#63 Ask Dr Boz Part 2


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

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

Welcome back Annette to the Keto Woman podcast and another episode of ask Dr Boz. We got another long list of questions here. See how many we can get through today. How are you doing today?

I am doing great. Thanks again for having me. Again, I just love your audience. They have been, some of the most engaged and ask amazing questions. So thanks for letting me participate and use this as a remarkable teaching opportunity.

Well we're not going to take up time with catching up with me this time. We're just going to dive straight into the listener questions. You'll be pleased to hear at home listeners. Okay, so let's start with Louise. Yes, my mate, Louise Reynolds who surprised me recently. Some of you who, in my Facebook group, who see me on social media, will know recently how she... She was very scheming and she said she was planning to come down and surprise me with a visit. And when I opened my front door, it ended up to be none other than Richard Morris. One of the 2 Keto Dudes. It blew me away. I opened the door, my outside light wasn't working, so I'm peering out into the darkness, and this voice comes back, hello Daisy. That's not Louise.

 She really did do a good job because she was consistent throughout. She gave me all these updates about her journey, how she'd been held up here, and held up there, and how the flight was going. Incredible. She did a very good job. So maybe the top tip to take away from that is, don't always trust Louise Reynolds.

Or trust her with a really good secret.

Exactly - no, a very good friend. And it's very typical of her to spend a lot of time and a great deal of effort in doing something...planning something really nice for somebody else. That's very typical of her. So it's nice to start off with a question from her.

So Louise says, as an older woman, she says...she's not so old...I've been working out lifting weights with the aim of further reducing body fat, trying to maintain 130 pound weight loss...we are actually weight loss twins, we both had weight loss surgery, we both had a very similar journey, we have lots in common...and she wants to improve muscle tone. While I'm lifting heavier weights, she uses the Stronglifts 5x5 app, so she's been tracking it - which you'll be pleased to hear - the scales now say I have gained 10 pounds since May, while my waist is still the same - my belt hasn't changed. Is this weight gain muscle? This doesn't make sense as I'm not looking Herculean and still have flabby jiggly bits. She doesn't have so many flabby jiggly bits.

That's beautiful because it is this process of when our bodies lose weight...I do a lot of education on igniting your autophagy and just that recycling of tissue, so 130 pound weight loss is amazing. Congratulations. That is a huge mark. I will tell you that in the course of internal medicine care for two decades, I can tell you there're only a handful of people that I've ever helped lose that much weight. And prior to the keto journey over the last couple of years, it was incredibly intense exercise, and they mostly gained it all back. So I just want to say congratulations for losing it and really igniting your metabolism to be able to keep it off. So the question really centers around, doc what's happening on the inside? So I'm just going to assume that these 130 pounds were off by May. So she was at that 130 mark, and really has been kind of plateaued, and looks like maybe even gained about 10 pounds since May.

Oh yes, she's actually lost that weight and maintained it for, I don't know exactly how many years, but at least several years before that.

If she was my patient, what I would first do is a little bit of studying. Because the weight gain on a ketogenic diet...people say I'm skinny, should I be on a ketogenic diet, I don't want to lose weight. There's an equation here that as much as we talk about calories aren't the most important, they still do weigh in, especially once your body has stabilized. I don't mean the amount of calories as much as I mean the timing of your calories. When you look at 130 pound weight loss, and then her body kind of just holds in this pattern, and really resets. You can make the argument that in many ways there's a psychological component that says they got to this level, they kind of are able to say thanks...thankfulness, almost relaxed, like look at how much better my life is.

And now she's been there for you say a better part of a year and is saying, I wonder if I can take it to a new level - a new level of health. And again, I commend her. When you've got that big of an accomplishment, and you just hold the zone of making sure all of your behavior changes are solid - that you do predictably get your good rest, and eat a ketogenic diet. Great. So now let's bio hack where she is right now. The first thing I would do is actually I would tell her to go do a DEXA scan. Most insurances...she lives in the United States, right?

No, actually she's Australian, but she's in the United Kingdom working and living. Now I happen to know that she has had DEXA scans, and I'm not entirely sure what the results were with that, but I know she has had them. So if that tells her anything, she will know that already, so I'm assuming that's not too much of a factor.

That's perfect. Because again, what we're looking for is, how do we take out the noise of weight and get to the...what is the body's makeup of where the weight's coming from? The first thing that I look at in older women that go to a ketogenic diet is, I've been impressed with how quickly their bone density increases. And that bone density is from these fat-based hormones that on a low fat diet, they really are difficult to push the hormones high enough to spark that bone growth. Again, they're all based out of cholesterol and fat, and so on a low fat diet many times they are lower than they should be. They get onto a ketogenic diet. The weight loss happens. But what's really happening that's exciting for me to watch is the brain repair that's happening, the coating of the neurons with a more dense fat around all their nerves. That's a slow process. It does not happen overnight, but it is amazing how much better their system works electrically - meaning the brain, neuro conduction, and the nerves. And then finally to watch what happens with the bone density - that a ketogenic diet produces enough of the hormones, one of those being your growth hormone. And as you age that's supposed to go down. But I will show you that the studies have seen that you can see a rise in that growth hormone if you ignite the process of a ketogenic diet.

