March 15, 2015


Random finding (plus pi)

The best part of parenting (so far)? Helping your kids overcome things you struggled with. It’s at least in the top 5.

Read Time 6 minutes

The best part of parenting (so far)? Helping your kids overcome things you struggled with. It’s at least in the top 5.

Last Saturday my daughter came home from dance class—something she normally loves—and seemed upset. A bit of prodding led to the cause: a girl in her dance class told her she was “as fat as a hippopotamus.”  My first reaction (note to self: probably not the right one) was to laugh out loud, given that my daughter is probably in the 10th percentile of weight for her age. I’m worried she’s too skinny!

Of course I realized quickly the “facts” were irrelevant in this case. Her body habitus was moot. But her feelings were hurt, and as we all know this wouldn’t be last time someone said something to her—true or untrue—that would hurt her feelings.  I won’t go through the entire discussion we had, as I’m sure those of you with kids have already been through this, and those of you without kids probably aren’t worrying about this type of interaction.

I did, however, decide to tell her about all the people who dislike me and say mean things about me, usually things that aren’t true. She was shocked, “Like what, daddy?” I gave example after example. She was amazed—and relieved, I suspect—to know that she wasn’t alone and that I was able to shrug it off after temporarily being upset by it. I even told her about folks posting videos on YouTube specifically attacking me.

So, when our little talk was over she asked if she could see one of the videos I alluded to. I was a bit hesitant, if only for some of the language used when folks rant against my existence (if she’s going to learn choice 4-letter words in earnest, it should be from me after all), but I figured it was a good idea. She could actually see for herself that people say mean things about her dad and he’s still, more or less, ok.

Which brings me to the point of this quasi-post…

In searching for said YouTube videos, which I eventually found, I stumbled across two talks I gave last year which made their way online, unbeknownst to me.

In keeping with the current spirit of my co-op blog posts, below are links to the two talks.

Talk 1: Evidence for (and against) the dietary guidelines restricting saturated fat



This talk is an updated version of a talk I gave a few years ago and shared on the blog, in 2012 I think. Even if you watched the earlier version of the talk, if you find this question interesting—what is the case for restricting saturated fat (SFA) intake—it’s worth watching this version. I find this particular topic especially interesting because I think it highlights the challenge we all have, myself included, in setting aside bias when confronted with new information. (My friend Carol’s amazing book, Mistakes Were Made (But Not By Me) cannot be recommend highly enough for people who want to understand how cognitive dissonance wreaks havoc in even otherwise functioning societies.)

And contrary to what some (perhaps many) of you might think, I don’t believe this is a settled debate across the board. What do I mean by that (i.e., “across the board”)? Certainly in this presentation I try to make the case that the continually falling recommendations for SFA—from 12% to 10% to 8% to 5% of total calories—are not supported by convincing science. In fact, such recommendations likely do harm, courtesy of the “substitution effect,” i.e., people end up eating more of other things—namely, sugars and omega-6 polyunsaturated fats (n-6 PUFA)—that likely cause greater metabolic derangement.

However, some readers may interpret the data I present to mean it’s perfectly safe to consume, say, 25% (or more) of total calories from SFA. I realize I may have to turn in my keto-club card, but I am convinced that a subset of the population—I don’t know how large or small, because my “N” is too small—are not better served by mainlining SFA, even in the complete absence of carbohydrates (i.e., nutritional ketosis).  Let me repeat this point: I have seen enough patients whose biomarkers go to hell in a hand basket when they ingest very high amounts of SFA. This leads me to believe some people are not genetically equipped to thrive in prolonged nutritional ketosis.

