Podcast – Food For Thought with Dr Helena Popovic

Voice Over:

The Dementia Researcher Podcast, talking careers, research, conference highlights, and so much more.

Dr Sam Moxon:

Hello everybody and welcome back to the Dementia Researcher Podcast and to our sideshow Food for Thought, where we talk about the best evidence-based diet and lifestyle changes you can action today to reduce your risk of developing dementia. My name is Dr. Sam Moxon. I’m a regular blogger here at Dementia Researcher and Helena Popovic, welcome to the Dementia Researcher Podcast. How are you today?

Dr Helena Popovic:

Very well indeed, Sam, thank you for the invitation.

Dr Sam Moxon:

Oh, good. It’s good to have you on here. So obviously this is, we call this the Food for Thought series where we talk about the impact and the power you can have to, I think, shape your future health based on the things that you put in your body. And so, the first question I actually like to ask we, and I might throw you a little bit off here because I didn’t actually supply this one beforehand, but it’s quite a simple one. It sort of helps gauge the room is what did you have for breakfast today?

Dr Helena Popovic:

I have poached eggs at home, and I’ve learned how to make them without the bits of cheap paper, avocado, stir-fried mushrooms, spinach, and zucchini.

Dr Sam Moxon:

Lots of veggies. Lots of veggies. I think I had a very similar breakfast except instead of eggs, it was sort of scrambled tofu, but with broccoli, mushrooms, onions, kale, that kind of stuff. Get veggies on the plate early on in the day.

Dr Helena Popovic:

I love stir-fried tofu as well. And for me, I’ve just got to add some coconut milk because that just, or coconut cream even, it just adds that kick and it’s beautiful. Yeah, I love scrambled tofu as well.

Dr Sam Moxon:

Oh, definitely. So, for the people that don’t know you and I think the best thing we can start with is by having you introduce yourself, provide a brief overview of your expertise, especially in the field of nutrition and dementia and the kind of things that you’re interested in, please.

Dr Helena Popovic:

Okay. Well, I’m an Australian medical doctor and I focus primarily on weight management, type two diabetes, and dementia, especially Alzheimer’s. And the three conditions are very much interrelated because midlife, visceral obesity, and type two diabetes both independently double the risk of developing Alzheimer’s. And we also know that brain changes leading to Alzheimer’s can start 20, 30 years before the onset of symptoms. But here’s the thing that’s going to worry people the most. I learned nothing about nutrition in my medical training apart from one lecture on vitamins and minerals. And unfortunately, that’s because doctors are only taught to use drugs, radiation, or surgery as methods of treating diseases. I was really disappointed that I was not taught about the impact of lifestyle choices other than cigarettes and alcohol. And so most doctors, not all, but a large majority of doctors actually know less about nutrition than the average health-conscious member of the public.

And I think it’s important for people to know that because if your doctor doesn’t talk about food as medicine, you walk away believing that it isn’t important. So back to your question about my expertise. I think the benefit of being a doctor is that at least it gave me the training to understand statistics and research papers to interpret data and to recognise whether a study has validity and why I’ve done such a deep dive into all things nutrition and lifestyle is, well firstly, I was a fitness instructor for 20 years and that taught me about the importance of food for optimal physical performance. Then my mother who had never smoked, died of lung cancer, then my father developed Alzheimer’s, and then my partner got throat cancer in succession, not all at the same time. And modern medicine had little to offer any of them. So basically, I had to look at other ways to help them. And what I kept finding in the medical research was the pivotal role that nutrition and exercise, sleep, stress, even our belief system played in keeping us healthy or making us sick.

Dr Sam Moxon:

I think it is fascinating and some of the points you touched on there, especially about not being taught nutrition in medicine. We had a guest on recently, Michael Greger, who’s published a book you may be aware of, it’s called How Not to Die, and he chose his medical school based on the one that offered the most content in terms of nutrition. And it’s still a very, very small amount. Now, what I think is going to be interesting today is I think we both have similar interests, which is looking at the role of diet on not just brain health, but overall health as well.

And we have on the show so far, we’ve mainly focused on people who specialise in vegan diets. And I think what’s going to be interesting is hearing about a different type of diet today, which you talk a lot about the keto diet, and I think in some ways there’s similarities between the keto diet and a whole food vegan diet focusing on fresh foods and that kind of stuff. But in other ways there’s different principles as well. So, for me, it’s going to be really interesting to hear the different perspectives on that.

Dr Helena Popovic:

Yeah. But they’re not mutually exclusive. You can be vegan and keto, you can be vegan and keto. It just takes a bit more work.

Dr Sam Moxon:

Well then let’s start with the first, I think most important question for this then. What led you to explore the impact of that particular diet on specifically dementia risk?

Dr Helena Popovic:

Well, I actually reluctantly came to keto through my partner’s cancer, not dementia. That’s where I started. Unfortunately, I didn’t know about the keto diet when dad had Alzheimer’s and I was perfectly happy eating a low-fat plant-based diet. But when my partner was diagnosed with inoperable throat cancer and he had none of the known risk factors, so no smoking, no heavy drinking, I then discovered the work of Dr. Thomas Seyfried. Now he’s a professor of biology, genetics, and biochemistry, I think it is at Boston College. And his research shows that a distinguishing feature of cancer cells is that they have lost their ability to produce energy using oxygen. So that means they rely on fermentation. And what that means is cancer cells have to rely almost exclusively on glucose and an amino acid called glutamine, but to a much lesser extent, they can only use glucose for energy.

