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April 30, 2018

Keto Cure with Dr. Adam Nally

Dr Adam Nally, aka Doc Muscles, collaborated with Jimmy Moore and Maria Emmerich to write the book KetoCure – A Low-Carb, High-Fat Dietary Solution to Heal Your Body & Optimize Your Health. This book takes Dr Nally's 18 years of medical experience and nearly 14 years living a keto lifestyle and presents a way for you to take control of your healthy using ketosis.

Sponsor:  This episode of the 40+ Fitness Podcast is sponsored by Fresh-Pressed Olive Oil.  They are offering you a $39 bottle of their high quality, fresh-pressed olive oil for only $1.   Go to 40plusfitnesspodcast.com/oliveoil to learn more.

Allan (06:53): Dr. Nally, welcome to 40+ fitness.

Dr Adam Nally (06:56): Thank you. It's a pleasure to be here.

Allan (06:58): They call you Doc Muscles and you have a story. I think they should call you the Keto Cowboy because a lot of your pictures are you with your horse and living out there in Arizona and all that. And it's like, yeah, I think of you more as the Keto Cowboy than Doc Muscles. But you kind of have both of them going on. Could you take just a moment and talk about the story of how you became Doc Muscles?

Dr Adam Nally (07:23): Well, you know, it's kind of funny. In medical school, the one way I blew off steam was lifting weights and so I was in the gym. They had a gym that was part of our medical school that we could go and use anytime we want it to and so I found myself in the gym lifting weights. It's a lot because that was just what I enjoy doing. The one on one day I was in there with a couple of friends and the trainer you turned to me and said, hey, if you keep doing it will be the doctor of muscles. And so one of my buddies who would rather golf then lift weights, he said, “We'll just call your Doc Muscles.” And so it was a stupid, little off-the-cuff comment.

A few days later we actually had to pick a Twitter name and that was right as Twitter had been released and we were communicating via social media. I couldn't think of a handle, so I just used Doc Muscles and that's the handle that I've had for Twitter and Facebook. It really wasn't intentional. Other than that, that's where it came from. I've always enjoyed weightlifting and always enjoyed the process of gaining muscle, being fit and my fitness has waxed and waned through that through the years as you go through schooling and training and various things, but I've always gone back to the fact that that weightlifting has been one of the big things I've enjoyed.

For me, weightlifting is cathartic. Plus now over being over 40 and understanding sarcopenia, now it's not just fun. It's actually important. It's critical. There's nothing to blow off stress better than just throwing around weights. Well, I have to say riding my horses is the other one that I enjoy. It's actually quite enjoyable and we're finding that weights play a huge role in insulin resistance, which I'm sure we'll talk about later. And it helps with testosterone.

Allan: I read this a study not too long ago by a Harvard scientist. They went through their hypothesis and they did their study and they basically found that the low-carb high-fat diet performed better than the standard way that they want you to lose weight (complex carbs and low fat). They acknowledged the low-carb high-fat diet but concluded that's too hard to comply with, so you should do it our way. He's not wrong to an extent. When you first try to get into Ketosis, it can be quite difficult and challenging once you're there. It's well worth the effort, but it's that kind of that first several days, where they use the term Keto flu. I prefer to call it carb withdraws as your body learns how to do different fueling systems. Can you talk a little bit about that keto-adaptation and then some of the hacks that you have that will help us get through that process a little bit more effectively?

Dr Adam Nally (10:30): That's a perfect question. You know, it's interesting. I've been doing a keto lifestyle for about 13 1/2, almost 14 years. In the first five or six years, it was more low-carb. What we realized though is that to be in Ketosis, you have to be very, very low carb. And that means in many cases is it's less than 20 grams a day of carbohydrate. And that's where a lot of the other researchers who I think were probably raised on bread and pasta, will say that's too hard and nobody can give up bread and pasta.

Allan (11:07): You find that when you think about eliminating that from your diet, it can be some challenge. But when you actually feel as good as you feel when you achieve a ketogenic state and you start to see a dramatic improvement in all of the inflammation and the other things that occur. You feel fantastic. You don't want to go back. When you do cheat and you go out of Ketosis, you feel so bad. You'll ask, “why did I ever live this way?” It is a very sustainable lifestyle.