What I mean by that is there are some rules. So Louise, I would want to know what time you wake up in the morning and then that wake up time will give me a pretty good guess that your circadian rhythm is hopefully matching the light hours. And I know I talked about this a lot in the last episode I did, but I just want to quickly remind you...if you wake up at six o'clock in the morning, and you put that cup of coffee in, And the coffee may be black, and I count that as fasting - I'm talking about me. But if you're looking at the process of igniting a weight loss, or getting off of a plateau, or in Louise's case, I would be wondering, have we been pushing her growth hormone, and spiking and valleying her growth hormone, to improve her bone density?

That weightlifting could be turning into some improved muscle mass - which you say, is that Herculean or not…but a DEXA scan would be able to tell us. So we want to say what time she get up in the morning, what time does a cup of coffee go in? And then how long does she eat for? Like, what is her time that she spends eating? And if she snacks all the way until bedtime, like oh I only ate twice today, but I had a handful of macadamia nuts at six o'clock, and then I had a little glass of kombucha at 8:30 last night...the calories that are going in are too spread out, and her history of being that overweight is going to lock down that reset. Like she's going to stay stuck at this level until she's resets her system.

Okay. I do have some answers for you because I happen to know Louise quite well. One thing I was going to ask you about though was the DEXA scan, because I have heard that that can be variable in how accurate it is, especially when it comes to differentiating between fat mass and muscle mass. Presumably it can be more accurate with bone density. And I think it's interesting actually...I mean, people joke around, don't they...saying, oh you know, I weigh x amount because I'm heavy boned. But it's interesting that you could actually increase some of your weight with the bone density. That is one thing. And with the muscle mass as well. So I happen to know that she is not like me. She's not really a snacker, and I think she quite often possibly just eats once a day.

She does tend to be very low-carb, verging on carnivore - she calls herself lazy carnivore. I know she sometimes does have a little bit of chocolate and some dairy, but very, very low-carb - often one meal a day. She's not really a snacker. I do happen to know though that her sleep is bad because for a couple of different reasons - she is often having to be up late at night talking to a partner in Australia, and again early in the morning. She does some consults with students, quite often really early in the morning - it can be five, six o'clock in the morning. So I know that she very often doesn't get enough sleep, so that potentially is a factor. But presumably all this weightlifting she's been doing, that's going to improve the bone density, and obviously the muscle mass as well.

Well, what I would contend is that she's doing the right activity to increase her bone density and her muscle mass, as long as her hormones aren't fighting her. That steadily elevated cortisol level, which is your stress hormone, it really resets during the sleep hours. So if her sleep is a little goofy, I would try to figure out a schedule that protects her sleep better. The other part that I would have her do would be...what is her morning fasting sugar and ketone levels when she first wakes up. What is that ratio? I would love to know what her insulin level is, but that's going to be a blood test and a doctor's visit, and then insulin's goofy so you should do it a few times to know that you get it right because so many variables go into it. And it's pretty darn expensive. The best next estimate of whether her insulin is low, would be to look at whether her blood sugar get into those 70s in the morning, maybe even 60s sometimes.

Yes, I think so. I think she does tend to be, yes, have nice low numbers actually with her blood sugar. And I think her ketones...I know she measures, so she could certainly give you those numbers.

And do you think are ketones are pretty good in the morning? Her blood ketones?

Yes, I have a feeling that she complains that they're not as high as she maybe thinks they should be, or would like them to be, but I know her blood sugar's always down. They're certainly well into that range that is quoted as being the range they need to be in. But I think sometimes she wonders why they aren't perhaps a little bit higher. But as we know, it's not always a numbers game. You don't have to hit certain numbers. Different people have different levels, don't they? That's ideal for them depending, to a certain extent, how much you're using them.

Right. So if she's got this weightlifting process that she's doing, what I would have her do is, I'd want her to hit a ratio of 40 or less. So let's say she's testing her blood sugars and her blood sugars are, 60 or 75 and if her ketones are less than one, so 0.9 0.8; that's going to put her ratio above a hundred, or in the high nineties to 100 depending on what her sugar is. So to say, well how can we increase that ketone? And this is where I would put, if in fact she's got nice low blood sugars but her ketone numbers are lower, then I would push her to fast longer. Like give me once a week - and this is what I do - I start on Sunday so she can watch me on social media, and then I fast until I hit a ratio of 40. Now in patients who are really sick, if I'm really fighting an autoimmune process, I want them to hit a 40 every morning in that ratio of taking their blood glucose and dividing it by the ketones.

That's what I've seen - we could see the improvement when they did that. If you have a situation like this where she's doing pretty good activity and saying, I wonder why the weight's going up, I would at least hit 40 two mornings a week. It might be that you say, I'm going to fast for 36 hours. Or maybe don't put a timer on the fast, as much as you put the bio-markers where you said, okay, your body hit our goal. And what you'll see is if she does this week after week after week, even just hitting it once, you're going to see about the second month that she realizes what hours it takes for her system to empty, meaning the glucose to go down, and the ketones to rise. And of course that's where the cognitive function is better. They feel better. I would push her to check that ratio in conjunction with what her story is.