And so severely reducing a carbohydrate intake can effectively starve cancer cells. And then conversely, you need to keep feeding your non-cancer cells as well as you possibly can, and fatty acids and ketones are the best way to do that. So that meant I had to learn about the ketogenic diet and because this was a life and death situation, my partner didn’t have a better alternative. We just had to do it and we had to do it well. So, I became a keto connoisseur pretty much in a matter of weeks. And then because I also had an interest in dementia, I looked at other applications of the keto diet. I mean, the good news is, for the record, my partner has been given all clear.

Dr Sam Moxon:

That’s fantastic.

Dr Helena Popovic:

Yeah, he did have chemo and radiotherapy, but there is no doubt on my mind that the ketogenic diet facilitated the effectiveness of his treatments because it starved his cancer cells, so they were easier to knock off. But then I went deeper into the keto diet, and the more I looked at it, the more applications I found, especially in curing with a capital C, not merely controlling, but permanently reversing type two diabetes, I can get a type two diabetic off their insulin in two days if they go on a ketogenic diet. It’s a cure for recalcitrant epilepsy, especially in children, drug resistant epilepsy. And that’s not debated. It lowers blood pressure, it treats fatty liver disease, I mean cures fatty liver disease. It can even massively improve, if not cure, depression and other psychiatric conditions, migraines, arthritic conditions, and of course neurodegenerative diseases like Alzheimer’s and Parkinson’s.

Dr Sam Moxon:

I think what you said there as well, that really resonates with me because I think without getting too political, I feel like we’ve been conditioned into thinking that this idea that what we eat can have such a profound influence on our health and on diseases it’s almost still seen by many as pseudoscience, but there’s so much evidence out there that it’s not. And type two diabetes is a perfect example of how much power you can have over your health with the things you put in your body.

Dr Helena Popovic:

Absolutely. And I don’t actually view the ketogenic diet as a diet. It’s actually a metabolic therapy, but I call it the ketogenic diet because that’s the popular vernacular. But it creates such profound biochemical changes in the body. It’s almost like taking a pharmaceutical agent.

Dr Sam Moxon:

And I think we need to remember that the whole body is a system. And so, something that goes in your gut doesn’t just stay in your gut and have an effect there. It will affect the microbiome. It will affect things that go into the bloodstream which circulate around and then have a knock-on effect on other organs. And it’s interesting, you talk about how it wasn’t initially rooted in dementia. It was the same for me with the vegan diet. For me, it was about inflammatory bowel disease, and then I noticed that I was feeling more sharp and more aware, and that led me on a path into looking at exactly what the foods I eat were having an impact on in different parts of my body.

And it’s just fascinating to know that I think it’s quite empowering to think that we can have more of an influence on our health. It’s not just genes being destiny. There are situations where, I mean, for me, what I noticed was a similar thing. My medicine that I was taking for inflammatory bowel disease was about 30 or 40% effective. And then when I changed my diet, I went into full remission and have been for 18 months now. So, there is, I think a complimentary role that a good diet can play on conventional medicine as well.

Dr Helena Popovic:

Well, food is not just calories and energy, food is information. You will have heard of the study of nutrigenomics and nutri genetics. So, food actually interacts with our genes just as much as different genes make us respond to different foods differently.

Dr Sam Moxon:

Yeah, there’s a physician called Michael Clapper, I think in his TED Talk talks about it said, he described it as the food playing your genes like a piano, which I thought was [inaudible 00:09:47].

Dr Helena Popovic:

Oh, I like that. That’s nice.

Dr Sam Moxon:

Yeah, it’s nice, isn’t it? Well, let’s get into the specifics then. So, what does the current research say about the relationships? In fact, no, let’s take a step back first. I’d like to know more about the diet itself and what it entails. I’ll jump the gun a bit because I’m very excited by the output of it. But yeah, so if someone wants to follow a keto diet, what does that entail and how is it different to other dietary approaches that people might be aware of?

Dr Helena Popovic:

Well, firstly, keto is short for ketones or ketone bodies. The terms are used interchangeably. But strictly speaking, ketone bodies are ketones produced by our liver in our body, whereas ketones could also include exogenous ketones produced in the lab. But we’re talking about the ketogenic diet. So, we’re talking about the ketones we produce, and ketones are water-soluble molecules produced in our liver when our blood glucose i.e., Blood sugar levels are low, and therefore our blood insulin levels are low. And so, our body has to break down fat for energy because there’s no glucose. And so that process of releasing fat from fat cells, carrying it to our liver and breaking it down into ketone bodies is called ketogenesis, the production of ketones. So basically, ketogenic diet is a way of eating those results in the production of measurable levels of ketones in our blood, which means greater than 0.5 millimolar and the person who’s then described as being in a state of ketosis.

