18. Nuanced Keto: Miriam Kalamian unlocks the power of diet in cancer therapy

 In this episode, Dr. Dawn Lemanne and Dr. Deborah Gordon engage with author and ketogenic diet specialist Miriam Kalamian, who shares her profound personal journey of treating her son’s aggressive brain tumor with a ketogenic diet. The discussion delves into the diet's impressive effects on the size of her son's brain tumor, the surprising--and critical--role of calorie restriction for effective implementation of the keto diet in cancer, and the best combinations of fasting and the keto diet for optimal results.

She outlines tailored dietary approaches for different cancers, and why keto is not "one size fits all" in cancer.

For example,  for brain cancer, particularly glioblastoma, a strict ketogenic diet with very low carbohydrates and calorie restriction is essential to maximize ketone levels and minimize glucose.

However, prostate cancer patients can follow a more moderate ketogenic diet, balancing carbohydrates to maintain quality of life and muscle mass, which is vital due to androgen deprivation therapy.

Dairy fats are avoided in hormone-sensitive cancers but are acceptable for brain cancer due to their easy digestibility and lack of systemic effect.  She discusses her experience with exogenous ketones, and when she recommends those.

Finally, Ms. Kalamian emphasizes the importance of professional medical advice when using diet as part of cancer therapy, and warns of the dangerous misinformation about the ketogenic diet on the internet, misinformation that often leads to poor outcomes. For instance, the common misconception that the ketogenic diet alone is a reasonable treatment for most cancers is dangerous. 

This episode offers invaluable insights into the potential of metabolic therapy in cancer treatment.

For more information on Miriam Kalamian's work
Her website: https://www.dietarytherapies.com
Her book: Keto for Cancer on Amazon

Dawn Lemanne, MD
Oregon Integrative Oncology
Leave no stone unturned.

Deborah Gordon, MD
Northwest Wellness and Memory Center
Building Healthy Brains

Chapters

• 3:16 Kalamian's emphasis on not using the ketogenic diet as a standalone cancer treatment for most patients and combining it with fasting and calorie restriction to enhance early results.
• 5:03 Miriam Kalamian's personal journey with her son, Rafi, who had a massive brain tumor the size of an orange in a four-year-old's head, led her to discover the ketogenic diet. Timestamp: [00:05:03.320]
• 8:18 The potential benefits and pitfalls of using the Internet for medical advice, highlighting the importance of connecting with sound medical information and professionals.
• 27:57 The significant role of calorie restriction in the success of the ketogenic diet, especially in producing high ketone levels and low glucose levels, which are crucial for cancer treatment. Timestamp: [00:27:57.380] - [00:28:02.740]
• 1:11:57 The difference in dietary approaches for different types of cancers, such as more lenient carbohydrate intake for prostate cancer patients compared to strict ketogenic protocols for brain cancer patients.

Transcript

[00:00:00.280] - Miriam Kalamian

We adopted Raffi when he was two, and when he was four, we learned he had this massive brain tumor. They told us it was the size of an orange, and this was in a four-year-old's head. He started out okay, but we watched this deterioration over time. And it's heartbreaking to see a little guy who's right on the edge of riding a bicycle, have to go back to training wheels and then ultimately to a tricycle, because he didn't have the balance, he didn't have the vision. So at the point that they wanted to move him to palliative care, he was really in pretty bad shape. So I put him on this extremely restrictive diet, and he was feeling better, and we're seeing more life in him. And three months later, when he had an MRI, I was hoping for anything. It's like, oh, please, back up the fact that what we're seeing here makes sense. And instead of just stability or whatever, there was a ten to 15% shrinkage in all dimensions on his tumor.

[00:01:05.530] - Dr. Lemanne

You have found your way to the Lemanne Gordon podcast, where Docs Talk shop. Happy eavesdropping. I'm doctor Dawn Lemanne. I treat cancer patients.

[00:01:24.370] - Dr. Gordon

I'm doctor Deborah Gordon. I work with aging patients.

[00:01:28.100] - Dr. Lemanne

We've been in practice a long time.

[00:01:30.450] - Dr. Gordon

A very long time.

[00:01:32.170] - Dr. Lemanne

We learn so much talking to each other.

[00:01:34.300] - Dr. Gordon

We do. What if we let people listen in?

[00:01:41.010] - Dr. Lemanne

For anyone who's used metabolic therapy and specifically the ketogenic diet, or keto, as it's sometimes called, to help with cancer treatment, today's guest needs no introduction. She's Miriam Kalamian, and she's written the book on the topic, aptly named Keto for cancer. She is perhaps the world's leading cancer nutritionist and expert on implementing the ketogenic diet during the treatment of brain tumors. You're about to hear how, while desperate to help her young son, who was suffering from a brain tumor, she stumbled across some scientific papers that gave her hope, and thus began her journey to understand the science behind the ketogenic diet. You're also going to hear how she navigated the pitfalls and difficulties of implementing the ketogenic diet with her young son. And this is key. You'll hear how the keto diet accomplished for her son what 54 chemotherapy treatments failed to do improved the brain tumor. Then we dive deep into the mechanisms behind the successful implementation of the ketogenic diet. We discuss how the principles behind the ketogenic diet can help end dementia, as well as other conditions. And Miriam Kolamian also warns how not to use the Internet for medical advice. She discusses who should embrace the ketogenic diet, who should avoid it, why it fails some people, common mistakes, and why combining the keto diet with fasting and calorie restriction can turbocharge early results.

[00:03:16.630] - Dr. Lemanne

She gives her opinion on why the ketogenic diet should not be used as a standalone cancer treatment for most patients. Warning. Parts of this episode are quite technical, but there's also plenty of simple human drama in Marion Kolamians story. So whether you're a doctor or an interested layperson, there's treasure for you in this episode. Enjoy. I am so happy to be able to talk to you. You have no idea what a help you've been for me professionally with my patients over the years. I can't even quite remember when I met you somewhere, at some conference somewhere. And I've been aware of your work and your books, and we run into each other here and there, and I have sent you patients for whom you've done just a wonderful job working with them when they needed to be in a state of ketosis to aid their cancer treatment. So thank you so much for all of your work, and why don't you tell us how you got started in this? I know it had something to do with a very personal situation for you.

[00:04:25.350] - Dr. Gordon

Yes.

[00:04:26.070] - Miriam Kalamian

Thank you. And I have to say, I have the confidence in what you do to be sending people to you as well. I think it's important for people to connect with sound medical information, and sometimes that doesn't happen if all they're getting is Internet videos. So, my story in nutrition begins with my son. We adopted Rafi when he was two, and when he was four, we learned he had this massive brain tumor.

[00:05:01.070] - Dr. Lemanne

How big was it?

[00:05:03.320] - Miriam Kalamian

Okay. When they describe things like that to lay people, they relate it to something that you can identify with. So they told us it was the size of an orange, and this was in a four year old's head. So how it could have gotten to that size and us not know that something was there? Well, the fact that we adopted him at two, we may have missed some of the early signs that he was then able to compensate for.

[00:05:30.830] - Dr. Lemanne

Because you think it was present before you adopted him? Okay.

[00:05:34.510] - Miriam Kalamian

Yeah, yeah. Rafi had a birth anomaly called polins. So it's syndactyly. And so that's a failure of apoptosis in at least one part of his body.

[00:05:47.330] - Dr. Lemanne

So tell our audience what syndactyly is. It's a connection of the fingers and toes with webs.

[00:05:53.020] - Miriam Kalamian

Yes. Yeah.

[00:05:53.940] - Dr. Lemanne

Okay.

[00:05:54.250] - Miriam Kalamian

So he had that. That was part of the Pollen syndrome. And what we learned later was that's also associated. Pollen's is also associated with disorders of the pituitary, the hypothalamic pituitary axis. And what kind of worse thing could you have there than a brain tumor? So, officially, it was a low grade glioma, but it was also huge diffuse, which means that it was all over, they said, spanning the diencephalon, which means it was in multiple areas. It wasn't confined to one region.

[00:06:30.090] - Dr. Lemanne

So it was going onto both sides of the brain. There's a split between the brain, but this tumor spanned that split, and it wasn't completely, it wasn't encapsulated like an orange. It was absolutely not, had edges that were not discrete.

[00:06:46.510] - Miriam Kalamian

Right. If this had been a juvenile pilot astrocytoma of the cerebellum, they could have popped it out, which is a very.

[00:06:55.040] - Dr. Lemanne

Circumscribed tumor for our audience. It's a little ball, and you just take it all out. It comes out in one piece.

[00:07:01.160] - Miriam Kalamian

Comes out in one piece. But this was diffusin infiltrated. So what you know, of course, you find that out, and this was in 2004, and there just weren't the Internet resources. And of course they said, don't go online. And that's the first thing I did was go online. And it was just devastating.