The other number that I would check is, I would love to know what is her blood sugar / ketone ratio after she works out. So again, the demand for energy is higher when they work out. I work out in the morning and when I check my blood sugars before the workout and after the workout, my blood sugars go up and my ketones go down while I work out. And I think it's been very teachable understanding of my own body to say, yes, I've taught my system that we use ketones to...I'm talking about myself in the plural...I use ketones to fuel my body during that workout and my body is adapted in a way that it can do that. And I think especially as long as she's been keto that I bet she's doing the same thing, which is a good sign.

But that confidence that what you're doing inside the muscle - inside the body - your sugar will probably go up, your ketones go down. But check it. See what happens while you work out. And I just think those kind of bio-markers help understand why is the weight going up. If you want that weight to go down, if you're really looking for the next level, at least get the numbers below 80. But if you're looking for any type of like remodeling, like getting autophagy to not have the flabby skin and all this stuff that there is pretty good evidence about. We can't send you to the lab to check your autophagy, but we can have you look at these ratios, and those are in your home. And I would push her to at least hit 40 twice a week. So fast long enough to get to 40 twice a week, and then the rest of the time try to stay under 80.

Oh, she'll take that on board, I think. She has a very acute scientific mind and so she'll see it as a project and we'll collect the data. Yes, I think that will appeal to her a lot. I can see her doing that and I'll get some feedback and find out what happens.

Okay. The next question is from Siobhan. You've mentioned, she says, concerns over low ferritin. It's one of your favorite topics, isn't it? How low is too low? Mine tends to run low, eg around 45 to 80 regardless of whether I'm eating chicken or pork or entirely red meat - several pounds of red meat a day. Could this be related to other problems I'm not aware of, like folate deficiency or is it not something you'd worry about with yourself if you are asymptomatic?

Well, so let's go back to why ferritin is such an important marker for me. I talk about brain performance and have quite a lot of patients that have had depression, or just slower mental processing because of trauma. It can be emotional trauma or physical trauma. So repairing brains is a very big part of how well their whole life does. Ferritin is one of those markers that you can't make some of the nerve, the brain hormones like the neurochemistry without iron being around. And ferritin is a little bus that runs around and delivers the iron. If ferritin is too low, the lowest I've seen is not measurable - like less than four. They were like zombies. Their brains were just turned off. Their speech was quiet. They couldn't articulate. The ferritin and iron goes back into their system, and bam! At least the brain is awake.

When somebody comes in and their ferritin is below 30, I do a really strong education to say, the fastest way to get this iron above...the minimum that I like to see patients at is 50. Between 50 and 150 is a good level If it's below 30, I'm really going to talk to them about liver - braunschweiger, liverwurst - whatever way they want to do it, and just how powerful that iron replacement is compared to elemental iron. Iron supplements are another great option. They just take a lot longer and you don't absorb as much. When they get below 20, I actually push them to go get iron put in their vein because it's going to take us so long to get from a low iron, that's that low - like in the teens. First of all, their brain's not going to focus long enough to keep doing what I tell them to do. They just can't. And it is 2018. This has been around for a while. You can go in and get iron put into your vein, and what would take you six months of iron tablets to replace, I can do with a two to three minute infusion. That's not overly expensive unless you go to and infusion center and then I've seen it cost like $2,000. If you just get it as an IV push in a clinic, it's pretty cheap. However, too low is anything below 30, I'm chirping at them. When they get above 40, I start to say you could have a little more, but it's not nearly as critical as when it's below 30, and specifically below 20.

I do a little bit more education on ferritin. Ferritin is something called an acute phase reactant, which means when your body has a response, ferritin is a protein. And so if I slug you on the arm enough to give you a bruise, you can see ferritin rise. So when people come out of like a car accident and they wonder how much blood loss they've had, but they have like 15 new bruises and a broken rib and an arm in a cast and you say, gee their ferritin's nice and high. You can't trust that. You've got to wait until the inflammation goes back down to see what is their true ferritin level. Ferritin is just a marker of how much iron your body has. I wouldn't worry about a range between 45 and 80 - that looks pretty healthy. But then could it be related to folate deficiency? Folate is another one of those....I'm a big fan of eating the sprouts of vegetables. First of all, it's very low carb with a really high density of nourishment. If you have brussel sprouts or broccoli sprouts, they are just really high in those leafy greens, and it doesn't take a lot to get you the nourishment that you need.

They're those things that taste irony, aren't they? I've always been a bit of an odd child in that I liked those irony things. Really dark greens and spinach. I still do. They're the things I love, but they're the things that are naturally rich in folate.

Absolutely. You can take a supplement. Folate's easy to take and absorb really well in the multivitamins, unlike iron. Those are a few rules with iron. Like don't take it on...acid needs to be there...lots of rules. But folate's pretty easy to absorb. And if you do any kind of greens, it's pretty easy to get that in. I would just tell her not to be fully deficient. Don't do that because it is a big part of how your body functions as well.