If you look at the standard American diet, the average plate on the American eats and probably other countries as well, 85 percent of what's on there is starch of some sort of some form of starch or carbohydrate or sugar and that, so our body gets used to those fuel types and amazingly the epigenetics forms around eating a certain way. Our genetics are designed to help us eat. We downregulate fat absorbing receptors in the gut and also in every cell in the body. They're called mct receptors and we downregulate those well when we start eating more fat and we shift to a keto diet, where we're decreasing the carbohydrate or increase in fat. Our bodies don't usually have as many receptors is that needs to absorb that fuel. So number one, you're not gonna absorb the fat as fast and so it takes a little time to get the fuel in. Number two, it takes weeks and sometimes a couple of months to upregulate enough for those receptors both at the gut and also in the cells to absorb that fat into the system and have it available as fuel.

And third, there is a conversion process in the liver that takes a little time in helping your body adapt to being able to convert the ketones even faster and that can take a little time, too. So there's this transition period of a couple of weeks to some people, a couple months where you may feel a little more fatigued. You may not have the energy or sustainability, but if you're an athlete, a lot of athletes will say, well, I felt more tired during this first two months period of time. I couldn't hit my race pace that I normally hit or I couldn't lift as hard as I thought it was lifting. And that's just because there's a problem with fuel as you're shifting over. So that's actually pretty normal.

A lot of the keto flu symptoms or that people get are not related to the adaptation period. They're actually related to dehydration or an inadequate salt intake or something. I haven't done a number of patients that come in and they just are afraid to eat 70 percent fat. There was tremendous fear and so instead of eating red meat or pork, they cut their carbs out and they keep eating chicken and they limit the fat. I have a few of them are still using that I Can't Believe It's Not Butter stuff or whatever that is. We want you to add the fat back in. So sometimes it's just you're not eating enough fat to bring your percentages up to 70 or 80 percent. It may that you're not taking in enough salt and that will be sodium, potassium, magnesium and zinc.

Then, as you mentioned, there's often a period of time where there is carb withdrawal. I have some patients that are so carb addicted, they'll actually get migraine headaches that kick in over that first week because of that carb addiction is so powerful. The fructose is converted to an aldehyde form in the liver that acts similarly to the morphine and actually stimulates a similar receptor in the brain that morphine does causing this, “Woah. I love that” kind of a feeling. And you have withdrawal from that. So those are the pieces that fall into that Keto flu or that adaptation period. You get fatigue and feeling groggy and lack of energy we often refer to as Keto flu, the adaptation period, depending on what, how and what your body's used to may take anywhere from a couple of weeks to a couple of months.

Allan (14:36): Now it's funny, the folks that sit there and say, you can't live without pasta or bread. They haven't met Maria Emmerich who is one of the coauthors on here and has a lot of recipes in the book. I made her actually did her braised duck with lemon thyme. I substituted with chicken and man, you know, that that's worth the price of the book right there. Just that recipe. She's so, she's so awesome. Jimmy Moore was also a coauthor on the book and he puts a lot of flavor on this from the perspective of someone who's really, really struggled. He's learned a lot over the years. He does his podcasts and so he's kind of one of the preeminent experts, along with yourself, on ketosis.

One of the things Jimmy really deals with, it's really kind of a huge, huge struggle for him, is insulin resistance. As we look at what is happening, and you even say it in the book several times, one of the core elements of the lifestyle diseases we get is our insulin levels. But if you are insulin resistance, using ketosis as a therapy is going to help you improve your health. Can you talk a little bit about insulin resistance and how ketosis can help us reverse some of those problems?

Dr Adam Nally (16:03): I've been in medical practice about 18 years in total, including residency and training. And the interesting thing I saw was these patterns that started arising in the first few years of my practice. People that would come in and they would have a little bit of weight gain, their blood pressure would start to creep up a little bit, their cholesterol starts to rise, and then they'd have gout or they'd have a kidney stone. Some of them have a little bit of neuropathy that occurs and they wouldn't be all at one time. They would have one of these or they'd have a couple of these things arise. And then I would notice their fasting blood sugar was just slightly high, and then a few years down the road and we'd all have a sudden see that they gained a little more weight, their blood pressure is creeping up and we were adding a few more blood pressure pills, an extra statin, and drug here and there. Women were coming in to see me saying, I am gaining weight, my periods are irregular, I'm having trouble getting pregnant, or various things like that.

So there were these patterns that kept occurring over and over and over again. And if you look back in the literature, these things didn't really show up in the early 1900s and late 1800s. They weren't there, but they started in the early 40s and 50s and 60s and then became predominant through the 70s and 80s. As you're looking at these patterns, you see these things repetitively over and over as you go through door number one and door number two in my office. It got to be quite fascinating. So in trying to understand me, I was struggling the same thing. If you meet my clan, many of the Nally's are 300 – 400 pounds. My father was almost 400 pounds when he died. If you look at his labs and my labs, they're almost identical in the early thirties and I was really worried that my father progressed to type 2 diabetes and was eventually on 150 units of insulin, 32 pills and dialysis. He ended up having a heart attack. I was looking down the same road. That bothered me and it bothered me that I was seeing it and I was doing what I was taught to do in school.

Yet it wasn't changing and my patients were doing what I was asking them to do, but it wasn't changing and we kept adding pills every year. That was very bothersome. What I started to notice was his insulin level. I would check it periodically. It would creep up and I started noticing that his insulin load was higher and higher. One of the things that I was trying to identify as is there another marker that we can use to catch diabetes earlier. One of the things I saw was triglyceride levels jump. We know that insulin directly stimulates triglycerides. If your triglycerides start to rise, what that basically says this, your insulin load was high in the last 24 hours, and so I started looking at patterns of insulin. What we found and what I've found in the literature is that 10 to 15, sometimes 20 years before you ever become a type 2 diabetic, your insulin levels will start to be high and those high insulin levels will create one of six patterns:

  1. Weight gain,
  2. high cholesterol,
  3. Elevated blood pressure,
  4. Infertility issues in women,
  5. Polycystic ovarian disease, and
  6. Thyroid changes.

All of these are patterns of the way the body's handling this excessive insulin load.

We know that from the perspective of weight gain, there are over 32 hormones that drive weight gain itself, but insulin seems to be the master hormone. So if your insulin's off, it throws the rest of these hormones out of whack and your body may use different patterns to try to accommodate that. With a high insulin load and based on your genetics, insulin resistance starts to identify itself.

Insulin resistance is a problem with many of the, what I call diseases of civilization. So high blood pressure, diabetes, weight gain, Gout, and kidney stones. These are all diseases that we didn't see much of before the 1900s. And all of a sudden we do. I started noticing is that about 85 percent of the people that walk through my doors had high insulin levels 10 to 15 years before we ever diagnosed them as diabetics. They were overproducing insulin in response to the sugar, the starch they eat.

If you give me a piece of bread, theoretically I should produce a slight sort of insulin for that piece of bread. But if you check my insulin when I eat that piece of bread, I'll produce 10 times the insulin in response to that bread. And that insulin acts like a worn away key. It doesn't quite get the cell open very effectively. So the body produces more of it. You have now 10 times the insulin floating around your body doing the job that one key was supposed to do.  Those 10 keys also stimulate other processes in the body that shouldn't have been stimulated by that one piece of bread.

Allan (20:30): I really enjoyed that metaphor that you had in the book where you talked about a worn key and how much additional effort it has to go on to actually open the lock. You're turning that key and if it were the way it was supposed to be, one key goes in and just does it, but our body doesn't react that way if we have this propensity to have more insulin in our system.

Insulin is not a bad thing.  You even say that in a book. It's actually a good thing because it's there to protect our brain by keeping our blood sugar levels at the level they're supposed to be, but we're just a little out of whack if we're going to get these surges of blood sugar and whatnot.

So the standard American diet (SAD) way of eating a is literally going to continue to take you down that sick path. I appreciate that you, you mentioned a lot of those diseases PCOS, heart disease, type 2 diabetes, weight gain, all those different things. I want to talk about a couple of them that are going to really hit home.

This was the first time I'd ever really seen anyone tie hypertension to this whole situation and how ketosis could help hypertension. Could you talk about that a little bit?

Dr Adam Nally (21:44): Well, it shocked me. I started applying the low-carb keto lifestyle and I noticed it helped me with my weight. So I said, well, let's try this with my patients and see what happens. We started measuring blood values and monitoring people's biometrics and seeing how they're doing. The amazing thing that I saw was that when people actually lowered their carbs got into ketosis within about two weeks, their blood pressure normalized. One of my patients was on three blood pressure medicines. All of a sudden he called me up and said, hey, I'm dizzy, I'm light-headed, what's going on? And so when we check their blood pressure and his medicines were actually too strong and we had the start are backing them off.

That puzzled me initially.  But the literature says, if you lose weight, you're going to see a drop in blood pressure. For every 10 pounds of weight you gain, your blood pressure goes up five points and vice versa,  It is the standard you're taught in school. But that was, I was seeing much more than that. I was seeing more dramatic drops in blood pressure and it didn't make sense. We started looking into the research that's there and we realized that this high insulin level actually stimulates the body to retain salt of sodium, potassium, and even magnesium. And so your body will hang onto these salts and water follows salt wherever it goes.

