The Keto Diet

So long, root vegetables! This week, we dive into the strange and surprising history of the 100-year-old ketogenic diet. Along the way, we encounter a Victorian bodybuilder, an infamous podcast bro and the possibility of a bad Meryl Streep performance (!). Get in, loser, we're counting macros!

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Links!

• What Is the Keto Diet and Does It Work? (NYT)
• The Ketogenic Diet for Weight Loss (Today’s Dietitian)
• Meet the Wackiest Billionaire Ever to Run for President (Money)
• Trailer for "First, Do No Harm"
• Keto Diet History - How the Ketogenic Diet Went Mainstream (Men's Health)
• 7 Dangers of the Keto Diet | Health.com (Health Magazine)
• 15 Keto Diet Side Effects to Know – Possible Keto Diet Dangers (Prevention)
• Ketogenic Diet May Lead to an Increased Risk of Type 2 Diabetes (The Physiological Society)

Transcript

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Mike: Hello, and welcome to Maintenance Phase, the podcast that butters your coffee.

Aubrey: [laughs] 

Mike: That’s a thing, right?

Aubrey: Yeah, I mean, sure. 

Mike: I'm Michael Hobbes. 

Aubrey: I'm Aubrey Gordon. If you'd like to support the show, you can do that at patreon.com/maintenancephase. We also have T-shirts at TeePublic. Both of those things are conveniently linked for you in the notes for this episode, and at maintenancephase.com.

Mike: And, slight announcement. This month's bonus episode is going to be a fad diet spectacular, so we are asking our listeners to send us the wackiest fad diet you've ever tried. We're going to read a couple of them on the show, and we're going to do some extra research and cover five or six of them in a lightning round. If you want to tell us the fad diet that you tried, email us at maintenancephase@gmail.com and just put “Fad Diet Bonus Episode” as the subject line. Also, let us know if you want us to use your name or you super-duper don't want us to use your name. Either one's totally fine. As usual, you can do that or not do that or support us or not support us. It's totally up to you.

Aubrey: Look at that. Keep listening anyway. 

Mike: Yes. 

Aubrey: Today, Michael Hobbes, we are going to be talking about one of our most requested topics, which is the keto diet.

Mike: The keto diet. I was very disappointed because sometimes we do taste tests on the show. I was hoping for this episode, you'd make me go buy a steak-- [crosstalk] 

Aubrey: [laughs] Look, get a steak, put a cube of butter on top while it's still hot. 

[laughter] 

Mike: "Mike, I need you to make seven strips of bacon.” 

[laughter] 

Aubrey: I will say before we dive in, heads up, this episode, it's going to be really difficult to talk about this particular diet without talking about calorie counts, tracking macronutrients, and that sort of thing. So, if that's something you're not up for, this'd be the one to skip. And if it's something you are up for, welcome. 

Mike: If you're not up for hearing conversations about bread, this is the episode for you, because we're going to have zero carbohydrates in this entire episode. 

Aubrey: Mike, tell me what you know about the keto diet.

Mike: Very little, honestly, because I've ignored this entire thing, because it's just the Atkins diet again, isn't it? 

Aubrey: It's like a much more restrictive version of the Atkins diet. 

Mike: [laughs] The Atkins diet, famously easy to live on in the long term. 

Aubrey: Yes. It is like the Atkins diet and like Ed McMahon's diet book and pretty much all the diets that we talk about fall into a handful of categories. One is low fat, which has heavy overlap with low calorie. There's another category that is low carb diets. There's another category that is cleanses and crash diets that are designed to be very short term. And then, there's another one that is just restricting food groups, like nightshades or restriction based on things other than macronutrients.

Mike: There are only like four diets.

Aubrey: But they all have utterly bananas origin stories, and that is what we're going to get today. 

Mike: What is your relationship with the keto diet? 

Aubrey: I have done the keto diet.

Mike: Have you really?

Aubrey: I sure have. It's real hard. My experience bore out what I found in the data, which is like any fucking diets, it works for as long as you do it.

Mike: Where are we starting? Walk me through this tale of low carb whoa[?].

Aubrey: The keto diet is high fat, low carb and limited protein. 

Mike: Wait, what? 

Aubrey: Yeah.

Mike: What? I thought bros were all about high protein.

Aubrey: Gains, bro. 

Mike: What foods is that? It's high fat, but low protein? You can't do eggs or nuts, right?

Aubrey: It's high fat, moderate protein. You're basically limiting your protein and getting as close as possible to eliminating carbohydrates. If you know anybody who talks about tracking their macros, chances are they're doing that for the keto diet.

Mike: I don't know anybody who's doing that because I don't know anybody because I haven't left the house in a year.

Aubrey: Good for you. [laughs] The classic keto diet is a 4:1 ratio. Four parts of your diet should be fat and one part of your diet should be a combined protein and carbohydrates. 

Mike: Okay, give it to me in like Denny's. If I walk into a restaurant, what am I ordering if I'm on the keto diet?

Aubrey: Probably coffee with butter in it. You're probably doing eggs. They have protein, but they're also pretty significantly fatty, and maybe, maybe, maybe you get a side salad. Maybe, maybe you get two or three berries on the side. 

Mike: So, moons over my hammy, but no hash browns and no toast?

Aubrey: Yeah, that's right. Vegetables are carbohydrates. So, you're also restricting the kinds of vegetables that you're having. 

Mike: What is the meat situation? Am I just eating a ton of sausage?

Aubrey: You can eat quite a bit of sausage. It's mostly people eat a lot of cream, they eat a lot of butter. Because of the way that the diet functions, people end up eating a lot of what are called “fat bombs". You keep trying to shoehorn more fat into your diet.