[00:07:20.730] - Dr. Lemanne

Let me stop you right there. So tell me, I've read everything you've written. I really have. And one of the things that you do talk about and speak about on other, you know, in other venues is the idea that, that, you know, patients and doctors are often not on the same team. The patient is actually in the stands. The playing field is not populated by the person who has the greatest interest in this. In other words, don't look around. Don't think about what treatments you might find out there. Tell us a little bit about how you think that needs to change and how you've work to change it. I'm going to bring you back to the topic of your son in a minute, but I really want to hear that. I think our patients, really, our patients, Deborah's patients, and my patients are the type who very much read the Internet and bring us information and say, hey, what do you think of this, Deborah?

[00:08:18.740] - Miriam Kalamian

Yeah, my clients, the ones that come to me, are more and more coming from either referrals or they're coming because they saw a YouTube video. And YouTube is great for that. It exposes people to information, but it also heavily exposes people to misinformation. So once you click on a video and you've watched that video, it may then send you another video that it will send you another video, suggested video. And there can be this point of divergence where people sort of lose the groundedness in, hey, there is a medical side to this. It's not just going to be about diet. It is not just about diet. And I love it when people get drawn back into at least considering what else they can do medically.

[00:09:11.460] - Dr. Lemanne

So the caveat. Oh, sorry, go ahead.

[00:09:14.340] - Miriam Kalamian

No, I'm just going to say I've had people contact me. They want to go to the most aggressive press pulse therapy out there that Thomas Seyfried talks about, the dawn drug, and they have like a stage zero breast cancer. And it's like, no, no, this is manageable without these extremes. So part of what's happening is dialing back on the extremes. I think one way we're going to get this more solidly into, it's just not going to happen at the level of the oncology clinic. You know, right now we're seeing that with brain cancer. We are seeing some support within that community, but not for the other cancers. But what is happening now is people who really know how to use AI can use a tool like AI and get some decent information provided to them that is more balanced than this YouTube polarization that happens. So, you know, quite often in the past, a new YouTube video will come out and all of a sudden I'm just deluged with adult children of people with cancer. And that's a whole different type of scene to be dealing with. So they may have been told they watched a video and they heard that three weeks of fasting is going to make their cancer disappear.

[00:10:40.920] - Miriam Kalamian

And it's like, so all of a sudden now they want this for their parents and they're contacting me. They want their parents who are elderly, frail. Deborah. Think of them as being in their seventies, sometimes even eighties. And now we're going to put them on a three week fast and that's going to cure their cancer. That's just not realistic. So, you know, I see the extremes, and I can imagine that same person walking into the doctor's office and telling the doctor that they're going to put their elderly parent on a three week fast and that's going to cure their cancer. No wonder that the gates just shut. The door just shuts. We're not listening. We're not going. We're not going there. We only have 15 minutes with you right now. And we're going to use that 15 minutes to talk about the treatment we're going to offer. That's what people are facing when they walk into the office. Unless that oncologist has come by it from a colleague that maybe experienced it either personally or with a patient, it's not likely they're going to be open to what you have to say. And it's not likely they're going to have the time to be a good listener for the concerns of the family.

[00:11:49.760] - Miriam Kalamian

So, yeah, with my consultations, so it's like, officially it's 75 minutes, but unofficially it's half a day. So it's not half a day with them, it's still 75 minutes with them. But there's the prep. There's the kind of the critical thinking that has to go into what really is the best route for this person. Who can I connect them with from what they. The point that they're coming in, who's going to be the most beneficial to them as a partner here? And unfortunately, we're still at that stage of just cobbling together the resources that we can. And some people I can give a ton of information to, and they're going to be able to handle it, sort through it. And other people, I'm very selective about what I can share because I just know it's going to end up causing more confusion. And that's part of the whole. The prep, the call, the follow up. You know, I really need to look at each person as an individual, and not just with a little tags, you know, pressed into their ear and their process through, I have to say, taking it back to my son, you know, I'd sign in at the clinic and he, you know, because we were going to New York at that point for a clinical trial, traveling from Connecticut to New York, and he always ended up somewhere around number 17.

[00:13:09.150] - Miriam Kalamian

And I felt like that they could have just, like, shouted that number out, like the belly counter number 17, and that would have been sufficient for them. The nurse in this particular clinic was the one that would prep the oncologist by reminding them of what my child's name was. And I was just mom. So, you know, is that what I wanted for my son at that point? He was like six, not even a seven year old, six years old. We are at the end of treatment. This is the very end of what they offered. Before I sat in that office and he told me he was moving my son to palliative care. It's like, over my dead body palliative care.

[00:13:52.640] - Dr. Lemanne

So you learned a lot through the Internet in the course of this thing. But there's something I want to read from your book, and this is in chapter two. And it says, if you do not have a science background, you will need to get up to speed with how to evaluate the quality of what you find online. That is so helpful. And so, going back to Rafi's story, you know, I know from your story that you did everything you were told, and he got worse. And then online, I think you found an article by Thomas afried. This was his 2007 article.

[00:14:38.260] - Miriam Kalamian

2007, yeah.

[00:14:39.580] - Dr. Lemanne

Yeah.

[00:14:39.890] - Miriam Kalamian

So. And it was about totally. It was totally serendipitous. And it was after that visit where I was told that we'd be moving our son to palliative care. And that meant.

[00:14:52.990] - Dr. Lemanne

So he had had all this treatment. You've done all the standard of care. You've been a good.

[00:14:57.450] - Miriam Kalamian

And a clinical trial.

[00:14:58.690] - Dr. Lemanne

And a clinical trial, you know, and how many years in are we now?

[00:15:02.150] - Miriam Kalamian

Two and a half.

[00:15:02.930] - Dr. Lemanne

Two and a half years.

[00:15:03.610] - Miriam Kalamian

Not even two and a half.

[00:15:04.530] - Dr. Lemanne

And the tumor is getting worse.

[00:15:06.330] - Miriam Kalamian

Worse.

[00:15:06.840] - Dr. Gordon

Okay.

[00:15:07.450] - Dr. Lemanne

Okay.

[00:15:07.820] - Miriam Kalamian

Go ahead.

[00:15:08.180] - Dr. Lemanne

And then you find this paper.

[00:15:10.090] - Miriam Kalamian

Yeah. So he had been through 54 individual treatments with a chemo drug, two chemo drugs, vincristine and carboplatin. 54 treatments with those drugs. And then three months later, as they described it again, it was lit up like a Christmas tree. So then at that point, it was like, what are we going to do? We tried another twelve sessions of a less toxic drug, and that sort of held our ground. It didn't get much worse. And then we moved to the unthinkable, which was surgeries for what they had deemed to be an inoperable tumor. So. And it was subtotal resections in both. He had two separate surgeries, 80% resection, and one not great. And a lot of damage to the. To that region, the thalamus and then the hypothalamus was about 30%. And that was a total disaster because that had grown back in eight weeks, plus 25% larger and more infiltrated. So.

[00:16:11.770] - Dr. Gordon

Can I interrupt you a second, Miriam? And how is Rafi doing at this point? Because that's not the normal course of the childhood you had planned for him. How was he personally and physically doing for those couple years?

[00:16:28.040] - Miriam Kalamian

In the beginning, he was really doing okay. He was moving through it. He developed an allergy to the carboplatin. So they did the last 17 treatments with him on high dose dexamethasone.

[00:16:39.430] - Dr. Lemanne

And because, you know, I want to interject there. So after six, seven eight carboplatin infusions. A lot of people do develop an allergy to carboplate, and it's a hard drug to continue to give over and over again without the patient developing sensitivity, which then has to be managed, which is very difficult.

[00:16:58.270] - Dr. Gordon

So they could have predicted that. But still, there's.

[00:17:01.100] - Miriam Kalamian

Still.

[00:17:01.580] - Dr. Lemanne

There were no other options. I mean, I think that's the point of all of.

[00:17:05.420] - Miriam Kalamian

Well, there was another option. We could have started with something a little less aggressive that a doctor up in Canada had been doing, but we weren't aware of it at the time. He was more interested in preserving quality of life. But I think when you're talking about a tumor that size and that infiltrated and the fact that it was a GPA and not a different tumor, so there was some.

[00:17:26.750] - Dr. Lemanne

So GPA, we'll explain that for our.

[00:17:28.930] - Miriam Kalamian

GPA is a juvenile pilot astrocytoma, but it was behaving unlike a juvenile pilocytic astrocytoma. And I think if they were looking at that tumor now, they would. Genetic analysis would have figured out why. But they didn't have that in 2000. And, well, he was actually diagnosed in 2004, right at the end of the year. They didn't have those kinds of tools. So, yeah, he started out okay, but we watched this deterioration over time, and it's heartbreaking to see a little guy who's right on the edge of riding a bicycle have to go back to training wheels and then ultimately to a tricycle, because he didn't have the balance, he didn't have the vision. So at the point that they wanted to move him to palliative care, he was really in pretty bad shape.

