Looking “Beyond Keto” with Dr. Terry Wahls

One of the ancestral community’s best-kept secrets is Dr. Terry Wahls’ dramatic success at reversing her own multiple sclerosis symptoms with a “Paleolithic ketogenic” diet. Seven years into her M.S. diagnosis, Wahls was mostly wheelchair-bound—sometimes able to walk short distances using canes or assistance—despite the best conventional medical care available.

After only five months on her exhaustively researched proprietary diet and lifestyle intervention, she could walk unassisted and rode a bicycle for the first time in 10 years. She remains fully active today and devotes her time to peer-reviewed research supporting this non-invasive approach to autoimmune conditions. (See this post for a summary of her recent studies.) Her book, The Wahls Protocol: A Radical New Way to Treat All Chronic Autoimmune Conditions Using Paleo Principles, [1] gives the details of this remarkable comeback. Her popular TED talk [2] also provides a great introduction.

In her book, Wahls credited her recovery from M.S. to the year-round ketogenic regimen she utilized. However, since the book’s publication, her experience and ongoing research have changed her perspective on what ultimately aided her recovery. She no longer recommends sustained ketogenic dieting—favoring instead what she terms metabolic resilience [3], stimulated by seasonal high-fat (potentially ketogenic) dieting supplemented by fasting strategies, while staying on a year-round low-glycemic Paleo Diet. [3]

Her new book, scheduled for publication in the spring of 2020, emphasizes this approach. The current working title is REVISED AND EXPANDED: The Wahls Protocol: A Radical New Way to Treat All Chronic Autoimmune Conditions Using Paleo Principles. [3]

Evolution of the Protocol

Professor Loren Cordain’s pioneering work The Paleo Diet: Lose Weight and Get Healthy by Eating the Foods You Were Designed to Eat [4] strongly influenced Wahls’ early research. She designed her own protocol around Paleolithic Diet concepts, adding a unique emphasis on vegetables (nine cups daily) to address micro- and phyto-nutrient deficiencies in the standard Western diet.

Her original protocol comprised various levels. There was the strong Paleo level, and an option to graduate to the Paleo-Keto level, called “Wahls Paleo Plus.” While Wahls and many of her patients have benefited from this Paleo-Keto combo, she also notes that all the published studies validating her approach use the “Wahls Paleo” level instead of the Keto level. [5]

She now recommends matching a high-fat, intermittently ketogenic diet to the traditional winter months of a patient’s genetic heritage. Ketosis could be induced, if desired, by including additional dietary fats or MCT oil. Olive oil is preferred over dairy fat and should be emphasized if triglyceride or total cholesterol levels spike. [3]

Fasting is central in the new protocol. In a recent email interview, Wahls revealed that her new book will extensively discuss time-restricted eating, intermittent fasting, calorie restriction, and a “fasting-mimicking” diet.

The revised book will also discuss the benefits of hormesis in diet and physical activity. This concept is characterized by biphasic dose response: low-dose exposure is beneficial while high-dose exposure is toxic. She will also address how behavior-change psychology and addiction medicine can combat overconsumption of engineered, hyper-palatable foods, as well as new information on both electro-stimulation benefits and stem cell research. [6]

“Metabolic switching” leads to resilience

Other researchers have also noted the hormetic benefits of intermittent metabolic switching, or transitioning from ketone- to glucose-based energy production within short time frames.

A 2018 study entitled Intermittent metabolic switching, neuroplasticity, and brain health notes [7]:

“This metabolic switch in cellular fuel source is accompanied by cellular and molecular adaptations of neural networks in the brain that enhance their functionality and bolster their resistance to stress, injury, and disease.”

The authors used the example of ancestral populations who experienced extended exercise, typically while fasted, followed by rest and re-feeding after a successful hunt.

This metabolic switching promotes neuroplasticity, optimizing lifelong brain function and resilience, especially neuronal circuits related to cognition and mood. [7] Other studies have separately shown that calorie reduction or fasting increases autophagy (cellular hygiene) [8] and that ketosis promotes mitochondrial biogenesis. [9]

The switching also protects against some lesser-known downsides of sustained ketosis. According to Wahls:

“I shift away from prolonged ketosis except for specific indication, as ketosis sends a cellular signal that we are lacking sufficient nutrition. [As a result], our thyroid is down-regulated toward hibernation, our sex hormones are down-regulated to reduce likelihood of pregnancy; short term there is an increase in nerve growth factors but long-term insufficiencies of thyroid and sex hormones accelerate brain atrophy.” [6]

Other drawbacks of sustained ketosis are the possibility of mineral deficiency—induced metabolic acidosis, as noted by Professor Cordain [10], and reduced microbiome diversity. [11-12]

The “resilience” lifestyle

Wahls has incorporated metabolic switching into her daily routine; the result is that she weighs the same as she did when she won a bronze medal in Taekwondo during the trials for the 1978 Pan American Games. [3]

Her current regimen includes [3]:

• Food selection: consistent adherence to a low-glycemic Paleo Diet.
• One meal per day
• Fasting: each month, for one week, either water-only (includes green tea) or calorie-restricted “fasting-mimicking” diet.
• December-March: high fat, lower carb macro ratios, including only non-starchy, raw, or fermented vegetables. She uses olive oil generously as a condiment and avoids most fruit in these months.
• April-November: low glycemic carbohydrates increase, mostly in the form of fresh fruits and vegetables—often from Wahls’ own garden (including cherries, berries, and paw-paws.) Fresh pesto, heavy on the olive oil and self-grown herbs, is a staple. Occasional small servings of cooked starchy vegetables are permitted.
• Ongoing: Electrical stimulation therapy, vibration-plate and strength training, and vitamin D supplementation. These are not a change from the original protocol.