Mike: It does get harder than the Atkins diet because in the Atkins diet, you only had to remember one thing, no carbs. So, it's like, "Have a Big Mac, but take off the bun." Whereas with keto, it seems like you're trying to maximize fat, and then it's okay to have little bits and pieces of other stuff. It just seems like there's more of a three-dimensional calculation going on.

Aubrey: Absolutely. There are some mnemonics and some devices that folks come up with to help remember all of the rules about keto. One of the big ones is folks will talk about only vegetables that grow above ground, no root vegetables, no onion, or very limited onion. No squash, even though that grows above ground, no winter squash. Leafy greens are okay, but you do have to be careful about which ones you do. Like brussels sprouts, for example, are like a yellow light food, but spinach is fine. It's confusing, frankly.

Mike: This is hard. I have to learn how plants grow? I'm not doing this. 

Aubrey: People can do keto in this way that is very lots of salads, veggie heavy. They can do it in a way that resembles other weight loss diets. There's also a way that folks can do it that is like, “I eat a bunch of keto-branded, bagged foods. I'll have bacon. I'll wash it down with diet soda,” like that whole thing. 

Mike: Oh, yeah.

Aubrey: That is something that folks who are keto devotees will refer to as dirty keto. So, they're like, “You're technically doing it, but you're doing it wrong.”

Mike: I love it when diets start engaging in weird gatekeeping. As soon as you create something, it's like, all of a sudden, you have to say like, “You're not doing it right.” That's the first thing to happen. [laughs] 

Aubrey: Yep. Well, we've also talked about this quite a bit of, sort of the social aspect of dieting is a performance of, like, “This is the kind of person I am.” 

Mike: Yeah, it's like vegan YouTube. 

Aubrey: The goal of a ketogenic diet is to enter ketosis, which is a real thing. It's the state in which your body burns fat for energy instead of burning glucose, and this is where the protein restriction thing comes in. Amino acids in proteins, especially in meats, can be converted into glucose and can upset that balance. That's why it's so important to limit the protein part, and that's also a part that many people who are casually on this diet don't do.

Mike: I don't know that I have a good understanding of what ketosis actually is. Isn't it your body going into basically a starvation state where it starts burning fat?

Aubrey: It's really wild. I have a quote for you from Today's Dietitian.

Mike: Give it to me.

Aubrey: “Essentially, the ketogenic diet promotes a pseudo fasted state. After three to four days of fasting or following a very low carbohydrate diet, the body deprived of dietary sugar and starch, reduces insulin secretion, and switches to primarily burning fat for fuel. The resulting overproduction of acetyl-CoA leads to formation of ketones in a process known as ketogenesis. Whereas the brain can't use fatty acids for fuel, ketones can cross the blood-brain barrier, providing fuel to the typically glucose-hungry brain, as well as to other tissues. The transition to physiological or nutritional ketosis usually takes about a week." 

Mike: It's basically you're depriving your brain of carbohydrates, which it usually needs, and then your body in response to that, starts making this other kind of brain food called ketones and starts feeding that to your brain, and it takes about a week to transition?

Aubrey: Yes, absolutely. It's not enough to have some ketones in your blood. You have to have a critical mass to get to ketosis. That's why there's this extraordinary restriction of carbohydrates. You're having less than one slice of bread a day, and you're just having a ton of fat, as much as you can. 

Mike: Do you think that when you were on the keto diet, you got to ketosis? 

Aubrey: I thought so at the time. Now knowing what I know about this diet, they'll sell these ketone strips that you use for urinalysis. 

Mike: What?

Aubrey: Yeah, so you pee onto these strips to tell you how many ketones are on your urine. What I've read from the research is, that isn't actually a measure of anything because it doesn't really matter if they're present in your urine, it matters if they're present in your blood. So, the only way to really test for that is with a blood test, and most people don't get blood tests. And most people kind of fudged the diet because it is so extraordinarily restrictive. So, what ends up happening is that folks are maybe in ketosis, probably not, and are just eating a shit ton of very fatty foods.

Mike: You know those photos that you know aren't photoshopped, but they look photoshopped? 

Aubrey: Yes.

Mike: This sounds like a similar thing, where like, “I know it's not fake, but it sounds fake.” There's these magical ketone elves in your blood, and they're feeding your brain. It sounds like something from like The Never-Ending Story.

Aubrey: It feels like a YouTube commenter on all of this. Just like, “Fake, gay.” 

[laughter]

Aubrey: Do you know where the ketogenic diet comes from? 

Mike: No, none whatsoever.

Aubrey: It does not come from weight loss, not by a fucking longshot. The ketogenic diet was developed as a modified form of fasting. That's where the pseudo-fasted state comes in. It was developed in order to treat epilepsy in children. 

Mike: Oh, interesting. 

Aubrey: Ancient Greece for hundreds and hundreds of years and many societies, fasting had been used as a treatment for epilepsy, and it seemed to work particularly in children. But the challenge with that treatment is epileptic people still need to eat. [laughs] 

Mike: Ah, footnote, asterisk. 

Aubrey: The first time anyone tested and studied fasting as a treatment for epilepsy was in 1911. It was in France. Epileptic people were put on a very low-calorie vegetarian diet, which included phases of both fasting and of purging. We're in full eating disorder territory here.

Mike: Oh, wow. Fasting and purging.

Aubrey: Of the 20 patients who took part in that study, two of them showed reduced symptoms. About half of them ended up falling off of the diet altogether, because it was so incredibly restrictive and hard to stay on. 

Mike: A 90% failure rate? 

Aubrey: Yes.

Mike: 18 out of 20. Okay. 

Aubrey: But also, if you're talking about epilepsy, you're talking about people who are having up to 90 small seizures a day, you can imagine, there are a lot of things that you would do. You’d be up for a lot of things to treat that. In the early 20th century, there's a big boom at that time in what we would now call wellness stuff. The early 20th century is when we get Coca-Cola, which is considered a health beverage at the time. It's where we get breakfast cereal, Post and General Mills, which are considered health foods at the time. It's where we got health spas.

