maths. It's not difficult. If you haven't got to sleep until two, three o'clock in the morning and you still want that eight hours, that's why it's so easy for it to keep getting later and later. I do know that that is probably the answer but I just have to make myself get up. I can be 100% resolved to do that, but when it comes around to it, it's really, really hard.

Let me give you some encouragement. The human brain really only can perform its best for 16 hours. So as you look at what we're trying to do is we know that that circadian rhythm, which is set by sunlight and as much as our electronics and our lights have messed with that, there still is signal in people who do the night shift, that they have a circadian rhythm that is still present in the morning. Now they end up with other rhythms that show up years later with a night-shift worker. But when you study their brain performance, when they took people who are sleep deprived. The study starts with medical students. So they want to get a good grade. They're very motivated to follow the rules. They get put in a sleep lab if you would, and without any distractions over the next three or four nights, got a really nice, good reset of sleep, so their sleep debt was kind of caught up. And they wake them up and they do these tests of intelligence. Kind of like how do you solve a puzzle, and how quick can you put this pattern together? And so it's kind of like an IQ test and it's timed. And you know they're smarty pants and so they did really well. And then they keep the students up for 24 hours and they did the test again. And then they kept them up another 24 hours and tested them at 48 hours. And then they let them get some sleep, and then they go back to their life, or not the life, but they go back to these places where we can monitor their sleep. Instead of giving them eight hours of sleep like they had before the tests, they deprive them of one hour. And they did that for a week.

At the end of the first week...now its seven hours instead of eight...I am a mom, I'm a doctor, I have a full life, and this is naughty that they did this and told us because it's seven hours instead of eight. At the end of a week, they were functioning as if they'd been awake for 24 hours. If you extended that seven hours versus eight hours for two weeks, they were functioning as if they'd been awake for 48 hours. So the brain's cognitive efficiency, its ability to perform has such a profound performance level of making good decisions, making reproducible, efficient, and calculated decisions based on rest. Based on eight hours of solid sleep…how are you doing? And if you're waking up, there’re points against that. And if you're not in bed for that long, you're certainly not getting the right hours.

They then let the students sleep again, retested them at the eight hour level. They went back to their performance that they had before and then they let them sleep six hours instead of eight hours. And at the end of one week they tested as if they'd been awake for 48 hours - two days. So the people who say, I can live on six hours of sleep, we have really good evidence. It shows what you're sacrificing is the mental acuity, very efficient performance that can only be found in the human brain associated with good rest. I get a lot of questions about why are my sugar's high or Doc this keto diet isn't working for me, and the first thing I'll talk about is their sleep. If you want your weight loss to continue, if you want your body's metabolism to go back to what it was designed to be - which, we aren't designed to be obese - we are designed to be a body weight that's pretty close to that BMI chart as much as that gets negative reviews from the masses. But that body weight, it matters and your body will gravitate back towards that if you give it the right tools and the right settings. And one of those settings is the reset that happens in your mind, in your brain, in those eight hours of sleep. So now that's the science. Now how do we help a behavior change? So let me give you some good ideas. It's not that you're maliciously staying up. You're staying up because it's been a pattern. You set a pattern and there's something comforting about listening to a story, whether that's on television or podcasts or books or reading. So escaping your life into a story has been a tradition for thousands of years in our human race that we use stories to kind of cope with life or learn life.

And you've got one of those habits. That's not a bad habit. That's better than drinking. Better than using other forms of escape where the habits can really hurt people too. So we say, how can we transfer the comfort that you give yourself with those stories to something else? And I would encourage that to be a desensitization skill or reset. And what I mean by that is, if you say, okay Doc, I'm not going to watch a movie, but I'm going to play scrabble or I'm going to play online a bubble-popping game or something. Again, that's an isolated activity with an electronic instead of a human relationship. Those lights are very stimulating to the pineal gland, which is what our circadian rhythm is set from. So if instead you said, okay midnight's the goal, I would actually push you back to about 9:30 that you turn off electronics, and even if I know...

Yeah, I'm making a face!

So you find something comforting that you can do to help reset yourself. I'll give you some suggestions. These are things I've had patients do over the last couple of months, maybe six months, that I've just really found helpful. I don't know if you have them in in your country, but in America there's been a kind of a swelling of something called a float. It's a really dense, highly saturated water filled with Epsom salt, which is again, a magnesium base. It kind of mimics the dead sea salt that you can't sink. So these little spas have essentially a pod. It's like a bathtub that has filters that clean the water when somebody's done, but the pods or the tank has such a high viscosity of like 1100 pounds of salt in the water.