In one particularly interesting case, a patient in self-prescribed nutritional ketosis presented to me with an LDL-P of more than 3500 nmol/L1i.e., more particles than could be measured by the NMR machine so the report simply said “>3,500 nmol/L”. despite feeling, performing, and looking great. Based on his through-the-roof desmosterol and cholanstanol levels, and a curb-side consult from the Godfather- I mean Dr. Tom Dayspring, I decided to try an experiment. You see, the logical thing to do in this setting would have been to start two drugs immediately (a potent statin to address the hypersynthesis and ezetimibe to address the hyperabsorption) or tell him to abandon ketosis altogether. But this patient was adamant about staying in ketosis given the other benefits, though obviously worried about the long-term coronary implications. So, we agreed that for a 3 month trial period he would reduce SFA to an average of 25 g/day (vs. about 75 to 100 g/day) and make up the difference with monounsaturated fat (MUFA).2We also reduced his omega-3 PUFA given very high RBC EPA and DHA levels.

So, on balance, he consumed about the same number of calories and even total quantity of fat, but his distribution of fat intake changed and he heavily swapped out SFA for MUFA.

The result?

His LDL-P fell from >3,500 nmol/L to about 1,300 nmol/L (about 55th percentile), and his CRP fell from 2.9 mg/L to <0.3 mg/L (and for the lipoprotein cognoscenti, both desmosterol and cholanstanol fell).

Pretty cool, huh? So, my point is this: while I believe the population-based guidelines for SFA are not supported by a standard of science I consider acceptable, it does not imply I believe SFA is uniformly safe at all levels for all individuals.

Some of you may be wondering about me. It turns out I’m in the group (recall: I have no idea how large or small this group is) that seems to do well—at least by the tools we have available to assess risk—with large amounts of SFA in my diet, if and when I elect to. Even when I was in ketosis, eating 4,000 kcal/day (literally getting 40 to 45% of my calories from SFA alone) my biomarkers—cardiovascular, insulin resistance, inflammation—were excellent. Better than they ever were or even are today. Though, my point still stands: there are some people who do not appear able to safely consume massive amounts of SFA.

One last point I’ll make on this highly charged topic. I realize there is a contingent within the LCHF community who argue that traditional biomarkers of coronary risk—such as LDL-C or its superior cousin LDL-P—“don’t matter” if one is on a low carb or ketogenic diet. Maybe they are right. I guess time will tell. But I am not convinced, at least not yet.  As a doctor I can’t look a patient in the eye and tell them a sky-high LDL-P is ok because they don’t eat carbohydrates. So if you’re following such a diet, and your LDL-P goes through the roof, I’d urge you to consider a variation of the diet.

(Note: If you post your NMR results, please understand I will not comment on them.)

Talk 2: It was the best of times, it was the worst of times—the tale of the U.S. healthcare system


This presentation has nothing to do with nutrition but is, nevertheless, a topic I’m pretty obsessed with: how do we achieve cost containment on healthcare in the United States? (Sorry non-U.S. readers, but we have a bigger problem right now, so I’m focusing on ours over yours!)

This is a pretty controversial topic, so before you jump down my throat, try to sit through the entire talk, especially the parts where I frame the question as one of optimization. Most problems that have been heavily politicized suffer a common problem: they fail to distinguish between what is desirable in a resource unconstrained world (e.g., free health care for everyone that provides perfect care) and what is plausible the real world (e.g., some combination of features, but not 5 starts across the board).

Hope you enjoy the departure from the usual topics.

Pi Day

The math geeks in the audience will appreciate that yesterday, March 14, 2015, represented a very special variant of pi day. Normally, March 14 represents pi to 3 significant digits, namely, 3, 1, and 4 (i.e., 3.14). Yesterday, however, being the pi day in 2015, was especially cute, because it advanced two more significant digits, 1 and 5, via the year (i.e., 3.1415). If you’re a watch geek, in addition to being a math geek–yes, I realize this is not a huge club–the beauty of a perpetual calendar (a type of watch that shows time, month, date, and year inclusive of leap years), made it a really fun day! Why? Because at 9:26 and 54 seconds you found yourself at the following place in time: the 3rd month, 14th day, 15th year (of this century), 9th hour, 26th minute, and 54th second, that is, 3.141592654–pi to 10 significant digits!