And you can give brief periods of ketogenesis and ketosis through fasting because the ketogenic diet is actually a fasting mimicking strategy. The same bi chemical and hormonal changes occur in our body when we are fasting as when we’re eating a ketogenic diet. It’s just that you can’t fast indefinitely. So, it’s not a long-term option. Strenuous exercise can also put us into ketosis and ketogenesis for a short period of time because it uses up the body’s glycogen and glucose stores. And this is what a ketogenic diet is based on restricting carbohydrates. That is really the basis of a ketogenic diet. So basically, it’s a very low intake of carbohydrates, less than 50 grammes a day, even as low as 20 grammes, an adequate intake of protein and the amount of protein is individualised. It depends on your age, ideal body weight, muscle mass, exercise, and enough intake of healthy fats to satiate you. And we can define healthy fats in a moment.

So basically, where I start with my patients is, and you can start anywhere, but I’ve got seven principles of a healthy ketogenic diet because just like you can have an unhealthy vegan diet, eating lollies, you can have an unhealthy keto diet as well. But I say number one, I start with what they can eat rather than what they can’t because then you don’t miss the stuff that you can’t eat because you’re already full on the things that you can. So, number one, prioritise protein because we need more protein, not less as we age, and I’d say at least 1.5 grammes per kilogramme of your ideal body weight. Then I say, so alliteration, so you can remember prioritising protein, number two, go green, add a variety of leafy green or cruciferous vegetables, three, flavour with fat. Now in nature, protein always comes with fat, whether it’s your soybeans, whether it’s your meat, there’s no food that’s pure protein.

So maybe nature intended us to eat them together. So, I tell people, leave the fat on your meat. This might gross you out being a vegan. Leave the crack on your pork, the skin on your chicken, because fat gives flavour and here’s the thing, you don’t need sugary artificial sauces if you retain the natural flavour of the food. And fat is one way to do that. And fat is not a problem. If you follow my next four principles, which are stop the three S’s. Stop soft drinks and all sugary beverages, stop sugar, and stop starches. And the next one is curbing your carbs. And curb your carbs really means eliminating not just refined starches, but also even what’s traditionally healthy. Because remember, this is a therapeutic intervention. It’s not simply a diet. So that’s why even you need to eliminate for a ketogenic diet to be in ketosis, you even need to eliminate grains, legumes, most, but not all fruits.

Most below ground vegetables such as parsnip, potatoes, and beetroot. But your above ground vegetables are fine, and we can unpack this in a minute, but I’m just sort of giving you the big picture. And then the last two principles, these are really, really important as well. Fast to last. Leave at least 12 hours between dinner and breakfast, preferably longer. So, after your last piece of food for the evening, if it’s 7:00 PM do not have breakfast before 7:00 AM, preferably 14 hours if you can do it, even 16. This helps you get into ketosis much quicker. And last but certainly not least, eat and cook food that is as close to its natural state and possible. In other words, ditch the junk food, fast food, convenience foods that constitute 80% of our supermarket shelves, even if they’re labelled keto friendly, because very often they’re not. So, the first thing you’ll notice is the ketogenic diet doesn’t require calorie restriction.

You can enjoy eating [inaudible 00:15:29]. And because proteins are the most satiating macronutrient and fats are a second, people find they aren’t as hungry. They don’t need to eat as often. And also, because you’re not producing insulin, your fat cells are able to release their stored fat to be used as energy. And so, a lot of people find that they effortlessly lose weight. You don’t have to lose weight, but you can do it effortlessly, which you can’t do if you’ve constantly got insulin on board because insulin locks your fat inside your fat cells. And the last thing about, the other distinguishing feature of a ketogenic diet is you can measure whether you are in ketosis, so you can adjust your carbon protein intake to make sure you’re on track, because if you’re not in ketosis, it’s not a ketogenic diet and it won’t work as a metabolic therapy.

And this is where sometimes you get these stupid headlines that say, ketogenic diet doesn’t work for X, Y, and Z, and then when you read the study, they’re eating a hundred grammes of carbs a day, that’s not going to put you into ketosis, and they haven’t actually tested whether they’re in ketosis. A low-carb diet is not necessarily a ketogenic diet, it’s a low-carb diet. And low-carb diets can definitely be helpful, but it’s still not the same as being in ketosis. So, I mean, I can discuss how to measure ketones if you’re interested. Blood, just a blood drop, breath, or urine, it’s pretty easy [inaudible 00:16:52] by commercial kits.

Dr Sam Moxon:

I think that one of the points you drove home there as well, anytime you see studies on diets and improving health is always that same key principle, which is to ditch the junk, ditch the process. And anytime you see, I get frustrated with this thing sometimes in news media’s vegan diet labelled unhealthy. And you look at what the person, or you see someone on a podcast saying, I ate a vegan diet and I felt terrible, but then you look, I always think, what were they eating? And it’s always beyond burgers, it’s always junk food. Well, of course you’re going to feel terrible if you eat that. So, it’s all about freshness, isn’t it? And it sounds like it’s the same principle here as fresh as possible.

Dr Helena Popovic:

Very much so.