So you can't sink and you're in this pod, and they turn off all the lights, and you have ear plugs in your ears, so there's no sound; there's no lights. And then there's this infusion of magnesium. Magnesium is one of the things we know can be absorbed through the skin; especially when we're trying to shut down our minds. If they're low on magnesium, this really helps. Now if your magnesium's normal, you're going to pee it out. It's not going to be any big deal. But one of the key signals that your brain will receive is a timeout. Jason Fung does a really good job of talking about removing a signal and that is the best way to reset it. Not decreasing it, but removing it. And same thing goes for the sounds and the lights.

You really feel like you're floating in space because you can't sink. Most people fall asleep by the time the hour is up because their brain just really finally shuts down. And I will contend that if you signed up for like three floats, by the third float...I've had such positive response from patients trying to reset their sleep habits saying, I'm trying to find something that can comfort you. Most of the spas here are open until 10 o'clock at night. So if you took the nine to 10 o'clock spa, on Monday, Thursday and Monday, over a course of 10 days, you would be amazed at how well you feel by just removing all sensation. Now you can do this in your own bathtub too. An Epsom salt bath in your own bathtub would be fine too.

What you want you might not do such a good job of - because you're all by yourself - is you've got electronics in your house and you've got distractions, and you got on the telephone and you're texting, and you're listening to a book. So it's not the sensory deprivation that happens when they do these little spas. Just try to remove all of that input. And boy, what a great antidote. Other things that I know are out of tradition, but are very helpful for the human brain to shut down when you're reprogramming sleep, is to get a pencil and paper and just journal.

Some people don't like the journal part of it and I do a workshop on brains of addiction and how do we break cycles? And one of the little activities I do is a three minute timeout. Nobody in the whole workshop - and I've had as many as 200 people in the room - nobody can make us sound. No burping, farting, laughing, nothing. Three minutes of complete silence. And then they take the utensil, should be a pencil in the wrong hand. So if you're right handed, it goes in the left.

Ah, yes. You mentioned this before. Yes, doing the cursive L's.

And that little rhythmic...just give yourself a three minute saying, I don't want to do this. I want to keep doing my electronics at night or whatever keeps you awake. That habit is powerful. It sounds silly. Like what could this possibly do? But I do a lot of work in jails and of course they just sit in the dark and if they're anxious, they have no tools to start.

And I can't tell you the number of letters I've received over the years saying, you came to the jail, you might not remember me, I did your silly little loop thing. I still do it to this day because it calms my brain so quickly. And there is something about the cursive language, the cursive writing - even if it's just an L loop, it doesn't have to be words - that's rhythmical and almost like hypnotic, a form of meditation for your brain. So I'm going to encourage you to detox starting around that 9;30/10 o'clock hour, giving two hours of anything to comfort you that doesn't have to do with electronics.

Yes. That's certainly going to be a tall order? I can certainly see the logic in what you're saying and yeah, I've got a very logical brain, so that always appeals to me. But yes I live in the middle of nowhere in rural France, so going to one of these isolated...that's not going to happen. But as you were talking about it and then you did say towards the end, it's something that you can do at home. I do actually have a tub of Epsom salts, so that is something I can do. And yes, as soon as you mentioned journaling, it's something that I encourage people to do, especially if they're trying to find a problem. If they're saying they've got a problem of some kind, whatever that is...their weight loss has slowed down or whatever it is, I always encourage people to journal. So it's something that I should start doing myself again because I have seen the benefits of it. I think it is a good way of just downloading those worries and concerns that you've had during the day instead of...and I'm very much the kind of person...I call it brain whirring, and I go to bed and certainly if there are things I'm still worrying about, they just go around and around and around in my head, and I can't get to sleep. I just lie there and I potentially lie there all night not being able to sleep. So yes, I can see the benefits of calming yourself down with the magnesium bath, downloading all those concerns onto a piece of paper and then going to bed. That sounds like a very good night-time routine.

Yeah. What you're trying to do is bio hack it a little bit, which is keeping in mind the brain only performs for 16 hours a day. You are human. That's the limit. After that, you're really hurting yourself. So shut off. To shut off at 16 hours can be like trying to flip a switch when you're a human. So adding magnesium definitely calms down the body. And one of the best, most relaxing ways to do that, I contend is still the skin. A nice warm bath - 40 minutes of pretty tepid water has got some good evidence behind the replacement of magnesium, and now you're adding tricks to your shutdown process that help protect you. Like remember that 16 hours is all you get. After that, you're going to have to undo this somewhere in the future. Maybe it's not tomorrow, but somewhere you're going to pay the price for the poor performance you're doing because you've been up too long. And then the next step is find things that comfort you. Find things that just help offload that stress.

Yes, and getting a bit more strict about the mornings. I'm one of these people who is really just not a morning person and feel so groggy if I get up early. But you just have to get through that and establish these new habits. I can see myself and I remember you saying before that whatever you feel like, you've just got to stumble through that grogginess until it becomes a habit and your body is used to getting up at that time of day, and starts to get alert that bit faster.