Mike: Yeah, I saw a documentary about that, starring Matthew Broderick.

Aubrey: [laughs] The Sausage King of Chicago, Matthew Broderick?

Mike: Yes. 

Aubrey: [laughs] By the 19s and 20s, fasting in particular is being popularized for everyone, by a couple of doctors who are disciples of this guy who is absolutely not a fucking doctor, whose name is Bernarr Macfadden. He was born Bernard with a D at the end, but he liked the name Bernarr with two Rs at the end because he said it sounded like a lion roaring. 

[laughter] 

Mike: What?

Aubrey: Surprise, this is now a free episode, at least just for a little bit, because I found out about this guy, and I was like, “Sorry, we're talking about this guy for a while.” 

Mike: Deep dive. 

Aubrey: He is fucking bananas. He is a wild ride. Bernarr Macfadden is credited as being kind of like the godfather of physical fitness culture in the US. He is early American bodybuilder. He's considered, I think, a precursor to folks like Jack LaLanne and Charles Atlas. He didn't have formal training in fitness or nutrition. But in 1899, he founded this magazine called Physical Culture, which was sort of like a proto Men's Fitness. He was also a little bit like Oprah Magazine, because he was on almost every cover, because almost every story was illustrated by photos of him. Actually, I'm going to send you a couple of these photos. 

Mike: Oh, yeah. Okay. [gasps] [laughs] 

[laughter] 

Mike: Oh, wow. Okay, you sent me the one where it looks like he's wearing a diaper first. I feel like he did it on purpose. 

Aubrey: I mean, they all look like he's wearing a diaper. [laughs] 

Mike: Oh, my God.

Aubrey: He's wearing these weirdly high-waisted underpants, basically.

Mike: We've got a photo of this white dude, who looks to be in his mid-40s or something. In one photo, he's wearing a sort of a jockstrap thing, but it's like a jockstrap with a girdle. So, it goes almost past his belly button, and it sort of holding his waist in and then his junk looks upset. It's all packed in there. And then, in the other one, he is wearing what really looks like an adult diaper. And he has this sort of Joe Pesci kind of look to him. 

Aubrey: He does have a Joe Pesci looks to him. 

Mike: I can also tell from his proportions that this is a short king.

Aubrey: It's also a really interesting look, I think, like what are the muscular ideals at the time. He's like a dude who has, I would say fairly muscular legs, fairly muscular arms, not really pecs, and a little bit of abs.

Mike: Yeah, the beauty centers for men are so fascinating because they've grown up around the invention of fitness culture and the invention of gyms. Previously, “fit men,” they didn't have giant pecs. They didn't look like The Rock, because the techniques of going to the gym and specifically working out, that didn't really exist then. You were doing a lot of calisthenics and more gymnastic-y techniques. Looking at these photos, other than the pose that he's in, you wouldn't necessarily think this is obviously a fitness guy. You're just like, “Yeah, he seems like a fit enough guy.” But that's not the first thing you notice about him. The first thing you notice is the diaper.

Aubrey: [laughs] Yeah, this is the pre-He-Man era of men's musculature. What I'll say about Macfadden, so many things to say about this guy, he started this magazine, Physical Culture. He then started one called Sport, which was like a proto Sports Illustrated. And he had the wildest fucking takes. I have a quote for you from Money Magazine, if you're ready to hear it.

Mike: Ooh. Do it. 

Aubrey: Macfadden remained obsessed with health, both his own and the nation's. He issued coffee, alcohol, tobacco, white bread, hats, bad for the hair, and often shoes. He opposed vaccines apparently due to a bad experience he'd had as a boy and expressed nothing but contempt for the medical profession, which returned the compliment. He was a big believer in fasting, milk drinking, high-fiber food, lots of chewing, sleeping on hard floors, and, of course, Bernarr Macfadden. By following his own advice, he believed he could easily live to 125, possibly 150.

Mike: I feel some of the people that were taking his diet advice should have been like, “Wait a minute, this guy is against shoes. Maybe some of the other stuff that he's saying also isn't super credible.”

Aubrey: "Hats are bad your hair." 

[laughter] 

Mike: So much of this stuff has the same masculine, let's toughen up our boys, society's getting soft, all that stuff, but sleeping on a hard board on the floor, it's just discomfort for discomfort sake. 

Aubrey: Absolutely. 

Mike: There's always a weird morality wrapped up in this.

Aubrey: Yeah. It feels not dissimilar from sort of health and wellness trends now. There's this belief that celery juice works more because it tastes like garbage. 

Mike: Yeah, it's also just totally ascientific. There's not really data on not wearing shoes.

Aubrey: Sleeping on hard floors?

Mike: Yeah. 

[laughter] 

Aubrey: Well, although we did get those toe-shoe running shoes 10 years ago.

Mike: Oh, my God.

Aubrey: Do you remember those?

Mike: Dude, the worst date I've ever been on, I made the mistake of criticizing those shoes. 

Aubrey: No.

Mike: And now [crosstalk] a 15-minute monologue-

[laughter] 

Mike: -uninterrupted. 

Aubrey: Wait, what was the headline of the monologue? 

Mike: They're good, and you should shut up.

Aubrey: [laughs] In addition to all of this, he ran a little wellness empire, including a chain of what he called “healthatoriums” where people could go and get trained up on his real garbage health takes. He opened one of New York's first vegetarian restaurants, which included a bunch of raw food options. He started a couple of military-style boarding schools focused on physical education. They were advertised, I believe, in the New York Times using the slogan, “To meet the needs of a nation at war.” 

Mike: Was it M-E-A-T?

