Susan Wood: You know, and this is really, really controversial. We can survive without carbohydrate because we, we can create it ourselves. Now, it's not, it doesn't mean to say we've got to survive without it. You know, we can consume it and most of us can cope with it perfectly well. But for some people, they may be, they actually function better with less carbohydrate and more fat.
Dr Rupy: Welcome to The Doctor's Kitchen podcast. The show about food, lifestyle, medicine and how to improve your health today. I'm Dr Rupy, your host. I'm a medical doctor, I study nutrition and I'm a firm believer in the power of food and lifestyle as medicine. Join me and my expert guests while we discuss the multiple determinants of what allows you to lead your best life. And my guest is the amazing Susan Wood, who is a UK registered dietitian and has been working for over 37 years in clinical practice, predominantly in the NHS and treating a wide range of paediatric and adult conditions. And today we're going to be talking about the ketogenic diet in all its various forms. In 2008, the referral of one young adult for the dietary management of drug resistant epilepsy sparked Sue's interest in the ketogenic diet therapy and since then, she's been pioneering the development of adult treatment protocols in the UK and raising awareness of the dietitians and adult neurologists to the potential that ketogenic dietary treatments can offer to adults. I first came across Sue's work when she lectured on my master's of nutritional medicine programme early this year in 2020. And I was just kind of blown away by the open-mindedness of Sue, how knowledgeable she was, how up to date she was in the research and just how passionate she is about accepting that yes, there are some issues with the way the keto diet is portrayed in the media, but fundamentally it really does have some significant benefits that warrant further research and further attention as well. I think you're going to find this podcast a real introduction into the power of keto diets, but a responsible podcast with the way in which we discuss it as well. I think initially I was treading around the subject with some trepidation, probably because of my lack of experience with it and my lack of understanding, but Sue's really put me on a trajectory to understand a lot more about what the benefits of keto are and the limitations too. In today's podcast, we talk about Sue and her background, the definition of what a keto diet is, the various forms, the uses beyond treatment refractory epilepsy, and you'll understand exactly what we mean by that terminology as well. We talk a little bit about brain oncology, so brain cancer and cancer tumours, and what the wider applications of keto could be as well for multiple sclerosis, dementia, a bit about diabetes and glucose management, and also the mechanisms that are potential ways in which the keto diet works. Most people think it's just about the production of ketone bodies and the regulation of glucose in the blood that's kept very stable, but actually there's a lot more research looking at how keto bodies and the actual diet can actually implement changes to the way your genes are expressed, so it has epigenetic effects, as well as changes to the microbiota, which we always love to talk about on The Doctor's Kitchen podcast as well. We talk a bit about the ways in which people can introduce ketosis, and I think just Sue's really a proponent of actually giving people the opportunity to explore these diets for themselves. We're all adults, we all have responsibility for our own health, and I think armed with the proper information is the best way to have these sorts of conversations. I really think you're going to find this interesting, even if you've never heard of keto before, or you've heard of it before and you weren't interested, I think this will give you some perspective on the clinical applications. If you want to find out a bit more about keto diets and you're a patient, I would highly recommend you check out matthewsfriends.org. It's a fantastic organisation that Sue is part of, and they do some fantastic work as well. It's similar to the Charlie Charlie's Foundation, I believe, in the US. So, Matthew's Friends.org, I'll check that out. And without further ado, I hope you enjoy the podcast. As I always say, one last thing, give us a five-star review if you enjoy the podcast and do subscribe to The Doctor's Kitchen.com. The newsletter gives you two weekly science-based recipes and the recipe I make for Sue, I made two keto recipes on today's podcast, will be found on YouTube. Go check it out. She really did enjoy it. Enjoy the podcast. So, tell me a bit about how you got into dietetics, because you've been in, you've been.
Susan Wood: Well, I've been a dietitian for, for yeah, for a very long time, for about 37 years. So.
Dr Rupy: 37 years?
Susan Wood: Yes.
Dr Rupy: So, what is your secret? Wow. I'm in shock.
Susan Wood: Yes. So that's it. So I am, I studied at Surrey, you know, where you were doing your masters. I studied at Surrey and, interestingly, when I was studying in my final year, there was a lot of interest in ketones. And that's back in '82. So we're talking about a long time ago because of course they've always been part of biochemistry and metabolism, you know, they're a natural component within us. So, so but there was a lot more interest in it in terms of therapeutic aspects. Um, but it seemed to sort of die a little bit, I think. They sort of fell out of favour because at that time there was an upsurge in the interest in fibre, definitely, but also, you know, fibre was, was, was gaining a lot of interest in terms of research terms. And also the fat heart hypothesis was emerging. And, and in a way, probably those elements, because they were sort of more novel at that time, you know, they were really coming through in terms of driving research and and research was wanted in those areas. And I think probably ketones just sort of fell a bit by the wayside at that point. And so I came back, I mean, I didn't, I didn't think about ketones at all until 2008 when a patient was referred. I was working in community hospital and we had a referral from the neurologist that did clinics at the hospital for a ketogenic diet. And you know, we didn't do ketogenic diets, you know, that wasn't part of our clinical practice. We knew it was done for children, but not for adults. This was an adult. So, after trying to refer the referral on and avoid dealing with it, finally it came back because again, referring on didn't work. They weren't going to have it. And so, so I decided to take a look at it and see what I could do and just on the basis that, well, you know, there was nobody going to be able to help them. So if I could just have a crack at it, it might be okay. And so I started investigating the possibilities for adults particularly, and really struggled to find other people involved. And finally met up with a colleague in London who was just trying to get, you know, get started really and treat some patients. So there was a few people just starting at that time, really thinking about adults and trying to develop it for adults. And most of the information I managed to gather really came from abroad, maybe from dietitians in South Africa or in America. So I linked across the world really with other people who are interested. And, and yeah, and adopted also elements from, from paediatrics. You know, that's all we had to go on and and just started like that. So it's been a very slow development really in terms of accessing or being accessible to adults, really, really slow. But there is much more interest and interest has been, has been developing over the world, you know, over the last 8, 10 years for adults, certainly it's been accelerating.
Dr Rupy: Absolutely. I've seen definitely, I mean, one of the slides you put up was the acceleration of the number of publications looking at ketogenic diets as well. So by the time you started looking at it for adults, had it been pretty established in the paediatric literature at that point?
Susan Wood: Yes, absolutely. And, and services, I think what really made the difference was that in 2008, there was a randomized control trial published and that was actually work that was carried out at Great Ormond Street Hospital in London. And so that was the first RCT within the world of paediatric and ketogenic. And endorsed its effectiveness as a, as a means to manage drug resistant epilepsy in children. So that was a really, that really was a landmark study. It was, it was brilliant. And that's made a lot of difference because you know, you know from the medical world that, you know, if you've got a really robust trial evidence, then you can actually, it can, it can endorse the funding for services, you know, you can actually then develop services based on that. Whereas if you don't have robust published evidence, if the trials haven't been done, it's not that it doesn't work, it's just that somebody hasn't done the trial in that way, then you, you really can't, you know, you can't justify things. You've got to have that level of evidence. So, so paediatric services have certainly expanded, you know, since that time, slowly, but latterly more rapidly.
Dr Rupy: I was going to say, it does seem slow because it's something that I think a lot of, especially primary care physicians would be pretty unaware of at this point.
Susan Wood: Yeah, and I think that what you've also got to realise is that it is very much rooted within management of drug resistant epilepsy. So and that's what the trial endorsed. So it wasn't endorsing any other treatment of any other condition. It was the treatment of drug resistant epilepsy in children. And so the services that we have really exist in all our children's hospitals up and down the country and in Ireland, in Northern Ireland, Scotland, England. And also, so it's really, it is really just focused in those areas and it really is a neurology focused, epilepsy focused treatment. So there hasn't been expansion to other areas and there really hasn't, there hasn't been crossover, a tremendous amount of crossover into the adult sector.
Dr Rupy: Yeah.
Susan Wood: So that's where it's really locked into a really quite a narrow area and that's why it doesn't come out into primary care unless you've got a child who you've referred in, they're in tertiary care for their complex epilepsy. They may end up on ketogenic therapy as part of their management program under their neurology team, the specialist neurology team. So it's quite specialized.