Dr Sam Moxon:

So then what does the current trends and the research say about the relationship between keto diet and dementia progression? And if I could ask as well about the mechanisms behind how this could work and how it might positively affect brain health.

Dr Helena Popovic:

I think that’s a really, really important question. Okay. Firstly, and there are a lot of mechanisms. So firstly, in neurodegenerative disorders of ageing, one of the characteristic features is cerebral glucose hypometabolism. Have you heard that? Dementia is essentially, and so is Parkinson’s and so most dementias and neurodegenerative diseases, they are a state of impaired glucose metabolism. The brain is starving. And it’s interesting that glucose metabolism in the brain deteriorates in a progressive region specific, disease-specific manner. So basically, the brain of a person with Alzheimer’s is less capable of using glucose for fuel, especially in the parietal and frontal lobes, the cingulate gyrus. And the deficit can be measured, it’s as much as 25%. That is huge. So, if the brain has lost a quarter of its energy, no wonder it’s not working properly. And you can see using FDG-PET scans, radioactively labelled glucose, fluoro-deoxy-glucose, it’s a standard test.

You can see how little certain areas of the brain are able to use glucose. So begs the next question, what factors contribute to brain glucose hypometabolism? So firstly, lots, and it can be different factors in different people, but firstly, you might have damage to the blood brain barrier and therefore delivery of glucose from the blood to the brain can become compromised. You’re just not getting enough glucose into the brain. You could have reduced blood flow to the brain, even though the blood brain barrier is okay, but if you’ve got high blood pressure, arteriosclerosis, heart failure, you’ll get less blood to the brain, and you know what’s good for the heart is good for the brain.

Very importantly, brain cells can develop insulin resistance so that even if glucose can reach them, glucose is not able to enter the cells. Now, not all brain cells require insulin for glucose. They don’t. But the regions that deteriorate in Alzheimer’s do tend to need insulin to allow the glucose. So that’s really interesting. So, the insulin resistance is a big factor. Another really big factor is mitochondrial dysfunction, and let’s talk about that in a minute because that’s another big topic, but mitochondrial dysfunction also massively contributes to Alzheimer’s and also neuroinflammation. And that’s because microglial consumption of glucose due to neuroinflammation is elevated. And so, you’ve got energy syphoned away from neurons into your microglia, basically that just leads to an ongoing negative spiral.

Dr Sam Moxon:

It’s fascinating because you’re talking a lot about insulin there, and I’ve heard Alzheimer’s almost be called type three diabetes because of this insulin. So, what’s the mechanism behind how it helps with mitochondrial dysfunction? Does it boost mitochondrial regrowth in cells?

Dr Helena Popovic:

Yes, it does. Couple of things. Number one, if the brain is supplied with ketones, it can use the ketones for energy in place of glucose. And so, you can actually restore the functioning of those neurons. And you can, just like you’ve got FDG-PET scans, you can do ketone PET scans and you can see that the cells can’t use glucose, but those very same cells can use ketones so that ketones are an alternative fuel source when glucose is not available.

Dr Sam Moxon:

Interesting. That’s really interesting.

Dr Helena Popovic:

I mean, you could even say, actually sometimes there are preferred fuel for the brain because if the blood has equal amounts of glucose and ketones, the brain will preferentially use the ketones. So, we’re not a hundred percent sure why, and that’s why a keto diet has actually been termed neuro keto therapy or a brain energy rescue strategy. And you can look up the work of Stephen Cunnane, Sherbrooke University in Canada. He’s shown very, he was one of the first people to show that the brain retains its ability to use ketones even when it can’t use glucose. And the higher the ketone concentration in blood, the more the brain will take up ketones. But the story gets even better because ketones are not just a fuel, they’re also signalling molecules and they have a neuroprotective effect. So, ketones, they’re beneficial to all neurodegenerative diseases because they modulate firstly your central and peripheral metabolism.

And so, by improving insulin resistance, by lowering blood pressure, by reversing type two diabetes, you’re actually removing three big drivers of dementia for a start. So that’s even outside the brain. Secondly, ketones do improve mitochondrial function and mitochondrial dysfunction lies at the heart of all metabolic diseases, even including depression, bipolar disorder, schizophrenia, and mental disorders are also a risk factor for dementia. Ketones also reduce inflammation. They reduce oxidative stress, like fasting, they stimulate autophagy, so they’re clearing up debris and toxins. Ketones even modulate the gut microbiome. And ketones increase the production of BDNF, brain derived neurotrophic factor, which you probably know stimulates the formation of new brain cells and it enhance neuroplasticity. And this is all well-documented in the medical literature. You just have to google ketones and neurodegenerative diseases or ketones and metabolic effects, and you’ll be inundated with studies. So, this is not speculation, it’s all been documented.

Dr Sam Moxon:

That sort of answered my next question, which was about specific studies or clinical trials that are trying to find ways to apply this in patients with dementia. So, is that something that’s underway now as why people are actually looking, clinical trials?

Dr Helena Popovic:

Yes, there are clinical trials underway. They have been. I also just want to say, I don’t know if your listeners will be familiar, that ketogenic therapies, they’re not a new idea. Like using fasting to treat epilepsy was like recorded in ancient Greek texts, 500 BC. But it wasn’t until the 1920s, like exactly a hundred years ago, that doctors discovered that like fasting, a low-carb, high fat diet could stimulate ketone body production. And therefore, a ketogenic diet actually became the treatment for epilepsy throughout the 1920s and thirties, and it was really successful. But when anti-seizure medications came along in the 1980s, a ketogenic diet was phased out because doctors were taught the drugs were easier than what was perceived as a restrictive diet. However, if children have drug resistant epilepsy, the ketogenic diet still remains an effective treatment. What I just find devastating is that almost no doctors offer patient’s dietary management of epilepsy.

And I know that a lot of them, like I go to people, would you prefer a drug, or would you prefer a diet, a drug with side effects, or would you prefer to try changing your diet? 90% of them, okay. Some people go, I can’t be bothered with the diet, just give me the drug. But the vast majority go, well, hell, I’ll try the diet. And especially with children, it’s not as hard as people think. It’s just a matter of getting into a routine. So, I want to quote [inaudible 00:25:19] because I think this is really important. He said that healing arose from the art of true living and the art of fine medicine combined. And unfortunately, medical schools have forgotten to convey half of the equation, the art of true living. But that’s my rant. But anyway, I recommend people look up the Charlie Foundation for ketogenic therapies.

I think it’s just charliefoundation.org. And that was because in 1993 and he was 11 months old, Charlie, he developed intractable epilepsy, multiple daily seizures. He had medications, he had surgery, nothing helped. And his parents finally learned about the ketogenic diet. And within a month he was seizure free, he was medication free. He had to be on the diet for five years, but he’s now like an adult and he can eat whatever he likes, and he hasn’t had another seizure. And then his parents founded the Charlie Foundation to offer hope to other families with children whose epilepsy wasn’t treated by drugs. But anyway, then as we got to fast-forward, probably the best Alzheimer’s and ketogenic diet treatment study was done by Dr. Matthew Phillips. He’s a New Zealand neurologist. He calls himself the metabolic neurologist. So just go to metabolicneurologist.com. And he did, it was 2020, he found that a 12 week, I think it was 12-week study, it was a crossover trial, so they did, I can’t remember the exact time, but they did a low-fat diet compared to a ketogenic diet.

And he’s actually got the whole ketogenic diet on his website, just anyone can download it and do the actual diet for themselves. And he found that it substantially improved daily functioning and quality of life over and above the low-fat diet. And there’s also, I won’t go into all the trials, but look up Dr. Dale Bredesen, Dr. Christopher Palmer, Dr Bret Scher, metabolicmind.org. There’s dozens and dozens of trials underway, and I mentioned earlier Stephen Cunnane. They’re doing a lot of trials and some, because Alzheimer’s is difficult in terms of compliance, and it is difficult with an older person to change what they’re doing. A lot of trials are looking at supplying people with MCT oil instead. Now, can I just rewind a bit? Because I think this is an important story.

In 2004, Dr. Mary Newport, she was a neonatologist. Her husband was diagnosed with early onset Alzheimer’s, he was 54, and within two years, he couldn’t drive, he couldn’t use a computer. He was an accountant. He couldn’t do anything. In 2008, she wanted to enrol her husband in clinical trials of emerging Alzheimer’s drugs. And she came across one that demonstrated positive effects of taking medium chain triglyceride oil. So, she thought, she was a neonatologist, so she knew that MCT oil constitutes 50 to 60% of the fat in coconut oil. So, she went out and bought coconut oil and just started giving her husband tablespoons, two tablespoons with every meal just out. And the previous day, without the MCT oil, he’d scored 14 out of 30 in the mini mental state exam and failed to qualify for the trial.

A few days later, he was scoring 18 out of 30. Now, that could have been coincidence. So, she just kept giving him coconut oil, and she’s written a whole book about this. It dramatically improved his functioning to the point where he could resume some kind of volunteer work. And now, she sorts of started it off, there have been various studies called Brain Energy Rescue, the one by Stephen Cunnane. You can look it up. Brain Energy Rescue with ketones improves cognitive outcomes in MCI. And the reason, and you can just buy MCT oil, it’s not expensive, over the counter. I love the taste of it because I love coconut, the taste of coconut. It tastes like, I will drizzle it into that tofu scramble, into scrambled eggs, drizzle it over vegetables, because I love the mushrooms, it works really well with, I love the flavour, but you can add it to anything you like.

Don’t cook with it. You don’t want to hear it, but you can use, and I wouldn’t go above, say, two tablespoons a day because it can give people a stomach upset if they go too hard too soon, start with one or two teaspoons. But why they work is MCTs, medium chain triglycerides, they’re composed of saturated fatty acids, which are different to the ones in meat. They’re really rapidly absorbed and transported to the liver where they’re converted into ketone bodies, the very same ketone bodies produced on a ketogenic diet. So particularly with Alzheimer’s and dementia, MCTs could be a way of inducing ketogenesis and providing the brain with usable fuel without following a strict ketogenic diet.