Yes. Interesting. I seem to remember that my ferritin levels were quite low so I looked them up because I thought, Dr Boz is not going to be very happy with me, and so I looked them up and mine is actually 11, and the reference range they give here in France is 13 to 150. I'm sure you've got something to say about reference ranges and although the lower limit might say one thing, that's not the what you would consider to be the optimal lower limit because that includes everyone, doesn't it? Including the extremes - which you don't want to be. Perhaps you could just have a bit of a mention about that before you tell me off about my ferritin level.

I think we have an answer for your sleep problems, actually. Looking at reference ranges, let's take glucose. If you go back into the textbooks from the fifties and sixties, the normal glucose range was from 60 to 80. When I tell patients that their glucose of 101 is not normal or 98 is not normal, they instantly say I googled it and I'm in the range. Where do you think we get these ranges? It's where we take a standard deviation - I think it's 1.5 standard deviations - in our population to tell us what is the range. And sadly the world is very low on magnesium. That range is interesting. The world is very low on iron. And the world is very high on blood sugar. So these ranges have evolved with our population and don't necessarily reflect what I would want for my patients, my children, my husband...for the people I care about to say, no, no. no, no, you don't want to be anywhere near that.

When you look at a ferritin level of 11, and so on that can you see the word that says saturation on that panel?

Yes, I might have that actually.

So while you look that up, I'll keep going. If you look at a ferritin of 11, what that's saying is when we drew the blood, we only found 11 buses that were scooting around your system delivering iron. And again, ferritins are proteins. If you don't have a lot of iron being delivered to the system, then there's nothing for it to do. If you increase the iron delivery, then the ferritin will compensate. Now that bus is so full I can't fit any more iron in it, so let's make some more buses. And that's this protein that is carrying around iron. And without any reference point for where you've been, just knowing that your buses are down to 11, you haven't been low on iron for a week or two. How long ago was your gastric surgery?

For me it's a constant problem. I come in low on iron, low on ferritin. It's been a consistent problem for a long, long time. In fact, when I had the last surgery - I had plastic surgery, and the surgeon actually insisted that I have a transfusion while I was in the hospital. It was ideal obviously because I was there hooked up anyway, so they put some iron in. And yes, my levels temporarily went up really high. I have tried to be much more consistent about supplementing. But I do supplement, but I've just really, really struggled to get my levels up no matter what I do. No matter what I supplement. I'm just looking at my panel here, and I don't know exactly if they translate...I've got transferrin. I've got two saturation numbers here. I've got saturation, iron in transferrin and it's listed as CTST here. I don't know if that translates directly...and that gives it in two different values. I've got one value of 4.12...and that's I think micrograms per liter, I'm not sure. The other one is 73.75.

Is there a percentage after the 73?

No, but the other one I have, which does have a percentage is called coefficient saturation of iron. That's 13.36.

So, that's awful.

Oh no.

Essentially what that saturation is doing is saying, let me just peek on this bus and see how many seats are filled with iron. When the saturation is 80, then you've got 80% of the seats filled with iron. So those buses are busy doing their job.

Ah, okay. So even though you've got fewer buses, they're full. It's not as bad as if you've got fewer buses and there aren't many people on them.

What it tells me is that when you have the low ferritin, but you have pretty high seats filled - so the saturation in there is filled - it says, she's increased her iron recently and she's trying to get ahead - it's working. The buses are filled. Because once the buses get - I think 60% or 70% - then there's more stimulation of making more of those proteins. But if your buses, only 13% of the seats are filled, there's no reason for you to make any more ferritin. There's just not enough iron for them to do anything. So the process, you've got to break the cycle. If you were coming in to me to get a kidney transplant, I would have to prove to the transplant team that you are ready to receive this kidney. And one of the factors for being healthy enough to receive a kidney is what is your ferritin?

We would break the cycle like that, with an IV infusion of iron. You can go back in the history books about IV iron and it used to be this awful thing...we put people in the ICU. It was really dangerous. But when I was in medical school, there was a pretty big breakthrough that they put sugar - and don't freak out for a ketogenic diet - but they put sugar around the iron and the delivery of the iron was so safe that we can now do it in a clinic. Now healthcare in our world has changed, so many times they just don't bother with it. Doctors kind of get nervous about the history lesson of iron being difficult, but truly the data...we give these IV infusions of iron to neonates, to babies that were born too early. It's very safe and it stops the cycle.

Because even if you start eating iron perfectly right now you say, I'm going to eat only braunschweiger for the next month, your gut has to absorb it and you've had a rewire, a re-routing of your system, or a gastric bypass. So it's not uncommon for stories like this to say, the reason she's tired, the reason she's still struggling with that resetting of her sleep cycle, is because her brain doesn't have any ferritin. It doesn't have any iron. That is a powerful change in how well they think, how well they concentrate. Not only do you add in that you're a menstruating woman who's had, you know, leaking out the other end too many years. When you're this low on iron, you shouldn't have a menstrual period when it's that low. Those are valuable little red blood cells, don't waste them.

