#90 Ask Dr Boz - Part 4


Originally published at: https://ketowomanpodcast.com/ask-dr-boz-part-4-transcript/

This transcript is brought to you thanks to the hard work of April Ihly.

Welcome back Annette, to another ask Dr Boz where we will get to the ask Dr Boz question from the get go. 

Absolutely. I'm so happy to be back. Thanks for having me back. We will tackle questions. We will not tangent onto a Dr Boz-Daisy duo. 

Well don't make promises you can't keep because I'm sure we will end up going off on tangents, but we'll try and keep on track at least to start with. 


Okay. Shuffling my papers. So this is back to April where we started last time with the story of getting some help for her mum who has early onset Alzheimer's and that was a really good development and that's happening now. She's getting them and by all accounts it's a good thing and it's helping. But April's questions, she has a few. "Can a small fatty umbilical hernia self-repair on Keto. I feel like mine has improved since I started."

Okay, let's talk about umbilical hernia. So again, a hernia is an opening or a defect in the lining of a space in your body. So we'll use the word inguinal hernias. And those are mostly associated with males. You can have an inguinal hernia as a female, but it's much more rare and you can have an umbilical hernia. The inguinal hernia is the space where the testes actually left the abdominal cavity and go into the the genitals during birth. And if that lining gets too much pressure, it will pop open a connection between the scrotum and the abdominal wall. And I use that as an example to explain what happens with umbilical hernia because it's much easier for people to visualize these two spaces having a connection. 

When it comes to umbilical hernia, you're supposed to have a seal all the way around the inside of your abdomen. When you were in your mother's womb, you were getting your nutrients and food through this vein and artery combination through your belly button. That cord got sealed and was supposed to completely adhese and scar off any opening. But if your tummy got big, if you have a weight problem, and you can even see this in little babies, if they have those cute little full tummies. If the scarring didn't happen at the time of birth, you'll see that the edge never could find its partner to seal. In their umbilical hernias, we worry only if the tissue comes through that opening and get stuck. So it's actually safer to have a large umbilical hernia as opposed to a small one. A small one, if the tissue kind of pops through this little tear or this lack of adhesing, of sealing, and then the tissue on the other side gets kind of irritated and happens to swell too big to pull back into the tummy, that's when you have a problem. 

I'm a big proponent of the less surgeries you have in life, the better you've done. So when I look at the need for an umbilical hernia, if you're a swimsuit model, we can help you. If your hernia is stuck, it's super painful, like it's going to cause gangrene and die, it's going to be an emergency, so it's not like, oh, it's a little tender. Nope, it got stuck as the tissue left the abdomen and got stuck on the other side of that opening. So when we look at can an umbilical hernia improve or repair, let's just unpack that a little bit further. As the mass inside your abdomen gets less with the weight loss associated with the Ketogenic Diet, you'll see that the pressure pushing through that little opening is now much less and the hernia will kind of retract back into the abdomen.

Will the scar ever seal shut?

No. That time it's torn. There's nothing stimulating it to connect back together. But is it an emergency? Should you have to go under the anesthesia to get your umbilical hernia repaired? For your brain's sake, I would say no way. I mean, every time, especially a patient with high inflammation, so if you've had an overweight tummy enough to cause an umbilical hernia, if you've been struggling with high insulin states of Metabolic Syndrome or God forbid, full diabetes, your brain doesn't need any help with destroying or putting stress on those brain cells. Anesthesia, every time we do it, you have a cognitive hit. I don't care what age you are, but if you're inflamed, if you have high inflammation in your system, the cognitive hit is higher. So I would not sacrifice brain cells to repair an umbilical hernia unless your whole income comes from being a swimsuit model and you need that little bulge to not be there. That's how I would answer that question. 

So yes, basically, yes, it's not ever going to repair, but it's going to get significantly better. 

Right. Good answer. Way To summarize what I just rambled on about

Okay. Another problem she has, although by all accounts from her update, it has got better. But I think this is an interesting one and this is a question I see from other people, so I do think it would be interesting to address it. When I fast, I feel great and the longest was 40 hours. The problem is that I feel awful when I start eating again. I've been slowly incorporating foods back in after a fast that no matter how slow or what foods I try, I always feel horrible for days. It's only when I start eating again and not while I'm fasting. I want and need to fast, but I'm developing a fear of eating again afterwards. What might be causing this? And I know from my own experience, I don't have as much of a problem as that, but certainly when I start eating again, I how should we put this politely? Have to run to the bathroom? And that always happens with me always when I start eating again and it's something I know that's going to happen, so obviously I plan for it, but this, I can see how this going on would just become a self fulfilling prophecy, if nothing else. But I have heard many other people saying the same thing. The fast is great. It's when they start eating again that they have problems. 

There's a few things, I've seen this multiple times as well, and here's the advice I give folks. First of all, I would start with, as you look at a GI system that's been shut down, which is what happens during fasting, it really slows down the movement, the gas, all of the secretions are much slower. You're going to restart it when you start eating again. And the first wave usually does end up with an urge to go to the bathroom. One of the better ways to do that is to make sure that that first bit of food is high salt and warmth. So I recommend leading that first moment of breaking a fast with warm, salty broth. That nutrients is great, the salt is great, it tastes really good. And that kind of leading syndrome of there's a lot of bone broth that does really does get absorbed before it ever gets to that large intestine. 