After capturing this wonderful moment in time, I sent the picture, below, to my watch mentor (also a math geek; yes I just wrote the words “watch” and “mentor” next to each other). He loved it, but his response was priceless: “Peter, don’t ever show this to any woman you have the slightest interest in….check that, don’t show it to any woman period. Pretty cool though. You are right. I dig it.”

Good thing my days of trying to impress the ladies are far in the rear view mirror.

Parting shot: I did a follow up podcast with Tim Ferriss a few weeks ago. It’s episode #65 which is available on iTunes. This was my first time doing the strange format of just talking by myself. Feedback appreciated if this should morph into something I do quasi-regularly on the blog.


Pi on abstract background with about 3500 decimal digits by Nicolo Canali De Rossi is licensed under CC by 2.0

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  1. “Parting shot: I did a follow up podcast with Tim a few weeks ago. It’s episode #65 which is available on iTunes. This was my first time doing the strange format of just talking by myself. Feedback appreciated if this should morph into something I do quasi-regularly on the blog”

    It was a great podcast, I could have listened to more :).

    Could you discuss the topic of PCOS and oestrogen and the effects of diet/exercise in the next podcast?

    • I’d really like to hear about oestrogen/diet/exercise too, as well as any thoughts you have on fibromyalgia and diet/exercise. I’m halfway through epp #65 and am really enjoying it.

    • I recently read that Attia Medical LLC is now in NYC. Where? How do I get in touch to perhaps schedule an appointment? Phone number, email address?
      You may recall tyhat we spoke some time ago, but I was reluctant to make the trip to San Diego.

  2. All things associated with nutrition seem enormously complicated to me. At the same time, I can’t help but think the answer to the million dollar question is right in front of my nose but I can’t see it. Spent much time researching different cultures looking for consistencies in diet. Lived with the Eskimos for a period of time. It seems to me, given the exact same inputs, under the same conditions, the results should always be consistent. However, two different people, given the same diet, do have very different responses. Furthermore, a single individual, consuming the exact same foods at two different times, also seem to have very different responses. It seems a somewhat logical(superficial) conclusion would be that diet does not relate. My only thought is that the conditions cannot be the same and therefore are not understood.

    Putting it in my own simplistic way, the y-axis would be the measure of health and the x-axis would be either different people, or the same individual, at a different time. If the inputs are equal and the results are different, the conditions are not understood. The million dollar questions, what is it? Ever changing genetic mutations? Off into the weeds, why does rapamycin appear to effect aging? Is it simply insulin response?

    • Honestly I think it’s pretty simple:

      Don’t eat processed food, don’t eat grains (except rice or similar products like oats), don’t eat dairy, minimise simple carbohydrates, minimise salt . Broken down a typical day could look like this:

      Breakfast – scrambled eggs with bacon or eggs, bacon, tomato or bacon/tomato/onion/egg omelette or oats with a dash of honey etc etc

      Lunch – fried rice with vegetables and egg or vegetable/chicken soup or meat with vegetables etc etc

      Dinner – vegetables and meat or a roast or rice and chicken or offal and rice stir fry or fish and rice etc etc

      Snacks – piece of fruit, handful of nuts, tuna etc etc

      Virtually all these things are simple to make. Some people don’t need to cut certain foods out of their diet and could thrive on nothing but salt, dairy, sugar and wheat bix but I think it’s highly unlikely that ANYBODY could eat the way I outlined and become obese, develop diabetes and similar diseases, nutritional deficiencies or intestinal issues. I reccomended avoiding grains and dairy because in my opinion, the evidence is pretty clear they are bad for lots of people and can be easily replaced with foods that are unarguably good for virtually everyone. I truly think the entire issue is being over complicated. Don’t get me wrong, sites like this are a necessity and the work Peter does is great to find out the body works.

    • Also I forgot to mention a couple of things:

      Offal meats contain more vitamins/minerals than any vegetable/fruit/grain/dairy product and they are easily digestible. So while many fruits/vegetables contain other beneficial substances, they are NOT neccesary to avoid nutritional deficiencies.