And obviously I'm being a little funny there, but the point I'm making is that you're at a higher risk to not get ahead when you're in this stuck situation. And it'd be the kind of situation where I'd say, go into your doctor, say, I've done this so many times, can't I have an IV infusion of the iron? And I don't know how it works in your world, but in our world it has to be low enough, or a certain level enough, for them to pay for it through your insurance. But I think the criteria, if it's anything like in America, with that low of an iron and consistently feeling that heaviness in the morning or that fatigue, I think you could be covered by some insurance companies. And if not, two infusions of this is worth like seven months of iron pills. So two infusions and you are leaps ahead for resetting this cycle, this problem.

Oh, it's very tricky and it's certainly something I will look into. But yes, the system is so completely different here. Sadly my GP is very aware that I have this problem, but like I say, it's been years that I've been borderline anemic, really. Yes to the extent that I mentioned that there was actually doubt as to whether I'd be able to have one of my operations because it was so low. So it's certainly not something that they're going to voluntarily let me do. I think the only option will be is to find out if there's anywhere privately that I can go and have it done. Yes, like I say, a completely different system. But I will certainly look into that because I know it's an issue. There's one question that I have that I've remembered that came up with this question on the thread, and it is something that's relevant to me and to a lot of other people. I forget who said it, so, forgive me for forgetting that, but someone mentioned that if you're hypothyroid - and I have the Hashimoto's form - that a lot of the groups that advise around that are saying that actually having too high ferritin is a problem, and that having a lower end of the scale ferritin, is potentially a good thing if you're hypothyroid. Do you know what they might be referring to?

Yeah. You're saying hyper or hypo.

Hypo. Hypothyroid. Yes.

Okay. Hyperthyroid is an over-functioning of a thyroid, right? Over-functioning of the production of those hormones. And especially if you had Hashimoto's, those proteins are coming out of your thyroid because antibodies have been attacking it. So it's an autoimmune problem. Your body is attacking the thyroid when it wasn't supposed to do that. But here you are. And in that setting, this excessive production of proteins can happen in many layers. When somebody has one autoimmune problem, like they have Hashimoto's, it increases your risk of getting other autoimmune problems.

Yes, I've heard that before. It tends to come in packs.

Right? So think of the excessive production of protein is another way - and I don't mean the protein in your muscles, I mean these little proteins that travel around and send messages from one cell to the next. And that's what's happening in Hashimoto's, is your body's getting a message from a protein that you're not supposed to make. Then you are an increased risk for having proteins that tell your joints to swell or to break down all your blood vessels and have lupus. So other autoimmune problems. But in general, the milieu of proteins is higher in people who have autoimmune disorders. So when they say, your ferritin might be high. Yeah, well, first of all, you don't have to worry about that. You're so darn low and your seats are empty on your bus, that we are so far from that problem, it's like not worth mentioning.

But in the spirit of answering the question, if they have a ferritin of like 280 and you say, oh my goodness, are they iron overloaded? No, they're autoimmune. Their body is attacking itself and is producing these extra proteins. One of them, it looks like it's ferritin. And so the ferritin can be high as a product of this immune system that's kind of gone awry. It's stimulating itself to produce things. And when that happens, all kinds of things go wrong. Ferritins are not normal. When I said earlier, it's an acute phase reactant, like you are producing a protein because you got all bruised up in a car accident, there are other things that are chronic inflammation that increase ferritin as well. So it is something that you have to look at all the numbers. Your history gives me the hint though, that you don't absorb it right, and that's from the surgery - of the weight loss reduction surgery - it's really common. And so that's why I would say skip trying to eat it. Put it in your vein. Your brain is depending on it.

Right? Yes. And that makes sense. I mean I didn't have the bypass, but presumably it's one of those things that I don't absorb as much just because the stomach size shrunk down. And I know that different things are absorbed in different places, but it's certainly been a problem for me for a long time. So yes, that's something I've obviously got to look at. Because I have taken supplements and I still struggle to get those numbers up.

It'll turn your stools dark and you'll have very little absorption because of the chemistry of what supplements are. If it was me. If I was in your situation, no kidding, I would do a liver fast. Like you only eat braunschweiger for the better part of a month. And I know that sounds very restrictive, like is that possible? But liver's high in vitamin C. Livers is a very fatty meat and if you had just bone broth and liver for a month, could you increase it on your own? The cells that are supposed to absorb it are clearly not working right. All meat has iron in it. Why isn't your system absorbing it? Because it's going to take you the better part of a month to navigate the system to find out could you even get IV iron, I'll tell you I do it here in the States, but I'm one of the very few that does this. That's a whole other story, but the point I'm making is in your case it's going to take you a month to crack the code on how would you possibly get IV iron. If in that time you did an ultimate challenge of saying if the cells in your gut are still alive, and present, and in the right pathway that food passes by them, then I would be on a bone broth and braunschweiger fast for a month and just say that's it. That's all you're going to eat for a month and watch what happens to your iron. Because that would tell both me and you whether you can absorb it. And once you get those cells out of hibernation and they're back to actively working, then you can go back to do what I tell most patients, which is: if you've got that low of iron, I can give you an IV, but braunschweiger, a tablespoon three times a week. That's powerful. That's a lot of iron. And even if you don't like the taste, eventually you'll get past it.

