Dr. Aron Choi – The Ketogenic Diet

DHP’s own Ashok Bhandari recently sat down with Dr. Aron Choi to talk about the ketogenic diet and its use in clinical practice. Dr. Aron Choi graduated from Bastyr University in 2014, with a doctorate in Naturopathic medicine. He’s currently practicing in the U-District in Seattle, with a clinical focus on chronic disease, whether it’s digestive, metabolic, or otherwise. He enjoys using diet and lifestyle modifications, like the ketogenic diet, in clinical practice, along with manual therapies and a lot of physical medicine – especially visceral manipulation, which he’s quite good at. He also enjoys practicing what he preaches; he’s an avid long distance runner, and he really focuses on diet, lifestyle, and exercise in his own life as well. (Watch this interview as a video here, or listen to the podcast here).

Dr. Aron, welcome. Thank you for sitting with us. So first off, just basics; what is the ketogenic diet?

Ah, the ketogenic diet. We hear about it so much. Simply put, it’s a way of eating that promotes your body’s ability to use fat as fuel. So if we think of our bodies, we have two main sources of energy: sugar or fat. We’re eating in a way to be able to access that fat as energy, and there are a lot of health benefits to that, which we can go into in a little bit.

Cool. Well let’s just name some of the simple ones. What are some of the simple benefits that people start to notice right away?

So a lot of people use ketogenic diet for weight loss. It’s also beneficial for children with epilepsy, it’s one of the therapies epileptic children might be put on if medications aren’t working as well for them. As an endurance athlete and as someone who wants to improve my cognitive function and my energy levels throughout the day, I’ll use it to make sure that I don’t need to fuel as often, or so I don’t need to have as many goos when I run. And just the amount of clarity I have on the ketogenic diet, it just seems to be a great way to eat to promote overall health.

Very interesting. That’s great, and that is kind of what I’ve heard. It’s starting to get used for a lot of different things now, but it’s been around for a little while, right? It was discovered a long time ago.

A long time ago. I was just actually reading up on this. So the research kind of first showed up in the 1920’s – 1930’s, but there’s actually references back to the Greeks way back. You know, Hippocratic method of things like using fasting and fat diets. And eating higher fats and lower carbohydrates kind of mimics fasting. In the 1920s or so, there was  Otto Warburg, who was studying cancer not just as a genetic disease but as a metabolic disease. He wanted to find a cure for cancer and he won a Nobel Prize for his work. He was friends with Einstein, so he tended to travel in a pretty well-known group of scientists. So, the research has been around for the ketogenic diet for a lot of different things. So cancer, epilepsy, you know bodybuilders started using it maybe a couple decades ago. There’s also research in performance and endurance sports.

So what got you interested in using it? What made it a part of your clinical practice as a tool for treatment?

My interest in nutrition and food started years ago. My mom is a pharmacist, a retail pharmacist, and it was her influence. She always said prevention is the best medicine and nutrition is important. So hearing that from my mom – whose job it is to help people take medications safely & responsibly – her telling me that nutrition is a big deal and has a big influence on health, kind of planted that seed. And it was only probably within the last year that I was speaking at a conference and met a friend – Alessandro Ferretti – who is a nutritionist in the UK. I met him through Dr. Ben Lynch of Seeking Health Educational Institute. He just showed amazing data, amazing information about how the ketogenic diet can be used to treat people’s illnesses and very severe issues with chronic fatigue or genetic issues. With food as that foundation for health. That is determinants of health and that is really the foundation for how we should approach people who are sick. Everything else is on top, you know? If we have a three-legged table, it’s not really going to do so well sitting up right without this, so we need that foundation there before we place other therapies on it. So that was a wake-up call for me say okay, I want to start experimenting with this on my own and start helping people kind of build a stronger foundation to be healthy so that we can help them feel better.

Fascinating. So clearly it’s changed a little bit since its inception back in the nineteen 20’s and 30s or when it was first written about by Dr, Warburg with his theory on cancer metabolism and all that. But what does it look like now? How has it changed, what does it look like in practice?