So you can see, even though the wave of peristalsis starts to send the wave down the gut, it's much less if they lead with that. Second of all, you can talk to many of the people who've had gastric surgery for weight loss that they will have, I wouldn't call it a full dumping syndrome where it's a lot of diarrhea, but I would call it like a high like reflexive trigger for their peristalsis when they start to eat again. And I haven't seen anybody successfully train out of that. So you've cut the nerves when you did that surgery and there's a part in there that's going to have this high almost reflex. And when you start eating, when you're eating all the time, the reflex gets worn out and it's not, you don't have the diarrhea, but when you've had a pause and then you restart it, the wave goes from top to bottom and they end up at the toilet. 

That may fit to some people, but that, uh, is not uncommon. The third thing that I've seen that's really important when thinking about what do you do to break a fast is consider whether or not what you're eating is something you're allergic to. And specifically, I point out lectins, I didn't even know what lectins were before before the ketogenic diet, but you know, from bell peppers to peanuts to even jalapenos have some lectins in them. If what you're eating are these wonderful ketogenic foods, but they are high in lectins, I have been amazed at how many of my patients when they cut out lectins, and really they did carnivore for about a month, so almost no vegetables, no peanuts, said my diarrhea went away. And so what I've reverse engineered is to say it is essentially an intolerance for lectins. And many of my celiac patients or gluten intolerance, even if they're not full celiac, really have an insensitivity to when they consume a lectin, they get very loose stools and they get more of a spasm in their gut and they do a beautiful kind of movement and absorption process. 

And then the fourth one is what I do, which is when I'm done fasting, I feel the need to celebrate. So I will eat too much. And even though I've gotten a lot better at it, it probably took me like 50 times fasting to say you do not deserve a celebration. It is not that big of a deal. You are going to be fine. So the amount of food at first, try not to celebrate after a fast. And again, this is a goal, so keep working towards it. But if you celebrate with fasting, by eating a large volume of food, you're going to pay the price. Your gut is just not goingto handle that as well. 

Yeah. Interestingly, I find it a good way to reset my satiety signals a bit, actually. I'm the opposite. I can't eat much. The first meal I have is always a lot smaller than I would normally have, so I go the other way. But yeah, I know for some people the temptation is to eat all the things. 

If you've ever done one that's been like four or five days, that's the ones where I really mess it up and like I've only done that a few times. Usually I do a 48 hour, maybe a 72 hour, but 36, 48 are much more normal in my life and I've don't have as much celebration. But boy, the times where I've pushed it, you'd think it was like a wedding or something.

It's funny how our brains have to compensate. Yes. Okay. This is the big one, really. This is the main one. "I've around 200 pounds to lose. I've had some great non-scale victories, but Ihave lost no weight at all." That's got to be really frustrating, right? If you've got all this weight to lose when you're over a certain size, that's the assumption that you think that the weight is gonna drop off fairly quickly. At least to start with. "I'm not in it just for the weight loss and while my inflammation is down, it's still really bad. I'm under 20 grams of carbs a day, at least 95% of the time and always under 30. I know I need to be patient and stay the course, but what are some potential reasons why I'm not losing the swelling and inflammation?" And I'm going to go on with along update now. 

That was her original question. I've pulled these questions from a list we had way back when we did the first ask Dr Boz and so I got an update from April to see where she's at now. "My main question is why are my blood sugars still so high and why am I not losing the inflammation and weight, although that's not my entire focus, after being Keto for so long?" Because of course she's now, she's been doing it for quite awhile. "I'm 46, menopausal and have severe sleep apnea and use a CPAP machine every night. I average about seven hours a night during the week on the weekends I often end up sleeping 10 or 12 hours to make up for what I've missed during the week. I don't set an alarm. I just naturally sleep longer. I know I need more sleep during the week, but I always wake up around seven hours. 

There's been a lot of stress in my family over the last two years. There hasn't really been a break between incidents. My dad passed away three days before Christmas in 2016 from stage four renal failure, liver failure and diabetes. His heart gave out. My mom had not yet been diagnosed with Alzheimer's but could barely take care of herself, so my sisters and I took that on. It was a huge source of contention for awhilewhile we figured out how to move forward. In the meantime, one of the family members was getting more and more toxic and dealing with them became an unavoidable nightmare. I've done what I can to remove them from my life, but they keep dragging out things that I have to be involved in, so I'm not completely free from that obligation. Mum was recently moved into a care facility. It's a good one, but there are still stresses in dealing with that. 

Work isn't really stressful, but there are times when it is. I'm also switching careers, so I'm dealing with learning a completely new career while still doing my current job. I started Keto in April, 2017 or what I thought was Keto. I think it was more low carb than Keto. I was told eat low carb and low fat because I had a lot of fat on my body. I started real Keto in June, 2018 after finding and devouring all the 2 Keto Dudes episodes. I had a relapse over the holidays. I was depressed because I had hardly lost any inflammation. My blood sugars were still ridiculously high and of course I hadn't lost a single pound. I recommitted in January this year and purchased a ketone glucose meter to start tracking. I attempted fasting but my body didn't respond well after the fast when I started eating again. Eventually I got over that and was able to fast without too many side effects. 