Aubrey: [laughs] 

Mike: To meat the needs? That would have been lit. 

Aubrey: Basically, Macfadden and a number of other health and wellness dudes, they're all dudes are promoting fasting as being generally a healthy thing to do as much as you can. And that popularization of fasting broadly fed into doing some more studying of fasting as a treatment for childhood epilepsy in particular.

Mike: So, he's a fasting guy, not a keto guy?

Aubrey: That's correct. He's fasting all the way. He's like, “Just stop eating food and you'll live to 150,” is essentially his vibe. The initial theory behind why fasting worked for childhood epilepsy was that it caused dehydration. That got disproved. Then, they thought maybe it was acidosis, which is increased acidity in the blood. That got disproved. Within a few years, they pursued this new theory of ketosis. Basically, the folks at the Mayo Clinic figured out that the body didn't need to fast completely. It just needed to enter this state of ketosis, and that appeared to be the mechanism that reduced these seizures.

Mike: What they're looking for is the effects of fasting but something sustainable, because obviously, you can't just not eat forever.

Aubrey: Absolutely. The Mayo Clinic runs the first trial of the ketogenic diet in 1921. Their findings at that time was that a strict ketogenic diet reduced seizures in 95% of epileptic kids, which is incredible. It's still on the books as a treatment, and it's still something that folks use. It's popularity kind of takes a dip in the late 30s, when they discover and introduce more effective anticonvulsant drugs. Prior to the sort of late 30s, the only anticonvulsants were really heavy-duty sedatives, like phenobarbital. So, if you're taking an anticonvulsant, you are also asleep for 24 hours. And because the ketogenic diet had this really specific use, that was the end of the diet for decades to come. Some people still use it as a treatment for epilepsy if that epilepsy was drug resistant or their kid didn't do well on the drugs, they would go, “Okay, ketogenic diet.” But it really died out, until the 1990s. We're going to go on a little Hollywood interlude here. It's fun. The number of characters in the story is really through the roof. 

Mike: Is it going to be popularized by Mel Gibson or something? 

Aubrey: You're so close? 

Mike: Oh, God.

Aubrey: There is a movie producer called Jim Abrahams. It's 1992. His son, Charlie, has been diagnosed with epilepsy, and he's looking for treatments and looking for treatments and looking for treatments. And he goes back through old literature and sees reference to old studies at Johns Hopkins and at the Mayo Clinic about the ketogenic diets. He puts his kid on the ketogenic diets, and says that within a matter of weeks, he fully stops having seizures. He starts this foundation called the Charlie Foundation for Ketogenic Therapies, around this time because of who this guy is, he's like relatively prominent, Dateline does an episode on the ketogenic diet as treatment for epilepsy, and there's quite a bit of public interest in response to that. 

Jim Abrahams, being a movie producer does not stop there. He directs a movie about his family's experience.

Mike: And that movie was Lethal Weapon Part V. 

Aubrey: [laughs] In February of 1997, ABC airs this made for TV movie, called First Do No Harm. I'm not going to say anything about it. I will just say I live for a trailer for a 1997 made for TV movie, and you and I are going to watch one.

Mike: Oh, please give it to me. 

[Trailer starts]

Narrator: Two-time Academy Award winning actress, Meryl Streep, returns to television. 

Mike: What?

Narrator: In a film directed by Jim Abrahams. 

Kid: Mom, mom, something’s wrong with Robbie. 

Meryl: Somebody help me please. Somebody help us. 

Doctor: This is Dr. Neves, he knows a lot about epilepsy. 

Meryl: Epilepsy? 

Narrator: When modern medicine can't find the answer.

Meryl: Maybe he's going to die. 

Narrator: How much suffering would you endure? 

Doctor: He's in status epilepticus. You run an overwhelming risk of permanent brain damage, even death.

Meryl: That's the choice? There's something wrong here. There's something really, really, really wrong. 

Narrator: How far would you go?

Security: Ma’am, ma’am. Excuse me.

Nurse: Do you know what would happen if he hadn't stopped you?

Meryl: I'm his mother.

Nurse: The institution can petition for legal guardianship of any child whose interest and well-being they feel aren't being served by his parents.

Meryl: But what if I feel that his interests are not being served by the institution? 

I've been doing some reading and I've come across a treatment for epilepsy.

Narrator: She needed an answer. 

Meryl: They took 58 sickest kids, put them on a ketogenic diet, and almost a third of them had their seizures go away. 

Doctor: There's absolutely no scientific evidence this diet works. 

Meryl: [00:25:25] I'm just doing what I think is right. 

Narrator: What you found-

Meryl: I think he's coming back to us, Dave.

Narrator: -was a miracle. First Do No Harm. 

[trailer ends]

Mike: Okay.

Aubrey: Tell me your reactions.

Mike: I have never said something like this cancellable on the show before, but Meryl Streep is not good in this. She's bad at acting in this and I don't know why. I feel very uncomfortable.

Aubrey: I will also say Allison Janney is a mean doctor. Very [crosstalk] being in this. 

Mike: Right. Loving it.

Aubrey: So, here's the interesting thing about this is that there's this whole through-line of like, “modern medicine doesn't have the answers” and blah, blah, blah. And it's like, “No, no, this was medically studied. There is evidence.”

Mike: Right. It's weird because they're saying there's no evidence for this, but what she's holding in her hand, that piece of paper is literally evidence. It's a study from Johns Hopkins.

Aubrey: Clearly this is like a deeply, deeply, deeply personal project for Jim Abrahams. I have no concept of what it's like to be a parent to an epileptic child and I have no desire to dunk on that. Here's what I will say is a little bit funny about the background story here. Jim Abrahams is not at this point known for writing and producing and directing dramas. He is known for writing and producing and directing comedies. 