      Also intermediate fasting seems to be beneficial for humans e.g. only eat between 12:00-8:00 each day. It increases insulin sensitivity and seems to be beneficial for how the body utilises nutrients.

      Chronically raised insulin levels are apparently at the heart of many modern diseases. Directly caused by simple carbohydrates, usually in the form of processed foods.

      Chronic systemic inflammation also seems to be at the heart of many modern diseases. Evidence points to grains/dairy being inflammatory in the human system, as well as raised inaulin levels being inflammatory.

    • Not sure about that rice advice. Also, it is LCHF, and getting enough fat in a low-fat world is actually sometimes a challenge.

    • @JW I personally think rice is one of the best carbohydrates. Everybody is different and some people might need to remove essentially all carbs from their diet (including rice/oats). It’s just that I’ve never heard of rice causing a problem for people. Also I know this site is LCHF focused but I think the average person could follow what I outlined reasonably easily and not feel left out when having dinner with friends or what have you. I still think personally LCHF is the way to go but we have to be realistic.

    • Sorry if I clicked the wrong “reply” button, but I had to address Nicky’s perception that rice is somehow OK whereas other carbohydrates are bad. Years ago I might have agreed with you. I am Chinese, and I seemed to have a disproportionate number of Asians among my patient population. As they and I aged together, I saw a greater and greater number of Asian patients with Type 2 Diabetes, a phenomenon I had not seen in my younger clinical experience. I’m not talking about the South Asian population (Indian and Pakistani genetics) whose incidence of Metabolic Syndrome, T2D, Cardiovascular Disease is quite well known. I’m talking about Chinese immigrants from Singapore, Malaysia, Indonesia, Hong Kong, China, and immigrants from the Phillippines, Indo-China, Japan, Korea and Thailand, and even their children. At the time (shame on me — but I graduated in 1972, and that was the underlying dietary message I learned), I blamed the high saturated fat and protein diet that they could now afford in the rich new world they emigrated into. My understanding now is that it was the carbohydrates that undid them. And what carbohydrates would it be for them? Well, certainly there was wheat in some of their noodles; and certainly there is too much unprocessed food and sugar in the easy packaged stuff you can get at supermarkets; but the overwhelming CHO in this population was Rice. Plain old Rice.

    • Ha ha! Good to know. I think the point he was probably making was less about intelligence and more about the narrow, narrow intersection of math and watch fanaticism in those with two X chromosomes.

    • I clicked the wrong “reply” button, meant to post it here.

      Same mentality that had Barbie saying: “Math is Hard,” “Let’s go shopping”.
      Sorry Peter, there’s no excuse for his comment.

    • Oh and one other thing. You should be aware that body image challenges aren’t the only way to destroy girls’ esteem, challenges regarding girls’ (women’s) mental abilities are equally destructive.

    • I dig it too.

      But the second point NS made is also very very important!!!! I am not sure my daughter understood how brilliant I always knew she was.

      Also, her best friend tried to schedule her own wedding at the local courthouse to coincide with the exact time on your watch!

    • I second your statement Laura. I think it’s majorly cool.

      And Peter, I figure there is a “narrow, narrow intersection of math and watch fanaticism” in the general population as a whole, regardless of gender. Oh, and I think that laughing out loud in response to what your daughter told you was absolutely the correct response. It helps bring home the point that the comment was WAY off base. And you got to help your daughter figure out how to deal with her own feelings when people say hurtful things that may or may not be true.

    • Someone might want to tell Attia’s pal that the current Fields’ medalist is a . . . a woman. He’d might enjoy getting used to it. 😉

  3. Great follow up r.e. talk 1. I do think as physicians we have to be very cognizant of the reality that not every patient will fit into the ‘box” we would like them to fit in. Playing with the ratios of MUFA to SFA is a great place to start instead of jumping straight to meds when LDL-P is heading in the wrong direction.