Water is kind of a boyfriend for salt. Salt goes here, the water follows.  Insulin is stimulating the kidneys to retain sodium and potassium salts. The blood pressure stays higher and it seemed like the more people followed high-carb low-fat diet their blood pressure crept up. And when I switched it around and we put them on a keto diet, their blood pressure would fall.  That correlated really well with the drop in their insulin loads. And the drop in their overall inflammatory markers. When we put a person in the ketogenic state, before they've lost even five pounds, I'll see 10 points in blood pressure drop, which didn't correlate with what you're taught in school.

So I thought this has to be hormonal. And so as you start looking, and that's what we talked about in the book, is there's a number of, of physiologic functions that insulin stimulates. When you have excess insulin present, you're going to see a dramatic rise in blood pressure. And when we returned that insulin level back to its baseline (normal) level, all of a sudden the pressure normalizes and it does so quite rapidly. It was an eye-opening process I was not expecting to see.

Allan: (24:04): Yeah, when I was first starting this journey and it's one of the things I did, I went to the doctor and he's like, you're prehypertensive. I asked what does that mean? He told me that I almost had high blood pressure. You're right on that line. So when you lose the weight, your blood pressure will go down. And my blood pressure did drop with the weight loss.  But ketosis is basically doing it faster.

I think that's a good thing to note is a, whenever you're going to change the way you eat, the way you move, the things you're doing, it's worth having a conversation with your doctor beforehand so they understand what you're about to do and at least can monitor your medications and things like that so you're not doing something that could potentially wreck yourself even though you're doing the right thing. You have to be aware that you know, if you start feeling a certain way, you need to talk to your doctor because you're actually improving your health, but your medication doesn't know that's what your intention is. So it's going to do what it's supposed to do and you want to. You want to make sure that you're working with your physician to do this.

Dr Adam Nally (25:08): Absolutely. I had a lady that called me up one day and just mad as a wet hen. She was upset that her husband got hospitalized because of the keto diet. And I said, well, who's your husband? She goes, well, he's not your patient. I said, well, did I put him on the Diet? She says, no, I did, but he's on four blood pressure medicines and he almost passed out and so she was really upset that her husband had to go to the hospital because he was so lightheaded. He had almost passed out.  His blood pressure dropped suddenly and he was overmedicated. So we talked to his doctor.

Allan (25:38): Talk to your doctor, please. They may not understand that the keto diet. They may not even agree with the keto lifestyle. Have the conversation with your doctor. You should share that information with your doctor and make good health decisions because the doctor is there to help you. They shouldn't be the decision maker. You should be the decision maker and the doctors there to facilitate you getting healthy, but if you have something you really believe is going to work, have that conversation, be armed, this book is a great way to arm yourself because you can just basically say, look, here's what I'm seeing, here's what I'm thinking.

Tell your doctor you want to give this a try and you need them to work with you and make this happen. And, and, and most doctors, once you kinda put it out there that way, they're like, okay, fine. If you have some problems with your blood pressure, give the of the office a call and we'll talk about lowering your medication or whatever. Don't put yourself in the hospital just trying something, work with your doc.

Now one that was very interesting and I knew there was a kind of a link and it's kind of almost a threeway linked – insulin, cortisol, and testosterone. There's this internal battle happening in your body that if any one of those things gets out of sync, they kind of mess with the other ones and I always knew that existed from the things that I've read, but you put it out there really, really clearly. Working on your insulin levels using the keto diet, you can actually improve your testosterone levels.

Can you talk a little bit about that?

Dr Adam Nally(27:18): Oh, absolutely. This is another shocker. You're applying these principles. All of a sudden people are getting better and you say, I didn't do anything to fix that. The patient didn't change anything. What happened?  Testosterone is a real complex hormone and the way it's produced and the way it responds. What we find is that because of a number of influences of this high insulin load the fat cells produce hormones. Our fat cells produce a plethora of hormones, at least eight of them specifically influencing the way blood sugars are handled and the way insulin responds.  They also affect the way the brain handles testosterone.  When you see this rise in insulin, what ends up occurring as you see changes in the way Leptin and some other hormones like kisspeptin and how those affect the pituitary gland, and then again go into effect the testicular production of testosterone.

It's very sensitive system. Minor things can influence it, and there's this dramatic effect.  About a third of men that come to my practice who are insulin resistant, will start to see their testosterone's drop.  I'm gaining weight. I have no energy. My Libido's gone and I just don't feel like I used to feel. They'll start to see a breast size enlargements and their wife is coming and going and doc, I gotta buy him a Bra. It gets to be a challenge and for many, it's very embarrassing.