You had the advantage last time that you'd just been on the other side of the pond and so the light was matching your schedule better and then you said, I couldn't believe how much better. I felt. I'm like, yep, that's how that works.

Exactly. So I know I can. Yes. That's a very good point to remind me of that actually because yes, I'm sitting here saying that I get really groggy if I wake up early in the morning, yet when I was in America for just over a week, I was awake and alert at half past six in the morning, and I didn't have what I tend to get here...if an alarm goes off, or even if I wake up early my tendency is to just feel groggy and go back to sleep. I didn't feel like that at all there. I was quite happy to well, I'm awake, I'll get up now. So, you're right, it's obviously possible for me to do it. Just need to establish a habit.

Right? So the good news is, is that you and many people trying to change behavior, the most powerful part is to not scold yourself. Just have forgiveness. This is a habit. This is how you change it. Set up some things that make it easier. Like don't have a super dark room that allows you to sleep when the light is up. And I know that, we want darkness when you sleep, so don't have the neighbors light shining in there.

Well actually, yes, that's a precise advantage that I have, and I only have very light curtains actually if I draw them, but I never draw them. Yes, there's no light coming in from anywhere unless it's daylight. So yes, it's perfect for me to just leave the blinds open. So yes, that morning light comes in, although obviously in the winter it comes in later, but still...

Yeah. Well you can have a couple more hours of sleep in the winter and still stay on your circadian rhythm. How have your migraines doing?

Yes. Good. I still get them, but not too often. And I think that they were tied quite a lot to hormones. I'm definitely in that peri menopausal period, and hadn't had a period for ages - since May. I didn't have one for about nine months and, no, I wasn't pregnant. And then they came back just for a little while and then they went away again in May, and all of a sudden earlier this month, I got one again and I got more migraines associated with that. So I think there was a tie in. So I think that has kind of helped them diminish. But not bad. I would say on average I still get probably one a week. I'd like it to be one a month, but certainly better. Better than they were.

So that's progress. We'll keep going on the sleep and I would contend that when the sleep is stable, the migraines will be even less.

Yes. I can believe that. I completely can believe that. So enough about me.

I know you're always a little hesitant to share, but I just think it's such a great teaching opportunity. So thank you for sharing. The good news is, is you're the leader of a tribe. So when you sent the casting call out to say, does anybody have questions? Wow. Look at all the questions you can get.

Yes, we got pages and pages. So I did mention in the post that, don't worry, there's going to be more than one episode. So yes, we've got lots. So let's get stuck in, shall we? Okay. So the first question is from Terrilee: Heart failure patients like myself are informed to limit salt. How do I keto on low sodium?

That's a great question. I'm going to use a couple of patient examples to do some teaching. So my dad is 75 and he has an injection fraction, which means the percentage of blood that's pumped out of his heart every time it beats is under 50%, somewhere in the forties. And this is officially what they call heart failures. When you're squeezing that blood out of the heart every time, if it's more than 70%, 80% of the blood that goes out of the chamber every squeeze, that's considered normal. As that muscle either gets too thick or becomes damaged because it got low on oxygen, that transition has a failing rate and it cannot squeeze as much. When somebody has heart failure that term is a representation that the blood going out of the heart, doesn't have the power behind it that it used to.

So people say, well, do I have heart failure? And one of the best ways that I start to look at heart failure is to go to your shin bone - the part of the front of your leg that's between your ankle and your knee. And I don't want you to touch on the muscle. I want you to actually go to the shin bone. And this is a place where you don't store fat. It should be bone. It should be skin. If you're dissecting a human being, it should be skin and then bone. So I have the patient usually put their foot up on my knee and then I take my thumb and I push on their shin bone. Usually they say, ow! What I'm trying to do is push on the thumb enough to make the blood not come into my thumb.

And again, I'm pushing on their shin right against the bone. And I push there for 30 seconds. If you think you have heart failure, this is one of the places where I would have you do this. And I'll tell you, even I've had times where this thumb print, after 30 seconds I lift the thumb up and I run my finger over the shin and I can feel the indentation. Fat does not leave an indent. Fat does not leave an indent. Fluid that's in the wrong spots - called oedema, the fluid outside the blood vessels - you'll leave an indent. And this is one of the markers - there's several, but this is one of the physical exam markers that you can do at home that my patients, I ask them how deep is the thumb print today. And this helps them measure how they're doing in their heart failure.

I can always do the fancy tests like the echocardiogram where we can measure your heart, but when there's an indent in your shin, it's one signal for me to say that your heart and your kidneys aren't getting that fluid out. So if you want to make the fluid worse, add a bunch of salt, which is where Terry Lee's question comes from. If you're on a keto diet, we talk about that fluid, that volume of fluid inside the blood vessels, it drops so quickly and your kidneys flush out the sodium and potassium and magnesium, to kind of keep up with the fluid coming through the kidneys, that you can get dehydrated. And so we say add salt, add water. Okay, now you have heart failure. So in the setting of heart failure, I tell my heart failure patients to look at their indentation on the shin of their leg.