Mike: Oh, is he Zucker and Abrahams? 

Aubrey: [laughs] You got it. 

Mike: Did he do Airplane? 

Aubrey: He wrote Airplane, Top Secret, The Naked Guy, Hot Shots! Part Deux and Scary Movie 4.

Mike: I didn't know it was that Abrahams. Oh, my God. 

Aubrey: Uh-huh. Also, Meryl Streep in the performance of a lifetime was nominated for a Golden Globe and an Emmy for this performance.

Mike: Okay, I'm clearly incorrect about my readings [crosstalk] from this trailer. Circling slightly back to not wanting to dunk on people who are trying to do the best for their kids, it seems like what he's done is totally understandable. 

Aubrey: Yeah, totally. 

Mike: But then, it seems like the issue here is when these stories get turned into TV-ready, Meryl Streep-ready narratives, then it's like they have to play up all of the conflict. For the third act triumph, they have to make it seem like the entire medical establishment was against her, and they were going to put her kid in jail and take him away, and play up the degree to which the medical authorities were opposed to it. Those kinds of triumph-over-medical adversity stories end up getting into the public bloodstream and just planting this idea that doctors don't actually care what's best for their patients.

Aubrey: Right. That plus Mean Dr. Allison Janney really feels like a real-- Now that's what I call “maintenance phase" kind of moment, where you're like, "Doctors are mean, and they don't care about you. You know best. They don't know shit.” It didn't feel this was a thing that had happened and that he was documenting in this way. It felt like we need a plot for this movie that is more than, "I did some research, and I found this and it worked for my kid." 

Essentially, what happens from here is that this leads to this major spike in research around the ketogenic diet as treatment for epilepsy. So, there's a study that comes out in 1998, once again from Johns Hopkins University. They publish an update in 2001. This was a larger study. There were 150 participants. Basically, their findings were a more modest version of what had been discovered in the 20s, that the diet could reduce seizures in epileptic kids, but that the biggest stumbling block was just being able to stick to a very restrictive and often very costly diets. After a year of this study, almost half of their subjects had dropped off of the diet. So, they couldn't really measure its effects because folks couldn't stick with it.

Mike: It's like a metaphor for all diets, that whether or not they're effective is secondary to the fact that most people can't maintain this level of restriction over the long term. It's almost like irrelevant whether it works or not, because no one's ever going to be able to do it forever.

Aubrey: Totally. Currently, the ketogenic diet is approved for use by the NHS in the UK. It's covered by many US insurance plans. It's pretty mainstream, although it's usually these days considered last resort for kids with drug-resistant epilepsy, that you get to drugs before you get to a dietary sort of fix. They know that it works, but they don't know why it works, and they don't know why it only works for some kids, like why it isn't universal applicable.

Mike: Hmm. It's like why do some people fart [unintelligible [00:30:16] and some people don't, basically.

Aubrey: It's exactly like that. 

Mike: Yes. Thank you. I needed that to help me understand it.

Aubrey: Here is where things take a turn. We've got this the lion's share of a century, this diet has been specifically for children who have this one specific health condition, and something happens where it takes a turn into weight loss land.

Mike: It turns out all those kids are thin and fit, looking amazing. 

Aubrey: They're ripped. 

Mike: Yeah, these ripped ass kids.

Aubrey: Low carb diets had already been a thing. As you noted, we had like the Atkins diet. Dr. Atkins' first book came out in 1972. There was a big wave of popularity then. There was another big wave of popularity of Atkins in the late 90s, early 00s. In 1976, there's another low carb diet comes out, called The Last Chance Diet, which is a real creepy name. This is a quote from Men's Health magazine. “In 1976, a ketosis leveraging method called The Last Chance Diet took off. Its rule, you drink a fat- and protein-rich concoction until you lose your desired amount of weight. The diet’s creator, osteopath, Robert Linn, sold $40 million worth of his elixir. But you were also supposed to have a physician supervision to ensure that you were getting the necessary vitamins and minerals. Few people did. Robbed of minerals, your body can't perform certain functions, like sending electrical impulses to your heart. As a result, The Last Chance Diet contributed to the deaths of at least 60 people.”

Mike: [gasps] What?

Aubrey: “The fallout included new regulations, a negligence lawsuit for Dr. Linn, and research on ketosis being banished to academic Siberia.”

Mike: Well, yeah.

Aubrey: You killed 60 people.

Mike: People are going to cite your publication, Chad.

Aubrey: Totally fucking wild.

Mike: The entire paradigm of that is ridiculous. Drink a shake until you reach the desired weight. Okay, great. Then what? You're going to go off the shake, and you're just going to gain all the weight back, because that's what bodies do.

Aubrey: Or, you're going to stay on the shake, and you're going to die.

Mike: And you're going to die. 

Aubrey: Fuck, dude.

Mike: Those are your options. 

Aubrey: There is this false economy of thin people thinking that the mechanisms to lose 10 pounds, and the mechanisms for fat people to lose 100 pounds are the same. So, they're like, “You just do it more.” So, because of that kind of facile logic, which I get how folks get there, there's also like, I would bet you money that a lot of the people who died were fat people.

Mike: I should say, I have people in my life that have been on low carb diets for years. I think most people, they started doing it during the Atkins wave, and have ended up adopting a modified version of it that more fits in with your life, that you have to go to social events, and you have to be a person and eat at restaurants sometimes. I don't think anybody can maintain the amount of restriction that was prescribed by Atkins or keto. But it's some modified version of just eating, I don't know, half or a quarter of the carbs that most people eat, that is actually a lifestyle that works for people.