Because that's the other point. Like I said, I have had an infusion before. If you get your numbers up with that temporary fix, is it going to be the case that unless you make other changes, it's just going to drop right back down again. You mentioned about this reset and restimulating, or is that just simply not going to work unless you do these other things as well?

Right. So somehow you've got to get iron sustainable in your system. You're at the age where menopause is hitting your world, you're not going to have menstruation as a loss anymore so it does get easier to get ahead. But I would contend that the fastest improvement for a lifetime, is see if you can wake up the cells that actually absorb iron. Sounds like they're not absorbing much. The infusion you had, you had somebody else's red blood cells put into your body and those are only going to last for about two weeks in your system before your body gets rid of them. Now you get the leftover iron that was in them. So that's the good part. You got an infusion of iron by way of those red blood cells, but you don't have to expose yourself to somebody else's blood parts to get iron.

You can just get iron and that I think is safer and less risk. What it does is, all that iron...suddenly those little ferritin buses are going to have a hundred percent saturation. They're going to be filled with iron, and that's going to say, hey, we're too full, we need to make more ferritin. And then you'll have higher. So then you get a higher carrying capacity and that allows you to not be right on the edge here. You cut your finger and you're going to have a lower… your red blood cells are already probably tiny little red blood cells instead of these big, plump, efficient, red blood cells that deliver oxygen. That's probably, in part, why your fatigue is still lingering.

Right? Yes. Really interesting. So it is a case of doing the two things at once, stimulating your system interaction, but then doing the sustainability part to keep it going. Very interesting. Well we've started talking about me again, so let's go back to somebody else.

Jojo has a question. She would like your thoughts on her recent overall cholesterol being so high at 357. What other tests should she get done? This is her first blood work since starting keto in July. She knows it's common for this to happen, ie the cholesterol going up, but the more advice she can get, the better.

Right? So why has cholesterol become this marker of worry for the world? And it is because it was linked to heart disease, except they didn't do such a great job when they first discovered this at linking the two in a correct manner. What I first and foremost remind patients is, cholesterol is the carrier. This is what carries fat from one section to the next. When I put you on a diet that's 85% fat, guess what? The carrier is going to get higher. The cholesterol is going to get higher. It is not the predictor of heart attacks. You can better predict a heart attack with the size of your waistline. If you put weight on in your tummy, that's a better predictor of a heart attack than your cholesterol was. So that's easy. You can do that one at home. Your morning fasting blood sugars, those are a better marker of a heart attack than cholesterol.

Other tests from your doctor? I would encourage every single person who wants to know if they have a risk of a heart attack to look at a calcium score. This is a very high speed, MRI that takes pictures of the coronary arteries. If you have a zero on your calcium score, it is a protector for the next 15 years that you will not have a heart attack. Way better than I can do with that cholesterol, which is going to change depending on what your diet has been for the better part of the previous six weeks before I checked the blood. When I look at a calcium score and it's zero, I can have a lot of confidence that the inflammation going on in their body is still very low and not depositing calcium into those coronary arteries.

Other markers that are somewhere in between are a Highly Sensitive C Reactive Protein. I say that very specifically a Highly Sensitive C Reactive Protein. This is a marker of inflammation that is designed to specifically predict what the inside skin layer of blood vessels is. In America there's this cartoon that would happen after school called The Magic School Bus and this teacher would teach you about science and things with the magic school bus. Her magic school bus could get really tiny and she'd drive down the arteries of a human body and teach about anatomy. So if you were driving down the artery and you looked around the skin layer that lines the tunnel, the Highly Sensitive C Reactive Protein helps me know is that inflamed? And that is a predictor of a heart attack. You're starting to put cholesterol deposits in that layer. Guess what? It's very inflamed and it's going to do that even before your blood sugar is high. Before you have a change in your Hemoglobin A1C, which is a predictor of diabetes.

If I needed to know if you are going to have a heart attack and I needed to be the most confident, if I got to grab which one I would look at first, it would be a calcium score in your coronary arteries and I'd vote for a zero. If I don't get to do that. You don't need a doctor's prescription to do that. If you look at any - in America anyway - if you look at any place in America, you can just call up the cardiology team and I think it's like $25. It's really cheap. So it's a quick MRI. It's a screen for calcium. And if your score is zero, congratulations. If it's like 250, we're talking about some significant risks. I have a patient over the last six months who it was like 2,500. So you talk about the question we started this with where they have heart failure, and boy that calcium score is...that's a delicate equation. We need them carefully monitored by a physician as they make some changes. But instead of focusing on the cholesterol, I would look at those markers instead.

I think another one that I've always thought as useful, and it's funny that this question follows on from Siobhan's question because she's the lipid queen. She loves her lipid analysis. But I always think the triglycerides are a useful marker. People talk about the size of LDL particles, don't they? But if you know your LDL, and you know your triglycerides...Triglycerides is literally a measure of how much fat is swimming around in the blood, isn't it? And you want it low. That, to me, whenever somebody says, my cholesterol is high, the first thing I ask them, but what are your triglycerides doing?