    Did you see the Seventh Day Adventist’s most recent study? I had a good laugh, once again, how the media presents such studies. Supposedly, the study shows a lower reduction in colon cancer if you are a pescovegetarian. Good news for those of us who eat fish!

    When looking at the study and comparing to the general population the vegetarians have basically the same colon cancer risk as everyone else according to the CDC’s cancer statistics (60 per 100,000 people/year=4.5 life time risk of colo-rectal cancer which is the same for the vegan folks! Not reported though!). Very small benefit in the OBSERVATIONAL study (not a good type of study imho!) to those that ate animal fat in the form of fish though.

    Still, look at the real numbers in the study though. Out of 77,?659 people in the study over 7.3 years only 490 patients got colon-rectal cancer. So what is the real risk of colo-rectal cancer over a 7.3 year time frame? 490 over 77?659 = 99.4 % chance of not getting colo-rectal cancer in 7.3 years! Sorry, I’m not changing my diet to pescovegetarian to “decrease my risk”. Silliness! More ammo in my opinion for fat and animal protein consumers like me: animal protein and fat will not give you cancer!

    We celebrated Pi Day yesterday as well by cooking a low carb pumpkin pie! The kids loved it.

  4. You know, ultimately right, wrong, or anywhere in between (and I know I mention this a lot here) you always give us as much thoughtful insight and knowledge as you possibly have time for, which is something we could certainly use as much of as we can get in today’s world, and I know there are a whole bunch of us who really appreciate it.

    I still do not understand how some people really have enough time on their hands, and they honestly somehow believe it is worthwhile, to try and tear somebody down out on the internet. Presenting an opposing perspective and trying to back it up with what evidence they have is one thing, but some people to just go to bizarre lengths to try and prove who is the biggest troll in the universe. I have a friend who is a very high profile video game designer and he has developed a skin made of exotic alloy with all the trolls that roll off of his back on an almost daily basis. Much of the time karma takes care of most that come after him, but every once in a while I’ll get to see him make use of his nearly surgical wit on twitter to take a few of them off at the knees. I hope I live to see the day when the greatest majority of people spend their time living a happier life and do their part to help us all move forward. I believe we are really going to need that if we are to advance much further than where we are now.

    For what it’s worth, in case somebody reading this is wondering about other people’s experience with designing their fat breakdown for a KD. I definitely feel like a bear in a hibernating torpor when I consume a particularly high SFA percentage. All I want to do is sit in front of the TV all day. I found that if I raised the percentage of MUFA much higher I felt a whole lot better and had better energy levels. I like the high end specialty olive oils and always try to buy the ones with the highest polyphenol counts but I often find them too robust for my palette so I tend to cut them with a high oleic sunflower oil which is nearly flavorless. Spectrum seems to be the easiest thing for me to get my hands on and their HO sunflower oil has a half a gram less of PUFA, per serving, than their high oleic safflower oil. At least according to their label anyway. I have not been able to find anything with a higher MUFA content than those 3 other than macadamia oil, which is interesting, but I like my macadamia nuts to taste like macadamia nuts and not very many other things. The oil tastes good but the flavor is very overpowering when combined with other foods and generally not very complementary to most foods. To me at least anyway. Kind of like virgin coconut oil. I like coconut but it just doesn’t go particularly well with many things you use oil for so if I use it I generally will use the refined oil as long as I can find an organic one that hasn’t been refined in a poor manner.

    Beautiful time piece BTW. I am as about as close to the epitome of a Myers-Briggs ISTP as you will find so I can fully appreciate some of the utterly mind boggling design and super intricate craftsmanship that goes into many luxury time pieces, but I oddly enough eschew them for utilitarian pieces that I can get caked in mud or take to the shallow bottom of the Gulf of Mexico. A Sinn U1 on a metal bracelet is going to be about as dressy as it gets for me.

    Thanks Peter!

  5. I really appreciate your thoughts on SFA here. I’ve been skeptical of the whole bulletproof way of life, and I think your effort to spread the word that something that is good for one does not mean it is good for all is so wonderful. Scream it from the rooftops and great post.