Aubrey: Yeah, totally. That's fine if you want to eat less bread or less pasta or whatever. Eat however you want, eat whatever you want. The number one gateway into disordered eating and full-on eating disorders is diets. That's the other thing to know, is I think people have this idea that like a diet is just a benign thing that you do for a while and that there aren't really consequences to it. As we will see, there are really significant consequences to diets broadly, but to this one in particular. Fucking tread lightly. Tread lightly, everybody.

Mike: Especially when we're talking about kids. 

Aubrey: Yes. 

Mike: I don't know. That's always the scariest thing, is people, anybody under 18, but especially littler kids. Argh. 

Aubrey: You don't like experimenting on children? 

Mike: I know. 

Aubrey: Interesting. The turn into keto specifically around weight loss really starts in 2013, and continues throughout the 20 teens.

Mike: Ooh, we're getting to the Instagram chapter of the story. 

Aubrey: Oh, buddy, it's not Instagram. It's actually podcasts. 

Mike: What?

Aubrey: We're the real enemy, Mike.

[laughter] 

Mike: Maintenance Phase comes out, podcasts are trash. Do not believe anything you hear in your earbuds.

Aubrey: Basically, there is a study published in Science in 2013. There's a press release attached to the release of this study. The press release says that the keto diet can “slow the aging process and may one day allow scientists to better treat or prevent age-related disease, including heart disease Alzheimer’s and many forms of cancer.”

Mike: Wait, this was in Science? 

Aubrey: Yep.

Mike: This sounds like some Dr. Oz citation needed shit.

Aubrey: Of course, shit this catches the ear of a bunch of biohacker kind of dude bros. The first and at the time biggest person to get on board is Tim Ferriss.

Mike: Oh, no. As soon as you said podcasts, I was like, “Oh, don't let it be the six-hour-workweek guy.” 

Aubrey: There it is. Four hours. How dare you? 

Mike: Oh, is that what it is? Okay.

Aubrey: Yeah. [laughs] Do you want to say something about Tim Ferriss for folks, who were-- for the uninitiated among us?

Mike: I just associate him with the TED Talkification wave between 2000, and I want to say 2015. I think it was before any of the sort of very realistic cynicism about technology that we all have now really kicked in. It was a time when you could just say stuff, like all college will be online and 15 years or all cars will be self-driving and five years. You could say stuff like that and people like, “Yeah, that sounds about right.” Tim Ferriss, whose podcast I've never listened to and I'm sure he's a nice guy, and I'm sure he means well, he was part of that wave. There just was a decade there, where there was just a lot of pop science coming out, that people just bought hook, line, and sinker.

Aubrey: Yeah, it was an era of science telling you what you want to hear and you being like, “That sounds great. Moving on.” 

Mike: But, yeah, it sounds like this would very much fit into that framing because, a lot of the science stories we heard at the time were very, like silver bullet-ish. Something like the keto diet, we already know what the ideal diet for humans is. We already know the way that everybody can lose weight, we'll solve the obesity epidemic. We have it right here. It just seems very tailor made for that time and that platform.

Aubrey: Yes, Tim Ferriss has this doctor on, Peter Attia, who makes a hell of a pitch for the benefits of a ketogenic diet. A little bit after that, Tim Ferriss has Dr. Dom D'Agostino on, who's a professor of pharmacology and physiology. He's one of the biggest proponents even now of a ketogenic diet for kind of anybody. At that point, Tim Ferriss has about a million listeners each month. So, the diet starts taking off. It's sort of a weight loss thing, but also an optimization thing. As we've said, science communications is hard, and there is a particular way in which Tim Ferriss’ show kind of beefs it. 

Here's a quote from Men's Health magazine about the episode with Dr. D'Agostino. It says, “Ferriss told the story of a friend with testicular cancer, who would fast for three days, entering into ketosis before chemotherapy.” 

Mike: Oh, my fucking God. 

Aubrey: [laughs] Just wait for it, buddy. “D'Agostino noted that anyone with cancer needs medical supervision of their diet, but also said, if you put your physiology into a state of fasting ketosis, that puts tremendous metabolic stress on cancer cells that are highly dependent for survival and growth on high levels of glucose and insulin. By subtracting them from those growth needs, they can die and you could potentially purge yourself of some precancerous cells.”

Mike: Ah, I hate this shit. There's always this perfunctory, like, “No, I'm not saying it's going to cure cancer,” followed by “basically, it'll cure cancer.” And then, if anybody calls you on it, you're like, “Well, I never said it was going to cure cancer.” But, of course, that's the impression you're leaving people with.

Aubrey: Dr. D'Agostino now says, “Cancer is, of course, much more complicated than just like, “Starve it of sugar and you'll be fine.” 

Mike: Really?

Aubrey: But this particular episode, is released with the title Dom D'Agostino on Fasting, Ketosis, and The End of Cancer. 

Mike: [laughs] Fuck. 

Aubrey: So, there is a pipeline from Tim Ferriss to other garbage podcasters. Do you want to take a guess? 

Mike: Oh, I know we're going to get a Joe Rogan appearance in this episode. 

Aubrey: You know it. Next up. Tell me what you would say for the uninitiated. I'm thinking particularly of folks listening in other countries. What would you say about Joe Rogan?

Mike: Joe Rogan is an actor, standup comedian, commentator guy, who ended up starting a podcast and has become, I believe, he's the most popular podcaster in the country. He does, I think, four or five episodes a week, like, he's unbelievably prolific. He has guests on, some of them are really good. He has smart people on and then he also every fourth guest is just a fucking crackpot, and he doesn't really push back. He’ll just have Alex Jones on who's like, “Yeah, the aliens are shooting lasers at us,” and Joe Rogan's like, “Oh, interesting. Wow.”

Aubrey: Yeah. Or like Jordan Peterson or whoever, where you're just like, “No, why?”

Mike: I know.

Aubrey: “Why are these the dudes?”

