Ketosis, where the body burns fats in preference to carbohydrates, is being promoted as an approach to weight loss and treatment for chronic diseases. I’ve taken a Quantified Self approach to tracking my experience with ketosis seeing a number of benefits and challenges along the way. One of the conclusions, which I’m testing further, is that the types of fats used to replace carbohydrates may be critical to optimal health in response to a ketogenic diet. These slides are from my March 17, 2015 presentation to the Quantified Self St. Louis Group (www.quantifiedstl.com) at the Cambridge Innovation Center.

1. Fat as a Health Food: Benefits &
Course Corrections During a
Year of Tracking Ketosis
Jim McCarter, MD, PhD
Entrepreneur in Residence, BioGenerator &
Adjunct Professor of Genetics, Washington University
Quantified Self St. Louis
Tuesday March 17, 2015, CIC

2. Vilhjalmur Stefansson, Artic Expedition 1913-1918, www.dartmouth.edu/~news/releases/2008/02/26a.html

3. N=1 Disclaimer
• This is my own experience.
• We all have different genotypes & phenotypes.
• We all respond differently to diet (& exercise, sleep, etc.).
• I am not providing medical advice.
• As you’ll see, this is a work in progress.

4. Daily
• Work
• Sleep
• Mood
• Exercise
• Steps & Stairs
• Weight
• Heart rate
• Food log & photos
• Blood glucose
• Blood ketones (BOHB)
• Exhaled ketones (acetone)
What do I measure?
Periodically
• Body fat & bone density (DEXA)
• Blood Pressure
• Blood Chemistry …
– Complete blood count with differential
– Comprehensive metabolic panel
– Fasting glucose, HGB A1c, HS CRP, TSH
– Lipid panel (TG, HDL, LDL)
– NMR Lipoprofile (LDL subfractions)
– Blood fatty acid profile (Ω 3 & 6)
• Gut Microbiome

5. In One Generation, U.S. Obesity Has Tripled
and Diabetes Has Increased 9-Fold

6. Working Hypothesis: Carbohydrate Over-Consumption
is a Driver of the “Diseases of Civilization”
Slide From: Prof. Tim Noakes, “Medical Aspects of the Low Carbohydrate Lifestyle”
https://www.youtube.com/watch?v=fL5-9ZxamXc

7. Carbs Result in a Glucose & Insulin Roller Coaster
(Post-breakfast munchies, Post-lunch food coma)
Slide From: Prof. Jeff Volek, “The Many Facets of Keto-Adaptation”
https://www.youtube.com/watch?v=GC1vMBRFiwE

8. Meta-Analysis Does Not Support a Connection
Between Saturated Fat and Cardiovascular Disease
Am J Clin Nutr 2010; 91:535.
Ann Int Med 2014; 160:398.

9. Bad Dietary Advice is Everywhere.
Fat Does Not Make You Fat.
http://www.extension.org/pages/63813/what-are-triglycerides#.VQOx9-E6994
This web site says that for Homer to lower his
high blood triglycerides he should stop eating
fat and eat more fruit & non-fat dairy.
This is just wrong. If Homer has high
triglycerides (a dyslipidemia which goes along
with low HDL and high levels of small dense
LDL) the single most effective thing for him to
do is to reduce sugar & starch in his diet.
Note: I’ve doubled my fat consumption while cutting my
body fat in half & reducing my blood triglycerides.

10. What is Nutritional Ketosis and
What Makes it Desirable?
- Benefits of ketosis include
- decreased hunger & fatigue, easier weight loss
- increased endurance (access to 80,000 kcal “fuel tank” of body fat versus
2,000 kcal glycogen store)
- Improved lipid profile – decreased triglycerides, increased HDL
But, ketosis is pretty controversial and challenging to implement.
- Ketosis is the production of ketone bodies from stored or
dietary fat. Ketones are a marker of fatty acid
metabolism.
- Ketones are naturally occurring and increase when fasting
or when carbohydrates in the diet are limited (e.g. breast
feeding, certain hunter gatherers).
- Ketogenic diets are used in the treatment of epilepsy and
are being tested for treatment of chronic diseases.
- A ketogenic state occurs after adaptation to fat burning
(~3 weeks after carbohydrate restriction).
- Nutritional ketosis is not ketoacidosis which occurs in
diabetes with high glucose levels & a lack of insulin.
- During fasting, ketones can provide 60% of brain energy
needs (the remaining glucose provided by gluconeogenesis).