That's very true. I used to tease patients that if they wanted to outsmart their cholesterol screen for a life insurance - triglycerides were something the life insurance would look at more than the cholesterol, than the number, she was just reporting, and I said, if you want to outsmart them fast for three days before you go into that test. Triglycerides are really a reflection of what did your body intake recently, and is the storage tank full. Triglycerides are high when the liver is already jam packed full of stored carbs, that you've already got your fat cells and muscle cells overflowing with store carbs, and so the body's turning them into fat lobules and trying to find a home for them. And those triglycerides, you're right, it's fat in the blood, but it has everything to do with the last few days.

So I tend to say, that's another thing that I get to learn from if I see that on the panel. But if I get to pick I want to know in my dad like, are you going to die of a heart attack in the next year? If he hasn't eaten for two days before he comes in for his triglyceride look, then I'm going to have a false sense of thinking he's safe when he's really not. But if I get a calcium score, it's a marker of actual disease that's happening now. It's cheap, there's no radiation. This is a magnetic MRI. It should be the gold standard. It is a better predictor of how well they're moving in the right direction. And again, you do not need a doctor's prescription to do it. It's done in a cardiology office usually. Our hospitals do them for screening. It's like a lead magnet or a funnel to get into the cardiologist. So be careful where you go but it is cheap. So I'd still push towards a calcium score over a triglyceride.

Yes, and it's definitely something that Ivor Cummins has been talking about and campaigning for a long time, hasn't he? He would like it to be a standard test that's performed, and yes, I can see why.

I think we've got time for one more question, and this comes from Kate. If night sweats interrupt your sleep - and it sounds like for her this is happening about every two hours - is there anything that can be done? She meditates. She started taking plant-based estrogen cream, and she does all the typical food and bedtime habits. Is there anything she can do to improve that? Maybe you've got an idea why it's happening and how she get around that. That sounds very uncomfortable to have to put up with that all night. We talk about how important sleep is, that's going to interrupt to isn't it?

Here are some assumptions I'm going to make about Kate. She's got night sweats and it's happening every couple of hours. She's got an estrogen cream, so that makes me think she's been to a doctor. The first thing whenever I hear about somebody who has night sweats, is that can be a danger sign. Unexplained night sweats are one of those medical mysteries that you should definitely...tuberculosis does this, a growing cancer does this. They are a warning signal that can be dangerous, so I'm going to assume because she's got a prescription medication there on her list that she's already been to a doctor and actually had her own medical advice on this. When I look at two hour cycle of night sweats, I get nervous about how long has she been practicing that? And I don't mean it in an accusatory way, I just mean that brains get wired and they keep using the same wires.

If she's in a transition in her health where she was on a low-fat diet and now is on a ketogenic diet, after they've gotten keto adapted....so let's say they're six weeks into a ketosis diet, we start to see that these hormones like growth hormone, and cortisol, and estrogen - fat-based - they all begin with a fat. And so those hormones start to rise. And so if you've had a low-fat diet and you've had the hormones that weren't great. And you can tell by, is there a hair nice and thick? Are their fingernails nice and strong? Is their skin nice and resilient? Those things are just kind of by-products of a healthy fat supplied diet. Those hormones have to be stable. But if the hormones have not been supplied...I talk about the supply chain, but in a ketogenic diet, what's really happening is the supply chain for testosterone, and estrogen, and cortisol, and growth hormone, those have been intermittent and they're not predictable when you're on a low-fat diet. But when you become ketogenic, you now have this constant steady supply of fat. The supply chain becomes predictable, but then it hits the body - especially for somebody who's not used to what estrogen is supposed to be - and the production of estrogen. Estrogen and progesterone can cause night sweats. If she's having ovaries that are sputtering, like they produce some estrogen and then they don't - that's because she's going through menopause. Or maybe it's the reverse - which I've seen happen - is they go on a ketogenic diet and the ovaries have kind of shutdown saying, we can't produce any extra energy to the ovaries. We have all these other things that aren't supplied. Ovaries are an extra, so they kind of go into early menopause. But then they get a ketogenic diet and bam, they start producing estrogen again.

And as those ovaries wake up, you'll see about almost a two month pattern of sweats that happen that I wouldn't be adding extra estrogen cream. I would say journey through this and just be checking your numbers in the morning that that glucose to ketone ratio that you're really hitting a good supply every day. I'd want her numbers to be 80 - like glucose divided by ketones at least 80 every morning for two months. And that would give me the confidence that she's supplying her hormones with a steady level, that whatever is blipping up and down to cause the night sweats, has stabilized. When women go through menopause, if they're estrogen would just stay high, they wouldn't have a night sweat. If it would stay low, they don't have night sweat. It's when it bumps up and down that it causes the body to just break out in a heat wave. If that's what this cause of her night sweats are, I would study herself a little better. First thing in the morning, check those numbers, and if you're hitting 80 every day and stay there for two months, and this will pass. Easy to say when I'm not the one staying up every two nights,so...

Yes, and it's interesting and it shows again how important the context is. And like you say, it does sound because she started doing a particular kind of treatment that she has consulted with a doctor. It's obviously important to reiterate what you said at the beginning that if you're getting unexplained night sweats, that it could be indicative of a serious problem. So that's definitely the first thing that you've got to do is go and see your doctor about that. But yes, certainly the first thing that came to my mind was menopause because it's just supposed to be at a typical thing that's associated with menopause, isn't it? That you just get hot flushes and sweats because of that. But like you were saying, it's not necessarily as simple and straightforward as that. It can be to do with a shift, a hormonal change for a number of different reasons, one that can just literally be starting to eat ketogenically.