And even if you don't have heart failure, I do this sometimes too to see how much fluid am I retaining. And when I'm feeling kind of punk, if I have swelling in my legs, it's another signal that things aren't working as efficiently as they should. Your lymph system, your blood pressure, your kidneys are all part of how that fluid stays out of that space. And when it sneaks into it, it says you might be falling behind. So when I have a patient who's on a ketogenic diet and they've had a history of heart failure...say my dad, he checks his weight every morning so he can tell you what his weight level is. The first few days that you do this, it's kind of noisy. But if you get about 15 data points of weight, you're going to see what's your typical weight. But the other thing I like them to add is how much fluid is in that space, in that shin bone.

And so if they have a big dent, a medium dent or a little dent - that tells me is it okay for them to add more salt? So if their weights are doing okay and they have a pretty strong thumb dent in there, I'm going to tell him not to add any salt until that that fluid is out of the shin bone. Because it says the body's got all this extra fluid. The other part that I have been very encouraged by with people with heart failure is that, sodium is one of the many electrolytes that hold on to the fluid inside your blood vessels. And you'll know when you're low on sodium because you get intensely thirsty. So listening to that signal is way more important than my blood tests, than my thumb pressure.

When people are intensely thirsty, it's a sign of dehydration and sodium being low. And I don't just mean I feel like I need a drink of water. When you look at heart failure patients that are constantly thirsty, their sodium is often low. But my heart failure patients have to follow up with me pretty closely on this ketogenic diet, and once they get the rules of where their body's at, once they get through the transition, then I use these things like, we look at blood pressure because blood pressure also tells you what's the volume of fluid and how well is your heart pumping through those hoses. And then we look at that little indent on their shin as a way to say, how are you doing? And if there's a big indent on their shin, I tell them to lay low on the salt, please don't add salt right now. Your body needs to get rid of that fluid and the salt is messing up the equation. So it's a long answer and it's complicated. So if patients have heart failure, the degree is also very important. That's one doctors should be walking with you on. And I do encourage patients to know about their own, like check your shin, see how much fluid you're storing.

Yes, that's absolutely fascinating. And I'm totally biting at the bit to do it myself now but I'm going to have to wait until afterwards. But yes, it is a standard thing isn't it? I hear it all the time. And I say it to people all the time when their saying...especially when they're starting keto and going through that carb withdrawal stage, if the having headaches...it's one of the things that I do if I've got a headache, is to take some more salt. It gets thrown about a lot, take more salt. Are you getting enough salt? And recently I've been regularly measuring out a teaspoon and a half of salt every day and making sure I take it through the day to see if it has a beneficial effect because I hear it so much and I say it myself so much. It's just interesting that it's just another one of those things that is potentially a general rule, but you have to be self-aware of what's going on in your own body.

And I like these simple tests you can do on yourself that just increase that self-awareness of your own health. So when you hear one of these people throwing out this generalization, eat more salt. Well, yes, okay. That's okay if you say it, but it's not necessarily going to be right for me.

Right? The other part is that if you have healthy kidneys and a healthy heart, salt is easy to get rid of. Your kidneys are really efficient at wasting it into your urine. So healthy people, if they have too much salt, their body gets rid of it. They don't say, oh, salt makes you swell. Well not if you've got good kidneys and you're hydrated. I can have a bunch of extra salt and it doesn't do that if you're healthy. I would contend that most people starting on a ketogenic diet, or coming from a place that their health hasn't been great, which might be what attracted them to this. If you're a seasoned keto producer the salt has a lot more forgiveness. On that first journey when the water's coming out and the shin thumb print is heavy, you might need a little help guessing what's the right replacement? And the scale gives you a pretty big hint too.

Hmm..interesting…very, very interesting. Yes, I will definitely hold off on throwing out that general advice. Just take more salt because it's not necessarily going to be appropriate. It's more a question of maybe more salt. Perfect. Okay.

Question from Sandy. She has a question about avoiding healing diverticulitis. Since a recent visit to hospital, she was just discharged a few hours ago when she wrote this question. Does a keto diet encourage...or I guess what she means by that is to potentially bring on an attack...because it's diverticular disease. I know it a little bit about this because my stepfather was diagnosed with it. Diverticular disease, when it has a flare up is diverticulitis, isn't it? And so obviously that's what she wants to avoid. Does she need more fiber to avoid recurrences? You get the point, what can she do? She wants to avoid this happening because it's obviously very painful. And I know there are all sorts of things that are said about what you need to avoid eating to avoid an attack. Like people talk about avoiding seeds or things that can get caught in those diverticular...because they're little pockets, aren't they? So perhaps you could just explain...better than I have...exactly what the problem is. And I know it's something that's very common as well, because I looked up the statistics and apparently it's something that's very typically you have, once you get to a certain age, but perhaps just explain a bit more about what it is and f keto can help. What maybe you need to avoid to having an onset of this problem?