11. Benefits & Challenges I’ve Experienced with
LCHF & Ketosis
10 Benefits
1. Achieved desired weight & body
composition
2. No longer hungry or tired after meals
3. Athletic stamina supports sustained
high intensity
4. No longer have symptoms of
inflammation
5. No longer get cold & flu symptoms
6. Blood pressure is down
7. Resting heart rate is down
8. Triglyceride is down
9. HDL cholesterol is up
10.LDL cholesterol subclass is favorable
pattern A
4 Challenges
1. Warm-up time for workouts is
longer
2. Prior sensitivity to cold
temperature has increased
3. Cholesterol is higher (likely benign)
4. Fasting glucose is higher
L.C.H.F. = low carbohydrate, high fat

12. Benefits & Challenges I’ve Experienced with
LCHF & Ketosis
10 Benefits
1. Achieved desired weight & body
composition
2. No longer hungry or tired after meals
3. Athletic stamina supports sustained
high intensity
4. No longer have symptoms of
inflammation
5. No longer get cold & flu symptoms
6. Blood pressure is down
7. Resting heart rate is down
8. Triglyceride is down
9. HDL cholesterol is up
10.LDL cholesterol subclass is favorable
pattern A
4 Challenges
1. Warm-up time for workouts is
longer
2. Prior sensitivity to cold
temperature has increased
3. Cholesterol is higher (likely benign)
4. Fasting glucose is higher
5. Cramping in calf muscles.
Cured by daily bouillon cubes for salt replacement

13. From A Standard American Diet to a
Low Carb High Fat (LCHF) & Ketogenic Diet
carbohydrate
protein
fat
U.S. Average Diet (2006 1) My Ketogenic Diet (estimated)
48.7%
15.7%
33.7%
USDA
Advised
US
Average
Carbs 45-65 48.7
Protein 10-35 15.7
Fat 20-35 33.7
1 Austin et al. Am J Clin Nutr 2011. 93:836.
Caloric Intake By Macronutrient
Low Carb
Hi Fat
Ketogenic
Carbs 7-14 3
Protein 13-21 13-21
Fat 69-76 80
3%
17%
80%
US Averages follow USDA guidelines

14. Numerous Dietary Plans Claim Beneficial Effects
Through the Restriction of Carbohydrates

15. Slide: Prof. Stephen Phinney, “The Art & Science of Low Carb Living & Performance”
https://www.youtube.com/watch?v=GkQYZ6FbsmI

16. What Do I Eat with a Ketogenic Lifestyle?

17. What Do I Eat with a Ketogenic Lifestyle?

18. Ketosis Shopping List
No Sugar, No Starch … But this is a diet closer to decadence than deprivation.

19. Optimal Nutritional Ketosis
Slide: Prof. Stephen Phinney, “The Art & Science of Low Carb Living & Performance”
https://www.youtube.com/watch?v=GkQYZ6FbsmI
BOHB 11/7/14

20. Tracking Ketosis Thru Daily Blood BOHB
mmol/L Beta-hydroxybutyrate
Points – days, Line – 7 day moving average
AM fasting 2.0±0.9
PM post-meal 0.9±0.6

21. Travel & Restaurants (Unexpected Carbs)
Lower Ketones, Fasting Spikes Ketones
Thanksgiving Moving Business Trip

22. Travel & Restaurants (Unexpected Carbs)
Lower Ketones, Fasting Spikes Ketones
fasting experiment
Juniper
Chestnuts Hodak’s
Almond Butter
Picnic One Market
Ketone dips are easier to
explain than spikes

23. Benefits & Challenges I’ve Experienced with
LCHF & Ketosis
10 Benefits
1. Achieved desired weight & body
composition
2. No longer hungry or tired after meals
3. Athletic stamina supports sustained
high intensity
4. No longer have symptoms of
inflammation
5. No longer get cold & flu symptoms
6. Blood pressure is down
7. Resting heart rate is down
8. Triglyceride is down
9. HDL cholesterol is up
10.LDL cholesterol subclass is favorable
pattern A

24. 1. Achieved Desired Weight & Body Composition –
DEXA Scan (Duel-Energy X-ray Absorptiometry) Verified
Date Nov
2001
Feb
2015
Weight
(lbs)
191 166.0
% Fat ~21-24 12.0
DEXA
Fat (lbs) ~40-46 19.9
BMI 23.9 20.7
Waist
(inches)
~34 31

25. 5 years at 183
8 years at 178
QS & Ketosis to
sustained 167±1.7
illness
days – blue points
50 day moving average – black line
pounds
1. Achieved Desired Weight & Body Composition –

26. days – blue points
20 day moving average – black line
Caloric
Restriction
LCHF
Reduced
Hunger
Ketosis
maintenance
LCHF
maintenance
pounds
1. Achieved Desired Weight & Body Composition –