I tried to get the optimal Dr Boz ratio, but even after fasting for 69 hours, I was still way off. I went mostly carnivore in February. Still couldn't hit the ratio. Ketonesrarely went over 0.5, they were at 0.1 or 0.2 most of the time and blood sugar still in the high one nineties regardless of how long I fasted or what I ate or the time of day. Recently I started an experiment. I eat only beef, usually ground beef or steak, butter, salt and water. I got a host of labs done beforehand, fasted. Waiting for the results to come in. My insulin a couple of weeks ago was 19.2 which is in range, thankfully. I plan to do labs periodically to compare. So far this seems to be helping as I've lost eight pounds in 12 days and my GKI is slowly improving." She believes that cortisol is to blame, at least in part for her constantly high blood sugars. 

"I get a 40 to 50 point spike in the morning around two hours after I wake up and take my first reading. The result is the same whether I'm just driving to work or laying around the house relaxing." She does tend to eat late in the evenings, but she's tied to that because of her work schedule, sometimes doesn't eat before 9:00 PM. She knows this is detrimental, but she doesn't believe it's the only cause, but she is trying to make changes so that she can eat a bit earlier. So that's a long update, but quite a bit of information in there that I thought might be useful. 

Right. I took notes, so I was trying to keep track of what my thought processes were. So you can tell she's watched some of the videos on my channel because she knows about checking those blood sugars with the blood ketones. She's clearly making ketones, which is powerful to just reassure this is a better metabolism than she's been at. And then to know that there's a 200 pound excess mass on her body. To hear the words, I have sugars in the one nineties after multiple hours of fasting and when I checked my blood tests and I only had an insulin of 19 as I was fasted, which is in this normal range, I would actually tell her that she has undiagnosed diabetes. So whether she knows that or not, I don't know if that's part of the journey. I didn't hear that in her presentation. But when your body has diabetes, it has, the efficiency for processing the glucose is broken, which is what causes the brain to deteriorate, the heart to deteriorate and the scramble inside the body to find a place for glucose. That when you have a blood sugar of 190 and your body's only producing that lower amount of insulin, that is a mismatch. The insulin should have been higher in her case. You'll say, but doc, the range of say, you know, if you can get it below five, you're doing great, so 19 isn't awful. Like those are with normal blood sugars. You should have produced more insulin to put away that sugar to get it out of the bloodstream, because that sugar is what is inflaming your system. It is what it is aging your blood vessels in your brain. So when I look at what would I do in a case like this, I would look at an A1c. 

I bet you it's, she's not making enough insulin anymore. Her cells for producing insulin have either fatigued or just cannot produce enough insulin for the mass of her body. So what do you do? She's doing a lot of things right, like to reset and to encourage her, is her metabolism really is the key to fixing this. Running her body's metabolism on a fat-based platform as opposed to a glucose based platform, she's heading there. Looking at weight loss in a diabetic, it's difficult. That is almost the taboo. We say you can't lose weight. You're a diabetic. Now, that's not true. But it's so hard when they do not understand their own glucose ketone ratios, that without monitoring that you will be so frustrated. You will think I'm doing everything right. I'm doing all the rules correctly. I can't fix the problem. I can't lose weight. I don't know if you've watched any of the videos I've done, but there's a type one diabetic that I followed on my show and again, so she doesn't make any insulin and she comes with an average sugar around 300 at the beginning of this journey. 

Now her sugars are around 100, 110, but if she fasts, which she's done the last couple of months now, it's the only time she's been able to lose weight and she's like, why is it that when I fast, I can do that? Number one, we cut her insulin in half because we don't want her blood sugar to drop too low. But number two, the ability when you lower insulin, especially if you've been given the same dose everyday, everyday, boom, you drop it down, you now give permission for those fat cells to open up and release their stored energy. You'll say, well, you know, why can, you know, what is it about producing a ketone that has to do with insulin? The state your insulin is at is goingto be pretty stable. Yes, it goes up and down when you eat, but the average number is going to be plus or minus 10 and your pancreas will keep that level at that certain range until a sudden drop in food or a rise in energy demands happen. 

When the sugars change, the insulin can change and that drop in insulin allows your fat cells to provide the ketones, to provide the source of, you're trying to lose weight, the weight comes from emptying a fat cell. You cannot empty a fat cell when the insulin stayed the same. You have to drop the insulin. So in a type one diabetic, we dropped the insulin during her fast and she's able to lose weight. Well, doc why don't you just drop her insulin the whole time? Because her sugars would be too high. It's a very difficult thing to navigate to help her with the weight loss and then keep lowering the insulin steadily over time to match what her glucoses are. In a case like what you've described, the first thing I would start with is, there's a drug called metformin and it's out there. 

If you've been in the Keto world awhile, you'll hear that it's gonna have some impact on mTOR and cancer prevention and longevity, but it's a diabetic medication. That's what it was first put on the market for and it's not insulin, but it does improve the efficiency of taking sugar from the blood and putting it inside the cells. So in a case like this where she's doing all these things right, I would augment her body's ability to do that with a prescription of metformin. I sometimes use that in people who say, I just want to help the sugars be better controlled. And even if they make plenty of insulin and they're not, metformin, it doesn't hurt you, doesn't lower your blood sugars too much. It just gets them from the bloodstream inside a cell easier. And that's really where she's struggling. 