    Also, side note, if that happened to my daughter I do not know how I would have reacted. Girls in particular can be so cruel. I think you handled it brilliantly, a girl’s confidence is the most gorgeous thing she can wear.

    • You said it… the cruelty is simply amazing to me. The best advice I was ever given about parenting is to show my vulnerability. Let my kids know I can be hurt, I can be sad, I can be afraid. Seems counter-intuitive, I know, but I’ve seen amazing results in the kids of my friends who have done this.

    • I agree, Whitney!

      My poor mother and her friend were called “hippo” (her no doubt) and “pottamus” as children. Her self-confidence was damaged for life. (No doubt there were other causes as well.)
      She was a beautiful woman, but was always trying to lose weight. I remember the Metrecal drinks from the 60’s.

      As she aged, and she lost her appetite while her frontal lobe dementia progressed, she became very thin. Even though she was dying (something she may not have understood),, she was so glad to be slimming!

  6. So Peter for those of us who have our 23andMe results, what should we be looking for to see if we’re in this “replace with MUFA” group? Ty!

    • It’s certainly possible that SFA sensitivity could be a result of evolutionary DNA mutation(s) that first occurred in more recent times, much like lactose tolerance:
      Logically, any such mutation(s) would probably have arisen in a population where MUFA were heavily substituted for SFA. The Mediterranean region would be a likely suspect region, and perhaps more SFA-sensitive patients might be found there. DNA analysis would need to be conducted on a sufficient (?) number of patients with known SFA sensitivity before common mutation(s) could be identified. Finding the exact genetic marker(s) will be difficult, because most people with SFA sensitivity are probably have no awareness of it. Perhaps 23andMe might be able to provide some insight to your question, but I suspect the answer is unknowable at this time.

  7. I’m a Math teacher, and I was pretty excited about yesterday! 🙂

    Thanks for this post. I’ve been trying to work out a variation of LCHF that will work for me. I think I’m in the small percentage that can’t tolerate high amounts of SFA. My cholesterol was through the roof and my doctor freaked out, but I thought it was more tied to untreated hypothyroidism than to being in nutritional ketosis.

    Anyway, although I refuse statins and I’m on medication for the thyroid issues, I still felt like I needed to watch my SFA intake. This post was confirmation of that.

    So, thanks again for all you do. I direct everyone I know to this website all the time, and I tell them about NuSI and how excited I am about what will come from it.

    I’ve been reading for a year (although this is my first comment) and I am cured of PCOS now. I thank God, but I thank you too!!!

    P.s: you sound like a great father. My dad called me fat when I was 14! :p. So now I obsess about staying a size 4. Sad, but true.

    • Milli, so glad to hear about your PCOS story. I hope the SFA journey solves it self with some experimentation. Sorry to hear about your dad. I obsess over this a LOT. My daughter knows I avoid sugar. I explain it in terms of sugar’s effect on my performance, not my waistline.

  8. Dr. Attia, always insightful views on your blog. Many thanks for your views. Great story about your daughter – who I believe is the same age as mine 🙂

    I may be one of the “fundamentalist LCHF” this blog is meant for. I might have to try to cut down on SFA and replace it with MUFA to see how it impacts my LDL-P, which was rather high when I measured last year.

    On a side note, when do we see some results from NUSI start coming in?

    Mickey G

  9. Peter,

    Interesting comments on the podcast re Theranos and tests you recommend for longevity purposes. That said, I’ve been on a high-fat diet with seemingly good results for a few years now, but I’ve been scared to get blood work done, in part because intimidated and unsure what I should be asking my physician to test for. At this point is there a standardized set of blood tests that are easy to request from a new physician? Are physicians accustomed to being asked to do NMR testing? Are Wellness FX, SpectraCell, and similar companies useful in this context?