I love this question. It is near and dear to my heart. The book that I wrote, which is about my mom at 71 who had had cancer for over 10 years; and her cancer was in the white blood cells. The way we first found out that she had cancer was she was put into the hospital for a diverticulitis attack. And 10 years go by with chemo, and not chemo, and life, but all along this diverticular disease continued. And when the book starts she had had a few flares of a diverticular problem, and that's when I started the ketogenic diet. At 71, knowing she has hundreds of pockets of these diverticular outpouchings in her lower colon. So let's just describe what diverticulosis is. As you look at the stools passing through the large colon, when it gets to the last section - I would say like two feet before the rectum, two feet before you go to the bathroom - there is an increasing water removal from the stool. So the stools become more bulky. During that phase the pressure inside the colon over years of life can be so much that it causes a weakening in part of the last section of that colon. And there is an outpouching.

So everybody's heard the word colonoscopy. If you're doing a colonoscopy and you feel that lower colon full of air, you can see that you're taking these little outpouchings and you're blowing up a balloon, essentially. So the inside of the lumen, the central part of the colon, is filled with air and it puffs out these little diverticula. But they're not reinforced with a nice muscle layer. They're very thin casings around this balloon. If you have one or two of them, no problem, but if you have hundreds - you don't usually end up in the hospital without quite a few of them - what happens is that as the stool traverses from that last two feet, if you get some stool stuck in these pockets, it doesn't have a muscle to squeeze it back out of there. You just have to hope for the movement of the stool, and the kind of forward motion to empty them out. And if the stool gets stuck in there, it's an abscess and that's going to require surgery. We try to reverse it with fasting, and with nothing by mouth, and some antibiotics in the veins. We do all kinds of things to reverse when you get close to the danger point. But if indeed you do get an abscess in that part of the colon because of diverticula, it's a surgical emergency. You are going to need a surgeon.

She's right to have a fear that the surgeon seems to think that she's going to have her colon cut out. And I just want you to see with my own mother at 71 in the last section of her colon with hundreds...I mean you can probably say thousands...she had so many diverticula, it was too many to count. I put her on a ketogenic diet. So that gives you the answer to say, is it safe? But in that same aspect, there were several things that were helpful for her to process and live life without upsetting her diverticular disease. They talk about not having seeds and not having popcorn, isn't it? But that turns out not to be that significant of a finding. What we think is a better progression of helping this disease state settle down...because having a little pockets isn't going to hurt you at all. You won't even know they're there…it's when they become inflamed, which is when we take the word diverticulosis, and we turn it into diverticulitis. That's what will end you up in the hospital.

Those hurt, they have lower pain, sometimes their bowels stop moving, and that really does require a surgical emergency. My patients who have diverticular disease and have been flipping in and out of diverticulitis, I will really be strict about the times that they eat. Bowels rest when you're not eating. So if you read the book, what happens with my mom is she does really well on the ketogenic diet, and then she gets a dose of IV sugar. She gets an IV in her arm and sugar goes into her veins, and everything swells up including those thousands of diverticula.

So again, it comes back to this how we talk about inflammation, and how keto reduces inflammation. And I was just thinking earlier, when you were saying that about it getting infected, but inflammation is presumably what starts causing all the pain that you get.

Yes, that's exactly where I was headed with that. She had such an infusion of sugar and then it inflamed anything that was delicate. And in her body, that section of her bowel was delicate. And it swelled up so much, it swelled the colon shut.


Yeah. At which point we did the most powerful thing to help her diverticula, and she fasted for over a month. And if you read the book, you'll see what happened during that month and how many things changed. But thank goodness she'd been on a ketogenic diet before that, so her body and her mitochondria were totally ready to use ketones as a fuel. And she lasted over a month before she actually did end up with surgery, but she should've died. She should've died. She should've died. Because no, there was no stool coming out her bum - it was all blocked.

And that was...you're supposed to die, so... The point I'm making is that when I look at what things do I encourage my patients to do when they have diverticulosis who've had flares, is time restricted eating becomes really powerful. What time restricted eating means is you start the clock with your circadian rhythm in the morning. So the sun comes up and your clock starts. Now I want you to limit that you only get the next 12 hours to eat. Now I have people play games and say, but I want to eat at night. And I'm saying, nope, you don't get to move your circadian rhythm, especially in the world of improving your immune system and that inflammatory response. So keeping the time restricted eating from...my mom has her first cup of coffee in the morning around 5:30 or 6:00, so I tell her she can't put food in after five 5:15 because I wanted it out of the stomach by the time those 12 hours are done.