Having said that, it’s just that you won’t have consistent levels of ketones. You’ll have the MCT oil, or your ketones will rise, and they’ll drop. And you’re also not going to get all the benefits of restricting carbs and correcting insulin resistance. But it’s certainly, I recommend everyone try some MCT oil, that has Alzheimer’s because you’ve got nothing to lose. In Stephen Cunnane’s study, he found that, they looked at five cognitive domains, they all improved. This is MCI though. So, they hadn’t yet developed Alzheimer’s, but episodic memory, there was executive function language, processing speed, attention, they all improved.

Dr Sam Moxon:

Yeah, you see a lot of interest in today around MCI because that’s probably the best therapeutic window for something like that.

Dr Helena Popovic:

Yes, exactly.

Dr Sam Moxon:

So, I’d like to ask now, so we’ve had all previous guests have been sort of purveyors of a plant-based diet, and there’s also a lot of studies out there that highlight benefits of plant-based diets for brain health. So, I’d like to get your thoughts on how the two compares. Is it the fact that in both the principle is fresh foods and to eliminate a lot of the processed stuff because there are some similarities, but also for a plant-based diet, you are eating more fruits and more beans and [inaudible 00:31:53] as well, so there’s differences to be discussed as well. So how do the two compares, do you think? And how much of it is making your diet as fresh as possible, having a benefit, and how much of it is specific food sources as well?

Dr Helena Popovic:

Okay, if you eat whole unprocessed foods, vegetables, fruits, legumes, meat, fish, poultry, you can be vegan, fine. As long as you’re not eating processed foods, you will dramatically reduce your risk of all diseases. And so that, if you are starting at a good place, if you are still young and healthy, when you start a whole food diet, it really doesn’t matter whether you are, in my opinion, whether you are vegan, vegetarian, omnivore, or carnivore, as long as you get rid of all the toxins in our processed food. And by that, I mean added sugar, vegetable oils, emulsifiers, artificial colourings, flavourings, preservatives, and any chemical designated by a number, that is what is toxic.

It’s not the piece of meat, it’s not the sweet potato. All those real foods are… This is my over. If you are healthy, this is what I recommend. You can eat anything as long as it’s from the land, from the sea, from the sky, or from a tree, not from a packet, not from a tin. If it comes in a box, I’d throw it in the bin. That is my sort of tongue in cheek recommendation. So, plant-based diets are fine as long as you don’t already have some kind of cognitive deficit. So, it’s like this, you eat a healthy diet, you are much less likely to succumb to infections. However, you could still get pneumonia. You can’t avoid everything. You might still get an infectious disease; in which case the healthy diet isn’t going to cure you. The antibiotic is. So, I see the keto diet as like the antibiotic.

You’ve now got an illness, a healthy diet on its own, good sleep, stress management, exercise will all help, but unfortunately will not be enough to reverse a starving brain. You actually need a drug, some kind of pharmacological therapy. And guess what? A ketogenic diet is like a pharmacological therapy. So that’s where I see the difference. The healthy plant-based diet is prevention. So is the ketogenic diet if you want to start it ahead of time. The ketogenic diet is in a league of its own because it has the biochemical effect, like a vegan diet without the keto does not provide the brain, the starving brain with ketones, it does not cure mitochondrial dysfunction. Do you see what I’m saying?

Dr Sam Moxon:

Okay, yeah, I see what you’re saying. Yeah, yeah. And like you said, before we started recording, it’s possible to combine the two. You can do vegan and keto.

Dr Helena Popovic:

Yeah, absolutely. You just eat lots of nuts, avocado, olive oil, tofu. You can do it.

Dr Sam Moxon:

Some of the most delicious foods, actually, I love nuts and tofu and avocado.

Dr Helena Popovic:

Absolutely. And look, just to say, ketones are a medicine, and the only reason people aren’t getting more excited about them is because there’s no money to be made by people changing the way they eat.

Dr Sam Moxon:

The same way there’s big pharma, there’s no big broccoli.

Dr Helena Popovic:

I love that too. That’s excellent. Now, some people who are into this space will say there are ketone salts, and esters on the market. Yes, there are. They’re not as effective as being in ketosis. I worry about the salts because you have to have a lot of them. And the ketone salts can overload you with sodium, potassium, calcium, and the esters are very expensive, and I haven’t tried them, but people say they taste dreadful anyway. So yes, there are ketones. This is exogenous ketones on the market. I don’t recommend them yet, only because they haven’t been studied and only because I don’t want to overload you with salts.

Dr Sam Moxon:

Okay. Yeah, I think that’s fair enough. So, I think there’s one, I wouldn’t say it’s an elephant in the room, but there’s one question that you probably get asked a lot, which is a keto change diet is also associated with high amounts of saturated fat, especially if you’re eating lots of meat, which we’re told is a risk factor for heart disease and dementia. So, my question is, how does this aspect of the diet impact the benefits for dementia and how can you address these concerns? Is it a case of the right fat or the right things with the fat? Because you’re removing all the process stuff. How do you pick apart the argument against it with the saturated fat intake?

Dr Helena Popovic:

Yes, it’s very much a case of the right fats and saturated fat is only a problem in the context of a high carbohydrate diet.