So maybe we didn’t mention this up front but it’s a lower carbohydrate, higher fat diet. If we think of a standard American diet, maybe 50-60% of our calories come from carbohydrates. Pasta, bread, cereals, a lot of those staples of a standard American diet. So in practice it might be lowering the percentage of those types of foods to maybe 10-15% of total caloric intake. And of course, when you reduce one food group you have to kind of replace it with another. And healthy fats are the way I like to approach the ketogenic diet. So I mean 70, 75% fats, and then the rest is clean proteins.

So it’s not so much just a diet, this is like a lifestyle modification, it’s like a treatment as a clinical tool. So I assume that there are more assessments or tests and specifications to the treatment than just putting somebody on a regular diet?

Yeah, absolutely.  With the ketogenic diet there’s no one-size-fits-all. So there are things you can do on your own, but if someone is using it to treat an illness, maybe they have cancer, maybe they have diabetes or high cholesterol, cardiovascular disease, etc., you want to approach that with caution. There are genetic issues inherited kind of diseases that might preclude someone from doing the ketogenic diet. If they can’t metabolize fat well, we’re not going to put them on a high-fat diet. It’s important to use it cautiously, to use it wisely, and there are assessments and tests. And also, we have to make sure that someone’s history doesn’t prevent them from maybe benefiting from this type of diet.

Interesting. So, we’re saying okay, almost a century that it’s been used in some way or another. What have you seen as far as the trend in popularity or acceptance? Is it gaining some traction in the medical world and the nutrition world or not so much?

It’s funny. I remember my first year of medical school, that was probably 2010. You know, first year medical school you’re learning the biochemistry, physiology, you think you know a lot. And a friend comes along, a college friend, and he’s like, “hey have you heard of the ketogenic diet?” And the only context I had heard of ketones in was ketoacidosis, which is a severe life-threatening condition that diabetics can experience and it sounded dangerous. This ketogenic diet; why would anyone be on this ketogenic diet, you know? It might kill them! But within the last couple of years, like I mentioned, I’m seeing that is different. Ketoacidosis is someone whose metabolism this uncontrolled, they’re severely sick, and it’s probably not right for them and that’s when we need to monitor. But now we’re understanding the wide applications and in health it’s becoming a lot more popular, and it’s actually not as extreme as it sounds. It’s a little different, but now it’s just kind of a way of eating, a way of living that healthy people can use, or people who are not feeling so well can use. And, I think that a lot of the stigma around it is lifting.

Okay, and with that little bit more acceptance and use, has the research kind of followed? Has the research started to show a little bit more about its safety, especially long term, or it’s effectiveness? Are you starting to see that?

Yeah, we’re starting to see that more. We’re seeing the ketogenic diet being studied in different areas. It started with epilepsy, then it was a little bit more working around cancer, then a little bit more work around performance, high-performance athletics, and neurodegenerative diseases like Alzheimer’s and Parkinson’s. There’s more research starting to emerge, and you know, it’s not complete. I don’t think we have definitive answers but there’s a lot of promise around demonstrating safety as something to explore. It’s not the answer, but it’s something I think we should consider strongly for a lot of people.

Interesting. So on that note, what role does something like the ketogenic diet play in the Naturopathic principles? What principles most strongly come up or guide your practice when you’re using the ketogenic diet in practice?

So, for people who are familiar with the Naturopathic principles, I mean it’s really about understanding the whole person, and teaching people how to be healthy; not just giving them something to take and expecting them to follow your orders. I think that’s where I enjoy working with, and helping people eat healthier, maybe by using the ketogenic diet. And the principle that I think that the diet therapies fall under is “Doctor as Teacher.” How can we show someone, how can we empower people to make better decisions around what they eat, to affect how they feel? So I think it’s easy to overlook the fact that “oh, what we’re eating is actually affecting our performance.” It affects your mood; when you come home and you’re hangry, you’ve been eating sugar all day, you know? How do you experience that with your significant other, are you snappier? Are you crashing throughout the day, are you reaching for that doughnut constantly? And coffee? Teaching people to make some decisions around how they eat can really have a lot of ripple effects, positive or negative, depending on what you eat. So how can we teach people how to do that? I’m not there to cut their food and put it in their mouth for them. They spend an hour with me every few weeks, or a month, or even longer, so what are those skills we are going to give people that they can go and implement on their own.