The other key there is your first instinct was to think of menopause. My first instinct was to think of fever of unknown origin, which is this danger signal of somebody better be looking. And I think that's why it's important that...why don't you see a lot of doctors out there saying generalized advice? And it's for stories just like this saying, well I heard this doctor on the podcast say x, y, and z. And I just want to remind everybody, I love teaching about the ketogenic diet and answering questions, but I do not replace your doctor's relationship. I've had a lot of folks reach out to me saying, how do I find a doctor like you in my area? And I would say take them my book. And I've had so many stories come back where they've said, I just wanted my doctor to open up their mind and see this. And I'll be honest, I've been that doctor where people bring me a bunch of things to read and I do try to read them, but sometimes it's like if I take a bath in activated charcoal, my fingernails grow better. And I'm like what? You know, some silly things that you're just like, I don't have the space for that. So when you first start saying to a doctor who's a traditionalist saying, I'm going to eat a bunch of fat and get skinny....

So instead of doing that, just take them my book and say, read the first 10 pages. And what it does is it shows the sceptic of me saying; this can't be real, could it? I would know this if this was real. And then I unpack where I found the first nuggets; where I had to stop my practice and look into this. And then as if a sign from God said, let me practice on the person I care about the most, which was my mother. And that's what the story does is tells you her story while I teach about this ketogenic process. And boy, I've had some amazing messages back saying, that's what I did. I took him the book, and by golly he's doing ketosis himself. So I would encourage you go to Google type in Any Way You Can, and take the book to the doctor if you want that. But do not take medical advice from me over a podcast.

No, exactly. Nothing beats that relationship with your own GP. But potentially you can influence them to change their opinion. I've certainly worked with my GP over things. I haven't managed to...there's certain guidelines obviously that they all fall within. And obviously as you've heard, I bump up against those with having the low iron, but he was very receptive when I went in and spoke to him about retesting my thyroid and treating with T3 and not just T4. So it's always worth having that discussion with them, isn't it? Because they are there ultimately to help you get as well as you possibly can.

Yeah. And I contend that relationship is not replaceable. That it is an incredible privilege to sit in front of someone as they tell me about their healthcare, and that I get to be on this journey with them. And with that responsibility is a host of education and commitment to saying, okay, this is my job to help you, and that cannot be substituted through a podcast. So just don't surrender that they're going to know you better than me. And if they don't quite think like you want them to, help them.

Exactly. The point we're getting at through this discussion of different topics - and it's something that I really love about what I see happening with women in particular who embrace keto - is that sense of empowerment, and the self-confidence to be able to help drive their own health treatment even if it means arguing a bit with their doctors. And putting across things that they've discovered because they get to know their body better with these little tricks that you shared with us, like about pressing your thumb down on your shin. But these seemingly silly little things, but all add together...getting your numbers, getting your blood glucose, your ketones, all the rest of it...really getting to know yourself well gives you that empowerment and that confidence to say, no, I know when I'm well, I know when I'm not well. Here's an idea of what my treatment could look like. I think when they really - doctors I'm talking about when I'm saying they here - when they really see that you're really invested in your own health, and you're prepared to put the work in and really work with them, I think they're more likely to help you rather than if you're just coming in with a list of problems all the time without potentially seemingly to want to help solve them.

It's very powerful. I like to write and I think the stories that you get privileged with as the patient...in my book you'll hear how I heard about a ketogenic diet? A patient told me. I know medicine can have this kind of closed down mindset, that they're in it for the drug companies, and they charge too much, and I'll tell you the system is broken, but the people that I attended medical school, that I know are my colleagues, in their hearts, they didn't do all that because they hate people. They want to help you. And if you can just kind of nurture that side of them, what you'll find is very caring industry of people who've done a lot to help another essential stranger, so give him a chance.

Of course. Yes. I completely agree with that. Well, we have more questions, but we're out of time. So we're going to come back with another episode very soon. But in the meantime, if you do have comments you'd like to make, if you've got a question of your own for Dr Boz, let me know and maybe see it featured here in the next episode.

Absolutely. I will include in the show notes, the glucometer thing that I talked about, and I wrote out those ratios that I was talking about - where this is what I recommend, and you can find them on my website as well. But I just want to again say thank you. Your audience is amazing. And when the podcast was posted the first time, it was just such an overwhelming response of wanting to learn, and being hungry for information. So I just say, you guys are the best, thank you.

They are. I have to second that. They're fantastic. We love you.

So I will be signing off and hopefully there's a positive response, and we can do this again.

Absolutely. I'm sure there will be. Well, thank you once again. It's been a pleasure talking to you again today.

Fasting before medical appointment: is 36-40 hours a mistake?
(Bunny) #2

Wow, that was mind blowing! I want more…lol You never get board listening to Dr. Boz!


I need to record some more with her. On it :smiley: