Dr. D'Agostino: But if we take these ketogenic diets and optimize it with specific phytonutrients and we add some fiber in and we add...then it becomes difficult to figure out what's doing what. But I do feel that there's some synergy in optimizing a ketogenic diet with plant, you know, fiber and phytonutrients that we know have anti-carcinogenic effects like curcumin and turmeric and EGCG, and, you know, there's groups at the Cancer Institute that spend their whole life studying just a handful of these phytonutrients, and they show that it has remarkable chemo-prevention effects. So we should be incorporating these into the ketogenic diet [crosstalk 02:17:43]

Dr. Patrick: Which brings us to the all meat, no carbohydrate diet really briefly, I mean, the carnivore... There's a lot of people that sort of feel like they've done a ketogenic diet, and they need to graduate somehow to another level of zero carb. What are your thoughts on...?

Dr. D'Agostino: Well, I'm not sure if it's like...I think it's going back towards kindergarten. There's no doubt that a carnivore diet is beneficial for some people, and I think it's therapeutic in some ways. It is a form of a ketogenic diet. I followed it, actually felt pretty good on it subjectively, but objectively, my biomarkers were...my LDL I think almost doubled on it. And then my triglycerides started to creep up. So this was a little bit of a concern for me. Like if you have...the fat pathways were a little bit backed up. For example, if you have an inborn error metabolism like carnitine deficiency either primary or secondary, a telltale sign is like an elevation of triglycerides, hypoketonemia, and then you have like, you know, a lot of...a cascade of different things. Like you're just not metabolizing fat as well as you should be. Whereas we know that certain omega-3 fatty acids can actually increase the carnitine, you know, transferase and actually augment fat oxidation, certain fatty acids can.

For me personally, I felt good...I felt fine, but my blood work was a little bit concerning. And when I went back to just adding more fish and omega-3 fats and more plants back into my diet, maybe it was a fiber, maybe it was phytonutrients, I felt just as good, but I brought my biomarkers, especially my triglycerides came back down again. But I think, you know, it depends on the type of meat that you're eating, the amount of food that you're eating. If you're eating the carnivore diet and creating a calorie deficit while you're doing it, I think it could be beneficial. But I don't think it's something that would be sustainable or optimal long-term. So it could be sustainable. It is for a number of people that I know. But I guess the question is, is it optimal? And I have no science. I'm not aware of any science that supports a carnivore diet as optimal for treating anything. Although I've been in communication with people who have benefited greatly from it. So I'm not going to criticize it too harshly. It is a form of a ketogenic diet.

Dr. Patrick: Yeah. Again, as you mentioned, it's like, well, are these people severely caloric restricting themselves? Are they just getting off of a terrible diet that's...? I mean, there's so many factors. And again, it's like, well, you know, to me...

Dr. D'Agostino: And the lack of fiber.

Dr. Patrick: Lack of fiber and, you know, the phytonutrients, which...

Dr. D'Agostino: Which kind of brings it back to the fiber issue too, right? Because it's obvious that we could do well off no fiber at all. So the question is like, you know, is fiber necessary? I don't think it's necessary, but I think it's optimal. So I think excluding it all together is not doing our bodies any favor. And I think when we add it back in...there's just so much good data on fiber that it's hard to ignore. So that's why, you know...

Dr. Patrick: What do you think the colonocytes and like getting the butyrate from fiber like what do you think is happening in the gut in someone with a no fiber diet? Like the butyrate is so incredibly important for gut health.

Dr. D'Agostino: It is. Yeah. And it's a primary fuel for colonocytes.

Dr. Patrick: It is.

Dr. D'Agostino: I don't know. I do know that if it caused, like, a massive disruption of the gut microbiome and intestinal permeability, it would show up on blood work as like hs-CRP elevation. Mine trended...it actually went up like from 0.1 to like point 0.2 or 0.3, but that's like... So I think humans are omnivores, and they're incredibly adaptable to any kind of diet. And I think that dietary diversity might be a good thing. But you have, you know, populations of people like in Africa or other areas where they just eat like one food all the time, and it could be like some cornmeal or it could be whale blubber in another, and they do perfectly well. They survive, they live a healthy life. It's just staggeringly remarkable that we have the metabolic flexibility and adaptation to eat almost anything.

You know, the question is what is optimal? Should we even be eating such a huge diversity of things? And I think that could be beneficial at least. You know, it gives us an array of different things that we can eat and we're grabbing nutrients from different areas. But yeah. I am kind of a little bit neutral on the carnivore diet. I think it's beneficial for some, but I think it's sub-optimal as a ketogenic diet.

Dr. Patrick: And as you mentioned, there's just a lack of empirical evidence. Like there's [crosstalk 02:22:49], which again is confounded all the time by many things. But there's really not a lot of research that have been done on...I mean, published and peer-reviewed and, you know, actually...

Dr. D'Agostino: But there are people doing it and they're thriving on it and they've corrected, you know, various...everything from autoimmune disorders. You know, there's superhigh achievers. You have Shawn Baker, who's just like a physical specimen, and he's just eating nothing but meat and doing very well and has...I don't know. I haven't seen his blood work, but I think it's okay. I mean, he's smart enough. I do think that if you're eating a carnivore diet and you're getting surplus amount of calories, which I kind of did because I added just a few pounds, and I think that negatively affected a lot of my blood work. But if you eat a carnivore diet and a calorie deficit, then I think it could be therapeutic and potentially helpful. So it all comes down to calories. People ask me if calories matter. I think they most certainly do, and I think we need to appreciate that because a lot of the ketogenic diet community, they said don't count calories, just count carbs or, you know, the calories don't matter if you eat this way. But calories absolutely matter.

Dr. Patrick: You mentioned having a...you do intermittent fasting sort of cyclically. Like how many times a week or how many meals a day? Like, you know, is it something that you alternate each week?

Dr. D'Agostino: My normal pattern is to have like a small ketogenic breakfast and then more or less fast through. Midday I'll have like a ketone supplement or maybe a small coffee but not past 2. And then I eat, we eat dinner typically between like 5 and 6. I probably try not to do a little bit later if I'm working late, sometimes it's later. But I consume most of like 80% of my calories between the 6 and 9 p.m. I know 9 sounds kind of late, but we go to bed around, you know, 11. But I get the bulk of my calories probably with dinner, which is around like five or sixish. A lot of my protein too. But in the morning I eat a ketogenic breakfast. Lately, I've been eating waffles and making waffles. There's different ketogenic waffle recipes that are really, really good. So I've been experimenting in the kitchen a bit with my wife.