Dr Rupy: And do you think patient interest in this is really driving a greater awareness in the clinical community? Do you think it's patients essentially going to the doctor like, you know what, I've heard about this through the grapevine or through Google. I want to go on it.
Susan Wood: Yeah, and I think probably it's turned a little bit within paediatrics because whereas in the early days, people might not have heard too much about it and it would have been introduced maybe by the, by their neurologist. People often know about it now, certainly know about it within the epilepsy world. And so it wouldn't be a surprise if they were, they were actually, it was recommended that maybe they would like to explore it. But it's not used as a first line treatment. It's used when, when the individual has actually failed, failed medication. So generally, the guidelines state that first line drug in appropriate dose, if you fail that, second line drug, appropriate dose. And then after that, so really you need to have failed two medications, appropriately selected medications at appropriate dosages before you would then be considered to be referred on for ketogenic diet therapy in a child. Now we are, that's changing a little bit in certain specific epilepsy conditions, you might start it earlier. We now treat more infants within the ketogenic world, you know, we're now realizing you can actually start it quite early on. And certainly it would be a first line treatment for a condition called GLUT1 deficiency disorder because you really have got to find a way of ensuring that that brain has fuel. And that condition obviously means that glucose can't get into the cells. So you really do need to supply that different fuel and ketones are that fuel.
Dr Rupy: And is there ever a scenario or a health care system where it has become first line therapy for epilepsy or is it always post?
Susan Wood: Within the, within the clinical ketogenic community, which is a very small community but connected worldwide, it's unusual for it to be first line. I would say that in the states occasionally it is. Um, because they, they operate a different health system there. But it's still not, it's not necessarily, and I don't necessarily think, you know, as even as a dietitian who knows that it works, I think that it's not necessarily the right thing for everybody at all. And if one, maybe if you can try one medication, it works and you don't get side effects from that medication, that's, that's great. That's great. Um, but if you are taking drug after drug or building up a number of drugs, you're getting side effects for those medications, then really those individuals ideally need to be offered the opportunity if they wish to explore this. And one of the fabulous things about it is that really it only takes about three months to know whether it's really going to work or not. So you don't have to be doing this for about a year or two and wonder whether it's going to evolve. It's a pretty rapid process. When you start switching the fuelling in the brain, you sort of start to know whether it's going to have an impact or not. So yeah, it's really not too long.
Dr Rupy: We should probably describe what the keto diet is actually. So because we're chuntering on about keto and actually its applicability. But I think for a lot of people there is a bit of miscommunication about it. Because the number of times I've been approached by both colleagues and patients and said, I'm on a keto diet. And my initial and I shouldn't really, but my initial thing is like, I really don't think you're on a keto diet because that is a very strict diet that you have to, you know, use different parameters and little testers to to know whether you're actually in nutritional ketosis or not. So, um, why don't we talk about what a keto diet is?
Susan Wood: So I would say that what I would do is probably define them as medical ketogenic diets, which are very, very precise and, you know, we that would be what we would class as the treatment that we use within epilepsy. So again, very meticulously modified, rigorous control over the macronutrients. So rigorous control over the carbohydrate, generally it is going to be lower than 50 grams of carbohydrate. And readily it may be a lot less than that. So rigorous control of carbohydrate, often there may also be control over protein as well and of course fat. So, you know, we often have total control over all those macronutrients. And so generally when we consume less than 50 grams of carbohydrate or so roughly, then that will in many of us trigger a state of starting to create ketones. So a ketogenic diet actually is quite a loose term because actually for you, you may start producing ketones even if you reduce your carbohydrate to 60 grams a day or 50, 40 grams a day. Another person maybe may not start to produce ketones until they get down to sort of maybe 30 grams a day if they're trying to do it just with the diet. So it's, it is a bit of a way, it's a loose term. So I think probably I'd rather differentiate it between, you might say medical ketogenic diets where you've just got really precise control of the macronutrients and you're trying to target symptoms. And so there is, there is quite a range and although we, I think probably what you're referring to when you were talking about the sort of meticulous manipulation was the classical ketogenic diet, which is really the approach that started in the 1920s. You know, that's and we're still using that regime today.
Dr Rupy: Yeah, because I was going to ask about the history of the keto diet and actually it goes back a lot more than people actually realise.
Susan Wood: That's right. So this treatment really evolved when it, when it became known, and again it was been known for a long time that fasting can often calm seizures. And so by fasting, we now know quite readily that of course that starts to create ketones. But fasting, so initially they found that fasting patients would stop seizures. So, but you they realized that you can't just fast somebody forever. You know, you are going to get malnutrition and eventually die. So you have to find another way of replicating the chemistry that you're generating by fasting somebody. And that's how they started to evolve in the 1920s, they started to find ways of actually manipulating the macronutrient intake so that you could create ketones. And that's where this classical regime evolved where you actually deliver the fuel, which is your protein, carbohydrate and fat in this sense of a ratio. And so you actually look at and certain some of the ratios were quite high ratios, so maybe four grams of fat to one gram of protein and carbohydrate combined. So you've got a very high fat intake, perhaps even it's going to be 85 to 90% of your fuel or your calories is coming from fat and the remaining is coming from your carbohydrate and your protein.
Dr Rupy: To give an image to the listeners of what that four to one ratio looks like, can you describe because what I'm cooking right now probably won't, won't fit the four to one ratio. What would that look like on a plate?
Susan Wood: Now, well, it can look like lots of different things and that's the, that's the intriguing aspect about this because it is all about numbers actually. And when we actually prescribe these regimes, we do give people very precise numbers to to target and then we give them ways of actually counting those elements. So choice lists and various ways that they can count them. So it's quite difficult for me to describe because the, it will depend on it's not just about that ratio, but it's the total amount of energy on that plate. So a four to one ratio meal will look different from for, you know, for say a two year old compared to a 20 year old or a 25 year old. And an important point also about this, this ratio business is the ratio is actually only just a mathematical tool. It's not a clinical, it's not a clinically defining treatment tool. So the ratio does not define the treatment. And when we're talking about very, very high ratios, a very high amount of fat compared to protein and carbohydrate, you've actually got to still manage to provide adequate protein for that person's requirements. You know, all these regimes have got to be individualized. And what we know is that when we start to use these rigorous regimes for larger bodies, so adolescents and adults, we've got to make sure that we're still providing enough protein. So these very, very high ratios sometimes don't work, so we have to just bring the ratios down. But it's, it's that's not, that's not a major problem. You know, really for everybody just to understand, it's just really that we're, we're actually encouraging the body just to utilize fat as its primary fuel. And by actually adjusting that, that fuelling system in the body, you end up really delivering a cascade of changes across multiple biochemical pathways. And that's probably where it delivers its therapeutic effects. So it really it's not just about glucose stabilization, it's not just about having ketones consistently present within the bloodstream. There are lots of other background changes that occur as well. It's a little bit like considering it, um, a bit like seeing an iceberg. You know, the top line is we can see very evidently that we've got changes in the glucose profile. So we've got a nice flat, steady glucose profile. We can see that we've got circulating ketones and that's how we might monitor it and define it. But behind that, below the water line of that iceberg, there is just masses of different things going on.
Dr Rupy: It's it's sort of similar to how I think we used to think about fruits and vegetables as just being chalk full of antioxidants, but actually there's a whole bunch of other things going on when you look at the metabolic pathways, how it interacts with your microbiota, how it changes redox signalling. Um, and I'd love to get a little bit more into the, um, the potential mechanisms of action for ketogenic diets in a bit. I'm going to bring you back down to this, this recipe for now. Yeah, back to the food. So all I've done, all I've done is I've just bunged everything in the pan really. I haven't bothered sautéing the ginger, garlic or anything because I kind of want it to infuse into that coconut milk. Um, I've used a little bit of coconut oil. I've bunged in some, some sugar snaps, some red peppers and I'm going to finish it off with a bit of cashew as well. Um, what, how do you tend to eat? What are you like? What are your go-to dishes?
Susan Wood: So in my, um, you know, in my sort of my own personal diet, um, I do tend to, certainly in the, over the years that I've been involved with ketogenics, I've certainly altered my pattern of eating. So I'm not, and I've tried it, I've tried going ketogenic because I needed to know how it, how, how to go about it and also how to travel and eat as I'm travelling and things like that because that's what, that's what our individuals have got to be able to do. They've got to be able to live with it. Yeah, totally. It would give you a really good perspective. Yeah, that's right. But and, uh, so no, I do eat, I do eat loads more fat and I eat less starchy carbohydrate, but I don't, I don't get on well with wheat. So it suits me to make things like those keto rolls and various other things. It suits me to eat those anyway.
Dr Rupy: Can we see these? Let me see this. Can we see those rolls? Yeah, yeah. So I completely forgot. It's very kind of you. But you're literally the second guest that's brought me some food in the kitchen. Oh, wow. These look amazing. Do you want to describe these?
Susan Wood: So, so what, um, probably the most difficult thing to for people to accommodate is really this absence of starchy background foods. And we use them as a vehicle, really. I mean, we use them as a vehicle to deliver the really tasty things, you know, the really nice things like cheeses or, or, you know, interesting flavours. But, um, it's really useful to have some sort of background vehicle and also say for taking out with you if you're, if you're needing to travel with food. And so instead of using wheat flour, what we tend to use is we use ground nuts and seeds as the background. And, you know, there are, there are so many options now on the internet. We've got, we've got recipes on the Matthew's Friends website, but there's so many options out there for different ideas of how to make breads and replica breads. So, no, they're really tasty. So they use whole, I've used, I've ground down whole almonds to make the flour and then.
Dr Rupy: Oh, you made them yourself? You actually.
Susan Wood: Yeah, I make, because I'd rather make them, I like the brown bit, I like them being ground.
Dr Rupy: Yeah, yeah, I know what you mean.
Susan Wood: So instead of using, it's cheaper also just to buy your own almonds and grind them. So, um, and then alongside that, I've put in some flax, a flax mix and some psyllium husk, which actually gives that sort of structure to the bread because of course we haven't got gluten in there. Um, and we use egg white as well, that provides a raising.
Dr Rupy: Oh, a binder. Yeah.
Susan Wood: And also some baking powder and a little bit of vinegar and some boiling water.
Dr Rupy: Awesome. I mean, they look great. They look like, you know, the kind of rolls you'd get in a small bakery or whatever. All right, this is your Thai style soup with loads of coconut milk. Thank you. Here's a spoon.
Susan Wood: Thank you very much.
Dr Rupy: Hope you enjoy that.
Susan Wood: It's looking lovely and colourful. That's the one thing I do say, it needs to be colourful.
Dr Rupy: Yeah, absolutely.
Susan Wood: And shiny too.
Dr Rupy: It's got to have that good colour shine ratio. Oh, that flavour is amazing.
Susan Wood: Good. I'm so glad you like it.
Dr Rupy: That flavour is absolutely amazing.
Susan Wood: That's gorgeous. Oh, I'm really glad. I'm really glad. I'm a big fan of like Thai style food as well and the flavour piece. I actually used, it's not very hot. You've not made it hot, hot. It's just really warm.
Dr Rupy: It's got a little hint of heat at the end because instead of finely chopping the chilli and whacking that in, I've literally just sliced it in half, taken the seeds out and then put it in so you get a hint of warmth at the back. And I've used for the first time a vegetarian fish sauce, which I never knew existed. Gosh. So you've got seaweed based um, the saltiness from the seaweed, which is really like quite pungent and concentrated. So that for me was a new find. So I love doing this experiment.
Susan Wood: The lunch is lovely, thank you. Really good.
Dr Rupy: And how did you enjoy your rolls?
Susan Wood: I love the rolls. The keto rolls are great. It's a new thing. I didn't know that was a thing. So I'm pleasantly surprised. And those, those crackers I'll definitely make.
Dr Rupy: They're really easy to do. Really easy.
Susan Wood: Yeah, I'm going to have to put the recipe for that actually in the show notes. I think a lot of people want that.
Dr Rupy: Yeah, no, absolutely. Yeah. Yeah. That's great.
Susan Wood: So we've talked a lot already in the break as well about a bit about yourself, how you got into this, you know, how long you've been in clinical dietetics, the history of ketogenesis as well in terms of the fact that it was there from the 1920s. The, the uses beyond epilepsy, I think are quite interesting. Have we covered pretty much, not everything to do with epilepsy, but the main points.
Dr Rupy: Yeah, I think it's difficult to say. I think what I would just say about epilepsy is that it's, it has to be, it's not a case of ketogenic diet or anticonvulsant medications. It's very much knitted in with the whole lot. So, um, and most individuals who even get a good response from ketogenic diet remain on maybe one or, you know, a couple of anticonvulsant medications as well. So it's not a, it's not separate. It's part of the whole neurological care. Um, and so I think it's really important to see it as that. It's part of the, it's almost like an anticonvulsant, but it's in food form.
Susan Wood: Yeah.
Dr Rupy: So it's, yeah, carefully monitored.
Susan Wood: Absolutely. Yeah. And how easy is it in your experience for people to be referred now, given that, you know, it's 10 years after we had those results from GOSH. Um, to be referred into clinical dietitians with expertise.
Dr Rupy: Well, I think, um, there are these, there are the neuro keto teams in the paediatric centres. And, um, yes, children are referred in and so the, there has been an expansion of availability of treatment in recent years for children. And I think that what's happened is there has been a slight expansion within the adult sector, but not sufficient. And I think there are, um, there are a number of adults who would like to explore it, but they just can't get treatment. Um, they might not be classed as having such difficult epilepsy or there just aren't the services around them to be able to offer the treatment, but they really do need help with the navigation. You know, it's, it's not, it's not great just trying that out by yourself. You could do with having the help and navigation. But having said that, we have encountered people being referred to us who have start on their own, you know, and then they've ended up finally getting referred. Um, and I think it's just that it's quite tough really doing it on your own and you may not navigate it ideally. You may not get the results you're looking for. And so it's really helpful to have, have, um, support from experts that know how to navigate. So they can get you to the place you want to go or they can actually say, look, we've done what we can and the effect, we can't seem to get maybe the optimal effect. Because it's about 50% of individuals with drug resistant epilepsy will get a 50% reduction in seizures. And that's if they have, they have, they have often by the time they've reached that, reached ketogenic therapy, they've failed many, many, many drugs. So the chance of another drug coming along and actually having that effect, um, well, there just aren't drugs around that would do that. So it's remarkable for, for those individuals who, who, who are drug resistant, um, it can still have a very significant effect, but still it doesn't always work. Um, and very, very occasionally, this is really, really occasionally, we get people who it makes them worse.
Dr Rupy: Yeah, yeah. So, you know, that's why it's just important to, to have some guidance to navigate.
Susan Wood: I definitely want to get onto the adverse, the potential adverse effects of the diet as well and the impact on quality of life. But, um, what I'm really interested in is the wider application of the ketogenic diet, which we've established is different forms and different ratios. Um, and, and how or why that might be having an effect. So the mechanism of action that we've briefly touched on, um, I'm assuming it goes beyond just the production of ketone bodies via your liver and the stabilization of glucose in your serum.
Dr Rupy: There's, it's, it's really quite difficult, even though it's been around for about 100 years now, um, the mechanisms of action, you know, it's very hard to pinpoint in each individual. Um, and there are many mechanisms of action. So, um, we do know, as you said about that stabilization of glucose and the provision of ketones as an alternative fuelling for the brain tissue. Um, that probably alters that, stabilizes the, the, um, the system, the neurotransmitter, the neurotransmission. And, and actually really just ramps up the, the, the wall against seizures coming through. Um, but also it's antioxidant status, um, inflammatory pathways are influenced, um, the gut microbiota are altered. And so there's just so many different aspects. Also epigenetic impact. So, you know, it's the way that genes are expressed. Um, and so really for each individual, it may well be that it's one thing or another thing that's the predominant reason why it's working maybe for them. Um, but I think it's also important to see it as not being something very specific. It's really, it's a really base level change in the system. Um, because every single cell in our body has to have fuel. You know, we are, we are just built of, you know, billions of tiny cells. Every cell has got to be fuelled. And if your fuelling's not working properly, or if your mitochondria just aren't functioning properly, um, then, you know, it is possible that maybe this shift in fuelling of the systems may actually enable things to work better. And I think this is this, it's this really base level, almost like just adjustment in the fuelling availability that is, has captured the interest in, in sort of broad neurological applications.
Susan Wood: Yeah, which is why it's quite interesting to see the potential applications of keto to things like, um, well, brain tumours that we'll get onto in a little bit, but multiple sclerosis and a whole bunch of other fields as well, chronic pain, migraine. Um, is there some sort of, um, uh, common feature in, in that you've got hyperfunctioning of the cells' ability to utilize glucose? Is that something that we're seeing in different.
Dr Rupy: I think that's, it's probably is that sort of, um, when, when, when a section of the brain or when the tissue is struggling, or if it's not appropriately fuelled, um, then it just can't work properly. So therefore, you know, this, this possibly this hypometabolic state, um, may underpin quite a lot of these, it may be a common link between some of these conditions. Um, and so just by altering and providing that alternative fuel and also the shifts in various pathways, just enables functionality to be improved. Um, those individuals with epilepsy who get, who, who do get benefits through the seizure control, but they also talk about other aspects such as just feeling a bit clearer, having more energy, um, and just being able to, you know, just being able to have a chat with somebody or be able to play with your kids and have energy. It's all these different things. And actually, um, it's not so much maybe about the seizures, it's about the life between seizures.
Susan Wood: Yeah, and I think it's a really important point you made because, uh, too often I see in clinical medicine that we judge the efficacy of drugs purely on, say, in the case of epilepsy, reducing the seizure threshold. Um, so increasing the seizure threshold. Whereas in reality, we want to be looking at the holistic picture of the patient. So there's no point removing seizures if it's at the expense of them being able to do normal cognitive tasks or have the energy to go outdoors. And it seems, at least from some of the papers that we've seen looking at small numbers, that people's fatigue, energy levels have improved whilst being on the keto diet, obviously mitigating against the other potential adverse effects as well.
Dr Rupy: No, and I think this is, I think it's a really tough, you know, within neurology, when, when, you know, a neurologist is dealing with patients with epilepsy and, um, it, it you have got to try and stop those significant seizures. You know, seizures are dangerous, particularly tonic clonic seizures. Um, you know, and you do have to try and control them, but it is always a really tricky balance. It's very, very tough. It's not an easy job, you know, because, um, because you have got to try and titrate things, but if somebody's carrying on having seizures, what do you do? Um, so, you know, I don't think that's an easy task. But, but this is where I just think that, well, ketogenics can just bring another element, the ketogenic diet therapy can bring another element into the mix. And it can then even modify those elements that we perceive as being, maybe the side effects of a medication. You can bring in the ketogenic therapy and all of a sudden things might just settle right down. So you've still got your five anticonvulsant medications in place. You might bring in ketogenic therapy, things settle down. You've then got the opportunity, um, or within the neurology team, you've got the opportunity to think, right, okay, do we need all these medications? Could we just peel them off very slowly, very, very slowly, um, and just reduce the doses so that you are just enabling just a little bit less medication and, and hopefully improving the quality of life of that individual.
Susan Wood: Absolutely. Yeah. And I guess again to the point about individualized medicine, it really does come down to, you know, which is worse? Is it the refractory epilepsy or is it the lipid profile that shows that there might be an increased risk? Um, what I'm really interested in and I haven't seen yet in papers is, uh, low carbohydrate or even ketogenic diets over a long time period following a patient to see if they are at increased risk. I think definitely the LDL, the lipoprotein profiles can give us an indication. Um, and certainly LDL is related to the mechanism behind atherosclerosis, but I think we're still learning about whether, you know, on these particularly strict regimes where they have all the other things probably optimized as well, um, whether that actually leads to increased cardiovascular problems.
Dr Rupy: No, and I think we've also got to be aware that there are, you know, we've just talked about all the different pathways that are, that are intervened, you know, and altered that don't really fit with the norm. Now, you could say that elements of those pathways may be disadvantageous, but also they may be tremendously advantageous. So when we're talking about the dialling down of various inflammatory pathways, um, you know, that's, that's a very positive side effect. Um, you know, and I think we just don't know enough yet. Um, there have been some longer, I mean, there are occasional patients who've sort of, certainly the American teams, the occasional patient turns up, you know, like 20, 30 years, they're still on the same regime as they were as a child. And they're still here, you know, they're still fine and they haven't got heart problems. Um, but no, we haven't, we haven't studied large numbers of people. Um, you know, because I suppose it's, it's really quite specialist. You know, there aren't thousands that have been on it for, for long periods of time. So I think that area, we've got to realise that, that it, it changes so many different aspects. And yes, I think it is important that people do monitor their lipids, but it's very, very important to look at that as a whole person's picture of where things have been dialled up and dialled down. And, um, there was an interesting paper, you know, you've, you've obviously got experience in general practice. Um, there was an interesting paper published, um, not that long ago that was looking at generally lower carb diets within general practice, um, mainly really targeting metabolic syndrome and type two diabetes and insulin resistance. Um, and, you know, again, all the aspects, all the different parameters were looked at. Um, and, and it was a very, very positive, you know, it's a very positive outcome in the background. So I think we've got to look at the whole picture and not just home in on the lipids. You know, we've got to look at aspects like, um, you know, what about the, the blood pressure, you know, and, and what about the other risk factors if, if that, I mean, most of our patients, they don't have metabolic syndrome, they don't have, they don't, they're not diabetic, you know. But I think when you're applying it to another sector, you've actually got to look at all the parameters and, you know, take a broad look at what's happening and is it, is it, you know, is it overall, is it, is it helping those individuals? And if it is, stick with it.
Susan Wood: Certainly, I'm of the perspective that of this spectrum of low carbohydrate diets where you have keto on one side and then you have lower carbohydrate, moderate carbohydrate, Mediterranean along that spectrum continuum. There are probably benefits to be had for individual patients along that line. Um, and I'm wondering whether there are ways in which we can appropriate which part of, which patients should be along that spectrum at some point in the future using certain parameters.
Dr Rupy: Now, as you're mentioning that, there's, there was a recent paper that was actually really, um, was really more talking about the, um, the muddling up of the description of ketogenic diet and low carb diets. And it was actually defining, trying to make a definition because I think when, you know, if an, what an individual chooses to do, that's not so much of an issue. But if it's talked about in academic and studies, in academic publications and studies, if somebody's talking about, well, this person was doing a ketogenic diet and this person was doing, but they're doing completely different diets, you know. So somebody in fact was doing more of a lower carbohydrate diet. The other one was doing keto, you know, you just, so you've got to have some sort of standards. And then there's also interest in, in, in low energy, you know, low calorie ketogenic diets as well. And that's an, so you're bringing in also almost like that, that deficit of energy alongside the ketogenic aspect. So this paper, I can't remember it off the top of my head, but if, you know, I will make sure you have the details of it because it's recently been published and just saying, look, we need to be clear about the nomenclature here because certainly if we're going to be studying these things, we need to know what we're studying and we need to be comparing apples with apples, not apples with pears. Otherwise you're just going to get mixed data.
Susan Wood: It's the same issue that is dogging the fasting world right now because people talk about intermittent fasting, 5:2, alternate day and water fasting in the same breath. And they, they, you know, include that in all the intermittent fasting, but they're very, very different. The mechanisms can be similar, but they, you know, the way you dose this is very different as well.
Dr Rupy: And this is where, I mean, these two areas, they sit side by side, you know, fasting and, and ketogenic diets. You know, they're, they're sharing, they're sharing the same sort of biochemical pathways, but there are differences. And I would say what's interesting about epilepsy is that we do find that for many individuals with epilepsy, um, fasting doesn't necessarily work brilliantly because they need the fuel. Somehow they need that stabilization of fuel. So, um, they, if they went without a meal or a snack, they may be very susceptible to seizures. And yet you'd think, well, no, but surely, you know, fasting. But, but no, for many of them, but we do find the occasional individual who actually, um, their ketogenic effect and their control seems to be, they seem to feel a lot better if they do have episodes of fasting, but that's very rare for us. We find that very unusual. So for epilepsy, we tend to see that there seems to be more benefit from regular fuelling, but in the right, that's a high fat, low carb mix, but keeping that brain fuelled steadily rather than leaving it for long periods without fuel.
Susan Wood: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Dr Rupy: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Susan Wood: And I think generally we need to start talking about ketones in a more positive fashion because the only time that I, the first time I heard about nutritional ketosis, I thought immediately ketoacidosis, very different, very bad, something that we see with type one diabetics. But actually ketones are a very normal part of our physiology, something that our liver does naturally, like first thing when you wake up, you might actually be producing some ketones, more likely, as you've fasted technically overnight. But yeah, maybe we should probably distinguish between nutritional ketosis and ketoacidosis.
Dr Rupy: No, that's right. So they're a normal part of our, you know, they're a normal part of our biochemistry and for most of us, there is a small number of individuals who really struggle to utilize fats and make ketones and produce this supplementary fuel. But for the majority of us, we are highly adaptable, multi-fuel systems. And so if carbohydrate isn't present, or if we have to go without food for any period of time, then we have this other mechanism, this other system that then kicks in and enables us to carry on. You know, if we were just reliant entirely on carbohydrate, um, you know, we would never, we wouldn't have, we wouldn't be existing. You know, we would not have survived. And that's why we've evolved in that way because we had to go for long periods without eating. So you've got to have another fuel on board. And, you know, what better fuel than what we, you know, we've got it just distributed right across our body for most of us, we've got really reasonable stores that can keep us going for quite a long time.
Susan Wood: Yeah, yeah. And in ketoacidosis is a unique scenario where essentially, I kind of use the analogy of you're sat in a boat and there's water everywhere. So you have glucose in your bloodstream, but you have no way of using that glucose and putting it into your cells because of the lack of insulin. And it's an issue where, um, for that reason, your body goes into hyperketosis where you're essentially pumping out loads of ketones and that unfortunately leads to a change in your blood pH levels, something that most medics at some point in their training will have come across and more than likely treated. Um, but that's very different from the levels of ketones that you'll get in your blood, um, when you're performing nutritional ketosis.
Dr Rupy: That's right. And I think probably the key thing that you mentioned there, the key difference is insulin. Um, and so, um, because, because nutritional ketosis is insulin mediated. I mean, there is insulin present, insulin is not at, um, it's not abnormally low, it's not absent. Um, and so it is actually being, it is there and in, in, in the background and in control. Um, and also the difference is that the glucose levels are within the normal range. So, you know, there are very well-defined differences, um, that link it to a normal physiological process rather than an abnormal, um, an abnormal and a dangerous metabolic situation. So, yeah, very, very different. And it's really, really important that people understand the difference. And that, um, you know, ketones are present, as you said, in all of us. And but as we are, when we are born, um, you know, we are operating on ketones.
Susan Wood: I don't think a lot of people realize that.
Dr Rupy: And, and, and really, you know, the way that, the danger at that point and colostrum that we secrete, you know, for the newborns is predominantly lipids and proteins. And, and therefore that again potentiates the ketosis. Um, and because the brain of a, of a, of a small human, it requires phenomenal amounts of energy. You know, we've got to keep it running and there is often a gap between the way, you know, the milk coming in and being able to fuel that, that, that infant and that brain. So ketones are so valuable at that point. Um, and, and then gradually we become less dependent obviously over time as we're fed, um, we become less dependent. But no, ketones are just part of us.
Susan Wood: Yeah.
Dr Rupy: They're part of our, our fuel mix.
Susan Wood: Yeah, absolutely. I'm fascinated by some of the work that you've done in the cancer field as well. Again, quite a controversial area, not that much evidence, but I'd love to talk about the potential uses in cancer. From my understanding, we probably don't have enough evidence to say that it improves survival or longevity or, you know, mortality rates with certain types of brain cancer. Um, but there may be some benefits that we can at least establish in the short term using some of the studies that you've been involved in.
Dr Rupy: Yeah, I mean it's interesting. There's been a lot of preclinical work done and, and I think maybe specifically it's been, um, within the brain tumour sector because that's an area that we really have not managed to find, we've not got an improvement in outcomes really for a very, very long period of time, for decades. We're not really seeing massive improvements in survival. Um, but I think it's very important to maybe consider that the brain tumour zone is a very big zone. And, um, the, the high grade cancerous tumours are at one, at one end. And that's where the predominant interest is because that's the area where people tend to have very short prognosis. Um, and the, you know, we desperately need to improve the outcomes. But there's a whole other area that's really relevant to keto, ketogenesis and ketogenic diets within the brain tumour sector. And that's that, you know, individuals with brain tumours readily have difficult to control seizures. And, um, and so this can be a really, a really terrible sort of quality of life issue and also fatigue as well. So the work that, um, that we did, I, I was, obviously the Matthew's Friends clinics were supported by the Astro Brain Tumour Fund, um, to actually support individuals, um, with dietetic support for ketogenic therapy. Those individuals wanted to try ketogenic therapy and then we supported them to do that. So they elected to do it and they came to us for help. So we were able to, we were funded to help them. And what was really fascinating was, um, really that quality of life aspect. Um, if they had terrible fatigue, readily, they got some benefits. If they were experiencing drug resistant epilepsy and were having seizures that weren't brilliantly controlled, they readily got benefits. Um, and so it's those elements because those within the brain tumour community, it's known that those are difficult areas to tackle. Um, because they are readily drug resistant, there aren't necessarily strategies that easily manage those. But by changing the fuelling in the brain, we do seem to be able to get some good effects. Um, so I think that's probably where I would say, I would say there's the most powerful, compelling reasons for trying to enable people if they wish to explore it. So for symptomatic individuals, I think there's, there's great potential. I think there's a very big question over, um, the high grade tumour area. Again, I would say from my experience of working with many, many individuals, the quality of life aspects seem to be very positive. Now, what I would say is that these are individuals who are choosing already to, they want to do this, they're electing to do this. Um, and for them, because they are, um, enabled to make those choices, they tend to be very proactive individuals. They're not just doing ketogenic diet, they're often doing a whole, a whole mass of different things. Um, and alongside standard of care, you know, um, they're not just doing diet and not, you know, it's part of their whole, their whole sort of gamut of things. They're doing, they're trying to integrate everything really. Um, but they, they report doing, you know, doing well, feeling positive and feeling well. But what, what I would say is that, you know, this, this is just not a quick, this is not a quick fix for cancer. And I would say that if, if it was, fasting and using ketogenic diets, we would have, we would have learned about that before now. You know, we would have realized, well, if people fast, wow, they produce a bit of ketones and they, they do really well. It's not as simple as that. But I do believe that there are some individuals that might do very, very well, but we don't really have a way of tracking it. And I think that's difficult. We don't know, we don't really have ways of monitoring and reading, almost like reading the metabolic signature. And we need to find ways of actually reading that and reading the impact and almost like getting a read out to say, well, what we're doing is actually changing the components we know are relevant or doing what we're doing is not making a blind bit of difference. And if, and that's what I'd really like us to be able to do. But, um, we don't. So people may initiate changes, um, and as long as they're feeling really well, I mean, that's, that's the other very important thing. If, if anybody changes their diet, not necessarily ketogenic diet, but changes their diet significantly and they don't feel right, they don't feel well, it doesn't matter whether they think that's the best diet on this earth, it may not be the right thing for them. So it's really, really important that people think carefully and also monitor how they're feeling. And if they're not feeling right, they're not feeling well, they're not feeling happy with what they're doing, they absolutely have to change it. Because it's not right.
Dr Rupy: Yeah, exactly. And it speaks to this whole idea of personalized medicine, which most people think of like, you know, high tech and and greater sort of, um, testing, but actually it's being intuitive as well.
Susan Wood: You've got to combine that. Yeah. And anybody who is using any dietary change to control any form of symptomatic issue, I think it's really important that people do start by thinking, right, where I am, where am I now? What am I doing right now? What, what would I like to change? What symptoms am I really targeting? And you do need to watch that. You need to really track yourself, almost like diarize what's happening. Um, and navigate. You do need to navigate because the difficulty is you might just introduce something and think, well, maybe this is the right thing to do. But then further on down the line, you know, a few months, you're thinking, well, actually, am I feeling any better? Am I not? But I'm really finding it difficult, but maybe I should stay with it or, you know, and that's, that's difficult then. So it's really important, I think, to think, well, what am I looking for? What do I hope for? What symptoms would, would actually make this justifiable, this change? You know, what would, what would I class as being a good outcome for me? What's my ideal outcome? What would be a reasonable outcome? And, um, and then work towards that. And if it's not working, change it.
Dr Rupy: Yeah. And this is why I really wanted to chat to someone like yourself about it because not only are you up to date with the research and reading the journals and you have a general interest, but you're also a clinical dietitian. So you're getting those first person stories from patients and there's like that you realize that, you know, just putting someone on a medical diet isn't the be all and end all. And also, I think we have this, um, we, we tend to think of our bodies as very binary machines. You know, if we learn, for example, that cancers preferentially use the glycolytic pathway and chew up glucose, then ergo, we should go on a ketogenic diet that reduces the glucose in our serum, blood levels, reduces insulin, and therefore treats it. Whereas in reality, cancer itself, just as a, as a particular condition, is evolving all the time and it can adapt to use.
Susan Wood: And it's different in everybody. And I think also just following on from that, it's very important to see that, you know, um, it's all very well making dietary changes. Um, but, you know, is your gut functioning well? Is your liver functioning well? Is your, you know, is your your kidneys functioning well? It's really, you know, um, for some individuals, it's not easy to change a diet. Um, and it may not be appropriate at the time. And so it's really important, I think, to get, to get good, you know, to get help. Um, and to talk to your dietitian, um, about, about diet, talk to them about what you've, what if you've read something, ask them about it, speak to them about it, speak to your oncology team. Um, because it may not be the right thing for you at all to do whatever change it is. You know, but, you know, and it's important that you do navigate the right path for yourself.
Dr Rupy: Do you think, um, clinicians and dietitians alike are becoming more receptive to the idea of different ways of treating illnesses, particularly oncology? Like, I know in America, there's definitely more talk of, um, metabolic oncology as a field in itself where we look at, you know, how we can, yes, introduce dietary changes, but perhaps even tinker with a few other, uh, adjuncts to chemo and radiotherapy.
Susan Wood: Yeah. I think it's maybe a little bit slower, well, you know, we're always slower than the US, aren't we? That's unfortunate. I think it's a bit slower in the UK and, um, and I think one of the difficulties, you know, when I, when I encountered ketogenics, um, you know, I had to really rethink my views. I had to challenge my own view of what this was going to mean. Um, you know, I perceived it was going to be, um, the diet was going to be inadequate in, in various vitamins and minerals and it didn't have enough of this and it didn't have enough of that. And, you know, I really shocked, I was shocked when I did the analysis and thought, well, actually this diet's really good. You know, it's one of the best, best profiles I've actually ever analyzed. So, you know, you have to think twice about it. So there are many, you know, there are many colleagues of mine, you know, working in, in various sectors of dietetics who may have not encountered, had to actually maybe look at this aspect. And it's, you know, it is, it is difficult because if you're not familiar with how things are put together and where the, you know, the alternative ways of finding your nutrients, um, and also, you know, one of the reasons that ketogenic diets are used by many people generally is in order to lose weight. One of the red flags within oncology is unexplained weight loss. So, you know, you're, it's not surprising that, you know, if you are, um, if you are an individual who has got a cancer diagnosis and you go along to see your oncologist or even your dietitian and say, look, you know, I want to do keto diet, they may just think, oh my god, you know, they're going to lose loads of weight and they're going to really become very unwell and, and if you, if you do it and don't put enough fats, you will lose loads of weight. You know, you may not feel very strong, you may not have the energy. So that caution is appropriate. Um, but having said that, there are individuals who do go into this and do get on with it and they do absolutely fine. So it always has to be, everything has always got to be individualized. You know, you can't, you can't really broadly say, um, that any dietary approach, and that could mean any different dietary approach, is suitable for, um, cancer patients or not suitable for cancer patients because they're, everybody's different. You know, you've got all sorts of different types of diagnoses, you've got different types of people, different age groups. So, um, it's very much, very important to take this down to that individual situation and understand the needs of that individual. And it might be fine for them, but the next person, it may be totally inappropriate.
Dr Rupy: Yeah. And I'm glad we touched on that because I think it's slightly a controversial area where we essentially sacrifice everything for maintaining weight. And for those, for a lot of patients, and this is frustrations that have been related to me from cancer patients that all my dietitian wants to talk to me about is maintaining my weight by any means necessary. That means eating whipped cream, it means eating chips, it means anything. They just want me to maintain weight because the evidence shows if you maintain weight, you have better clinical outcomes. Whereas with a keto diet, even if you're doing a keto diet well, you can still lose weight.
Susan Wood: Yeah, initially, I would say initially some people and certainly those individuals that I've worked with who, um, might be doing it for their, their brain tumour. Um, I'm, I'm just trying to remember the numbers, but, you know, not, I think about 60 to 70%, maybe even 80% did lose some weight. Most of them were quite happy with that. And this is the interesting thing, you see, because actually, if you think about, you know, we just basically, we are a nation of, we tend to be more overweight than underweight. You know, there is that issue. And that's a bit of a conflict really, because, you know, most of the time we're trying to get everybody to lose weight. And then all of a sudden we've got a dietary approach that might help some people to lose weight effectively, but we don't necessarily want to use it because it's ketogenic. But no, I think it's, it's, and this is where I think it's the individuality situation. So, and also we have, we, we are fearful of including extra fats in our diet. Um, you know, that's been ingrained in the population. Um, and in us, you know, as a dietitian, again, I had to go through that sort of change in my approach and really just see things as macronutrients and we just need fuel. So if you're removing the carbohydrate fuel, and you don't want to lose weight, you've got to add another fuel to the mix. And the absolute perfect fuel to add to the mix is more fat. You don't want to add more protein. We don't need more protein. We have ample protein. And certainly, um, you know, within this ketogenic world, we don't want excess protein either. So, um, but fat is perfect. That's exactly what we need. So it is difficult sometimes for some individuals because they think, right, I want to do ketogenics, but then all of a sudden, oh my gosh, I've got to start adding fat to my meals. And I'm really worried because I think fat's going to cause my heart disease, you know, and all this conflict. And I think, um, so probably that's the reason why we have this issue now. Because people don't see them as evens. You know, this is just a different form of fuel. Um, they see them loaded with this, that's bad. Fat's bad, carbohydrates are good. And, you know, um, nutritional science is much, much more complex than that.
Dr Rupy: Yeah, yeah. I think we need to start being less binary about it and actually appreciate that when someone is on that different a macronutrient mix, their internal environment is completely different and your body functioning functions in a completely different way. In an environment where your insulin is low and your glucose is stable and you're fuelling your cells using ketone bodies, it's a completely different state of environment rather than like a high carb, high poor saturated fat diet as well.
Susan Wood: Yeah, and it's very, very different. And I think the key thing is that lowering the carbohydrate because the, you know, the reduction of the carbohydrate does that underpinning that massive background change. And the fat is just there as a fuel. You know, that's just your fuel. That's all it is. Yeah. Um, and you need it there. Otherwise you are going to, the body doesn't matter, you know, if it's in that, if it's been switched, it doesn't really care. It needs to use fuel. So if you put it in from the outside, it'll use it. That's fine. If you don't put enough in from the outside, it'll start using its bank and you'll lose weight. But, you know, um, in, in medical ketogenic therapy, this we can, we can, we can apply this to infants, we can apply it to children. Um, we can still get them to grow. We do think that they don't maybe grow in height as well as they might on ketogenic diets. And that's why we don't often use, we may just use them for a couple of years. We don't keep them on them forever. Um, and so, but, but, but we can, they can grow, they can grow perfectly well. And with adults, you can actually maintain weight. So often people might lose, initially might lose a kilo or so, maybe a kilo and a half, a couple of kilos. And they almost, their shape often changes. So often their waist shrinks. Um, so their actual body shape might change, but their body weight might not change an awful lot. Um, and, and it's perfect, you're perfectly able to maintain your weight, but you do have to then, you have to have enough fat fuel to keep your weight up.