That doesn't mean that you're gobbling it down right at the top of that 12th hour. That doesn't work. I need you to be finishing the eating at the 11th hour so it's out of your stomach by the 12th hour, giving you 12 hours of time restriction where your bowel gets to reset and rest. And if you want to look at the best protection against a diverticular disease, it is time restricted eating. The colon gets to rest when you stop eating. And so if they snack all day long, and what many people don't realize is that your metabolism begins the first drink you have in the morning, especially if there's anything in it. If it's water, you can make the argument that you're continuing a fast, especially if the volume of water is, I don't want, people tend to have low volumes of water, but if you're looking at a trial, how does the GI start its secretions, and the liver start its metabolism? Circadian rhythm matters, the sunlight matters. And then that first gulp of a significant amount of liquid will start your metabolism going. My mom drinks coffee. That coffee is her first thing in the morning, and from 12 hours after that I want her not eating anymore. And that's what I do with my diverticular patients. That's difficult to do. We talked about changing habits with your sleep patterns, but it is just as difficult when I ask a patient to say, I want nothing in your mouth after, essentially 5:30.

Yeah, that's another thing I'm a shocker for. So that time restricted window, but also you did mention there, so there's this benefit as well in not eating too often, even within that window.

Right. The first place I limit is to get them to only eat during the 12 hours. The second thing is I want you eating your food in a bolus. And what that means is eat, feel full and then stop. And that kind of bolusing of food, meaning not trickle it in over time, it gives the bowel times to rest, which is really important with the diverticular process. So when it comes to fiber and other things, a ketogenic diet does not tend to be high in fiber. I've told patients forever how important their fiber intake is. As I've transitioned into a ketogenic way of living and really looked at some of the evidence that says, if you time restrict, if you eating with a bolus, that gut lining is actually pretty healthy.

It's not a mandatory. There are lots of times where our bodies went without significant amounts of fiber. Fiber has been the mantra in the medical literature though, saying, keep the bolus really full of fiber in those last two feet of colon if they have diverticula. And again, the science behind that is to say, don't let the stools slip into those diverticular pockets. And the way you can kind of hold the osmotic pressure is to keep the fiber in the stool. And that's one option. But I would contend you got to eat a lot to do that, and on a ketogenic diet it's going to be really difficult to reach the threshold of how much fiber is necessary. I would push you to time restricted eating, and eating a real meal when you eat.

And it feels logically to me that if you can improve how everything's behaving in the first place - so your colon and those diverticular are less sensitive, less inflamed in the first place - exactly what you're eating becomes less important anyway.

Yes, I've seen the process of inflammation reverse at such a profound level on the ketogenic diet, better than anything I've done in 20 years as far as prednisones, or really strong chemotherapy drugs to kind of shut off arthritis, and shut off Crohn's disease. You have these powerful drugs that will shut things down, and they are amazing. I'm thankful to live in this generation of healthcare. But when you added a ketogenic diet - which kind of got to the root of where this inflammation was coming from - not only did those medications work better, but some of them got off of all that. And that's been another place where you look at what's going wrong with the diverticula? You look at all the people who have diverticular outpoachings, and it's a big percentage of all of us.

Inflaming those is an immune system that's kind of teetering on the edge of not protecting our bodies as well. And I contend that the longer you are on a high fat diet, the better you supply the body with the nourishment to have a stronger immune system, to have those lower inflammatory responses, or at least not overproduce the inflammation when you have your inflammation response.

So if you have this vulnerability, if you like, if you have diverticular disease, you're on keto, great, because it's going to put you in the best possible position for these episodes not to happen. But I have read in my Facebook group, people who've had the odd attack. So the chances are that the reason that's happened is that maybe they've gone a bit high carb for some reason? But presumably, other things can impact that inflammation. So maybe, again coming back to lack of sleep, or maybe they get stressed. All those things I guess, can potentially inflame things and make them really hyper vulnerable to an attack.

The other part about what you just said is that there's this guessing, like oh, I've got diverticular disease...I don't want to have diverticulitis...how can I protect myself? And I give this generalized answer, like this is what I do generally, but I don't skip the part where I tell this patient, you should help me. Help me see what's going on inside your body. And that really comes with checking these biomarkers that you can do at your home. That is your blood sugars and your blood ketones. It is one of the things I do on Instagram. I start a fast every Sunday and I fast until I hit a biomarker. I call it a ratio of 40. This is again trying to hit that autophagy; how to keep my body's inflammation low; how to keep my body burning on a ketogenic journey.