27. RELATIVELY
EASY
HUNGRY ANGRYHANGRY!
pounds
1. Achieved Desired Weight & Body Composition –

28. 2. No Longer Hungry or Tired After Meals
3. Athletic Stamina for Sustained High Intensity
• No longer feel the need for
an after breakfast snack
• No longer feel the need for
an after lunch nap
• Able to sustain longer
periods of intense
concentration
• Swimming – Able to sustain near sprint
pace for long distances
• Basketball – Effortless intensity while
opponents half my age are winded
• but … longer warm-up time required
(especially for running)
Slide From: Prof. Jeff Volek, “The Many Facets of Keto-Adaptation”
https://www.youtube.com/watch?v=GC1vMBRFiwE

29. • Hip Pain During Long Runs => Resolved
• Shoulder Pain During Swims => Resolved
• Verified with C-Reactive Protein Test (3/10/15)
4. Reduction in Inflammation Indicated by
Resolved Joint Pain & Verified by Low CRP
Low Risk
<1.0
Mg/L HS CRP
Average Risk
1-3
High Risk
>3.0
0.4
10th percentile1
Active Infection
>10.0
1 Rifai and Ridker. 2003. Population Distributions of C-Reactive Protein in Apparently Health Men
and Women in the U.S.: Implication for Clinical Interpretation. Clinical Chemistry, 49:666-669.

30. 5. LCHF/Ketosis Plus Vitamin C Has
Reduced Cold & Flu Symptoms
Colds 2010 Colds 2014
3/5 3/6 3/7 3/8
4/8 4/9 4/10 4/11
6/14 6/15 6/16 6/17
10/20 10/21 10/22 10/23
10/24 10/25 10/26
10/27 10/28 10/29
10/30 10/31 11/1
5/21 5/22 5/23
Sore throat
Cough, Sneezing,
Nasal drip, etc.
- Colds initially got worse on
LCHF (2013)
- Disappeared with Introduction
of 2000mg daily Vitamin C in
fall of 2013
- Still notice exposure – awake
with a tickle in throat, but
then resolves
22 days vs. 0 days

31. 6. Blood Pressure Has Decreased From
Pre-Hypertension to ExcellentmmHg
May 2009 Nov 2010 Mar 2013 July 2014
systolic
90
136
diastolic
78
127
80
127
Mar 2011
76
130
68
104
120
76
Mar 2015
Keto
<20g
LCHF
(<50g carb)
Prior Diet
(estimated 300-400g carb)

32. 7. Resting Heart Rate is Down From 65
to 50-55 Beats Per Minute
With Fitbit Surge, 50 overnight, 53 while preparing this slide.

33. 8 & 9. On LCHF, Triglyceride Dropped 3X
and HDL (“Good”) Cholesterol Rose 2X
Ketosis
(<20g carb)
LCHF
(<50g carb)
Mg/dL
January 2010 April 2013 July 2014 March 2015
Prior Diet
(estimated 300-400g carb)
HDL
TG
46
78
99
85
139
75
41
94
“HDL >60 is considered
protective of heart disease”
“TG <150 is desirable”
“TG/HDL Ratio less than 2:1 is ideal”
3.02:1 1.04:1 1:2.41 1.11:1

34. Benefits & Challenges I’ve Experienced with
LCHF & Ketosis
4 Challenges
1. Warm-up time for workouts is
longer
2. Prior sensitivity to cold
temperature has increased
3. Cholesterol is higher (likely benign)
4. Fasting glucose is higher

35. HDL
TG
3. High LDL But Subclass Shows Favorable
“Pattern A” (Large Buoyant) Particles
LDL
January 2010 April 2013 July 2014 March 2015
Ketosis
(<20g carb)
LCHF
(<50g carb)
Prior Diet
(estimated 300-400g carb)
98
91
122
182
“Conventional medicine: LDL > 160 is high”

36. Clinical Practice Has Not Kept Pace with
the Evolving Science of Cholesterol and
Cardiovascular Disease (CVD) Risk
• Cholesterol – lipid soluble molecule essential to animal cell membranes
• 1950s – High dietary cholesterol increases blood cholesterol - incorrect
• 1970s – High total cholesterol as a CVD risk factor – incorrect
• 1980s – Cholesterol & triglyceride carrying particles
– Low blood HDL (high density lipoprotein) a CVD risk factor - correct
– High blood triglycerides a CVD risk factor – correct
– High LDL a CVD risk factor – incorrect (its more complicated)
• 1990s – Discovery of LDL subclasses (Ronald Krauss, Children’s Hospital Oakland)
– High blood levels of small dense LDL (Pattern B) is a CVD risk factor - correct
– Small Dense LDL (Pattern B) is prone to oxidation and vascular invasion
following inflammation
– Large Buoyant LDL (Pattern A) is not associated with CVD
• 2000s
– High dietary carbohydrate correlates with low HDL, high TG, high Pattern B LDL
– High dietary saturated fat correlate with high Pattern A LDL
• 2011s
– Liposcience launches clinical NMR Lipoprofile Test for LDL subclasses