Dr Rupy: This is a great segue into the adverse effects of a ketogenic diet because I feel like you're, we've promoted the benefits of it.
Susan Wood: No, absolutely. And we have to talk about the, yeah, the downside. That's right. The negative effects.
Dr Rupy: So the potential downside. I've heard there are many different, you know, types of things that we need to think about.
Susan Wood: So one thing, and again, I just, um, again, I just had a call before I came in to hear one of my patients had got a little, you know, this is a little child, um, has renal stones. And this is a, this is exaggerated or the risk is exaggerated on ketogenic diets. Um, and so it may well be that that individual already has a, you know, a tendency. Uh, and it would be exaggerated in somebody with profound disability who maybe is not drinking that well or is, is fluid limited, um, not mobile, you know, there are other risk factors. But yeah, renal stones are a downside. It doesn't affect everybody, but it is a risk. And so it's really important when we're using medical therapy that we would normally always check, we do biochemical, full biochemical profiles before we treat the individual and they're checked regularly every three to six months. And we would, in some children, you may even do renal scans, you know, you'll just do an ultrasound to check that the regularly.
Dr Rupy: Yeah, you might do.
Susan Wood: Um, or if somebody has got a, they've, they've had a risk in the past or they've had a stone in the past, you might do regular scans. And there are certain drugs that might increase the risk as well within the epilepsy field. So those individuals we'd be much more, much more cautious. So yeah, renal stones, that's, that's something that individuals get. And I have, I think, um, over, you know, over 100 brain tumour patients, probably two, um, developed renal stones as a result of their diet.
Dr Rupy: Yeah, yeah. And the more common ones that you see, I'm assuming, are gut related issues.
Susan Wood: Yeah, and again, that's, that's an interesting, about maybe about a half may get a degree of constipation. Um, it, it varies, but yes, generally, you can imagine why because there is this massive change in, in the, the microbiota and that probably drives this change within the, the bowel frequency. And constipation is probably the most common aspect. Um, uh, with occasionally individuals might get diarrhoea and again, that may be associated with other elements, maybe if they're having, if you're introducing MCT and they're just building up tolerance, there may be more issues like diarrhoea. But yeah, maybe get altered bowel habit definitely. And we always try and preempt that. We always talk a lot about bowels. We never stop talking about bowels as dietitians. We always talk about bowels. Um, but you know, we're, we're preempting it. So if you've, if you're starting with an individual that has already has a tendency to constipation, then you absolutely try and make sure that they're already on something that's helping them to, to move. Um, and then we would incorporate, try and incorporate things like maybe flax into their diet, um, plenty of green vegetables and just try and get, get as much, um, fibre and fluids in as well to try and just keep things going. So yeah, we always try and preempt that. Um, I have had individuals who, and this is again, I'm talking about adults, um, who have had massive improvements in their gut symptoms. They had two gentlemen who happened to be, uh, individuals who had brain tumours who had massive transformations in their, um, their basically they had, they had severe reflux. And so when somebody has got severe reflux, you do think, gosh, you know, I wonder whether this is going to be okay. Now those two individuals actually it resolved completely. And that's unusual. You know, you'd think that's just not right, surely that's not right. But what I would suspect it was, it could well be that for those individuals, um, the introduction of the ketogenic diet actually excluded something from their diet that was causing them a problem.
Dr Rupy: Right. Yeah, yeah.
Susan Wood: So they, um, so whatever it was, that improved. And that was a real shock because you don't expect somebody to stop, you know, having reflux. But for them it was amazing. You know, they just had it for years and they just felt so much better because they could sleep better, you know, they felt better. So, you know, it can affect the gut in different ways. Um, you don't normally get things like issues like vomiting and problems like that. I mean, I think if that was occurring, um, you know, we'd think there was something significantly wrong with the approach. Possibly if it'd been driven in a bit too fast and there was alterations in, you know, in, if there was very high ketones, you will get vomiting. Um, and so, but generally we don't, don't generally get problems with vomiting. So it's more just the bowel.
Dr Rupy: With adults, um, particularly on the keto diet, do you see, uh, either an improvement or a worsening of their cardiovascular profile from a lipid perspective?
Susan Wood: No, that's, that's a very important area. And what I think what we do see is, and this is part of the reason why we always do make, as part of the background biochemical profile, the lipid profile is very important to check. And I think it's, it's, there's, there's a couple of different reasons why we think it's really important to check. One is because it's for the individual, for the patient, we want to see where they're starting out. But also, if you don't get a baseline and you just start picking up, you do it after the diet has been initiated, um, you may end up with sort of raised lipids, but they were always there in the first place. Right. Yeah, yeah. You know, so, um, so I think it is important to see where that individual, because we're all different. We start out differently. And what we tend to see in the early stages, you will get an, an increase in the LDL profile. So LDL, you will also get an increase in HDL and the triglycerides tend to be quite low.
Dr Rupy: Oh, low, right.
Susan Wood: Yeah, low. Because really triglycerides levels are more a, they're more a reflection of carbohydrates than actually of fat intake. So triglycerides tend to be low and HDL's tend to rise, but the LDL rises too.
Dr Rupy: Yeah. You can understand why, I suppose, because LDL and HDL are essentially trafficking molecules for your fat particles.
Susan Wood: That's right. And, and you know, you are changing the, you're changing the, the way that that that fats are being transported around the, the system immensely. And so what we tend to see initially is you get quite, you do get things ramping up, but then there have been some papers published to suggest that by about 12 months, you tend to get things settling back down again. So there is an adaptive adaptation and a settling. But we never see that, you know, when you're treating, when you're trying to treat a difficult, complex condition such as drug resistant epilepsy, um, it's very, very unlikely that lipids would be a, that the lipid change in the lipids would actually stop the treatment. Because you've got to really balance up where your benefits and your risks are. And the risks are not that high. Um, and the benefits for some individuals are immense. So, you know, so we track because it's really important to track and know what's happening so that we've got a feeling of what's going on in the background. But, um, if lipids do become higher, we're, we are not totally alarmed and we don't, we don't expect their lipids to fall into what you might class as standards. Um, so we just track and monitor.
Dr Rupy: Yeah, these are very unique patients and I guess again to the point about individualized medicine, it really does come down to, you know, which is worse? Is it the refractory epilepsy or is it the lipid profile that shows that there might be an increased risk? Um, what I'm really interested in and I haven't seen yet is, uh, low carbohydrate or even ketogenic diets over a long time period following a patient to see if they are at increased risk. I think definitely the LDL, the lipoprotein profiles can give us an indication. Um, and certainly LDL is related to the mechanism behind atherosclerosis, but I think we're still learning about whether, you know, on these particularly strict regimes where they have all the other things probably optimized as well, um, whether that actually leads to increased cardiovascular problems.
Susan Wood: No, and I think that we've also got to be aware that there are, you know, we've just talked about all the different pathways that are, that are intervened, you know, and altered that don't really fit with the norm. Now, you could say that elements of those pathways may be disadvantageous, but also they may be tremendously advantageous. So when we're talking about the dialling down of various inflammatory pathways, um, you know, that's, that's a very positive side effect. Um, you know, and I think we just don't know enough yet. Um, there have been some longer, I mean, there are occasional patients who've sort of, certainly the American teams, the occasional patient turns up, you know, like 20, 30 years, they're still on the same regime as they were as a child. And they're still here, you know, they're still fine and they haven't got heart problems. Um, but no, we haven't, we haven't studied large numbers of people. Um, you know, because I suppose it's, it's really quite specialist. You know, there aren't thousands that have been on it for, for long periods of time. So I think that area, we've got to realise that, that it, it changes so many different aspects. And yes, I think it is important that people do monitor their lipids, but it's very, very important to look at that as a whole person's picture of where things have been dialled up and dialled down. And, um, there was an interesting paper, you know, you've, you've obviously got experience in general practice. Um, there was an interesting paper published, um, not that long ago that was looking at generally lower carb diets within general practice, um, mainly really targeting metabolic syndrome and type two diabetes and insulin resistance. Um, and, you know, again, all the aspects, all the different parameters were looked at. Um, and, and it was a very, very positive, you know, it's a very positive outcome in the background. So I think we've got to look at the whole picture and not just home in on the lipids. You know, we've got to look at aspects like, um, you know, what about the, the blood pressure, you know, and, and what about the other risk factors if, if that, I mean, most of our patients, they don't have metabolic syndrome, they don't have, they don't, they're not diabetic, you know. But I think when you're applying it to another sector, you've actually got to look at all the parameters and, you know, take a broad look at what's happening and is it, is it, you know, is it overall, is it, is it helping those individuals? And if it is, stick with it.