Right. So with using a diet in clinical practice, as a lifestyle modification, I would assume that it comes in pretty low on the therapeutic order?

Yeah, so if we think of that therapeutic order – the different levels of intervention – starting with establishing a basis for health, removing obstacles to cure, then maybe pharmaceuticals and surgery as higher interventions, we might call it a lower level intervention. So it’s a low force intervention, but it doesn’t really say anything about its effectiveness. I think a diet therapy is a low force intervention with very high effectiveness. That’s the way I think about it, and I’d rather use something low force with high effectiveness, than have to get to a point where I have to use a medication, or I have to resort to surgery.

Okay, so going into a little bit more of your actual practice with it, what are the most common conditions that you see that you think, “okay hey this is somewhere  I can use the ketogenic diet?” When does this come up most often for you?

Day to day, I have a lot of people with metabolic syndrome. They might be a little overweight, their cholesterol is little high, high triglycerides, high blood pressure. A lot of these common precursors to some of the top causes of death in the United States. You know, number one is cardiovascular disease, number three is strokes, cancer is up there, diabetes too. So this metabolic syndrome, these dysfunctions in metabolism, using glucose and being able to use fat as fuel flexibly seems to be at the root of a lot of severe illnesses that people are going to eventually suffer from. In practice, using the ketogenic diet we can help correct that high cholesterol, that hypertension, the high blood sugar, and the insulin insensitivity, with very low force and high effectiveness.

Cool. So, this is where it gets interesting for me and I get I get really excited to compare the two, when you look at for example like you said metabolic syndrome somebody walks into a doctor’s office and they get the standard conventional treatment for that how does that compare to the ketogenic diet or naturopathic treatments along with the ketogenic diet as far as the force of intervention. Where it falls on the therapeutic order you know are those even comparable.

I think they are. Well, we’ll compare them. So if someone comes in with metabolic syndrome, they’re gaining a little weight, their waist size is increasing, their cholesterol is high, their triglycerides and their blood pressure is high, what you’ll often see is if they’re high enough you’ll start managing them with medication. So one medication for blood pressure, one medication – statins – for cholesterol, one medication for high blood sugar – metformin for example, and what we’re doing is just addressing symptom by symptom without actually getting to the underlying cause. And in some cases, you have metabolic syndrome and you’re not sick yet, so maybe we’ll wait and see until you’re sick? I mean, what are you waiting for? Or, the patient is left with advice like, “focus on your lifestyle and diet and exercise a bit more.” Okay, what does that mean? So from a Naturopathic standpoint, from the way I like to look at it is how do we re-establish a basis for health, how do we prevent that metabolic disease from progressing to a point where they might need medication. Or if they’re on medication how can we kind of wean them off some of those medications so they are not on them for life. Which is also what I see; people who are on medications are just kind of expecting to be on them for life. I wouldn’t want my patients to think they have to take something, take a medication, which you know they have adverse effects, they’re not harmless. So why would we try to keep someone on them forever if we know that they might suffer some other consequences down the line?

Interesting. So in fact we can actually not only act at a possibly lower therapeutic order or a lower force, but we can actually lower the therapeutic order that is being used to treat them in general. Like you said, taking them off medications or weaning them off. That’s pretty effective, that’s pretty good. And that, like I said, that’s what’s most exciting for me to compare and see that there’s different times when we can use different therapeutics and get wonderful results without a high force.