The big challenge is that there's not a lot of great treatment for this other than giving testosterone and giving testosterone has some significant side effects. Just giving the testosterone itself didn't fix the problem. So as we started applying keto lifestyles and we started naturally lowering the big insulin response by just removing the starches and the sugars out of the Diet and giving people back fat that what that does is it allows number one, the insulin level to drop. And number two, when you're giving people back real fat that now the body can create testosterone from the fat.   Testosterone is a form of, a derivative of cholesterol, which is a platform of the fat.

And as your body now has the adequate fat present to make adequate testosterone. We this improvement in the overall function. So I'd see guys testosterone's jumped 150 points back up to normal just by making a dietary change within a couple months. And it was dramatic.  We're getting a better response with just this dietary change than I was with given them topical testosterone creams and things of that nature. So I'm very effective in a very brief way. The book actually goes into a lot more of the detail of how that works from a physiological level. But it was another one of those shockers for me to keep seeing this repetitively over and over again. Guys, testosterone's are getting better.

Allan (30:11): Yeah. I interviewed vegan on one of my episodes when I first started.  He had a good argument for the vegan lifestyle and how it works and people are healthy. And I'm like, I don't know that I could go completely Vegan, but I'm going to go pescatarian.  I'm going to eat fish because I live on the Gulf coast. I had a blood test. My lipids always run really high, which I'm not very concerned with because my, my HDL relative to my triglycerides are awesome. In fact, sometimes my HDL is higher than my triglycerides by a good bit.

I gave it a go and my LDL did drop a little. It didn't drop what I would call significant, but my HDL plummeted, my testosterone plummeted, I gained weight. I found this is unbelievable. I'm eating the way skinny people eat and I'm getting fat. It made no sense to me whatsoever except for the fact that get satiated because I wasn't eating enough fat. And so here I am eating some nuts but a lot of fruit and vegetables and fish.  But even though fish has a good fat, it's still generally lean.

I actually gained weight being a pescatarian. It's not what my body needed, so I eat a keto diet, but I eat it on a seasonal basis.  I think that makes it a little bit more sustainable for me because, well my brother is a brewmaster and I love beer and I occasionally enjoy a couple glasses of wine a and things like that and those will sometimes bring me out of Ketosis. I enjoy tailgating. I'm in the southeast, you know, I love football. Are you an Arizona or Arizona state fan? Before I go too far.

Dr Adam Nally (32:31): Oh, I, you know, I'm gonna I'm gonna upset somebody. If I tell you that I actually met my father-in-law, went to ASU. I've got another brother-in-law that went to U of A. So I kind of have to play the fan.  I didn't go to either. I actually went to Grand Canyon University. So I'm a Lopey. I see from that perspective there, but it depends on which family member room with his team on really for at the time. So yeah. when they're playing each other, I watch from home.

Allan (33:05): So during that season I just want to be able to go and kind of enjoy myself and I realized I'm not going to feel my best. I'm not going to operate and maintain my best, but you know, I'm basically going to take that time to enjoy my life. And then when it's over, then I'm going to go into my winter where now I've got to go and get back into ketosis. The way you know, my ancestors very likely spent a large portion of their life being from northern Europe.

Getting into the keto lifestyle is not hard if you have that determination to get there in the first place, but I see so many people wanting to hold on to some semblance of the way they used to eat and they typically do this through artificial and some natural sweeteners.

Can't I use the zero calorie sweeteners? And if I am going to use one, which one would be the best one for me to consider using? I'm not a scientist, I don't know all the science around all of it. I know that there's a lot of ill effects for quite a few of them and there are new ones popping up every day and it's just too much to keep up with. I feel that just eating whole food is the way.  At some point you're going to find that a carrot is actually probably too sweet for you when you actually try to just eat a carrot because your body's telling you there's a lot of sugar in this. A strawberry tastes delicious.

We used to put sugar on blackberries and I have no idea why I used to do that because now I eat them without. But I can't have more than three or four of these because they're just so sweet. You do change your palate. But that said, there just are some people who feel they need that bridge or something, that sweetener thing and to get them to the next level. Can you talk a little bit about these, some of the artificial and the natural sweeteners, and what is the right one for us to consider if we were going to do one?

Dr Adam Nally (35:16): Okay. I practice from a perspective of people. People have to live their lives. You know, you still have life. You're still going to show up at Aunt Matilda's house and she's going to want you to eat a cookie.  If you don't eat that cookie, she's gonna be really upset. You may be offended at Matilda for the rest of your life and then she writes you out of the will. Or she dies the next day and you just feel horrible, but you know, you never ate a cookie and she just was going to hit you for eternity. We have to understand that people h