Dr Rupy: I'm of the perspective that of this spectrum of low carbohydrate diets where you have keto on one side and then you have lower carbohydrate, moderate carbohydrate, Mediterranean along that spectrum continuum. There are probably benefits to be had for individual patients along that line. Um, and I'm wondering whether there are ways in which we can appropriate which part of, which patients should be along that spectrum at some point in the future using certain parameters.
Susan Wood: Now, as you're mentioning that, there's, there was a recent paper that was actually really, um, was really more talking about the, um, the muddling up of the description of ketogenic diet and low carb diets. And it was actually defining, trying to make a definition because I think when, you know, if an, what an individual chooses to do, that's not so much of an issue. But if it's talked about in academic and studies, in academic publications and studies, if somebody's talking about, well, this person was doing a ketogenic diet and this person was doing, but they're doing completely different diets, you know. So somebody in fact was doing more of a lower carbohydrate diet. The other one was doing keto, you know, you just, so you've got to have some sort of standards. And then there's also interest in, in, in low energy, you know, low calorie ketogenic diets as well. And that's an, so you're bringing in also almost like that, that deficit of energy alongside the ketogenic aspect. So this paper, I can't remember it off the top of my head, but if, you know, I will make sure you have the details of it because it's recently been published and just saying, look, we need to be clear about the nomenclature here because certainly if we're going to be studying these things, we need to know what we're studying and we need to be comparing apples with apples, not apples with pears. Otherwise you're just going to get mixed data.
Dr Rupy: It's the same issue that is dogging the fasting world right now because people talk about intermittent fasting, 5:2, alternate day and water fasting in the same breath. And they, they, you know, include that in all the intermittent fasting, but they're very, very different. The mechanisms can be similar, but they, you know, the way you dose this is very different as well.
Susan Wood: And this is where, I mean, these two areas, they sit side by side, you know, fasting and, and ketogenic diets. You know, they're, they're sharing, they're sharing the same sort of biochemical pathways, but there are differences. And I would say what's interesting about epilepsy is that we do find that for many individuals with epilepsy, um, fasting doesn't necessarily work brilliantly because they need the fuel. Somehow they need that stabilization of fuel. So, um, they, if they went without a meal or a snack, they may be very susceptible to seizures. And yet you'd think, well, no, but surely, you know, fasting. But, but no, for many of them, but we do find the occasional individual who actually, um, their ketogenic effect and their control seems to be, they seem to feel a lot better if they do have episodes of fasting, but that's very rare for us. We find that very unusual. So for epilepsy, we tend to see that there seems to be more benefit from regular fuelling, but in the right, that's a high fat, low carb mix, but keeping that brain fuelled steadily rather than leaving it for long periods without fuel.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: And I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you don't really want somebody who's just really, I mean, we can do it, we can do it, we can get an effect, but it's probably harder to maintain a stable, a stable effect.
Dr Rupy: I think, you know, it's so interesting because there's so many other parameters that we probably need to determine as to which patient would benefit from fasting and what, like what their fat stores are at the moment.
Susan Wood: That's also really crucial because some people, you know, have got a low BMI. Um, and, um, they, it, it may be much harder for them to maintain stable ketones and stable levels. So really there is a risk actually treating people who have got a very low BMI because it they may just be more brittle. Um, so you're probably better off with somebody who has got, you know, they're sort of 18 and above, um, as a BMI, you''ve got to have an open mind and you've got to be prepared to challenge your own views. And I think that's the key thing. And I think that's what I've learned over the years. I've learned that I don't know everything. And I've learned that I've got to be prepared to listen to people and to listen to what they're saying and to listen to what they're feeling. And then to try and work with them to find the best way forward for them. And I think that's what we've got to do. We've got to be prepared to do that. And I think that's what's so exciting about this area. We've got a long way to go.
Dr Rupy: Definitely. Absolutely. Yeah. And if people want to, wanted to find out a bit more and they've, you know, listened to this podcast, they know someone with, uh, refractory epilepsy or cancer, where do you think the best sort of resources are out there?
Susan Wood: Well, in terms of, um, you know, general information about sort of the lower, the general sort of consumer information about lowering carbohydrate and having more fats, I would say that dietdoctor.com is a really good starting point. Um, has a lot of information on there. It's really nicely produced, nice and, nice and bright and graphic, you know, it's nice and clean and clear. It's got a lot of good information. Um, obviously the Matthew's Friends website, um, has got some background information, but we're very mainly focused on the medical ketogenic therapies, which is of course really about the epilepsy side of things, but there's lots of information, there's ideas, and there is also access information to access lists of centres that are providing the therapy, um, you know, for clinical therapy. Um, so within epilepsy, you know, you can be referred to a specialist centre. There are adult centres, there are paediatric centres. When we're talking about, um, any other application, there's very little.
Dr Rupy: Yeah.
Susan Wood: Sadly, there's very little.
Dr Rupy: Yeah. And so what I would like to do is enable those individuals who want to look down and want to look at specific things, they can look at them. But we don't bring it as a like a, you know, because there's a lot of people just listen and they and but if they want to really know more about certain things, then we can probably put key papers that are really informative and and sensible.
Susan Wood: We will definitely link to those in the show notes. And um, like I said, I really do appreciate you coming down. It's been an absolute pleasure to listen to you again for the second time. Uh, and do stay in contact because I'd love to, you know, talk about this again, perhaps at some point. Yeah, maybe even get some sort of like patient anecdotes or something because I think the work that you're doing is underrepresented and I think it's underappreciated. And I think, you know, the more open conversations we have about the benefits of different dietary regimes, the better it is for everyone. And so this is one of my gripes within clinicians and and patients as well. It's easy to dismiss things without really looking into it and just saying everything's nonsense, whereas actually you need to dig a little bit deeper and look at, you know, how this impacts individuals. And if people are saying, I feel great on this, then it warrants more attention. So thank you so much for your work.
Dr Rupy: No, that's great. No, thank you for inviting me because of course it enables me to talk about my favourite subject.
Susan Wood: Yeah, and have some food.
Dr Rupy: And have some food. Which is even better. Yeah, being cooked for, that's great. So thanks ever so much. Thank you.
Susan Wood: No worries.
Dr Rupy: I really hope you enjoyed that podcast with Sue. She is absolutely brilliant. I should say that she continues to oversee the treatment of adults and children with drug resistant epilepsy and mentors NHS teams who are keen to explore ketogenic diets in clinical scenarios, uh, in, in adults with, for example, status epilepticus. Um, so you can definitely find out more from her directly. I've put her contact details on the show notes, plus all the, uh, references to the studies that we discussed today, as well as some extra reading materials for you. She recommends, um, a book that gives you a real deep dive into the history of keto, as well as the potential uses of keto. It's a book by Mary T. Newport, who's a doctor, um, who's, uh, husband sadly passed away from Alzheimer's, but she used, uh, a low carbohydrate diet, um, in treatment of that and, and actually did a lot of research in that too. Um, just to summarize, you know, we talked about what a keto diet is, the history of keto, the uses beyond epilepsy. Um, and I think the show notes in this particular episode are going to be really useful to give you a little bit more context, uh, to what we were talking about today. Um, as always, please do, uh, give this a five-star review. Sign up to the newsletter. We'll post the recipes on YouTube and we give you science-based recipes every single week when you sign up to The Doctor's Kitchen, uh, um, the doctorskitchen.com and check out the newsletter there. Have a wonderful day and I'll catch you next week.