[00:18:16.290] - Dr. Lemanne

So palliative care, meaning. God, mom, they were calling you. We have done everything we could. Nothing else is an option for your child. Take him home, enjoy him, and keep him comfortable.

[00:18:31.730] - Miriam Kalamian

Is that not what they said? What they said was, we have this thing called TPCV. It's a cocktail of four drugs. And maybe he will have some response to that, but we don't really think so. And the downside of what actually what he said was there was a one in three chance of any response and a one in ten chance of a response at, I think he said 15 months. But it was going to mean hospitalizations and blood transfusions because of the drugs. And that's how I. I was investigating one of those drugs that was going to cause, they said, possible kidney damage. You got a double glove to work around any of his urine.

[00:19:19.500] - Dr. Gordon

You send that doctor back to school and give him the definition of palliative care.

[00:19:25.230] - Miriam Kalamian

Palliative care, exactly. Palliative. Well, hospice care means no treatment. But palliative care, they do continue to.

[00:19:32.870] - Dr. Gordon

Treat, but to make them so much more uncomfortable.

[00:19:37.260] - Miriam Kalamian

Yeah, yeah, yeah. So, yeah, I was looking up one of the drugs, and I was at my mom's home, and she was in her eighties, and she had an inkjet printer. And I couldn't print this out, but it was all about the toxicity of cytotoxin. I mean, even in the name. My God. So I went back a few days later and at another location to go to, I bookmarked it and I went to print it out. And all of a sudden, it's not this article on cytotoxin. It's this paper out of Doctor Seyfried's lab. And it was the effect of a calorie restricted ketogenic diet on a mouse model of glioma. And I read it. It was just the abstract. And it was like, well, wait a minute. I know I'm not supposed to be paying attention to any mouse model stuff. That's what they told me. Years away from anything, if at all. But they were using two pediatric glioma patients as part of the rationale for doing this study. So I emailed. I was, like, totally ignorant about research because I'd been told to be ignorant about the research. Don't look at mouse model research.

[00:20:47.600] - Miriam Kalamian

So I emailed the author, which turned out, of course, to be a PhD student. And then what I get back in return, a couple hours later, is an email from Tom Seyfried. And as that's his lab, and he provided me with the only resources that we had to at the time, which was the Charlie foundation. He said that, you know, he had contacts within the Charlie foundation, which was for epilepsy, using this diet for epilepsy. And he told me about Johns Hopkins work and John Freeman's work. And I found out that the fourth edition of the Johns Hopkins book on pediatric epilepsy had just been published. So with the enabling paper on the two pediatric brain tumor patients and the Charlie foundation moderated Forum and the book, we started our son. A couple weeks later. He failed the clinical trial, obviously, and at this point, he'd had to have a shunt placed for the pressure in his brain. And he was falling apart, sleeping a lot. And even when he was awake, he wasn't really with it.

[00:22:01.600] - Dr. Lemanne

Just for our audience, the Nabeling case series is two patients, pediatric brain tumor patients, who. Why don't you tell us a little bit, just in a couple of sentences, what those two cases showed you and why they impressed you.

[00:22:17.850] - Miriam Kalamian

Linda Nabling was a doctoral student, as I found out later, and for her dissertation, she speculated that this pediatric diet for epilepsy. For pediatric epilepsy, might be beneficial. And there were two children for cancer, correct? For cancer, yeah. There were two children with brain tumors. And PET technology was really. PET scans were really new at the time, and so she got permission to do this because it's pretty non invasive.

[00:22:45.420] - Dr. Lemanne

And I'm sorry to keep interrupting you, but a PET scan is a. For our audience is a photograph of your tissues using glucose. So if you have a tumor, the glucose collects in the tumor, and we can see it on our photographs. We inject a bit of glucose with. You can consider them little flashlights or torches. And so when we hold the photographic plate over your body, we can see where all the torches have collected. And if you have a tumor, we can see them collecting in your tumor. And it's a photographic proof that tumors, most of them, are very, very interested in glucose and will collect glucose to use as fuel.

[00:23:26.770] - Dr. Gordon

Yes.

[00:23:27.250] - Miriam Kalamian

And now that's important.

[00:23:29.650] - Dr. Lemanne

Yeah.

[00:23:30.220] - Miriam Kalamian

Instead of using a PET scan on the brain, because the brain is such an avid user of glucose, now they use MRI with a different type of contrast material to watch for metabolic activity rather than glucose uptake. And quite often, they're one in the same. But at the time, it was pet technology that they used. And so there was this image of the tumors at baseline, and then the tumors eight weeks later when these children were fed a ketogenic diet that I believe it, in at least one case, was quite a bit of MCT oil, too. Medium chain triglyceride oil that converts to ketones. So the ketogenic diet that they used was a formula that had been developed for the use of children with epilepsy. And I have to tell you, that stuff was a disaster at the time. That was.

[00:24:21.700] - Dr. Lemanne

Did you, son?

[00:24:23.510] - Miriam Kalamian

No. No.

[00:24:24.540] - Dr. Lemanne

Okay.

[00:24:25.080] - Miriam Kalamian

No. 93% of it was fat, but it was all hydrogenated soybean oils. So at the time, I didn't understand how devastating that could be on its own. But because I had found out about the Charlie foundation, instead of going with a formula, we fed our kid real food. So it's real food, but it was carb restricted. He was down below 20 grams of carb a day. And it was calorie restricted because Thomas Seyfried's work had shown that calorie restriction was important part of this. And it was okay to do this for our son, because part of his. Deborah, you asked about how he was doing. Well, he was, at this point, he was what they call experiencing hypothalamic obesity, which is when the pituitary is not functioning anymore. There's this state of hyperinsulinemia, which is driving glucose into fat cells. And he was probably, at that point, 15 or 20 pounds heavier than he should have been for his age. That had happened almost in a heartbeat.

[00:25:28.390] - Dr. Gordon

And if you had tested, when you tested his. His blood, his insulin levels were consistent with that. They were higher than they should be.

[00:25:39.770] - Miriam Kalamian

We never knew to do that early on. There was no. They didn't do that for kids on the diet with epilepsy, because it wasn't a problem. So it wasn't part of their protocol. It's now a part of my protocol to be looking at insulin fast.

[00:25:52.700] - Dr. Gordon

But in retrospect, you would say that actually this hypothalamic obesity problem would actually drive up his insulin levels higher.

[00:26:01.230] - Miriam Kalamian

Yes, that's what it does.

[00:26:02.370] - Dr. Gordon

Which blocks ketogenesis.

[00:26:04.550] - Miriam Kalamian

Yes. Yeah. But the fact that he was so protein carb, calorie restricted. His body had to use that fat.

[00:26:15.080] - Dr. Gordon

Had to do something.

[00:26:16.040] - Miriam Kalamian

Yeah. So his body had to use that fat. He had to go into ketosis.

[00:26:19.970] - Dr. Lemanne

So you found. Oh, so go ahead. I'm sorry.

[00:26:22.910] - Miriam Kalamian

No, go ahead.

[00:26:23.530] - Dr. Lemanne

Well, so you. He's got worse. On his two years of standard treatment, 50 something treatments was offered yet another palliative round with four chemotherapy drugs, which you declined at that moment. You also found Thomas Seyfried and the Nebelung papers. And so you put him on this diet and terrified.

[00:26:48.900] - Miriam Kalamian

I was terrified.

[00:26:50.180] - Dr. Lemanne

What happened to the tumor then? So the doctors haven't been able to make it shrinking? Yeah.

[00:26:55.200] - Miriam Kalamian

Okay. So when he failed the trial, he had an MRI that the official, like, okay, we knew he'd failed it a couple of weeks before because he had to have that shunt placed. But now we had the official MRI that said he had failed the trial. And the next day, I fasted him. He was in ketosis by that night, panting, he was in, I would guess, metabolic acidosis. The pee strips were turning bright purple. Second urine hit them. But because I had that Johns Hopkins book in hand, I knew what to do, which was to give him a couple of tablespoons of fruit juice, I believe it was orange juice. And that settled him down. And we went from there. But it was terrifying. So we had this MRI. We got good at the diet. We were working things out to the second decimal point, which is not necessary. For cancer, I have to add, necessary maybe for epilepsy with the brain chemistry, but that's not our goal here. So we were working things out that way.

[00:27:57.380] - Dr. Lemanne

Were you using the classic keto diet, the John Hopkins four to one?

[00:28:02.740] - Miriam Kalamian

I thought I was four to one.

[00:28:04.550] - Dr. Lemanne

Okay, tell us what. Tell our audience what four to one means and what you were actually doing.