Not because I have some super goal for myself... I'd like to lose a little more weight, but I like the way my brain functions. It's almost a way to keep you accountable. I have patients who are looking for examples like, nobody fasts. Okay, I'll fast and I'll post my numbers on Instagram. This is possible. Then I have other patients that do it and they kind of send me the numbers and stuff. The point I'm making is that if this gal really wants to know what's wrong - am I at risk for having a flare? Check your numbers. In my mom's case, I would have her check her blood sugar first thing in the morning. For the ladies, put it next to the toilet. I don't want you going letting the dog out, going and making them a cup of coffee, I want you checking it right when you empty your bladder in the morning. Put it in that place where you go to the bathroom and check your blood sugar, and then check your blood ketones. I can tell you that not only does that help me when the patient tells me, but it's such powerful feedback for the patient to say you're waking up in the morning and I know you think you're on a ketogenic diet, but your ketones are less than 0.3 and your blood sugar is still 95 in the morning. And I think that helps them see why I want you to time-restrict that eating is because you didn't empty your liver last night, you still have leftover carbs that your body is still producing and fueling off of, and now you don't get to push your circadian rhythm back.

Your body already started when you woke up this morning and the light hits your eyeballs, and the first cup of coffee hits your stomach. Those break the fast in the sense of this medically-restricted diet. You can talk about fasting in another realm, but if you're looking for how can I help this diverticulitis not to happen, I want the blood glucose divided by the blood ketones - I want that ratio to be less than 40. The more days she can hit that, the better I know she's going to be protected from a flare. If she really wants to stay away from the surgeon, that ratio is what I would encourage her to reach for. With my mom, who had this problem and then she had cancer, we wanted her ratio to be less than 20. And I know that when you're using the metrics for the European glucose versus the American glucose, you guys use a GKI, Glucose Keto Index, because you've got to divide your glucose by 18.

It's a one-to-one ratio in your market. But in America you'd have to divide the glucose by 18, and then you have to compare it to your ketones. And then you want a one-to-one ratio. And I'll tell you that was too much math for my mom. She's a smart woman, but she was sick and I needed something simpler. So I took the glucose divided by the ketones, and if we could get the number under 20, we hit our goal. And we were super strict. When you read that book and see what we did during the time where her diverticula had blown up to the point where she couldn't have a bowel movement, we only reached the ratio of 20 a couple of times.

But she fasted and you can read what that's like in the book. She did that for all 34 days or something like that. In my case, I tell patients if you want weight loss, if you're trying to get off a plateau - and I know several of the other questions were about what happens with a plateau - I tell them, look at your glucose first thing in the morning, divide it by your ketones, and if your ratio is 80 or less, you've got a pretty good chance you're going to be in a weight loss zone. You don't hit that once a week. You need to be hitting that every day if you want to lose weight. If you want to take it to the next level, which I encourage my patients to do...is a form of autophagy. And I talk a lot about how you recycle that body.

This woman has diverticular, which means things have gone wrong. That's not normal. As much as it's a population in 2018 - where most of us have this, if you go back and look at mummies, they didn't have this problem. They had a different lifestyle, a different diet, a different body mass. Their insulin levels were nowhere near as high as ours have been as a population. So just because it's common, it doesn't mean it's normal. So here she is, later in her years trying to say, uh-oh, this has happened. Can I undo this? And I don't make any claims about undoing diverticulus, but I know that autophagy helps to recycle those broken cells; those broken parts of inside the cell; the debris that's in your brain; for dementia; for cancer prevention; is linked to how well you hit autophagy at a regular routine basis. So these fasts that I start on Sundays and I post my numbers for, once I hit 40, I then go back to eating a ketogenic diet.

If I was being perfect...if I had Crohn's disease, or I had ulcerative colitis, or I had psoriasis where I was really trying to get my immune system to reset, I would set a goal of hitting that 40 every day for at least 90 days and maybe a lifetime, because it would reverse and repair and we could have a pretty strong level of confidence that your system really does have some undo buttons in it...and that's in this autophagy state. We can't send you to the lab and say, are you in autophagy? But we can have you looking at some of the biomarkers at your own disposal. I've tested a whole bunch of glucose monitors to say which ones work the best. I can send you a link to the one that I've found. My patients have said this for years, but now I really have pricked my finger enough times to say, all right, at least when I use this test strip, it's giving me the right numbers.

Don't be duped by saying we have the cheapest strips. Sometimes those are taking four or five tests from my patients to get a number. The other side of that coin is you can test, you don't need my prescription to do this. You can be at your house in your world, in your life, and you don't need a doctor's visit to do this. Just order the test strips and test yourself a few times saying, well, why am I stuck? Is this possible? How hard would it be from my body to reach that? And that's the empowerment that I think 2018 medicine really has is that as long as you have somebody gifting you the knowledge, you can really bio hack your system into a lot better health.