Readers should note that Wahls follows this strict regimen to keep her M.S. symptoms at bay. This is not a “weight loss” program as such, and medical supervision of any new diet, especially one built around fasting, is recommended.

Should extended keto be medically supervised?

Again, while we do not promote a long-term ketogenic diet here at The Paleo Diet, there are health reasons, such as those that Wahls addresses, that may necessitate longer ketogenic periods. Medical professionals have successfully treated epilepsy with keto for almost one hundred years. [13]

More recently, a ketogenic diet has been shown to be effective in the treatment of Alzheimer’s disease, [14-15] multiple sclerosis, [16] and even cancer. [17]

The question is whether that can be done in a healthy manner. The fact is that even Wahls has shifted away from a long-term ketogenic approach.

Patients succeed on a ketogenic diet by following strict guidelines, typically under medical supervision. Full compliance is reported to be difficult, although even partial compliance may have some effect. [18]

These guidelines are not popular “diet book” DIY plans, but tailored “prescriptions” by medical doctors—including Wahls.

The potential negative health consequences of unrestricted, general use by the public of a ketogenic diet—often promoted by non-medical authors and bloggers— could be partially mitigated by greater physician involvement, assuming said doctor understood diet-based therapies in general, and keto in particular, and how to implement them.

A less physician-intensive approach might be at least a relaxed version of Wahls new regimen: keep moving, eat less (and less often), eat more fat in winter, and stay low-glycemic Paleo.

Wahls’ evolved rationale for abandoning year-round keto, based both on personal experience and published research, appears both biologically and historically sound.

References

1. Wahls, Terry, M. D., and Eve Adamson. The Wahls Protocol: A Radical New Way to Treat All Chronic Autoimmune Conditions Using Paleo Principles. Reprint edition, Avery, 2014.

2. Wahls, Terry. YouTube. 30 Nov. 2011,

3. Email interview, 1/21/20

4. Cordain, Loren. The Paleo Diet: Lose Weight and Get Healthy by Eating the Foods You Were Designed to Eat. Revised edition, John Wiley & Sons, 2010.

5. Email interview, 9/3/19

6. Email interview, 2/7/20

7. Mattson, Mark P., et al. “Intermittent Metabolic Switching, Neuroplasticity and Brain Health.” Nature Reviews. Neuroscience, vol. 19, no. 2, 2018, pp. 63–80. PubMed, doi:10.1038/nrn.2017.156.

8. Antunes, Fernanda, et al. “Autophagy and Intermittent Fasting: The Connection for Cancer Therapy?” Clinics, vol. 73, 2018. PubMed Central, doi:10.6061/clinics/2018/e814s.

9. Hasan-Olive, Md Mahdi, et al. “A Ketogenic Diet Improves Mitochondrial Biogenesis and Bioenergetics via the PGC1α-SIRT3-UCP2 Axis.” Neurochemical Research, vol. 44, no. 1, Jan. 2019, pp. 22–37. PubMed, doi:10.1007/s11064-018-2588-6.

10. Cordain, Loren Ph.D. “Paleo Diet Guide – Ketogenic Diets: Long-Term Nutritional And Metabolic Deficiencies | The Paleo Diet^TM.” The Paleo Diet®, 19 June 2018, https://thepaleodiet.com/ketog….
11. How a Low-Carb Diet Might Impact Gut Health. https://www.medicalnewstoday.com/articles/323171. Accessed 17 Feb. 2020.

12. Brinkworth, Grant D., et al. “Comparative Effects of Very Low-Carbohydrate, High-Fat and High-Carbohydrate, Low-Fat Weight-Loss Diets on Bowel Habit and Faecal Short-Chain Fatty Acids and Bacterial Populations.” The British Journal of Nutrition, vol. 101, no. 10, May 2009, pp. 1493–502. PubMed, doi:10.1017/S0007114508094658.

13 Wheless, James W. “History of the Ketogenic Diet.” Epilepsia, vol. 49 Suppl 8, Nov. 2008, pp. 3–5. PubMed, doi:10.1111/j.1528-1167.2008.01821.x.

14. Bredesen, Dale E. The End of Alzheimer’s: The First Program to Prevent and Reverse Cognitive Decline. Avery, an imprint of Penguin Random House, 2017. Electronic edition

15. Newport, Mary T. Alzheimer’s Disease: What If There Was a Cure?: The Story of Ketones. Second edition, Basic Health Publications, Inc, 2013.

16. Whiteside, David. “How Dr. Terry Wahls Improved Her Multiple Sclerosis Symptoms.” The Paleo Diet®, 18 Jan. 2020, https://thepaleodiet.com/dr-terry-wahls-improved-multiple-sclerosis-symptoms/.

17.Seyfried, Thomas N., et al. “Press-Pulse: A Novel Therapeutic Strategy for the Metabolic Management of Cancer.” Nutrition & Metabolism, vol. 14, no. 1, Feb. 2017, p. 19. BioMed Central, doi:10.1186/s12986-017-0178-2.

18. Bredesen, P. 308