[00:28:09.690] - Miriam Kalamian

Yeah. So that ketogenic formula was four to one, in my understanding of it, because I had no background in nutrition, was that it was. For my understanding, it was four calories from fat in a ratio to the calories from carbs plus protein. But it wasn't. It's supposed to be grams, and grams of fat is more than twice the calories of grams from either protein or carbohydrates. So those two are four. From fat, it's nine. So my four to one diet was calorie restricted, was actually more like a 1.2 to a 1.5. I'll get to that part in a moment. I put him on this extremely restrictive diet and he was feeling better and we're seeing more life in him. And three months later, when he had an MRI, I was hoping for anything. It's like, oh, please back up the fact that what we're seeing here makes sense. And instead of just like stability or whatever, there was a ten to 15% shrinkage in all dimensions on his tumor.

[00:29:26.010] - Dr. Lemanne

I want to stop right there. So you and this diet that you were able to put your son on accomplished what all of the chemotherapy, including the clinical trial, had not been able to accomplish initially.

[00:29:40.800] - Miriam Kalamian

To give it credit, on the carboplatin initially on the first MRI monitoring mi, they thought they saw maybe a 10% shrinkage, but that then after that, it was just stable, stable, stable. And then he stopped the treatment at the end of the treatment. And that's when the rebound was just. Within three months there was rebound. And then we did, it was another twelve vinblastine instead of in Christine treatments. And then the clinical trial was also nine weeks of chemotherapy, oral chemotherapy. So it wasn't just that initial 54, he had had these treatments, plus a.

[00:30:15.540] - Dr. Lemanne

Total of four surgeries somewhere in there, and you're still. Your treatment. With the diet accomplished a greater and more. I think it sounds like the radiologists were more able to convince themselves that there was a 15%.

[00:30:31.450] - Miriam Kalamian

Ten to 15%. I didn't believe it. In the local center, they've got it wrong. So we sent it to his fancy oncologist out on the east coast. I won't be more specific than that. And we sent it to another center that he'd been at. I won't be more specific than that, but they were both members of the, I believe they were both members of the brain tumor pediatric brain tumor consortium, and they concurred that that's what they saw as well. So now I have three opinions on this MRI. And it was like it did what now? I have to say, too, for the, for the sake of full disclosure, in order for the oncologist to follow him, we did have to take on a treatment. But the treatment was the vinblastine, which is less toxic at two thirds the dose. But he had already failed this drug at full dose, so it wasn't going to be like this was me. And after a few sessions of this, the oncologist said, we're going to take him off the vin blasting because it's not the reason why this is happening, but we'll continue to follow you.

[00:31:36.610] - Dr. Gordon

Oh, that's great. That's an accomplishment, Miriam.

[00:31:41.410] - Dr. Lemanne

I want at this point, Miriam, for you to tell us. I have Thomas Seyfried's book here, and you've written a chapter in his, his 20, I think it's 2012 book.

[00:31:52.330] - Miriam Kalamian

Yes, 2012.

[00:31:53.260] - Dr. Lemanne

And you talk about the calorie restricted versus the fed state in ketosis and the ketogenic diet, and you had your son on the calorie restricted ketogenic diet at this point. Tell us a little bit about that. And I think that's something that, with my patients, anyway, there's a big misunderstanding about the power of the calorie restriction restricted ketogenic diet versus the fed state ketosis. Talk about that. You've learned.

[00:32:28.300] - Miriam Kalamian

That'S where you're going to get the highest ketones and the lowest glucose, because the body really thinks that it's in a starvation state. And when is it ever going to see another rush of glucose coming in with a child? Boy, that adaptation happens almost instantly, because even though he was hypothalamically obese at the time, he was still very young and that had been a real quick put on. So it took longer for him than it does for kids without that complication. But, yeah, just to put a little light on what hypothalamic obesity is, it is a drive to eat. As you're eating, you're thinking about the next food you're going to eat. And I would shut my eyes for ten minutes and he'd be out eating green tomatoes off the vine. Or one time he picked up some, there was pears, dead fall, you know, windfall pears out in the yard with hornets in them and he's out there munching on those. He ate dog biscuits off the floor. I mean, this is a child who would eat anything that wasn't nailed down because he was just driven to eat. That's how strong that was.

[00:33:40.680] - Miriam Kalamian

And it took a couple months to.

[00:33:42.050] - Dr. Lemanne

That, but that got better.

[00:33:44.740] - Miriam Kalamian

Yeah, it went away.

[00:33:45.970] - Dr. Lemanne

Well, you know, one of the things that I, you know, try to impress about my patients is that you get more bang for your buck in the anti cancer part of things. If you're also calorically restricted, if you.

[00:33:57.940] - Miriam Kalamian

Can do it, if you can do.

[00:33:59.290] - Dr. Lemanne

It, and it's not sustainable, you can only, you can only lose so much weight. But I want to hear doctor Gordon in the dementia world and in a lot of your groups where your research, that's also a thing, where you are getting patients into a fasted state a lot, where they are a bit calorically restricted. And I think that's because you find that that's more powerful than just a fed state. Ketosis in terms of dementia.

[00:34:30.880] - Dr. Gordon

I think it's a lesson I keep kind of, you know, circling the wagons about, because so many of my patients, as I'm. So this is my dementia patients, that I want to be in ketosis. So many of them, as I start with them, they have sarcopenia, osteopenia, even osteoporosis, and I don't want to go there. But what I really learn again and again, but really learn from reading your book, is I need to put them in that calorie restricted, extreme kind of diet. Even using fats, I may not want them to stay with after the first month or so to get them into ketosis. Because once your son was in good ketosis, or once my patients are in good ketosis, it's easier at that point to add back in protein, a little bit more protein than it is to say, no, no, stay with your protein. I don't want you to waste away and then never see them get into ketosis. And I think this is a really good reminder for me that I need to be a little bit more generous with dairy fats, which usually I don't ask my. I ask my cognitive patients to avoid because they're apoe four and that's not really great for their blood lipids and coronary calcium score.

[00:35:58.860] - Dr. Gordon

But in the first month, more cream, less protein, less calories. I think I'm going to regroup on my planning because for many of them, when they don't calorie restrict. It takes a really long time and a skillful person to get into ketosis. And some people really don't seem to be able to do it.

[00:36:20.620] - Miriam Kalamian

But yeah, and I think you have to like it. People get into like one state and then they want to just stay there. They don't realize that this needs to change over time. And in the beginning they might be making beautiful ketones out of their body fat because they are either on purpose or inadvertently calorie restricting. Because when you cut out over half the calories that are coming from in the diet that are coming from these carb containing foods, and for quite a few people, it's quite a bit more than half their calories. If you don't replace that with fat or protein, they are going to lose weight. Well, we don't. Unless they've been living as a vegan, we don't really want to. Quite often, we're dialing back on the protein rather than adding more protein, at least in the beginning. But you have to change this up over time because what you're seeing in the beginning with those high ketones, like I said, it's coming out of the body fat. It's not really that their bodies have made a great transition. They're just in this semi starvation state making great ketones. But it gets to a point where instead of calorie restriction, you got to think about calorie control.

[00:37:30.720] - Miriam Kalamian

If I use the tools that I use quite often, the calories, if they're staying with a low carb diet, the calories look a little low as far as maintaining their mass. And then people worry about their metabolism dropping. This doesn't seem to happen with the people that I can help manage over time. Because what I'm going to be looking at, like you said, especially since so many of the people I'm working with have systemic cancers rather than like a brain cancer, is a whole different ballgame. So systemic cancers, and they're older. So they're dealing with everything that you've said about older, you know, older people, and they're dealing with that and then trying to make this massive switch in their food choices, man, they need a lot of support in the beginning to make this kind of a change. And it also, it's a mental thing, because if they have come to us through their research, they may now be afraid of a whole list of foods. I mean, there's some things I want them to, like, never have in their lives again. But there's other things that I think they're being unrealistically fearful about.

[00:38:44.990] - Miriam Kalamian

And one of them, like I said, is dairy. So dairy fats, I don't like to see them with people who have hormone sensitive cancer, but somebody with a brain cancer, why not use dairy fat? It's very easily digestible for most people. And maybe you have to ferret out who has food sensitivities. We all kind of develop some amount of that as we get older. The dairy proteins can be an issue here because they do elicit a release of insulin that's independent of a rise in glucose. I try to make that point with all my clients. It's very anabolic stuff. It's meant to turn a baby calf, little tiny animal, into a huge animal in a short period of time. Of course, it's got anabolic potential here. Let's keep it at a minimum.

[00:39:33.500] - Dr. Lemanne

Tell us a little bit about fasting and how you use that. I use fasting, for instance, to jumpstart the development of ketones. So a person can fast for 24 to 48 hours, usually for most people, and it depends on youth a little bit, or metabolic youthfulness. Anyway, usually by 48 hours, we're developing a nice ketone crest, but, and then we can slide into the ketogenic diet. And I've heard you talk about that, and I've also heard you talk about how you love to get people into ketosis first to preserve their muscle, their lean mass, before you start any type of fasting. So tell us a little bit about how you the art of using fasting in your practice.