37. • While overall LDL is high, subclass shows favorable “pattern A”
(large buoyant) particles indicative of high saturated fat diet
• Genetics X Dietary changes in transition from LCHF to ketosis
could have driven higher LDL
e.g. “subjects carrying the apo E4 allele are more responsive with regard to
LDL-C lowering in response to dietary fat & cholesterol restriction than
subjects carrying the apo E3 or apo E2 alleles” Ordovas et al. Atherosclerosis,
1995, 118:S11-27.
• While probably benign, high total LDL with pattern A is less explored territory. Planned upcoming
modifications to ketogenic diet may lead total LDL lower while retaining favorable lipid profile.
<90
22.1
NMR Lipoprofile
Results
3. High LDL But Subclass Shows Favorable
“Pattern A” (Large Buoyant) Particles

38. Blood Glucose Measurements Taken
Simultaneous with Ketones
mg/dL glucose
Points – days, Line – 7 day moving average
AM fasting 94.0±8.4
PM post-meal 97.8±10.6

39. 4. Glucose Has Trended Higher Over the
Course of the Ketosis Experiment
mg/dL glucose
Points – days, Line – 7 day moving average
AM fasting 94.0±8.4
PM post-meal 97.8±10.6
AM fasting 89.4
for first 7 weeks
AM fasting 96.3
for next 14 weeks

40. 4. Glucose Has Trended Higher Over the
Course of the Ketosis Experiment
Hemoglobin A1C of 5.4%
Normal Range 4.0 – 5.7
Pre-Diabetes 5.7 – 6.4
Diabetes >6.5%
AM fasting 94.0±8.4
PM post-meal 97.8±10.6
AM fasting 89.4
for first 7 weeks
AM fasting 96.3
for next 14 weeks
- Could be an indicator of insulin resistance

41. While a Hotly Debated Topic, Some Studies Link
High Saturated Fat Diets to Insulin Resistance
• Several studies specifically implicate the saturated fat palmitoleic acid (16:0)
with insulin resistance
• Medium chain triglycerides (MCT) including lauric acid (12:0) & myristic acid
(14:0) do not appear to be associated with insulin resistance
• Replacement of saturated fat with the monounsaturated fat (MUFA) oleic acid
(18:1) was beneficial in some studies
Am J Clin Nutr 2001; 73:544-9.
Diabetologia 2001; 33:312.

42. My Mid-Course Corrections – Continue LCHF &
Ketosis But Cut Back on the Palmitic Acid 16:0
Less of These More of These
Palm Oil –
45% 16:0
Lard –
40% 16:0
Coconut Oil –
11% 16:0
71% 12:0,14:0
Olive Oil –
7-20% 16:0
55-83% 18:1

43. Personal Conclusions & Next Steps
- Health effects of LCHF & Ketogenic Diet have been generally beneficial but
with room for improvement - optimal results during LCHF (20-50g carbs)
- Able to transition in and out of ketosis without much penalty to
ketoadaptation (i.e. retain energy, return quickly to ketosis)
- Increasing saturated fats (e.g. palmitic acid) during ketogenic diet may
have had unfavorable effect on LDL and glucose
- Next steps. Continue to measure while …
1. Test altered dietary fat – MCT & oleic acid for palmitic acid.
2. Test return to LCHF – somewhat higher carbohydrate levels – e.g.
more tomatoes, carrots, beets, turnips, parsnips, fruit.
3. Test slow release carbohydrates (e.g. Generation UCAN super
starch) as an alternative to saturate fats.
- Lots of data still to analyze – food log, gut microbiome, etc.
- Data not yet captured – genotype, fatty acid profile, etc.

44. Broader Conclusions
- Dietary changes will be key to reversing the epidemic of obesity, diabetes,
metabolic syndrome, & heart disease.
- Most Americans could benefit from reduction in consumption of sugar &
refined grains.
- Determining the calories that can best replace those carbohydrates is
critical.
- Ketogenic diets may have utility for treatment of chronic diseases.
- Proper formulation of ketogenic diets will be important including selection
of proper fats (MUFA, Ω3 PUFA, certain SFAs)

45. The deceptively simple question: what should we eat?
Thanks to my
family for their
patience with
daddy’s crazy
experiments!