Dr Sam Moxon:

Okay.

Dr Helena Popovic:

And I’ll tell you why in a minute. Like saturated fats, you’ll know predominantly found in coconut oil, butter, meat, cheese, full cream, dairy products, and they’re described as saturated. I think people need to know the biochemistry to understand why they’re not harmful. They’re described as saturated because they have no double bonds, so all their bonds are saturated. That means they’re the most chemically stable of all our dietary fats. They do not oxidise as readily as your monounsaturated fats and particularly your polyunsaturated fatty acids. Now, monos and polys are healthy in the right amounts, but saturated fats are the most stable. They melt at a high temperature compared to monos and polys. So, they tend to be solid at room temperature. And importantly, they don’t react with oxygen because they have no free bonds to grab onto the oxygen atoms.

And they have a lot of really important roles in our body. They don’t just provide us with energy. They’re important components of cell membranes, and they regulate all the traffic going into and out of our cells. So, they affect our cellular functions and they do not clog our arteries. The problem is sugar, not fat. Why? So, you’re going to say, okay, so why have we been told that saturated fats cause heart disease? Doctors made a big fat mistake. It began with a flawed 1950s, I think it was hypothesis by a very charismatic epidemiologist called Ancel Keys. He postulated after, I think President Eisenhower had a heart attack, that saturated fats cause heart disease.

And this hypothesis then engendered a series of very poorly designed studies, biased interpretations, and food companies actually bribing scientists to blame saturated fat for our health problems. And you’d say, why would the food industry do this? To ramp up sales of their vegetable oil and sugar laden products. And as I said, the only time that saturated fats are harmful is when they’re combined with unhealthy additives to create processed foods. And in the last decade, rigorous worldwide research, hundreds of thousands of patients and people have exonerated saturated fats from causing heart disease.

There was a study in 2010, it was more than 300,000 people. It was 11 American and European studies, and they showed that if you replace saturated fats with carbohydrates, you actually increase rather than decrease heart disease. There was a British review of more than 70 studies, I think more than 600,000 participants. There was no association between saturated fat consumption and heart disease. Here’s the thing, the reason that vegan diets and vegetarian diets and low saturated fat diets appear healthier is because a lot of it is healthy user bias. If you are vegan or vegetarian, you don’t just bumble your way into that. It means you have thought about what you eat. Do you know what I mean? People who just didn’t care what they were likely to eat, the hamburgers, not exercise, eat more saturated fat because they were told not to. And I was like, I don’t care. So, if you were health conscious, you made a conscious effort to not just lower saturated fat, but to eat other healthy foods, to exercise.

Most vegans that I know are more likely to exercise, more likely to meditate, more likely to be health conscious, more likely to have a high socioeconomic status, all of which improve their health just as much as their diet does.

Dr Sam Moxon:

Okay. It’s multifactorial.

Dr Helena Popovic:

Multifactorial. So, I think the real damage in our diet is the added sugar because table sugar is fructose and glucose, fructose, actually, when it enters brain cells, it actually drops brain cells energy. And it is one of the key things that causes mitochondrial dysfunction. It causes insulin resistance and the glucose and to eating too much. So, fructose is the real toxic agent because it actually impairs communication between brain cells. So, I say, every soft drink is a bullet to our brain. If you did nothing, just gave up soft drinks and all sugary beverages, including fruit juices because you’re removing the water and the, sorry, you’re removing the fibre. So, you’re getting a big dose of sugar to your liver, to your brain.

So, fructose actually lowers brain cell energy and damages your mitochondria. And excessive glucose, it causes insulin resistance as well, but it can also be converted to fructose. And so excess glucose can have the same effects as excess fructose, and by excess, nobody gets type two diabetes by just eating a plant-based whole food diet. They get diabetes by eating all the added sugary products and refined bread and refined starches in [inaudible 00:42:08] supermarket shelves. So, in the context of removing those things, a saturated fat, saturated fats are not harmful.

Dr Sam Moxon:

It’s interesting as well because that was a big cause of the obesity crisis in America is low fat products, whether you use the fat and replace it with sugar, so people getting too much sugar. So, I think, see, I could speak to you about this for hours, but I think they’ve got two final questions that I’d like to ask you just to help really round this off for the listeners. So, should this be personalised person to person, what’s your advice for somebody who’s interested in adopting this kind of diet? Where should they start and how can they make that transition?

Dr Helena Popovic:

Definitely personalised. It depends, if a person comes to me, it’s going to depend on their goals, their medical condition. And also, the ketogenic diet isn’t hard biologically. People actually, when they get it, it’s not as hard as people think. What’s hard about it is we live in a carb centric, fat phobic world, and it takes a long time for attitudes and practises to change. And the difficulty of a ketogenic diet is the horror that their other doctors and friends are going, oh, that diet’s going to kill you. That diet’s going to clog your arteries. Didn’t you hear? That’s a really dangerous diet. It’s not. So, it’s really social and cultural that makes the diet difficult. It’s not the diet itself. So basically, I actually start with the person’s values and cultural beliefs. So, I unpack their beliefs first, and I start with the low hanging fruit.