The next thing I would consider is really getting her a continuous glucose monitor for a two week experiment because it would be very powerful to see what is the range of her sugars. And if the sugars are all hanging out between 150 and 200 or 150 and 250, you've got to get on board with an internal medicine or primary care family practice doctor to address the lowering of the sugars with added insulin. And that's gonna sound like the enemy at first. But trust me, you gotto control the sugars in order for the inflammation to be better. If she was trying to avoid that, avoid being an insulin dependent, and this would be a type two diabetic even though it's from fatigue of insulin production that we're kind of stuck with here. We look at matching her cortisol. I mean that is incredible amount of stress. 

Her stress level is powerfully overriding the production of releasing glycogen, releasing sugar from storage. So that's part of where all of this sugar stuff has come from. So what I would say is she knows what I'm going to say cause she said, I already tried this. I know I'm doing this wrong. So especially women over 40 and I do this because I get a ton of messages from them saying, Dr Boz, I'm at a stall, I can't lose weight. And you know that woman over 40 I'll say, allright, you see what time the sun comes up, you have eight hours to eat. And it's because that sun comes up and your brain sends a signal to release cortisol, which tells the liver, give me some of that stored sugar called glycogen. And your sugars go up and the energy in your body rises while you're asleep and that's what wakes you up in the morning. 

You will have a churn of extra cortisol for the next six to seven hours after that. So we say sunrise plus eight hours is your eating window. Even if you say, but I don't eat in the morning, I fast. I'm like, yeah, but you didn't tell your brain and your liver that, you didn't tell the sun that. And so keeping the calories low during that time is a great way to burn those sugars. Have black coffee, continue to fast during that time, but set the timer to say, I need your big meal to be before that eight hours is up. What she needs, she's like, well I can't do that with my work. I'm like, get a doctor's note. Find a way that you're not eating after that. Because what's happening is even if she's eating the most ketogenic meal, she is still producing cortisol every time she eats. 

And like, what? Like she's in a high stress state so she is churning another wave of cortisol by eating, you know like, okay, so I need only one wave a day. We can't stop the sun from coming up. So that's goingto be the one wave of cortisol we use and as that wave takes its time and goes up and down by the end of that eight hours. That's why I like them eating in the middle of the afternoon, that two to three o'clock when they're stuck with a stall, I need them to eat. I need them to have high fat. I need them to eat to satiety. They're fully satiated and then I need them to have none after that. That is difficult. It is a social time to eat. It is a very challenging goal. So to wake up tomorrow and ask her to do this is kind of unlikely, but if we say, all right girl, wegotto back it off the edge. 

You're going to start with, thereis no food after seven o'clock at night. Even if you work the night shift, I need you to respect that. You gotto find a way to get the food in before seven o'clock. If you don't, find a way to fast until the next morning. My husband teases me because I tell him when he wants to eat late at night, honey, your clock will reset and he uses this against me whenever I want to do that late at night, your clock will reset, but it will. If you can push through that wave of hunger after that seven o'clock hour and once you've mastered seven o'clock, then we're going to back you to six o'clock and we're going to keep going back until you can get your eating to be within the eight hours after sunrise and you will reverse the problem. 

You will start using energy as fat cells. You see it already in the times where you've successfully fasted and I would contend that that has been your lifesaver. I mean that by you're not, I mean to have the body mass that, that you've struggled with and then to see that your sugars have been in the 190 long enough that we have some sort of insulin production fatigue, like the insulin is not meeting the demands of your body. It says the algorithm is advanced. We are at the later stages of a diabetic journey. We can help with Metformin, but nothing will be as powerful as her honing in the hours that she eats. Fasting is one of those way`s she can do that, but putting the food to match the sun is going to be super important. 

Yeah. As you're speaking, I'm trying to think of a practical way that she's going to be able to do this. She obviously has this problem. I think she finishes work maybe around seven. This is why by the time she's got home, yeah, and even prepared something quickly, it's difficult, but I'm thinking so, okay, so what is the solution here? Obviously weekends, no problem. Can follow a plan at the weekends where you're saying, so really all her food needs to be in before, what, three, four o'clock in the afternoon? 

That would be amazing. But again, if you start her there, that could be too heavy of a goal. 

Yeah, absolutely. And I get what you're saying about moving it back. All I'm thinking is that during the week that's not goingto be possible, even from that 7:00 PM. But what I'm thinking is maybe, especially if she could incorporate some fasting days during the week, that obviously completely solves the problem, but also potentially being open to maybe going for the breakfast and lunch option. I think it might be difficult to have much of a meal at work, so maybe the big meal being the breakfast. I don't know, I mean it's a real massive change isn't it? It's a big jump to go from one thing to the other, but maybe.

Here's a couple things I've done, because I've actually had this same scenario in my clinic where I've said, all right, let's fail upwards. Let's improve upwards. 

I'm thinking of that push back. I'm sort of sitting in her position saying, well, I don't get home, I don't leave work until seven how am I supposed to eat my meals before seven you know, what can I do? 