Yeah and maybe I didn’t share this story with you. One of my patients who kind of had this metabolic syndrome picture: mid-forties, busy guy, works in finance, travels a lot, ten days a week on the road. You know, wife and two active children. They’re living a good life but also very busy life. And he came in with these medications and we discussed the ketogenic diet and he was fully committed, he didn’t want to be on medications forever. He used to be a triathlete swimmer and maybe let himself go a little bit and so we made some changes. One of those changes was making some changes to his breakfast. He ate cereal every morning since he was in college, and we made some changes in terms of what he was eating. So he started eating lower carbohydrate – higher fat meals for breakfast, and in a couple months he lost nine pounds. He had not been sleeping well for a long time and he started sleeping better. He had some other symptoms that maybe were just kind of bugging him and there was no clear issue, but those kind of went away just by making simple but effective lifestyle diet changes.

Fascinating. And like you said it’s simple. And that leads into what I wanted to talk about next. What’s the purpose of going and seeing a Naturopathic doctor or anybody who’s an expert on the ketogenic diet instead of just going on Dr. Google and just starting the ketogenic diet on your own? Are there risks involved in doing that?

When I think of medicine or therapies to address a specific problem, there’s always some amount of risk. If someone’s considering the ketogenic diet for a health issue like diabetes, high cholesterol, or maybe they had some cardiovascular disease; you want to work with a doctor to make sure it’s right for you. We want to make sure we don’t compromise your health if it’s already a little bit compromised. You want to make sure your cholesterol isn’t skyrocketing because you have some hereditary issue that kind of precludes you from eating a high fat diet. We don’t want your diabetes to be uncontrolled while you’re making some of these changes. So maybe your insulin level – if someone is dependent – they might need to reduce their insulin dose because they’re becoming more insulin sensitive. Or their blood sugar isn’t as high as it used to be. Or with blood pressure, if someone’s blood pressure is dropping and they keep the same dose of blood pressure lowering medications, their blood pressure might drop too low and then you have issues. So when we work with someone who’s trained to think about these things, monitor these things, then you can be rest assured that you’re approaching it as safely and effectively as possible.

Okay that’s great. So here’s where I want to give you your chance to kind of jump on your soapbox a bit and give your top health tips. Basically what I like to call the “3 top three.” So the first three is three things that you want every patient to avoid or you would tell every person to just avoid to maximize their health.

I would say the first is stress. You know, largely I think it’s psychological and emotional stress. You’re working 24/7, thinking about work all the time, feeling anxious, reading the news, you know, which is often negative news. And that can really affect not just your emotional health but your psychological and physical health as well. Stress also includes physical stressors, you know: Are you sitting too much? That’s a physical stress. Are you eating poor quality food? That’s a physical stress. So removing the biggest sources of stress in your life to help your body actually do what it was designed to do, and be healthy and to feel healthy. Along the lines of a ketogenic diet, if someone’s not ready to jump in all the way, one of the simple things – maybe not easy – is avoiding processed sugar. Processed sugar in tiny amounts is fine but I think it’s just we are eating so much sugar without even knowing it. That protein bar, you know, I used to eat a lot of Clif bars, like yeah these are energy health bars! And you look at the back, and it’s like 25 grams of sugar, which is maybe like half a can of soda worth of sugar. Just for reference, a can of soda is like nine teaspoons of sugar, which is a lot. And you might not even realize you’re eating that much. And we know that having that much sugar affects your weight, it affects your mood, it’s inflammatory. So avoiding sugar in any appreciable amount will make a big difference. The third thing to avoid is highly processed oils. So people are thinking, “oh the ketogenic diet, it’s a license to eat fried foods or all the bacon and all those goodies that I really love.” You know, donuts, whatever. However, highly processed oils; canola oil, vegetable oil, corn oil, soy oil, which are found in a lot of processed foods these days. It’s like putting damaged fats into your body and just asking for inflammation. If we think of ourselves, the cell membranes are made from fatty acids. Do you want damaged building blocks making every cell in your body? Probably not. So I say avoid processed oils, and start thinking about how can I eat higher quality fats. From avocado’s, coconut oil, virgin olive oil. Things that aren’t fried to death!

Okay cool three things to avoid, that’s great. So the next is three things that everybody should do on a daily basis. Three daily practices for balance in daily health.