Mike: And also, he's very, very popular with a specific tranche of dudes who are probably 18 to 34, straight, white, lean conservative, but don't necessarily identify as conservative. There's a massive group of like this type of bro in the country who really like his show.

Aubrey: Yeah, I would say folks who say, "I don't really subscribe to a particular political party. I like to think for myself." 

Mike: Yeah. 

Aubrey: According to Men's Health magazine, at this point, Tim Ferriss had a million monthly listeners, Joe Rogan had 30 million monthly listeners.

Mike: Jesus Christ.

Aubrey: Rogan also has the same guy, Dom D'Agostino, on but it's the first of many guests that he has on to talk about keto diet. Some of them are doctors and researchers and other scientists, but a lot of them are like athletes and biohacking bro guys. 

Mike: No. And all the while, you can pretend that all you're doing is asking questions. It's this built-in defense mechanism where it's like, “We're not necessarily saying everybody should go on the keto diet. We're just dedicating hours every month to saying, well, will it improve sports performance? Will it cure cancer?” And so, the amount of attention that you're placing on his one very specific thing is in many ways more important than what you're actually saying about it.

Aubrey: Totally. It also, I will say is astonishingly marketable. Here's another quote from this great Men's Health piece. “Within a year of the Rogan podcast, Orion Research estimated keto as a $5 billion industry, and because people on keto often lack nutrients like vitamin C, magnesium and fiber, there's been a supplement gold rush for brands behind products that make staying on the diet easier.”

Mike: Well, so it's a diet that seems a little bit faddish. Do we have a term for this? 

Aubrey: [laughs] 

Mike: I'm wondering if we have some pithy phrase that we use when diets peak and interest.

Aubrey: I will say I did some searches for Joe Rogan keto, just to see sort of what's out there. The top responses were keto food and supplement brands who've done some SEO being, "We're Joe Rogan's favorite keto supplement," so overwhelmingly the responses were folks figuring out how to market their product around Joe Rogan in particular.

Mike: It's also the perfect fad diet structure, because like cleanses, it's almost impossible to maintain. People are going to end up breaking the rules, because they can't handle it, and then it's never the diet that failed, it's you who failed.

Aubrey: That's right. That's essentially how we get to today, is it becomes this big thing amongst men ages 18 to 34, which is an extraordinarily desirable advertising demographic. It blows up as an industry and it becomes one of the most popular diets in the United States.

Mike: Is that where it is now? Has it crashed or is it still peaking?

Aubrey: It's still up there. But what is often missing from conversations about the keto diet, even in the research honestly, is discussion of the risks of the diet. The laundry list of considerations is astonishing. I found a bunch of research and a bunch of popular media articles that were like, “Here are three or five things to know before you go on the keto diet.” All of those listed different things, and almost all of them said, “You don't really have to worry because you'll be losing weight, and isn't that what matters the most?” Including in the research, like including researchers are saying, like, “It's not that big a deal because you're losing weight, and really what you need to do is lose weight.”

Here are the things that they're saying are not that big a fucking deal. The first one that folks do talk about quite a bit more is something called the keto flu, is this a phrase you've heard before? 

Mike: No.

Aubrey: The theory is that is you get rundown while your body is figuring out how to operate without glucose. Side effects include dizziness, fatigue, headaches, nausea, vomiting, insomnia, lowered tolerance for exercise, lethargy, and constipation. Another one that folks talk about a fair amount is bad breath. Folks will describe it as being kind of fruity, but bad fruity.

Mike: Bad fruity?

Aubrey: [laughs] 

Mike: [crosstalk] called me in high school. 

Aubrey: I was going to say that's how I identify, bad fruity. There's also a phenomenon that is mostly anecdotal. So, there hasn't been research into it, but I wanted to include it because it's so gross. 

Mike: Thank you. 

Aubrey: You're welcome. I know what you like, Mike. And you like talking about vaginal odor.

Mike: Oh. Why all the smell stuff? 

Aubrey: [laughs] 

Mike: I don't get it.

Aubrey: There are these anecdotal reports of something called keto crotch, which I hate. That is essentially like people with vulvas reporting that they have vaginal discharge that has a stronger and more unpleasant smell.

Mike: Are we learning this whole time throughout human history, carbs were what kept our junk fresh? 

Aubrey: [laughs] 

Mike: That was it? Now we know?

Aubrey: Just use them as air fresheners, just dangle a bagel. 

Mike: I knew there was a reason for carbs. 

Aubrey: In addition to losing fat on the keto diet, folks will lose muscle mass. So, folks do lose body fat, but they also lose more muscle mass than on other diets, which is really interesting to me given that it is sort of popularized by shred bros, like Joe Rogan.

Mike: But keep in mind, they're also disgusting to make out with [crosstalk] on, and lethargic and irritable and maybe vomiting.

Aubrey: In addition to all of this, the keto diet has been linked to really significant liver, kidney and gallbladder problems, because all three of those things are processing macronutrients in your body, and all three of those things can get really fucked up by radically changing how much work they have to do. If you have any liver issues, like fatty liver disease, like cirrhosis, whatever, adding so much fat to metabolize could make those worse. And if you don't have them, it can increase your risk for future liver issues. Your kidneys metabolize protein. So, when folks don't get the protein balance just right, the keto diet can cause major kidney issues, it can also cause kidney stones.

Mike: Those hurt.

Aubrey: And your gallbladder is responsible for producing bile to break down fat and eating that much fat, especially abruptly, can overwhelm it. 

Mike: Holy shit. 

Aubrey: It's real rough. These are serious side effects that are for keeps. Those are long-term issues. On top of all of that, the keto diet is one that is very low in fiber, because you can't eat beans, you can't eat grains, you can't eat a lot of vegetables. So, that can cause both constipation and diarrhea, depending on which direction your body goes with it. So, either way, you're going to have weird poops. It can lead to mood instability and reduce cognitive function, again because your brain needs sugar to function. 