So, right. Yeah. Planning and having that break at work to eat your meal at work those are great ideas and they could work, but it is a different approach. What I would contend was if she gets to 7:00 PM and she just cannot imagine not eating, I would encourage her to do exogenous ketones. I would make a shake of ice and ketones and sip on that. It is fuel. It will enhance her metabolism. It is not sugar that goes in with, I mean she's got plenty of sugar happening. That's the problem actually. She's got really high sugars. So when we fail upwards, if we add ketones to her situation and say, okay, we want you not eating anything at all, but if you're goingto put something in, we're going to add something that over the next couple of days you will have a stronger metabolism because you put more ketones in to burn for your metabolic health than you wouldhave had, had you, I mean, even if she wouldhave fasted, her ketones will still be at a lower level until she gets that metabolism rising. So when I say fail upwards, it's not perfect. I would love a whole script and put her into like a, you know, calculate what she should do and follow the rules specifically. But when the enemy is us, you say, allright, what could she do that would feel good to her? And you know, those exogenous ketones, mix them with a little cream if she needs to have, you know, some fat with it. If it happens to be MCT, it's even better. So now she's got two ways her body's adding ketones. It's going to be the energy or the fuel she needs and it will become this mindset that says, if I want to eat, I have to do that before seven o'clock. 

Or the only option I have left on the table is to add ketones without food. And that has worked amazing. Like I have two people. I'm thinking in mind that it did improve. It took about three weeks for them to say I figured it out, but I only figured it out because I did it with that messy version where I couldn't not eat, I wasn't strong enough to fast, but I put in ketones and by about the fifth day they start thinking in a different way. They start strategizing and the next choice was better and the next choice was better. Now they don't do those exogenous ketones at all, but for bridging that, it really did help her. The two I'm thinking about saying, oh look at that. You got home from work, you did not carb crave. You did not even like ketoglutton, you know like they're, everything I eat is Keto, doc.And like I know, but you're putting in so much mass, I can't get to tap into the stored fat cells that you're trying to lose for weight. And if you want to do that, we have to shift the metabolism. So fail upwards and that will shift it. 

Yes, because ultimately like you're saying, if you're goingto ride that cortisol wave and eat while you can, and if the only time you can eat at home and have that meal is breakfast, ultimately that's going to be your goal is fasting and breakfast during the week with meals into the afternoon at the weekends. But you're right, it's just that massive jump. But if you can bridge that gap and then get to a place where you're doing something that works, even if you thought it couldn't work into your schedule, but if it's goingto get you where you want to go. You know, this is a big problem that she's got to solve, isn't it? 

And it's not uncommon. 

There's only so many ways to do it. 

It's a great question because she's doing everything right. She's invested to understand her own body chemistry and she can see that there's a problem. She has sugars in the 190 range. That's diabetes. There is a break in metabolism. If I could get a reign on this, if she could get the numbers down, if I could get her to fast for a month, okay then we'd be fine, but that doesn't fit life. Look at all the stress she's had. Look at the lack of sleep. You know her support system is obviously good enough to do as much as she's doing. So asking her to be the perfect results. That's ridiculous. There's no chance for longterm success by saying, oh honey, if you just fast for the next 40 days, you're going to be fine. 

She can stay off of insulin longterm, if we can shift her metabolism to a higher ketone base and essentially what she's going to be doing is we want her using the calories stored in those fat cells so it will become a lower calorie ketogenic diet is what will, because she's already keto adapted. As long as we can keep the ketones burning, the size of her meals will get smaller and those are conscious choices, but also subconscious because she feels good. That does play a part. I don't usually talk about a calorie restricted ketogenic diet unless I'm talking with seizure patients, cancer patients, or in a situation like this where I really need a metabolic boost in her system to keep her off of injectable insulin. So pushing to bridge that eat during the cortisol phase and once you kind of find the rhythm that you're now eating in that eight hours after sunrise, that's when we would talk about now we want your meal sizes to be smaller. And the reason why is I need to tap into the calories you've stored as fat. That's how get the weight loss gone. That's how your insulin needs will be less when your body mass is less. It's a three step process here. 

Well, hopefully she can see a way through this and start seeing a change because I really feel for her. I've seen how hard she works and as you've seen, you know, she's a smart cookie. She's worked out a lot of these things for herself. She knows where the issues are and she works really, really hard at it, you know, and is prepared to be very restrictive in what she eats to work really hard to do the work with the tracking and all sorts of things. And it's just must be so, so frustrating. I really do feel for her. 

Well, I do hope she's got a support system of people encouraging her because that, I mean, had she not taken on Keto in the last chapter, she wouldhave been in an ICU somewhere with a completely failed pancreas. So she needs to know that the choices she made to make this shift have been life altering even though she can't see the disaster that would've happened. I'm certain of it. 

That's very true actually. Yes. That's a very good perspective, is to actually see what feels like such small steps forward as actually really massive leaps. 

From where it shouldhave been, right, where she was headed. 

Right. Okay, so this is another one that's in the ballpark of where we've been talking and I know is something that you're really passionate about and that's brain injuries. This is from Sarah. Sounds like they've been a bit unlucky in their family. "I have so enjoyed your episodes with Dr Boz. With her experience with brain injury, it would be helpful for me and my family if she could address concussions and how Keto helps them to heal. I have had at least two in my life. My son had a serious concussion a few years ago when he was 16 and now my daughter also. She has just turned 16. They are both soccer players. I watched the brains of addiction video you posted. Thank you. Does a concussion leave defects in the brain such as the ones in the pictures you showed? Does Keto help heal these holes over time?" 