[00:40:22.910] - Miriam Kalamian

Yeah, so some people come to me and they've already done the fasting, and they may be okay with it. They may have lost a little muscle mass, but maybe they've gotten it back since then or now they could be really depleted. So we got to look at how much of this, and I always ask that question, how much of that they're doing. But there's all kinds of fasting. It's not just water, only fasting. You can do a modified fast with, like, bone broth or vegetable broth. You can, you know, add some ketone salts in there. And I think these ketone supplements have been an incredible boon to us in terms of being able to get people into ketosis in a more gentle way. It used to be that people, as they made that transition, they would experience some horrible, what we call keto flu. I see less and less of that over time, except for people who are older, heavy, have a lot of other metabolic issues, and maybe I'll see quite a bit of that until their body.

[00:41:19.550] - Dr. Lemanne

Exogenous ketones to deal with the keto flu. Let's talk about that. That's something new to me. Tell me about that.

[00:41:26.020] - Miriam Kalamian

Oh, okay. So a lot of keto flu could just be this sudden drop in insulin. You're not making insulin anymore, and that does. Well, you're not making much because your body doesn't need it. Insulin is secreted in response to the carbohydrate. And if all of a sudden you don't have glucose in the bloodstream, you don't have the need for that stimulation. Pancreas to produce insulin. So when insulin drops the kidneys, it changes the way that the kidneys handle sodium. So you flush sodium. So that's the initial diuretic effect of moving into ketosis is this. And that's. And you'll see some beautiful ketones there when that happens, too, because that concentrates them, too, as they lose fluid. So anyway, you got that going. You got that part going on with the early stages of fasting, and that when you flush out the electrolytes, it's not just sodium. You're also flushing magnesium and potassium. You actually can get a little dizzy. The dehydration, you know, as doctors, medical doctors, what dehydration does? A drop in blood pressure, especially if somebody's on blood pressure medication, and now their blood pressure might be too low or somebody's right on the edge of normal, and now their blood pressure might be low.

[00:42:43.940] - Miriam Kalamian

So ketone salts. I prefer salts over using esters for this application. So I use different things for different purposes. But for this application, I like the ketone salts because the one that I go to most frequently is really high in sodium. You're replacing sodium at the same time you're giving some exogenous ketones. Their body doesn't have to learn how to make them just yet if you're giving them in that way. And that does protect the brain having them on board, because early on, the cells don't have as many of these transporters for these ketone bodies.

[00:43:24.280] - Dr. Lemanne

So do you start the ketone salts at the same moment that they start the transition to a ketogenic diet?

[00:43:31.190] - Miriam Kalamian

And what if they're doing it with the fast?

[00:43:32.700] - Dr. Lemanne

What do you use and what doses? How does that look? And do you taper them off?

[00:43:36.790] - Miriam Kalamian

Yeah. If they're going to start with a faster, if they're doing fasting around chemotherapy, then I am going to recommend something called ketostart, because I trust in how it was manufactured.

[00:43:48.320] - Dr. Lemanne

Keto start?

[00:43:49.340] - Miriam Kalamian

Keto start, yeah. If you're familiar with Dom D'Agostino and his wife, Chile Chillo, is the one that has really put that one, that particular product out there. But Dom is the guy that brought this, the whole ketosis, exogenous ketones, kind of forward. So anyway, so this ketone salt is high in sodium, but it's like 1 gram of sodium, approximately. And it's also about that in calcium as well. And then a minor amount. Yeah. For a sachet. And it's pleasant tasting. And so it's a powder, and you.

[00:44:27.430] - Dr. Lemanne

Mix it in water?

[00:44:27.970] - Miriam Kalamian

It's a powder, yeah.

[00:44:28.960] - Dr. Lemanne

Okay.

[00:44:29.760] - Miriam Kalamian

So I recommend that somebody use half of a half of one of those sachets, and they mix it in a full liter bottle, and then they sip on it while they're going through this fasting. And then. So it's supplying them with some sodium, which is replacing what they. What they're losing through the fast. But it's. It's also giving them these. The key. It's ketone salts. So.

[00:44:53.380] - Dr. Lemanne

So a half a sachet per day, mixed in a liter of water, and sip on it throughout the day. During.

[00:44:59.590] - Miriam Kalamian

Yeah, if you're. You can do half in a bottle, sip on it in the morning, and then do another half in the afternoon. So you can do it that way because. And some of it depends on where they're starting with the sodium levels. So a lot of people with brain tumors, I don't know if you see this or not with other cancers, but I know with brain tumors for sure, their sodium is often quite low.

[00:45:24.070] - Dr. Lemanne

So. Yes, yes. So, of course, all of our listeners, please don't do this without checking with your doctor and making sure that this is something that's right for you. Are there any blood tests that you recommend that need to happen along with this, or is this something that people can typically do with their doctors, but they don't have to check a frequent blood test?

[00:45:49.550] - Miriam Kalamian

You know, whether you eat or choose not to eat unless you have some underlying other health issues other than the metabolic stuff, I think it's really okay to do it. I don't think there's any harm in somebody taking half a sachet of a ketone salt, whether or not they are in ketosis or even following a regular, you know, just a regular old diet.

[00:46:14.760] - Dr. Lemanne

So are these prescriptions, or are these something you can buy over the counter? Okay, so they're over the counter. Okay.

[00:46:19.870] - Miriam Kalamian

Yeah.

[00:46:20.180] - Dr. Lemanne

All right.

[00:46:20.470] - Miriam Kalamian

I think they're still being sold mostly as sports supplements because they can't be used to treat. And as far as following people with labs. That's not my job. So I am not a medical doctor. I'm the nutrition person. But I still want to look at labs because I want to see what's their baseline. Here.

[00:46:40.300] - Dr. Lemanne

I will do medically supervised fasting, and I'll check daily electrolytes, uric acid, calcium, some, you know, various labs, and creatinine bun for hydration status. Anything that I think is pertinent will do. Glucose, and I'll check their blood pressure every day. They'll usually check into a, you know, if they're coming from a distance, they'll check into a local hotel, and I'll actually go there and do this physical exam and get the blood drawn and those kinds of things. So, yes, with a full. And these are for multi day fasts. So, you know, five to seven days of water only, no calories. In a medically supervised situation, medically supervised.

[00:47:23.240] - Miriam Kalamian

Is the key here when you're going to do a fast like that. And there are people that I felt were too fragile to be doing this on their own, and I pretty much have told them that they need to work with you on that because you do order the labs. Even if they're not, it's my understanding you can still order labs for a lot of people, or they can go to like a quest lab and then share that information with you.

[00:47:45.670] - Dr. Lemanne

Around here, we now have mobile phlebotomy. So for $50 or so, you know, a phlebotomist will come to your house or hotel room and draw the blood and deliver it to the hospital or the airport, wherever it needs to go. That's the base rate. There might be a little bit extra if the airport's farther away or it's an odd hour or something. But, yeah, so that's been a big change and been really helpful for, for people who need and want to do that. But yes, when you're doing these, really, you know, I tell people these are a type of operation. We're operating on your molecules and cells, but these are medical operations. And so you want to be respectful of the process, get the supervision that you need.

[00:48:28.660] - Miriam Kalamian

If somebody has a history of atrial fibrillation, those kinds of things are really more susceptible to getting triggered by the drop in electrolytes and the dehydration. So that's a person that I'm not going to ever suggest to do a fast outside of supervision by a medical doctor. People run into problems doing this stuff. If they have the underlying medical issues, they get dizzy. That is a risk factor for falls, and you can do some serious damage with a fall, especially when they're elderly. I remember somebody who, she was elderly, and she took a fall on the stairs. This had nothing to do with me. I hadn't suggested she do anything. This is prior to me meeting with her. And that's a pretty serious thing for a woman in her eighties to be attempting this on her own and having that kind of an accident. So, yeah, with our son, it still, it was terrifying because I really, the only people that there was nobody out there to help us at that point. So we were basically just using the book. And I had thankfully, thankfully, thankfully connected with two women that were the moderators on a Charlie foundation forum for families who had their kids on what's called a modified Atkins diet, which is big in the epilepsy world.

[00:49:57.330] - Miriam Kalamian

It's less, they've, they have learned over time there as well that in a lot of cases, kids don't have to be calculating stuff out to the second decimal point. They can live with this modified atkins, which is basically keeping carbs low but not micromanaging the protein or fat intake. And for the kids that this is successful for, it's a lot easier on them and it's a lot easier on the families as well.

[00:50:23.140] - Dr. Lemanne

The Charlie foundation is a fantastic resource. You mentioned protein. I think your thinking has evolved on protein over the years. In your 2017 book, Keto for Cancer, which is a fabulous book. Everybody, please read this book, absorb it, read it again and use it. It will really help you understand the whys and also the hows of the ketogenic diet in malignancy and how best to make it work for you. In there, though, you talk about how, at least in brain cancer, your opinion then, and maybe it still is, is that the lower the protein, the better. That protein may be problematic in brain cancer. Talk to us about your thinking on that and whether that's changed and why you think what you think.