46. Appendix

47. Here’s one book recommendation if you want to
try implementing nutritional ketosis …
Start with Chapter 9, fluid & electrolyte management

48. In My Case, Trend Toward Lower Glucose with
Higher Ketones But Correlation is Weak

49. Fatty Acid Synthesis Pathways
palmitic palmitoleic
stearic oleic
linoleic
linolenic

51. Jim McCarter LCHF (Low Carb High Fat)
Shopping list, 3/12/15
Vegetables - LOTS
Cucumber, avocado, broccoli, peppers, artichoke, cauliflower, spinach,
lettuce (iceberg, bib, arugula, etc.), kale, collard greens, cabbage, parsley,
celery, bok choy, green beans, eggplant, radishes, asparagus, Brussel
sprouts, onions, scallions (green onions), leeks, shallots, chives, ginger,
pea tips, mushrooms – shiitake, porcini, Portobello, etc., squash –
zucchini, butternut, pumpkin, bamboo shoots [In moderation - tomatoes,
peas, carrots, turnip, parsnip, beets, peas, taro, edamame]
Fruits [In moderation]
Raspberries, blackberries, strawberries, limes, lemons
Grains/Starch (replacements)
Ground flax seed (replacement for morning cereal), coconut flour
(ingredient for making wraps)
Oils/Fats/Oils
Coconut oil – (LouAna), Extra virgin olive (high quality brand), grass feed
butter (Kerrygold), avocado oil, cuts of pork fat from butcher, duck or
goose fat, canola oil

52. Jim McCarter LCHF (Low Carb High Fat)
Shopping list, 3/12/15 continued
Protein (meats, seafood)
Eggs - LOTS (chicken & quail), meats – many – (choose fatty cuts like
pork belly, bacon, pot roast, avoid lean), beef, pork, chicken, turkey, duck,
rabbit, etc., liverwurst, pate, corned beef, spam, seafood – many, choose
fatty fishes, all shell fish, canned tuna, sardines, anchovies, [In
moderation – tofu]
Dairy
Cheeses – many, feta, mozzarella, Swiss, American, sour cream, crème
fresh, cream, half-half. (Avoid processed cheeses with added sugar)
Condiments (all unsweetened – read the label)
Bouillon cubes – LOTS, sea salt, malt vinegar, horseradish, salsa, ginger,
olives, tapenade, capers, sun dried tomatoes, hot peppers, pickles,
mustards, lots of herbs & seasonings, [In moderation – unsweetened
peanut butter, almond butter, sunflower butter, soy sauce]
Nuts & seeds
Almonds, walnuts, pecans, pistachios, cashews, macadamia, peanuts,
sunflower, hazelnuts, pumpkin seeds, sesame seeds, chia seeds

53. Jim McCarter LCHF (Low Carb High Fat)
Shopping list, 3/12/15 continued
Snacks [In moderation]
Unsweetened cocoa – ground or bars (85-100%), pork rinds (chicharrone), Cacao
bliss
Drinks
Water (Mendota sparkling, club soda), coffee, tea, [In moderation – wine]
Vitamins, minerals & Supplements
Bouillon cubes – 2 daily in hot water
Magnesium supplements –slow release Mag64 (64mg twice daily)
Vitamin C – 1000mg twice daily
Omega 3 - DHA & EPA – 1200 mg daily combined from algal sources.
Multivitamin – generic equivalent for Centrum Silver, Vitamin D3
Things I avoid –
Sugar (table sugar, HFCS, soft drinks, fruit juices, jelly, honey, candy, ‘energy’ drinks & bars),
All grains – wheat, oats, etc. (bread, pasta, beer, rice, all baked items, all items using flour – e.g. fried
chicken), Potatoes (fries, chips, mashed, etc.).
[If LCHF but not ketogenic, could eat sweet potato, yam, white rice, & sweet corn in moderation.]
Most vegetable oils with Ω6 polyunsaturated fatty acids (corn, soy, safflower, sunflower, peanut oils, etc.)
Vegetable-seed based fats & spreads (mayonnaise, margarine)
Most fruit (see exceptions). [If LCHF but not ketogenic, could eat more fruit in moderation.]
Most legumes including baked beans, refried beans, soy milk, etc. (see exceptions).
Milk, ice cream. [If LCHF but not ketogenic, could eat unsweetened yogurt in moderation.]
Artificial sweeteners. (Sugar free protein bars, sugar-free gum, etc.)