I love this question. I do this workshop called Brains of Addiction: From Trauma to Repair. And the foundation of that format is an 8 to 10 hour course, which sounds like a lot, but people are so hungry for this exact question. And it may at first sound like I'm goingto talk a lot about addiction, but I really spend time talking about the traumatic injuries to our brain and what we know about healing them. There are many parallels to addiction, but her kids at 16 and 16 having concussions, she is near and dear to my heart for, for being passionate about, how I think of the job as moms is, it's my job to develop your brain to the highest level and make sure you're not in my basement at 30. And I think of that as what is the, what are the foundational rules for brains and repairing them, as you guide your teenagers through these injuries. 

Because when they have a concussion, there is very good evidence you can see on those videos that I've talked about, that the brain no longer conducts messages through the sections that are swollen or concussed and as long as that swelling repairs and completely goes away, you can see that brain awaken. But if you want the biggest enemy for a concussed brain, there are two that are so common in our teenagers today. Number one, they have an unstable bedtime and it's too late. They are pushing their brains to be awake too late. They are stimulating their brains with screens for at least two hours before going to bed, and the depth of sleep needed to repair the brain, specifically making something called BDNF, brain-derived neurotrophic factor. That protein is what repairs our brains. And if you're not getting that good teenage 10 hours of sleep, especially after an injury, you are inhibiting the brain's ability to repair.

Because they're forced to get up early as well, aren'tthey? I've heard people talking about this, we should really be starting teenagers at school much later. 

I would actually say that it, shifting that to an earlier bedtime is just as easy for our society to do and actually probably plays forward in the neural programming better than starting their school day later. I say this as a mom of teenagers where it would be perfectly easy for me to have them start later, but I'm saying I want their brains to play forward with the best neuro programming and that really does say getting their head to bed earlier, showing them the respect needed for repair of a brain. But the other major enemy out there is sugar. And when watching a teenager's brain go up and down in sugar production, unbelievable how damaging that is for a scar that's already swollen in their brain. 

In that brains of addiction video, you'll see a picture of a diabetic and that diabetic hasn't, doesn't have an alcohol problem, they don't have a drug problem, they haven't had concussions, that is simply from their diabetes. And it is the swelling that happens in their brain and stops the conduction of messages going through because of the repeated swelling from high blood sugars. So to get that concussed brain to repair, pushing their brain to use ketones over glucose, very important. Number two, bedtimesof the whole family. If you want a teenager to do something, telling them to do it without doing it yourself, good luck. So now you have 16 year old brain injured teenagers who are going to be moody and irritable because that's the journey they're in. But I would contend that their moodiness and irritability grow worse every time you stop the maturation or the maturing process of their brain, which happens with a concussion. 

But it also happens when they have poor sleep, when they have excessive sugars go up and down. My youngest son is a wrestler and between him or his buddies, whenever they have concussed brains, I've had consults in the homes of his friends saying, all right family, I know this is hard, but all screens need to be off by seven o'clock at night. If you have something you need to watch, you can put it off till tomorrow. No screens in the bedroom. Everybody's phone goes in the basket at seven o'clock. 

Wow. That is hard. 

What is powerful though is, and some of them did the Ketogenic Diet. Others supplemented the ketones to get the family onboard and then has actually graduated to a very sustainable ketogenic lifestyle for that family. But it wasn't easy at the beginning. And that commitment to say, when you see the suffering that happens longterm with concussions, it's powerful how many brains don't return to normal because they aren't given the six months time to repair. So you say, well, how long do you have to do this? If it's a teenager, it's a six month process of getting that inflammation out and allowing their brain to return back to the normal growth pattern and for heaven's sakes, don't let them get another head injury in the meantime, so that can mean a limited amount of the sport activity until they graduate. I can't emphasize enough how powerful it is when the families choose to engage in those treatment programs versus not. In that first couple chapters of my book, I talk about these brains of kids who had seizures and then years later, you know they get put on the ketogenic diet because they're the misfits. They didn't fit the treatment protocol, they didn't respond to the prescription medications, and we have a couple of autopsies from these seizure kids that are now in their seventies or eighties and they're at autopsy. Their brains are beautiful. 

That's not how it's supposed to be. That environment of low inflammation, specifically fed by a high fat diet is a powerful repair process for the human brain. Getting those kids to journey onto that type of eating, they have temptations at every turn. It can be really difficult. So showing them the process and the progress by sharing some of the stories from that book or looking at some of those youtube videos, that's how these moms motivated their kids to get on board. Because what they were saying was ridiculous and no, no way. But just looking, saying, hey, you've got a brain that had this injury. If we want it to repair, here's the rules. We need really good sleep and the sugars have to be low. You can't be carving up day after day after day. It's gotta be a Ketogenic Diet. Very good question, though, because I get that a lot. 

So there is hope then


You know when you've seen these scary videos with all these pictures of holes, what you're saying is that you can heal them.