[00:51:14.220] - Miriam Kalamian

It's absolutely changed. And there is in that book, and most people miss it. There is a sidebar. It's a full page of who should not be restricting to that degree in protein. But people don't read that. They read the text and they don't, like, refer back to that. So I have written another book, but it's not out there yet. It's more of a quick start guide, and I make much more of a point of it right within the text of it. And I also, like you said, my thinking has evolved, and we have these new tools. If we need to boost ketosis we have ketone salts, we have ketone esters, like, prior to radiation or hyperbaric oxygen. We can use an ester that really boosts ketones. We got MCT oil, and there's, like, bazillions of that choices out there. And we even have emulsified MCT oil for the people who can't tolerate regular MCT. And that's quite often it's older people.

[00:52:12.710] - Dr. Lemanne

So what you're saying is that we don't have to be as careful in limiting protein because we can still raise the ketone level. And that seems to be the secret sauce. So tell us, why did you write that one sentence in your book about, in 2017 about brain cancer? And how has your thinking changed? Maybe it's just the additional ways to raise the ketone levels, those tools. But what made you think that in 2017?

[00:52:40.770] - Miriam Kalamian

I was still running off the epilepsy model because there really hadn't been a whole lot prior to that. So the epilepsy model keeps protein really low. So I was figuring it at 0.8, to get technical, it was 0.8 grams/kg of lean body mass, which is really hard to estimate in people. And there's rarely. I'm not going there anymore. I'm not even going to one. I'm mostly starting people at 1.2 grams/kg of an estimated lean body mass. But I quickly want to move them up 1.31.41. .5 and then part of that. I mean, if you look at the work of Stuart Phillips and his excellent paper on anabolic resistance in older adults.

[00:53:32.180] - Dr. Lemanne

Oh, talk about that. Please talk about that.

[00:53:33.930] - Miriam Kalamian

Oh, my God.

[00:53:34.430] - Dr. Gordon

Yeah.

[00:53:34.750] - Miriam Kalamian

So I will share that with you, if you.

[00:53:38.430] - Dr. Lemanne

If you please send that paper. And I will put it up on our. On the website for this podcast or our listeners. Listeners can look at it, too.

[00:53:46.200] - Miriam Kalamian

Okay. So, again, none of this was really explored or known at the time I wrote my book, and I wrote it in 20 1617. So anabolic resistance refers to the change in the ability over time for older people. Deborah, you're very familiar with this. To be able to build muscle mass or even maintain what's considered normal in aging is that we're going to just like, we're going to lose it either quickly or we're going to dribble it out over time. And I certainly saw that with my mom. I mentioned that earlier before we started this is that I watched my mom deteriorate from the age of 90 to 95, and that was sarcopenia. She died at 78. There was just nothing left I mean, she died at 95, at 78 pounds, because there was just nothing else left on her body at that point. So with that in mind, it's a change in the number and the quality of the enzymes we're producing within the muscle tissue and the signaling that goes on that's anabolic rather than building, rather than catabolic, which is the disintegrating part of it. What Stuart Phillips hits home is that for older adults, and he's talking about over 60, that they need to have a couple of boluses of protein, and one of them really should be before noon, because we are much more, our bodies are much more able to utilize these nutrients earlier in the day.

[00:55:32.360] - Miriam Kalamian

We become more insulin resistant. Everybody does towards evening. So to get that bolus of protein at least before noon, and he's talking 25 grams at a minimum for women and 30 grams at a minimum for men. And then given the amount of time it takes for the body to utilize that protein, then you give it another bolus of protein probably about 5 hours or more later. So his way of approaching it, which is not cancer specific, is to do that in the morning and then to do it in the evening meal. I try to discourage people from taking a lot of protein in the evening meal. If they're dividing it into two meals, we're going to put more of it into that first meal. And we're going to kind of insist on something in the middle of the day so that we can keep protein in the evening meal at like 25 for women or 30 for men. But we're going to.

[00:56:25.770] - Dr. Gordon

Why do you want to keep it so low in the evening?

[00:56:27.780] - Miriam Kalamian

In the evening? Oh, thank you. Because I kind of skipped by that, because it takes longer to digest protein. So you go to bed after like 2 hours after a meal that has protein, you're still in the process of digesting it. So first of all, that's putting a stressor on the body. Our bodies are not really, our circadian rhythm does not support that. We have, like I said, more insulin resistant. Actually, the melatonin we produce makes our bodies more insulin resistant overnight. And that is like a feature that has protected us over our years of evolution, but it's not really helpful for cancer because you put all those protective.

[00:57:09.400] - Dr. Lemanne

Tell our audience how melatonin secretion and the resultant insulin resistance from that is adaptive over time, over millennia of evolution.

[00:57:21.120] - Miriam Kalamian

Well, we didn't have the excess in nutrients until very recently. Humans didn't exist. 70% of humans were not overweight or obese. So we didn't have all this nutrient storage on board. So we went to bed with. We went to sleep with whatever we were able to scrounge during the day. And so that protects us from getting. From our glucose getting too low at night to make slight diabetes.

[00:57:50.520] - Dr. Lemanne

So it prevents that dip in glucose overnight. That might be harmful.

[00:57:56.480] - Miriam Kalamian

Yes.

[00:57:57.480] - Dr. Lemanne

Okay.

[00:57:57.940] - Miriam Kalamian

Yeah. So if you eat too close to bedtime, you're still digesting that meal, and you're putting all these nutrients into the bloodstream at a time where there's no competition. So the normal cells are like taking a nap, taking advantage of this downtime. And the unhealthy cells are sort of driven at a higher, I guess, metabolic rate would be the term for it. So they're, you know, they want to multiply, so they're going to drag the nutrients in, even though that's not what's going on in the normal cells. So to support the normal cells without inadvertently feeding the cancer cells, just move that meal up. And I use the term that I learned from you, dawn forks down, every client, it's forks down at least 3 hours before bedtime. And I wore one of these little cgms to test that the first time I wore one of these cgms, continuous glucose monitor. I ran my own little experiment. I had a normal, for me dinner 2 hours before bedtime. My bedtime number was where I expected it to be. What I didn't expect was that my glucose ran close to 100 all night, which was like, what?

[00:59:17.620] - Miriam Kalamian

My glucose never looked like that in the daytime, but this is what it was doing overnight.

[00:59:22.110] - Dr. Gordon

Interesting.

[00:59:22.720] - Miriam Kalamian

So, the next night, the same exact meal, 4 hours before bedtime. And my glucose was like low seventies to low eighties overnight, which is where I would expect it to be. So, yeah, that was a wake up call. And I do encourage all my clients at some point, not right in the beginning, but at some point, to wear a continuous glucose monitor, see what's happening when you're stressed.

[00:59:47.750] - Dr. Lemanne

Those are becoming over the counter now, I think.

[00:59:50.750] - Miriam Kalamian

Dexcom. Dexcom this summer says they're going to have one over the counter. I have a lot of canadian clients that can already buy it over the counter. And globally, people can quite often get them a lot easier than we can here in the states.

[01:00:03.360] - Dr. Lemanne

I encourage all my patients who are interested in such things to use continuous glucose monitor, at least for a month or two, just so they get a feel for what their blood sugars do with these various maneuvers. So, an early supper versus a late supper, a late breakfast versus an early breakfast, and more calories in the morning versus the biggest meal at night, those things make a big difference for a lot of people. And seeing it is really helpful and helps people really understand why they want to follow these rules that might seem rather arbitrary. So I think an early supper is really important, and it's much more powerful than a late breakfast, metabolically. And, you know, so if you're going to do a long overnight fast, if you're going to do it by skipping breakfast, yeah, I guess that's better than not doing it. But it's not nearly as. It's not as powerful as doing it by having an early supper.

[01:01:02.170] - Miriam Kalamian

Absolutely.

[01:01:03.290] - Dr. Gordon

And as we know now, for brain patients who are coming for cognitive concerns recently identified in the last half dozen years, the glymphatic system, which does the house cleaning of the brain so you can be ready to build new brain cells, only happens with an unfed circulation. So the brain is not processing incoming data and food at that point, and the lymph system can take away the drainage. So all my cognitive patients, I'm going to start using that, although you have to say, forks down and stay out of the cupboard for at least 3 hours before bed. But I'm going to take this opportunity that I'm speaking to sneak in one little question before you go on. This is so interesting about thinking about the anabolic resistance of senior, of older people, my age group, my patient's age group. It's harder for us, our muscles and our bones to get the message to build and without overly stimulating any possible malignancies we might have. And as I've learned from the esteemed doctor Don Lamon, at some point in my life, I've had a cancer, most likely, and my body's immune system has probably been able to take care of it.