That's right. There are a couple of things I wanted to say there. I love it when I'm listening to something you're saying and it's ticking over in my brain. Hmm, I need to change a little bit what I do. When you said about how it's really important to make it the first thing you do, and not the thing you do after you've pottered around, and you've let the dogs out, and you've made yourself a cup of tea, and then you've...you can guess this is what I quite often end up doing. So that's something that's going to change tomorrow and be stricter about making it the first thing I do. But yes. So what I tend to do, I have a little diary and I put my numbers in every day.

I tend to weigh myself every day. It's just something I do. I don't freak out when the numbers go up and down. In fact, I find it interesting with the fact that I can see that they do go up and down for no reason at all, actually reassures me not to take it too seriously, but I write that down, and then I write down my glucose and my ketones. So yes, it's an interesting point that it's important when you do it. But the other thing I was going to say...you talk about the test strips and how you can do it at home, but they do add up. They can be costly. But it's the kind of thing I think that if you can do it rigidly for a while, and then you get a good sense of how you feel at different levels...for me, I can tell if my ketones have dipped because my mood goes down and I get more headaches.

If you test for a while and you've invested a bit of money in doing that, as long as you carry on doing what you were doing in that period of time when you've been testing and you know regularly that you've hit that less than 40 or whatever marker; as long as you keep reproducing that, you don't actually need to be testing anymore. It's only really getting yourself into the routine, isn't it? Once you're in that routine, you know what you're doing, you know what works, you don't have to keep testing ad infinitum. It might be useful to come in and retest every now and then, but you don't have to be doing it for the next 10 years.

I think of it as the cost of discovery. That you're going to pay $200 to come see the doctor - your insurance is going to cover a bunch of that. But if you spent that $200 on just you learning about you...I mean I think the kit that I...I'll send you a link on the one that has both ketones and glucose in the same monitor. And again, the reason I've kind of gravitated towards this monitor is because I have spent six strips to get a ketone level on some of these other monitors. And nothing makes me more angry than having to poke my finger again. And just that cost. So, those strips are really reliable but then more importantly, the knowledge of what's going on in you.

This person sends in a question and I instantly have a profile in my mind from the thousands of patients I've seen over 20 years, but it's a guess of what she's like, and what the problems are, and where she's been, and where she's going. She could best understand herself if she did one week, just every day, get up in the morning first thing glucose and ketone numbers. And if you're using the American numbers, you take that and divide it. And what you're looking for is a ratio of 40 or less. And if you don't hit that, I'm telling you, you need to restrict the time that you're not eating, and you cannot move the morning number. You have to move the evening number. I tend to start patients at 10 hours. At the 10 hour mark, you should have no food. That gives you 14 hours of eating and then I remind them that when the 10th hour gets there, you're not eating. You ate probably half an hour to an hour ago, because it should be out of your stomach. So I really want you truly done with food at the 10th hour so that you get the 10 hours break. And if you're waking up every morning with 10 hours of fasting and your ratio isn't below 40 - and that's your profile with the diverticular story - I would contend you're in trouble. You're going to end up with a flare.

If you're saying, doc, I'll do anything; I want to do anything to not end up in surgery. Like, okay, here's the rules: first thing in the morning, test yourself for a week. Get that ratio below 40. And if it means that your body is so insulin resistant, and you've been overweight for so long that you had to fast for 12 hours every day, or you had to time restrict for 14 hours every day, I'm telling you, it gets better, okay. This is a skill that you learn to say no in the evening to food. Salt and water is the only thing you get after that time. And I can't tell you the number of patients that have walked away from some serious medical interventions because they got the numbers, they checked them. Now they usually come to my keto group because you kind of need a little support...it's a lonesome journey if you're doing this all by yourself. There's plenty of ways of support: from listening to podcasts, to checking out YouTube videos to having a support group of your own. But those all have been the links to say how do you change the trajectory that your health is going...measure yourself!

Yes. It's very true. I meant to say earlier, when I write those numbers down and I can guarantee that if I've had a snack late at night and because I always write it underneath, if the blood sugars up a bit higher than it should be - than it normally is - maybe the ketones are down, maybe not. It kind of depends, but the blood sugar is the definite marker. If it's higher than it normally is, and I put underneath with big exclamation marks, that'll be the late night snack.

It's real. You are human. There is something powerful about changing behavior with that instant feedback for how you see yourself.

Yes, it's very good to have it there in black and white, isn't it? Because it's something you can't argue away. Well as usual Annette, you've gone into such amazing depth and given us so much information and knowledge to take away. We're up to our time on this episode, so we're going to round it out now. I knew when I put up this topic in the group that I was going to get lots of questions, and that we were going to have to go onto multiple episodes, so that's what we're going to do. Thank you very much for making a start on this big long list and we'll be back soon with some more questions and answers.

Excellent. All right. Well, tune in next week.