Absolutely. And I think that's the part that when people say, why would the average person look at a doctor Boz ratio or what, you know, getting that glucose and dividingmy ketones, why would you look at these numbers? That sounds kind of geeky. I give them affirmation that says, no, you have a really important repairing process that's happening every day in your brain. And some of the injuries we don't know about, they've led to chronic depression because the scar never healed from that injury long ago. Andyousay, well doc, it's been 30 years. Can I do anything about it? Like yeah, stay in Ketosis for three to six months as an adult and watch what happens. And you're like, what? No cheat days. I'm like, no, no cheat, that we're repairing a brain here. And again, if I, if I have that as the leading conversation with somebody who going into the ketogenic diet, I can often lose them. It sounds impossible, but once people have been keto adapted and they really feel the positives and the energy and the focus and the improvement they have with a Keto diet, and then they say, are you saying that if I do a really good job of this for three to six months, that my old brain injuries have a chance of healing? And I'm saying yes, but it has to be a steady chemistry environment for them to repair. And that wins the conversation. 

Right. And it all starts becoming more feasible and doable, doesn't it? When you start feeling better. You know a lot of people start Keto and they think they could never eat this way for the rest of their lives, but they actually start doing it and realize how delicious it is. And yeah, this could be a lifestyle. This is not just a diet. And I feel great to boot. 

And if you ever didn't remember that, you felt great, itt's that first time where you binged saying, I have done a great job for several months and then they have, you know, carb up and you're like, oh, I'm heavy, I'm swollen. I can't get my ring off. I just feel my joints hurt again. It didn't take long for all that to come back and then suddenly you say, well, it wasn't that bad of a list of foods. Actually they were pretty good. So if you're saying that I could journey in that direction and feel that good, now you have other reasons why they stay the course and they hop on the bandwagon quicker and yeah.

Well that's why people tend to stay. I find a lot of people start from a weight loss perspective and might see it as short term, but they start to feel so good and that's what keeps them, that's why they stay the course, is for the health benefits. 

Absolutely. And that is a real improvement in the conversations that even were happening at the time where I was first writing this book where I couldn't hardly find anybody to sit still and say, no, no, no, this is my plan for a life. Is that safe? And now you hear all the evidence of improved telomere length and improved longevity and brain function and you know, repair. You know, you look at the of national sports physicians that attend these metabolic health summits or conferences because they want to enhance the repair process of their athletes on the team. That's the difference between and win or lose, is how quickly they can repair and nothing beats the anti-inflammatory state of a ketogenic athlete. You can hardly find a national athletic league, from my standpoint, that doesn't at least talk about the ketogenic diet being part of a good option for their athletes. 

Right. I mean you could call it, that could be another name for keto couldn't it? Anti inflammatory diet. 

Yes, andin fact my husband does not like theword ketone. He thinks it's too sciency and so when I was writing writing the book, he's like, you've got to come up with a better name than Keto. It just sounds like chemistry. And I'm like, it's because it is honey. 

That's not a bad thing. 

So one of my options was, well I can call it the anti-inflammatory diet, but that's just so many syllables over and over again, I don't think it works. So I agree with you. 

This is a question from Shelly and is about tinnitus. It's short and sweet. "Do you have any experience of healing tinnitus with Keto?" I can instantly tell that she hasn't read my book because I put together a list of things that surprised me when I had implemented the Ketogenic Diet in my internal medicine practice and done it for other reasons, but I had the first two patients that came back and said, you know that ringing in my ears that I've had forever and ever and you gave me these meds and we tried this and that and nothing really worked? I was afraid to tell you because I thought it would come back, but it really is gone. And that really landed in their journey about three months into the real journey. And I say that importantly. At first they were a little bit Keto, meaning they'd checked a couple of urine Keto strips and they had turned pink and then they fell off the wagon and then they went back on and then they carb cycled where they did good job during the week but had a bunch of beer on the weekend and then something, in each of their stories it was different, something pushed them to say, all right, I just need you to give me three months of not screwing this up. You can do this. It's better than anything else we have. And if this doesn't work, we can take you to surgery. So they manned up, girled up, whatever, and did it. 

And they took their doctor Boz ratio, meaning they'dcheck their sugars and their ketones and really monitored that they were in ketosis and it wasn't that great of a ratio. They had a Dr Boz ratio of like under 120, so not terrifically wonderful. Just pretty good. And it was constant. 

I was going to say, it's that consistency thing that you were talking about before, just being in Ketosis for a block of time. 

Right. And you know, it's, it's that same thing. What would you pay to take away that buzzing in your ear? And it's haunting. I mean I have spent hours and tons of time just trying to crack the puzzle of why it happened and what, and really, I have come back to after years of, you know, struggling with this, is they have kind of an arthritis, if you would, in their ear. 

I was goingto ask you, isn't it one of those things, is it difficult to pin down exactly what it is, what causes it? 

Right. So you're conducting a sound when it's not supposed to conduct. So I always tease my kids which substance conducts sound the best? Air, water or a solid? And sometimes they'll get it right. Sometimes they won't. And I said it's a solid and if you put your ear on the railroad tracks and you could hear the train coming. You remember how they used to do this and that? Okay. Put your ear on the railroad tracks. Is the train coming? You could hear it on the rail long before you could ever hear it in the airwaves. You look at telephone wires. I mean they conduct sound. So you look at your ear and the same thing happens. 