[01:02:22.520] - Dr. Gordon

And I wanted to keep being able to do that. So I don't want to over feed any little random cancer cell that might exist there. So, one of the tools we used in cognitive patients is creatine supplementation, and really stress that for patients that it enables an anabolic message to the muscle, even if they're at bed rest and can't exercise. So my question, because I learned from your book about cancer promoting amino acids, where does creatine fall in that category? Am I, is that something that should be taken really, really with food and not, oh, you know, randomly some other time?

[01:03:07.900] - Miriam Kalamian

I think that's an excellent question, and I would love to have an evidence driven answer, but instead, what I did was talk to a number of people who are savvy cancer savvy and asked if they saw any downside to creatine. Because creatine is, I recommend it for all my clients, whereas I don't recommend collagen for all my clients. Even though it has a benefit for people without cancer. I think it has a really potential downside for people with cancer. But creatine and then hmb hydroxymethylbutyrate. So I have a little protocol for people that I share with them. The ones that are, I start earlier than 60 with that. It's sort of if they're in their fifties and they've been in a catabolic state due to their cancer, I really want them to be able to be able to build some muscles. So we also talk about, and this is important, doing the exercise, the strength training exercise. Even if they're confined to a chair, I want to see them make some effort at strength training and then to feed the muscle afterwards, because you're activating the signaling pathways in the muscle that are going to draw some nutrients in.

[01:04:21.380] - Miriam Kalamian

So even if it's less than it would have been in your twenties, it's still something. And by again, you're setting up a competition between the cancer cells and the normal cells. So if somebody's going to like, have some cheese, do it after exercise, let's like, we're not going to have it as a snack while you're sitting and watching tv. It's very after.

[01:04:41.380] - Dr. Lemanne

Are you saying, are you saying that you can get your body muscles to compete with any cancer cells and beat them by exercising and then the muscle cells will be able to grab up all the food and the cancer cells will starve?

[01:04:56.940] - Miriam Kalamian

Yes. So the muscles are going to take up those amino acids that we don't know on an individual level is we assume glutamine is a problem for a lot of people, but it's not necessarily the dietary uptake of glutamine. So you have, when you exercise a muscle, you're breaking it down, you're releasing glutamine into the system, but your muscles are also calling for it. So that's kind of a, okay, it's letting it go, but it's also drawing it back in. But when you, you know, when you eat one client recently, a pound and a half of beef, it's like, that's not gonna, that's not, you're just kind of eating and then taking a nap, that's not gonna work for you.

[01:05:35.730] - Dr. Lemanne

So is it better to exercise before, before you eat that pound and half of beef or afterwards, or both before.

[01:05:43.240] - Miriam Kalamian

And then the after part is you are always going to have a rise in glucose. A little bit of a rise for some people, but a pretty profound rise for some others. Depending on your metabolic state and the types of foods you're choosing, you're going to see a rise in glucose. What better way to get rid of that glucose than by using your big muscles? They are an incredible sink for glucose so that you move those muscles. Take a walk, 15 to 20 minutes. I did that. I've done that with my CGM. I see how powerful that is.

[01:06:15.180] - Dr. Lemanne

Yes, the blood sugar. Just a ten minute walk, I tell my patients, go out for a ten minute walk and watch your blood sugar go down with each step. So should we work out with maybe resistance training, eat our high protein meal and then immediately go for a walk? Should that be the. The schedule that we make for ourselves?

[01:06:37.690] - Miriam Kalamian

And, you know, I realize it's not possible to do that with every meal, but. And you can't do it in the winter, obviously, you can't go out after dark, but at least stay on your feet. So eat your dinner and then use that time maybe to sort through your laundry or load the dishwasher or something. But stay on your feet for a little bit.

[01:06:57.030] - Dr. Lemanne

Don't go into that.

[01:06:59.220] - Miriam Kalamian

Yeah, no naps ever after eating. That's really counterproductive.

[01:07:04.770] - Dr. Lemanne

Talk to us about plant versus animal protein sources. We just talked about a pound and a half of beef. I don't think I've gotten that high, but I have probably gotten a pound in at a time.

[01:07:18.090] - Miriam Kalamian

Without cancer, you can get away with a lot of that. There are people who really do thrive on a carnivore type of diet, but I don't recommend it for people with cancer because I do think, like I said, well, you're putting all those nutrients in and cancer cells, because they're rapidly growing, are going to take more than their, the lion's share, let's call it, of the animal protein.

[01:07:43.830] - Dr. Lemanne

So say I'm going to sit down and eat a pound of pea protein or, you know, some other type of plant source. Is that going to be better for me than eating a pound of animal sourced protein if I have cancer?

[01:07:56.230] - Miriam Kalamian

Great question.

[01:07:56.690] - Dr. Lemanne

Or if I don't have cancer.

[01:07:58.690] - Miriam Kalamian

If you're going to use an isolated protein powder, don't use an anabolic, animal sourced powder, is the way that I feel about it. There is protein.

[01:08:10.930] - Dr. Lemanne

So you mentioned. Are you talking about whey and collagen?

[01:08:14.450] - Miriam Kalamian

Yeah, whey and collagen.

[01:08:15.990] - Dr. Lemanne

Okay.

[01:08:16.470] - Miriam Kalamian

Okay. Pea protein, only about 80% of it is bioavailable because there are things that interfere with the digestion. That's one of the problems with legumes in general. But there is one called plant fusion, not to hawk a particular product, but that one is sprouted. And I heard about that from Rhonda Patrick, who's a great source of information for healthy aging, not necessarily specific to cancer. But I did get that from her. And she's also the person that I found out about, Stuart Phillips. She did this. I found the paper. She did this interview. I'll share that with you, too, because it's great. But what you won't hear is a Q and A that happened afterwards, because the Q and A's that she does are for people who, like, pay for this access, and I do pay for this access. And I was incredibly interested. It was a question that I had what somebody else had asked, and that was, you know, she's interviewed Walter Longo many times, and he's all about plant protein and he's all about this fasting mimicking diet that is plant based caloric restriction.

[01:09:30.270] - Dr. Lemanne

Yes.

[01:09:31.110] - Miriam Kalamian

Yeah. So somebody asked, how do you reconcile what Valter Longo says about plant proteins with what Stuart Phillips is saying about animal source proteins? Because he's talking about, you know, protein quality.

[01:09:47.770] - Dr. Lemanne

So tell us what, tell our audience what Stuart Phillips is advocating. So Valter Longo, of course, is on the vegetarian, more on the vegetarian or plant based? Heavy, plant based. And Stuart Phillips.

[01:09:59.860] - Miriam Kalamian

Stuart Phillips is talking about optimal metabolic health using animal sourced proteins that are high in, particularly leucine.

[01:10:07.790] - Dr. Lemanne

Okay, so the branch chain amino acids.

[01:10:10.930] - Miriam Kalamian

So, you know, we're in two different directions there. How. And somebody asked, how do you reconcile that? And it was a great, it was a great response. She said that. And I'm paraphrasing because I don't remember her exact words, but that Valter Longo was looking at it from a population base. And when you look at population, you're looking at people who are, you know, 70% of us are overweight or obese and are metabolically unhealthy. And this may help them because they might be, you know, might help them to dial back on overall bad eating patterns, whereas Stuart Phillips is looking for optimal individualized metabolic health. And so that's an area that I have to get into with my clients because I do think that an overabundance of animal protein can be too stimulating for cancer cells. So you, you want to be sure you've knocked that back. But so for some cancers, like prostate cancer, I do like there to be a balance. I do like more plant protein, maybe half to two thirds plant proteins and the rest coming from animals.

[01:11:18.320] - Dr. Lemanne

It's difficult to get protein from plants and ketosis because plants are basically made mostly out of carbohydrate. So how. Tell us a little bit about how you navigate that issue. That's absolutely.

[01:11:32.790] - Miriam Kalamian

So with something like prostate cancer, I'm not going for that. 20 grams of carbohydrate and the optimal ketosis. We're not going there with that because I don't see any benefit to doing that to people with prostate cancer. I'm not really sure of what I'm seeing or why I'm seeing it, but my clients seem to do better, the ones with prostate cancer, the older people.

[01:11:57.250] - Dr. Lemanne

And are we talking certain stages of prostate cancer, like early stage people on watch and wait or the active surveillance, or are we talking about people with metastatic prostate cancer?

[01:12:07.610] - Miriam Kalamian

I'm talking about with metastatic. I don't see any benefit in going really rigorous ketogenic. So we're gonna get. We're gonna manage the protein a little differently. And the other thing about advanced prostate cancer is if they've been on these androgens depleting therapies, they're losing muscle mass and replacing it with. They're gaining weight, but it's fat weight, and they're losing muscle at the same time. So, you know, we definitely want them to be able to access their fat stores, but I don't think we. We want to further compromise what's going on as far as their muscle tissue goes. But, yeah, I'm going to encourage them to take in more, a little more carbohydrate and to use some of these other strategies with the ketone salts or, and Deborah, this, for your population, emulsified MCT oil is one of the things that, in Parkinson's world, in the Alzheimer's world, they're doing some of these clinical trials using this emulsified version because it is more readily tolerated and it does boost ketosis, and it does balance out the protein and the carbohydrate intake at a meal. I'm basically going, for most of my clients, they've got at least cover their protein intake in grams.