    • Be very specific with your doctor. My husband was, asking for the NMR, I can no longer recall all the details, but he was very specific when he asked the doctor whether she could get that test. She said yes and was so glad he was so interested/proactive re his health. When he got the results, it was not the NMR but only a calculated APO B.

  10. This is a copy/pasta response I drunkenly made to Ivor Cummings (Cholesterol Conundrum/Fat Emporer Irish guy) on Bill Lagakos’s blog last year, which explains my (mis)understanding of the LDL-P situation:


    Ivor: “I am interested in locking down on particle number being directly causal as opposed to partially associative too”–

    Ash: Good luck with that, probably as misguided as the idea that cholesterol itself is evil.

    My current analogy* for particle number is one of traffic and roads. If the roads in your city are narrow torn up and potholed and poorly maintained and badly signed with shitty traffic flow and fuckwit drivers etc then the number of cars on it is a huge issue. You’ll get away with a small number of cars as when there’s the inevitble crash the ambulances/maintenance crews can get in and fix without much issue apart from little room on the shoulder. But if you have way too many cars there are more crashes, and subsequent pile-ups, and the emergency services either can’t get there to fix it in time OR they themselves become part of the pile-up.

    Then imagine a marble-smooth nice wide freeway, well maintained at the first sign of a pothole, traffic is well directed and flows like beer at Schutzenfest, and the drivers are a bunch of Canadians. Sure, the occasional crash happens, but emergency services can get there quickly and easily and they have plenty of room to deal with the situation. In this case it doesn’t really matter if there’s only several hundred cars, or a couple thousand.

    So yeah to me particle number is strictly correlative, because discordance. You simply can’t find near 100% of the time it being there. High particle number in a super inflammatory environment – MURDER ON THE DANCE FLOOR. High particle number in a well oiled machine – STAYIN’ ALIVE.

    *subject to change if I hear better :p


    Keen to hear if I’m on the right track or full of crap.

  11. Hi Peter,

    Thanks for another great post and the podcast.

    1. Among the signals you mentioned about the unsuitability of KD for an individual, could we add that drop in libido, drop in basal tempaerature to 96.8 and deterioration in the quality of sleep and mood for an individual even after being fully adapted to KD might also suggest that KD is perhaps not suitable?

    2. You mentioned caloric restriction in the podcast in the context of post exercise carbs/whey, do you deliberately restrict calories in your diet? If so, how do you achieve this? Is it via IF?


  12. Hi Peter,
    Always enjoy your thoughts and articles. Thanks for taking the time to write them. I am wondering if you have looked into the link between iron and LDL oxidation. I dropped my LDL from over 200 to below 100 after reducing my iron levels, which were high enough to induce inflammation as measured by UIBC and TIBC tests. I also did not dramatically reduce my fat consumption though I did rotate from saturated to more monosaturated fats. However, I still eat eggs every day and only buy whole milk yogurt and cheese. So I still get a decent does of saturated fats. I’m wondering if saturated fat is only a necessary (but not sufficient) condition and that inflammation must be present to throw things out of whack. Varying levels of iron loads across people can also explain the ability to handle saturated fat, though I am just hypothesizing.

    • Peter,
      There was no reply link to your response to my post so I have to reply back to myself. Regarding iron, I do not know that the change is solely due to reducing iron levels vs some other change. I posed it as a hypothesis and was wondering about your thoughts. But I am a fairly stringent diet self-experimenter and that was the single biggest change I made between blood tests.

      I had experimented with reducing saturated fat and increasing carbs two blood tests ago and while they improved things a little (LDL-C dropped from 265 to 205), this latest drop was huge (205 to 89). My saturated fat decrease and carb increase in my latest blood test was only marginal. So I suspect it was the iron, though I can’t say for certain.

      Also I had posted my numbers on Paul Jaminet’s forum and he was worried that I now have anemia due to my low LDL. He didn’t think the carb increase could have done it. So he thinks there is a link between LDL and iron though he did not go into details.