It's got a fluid that sound conducts through and that's inside the inner ear conducting the sound, moving that energy into a nerve that gives you a sound that your brain knows what it is. If you now crystallize that or it gets a hardening, now the sound conducts quicker and faster at the slightest movement. That's why sometimes you can say doc it seems to be my pulse. Like, yeah, the movement of that blood creates a vibration and sound is a vibration. So I need you to stop conducting that sound. I need you to block that out. But they can't. It's signaling too high from their baseline. So to undo that means the swelling in the other parts of the ear need to reduce. So you need to remove the water and remove the inflammation from the inner ear. Well, you can't unless you've got the whole body's anti-inflammatory, or removal of inflammation happening. 

And in some people they get lucky enough where if there is some crystallized or hardening or calcification that's happened in the inner ear, the swelling now isn't surrounding that crystal. And so the solid crystallized compartments don't touch anything else and that's when the sound stopped. It's super sciency and kind of gets into a microscopic level. But I hope you can imagine like as soon as there's nothing conducting the sound, as soon as you separate the water from the crystal, you have no more ringing in the years. Well that is, that's a advanced level of your removal of inflammation. It's on the inner part of your ear. So we had to keep them in Ketosis for several weeks in a row. I didn't do it for that reason. We were doing ketosis three months for other reasons and they came in on their own saying, guess what? And like no way. And then then I've had a few other patients do the protocol. They have to stay in that zone, they have to stay in ketosis. And then of course, like anybody, a couple of them fell back off. The swelling came back. Boom. 

I was just gonna say, I bet it comes back full force.

Oh yeah. You look at those kids who had the seizures and they stayed on the ketogenic diet because every time they weren't on a ketogenic diet, they had a seizure. It was forced compliance. And so when people say, oh, shucks, like if I go off, I have my ringing in my ears back. I instantly compare it to that. I'm like, this is nothing compared to a seizure. You can do this. And it gets a little easier. Besides, if they get their autophagy, there is a chance that they can recycle those crystals, recycle that arthritis. And I don't over promise that, but I've been very impressed with, the longer they're lean with ketosis, the less orthopedic surgeries I am referring for. 

Oh, that's really interesting. You start to worry that you're gonna sound a bit like a broken record though, don't you? Because it's like any kind of condition somebody mentions Keto, but seriously, if any condition is an inflammation disorder, it's going to help isn't it? 

Yes. I look at my clinic and think what would it not help? Because it does, it sounds like a panacea. You're over promising, this is never goingto work. And you're like, no, no, really. You just have to link it to inflammation for the science to be broken down. And the longer I do this, the more I see. Yup. That has an inflammatory component as well. From brain health to heart health to arthritis. Yep. Inflammation is in all of them. And it speckles not just an internal medicine clinic, pretty much every clinic for primary care. That's why you see more physicians saying, alright, teach me how to get my patients wrapped around this. And the more we can educate them, the better the outcomes have turned out. So I highly encourage the woman who wrote that in to go check that chapter out in my book. I do write about that story of the patients in that book because it was shocking to me. Like who knew? 

Yeah. Wasn't something you were expecting. I forget which speaker it was. It might have been Dr Westman, at the conference at Denver. And he was talking about all these different parts of medicine and how not necessarily Keto specifically, but changing sort of health and lifestyle certainly in that direction should be a primary care, because it impacts all these different branches. 

He is one of my heroes, Dr Westman. He is internal medicine as well. So he has this kind of sorting of how he thinks about problems that matches the way I think about problems. And if you talk about beacons and leaders in my world, he is one of my favorites. So I just would say any lecture where he's been talking about sorting of improving the health of your body, check it out on youtube because I'm gonna bet it matches what we just talked about here. 

You absolutely have to get to the conference at Denver. I thought of you while I was there. It was just, it was amazing. It's the first time I've been to a conference like that that's so full on turnover of speaker after speaker after speaker. You know, hard and fast, sort of half an hour presentations and I thought, wow, my brain is just going to shut down because it's going to be overload and I'm just gonna have to zone out by about two o'clock cause they start really early as well. 

Yes, we internists. Any physicians, you have rounds, and early, absolutely. 

So the day kicks off really early and also the clocks wound back. So it ended up being like ridiculously early on the Sunday. I was actually fine with it because of the jet lag. So I was fine being up early but I really thought it would be just too much. You know, for someone like you, you'd love it. But actually it was fine. They really got the pace of thelectures going well. So it just, it was so stimulating and interesting. I could see you there really, really enjoying it. So you must, you must go next year. 

I'm looking forward to the next year. I truly have been in hiding waiting for this decision from the medical board saying I just, I don't want to have any reason to take any media or take any attention. And so hiding was safest, but I was envious of, and waiting for the lecturers to come out on YouTube so I could watch them myself and have not been disappointed. Very, very powerful presentations and conference. 

Absolutely. I really enjoyed it. It was fantastic. I guess you're going to be all the conferences next year then?

I'd like to be, yes. I told my husband I'm going to become a Keto junkie starting now. 

There are worse things. Well, thank you so much. We still have some questions, but they're going to have to wait for another episode, but I will keep them here and I will try and get you back soon to go through the rest of them. 

Well, Daisy, I just want to say thank you so much for having me on your podcast. I really find the format of the discussions and just the tone of how you connect with people very attractive. So thanks for including me on your list and I look forward to more episodes. 

Well, thank you for coming back and I look forward, too. Thank you Annette. 

You betcha.