[01:13:22.540] - Dr. Lemanne

And if we're going to take in grams, if we're going then with plant based protein, we're not going into ketosis as heavily, at least not as heavily using exogenous ketones to get ketone level of.

[01:13:36.180] - Miriam Kalamian

Okay to boost it. But our goal there is for quality of life to stay high and you're not going to be in a good quality of life with advanced prostate cancer if you're combining it with a rigorous ketogenic diet. It's just not going to support your muscle mass and the frailty and the fatigue and all the things that are associated with that kind of depletion are going to take over. So I'm aiming there for the best quality of life for the longest period of time with a more modified ketogenic diet. With brain cancer, prognosis is so poor with like GBM that, yeah, protein restrict because the same. The things that are driving the muscle loss in prostate cancer are not there in brain cancer. There's no systemic or very little systemic effect from the brain cancer. It's all about what's going on in.

[01:14:30.680] - Dr. Lemanne

The head for our audience. The brain cancers like glioblastoma tend to remain in the brain, very, very rarely metastasize outside of the brain. So that's what the discussion has mentioned, this.

[01:14:46.270] - Miriam Kalamian

Yeah, go ahead. I was just saying there's so few treatments, there's like a standard of care. So that's why I am so certain of the benefit for just about everybody with that kind of aggressive brain cancer to do a ketogenic diet, because the.

[01:15:05.660] - Dr. Lemanne

Standard of care gives a 13 to 18 month lifespan. Median lifespan, yeah. I mean, that's half. Half live less than that and half live more than that. It's not average.

[01:15:19.430] - Miriam Kalamian

Well, and a couple of the months that they're, a couple of those precious months are spent dealing with the side effects of the aggressive upfront treatment with six weeks of radiation to the brain.

[01:15:34.240] - Dr. Lemanne

So we have talked about, you know, your experience with your very young son, and he had a hypothalamic issue, hypothalamic obesity. And we've talked about prostate cancer and older men on androgen deprivation therapy. What gender differences, just in general, do you see in implementing the ketogenic diet? So are there differences between how you do it with women and how you do it with men? And I'm talking about adults here, actually.

[01:16:05.900] - Miriam Kalamian

There are not. Okay. There are not any differences in how I do that. It's more cancer specific in what they're coming in with and what therapies are going to be given. Like if a woman is going to be given something called a PI three K inhibitor, it's going to raise their glucose to diabetic levels. And so, yeah, we do have to be more aggressive with lowering their glucose, not necessarily even raising their ketones, just lowering the glucose because the insulin response is going to be feeding the cancer cells.

[01:16:39.870] - Dr. Lemanne

So alpelisib is one of the drugs that does that. The brand name is Piqray, and we have to put patients on three or four antidiabetic medications at the same time. They're on metformin, and. And, you know, as if they have terrible diabetes, which they do for the moment, that they're on this drug, which is supposed to treat a cancer that is glucose avid. So have you been able to control people's glucose with the ketogenic diet when they're on these medications?

[01:17:11.090] - Miriam Kalamian

Not successfully, I have to say. They're on a PI three K inhibitor. We're not going to see them in ketosis unless they are so heavy that they can be so calorie restricted that they're still going to make ketones and lower their glucose in the process. But a lot of these women are on the verge of diabetes to start with, or definitely pre diabetic to start with, so it doesn't take a whole lot, and it's incredibly frustrating for them. So, metformin, great. But a sglt two inhibitor combined with a ketogenic diet, you can get problems with kidney damage. So that's a medical management thing. I'm not a doctor. If they come to me and they're on one of those inhibitors, I ask them to talk to their medical team, see if they can switch off of that particular. Because there's so many options for diabetes, they don't need that one.

[01:18:08.080] - Dr. Gordon

Can I ask you about two more medications? And I'm not thinking of the cancer that you two, so much you're referring to, but just in general, I would imagine, like any medical specialty, a lot of the patients you get on cancer are that 70% of this country that's a little bit overweight, has a little bit of metabolic syndrome, and medications I would use for those people even not getting into ketosis, but I wonder how it would affect their ketogenesis. Are acarbose, which interferes with glucose absorption. And in the gut, have you seen any interaction between acarbose and ketogenesis?

[01:18:51.900] - Miriam Kalamian

I have not had anybody come to me that's been on that, so I'm not familiar with it now.

[01:18:56.590] - Dr. Gordon

And then, one of the prescriptions that patients are interested in now, when they're interested in longevity, and it has mixed results in the metabolic world, or is rapamycin. And have you had any patients on rapamycin?

[01:19:14.670] - Miriam Kalamian

Only one that I can recall offhand, and that was because that was the standard of care for that particular cancer. And I don't remember exactly what that cancer was.

[01:19:23.770] - Dr. Lemanne

That would be kidney cancer.

[01:19:25.270] - Miriam Kalamian

Kidney cancer, yeah.

[01:19:26.520] - Dr. Lemanne

And rapamycin has been used to treat kidney cancer, although that's not a prominent use now, but it certainly is a darling of the longevity anti aging community. But the drug alpelisib, or Piqray, which came up a bit earlier. Yeah, okay, Piqray, yeah, Piqray for breast cancer, causes a nasty little diabetes situation in every patient who takes it.

[01:19:51.090] - Miriam Kalamian

But I still think that they're going to get lower glucose levels, even if they can't get into ketosis, because with sustained insulin, what those inhibitors do is they interfere with the phosphorylation of the insulin receptor, hopefully just on the cancer cells. That leaves more glucose in the system. I'm not really sure. I might be saying all that wrong. But the insulin. You don't want insulin to remain high because insulin is a cancer promoter. On cancer cells, they can be up to ten times the number of insulin receptors on a cancer cell, because they are programmed for growth. They've changed their whole way of being to encourage growth and reproduction. More insulin receptors, more opportunity to stimulate that anabolic response. That's one of the reasons why anabolic hormones in something like dairy, dairy proteins, is going to be an issue for them. And so the other part of that is insulin. High levels of insulin suppress your own ketone production. And then you look at the other factor, which is highly underrated, and that is stress. So, stress, people who wear a CGM can actually see changes in their glucose related to stress. I had an incident where I was driving to a trailhead to go for a hike, and the road had.

[01:21:27.080] - Miriam Kalamian

The road was in terrible shape, uphill one lane, and there had been a fire that wiped out the trees. So I could see over the edge of this thing. I was terrified. I get to the trailhead, my glucose was 145, and that had nothing to do with food. It was 145 due to my stress response, which stimulates the adrenaline I was producing, was stimulating. And cortisol. The cortisol, my glucose to make liver. My glucose to release liver sugar. Let's see. My liver was making sugar and it was releasing sugar at the same time, 145. Anyway, terribly underestimated. That's another thing you'll see with a walk in nature. Walking on the city streets might not. Might get you somewhere, but walking in nature really makes a profound drop in glucose levels. Just meditation, prayer, things that people do for, you know, calm state of mind, calms down, stimulating that vagus nerve, all those things can result in lower glucose level. For somebody who's a high stress person.

[01:22:41.140] - Dr. Lemanne

So you've just outlined a new application for cgMs, continuous glucose monitors stress monitoring. Miriam Kolomian this has been amazing. I think.

[01:22:53.700] - Dr. Gordon

Wait, I have another 2 hours of questions for her.

[01:22:56.780] - Miriam Kalamian

I have questions, too.

[01:22:59.110] - Dr. Lemanne

We have to have session number two with this. We need to invite you back for session number two. If you'll, if you'll come. We'll have a wonderful time. I want to just thank you so much for your wisdom and your knowledge and for your time today.

[01:23:16.170] - Miriam Kalamian

My pleasure.

[01:23:17.290] - Dr. Lemanne

Our audience will be very, very grateful to hear what you've got for them.

[01:23:23.480] - Miriam Kalamian

Thank you.

[01:23:25.380] - Dr. Gordon

Thank you. You have been listening to the Lamon Gordon podcast where docs talk shop.

[01:23:33.850] - Dr. Lemanne

For podcast transcripts, episode notes and links, and more, please visit the podcast website@dockstalkshop.com happy eavesdropping. Everything presented in this podcast is for educational and informational purposes only and should not be construed as medical advice. No doctor patient relationship is established or implied. If you have a health or a medical concern, see a qualified professional promptly.

[01:24:10.160] - Dr. Gordon

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[01:24:22.180] - Dr. Lemanne

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[01:24:36.640] - Dr. Gordon

Again, if you have any medical concerns, see your own provider or another qualified health professional promptly.

[01:24:43.530] - Dr. Lemanne

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[01:25:01.150] - Dr. Gordon

Doc's talk Shop is recorded at Freeman Sound Studio in Ashland, Oregon.