    • This is interesting. I am homozygous for the C282Y mutation on the HFE gene and suffer from haemochromatosis. Fortunately I found out about it from 23andme and have confirmed via multiple blood tests and consultation with a haematologist. I just had my lipids re-done for the first time in 2 years and my LDL has gone from 40 to 104 (LDL-P was ~1400 but I didn’t have a previous number) however there are far too many other variables (it was 2 years ago) for me to be able to pin it on the increase in my transferrin saturation (~70%->99%). I have recently (about 2.5 weeks ago) massively increased my fat intake as part of a ketogenic diet and 2 weeks ago I ran a 100 mile ultra so many of my blood markers are currently a bit of a mess (thyroid, CRP etc).

      I would be interested in any further info anyone has on iron and its affects on lipid profiles. I will certainly be lowering my iron levels back into normal range and making an effort to move to a low iron diet so that I can manage things without treatment. I will also be getting all of the tests re-done in about 2-3 months but I would just be guessing if I said that any change was caused by the iron.

      One thing is for sure, everything I read, and everything my haematologist tells me is that even slightly increased iron levels are being shown to have unpleasant effects so I think I need to be more sensible in my diet and keep them low, especially as I have been lucky to find out about the condition before it has any nasty side effects.

      Thanks for the fantastic blog Peter. I love what you are doing at Nusi and find the depth and detail to all of your articles to be amazing. There are too many people writing blogs about keto that basically just say “eat lots of butter and cream” and tell people to ignore their LDL-P numbers…I find that reckless so I am happy you are willing to challenge the keto lobby occasionally. This is also one of the only blogs that has good info for athletes which I have found invaluable. I have been reading your blog repeatedly for the past 2 months and just waiting for a good time (post races) to attempt my keto-adaption. My main reason for trying this is that I like the idea of being metabolically flexible in long endurance events and I am really not convinced that dumping 50+ gels into your body in a 24 hour period is good for you long term…

      Thanks again.


  13. “are not better served by mainlining SFA, even in the complete absence of carbohydrates ”

    I’ve recently come to the conclusion that a ketogenic diet is not for me. I still limit my carbs, especially sucrose and HFCS, but I find myself feeling much better with the occassional potato and fruit, and I also find myself feeling better with more protein than a ketogenic diet allows.

    The point you’ve made, more than a couple times on your blog, is that needs vary by individual. I think that’s been my biggest epiphany over the past 6 months or so

    “such as LDL-C or its superior cousin LDL-P—’don’t matter’…Maybe they are right. I guess time will tell. But I am not convinced, at least not yet.”. I got the impression from your Tim Ferris podcast a few days ago that you’re even less tentative than that. It will be interesting to see what the data tells us, now that a lot of people are shifting focus to LDL-P, and are giving more skepticism to the lipid hypothesis.

  14. Hey Peter –
    I am a primary doc practicing 30 yrs now . Regarding cost containment – and advising folks on exercise – do you have an opinion on the McGuff method vs lower intensity methods? I ask only about strength training – another words I am accepting the hypothesis that strength training for the populace will add more fitness benefit than “cardio” .
    I know that strength training would not be a “normal” issue to bring up in discussing health care cost containment but I do agree with DOug McGuff . He was asked what one thing anyone can do to improve their health , and his answer was strength training .
    Enjoyed the monologue podcast. Keep up the good work.
    FWIW, I am a parent also and did show my kids my vulnerable side at times. Good job .

    • Yes, I’m a proponent of Doug’s work and methods. If you can only spend an hour per week exercising, there is little I can think of that gets more bang for $.

  15. After reading this I had to ask myself,” Who dislikes Peter Attia” after all you are a very personable guy. So I did some searching on You tube and found the Australian vegan guy who wants to race you. lol . There is also a young girl that I follow, Kendall Jones. She is a big game hunter and is attacked constantly by vegans and peta. She is quite good at rebuffing their insults. Thought you might use some of her ideas. Keep up the great work!

  16. I find it particularly cool that pi day was (and always is, at least in the US) Einstein’s birthday.

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