I like how you say daily habits because habits are kind of the foundation for how you feel. So the first habit I think is movement. Starting your day with 15 minutes of walking, maybe it’s going to the gym. Just get the blood flowing, get the heart pumping a little bit. And we know that when you move it kind of increases your brain function and insulin sensitivity, it’s also relaxing, a little stress reliever. So when you start the day taking care of yourself, I think the rest of the day starts feeling like things kind of fall into place a little more easily. So the first tip is start exercising in the morning. Number two: getting enough sleep. That’s an underrated kind of health enhancer and performance enhancer. We think that “oh we have to work harder,” but when does your body actually recover? When does your body actually repair and build? It’s when you sleep, and we know sleep is really important. If we think of people who work the night shift, they have higher risk for heart disease, they have higher risk for depression, and they have higher risk for just all cause mortality. So sleeping, it’s a good habit. Seven-eight hours, and everyone’s a little different. But start playing around with that. The third thing to incorporate is community. Surround yourself with people you would like to be like and that you enjoy being around. If you’re trying to eat healthier, you’re not going to go hang out with people who are… I can’t even think of a good example, you know not to demonize anyone. But if you want to eat healthy, you hang out with people who enjoy eating fresh foods, where it’s normal to eat healthy, and then you’re more likely to eat healthy in return. Or if you want to exercise more, hang out with people who exercise. I wanted to be a runner or I wanted to run more, and I started running with a group, for which it was normal to run every day at 5:30, 6:00 a.m. And it just becomes kind of normal because everyone’s doing it.

Okay great. So last thing: three things for optimal health in general, or three tips for overall good health.

Yeah, so if we think of the habits, I think the first thing is establishing some type of routine that is healthy. It’s not doing it all at once. So if you feel like you want to make some changes with your diet and you want to be a little healthier, you want to exercise a little bit more; you’re setting yourself up for failure if you try to do it all at once. So pick one thing, maybe it’s your sleep. Okay, I’m going to start turning down the lights an hour before I go to sleep, I’m going to turn off my phone. Or, I’m staring at Netflix for an hour and watching The Walking Dead wondering why I’m having anxiety at night, it’s like okay maybe there’s some things you can do to help yourself sleep better. So it’s establishing one small habit that you can start making that first step towards that health goal. One small step. Number two for optimal health; start by identifying what is my biggest source of stress. It’s different for everyone. Maybe it’s a relationship that’s been just kind of hanging over your head, how can you start creating something a little more positive around that. If it’s too many bags of chips, you know I use that example because that was mine. When I started in medical school I found myself eating entire bags of kettle chips at night because I was essentially dealing with stress. And that carried on for a long time. So that was my source of stress and how I was dealing with it. And once I started removing that from my life, I started feeling a lot better. Odd. The third thing for optimal health, I think this is kind of underrated for stress, and it’s at hydrotherapy. Whether it’s taking a hot Epsom salt bath, finishing with a cool shower. It gets the circulation going, it’s calming, it’s relaxing. I think people need a few more baths, you know? I’m not afraid to add a little lavender oil, light some candles… okay maybe no candles but you know, creating a mood to where you can relax, where you can have personal time. So those are kind of three practical things I think you can start doing for optimal health.

That’s awesome. I love doing these little segments of getting everybody’s tips because I feel like I have this big journal of all the good things I can do for my own health now every time I talk to another doctor sitting here. So that’s great! So Dr. Aron, I know that people are going to watch this, I know people already talk about the ketogenic diet and they’re going to be interested. They’re going to want to know more and they’re going to want to know more about you and your practice, maybe follow that a little bit. Where can people go, what can they do to learn more about it?

I actually created a seven-day keto breakfast challenge for this very reason. What’s that first step someone can take? So I created a small challenge, it’s totally free. There are recipes that people can access, and videos of myself and my partner, chef Heidi, who came up with the recipes, talking about the ketogenic diet. So you can go to my website, www.aronchoi.com/keto-challenge. Or just www.aronchoi.com to see what I’m up to. I write blog posts and I kind of do that regularly, so if people are interested, that’s where they can find me.