The last one, which is fucking wild as shit, is that it has been linked to an increased risk of diabetes and heart disease. 

Mike: Oh, my God.

Aubrey: This is one of those moments where it's like, “Oh, cool, we're throwing everything out the window for the promise of weight loss.” There's one doctor in a piece that I read, who called it 'a cardiologist’s nightmare.' 

Mike: Do we have a sense of what it does to be on this ketosis for a long time?

Aubrey: We don't really, in part because this level of popularity is very new. We're talking about the last six years tops.

Mike: Luckily, nobody can do it for very long. That reduces the risk that no one can last more than a month or two on this.

Aubrey: Almost all of the research, what they found is that it works well for weight loss for somewhere between two and six months. And then after that, it levels off and performs the same as a low fat diet or as any other diet that you might go on. It's the same kinds of numbers that you see from those diets. It has a bunch of that splashy, "It works twice as well," but it's, "Instead of three quarters of a pound lost in a month, you'll lose a pound and a half." 

There is also according to Prevention magazine, keto can increase the likelihood of eating disorders and particularly of bingeing behaviors. 

Mike: Yeah, that makes sense. 

Aubrey: Yes, totally. This is from Prevention magazine. “Cutting out carbs can cause the brain to release a chemical called neuropeptide Y, which tells the body that we need carbs. When we don't get those carbohydrates, our body needs this chemical builds up and can intensify cravings, which can increase the risk of developing disordered eating patterns. It has nothing to do with not having enough willpower. It's more to do with the body's biological response to deprivation,” says Laura Lu, a registered dietitian."

Mike: There's a reason why we have these three macronutrients in most. There's vast diversity between diets around the world. Different world regions have different crops, but the ratio of these different macronutrients is reasonably consistent. There's probably a biological reason for that.

Aubrey: Yeah, there totally is. This level of fixation on which food groups you can or can't eat for optimal health and for weight loss, and all of that sort of stuff is, in the scope of human history, extraordinarily recent. Here is the final side effect. Are you ready? 

Mike: Hmm.

Aubrey: Early death.

Mike: [laughs] 

Aubrey: This is a quote from Health magazine. “A 25,000-person study presented at the European Society of Cardiology Congress suggested that people on the lowest carb diets had the highest risk of dying from cancer, cardiovascular conditions, and all other causes.” 

Mike: Oh, weird.

Aubrey: Another study published this month in The Lancet also found that people who followed diets that were low in carbs and high in animal proteins, typical of the keto diet, had a higher risk of early death compared to those who consumed carbs in moderation.

Mike: Yes, but most of that risk is because they're listening to Joe Rogan, and they fall off of a ladder. 

Aubrey: [laughs] 

Mike: They're just not paying attention to their surroundings.

Aubrey: It was really overwhelming to me to look at these. Aside from Fen-Phen, we have not looked at a diet or a cleanse that has been, like, “One of the side effects is you might die from four different things.” It's fucking bananas.

Mike: I know. It's funny compared to the Halo Top episode, where the worst thing was that the ice cream was just okay. 

Aubrey: [laughs] 

Mike: It might not be as good as Breyers.

Aubrey: Yeah, that's exactly right. US News & World Report every year ranks the best and worst diets for overall health via a panel of doctors and dietitians and other health care providers. They ranked 39 diets last year, keto was ranked number 37. 

Mike: Oh, wow. What was the best diet?

Aubrey: The number one diet is the Mediterranean diet, number two is the DASH diet, and tied for number two is the Flexitarian diet. 

Mike: Basically, the diet that allow you to live a semi normal life are the ones that are the most sustainable. Shock horror.

Aubrey: And the ones that include pretty much every food group. The other thing that I will say that we haven't really touched on much here, and this is just anecdotal from my own personal experience on this diet, I was astonished at how costly it was and how time consuming it was. Because you can't really get food at restaurants because you don't know for sure what they're putting in their burger patty, do they have fillers in there? Do they add bread crumbs to bind it or egg or whatever? You have to prepare your own food overwhelmingly, and that food is fucking expensive. My grocery bill just about doubled.

It could be the skeleton key for all kinds of things. It probably isn't. But even if it was, you would then have to grapple with, okay, we already know that minority stress increases the risk of almost every disease. So, the people who are the poorest and have the greatest barriers to accessing basic needs in their life are at the greatest risk for those disease. How are they going to pay twice as much for a diet that they can't stick to and that most research says you should probably only stay on it for two to six months?

Mike: That's before we even get to the cost of all the Febreze for your crotch.

Aubrey: [laughs] Your summer's eve bill is going to be astronomical.

[laughter] 

Aubrey: The last thing I would say on all of this is fucking Joe Rogan likes it. 

Mike: Yeah. Jesus Christ. 

Aubrey: Do you really want to agree with Joe Rogan on anything? I don't really.

Mike: Anything that sits adjacent to an hour and a half long conversation about race and IQ, you should probably just discard on its face. 

Aubrey: Versus us having a 2-hour-and-15-minute conversation about the keto diet. [laughs] 

Mike: I know. [laughs] 

Aubrey: But, yes, totally, like don't. That's not the guy. 

Mike: I was going to say so if you're on the keto diet, stay on it, but no. [laughs] If you're on the keto diet, stop. 

Aubrey: [laughs] Listen, I'm not here to tell you don't eat the keto diet. Even if I did, fucking glass house, I did it. This is a place where it's really worth digging in on what the actual research actually says, and straight up doing your own research into some primary sources.

Mike: Also, anyone who is trying to sell you on this diet, first check whether or not they're wearing shoes. 

Aubrey: [laughs] 

Mike: That's the first [unintelligible [00:55:12].