I really do start with the processed food first. And I say, let’s get rid of the soft drinks. Let’s get rid of, can you lower your alcohol? Because we know that the healthiest level of alcohol consumption is zero. So, we work through the processed foods first. So, number one, the added sugars. Number two, the vegetable oils. So that means vegetables are not vegetable. You may realise they’re seed oils that have been highly, highly processed, and you probably had podcasts on that, so I won’t elaborate, but get rid of the sunflower oil, safflower oil, corn oil, soybean oil, rice bran oil, canola oil, corn oil, get rid of those oils as well, start to do home-based cooking. And probably the easiest place to start is I actually tell them to leave that overnight fast. Start with an overnight fast. How long can you leave between dinner and breakfast?

Because if you can leave that to 12, 14, 16 hours, that already sort of kickstarts you into ketosis. So [inaudible 00:44:42] number one, overnight, fast, as long as you possibly can. Number two, can you exercise on an empty stomach because that will further push you into ketosis. This is how I start my day. I’ll do the fast. Usually, well, 14, well, I’ll wake up, I’ll exercise, and then I’ll have breakfast. So, by that stage, it’s usually 14, 15 hours, sometimes 16 between dinner and my first meal of the day, avoid snacking because you don’t want to be continually spiking your insulin levels. And if you do eat enough protein and fat, you don’t get hungry in between. So, to reiterate, start with the fast, add some exercise, add some strength training, because the more muscle mass we lose, the more insulin resistant we become.

And people underestimate, strong muscles equate to a strong mind. Hand grip strength actually reflects mental strength. You can test a person’s hand grip strength, and the better, the stronger they are, the better their cognition and the better they perform in memory tests. So do some strength training as well. So, we haven’t even got into the diet yet because those three things all help to get you into ketosis without even changing your diet yet. Then we start to, okay, what proteins do you enjoy eating? Prioritise your meal around them. I just sort of say, start with a Palmer protein. What fats do you enjoy? Leave the fat on your meat. Drizzle olive oil. You can use olive oil; you can use coconut oil. You can use certainly your linseed oil, flaxseed oil on your salads.

And then we talk about right. Now, let’s get rid of, start with the refined starches. And then even it depends on their condition. If they’ve got dementia, if they’ve got type two diabetes, if they’ve got fatty liver disease, they need to be in ketosis. But if they’re pre-diabetic, if they’re just not on top of their game, then they might just get away with cutting out the unprocessed food and just going a bit lower carb. So, it does depend.

Dr Sam Moxon:

And I think for the final question, I could ask something really scientific and something really enlightening, but I’d actually like to finish on a more personal note, which is, what’s your favourite ketogenic meal? If you had to pick one, what would you cook?

Dr Helena Popovic:

It’s actually what I had for dinner tonight. I love really good wild caught salmon or where in my part of the world, New Zealand salmon is really good, so it’s just beautiful fish, just grilled or baked in the oven. And then I’ll have it with a whole heap of green vegetables. I love it with spinach or kale, broccolini, cooked anyway, I like them in, I’ve got this thing called a George Foreman. It’s like a sandwich toaster. I just love my eggplant, my zucchini, and my broccolini in that. That’s actually what I had for dinner tonight, and that is my favourite ketogenic meal, it’s my favourite meal, anyway.

Dr Sam Moxon:

Yeah. Yeah, that sounds delicious. Well, thank you for joining us. I think it’s been really an enlightening discussion. I think our listeners will find it fascinating, so thank you very much for joining us.

Dr Helena Popovic:

My absolute pleasure.

Dr Sam Moxon:

Maybe we should follow this up in the future and see how things are going.

Dr Helena Popovic:

Yes, I really enjoyed talking to you. Thanks for the invitation. Forgot to mention, I have written a book called, I’ve written several books, but the one of interest to this podcast, Can Adventure Prevent Dementia? A Guide to Outwitting Alzheimer’s. It goes through everything we’ve talked about, but it goes way beyond diet. It’s not just diet, and it works people through just starting to lower their sugar, starting to reduce their starches, starting to introduce healthy fat. But it goes through all the different forms of exercise, how to get someone with Alzheimer’s to exercise. It goes through sleep, obstructive sleep apnoea, the importance of getting your hearing checked, dental hygiene. It goes through even your beliefs and the stigmas and all the things that we say to ourselves that talk ourselves into getting old. So Can Adventure Prevent Dementia? it’s available on my website, which is drhelenapopovic.com or on Amazon. So, if you really want more of this and really want to help someone with dementia or prevent dementia, my book has the answers.

Dr Sam Moxon:

We’ll put links to that in the show notes as well, so the listeners can access that. Well, thank you very much for joining us. Thank you all for listening, and we’ll see you next time.

Dr Helena Popovic:

Pleasure. Thank you.

Voice Over:

The Dementia Researcher Podcast was brought to you by University College London, with generous funding from the UK National Institute for Health Research, Alzheimer’s Research UK, Alzheimer’s Society, Alzheimer’s Association, and Race Against Dementia. Please subscribe, leave us a review, and register on our website for full access to all our great resources. Dementiaresearcher.nihr.ac.uk.

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